1
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Roland LT, Humphreys IM, Le CH, Babik JM, Bailey CE, Ediriwickrema LS, Fung M, Lieberman JA, Magliocca KR, Nam HH, Teo NW, Thomas PC, Winegar BA, Birkenbeuel JL, David AP, Goshtasbi K, Johnson PG, Martin EC, Nguyen TV, Patel NN, Qureshi HA, Tay K, Vasudev M, Abuzeid WM, Hwang PH, Jafari A, Russell MS, Turner JH, Wise SK, Kuan EC. Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations. Int Forum Allergy Rhinol 2023; 13:1615-1714. [PMID: 36680469 DOI: 10.1002/alr.23132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.
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Affiliation(s)
- Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Christopher H Le
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Jennifer M Babik
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christopher E Bailey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Lilangi S Ediriwickrema
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California, Irvine, Irvine, California, USA
| | - Monica Fung
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joshua A Lieberman
- Department of Pathology and Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University Medical Center, Atlanta, Georgia, USA
| | - Hannah H Nam
- Division of Infectious Diseases, Department of Medicine, University of California, Irvine, Orange, California, USA
| | - Neville W Teo
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Penelope C Thomas
- Department of Radiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Blair A Winegar
- Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Abel P David
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Patricia G Johnson
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Elaine C Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Neil N Patel
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kaijun Tay
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Waleed M Abuzeid
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Aria Jafari
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew S Russell
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University Medical Center, Atlanta, Georgia, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
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2
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Saini H, Mann H, Saini I, Bhanot N, Kelly K, Rana S. Isolated cerebral mucormycosis: A case discussion. IDCases 2023; 33:e01821. [PMID: 37415782 PMCID: PMC10320071 DOI: 10.1016/j.idcr.2023.e01821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 07/08/2023] Open
Abstract
We report a case of a 32-year-old male with a history of type 1 diabetes, inhaled drug use, and alcohol use disorder, who presented with encephalopathy, holocranial headaches, neck pain, confusion, and generalized tonic-clonic seizures. The patient initially presented at a rural community hospital with a fever and was found to be in diabetic ketoacidosis (DKA). He was also hemodynamically stable but stuporous, prompting intubation to protect his airway. Despite initial treatment measures, his neurological condition worsened and he remained ventilator-dependent. Key findings include a high glucose level, presence of ketones, and evidence of drug use. Blood cultures showed no growth, but his febrile state persisted. Cerebrospinal fluid (CSF) analysis revealed mild pleocytosis, hyperglycorrhachia but normal protein, with no growth. Neuroimaging showed right hemispheric slowing on EEG and diffusion restriction in the right frontal lobe on MRI. The patient's neurological status worsened on the second day of admission, manifesting as sluggish pupillary reflexes, right third nerve palsy, and decerebrate posturing. Emergent MRI suggested cerebral edema, leading to initiation of hypertonic saline. This case highlights the diagnostic challenges and critical management considerations in a patient with multiple comorbidities presenting with unexplained neurological deterioration, emphasizing the importance of a comprehensive and timely approach to diagnosis and treatment.
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Affiliation(s)
- Harneel Saini
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Harinoor Mann
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Ishveen Saini
- Lake Erie College of Osteopathic Medicine, 1858 W Grandview Blvd, Erie, PA 16509, United States
| | - Nitin Bhanot
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Kevin Kelly
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Sandeep Rana
- Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, United States
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3
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Chen CH, Chen JN, Du HG, Guo DL. Isolated cerebral mucormycosis that looks like stroke and brain abscess: A case report and review of the literature. World J Clin Cases 2023; 11:1560-1568. [PMID: 36926404 PMCID: PMC10011993 DOI: 10.12998/wjcc.v11.i7.1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/07/2023] [Accepted: 02/10/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Cerebral mucormycosis is an infectious disease of the brain caused by fungi of the order Mucorales. These infections are rarely encountered in clinical practice and are often misdiagnosed as cerebral infarction or brain abscess. Increased mortality due to cerebral mucormycosis is closely related to delayed diagnosis and treatment, both of which present unique challenges for clinicians.
CASE SUMMARY Cerebral mucormycosis is generally secondary to sinus disease or other disseminated disease. However, in this retrospective study, we report and analyze a case of isolated cerebral mucormycosis.
CONCLUSION The constellation of symptoms including headaches, fever, hemiplegia, and changes in mental status taken together with clinical findings of cerebral infarction and brain abscess should raise the possibility of a brain fungal infection. Early diagnosis and prompt initiation of antifungal therapy along with surgery can improve patient survival.
