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Patel EJ, Ahmad M, Schwartz BS, van Zante A, Kersten R, Loftus P. Invasive Fungal Sinusitis in an Immunocompetent Patient After Sinus Surgery for Chronic Rhinosinusitis with Nasal Polyps and a Mycetoma. Laryngoscope 2024. [PMID: 38651570 DOI: 10.1002/lary.31463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/25/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Abstract
Acute invasive fungal sinusitis (AIFS) classically presents as an aggressive fungal infection that can spread beyond its origin in the sinuses in immunocompromised patients. Although there have been reports of AIFS in immunocompetent, non-diabetic patients, it is extremely rare and the true mechanism behind it is unknown. A thirty-eight year old immunocompetent, non-diabetic woman underwent bilateral ESS for chronic rhinosinusitis with nasal polyps at a tertiary care center and post-operatively developed AIFS. Patient underwent uncomplicated ESS, was packed with foam containing triamcinolone and discharged on steroid rinses and a prednisone taper. Surgical pathology demonstrated left-sided colonization with non-invasive fungal elements consistent with a mycetoma. She presented on post-operative Day 11 with headache and left-sided retro-orbital pain. A culture of her left nasal cavity grew Rhizopus spp and MRI demonstrated evidence of invasive fungal infection of left sphenoid mucosa as well as inflammatory changes in the left orbit centered at the orbital apex. She was started on amphotericin and underwent a left-sided debridement with biopsies which demonstrated angioinvasive fungal disease. Her vision in her left eye worsened to 20/800 and she was treated with transcutaneous retrobulbar injection of amphotericin B. After stable interval imaging she was discharged on a long-term course of antifungals. Extensive immunologic work-up was unremarkable. We describe a case of an immunocompetent patient who developed AIFS after sinus surgery for CRS and a mycetoma likely as a result of local immune suppression and post-surgical trauma. Laryngoscope, 2024.
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Affiliation(s)
- Evan J Patel
- Department of Otolaryngology-Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Meleha Ahmad
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Brian S Schwartz
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - Annemieke van Zante
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Robert Kersten
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Patricia Loftus
- Department of Otolaryngology-Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
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Sharma A, Godha S, Verma J, Bhalot L, Gupta Y, Mundra RK. Novel Grading System Based on Nasal Endoscopy: Our Experience with 650 Mucormycosis Cases. Indian J Otolaryngol Head Neck Surg 2024; 76:1667-1673. [PMID: 38566709 PMCID: PMC10982223 DOI: 10.1007/s12070-023-04380-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/18/2023] [Indexed: 04/04/2024] Open
Abstract
Rhinocerebralmucormycosis, is a progressive fungal invasion of a hard palate, paranasal sinuses, orbit, and brain. Post covid the huge number of mucor cases reported in our institute. To combat them a uniform assessment scale was needed as multiple healthcare workers were involved. Thus, a novel linear grading system on nasal endoscopy was developed for the early management of patients to prevent morbidity and mortality. A Prospective study of 650 patients in Epidemic duration from April to June 2021 in a tertiary health center, Central India. Patients subjected to Nasal Endoscopy with 0degree 4 mm Telescope and classified into 5 categories according to the severity of the disease. In a novel grading system, minimum patients were of grade 0, maximum was in Grade I. Maxillary sinus was most commonly involved. This novel grading system on nasal endoscopy makes the management of patients much easier in an epidemic, reducing human errors, morbidity, and mortality of the fulminant disease.
