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Dogra S, Arora A, Aggarwal A, Passi G, Sharma A, Singh G, Barnwal RP. Mucormycosis Amid COVID-19 Crisis: Pathogenesis, Diagnosis, and Novel Treatment Strategies to Combat the Spread. Front Microbiol 2022; 12:794176. [PMID: 35058909 PMCID: PMC8763841 DOI: 10.3389/fmicb.2021.794176] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/30/2021] [Indexed: 01/01/2023] Open
Abstract
The havoc unleashed by COVID-19 pandemic has paved way for secondary ominous fungal infections like Mucormycosis. It is caused by a class of opportunistic pathogens from the order Mucorales. Fatality rates due to this contagious infection are extremely high. Numerous clinical manifestations result in damage to multiple organs subject to the patient's underlying condition. Lack of a proper detection method and reliable treatment has made the management of this infection troublesome. Several reports studying the behavior pattern of Mucorales inside the host by modulation of its defense mechanisms have helped in understanding the pathogenesis of this angio-invasive infection. Many recent advances in diagnosis and treatment of this fungal infection have not been much beneficial. Therefore, there is a need to foster more viable strategies. This article summarizes current and imminent approaches that could aid effective management of these secondary infections in these times of global pandemic. It is foreseen that the development of newer antifungal drugs, antimicrobial peptides, and nanotechnology-based approaches for drug delivery would help combat this infection and curb its spread.
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Affiliation(s)
- Shreya Dogra
- Department of Biophysics, Panjab University, Chandigarh, India
| | - Akanksha Arora
- Department of Biophysics, Panjab University, Chandigarh, India
| | - Aashni Aggarwal
- Department of Biophysics, Panjab University, Chandigarh, India
| | - Gautam Passi
- Department of Biophysics, Panjab University, Chandigarh, India
| | - Akanksha Sharma
- Department of Biophysics, Panjab University, Chandigarh, India
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Gurpal Singh
- University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Ravi P. Barnwal
- Department of Biophysics, Panjab University, Chandigarh, India
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Wand O, Unterman A, Izhakian S, Fridel L, Kramer MR. Mucormycosis in lung transplant recipients: A systematic review of the literature and a case series. Clin Transplant 2020; 34:e13774. [PMID: 31860739 DOI: 10.1111/ctr.13774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mucormycosis is a rare infection in lung transplant recipients (LTR). Our objective was to better define the clinical presentation and optimal management of this frequently lethal infection. METHODS A systematic review of the literature was performed to identify all published cases of mucormycosis in LTR using PubMed/MEDLINE. These cases were analyzed together with a new case series from our clinic. RESULTS Literature search yielded 44 articles matching the inclusion criteria, describing 121 cases. Six additional cases were identified from our clinic. Data regarding infection site and outcome were available for a total of 53 patients. The lungs were the most common site of infection (62%), followed by rhinocerebral and disseminated disease. Most cases (78%) developed in the first post-transplant year, with over 40% of them in the first month. Additional risk factors for mucormycosis were identified in over half of the patients. Surgical debridement was uncommon in pulmonary infection (9%). Posaconazole therapy was used in 35% of cases, mostly in combination with amphotericin B. Overall mortality was 32% but varied according to site of infection. CONCLUSION Mucormycosis in LTRs tends to be an early post-surgical infection, associated with additional risk factors and intensified immunosuppressive states, and most often affects the lungs, where surgical debridement is rarely feasible. Posaconazole as first-line therapy should be further explored.