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Affiliation(s)
- Cai-Hong Chen
- Department of Neurology, Hangzhou Ninth People's Hospital, Hangzhou 311225, Zhejiang Province, China
| | - Jing-Nan Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine, Hangzhou 310005, Zhejiang Province, China
| | - Hang-Gen Du
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine, Hangzhou 310005, Zhejiang Province, China
| | - Dong-Liang Guo
- Department of Neurology, Hangzhou Ninth People's Hospital, Hangzhou 311225, Zhejiang Province, China
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4
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Alali M, Balsara K, Khaitan A, Streicher DA, Barros KL, Budnick HC, Schulte RR. Successful isavuconazole salvage therapy for cerebral mucormycosis in a child with relapsed leukemia: A light in the dark tunnel. Pediatr Blood Cancer 2023; 70:e29807. [PMID: 35657144 DOI: 10.1002/pbc.29807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Muayad Alali
- Department of Pediatrics, Ryan White Center for Pediatric, Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Karl Balsara
- Department of Neurosurgery, Goodman Campbell Brain and Spine, Riley Hospital for Children, Section of Pediatric Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alka Khaitan
- Department of Pediatrics, Ryan White Center for Pediatric, Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Drew A Streicher
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kathryn L Barros
- Department of Pediatrics, Ryan White Center for Pediatric, Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hailey C Budnick
- Department of Neurosurgery, Goodman Campbell Brain and Spine, Riley Hospital for Children, Section of Pediatric Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachael R Schulte
- Department of Pediatrics, Section of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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5
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Egger M, Hoenigl M, Thompson GR, Carvalho A, Jenks JD. Let's talk about Sex Characteristics - as a Risk Factor for Invasive Fungal Diseases. Mycoses 2022; 65:599-612. [PMID: 35484713 DOI: 10.1111/myc.13449] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 12/01/2022]
Abstract
Biological sex, which comprises differences in host sex hormone homeostasis and immune responses, can have a substantial impact on the epidemiology of infectious diseases. Comprehensive data on sex distributions in invasive fungal diseases (IFDs) is lacking. In this review we performed a literature search of in vitro/animal studies, clinical studies, systematic reviews, and meta-analyses of invasive fungal infections. Females represented 51.2% of invasive candidiasis cases, mostly matching the proportions of females among the general population in the United States and Europe (>51%). In contrast, other IFDs were overrepresented in males, including invasive aspergillosis (51% males), mucormycosis (60%), cryptococcosis (74%), coccidioidomycosis (70%), histoplasmosis (61%), and blastomycosis (66%). Behavioral variations, as well as differences related to biological sex, may only in part explain these findings. Further investigations concerning the association between biological sex/gender and the pathogenesis of IFDs is warranted.
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Affiliation(s)
- Matthias Egger
- Division of Infectious Diseases, Medical University of Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Medical University of Graz, Austria.,Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Clinical and Translational Fungal - Working Group, University of California San Diego, La Jolla, CA, USA
| | - George R Thompson
- University of California Davis Center for Valley Fever, California, USA.,Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, California, USA.,Department of Medical Microbiology and Immunology, University of California Davis, California, USA
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's -, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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6
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Isolated Cerebral Mucormycosis Caused by Lichtheimia Species in a Polytrauma Patient. Diagnostics (Basel) 2022; 12:diagnostics12020358. [PMID: 35204449 PMCID: PMC8871058 DOI: 10.3390/diagnostics12020358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
Isolated post-traumatic cerebral mucormycosis represents an extremely rare and severe disease. A case of isolated cerebral mucormycosis infection caused by Lichtheimia spp. in a 21-year-old multi-trauma patient is presented. The patient was hospitalized in the intensive care unit and underwent craniotomy due to brain injuries. Two weeks following the initial procedure, pus drained from the surgical wound was microscopically examined and cultured, yielding Lichtheimia spp. Imaging showed parietal, temporal and frontal abscesses at the right side. The patient was commenced on amphotericin B and underwent surgical debridement, while histopathological examination of the affected tissue demonstrated broad, aseptate hyphae, findings typical for mucormycetes. The patient passed away due to heavy traumatic injuries after 2 months. It is speculated that direct inoculation was the portal of entry for infection, and that high steroid use for 2 weeks following inoculation contributed to the severity of infection that developed. Isolated cerebral mucormycosis in immunocompetent hosts is an extremely rare, but severe disease. Diagnosis is established through direct microscopy, histopathology and/or cultures. PCR-based techniques are useful either to detect mucormycetes in tissues, especially when cultures are negative, or to accurately identify the fungi grown in cultures at the species level. A high suspicion index, especially in the necrotic lesions of traumas, is of the utmost importance for early diagnosis. Appropriate surgical debridement, as well as antifungal therapy, including amphotericin B, represents the treatment of choice.