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Affiliation(s)
- Anshul Sharma
- Department of Otorhinolaryngology, Gandhi Medical College, Bhopal, MP India
- Department of Otorhinolaryngology, M.G.M Medical College, Indore, MP India
| | - Surbhi Godha
- Department of Otorhinolaryngology, M.G.M Medical College, Indore, MP India
| | - Jagram Verma
- Department of Otorhinolaryngology, M.G.M Medical College, Indore, MP India
| | - Lokesh Bhalot
- Department of Otorhinolaryngology, M.G.M Medical College, Indore, MP India
- Department of Otorhinolaryngology, Government Medical College, 289, Kasturba Nagar, Ratlam, MP India
| | - Yamini Gupta
- Department of Otorhinolaryngology, M.G.M Medical College, Indore, MP India
| | - R. K. Mundra
- Department of Otorhinolaryngology, M.G.M Medical College, Indore, MP India
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Dallalzadeh LO, Ediriwickrema LS, Fung SE, Men CJ, Kossler AL, Kupcha AC, Mawn LA, Burkat CN, van Landingham SW, Conger JR, Simmons B, Pham C, Akella SS, Setabutr P, Ho T, Couch SM, Kim JS, Demirci H, Korn BS, Kikkawa DO, Liu CY. Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study. Orbit 2024; 43:41-48. [PMID: 36880205 DOI: 10.1080/01676830.2023.2186435] [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: 10/14/2022] [Accepted: 02/25/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM). METHODS In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality. RESULTS Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality. CONCLUSIONS Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.
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Affiliation(s)
- Liane O Dallalzadeh
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
| | - Lilangi S Ediriwickrema
- Division of Ophthalmic Plastic and Reconstructive Surgery, Gavin Herbert Eye Institute, UC Irvine, Irvine, California, USA
| | - Sammie E Fung
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
| | - Clara J Men
- Division of Oculoplastic and Orbital Surgery, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Andrea L Kossler
- Division of Oculoplastic and Orbital Surgery, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Anna C Kupcha
- Division of Oculoplastics and Orbital Disease, Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee, USA
| | - Louise A Mawn
- Division of Oculoplastics and Orbital Disease, Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee, USA
| | - Cat N Burkat
- Oculoplastic, Orbital, & Cosmetic Facial Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Suzanne W van Landingham
- Oculoplastic, Orbital, & Cosmetic Facial Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Jordan R Conger
- Division of Ophthalmic Plastic and Reconstructive Surgery, Gavin Herbert Eye Institute, UC Irvine, Irvine, California, USA
| | - Brittany Simmons
- Division of Oculoplastic, Orbit, and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Chau Pham
- Division of Oculoplastic, Orbit, and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Sruti S Akella
- Oculoplastic and Reconstructive Surgery Service, Illinois Eye and Ear Infirmary, University of Illinois, Chicago, Illinois, USA
| | - Pete Setabutr
- Oculoplastic and Reconstructive Surgery Service, Illinois Eye and Ear Infirmary, University of Illinois, Chicago, Illinois, USA
| | - Tiffany Ho
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Steven M Couch
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jane S Kim
- Division of Eye Plastic, Orbital and Facial Cosmetic Surgery, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Hakan Demirci
- Division of Eye Plastic, Orbital and Facial Cosmetic Surgery, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Bobby S Korn
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, California, USA
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, California, USA
| | - Catherine Y Liu
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
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Kurysheva NI, Kapkova SG, Naumova VI, Smolev DM, Lishchuk SV, Nekrasova EY, Kim VE. [Late diagnosis of rhinocerebral mucormycosis in patients with COVID-19 (case studies)]. Vestn Oftalmol 2023; 139:110-121. [PMID: 38235637 DOI: 10.17116/oftalma2023139061110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
From the beginning of the COVID-19 pandemic, the incidence of secondary infections (both bacterial and fungal) has increased due to immune suppression associated with the use of corticosteroids or broad-spectrum antibiotics as a part of COVID-19 treatment protocol, which may exacerbate a pre-existing fungal disease or cause a new infection. Ophthalmologists are often involved in taking medical and surgical decisions in these complex cases. In this regard, a strong clinical suspicion should be applied to possible secondary fungal infections in COVID-19. Their early diagnosis and treatment may reduce mortality due to COVID-19 associated rhinocerebral mucormycosis (ROCM). This article describes two clinical cases of late detection of ROCM with two different scenarios, and compare the features of these cases with the literature data.