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Affiliation(s)
- Ori Wand
- Pulmonary Institute, Rabin Medical Center, Petach Tiqwa, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pulmonary Division, Meir Medical Center, Kfar-Sava, Israel
| | - Avraham Unterman
- Pulmonary Institute, Rabin Medical Center, Petach Tiqwa, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Yale University School of Medicine, New Haven, CT, USA
| | - Shimon Izhakian
- Pulmonary Institute, Rabin Medical Center, Petach Tiqwa, Israel
| | - Ludmila Fridel
- Pathology Institute, Rabin Medical Center, Petach Tiqwa, Israel
| | - Mordechai R Kramer
- Pulmonary Institute, Rabin Medical Center, Petach Tiqwa, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Voltan AR, Quindós G, Alarcón KPM, Fusco-Almeida AM, Mendes-Giannini MJS, Chorilli M. Fungal diseases: could nanostructured drug delivery systems be a novel paradigm for therapy? Int J Nanomedicine 2016; 11:3715-30. [PMID: 27540288 PMCID: PMC4982498 DOI: 10.2147/ijn.s93105] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Invasive mycoses are a major problem for immunocompromised individuals and patients in intensive care units. Morbidity and mortality rates of these infections are high because of late diagnosis and delayed treatment. Moreover, the number of available antifungal agents is low, and there are problems with toxicity and resistance. Alternatives for treating invasive fungal infections are necessary. Nanostructured systems could be excellent carriers for antifungal drugs, reducing toxicity and targeting their action. The use of nanostructured systems for antifungal therapy began in the 1990s, with the appearance of lipid formulations of amphotericin B. This review encompasses different antifungal drug delivery systems, such as liposomes, carriers based on solid lipids and nanostructure lipids, polymeric nanoparticles, dendrimers, and others. All these delivery systems have advantages and disadvantages. Main advantages are the improvement in the antifungal properties, such as bioavailability, reduction in toxicity, and target tissue, which facilitates innovative therapeutic techniques. Conversely, a major disadvantage is the high cost of production. In the near future, the use of nanosystems for drug delivery strategies can be used for delivering peptides, including mucoadhesive systems for the treatment of oral and vaginal candidiasis.
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Affiliation(s)
- Aline Raquel Voltan
- Department of Drugs and Medicines, Faculty of Pharmaceutical Sciences, Univ. Estadual Paulista, Araraquara, Sao Paulo, Brazil
| | - Guillermo Quindós
- Immunology, Microbiology, and Parasitology Department, Facultad de Medicina y Odontología, Universidad del País Vasco, Bilbao, Spain
| | - Kaila P Medina Alarcón
- Department of Clinical Analysis, Faculdade de Ciências Farmacêuticas, Univ. Estadual Paulista, Araraquara, Sao Paulo, Brazil
| | - Ana Marisa Fusco-Almeida
- Department of Clinical Analysis, Faculdade de Ciências Farmacêuticas, Univ. Estadual Paulista, Araraquara, Sao Paulo, Brazil
| | | | - Marlus Chorilli
- Department of Drugs and Medicines, Faculty of Pharmaceutical Sciences, Univ. Estadual Paulista, Araraquara, Sao Paulo, Brazil
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Gamaletsou MN, Sipsas NV, Roilides E, Walsh TJ. Rhino-Orbital-Cerebral Mucormycosis. Curr Infect Dis Rep 2012; 14:423-34. [DOI: 10.1007/s11908-012-0272-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fungal infections in pediatric lung transplant recipients: colonization and invasive disease. J Heart Lung Transplant 2009; 28:1226-30. [PMID: 19782585 DOI: 10.1016/j.healun.2009.06.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the epidemiology and investigate the impact of colonization and pulmonary fungal infections (PFIs). METHODS In this investigation we performed a retrospective analysis of 55 pediatric lung transplant recipients from 2002 to 2007 at a single institution. Associations between risk factors and time to post-transplant colonization, PFI, and other outcomes were assessed using Cox proportional hazard models. RESULTS Although 29 patients had positive pre-transplant colonization, 33 (60%) were colonized post-transplant and 20% (11 subjects) developed proven or probable PFI. In a multivariate model, post-transplant fungal colonization was associated with older age (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.1 to 7.6), cytomegalovirus (CMV) prophylaxis (HR 5.6, 95% CI 1.3 to 24.6) and respiratory viral infection prior to fungal colonization (HR 2.9, 95% CI 1.0 to 8.3). CONCLUSION Neither fungal colonization nor PFI was associated with the development of chronic allograft rejection or death.