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7
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Central Nervous System Fungal Infections in Paediatric Patients. CURRENT FUNGAL INFECTION REPORTS 2022. [DOI: 10.1007/s12281-021-00427-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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8
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Wen B, Cai L, Cai Y, Du X. Case Report: Metagenomics Next-Generation Sequencing for Diagnosing Cerebral Infarction and Infection Caused by Hematogenous Disseminated Mucormycosis in a Patient With Acute Lymphoblastic Leukemia. Front Med (Lausanne) 2022; 8:779981. [PMID: 34977080 PMCID: PMC8718678 DOI: 10.3389/fmed.2021.779981] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/30/2021] [Indexed: 01/15/2023] Open
Abstract
Disseminated mucormycosis, a serious complication, is associated with high mortality in patients with acute leukemia after chemotherapy. Blood cultures are always negative because of recurrent empirical antifungal treatments. The identification of pathogens is important for diagnosis and therapy. In this case report, we diagnosed culture-negative disseminated mucormycosis with Rhizomucor miehei infection leading to cerebral infarction in a patient with leukemia using metagenomics next-generation sequencing (mNGS) form peripheral blood, cerebral spinal fluid, and bronchoalveolar lavage fluid. mNGS technology can be applied to precisely diagnose culture-negative disseminated mucormycosis.
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Affiliation(s)
- Bingbing Wen
- Department of Hematology, The Second People's Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Lisheng Cai
- Department of Hematology, The Second People's Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yun Cai
- Department of Hematology, The Second People's Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xin Du
- Department of Hematology, The Second People's Hospital of Shenzhen, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
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9
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Sameer F, Dhananjay D, Rupali M, Mihir V. Isolated cerebral mucormycosis in post-COVID-19 pneumonia. NEUROIMMUNOLOGY REPORTS 2022. [PMCID: PMC9040436 DOI: 10.1016/j.nerep.2022.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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10
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Chandra S, Sharma S, Vats R, Pandey S. Isolated cerebral mucormycosis masquerading as a tumor in an immunocompetent patient. AUTOPSY AND CASE REPORTS 2021; 11:e2020233. [PMID: 33968820 PMCID: PMC8020582 DOI: 10.4322/acr.2020.233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Mucormycosis is an opportunistic fungal disease that commonly presents as cutaneous or rhinocerebral infections associated with immunocompromised states. It may exceptionally present as isolated involvement of the brain with a varied clinical presentation, which may be difficult to diagnose early, leading to increased mortality. Herein, we report the case of a 42-year-old immunocompetent female with left-sided limb weakness and a history of recurrent vomiting and headache for the last two years. Clinically, glioma was suspected, but histopathological examination revealed a few broad aseptate fungal hyphae. As no other organ was involved, the diagnosis of isolated cerebral mucormycosis was rendered. Reporting this case, we show an unusual presentation of a central nervous system mucormycosis masquerading a tumor in an immunocompetent patient. The case also highlights the importance of a careful histopathological examination to avoid missing the presence of occasional fungal hyphae. Ideally, recognition of fungal hyphae in the brain, during intraoperative consultation, can prompt brain tissue culture for definitive diagnosis and early empirical antifungal therapy, which may prove life-saving.