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Affiliation(s)
- N I Kurysheva
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
- Postgraduate Education Academy, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of Federal Medical Biological Agency, Moscow, Russia
| | - S G Kapkova
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
- Postgraduate Education Academy, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of Federal Medical Biological Agency, Moscow, Russia
| | - V I Naumova
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - D M Smolev
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - S V Lishchuk
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - E Yu Nekrasova
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - V E Kim
- State Research Center - Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
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Aggarwal A, Raj N, Bhardwaj K, Misra RN, Malik A, Bajaj S. A pictorial review of imaging manifestations of rhino-orbito-cerebral mucormycosis–emerging threat in COVID pandemic. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [PMCID: PMC8894831 DOI: 10.1186/s43055-022-00735-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Mucormycosis is an aggressive invasive fungal infection caused by mycocetes fungi. It is an opportunistic infection, associated with high morbidity and mortality. In the current era of COVID-19 pandemic, the entire world has witnessed a dramatic upsurge in cases of Mucormycosis. Paranasal sinuses are the commonest site to be affected with the tendency for rapid spread to orbit, face, and brain. Early diagnosis and prompt medical or surgical intervention are the only ways for preventing morbidity and saving precious lives. Imaging plays a crucial role not only in diagnosis but also in defining the extent of the disease for presurgical mapping. Black turbinate sign in the nasal cavity, mucosal thickening in paranasal sinuses with periantral invasion, and bony erosion are the early diagnostic signs. This pictorial review shall provide a comprehensive review of the various imaging manifestations of rhino-orbito-cerebral mucormycosis with a final proposed reporting checklist.
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Prasad S, Gaur A, Mehta A, Kaushal N. Rhino-orbital mucormycosis in a patient with no susceptibility following P.vivax malaria infection-a case report. BMC Ophthalmol 2022; 22:389. [PMID: 36183076 PMCID: PMC9525941 DOI: 10.1186/s12886-022-02611-8] [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: 01/09/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Mucormycosis is a potentially lethal, angioinvasive fungal infection caused by the Mucoracea family comprising Mucor, Rhizopus, and Absidia species. It is commonly associated with uncontrolled diabetes mellitus, the use of corticosteroids, immunosuppressive drugs, and Covid-19 infection. The occurrence of mucormycosis in an immunocompetent patient is rare. Also, only a few case reports have been published where patients developed mucormycosis with associated malarial infection. Case presentation A young female presented with a 3-weeks history of painful swelling and outward protrusion of the right eye with complete loss of vision. She had a history of P.vivax malaria two weeks before her ocular symptoms. On ocular examination, there was proptosis and total ophthalmoplegia with loss of corneal sensations in the right eye. Hematological examination revealed normocytic normochromic anemia and thrombocytopenia. MRI was suggestive of right-sided pansinusitis and orbital cellulitis with right superior ophthalmic vein thrombosis and bulky cavernous sinus. Nasal biopsy was negative for fungal culture. An emergency surgical debridement of all the sinuses was done with right orbital exenteration. Histopathology confirmed the diagnosis of mucormycosis and the patient improved post-operatively on systemic antifungals. Conclusion Such an association of mucormycosis with malaria infection is rarely reported in the literature and is hypothesized to be a result of immunosuppression caused by malaria. Also, emphasis is laid upon having a high index of suspicion for fungal infection in the setting of pansinusitis even if the risk factors are absent. We hereby report a case of rhino-orbital mucormycosis following P.vivax malaria in a 20-year-old female with anemia and thrombocytopenia.
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Affiliation(s)
- Sonali Prasad
- Department of Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, Near AIIMS, Ansari Nagar West, 110029, Delhi, India. .,, New Delhi, India.