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Danziger-Isakov LA, Worley S, Arrigain S, Aurora P, Ballmann M, Boyer D, Conrad C, Eichler I, Elidemir O, Goldfarb S, Mallory GB, Michaels MG, Michelson P, Mogayzel PJ, Parakininkas D, Solomon M, Visner G, Sweet S, Faro A. Increased mortality after pulmonary fungal infection within the first year after pediatric lung transplantation. J Heart Lung Transplant 2008; 27:655-61. [PMID: 18503966 DOI: 10.1016/j.healun.2008.03.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Revised: 02/20/2008] [Accepted: 03/12/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Risk factors, morbidity and mortality from pulmonary fungal infections (PFIs) within the first year after pediatric lung transplant have not previously been characterized. METHODS A retrospective, multicenter study from 1988 to 2005 was conducted with institutional approval from the 12 participating centers in North America and Europe. Data were recorded for the first post-transplant year. The log-rank test assessed for the association between PFI and survival. Associations between time to PFI and risk factors were assessed by Cox proportional hazards models. RESULTS Of the 555 subjects transplanted, 58 (10.5%) had 62 proven (Candida, Aspergillus or other) or probable (Aspergillus or other) PFIs within the first year post-transplant. The mean age for PFI subjects was 14.0 years vs 11.4 years for non-PFI subjects (p < 0.01). Candida and Aspergillus species were recovered equally for proven disease. Comparing subjects with PFI (n = 58) vs those without (n = 404), pre-transplant colonization was associated with PFI (hazard ratio [HR] 2.0; 95% CI 0.95 to 4.3, p = 0.067). Cytomegalovirus (CMV) mismatch, tacrolimus-based regimen and age >15 years were associated with PFI (p < 0.05). PFI was associated with any prior rejection higher than Grade A2 (HR 2.1; 95% CI 1.2 to 3.6). Cystic fibrosis, induction therapy, transplant era and type of transplant were not associated with PFI. PFI was independently associated with decreased 12-month survival (HR 3.9, 95% CI 2.2 to 6.8). CONCLUSIONS Risk factors for PFI include Grade A2 rejection, repeated acute rejection, CMV-positive donor, tacrolimus-based regimen and pre-transplant colonization.
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Affiliation(s)
- Lara A Danziger-Isakov
- Department of Pediatric Infectious Diseases, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Uçkay I, Chalandon Y, Sartoretti P, Rohner P, Berney T, Hadaya K, van Delden C. Invasive zygomycosis in transplant recipients. Clin Transplant 2007; 21:577-82. [PMID: 17645724 DOI: 10.1111/j.1399-0012.2007.00684.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Zygomycosis are rare fungal infections occurring mainly in immunocompromised patients. To date only 160 cases have been published in transplant recipients. We report four new cases of zygomycosis in transplant recipients illustrating the large clinical spectrum of this infection: one disseminated infection with heart involvement and one rhinocerebral infection with dissemination in two bone marrow transplant recipients, one cutaneous infection in a liver and one pulmonary infection in a kidney recipient. All cases, except the cutaneous infection that was accessible to surgical resection and a systemic antifungal treatment, were fatal. In transplant recipients cumulating risk factors for zygomycosis, a high index of suspicion is required. Early diagnosis and combining surgery with systemic amphotericin-B are mandatory to improve survival rates.