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Affiliation(s)
- Smita Chandra
- Swami Rama Himalayan University, Himalayan Institute of Medical Sciences, Department of Pathology, Dehradun, Uttarakhand, India
| | - Shubhi Sharma
- Swami Rama Himalayan University, Himalayan Institute of Medical Sciences, Department of Pathology, Dehradun, Uttarakhand, India
| | - Ruchir Vats
- Swami Rama Himalayan University, Himalayan Institute of Medical Sciences, Department of Neurosurgery, Dehradun, Uttarakhand, India
| | - Sanjeev Pandey
- Swami Rama Himalayan University, Himalayan Institute of Medical Sciences, Department of Neurosurgery, Dehradun, Uttarakhand, India
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11
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Meyerowitz EA, Sanchez S, Mansour MK, Triant VA, Goldberg MB. Isolated Cerebral Mucormycosis in Immunocompetent Adults who Inject Drugs: Case Reports and Systematic Review of the Literature. Open Forum Infect Dis 2020; 7:ofaa552. [PMID: 33409328 PMCID: PMC7765436 DOI: 10.1093/ofid/ofaa552] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 01/16/2023] Open
Abstract
Background Mucormycosis involves life-threatening rapidly progressive angioinvasion with infiltration across tissue planes, resulting in necrosis and thrombosis, most commonly seen in the setting of immunocompromised states. We describe 2 cases of isolated cerebral mucormycosis in immunocompetent adults and describe this syndrome in detail in the context of a systemic literature review. Methods Using the criteria (1) isolated cerebral disease, (2) mucormycosis (by polymerase chain reaction, culture, or pathology), and (3) affected an immunocompetent individual, we identified 53 additional cases from 1969 to 2020. Results Of these 55 cases, ~60% occurred in men, >70% were in patients under age 35, 92% were associated with intravenous drug use, and >85% had infection centered in the basal ganglia. Many presented with cranial nerve deficits, headache, focal weakness, or altered mental status. Conclusions No patient survived without amphotericin, and steroid administration was associated with worse outcomes. Given the current opioid crisis, this syndrome may be seen more frequently.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarimer Sanchez
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael K Mansour
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Virginia A Triant
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marcia B Goldberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Microbiology, Harvard Medical School, Boston, Massachusetts, USA
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12
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Skiada A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and Diagnosis of Mucormycosis: An Update. J Fungi (Basel) 2020; 6:jof6040265. [PMID: 33147877 PMCID: PMC7711598 DOI: 10.3390/jof6040265] [Citation(s) in RCA: 268] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 12/17/2022] Open
Abstract
Mucormycosis is an angioinvasive fungal infection, due to fungi of the order Mucorales. Its incidence cannot be measured exactly, since there are few population-based studies, but multiple studies have shown that it is increasing. The prevalence of mucormycosis in India is about 80 times the prevalence in developed countries, being approximately 0.14 cases per 1000 population. Diabetes mellitus is the main underlying disease globally, especially in low and middle-income countries. In developed countries the most common underlying diseases are hematological malignancies and transplantation. Τhe epidemiology of mucormycosis is evolving as new immunomodulating agents are used in the treatment of cancer and autoimmune diseases, and as the modern diagnostic tools lead to the identification of previously uncommon genera/species such as Apophysomyces or Saksenaea complex. In addition, new risk factors are reported from Asia, including post-pulmonary tuberculosis and chronic kidney disease. New emerging species include Rhizopus homothallicus, Thamnostylum lucknowense, Mucor irregularis and Saksenaea erythrospora. Diagnosis of mucormycosis remains challenging. Clinical approach to diagnosis has a low sensitivity and specificity, it helps however in raising suspicion and prompting the initiation of laboratory testing. Histopathology, direct examination and culture remain essential tools, although the molecular methods are improving. The internal transcribed spacer (ITS) region is the most widely sequenced DNA region for fungi and it is recommended as a first-line method for species identification of Mucorales. New molecular platforms are being investigated and new fungal genetic targets are being explored. Molecular-based methods have gained acceptance for confirmation of the infection when applied on tissues. Methods on the detection of Mucorales DNA in blood have shown promising results for earlier and rapid diagnosis and could be used as screening tests in high-risk patients, but have to be validated in clinical studies. More, much needed, rapid methods that do not require invasive procedures, such as serology-based point-of-care, or metabolomics-based breath tests, are being developed and hopefully will be evaluated in the near future.
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Affiliation(s)
- Anna Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Correspondence: ; Tel.: +30-2107-462-607
| | | | - Maria Drogari-Apiranthitou
- Fourth Department of Internal Medicine, General University Hospital “Attikon”, National and Kapodistrian University of Athens, 12462 Athens, Greece;
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13
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Isolated cerebral mucormycosis associated with intravenous drug use. J Mycol Med 2020; 30:101046. [PMID: 33067115 DOI: 10.1016/j.mycmed.2020.101046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/20/2020] [Accepted: 09/28/2020] [Indexed: 11/20/2022]
Abstract
We present an uncommon case of isolated basal ganglia mucormycosis in a patient without any known cause of immunosuppression, but with a history of drug injection. The patient presented a good clinical and radiological response to antifungal treatment without aggressive surgical debridement (liposomal amphotericin B combined with isavuconazole for 4 weeks followed by isavuconazole as maintenance therapy for 10 months).