| | - Aman Gaur
- Department of Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, Near AIIMS, Ansari Nagar West, 110029, Delhi, India
| | - Anuj Mehta
- Department of Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, Near AIIMS, Ansari Nagar West, 110029, Delhi, India
| | - Nimisha Kaushal
- Department of Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, Near AIIMS, Ansari Nagar West, 110029, Delhi, India
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Sharifi A, Akbari Z, Shafie’ei M, Nasiri N, Sharifi M, Shafiei M, Zand A. Retrobulbar Injection of Amphotericin B in Patients With COVID-19 Associated Orbital Mucormycosis: A Systematic Review. Ophthalmic Plast Reconstr Surg 2022; 38:425-432. [PMID: 35943425 PMCID: PMC9451608 DOI: 10.1097/iop.0000000000002256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Following COVID-19 infection a rising count of rhino-orbito-cerebral mucormycosis is observed, requiring orbital exenteration, a disabling lifetime affecting surgery. One of the potential interventions for globe salvage in these patients is retrobulbar injections of amphotericin B. This study was conducted to review protocols, outcomes, and side effects of retrobulbar injection of amphotericin B in patients with COVID-19 associated rhino-orbito-cerebral mucormycosis (CAM). METHODS The PubMed, Scopus, Web of Science, and Embase databases were searched using a comprehensive string of relevant keywords. All English studies with the confirmed diagnosis of CAM infection were included. We excluded all studies in which retrobulbar injection of amphotericin B was not implemented in any of the patients or there was a lack of clarified and detailed data about this procedure among participants. RESULTS A total of 647 cases had a history of retrobulbar injection(s) of amphotericin B in 13 reviewed studies with 3,132 subjects of CAM. The most common protocol was the retrobulbar injection of 1 ml of 3.5 mg/ml liposomal amphotericin B for 3 doses daily or on alternate days. We discerned that the globe salvage rate was 95.0% in eyes with a history of retrobulbar injection(s). The total rate of orbital exenteration was 14.9%, regardless of the history of retrobulbar injection of the drug. Other outcomes of this intervention were vision salvage and reduced major ophthalmic complaints, including pain, swelling, chemosis, ptosis, and ophthalmoplegia. The side effects of this intervention were not serious, and most of them were transient. They included swelling at the injection site, restriction of ocular motilities, exacerbation of orbital inflammation, and even intensification of visual impairment in a few cases. CONCLUSIONS Retrobulbar injection of amphotericin B should be considered a nearly safe and protective intervention against orbital exenteration in patients with CAM. It may also be effective in saving vision. Since the effectiveness of orbital exenteration in the survival of patients is not ascertained, retrobulbar injections can be considered an alternative intervention.
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Affiliation(s)
- Ali Sharifi
- Department of Ophthalmology, Shafa Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Akbari
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Shafie’ei
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Naser Nasiri
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Meraj Sharifi
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohadeseh Shafiei
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Amin Zand
- Department of Ophthalmology, Shafa Hospital, Kerman University of Medical Sciences, Kerman, Iran
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Ashraf DC, Idowu OO, Hirabayashi KE, Kalin-Hajdu E, Grob SR, Winn BJ, Vagefi MR, Kersten RC. Outcomes of a Modified Treatment Ladder Algorithm Using Retrobulbar Amphotericin B for Invasive Fungal Rhino-Orbital Sinusitis. Am J Ophthalmol 2022; 237:299-309. [PMID: 34116011 DOI: 10.1016/j.ajo.2021.05.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess whether a modified treatment ladder algorithm incorporating transcutaneous retrobulbar amphotericin B (TRAMB) for invasive fungal rhino-orbital sinusitis can reduce the risk of exenteration without compromising survival. DESIGN Retrospective, comparative clinical study with historical control subjects. METHODS Fifty consecutive patients with biopsy-proven invasive fungal sinusitis and radiographic evidence of orbital involvement were evaluated at a single tertiary institution from 1999-2020. TRAMB was incorporated as part of the treatment algorithm in 2015. Demographics, underlying immune derangement, infective organism, ophthalmic examination, surgical care, and survival were compared in a quasiexperimental pre-post format, dividing patients into a pre-2015 group and a post-2015 group. Risk of exenteration and mortality were the primary outcomes. RESULTS Baseline characteristics did not differ significantly between the 2 groups. Nearly all patients underwent a surgical intervention, most commonly functional endoscopic sinus surgery with debridement. TRAMB was administered to 72.7% of the post-2015 group. Exenteration was more common in the pre-2015 group (36.4% vs 9.1% [95% confidence interval {CI} 5.2-48.8]; P = .014), while mortality was similar (40.0% vs 36.7% [95% CI -22.1 to 29.3]; P = .816). After adjusting for potential confounders, patients treated after 2015 were found to have lower risk of exenteration (relative risk 0.28 [95% CI 0.08-0.99]; P = .049) and similar risk of mortality (relative risk 1.04 [95% CI 0.50-2.16]; P = .919). CONCLUSION Compared with historical control subjects, patients with invasive fungal rhino-orbital sinusitis who were treated with a modified treatment ladder algorithm incorporating TRAMB had a lower risk of disfiguring exenteration without an apparent increase in the risk of mortality.
