Fatal rhino-orbito-cerebral mucormycosis in a patient with liver disease

Invasive rhinocerebral mucormycosis in a patient with liver cirrhosis leading to fatal massive stroke

Immunocompromised status is associated with invasive fungal infections including mucormycosis. These infections are challenging to treat and associated with high overall mortality.

Here we report a fatal case of invasive mucormycosis in a cirrhotic, diabetic patient. Despite the swift diagnosis and management; the fungal invasion of the right internal carotid artery lead to massive ischemic stroke.

Timely diagnosis and management is crucial for management but it seems not always enough and new approaches for treatment must be sought.

A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis-has anything changed in the past 20 years?

BACKGROUND

Rhino-orbital-cerebral mucormycosis (ROCM) is an uncommon yet potentially lethal fungal infection. Although most cases originate from developing countries, an ageing population and increased prevalence of chronic illness may mean some clinicians practicing in developed countries will encounter ROCM cases in their careers. Yohai et al published a systematic review of 145 case reports from 1970 to 1993 assessing prognostic factors for patients presenting with ROCM. We present an updated review of the literature and assess whether survival outcomes have changed in the two decades since that seminal paper.

SEARCH STRATEGY

An extensive Medline literature search was performed for case reports published between 1994 and 2015.

RESULTS

In total, 210 published cases were identified from the literature review, of which 175 patients from 140 papers were included in this review. Fifty-five were female, with an overall mean age of 43 years. Overall survival rate was 59.5%, which was not significantly better than the previous series reported (60%) reported by Yohai et al. Survival rates in patients with chronic renal disease had improved, from 19% to 52%, and in patients with leukaemia (from 13% to 50%). Facial necrosis and hemiplegia remained poor prognostic indicators (33% and 39% survival rates, respectively). Early commencement of medical treatment related to better survival outcomes (61% if commenced within first 12 days of presentation, compared to 33% if after 13 days). Timing of surgery had less of an effect on overall survival. However, in 28 cases that did not receive any surgical treatment, survival was only 21%.

CONCLUSIONS

Although overall survival rates have not improved, survival in patients with renal disease were better, potentially due to the introduction of liposomal amphotericin B which is less nephrotoxic. Prompt recognition of ROCM, reversal of predisposing co-morbidities and aggressive medical treatment remain the cornerstone of managing this highly aggressive disease.

A tip from the nose: rhinocerebral mucormycosis in a patient with alcoholic liver cirrhosis and cocaine abuse, an uncommon association

We present the case of a 28-year-old man with a long-standing history of cocaine abuse and Child-Pugh class C alcoholic liver cirrhosis who developed severe lower respiratory tract infection complicated with septic shock and multiple organ dysfunction. He was managed in the intensive care unit. On the eighth day after admission, he developed a nose discolouration, which was initially thought to be associated with high-dose vasopressors. Despite the reduction of vasopressors, the lesion progressed rapidly. It was later diagnosed as rhinocerebral mucormycosis. Amphotericin B was administered, but unfortunately the patient succumbed to the complications postinfection. The association between alcoholic liver cirrhosis and rhinocerebral mucormycosis should be known and prompt recognition warrants immediate treatment.

Invasive mucormycosis in a patient with liver cirrhosis: case report and review of the literature

INTRODUCTION

Cutaneous Mucormycosis is a rare opportunistic infection caused by Zygomycetes class of fungi that is often fatal, requiring aggressive local control as well as systemic therapy. Few cases of mucormycosis were described in patients with liver cirrhosis, mostly rhino-orbital. To our knowledge, only two cases of upper extremity involvement was reported in cirrhosis while a few cases were reported in the post-transplant setting. We report herein the third case of upper extremity mucor infection in the setting of liver cirrhosis.

CASE PRESENTATION

We described a rare case of forearm infection originating in a traumatic intravenous access portal in a 25 year-old woman with liver cirrhosis secondary to autoimmune hepatitis.

DISCUSSION

She developed acute on chronic liver failure during the last trimester of pregnancy, which was terminated. Painful, erythematous lesion was noted on her right forearm in the area of intravenous access, which later became necrotic. Extensive debridement was done and histopathological examination confirmed the diagnosis of mucormycosis. The patient started on Amphotericin B. Her condition continued to deteriorate and ended up with above elbow amputation followed by right shoulder disarticulation. She died two days later due to multi-organ failure. In conclusion, forearm mucromycosis in liver cirrhosis can be fatal.