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14
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Zhang GJ, Zhang SK, Wang Z, Zhu YX, Kong J, Huang LL, Guo YJ, Wang YJ, Zou RC, Xie CM. Fatal and Rapid Progressive Isolated Cerebral Mucormycosis Involving the Bilateral Basal Ganglia: A Case Report. Front Neurol 2020; 11:295. [PMID: 32373057 PMCID: PMC7187894 DOI: 10.3389/fneur.2020.00295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/30/2020] [Indexed: 12/30/2022] Open
Abstract
Isolated cerebral mucormycosis is a clinical type of mucormycosis that is estimated to account for 8% of all mucormycosis cases. The clinical symptoms of isolated cerebral mucormycosis are elusive, and thus conventional techniques often lake sensitivity and specificity. Moreover, cultures are often negative, even when direct microscopy examination is positive. Although histopathology will probably remain the gold standard for the diagnosis of mucormycosis, obtaining a biopsy specimen is not always feasible in most vulnerable populations. Thus, molecular approaches are currently used as an advantageous assistant examination method to improve the early identification of the causative agent and subsequently guide therapy to improve the prognosis of patients. Here, we report a case of isolated cerebral mucormycosis caused by Rhizopus microspores in a healthy young adult that was identified using next-generation sequencing technology.
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Affiliation(s)
- Gao-Jia Zhang
- Department of Neurology, Nanjing Lishui People's Hospital, Nanjing, China
| | - Shao-Ke Zhang
- School of Medicine, Southeast University, Nanjing, China
| | - Zan Wang
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Yi-Xin Zhu
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Jun Kong
- Department of Neurosurgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Li-Li Huang
- Department of Intensive Care Unit, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Yi-Jing Guo
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Yan-Juan Wang
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Rong-Cheng Zou
- Department of Neurology, Nanjing Lishui People's Hospital, Nanjing, China
| | - Chun-Ming Xie
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
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15
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Challa S. Invasive Fungal Infections of the Central Nervous System in Immune-Competent Hosts. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00384-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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16
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Chikley A, Ben-Ami R, Kontoyiannis DP. Mucormycosis of the Central Nervous System. J Fungi (Basel) 2019; 5:jof5030059. [PMID: 31288475 PMCID: PMC6787740 DOI: 10.3390/jof5030059] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022] Open
Abstract
Mucormycosis involves the central nervous system by direct extension from infected paranasal sinuses or hematogenous dissemination from the lungs. Incidence rates of this rare disease seem to be rising, with a shift from the rhino-orbital-cerebral syndrome typical of patients with diabetes mellitus and ketoacidosis, to disseminated disease in patients with hematological malignancies. We present our current understanding of the pathobiology, clinical features, and diagnostic and treatment strategies of cerebral mucormycosis. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability. Emerging molecular diagnostics, advances in experimental systems and the establishment of large patient registries are key components of ongoing efforts to provide a timely diagnosis and effective treatment to patients with cerebral mucormycosis.
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Affiliation(s)
- Amanda Chikley
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas, M.D. Anderson Cancer Center, Houston 77030, TexasTX 77030, USA.
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17
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Serris A, Danion F, Lanternier F. Disease Entities in Mucormycosis. J Fungi (Basel) 2019; 5:jof5010023. [PMID: 30875744 PMCID: PMC6462957 DOI: 10.3390/jof5010023] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022] Open
Abstract
Mucormycosis is an emerging life-threatening fungal infection caused by Mucorales. This infection occurs mainly in immunocompromised patients, especially with hematological malignancy, transplantation, or diabetes mellitus. Rhino-orbito-cerebral and pulmonary mucormycosis are the predominant forms. Interestingly, location is associated with the underlying disease as pulmonary mucormycosis is more frequent in hematological malignancy patients whereas rhino-orbito-cerebral mucormycosis is associated with diabetes. Cutaneous mucormycosis results from direct inoculation, mainly after trauma or surgery. Gastro-intestinal mucormycosis occurs after ingestion of contaminated food or with contaminated device and involves the stomach or colon. Disseminated disease is the most severe form and is associated with profound immunosuppression. Uncommon presentations with endocarditis, osteoarticluar or isolated cerebral infections are also described. Finally, health-care associated mucormycosis is a matter of concern in premature newborns and burn units. Clinical symptoms and CT scan findings are not specific, only the early reversed halo sign is associated with pulmonary mucormycosis. Circulating Mucorales DNA detection is a recent promising diagnostic tool that may lead to improving the diagnosis and prompting therapeutic initiation that should include antifungal treatment, correction of the underlying disease and surgery when feasible.
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Affiliation(s)
- Alexandra Serris
- Université Paris Descartes, Centre d'Infectiologie Necker Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), 75015 Paris, France.
| | - François Danion
- Université Paris Descartes, Centre d'Infectiologie Necker Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), 75015 Paris, France.
| | - Fanny Lanternier
- Université Paris Descartes, Centre d'Infectiologie Necker Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), 75015 Paris, France.
- Centre National de Référence mycoses invasives et antifongiques, Unité de Mycologie Moléculaire, Institut Pasteur, 75015 Paris, France.
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