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Affiliation(s)
- Davin C Ashraf
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Oluwatobi O Idowu
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Kristin E Hirabayashi
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Evan Kalin-Hajdu
- Department of Ophthalmology (E.K-H.), Université de Montréal, Montreal, Quebec, Canada
| | - Seanna R Grob
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Bryan J Winn
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - M Reza Vagefi
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Robert C Kersten
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA.
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Rudrabhatla PK, Reghukumar A, Thomas SV. Mucormycosis in COVID-19 patients: predisposing factors, prevention and management. Acta Neurol Belg 2022; 122:273-280. [PMID: 34820787 PMCID: PMC8612391 DOI: 10.1007/s13760-021-01840-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/05/2021] [Indexed: 12/15/2022]
Abstract
India is considered the diabetes capital of the world and has the highest burden of mucormycosis. Bacterial, viral and fungal co-infections are increasingly being reported in severe acute respiratory syndrome virus 2 (SARSCoV-2) infected patients. India is one of the worst affected countries during the second wave of the COVID-19 pandemic. This combination of diabetes mellitus, COVID-19 and mucormycosis has led to the drastic upsurge of COVID-19-associated mucormycosis (CAM) in India. Immunosuppression, iron disequilibrium, endothelial injury, ketoacidosis and hypoxia are some of the other COVID-19-related risk factors for CAM. There has been an increase in the proportion of mucormycosis affecting paranasal sinuses and central nervous system (CNS) in CAM compared to pre-COVID-19 literature due to the SARSCoV-2-related pathophysiological mechanisms, complications and treatment strategies. CAM is a medical and surgical emergency, and it can present with non-specific symptoms and signs initially resulting in diagnostic delay. High index of suspicion and regular screening for features of CAM are of paramount importance to prevent lethal consequences. Rapid action with a tripod approach consisting of withdrawal of immunomodulators, early antifungal therapy and extensive surgical debridement is considered the best possible treatment model. We review the published data to give a detailed account of the predisposing factors and their mechanisms, diagnostic work-up, treatment modalities and prevention strategies of CAM with special emphasis on CNS mucormycosis.
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Affiliation(s)
- Pavan Kumar Rudrabhatla
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Aravind Reghukumar
- Department of Infectious Diseases, Government Medical College, Thiruvananthapuram, India
| | - Sanjeev V. Thomas
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
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Pai V, Sansi R, Kharche R, Bandili SC, Pai B. Rhino-orbito-cerebral Mucormycosis: Pictorial Review. Insights Imaging 2021; 12:167. [PMID: 34767092 PMCID: PMC8587501 DOI: 10.1186/s13244-021-01109-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/10/2021] [Indexed: 01/09/2023] Open
Abstract
Mucormycosis (MCR) is a fulminant, potentially lethal, opportunistic fungal infection. Diabetes, immunocompromised states and elevated serum iron levels are the most important risk factors for contracting MCR infection. Recently, MCR co-infections have been observed in patients with COVID-19 disease owing to a complex interplay of metabolic factors and corticosteroid therapy. Rhino-orbito-cerebral mucormycosis (ROCM) is the most common clinical form of MCR infection and refers to infection of the nasal cavities, paranasal sinuses, neck spaces, orbits and intracranial structures. Sinonasal inoculation is typically the primary site of infection; the necrotising and angioinvasive properties of the fungus facilitate its spread into adjacent structures. In this review, we discuss the pertinent mycology and risk factors of MCR infection. The review also aims to acquaint the reader with the cross-sectional imaging appearances of ROCM and its complications. All the cases discussed in this pictorial essay are microbiologically and/or histopathologically proven cases of ROCM with concomitant COVID-19 infection.