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Affiliation(s)
- Ilker Uçkay
- Service of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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Mucormycosis of the Bronchial Anastomosis: A Case of Successful Medical Treatment and Historic Review. J Heart Lung Transplant 2007; 26:857-61. [DOI: 10.1016/j.healun.2007.05.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 05/03/2007] [Accepted: 05/17/2007] [Indexed: 11/16/2022] Open
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Almyroudis NG, Sutton DA, Linden P, Rinaldi MG, Fung J, Kusne S. Zygomycosis in solid organ transplant recipients in a tertiary transplant center and review of the literature. Am J Transplant 2006; 6:2365-74. [PMID: 16925570 DOI: 10.1111/j.1600-6143.2006.01496.x] [Citation(s) in RCA: 190] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Zygomycetes are ubiquitous fungi that can cause invasive disease associated with high mortality. We report 10 solid organ transplant recipients with zygomycosis (incidence 2 per 1000) and reviewed 106 cases in the English-language literature. These included renal (n = 73), heart (n = 16), lung (n = 4), heart/lung (n = 2), liver (n = 19) and kidney/pancreas (n = 2) transplant recipients. All patients were receiving immunosuppression and the vast majority steroids. The clinical presentation included rhino-sino-orbital (n = 20), rhinocerebral (n = 16), pulmonary (n = 28), gastrointestinal (n = 13), cutaneous (n = 18), renal (n = 6) and disseminated disease (n = 15). Most frequently isolated genera were Rhizopus (73%) followed by Mucor (13%). The overall mortality was 49%. While rhino-sino-orbital disease had the best prognosis, rhinocerebral disease had high mortality (93%) comparable to disseminated disease. A favorable outcome was associated with limited, surgically accessible disease and early surgical intervention along with amphotericin B administration.
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Affiliation(s)
- N G Almyroudis
- Department of Medicine, Univeristy of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania, USA
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Abstract
Mucormycosis endocarditis after cardiovascular surgery is a rare and usually fatal complication. Here, we report one case of mucormycosis occurring in the pulmonary artery and the residual patent ductus arteriosus (PDA) in a 9-year-old girl, who had been successfully cured with the combination of the emergent surgical removal of infected tissues and the subsequent antifungal drug therapy.
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Affiliation(s)
- Lin Chen
- Department of Cardiovascular Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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Linden PK. Amphotericin B lipid complex for the treatment of invasive fungal infections. Expert Opin Pharmacother 2004; 4:2099-110. [PMID: 14596663 DOI: 10.1517/14656566.4.11.2099] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Amphotericin B lipid complex (ABLC; Abelcet, Enzon Pharmaceuticals) has become the dominant marketed lipid amphotericin B compound to emerge since the approval of these agents from the mid-1990s onwards. This agent is a 1:1 combination of amphotericin B and a lipid moiety consisting of dimyristoyl phosphatidylcholine and dimyrisoyl phosphatidylcholine, which exists in a ribbon-like molecular structure. ABLC undergoes rapid reticuloendothelial uptake from the circulation and achieves significantly higher tissue concentrations in the liver, spleen and lung compared to comparably dosed conventional amphotericin B. ABLC is approved by the FDA for all mycoses in amphotericin B-intolerant or -refractory infection. Randomised, controlled trials of amphotericin B have shown comparable efficacy in candidiasis and an improved outcome in invasive aspergillosis versus historical controls. ABLC has demonstrated a reduced incidence of nephrotoxicity and infusion reactions versus amphotericin B. Comparative studies against other lipid formulations are quite limited and have shown variable differences in infusion toxicity, nephrotoxicity, hepatotoxicity and clinical efficacy. Postapproval experience has shown substantial efficacy for less common mycotic pathogens including zygomycosis. The precise position of ABLC versus both other lipid formulations and expanding formulary of new antifungal agents is in flux. Future studies which examine its clinical efficacy, role in combination therapy, toxicity and cost-effectiveness in these complex patients are needed.