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Affiliation(s)
- Vivek Pai
- Department of Radiology, SevenHills Hospital, Mumbai, India
| | - Rima Sansi
- Department of Radiology, SevenHills Hospital, Mumbai, India
| | - Ritesh Kharche
- Department of Histopathology, SevenHills Hospital, Mumbai, India
| | | | - Bhujang Pai
- Department of Radiology, SevenHills Hospital, Mumbai, India
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CT appearance of gastrointestinal tract mucormycosis. Abdom Radiol (NY) 2021; 46:1837-1845. [PMID: 33170347 DOI: 10.1007/s00261-020-02854-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 12/25/2022]
Abstract
Mucormycosis is a fungal infection caused by fungi of order mucorales. It is most commonly seen in patients with an impaired immune system due to any cause. Gastrointestinal mucormycosis is the least frequent type and may be a primary disease or a feature of generalized mucormycosis. Angioinvasion is the hallmark feature of mucormycosis, leading to bowel infarction which is the responsible for the most common clinical complaint of pain, and is also responsible for most of the imaging findings in this disease. The stomach is most commonly involved organ in the gastrointestinal tract and pneumatosis and lack of gastric wall enhancement are the most common imaging findings. Areas of bowel wall thickening and/ or lack of enhancement are seen in small bowel mucor and perforation can occur due to ischemia. Colonic mucor can present with mural thickening, or complete lack of definition or 'disappearance' of bowel wall with associated air containing collections. Mucormycosis affecting the bowel has a high mortality rate and early recognition and intervention may improve patient outcomes significantly. It should be suspected in immunosuppressed patients with imaging findings of unexplained bowel ischemia, infarction and/or pneumatosis without any obvious visible vascular thrombus.
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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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Ruhnke M, Behre G, Buchheidt D, Christopeit M, Hamprecht A, Heinz W, Heussel CP, Horger M, Kurzai O, Karthaus M, Löffler J, Maschmeyer G, Penack O, Rieger C, Rickerts V, Ritter J, Schmidt-Hieber M, Schuelper N, Schwartz S, Ullmann A, Vehreschild JJ, von Lilienfeld-Toal M, Weber T, Wolf HH. Diagnosis of invasive fungal diseases in haematology and oncology: 2018 update of the recommendations of the infectious diseases working party of the German society for hematology and medical oncology (AGIHO). Mycoses 2018; 61:796-813. [PMID: 30098069 DOI: 10.1111/myc.12838] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/05/2018] [Indexed: 01/05/2023]
Abstract
Invasive fungal diseases (IFD) are a primary cause of morbidity and mortality in patients with haematological malignancies. These infections are mostly life-threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly, Aspergillus and Candida species are involved. However, other Non-Aspergillus moulds are increasingly identified in case of documented IFD. For definite diagnosis of IFD, a combination of diagnostic tools have to be applied, including conventional mycological culture and non-conventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. Although varying widely in cancer patients, the risk of invasive fungal infection is highest in those with allogeneic stem cell transplantation and those with acute leukaemia and markedly lower in patients with solid cancer. Since the last edition of Diagnosis of Invasive Fungal Diseases recommendations of the German Society for Hematology and Oncology in 2012, integrated care pathways have been proposed for the management and therapy of IFDs with either a diagnostic driven strategy as opposed to a clinical or empirical driven strategy. This update discusses the impact of this additional evidence and effective revisions.