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Affiliation(s)
- Peter K Linden
- Abdominal Organ Transplant ICU, University of Pittsburgh Medical Center, Dept Critical Care Medicine, 602-A Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
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Brandão A, Marroni CA, Cerski CT, Gleisner AL, Zanotelli ML, Cantisani G. Zigomicose após transplante hepático em adultos: relato de três casos. Rev Soc Bras Med Trop 2003. [DOI: 10.1590/s0037-86822003000600014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Relatam-se três casos de zigomicose após transplante hepático em uma série de 300 pacientes. O diagnóstico foi anatomopatológico (dois casos à necropsia e um à cirurgia). A doença manifestou-se de diferentes formas: rinomaxilar, gastrointestinal e, em um paciente, comprometeu a anastomose da artéria hepática. Neste caso, retirada cirúrgica da região comprometida e uso de anfotericina-B possibilitaram a cura.
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Affiliation(s)
- Ajacio Brandão
- Santa Casa de Misericórdia de Porto Alegre; Universidade Federal do Rio Grande do Sul
| | | | - Carlos Thadeu Cerski
- Santa Casa de Misericórdia de Porto Alegre; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre
| | | | | | - Guido Cantisani
- Santa Casa de Misericórdia de Porto Alegre; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre
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Gallagher JC, Dodds Ashley ES, Drew RH, Perfect JR. Antifungal pharmacotherapy for invasive mould infections. Expert Opin Pharmacother 2003; 4:147-64. [PMID: 12562305 DOI: 10.1517/14656566.4.2.147] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence of invasive mould infections is increasing and is associated with significant morbidity and mortality. Among the most prevalent of these infections are those caused by Aspergillus and Fusarium species. Invasive disease caused by moulds frequently presents as a pulmonary infection, but haematogenous infection can occur. Some moulds cause cutaneous disease through either direct inoculation of the skin or secondary spread to the skin after dissemination from another body site. Early diagnosis can often be difficult and, unfortunately, diagnosis occurs late in the course of illness in many cases. Treatment options have historically been limited by the need for intravenous administration (amphotericin B), significant toxicities (amphotericin B), lack of reliable in vitro activity (e.g., amphotericin B in Fusarium and Scedosporium apiospermum infections) and relative lack of clinical experience with newer agents. The recent approval of voriconazole (Vfend, Pfizer) introduces a treatment option that demonstrates both in vitro and in vivo activity against a variety of moulds. With the recent development of the new echinocandin class of antifungal agents and newer broad-spectrum azole antifungal agents with in vitro mould activity, there is a renewed emphasis on fungal treatment strategies. Antimould therapy presents challenges in adverse effect avoidance and management, drug interactions and pharmacoeconomic considerations. Furthermore, combination therapy is being explored with these various new antifungal agents. The administration of an optimal fungicidal therapy early in the course of the illness and control of the underlying disease are vital to prevent complications and mortality from these tenacious mycoses.
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Affiliation(s)
- Jason C Gallagher
- Duke University Medical Center, Division of Infectious Diseases, Box 3353, Durham, NC 27710, USA
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Zander DS, Cicale MJ, Mergo P. Durable cure of mucormycosis involving allograft and native lungs. J Heart Lung Transplant 2000; 19:615-8. [PMID: 10867344 DOI: 10.1016/s1053-2498(00)00103-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Among the spectrum of fungi causing disease in lung allograft recipients, fungi in the order Mucorales represent uncommon pathogens. Lung transplant patients, however, often possess more than one risk factor for development of life-threatening mucormycosis. We describe a unique case of pulmonary mucormycosis involving both the allograft and the native lungs, in a single lung transplant recipient with steroid-induced diabetes. Extended intravenous amphotericin B and oral fluconazole therapy, reduction of immunosuppression, and blood glucose control achieved a durable cure without the need for surgical intervention. Early diagnosis with prompt initiation of multiagent antifungal therapy, prolonged continuation of antifungal therapies, and amelioration of contributing conditions are important elements of the treatment strategy that led to successful resolution of the infection.
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Affiliation(s)
- D S Zander
- Department of Pathology, University of Florida College of Medicine, and Veterans Affairs Medical Center, Gainesville, Florida, USA.
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