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Affiliation(s)
- Markus Ruhnke
- Department of Haematology & Oncology, Paracelsus-Klinik, Osnabrück, Germany
| | - Gerhard Behre
- Department of Haematology & Oncology, Universitätsklinik Leipzig, Leipzig, Germany
| | - Dieter Buchheidt
- Department of Internal Medicine III, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Maximilian Christopeit
- Department for Stem Cell Transplantation, University Medical Center Eppendorf, Hamburg, Germany
| | - Axel Hamprecht
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany
| | - Werner Heinz
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Claus-Peter Heussel
- Department of Interventional & Diagnostic Radiology, Thorax Centre, University Hospital of Heidelberg, Heidelberg, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Oliver Kurzai
- National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knoell-Institute, Jena and Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Meinolf Karthaus
- Deparment of Haematology & Oncology, Municipal Hospital Neuperlach, Munich, Germany
| | - Jürgen Löffler
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Municipal Hospital, Potsdam, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | | | - Volker Rickerts
- Konsiliarlabor Für Kryptokokkose und Seltene Systemmykosen, Robert-Koch-Institut Berlin, Berlin, Germany
| | - Jörg Ritter
- Division of Haematology & Oncology, Department of Paediatrics, University Hospital of Münster, Münster, Germany
| | - Martin Schmidt-Hieber
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | - Nikolai Schuelper
- Department of Haematology and Medical Oncology, Göttingen University Medical Centre, Göttingen, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | - Andrew Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Jörg Janne Vehreschild
- Department of Internal Medicine I, German Centre for Infection Research, partner-site Bonn-Cologne, University Hospital of Cologne, Cologne, Germany
| | - Marie von Lilienfeld-Toal
- Department of Internal Medicine II, National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knoell-Institute, Universitätsklinik Jena, Jena, Germany
| | - Thomas Weber
- Department of Internal Medicine IV, Universitätsklinik Halle, Halle, Germany
| | - Hans H Wolf
- Department of Internal Medicine IV, Universitätsklinik Halle, Halle, Germany
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Choi YR, Kim JH, Min HS, Won JK, Kim HJ, Yoo RE, Kang KM, Park SW, Yun TJ, Choi SH, Sohn CH, Rhim JH, Kim SC, Ryu JW, Na DG. Acute invasive fungal rhinosinusitis: MR imaging features and their impact on prognosis. Neuroradiology 2018; 60:715-723. [DOI: 10.1007/s00234-018-2034-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/04/2018] [Indexed: 12/29/2022]
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Diagnosing filamentous fungal infections in immunocompromised patients applying computed tomography-guided percutaneous lung biopsies: a 12-year experience. Infection 2017; 45:867-875. [PMID: 28956284 PMCID: PMC5696440 DOI: 10.1007/s15010-017-1072-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 09/16/2017] [Indexed: 12/30/2022]
Abstract
Background Invasive fungal diseases (IFD) are an important cause of morbidity and mortality in immunocompromised patients, and early diagnosis and management are a challenge. We evaluated the clinical utility of computed tomography (CT)-guided percutaneous lung biopsies in diagnosing IFD. Methods Between 2003 and 2014, we analyzed 2671 CT-guided lung biopsies, from which 157 were IFD associated; we aimed to determine microbiological-based diagnostic accuracy of calcofluor white staining (CFWS), culture, Aspergillus antigen detection (GM), broad-range fungal PCR, and Aspergillus PCR per sample. Results 127 (81%) specimens were microscopically positive for any fungal elements, 30 (19%) negative. Aspergillus and non-Aspergillus like hyphae were obtained in 85 (67%) and 42 (33%) specimens, respectively. CFWS positivity was defined as proof of infection. Sensitivity, specificity, and positive (PPV) and negative predictive (NPV) values for CT scan were 100, 44, 80, and 100%, for Aspergillus PCR 89, 58, 88, and 58%, for broad-range fungal PCR 90, 83, 95, and 90%, and for GM 94, 83, 95, and 90%. The most common CT features were patchy opacifications with central necrosis (78%) or cavern defects (50%), less common were air bronchograms (39%) or ground glass halos (39%), and all other features were rare. The overall pneumothorax rate subsequent to biopsy was 19%, but in only 2% of all cases the placement of a chest tube was indicated. One case of fatal air embolism occurred. Conclusions CT-guided lung biopsies have high diagnostic accuracy in terms of microscopic examination, and complication rates are low. Molecular-based and antigen tests applied on fungal hyphae-positive specimens showed comparable results.
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Abstract
PURPOSE OF REVIEW To summarize diagnostic techniques for invasive fungal rhinosinusitis and provide a review of treatment options once disease has spread to the orbit. RECENT FINDINGS Improved imaging criteria, polymerase chain reaction and other serologic tests show promise in advancing our ability to accurately diagnose invasive fungal disease. Currently, there exists three treatment options for infected orbital tissue: exenteration, conservative debridement and transcutaneous retrobulbar injection of amphotericin B. Exenteration, the most frequently reported intervention, has not been proven to enhance survival. Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are increasingly considered reasonable first-line options. SUMMARY Although investigative tools are improving, invasive fungal rhinosinusitis can still pose a diagnostic challenge. No one treatment option for the orbit has been proven superior to another. Therefore, it is justified to initiate therapy by prioritizing less morbid procedures. If deterioration is continually noted, more invasive interventions can then be employed. The treatment algorithm established at our institution is provided.
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Patil A, Mohanty HS, Kumar S, Nandikoor S, Meganathan P. Angioinvasive rhinocerebral mucormycosis with complete unilateral thrombosis of internal carotid artery-case report and review of literature. BJR Case Rep 2016; 2:20150448. [PMID: 30363635 PMCID: PMC6180875 DOI: 10.1259/bjrcr.20150448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/23/2015] [Accepted: 01/04/2016] [Indexed: 01/17/2023] Open
Abstract
Angioinvasive rhinocerebral mucormycosis is an acute fulminant infection caused by fungi of the order Mucorales that targets uncontrolled diabetics and other immunosupressed individuals. Early imaging features of angioinvasiveness include the presence of thrombosed vessels, especially in the orbital regions and the “black turbinate” sign representing devitalized paranasal sinus mucosa. Intracranial extension carries a grave prognosis, with death reported in 90% of cases. This case report highlights the early and key imaging features of angioinvasive rhinocerebral mucormycosis and a rare complication of complete internal carotid artery thrombosis.
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Affiliation(s)
- Aruna Patil
- Department of Radiology, Apollo Hospitals, Bangalore, India
| | | | - Sharath Kumar
- Department of Radiology, Apollo Hospitals, Bangalore, India
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Choo JY, Park CM, Lee HJ, Lee CH, Goo JM, Im JG. Sequential morphological changes in follow-up CT of pulmonary mucormycosis. Diagn Interv Radiol 2015; 20:42-6. [PMID: 24047721 DOI: 10.5152/dir.2013.13183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE We aimed to describe the computed tomography (CT) features of pulmonary mucormycosis including sequential changes between follow-ups. MATERIALS AND METHODS Between June 2001 and May 2011, five patients (three males and two females; median age, 43 years; age range, 13-73 years) who had been pathologically diagnosed with pulmonary mucormycosis constituted our study population. Their clinical and CT features including sequential changes over follow-ups were evaluated retrospectively. RESULTS All patients were immunocompromised due to either hematologic diseases (n=3), diabetes mellitus (n=1), or steroid administration for autoimmune hepatitis (n=1). All patients had symptoms such as fever (n=5), tachycardia (n=1), or pleuritic chest pain (n=1) on admission. Regarding the clinical outcome after treatment, one patient died, and the remaining four recovered from the disease. In terms of initial CT features, the morphologies of pulmonary mucormycosis included a single mass (n=3), consolidation (n=1), or multiple masses (n=1). There were seven pulmonary lesions in total, 3-7 cm in size, which showed a CT halo sign (n=3), reversed-halo sign (n=2), or air-fluid levels (n=2). On follow-up CTs, the lesions of all patients contained necrosis. All three patients with a mass or masses with a CT halo sign on initial CT had a decreased surrounding halo followed by central necrosis, and the lesions gradually decreased in size on recovery. CONCLUSION Pulmonary mucormycosis usually manifests as a mass or masses with a halo or reversed-halo sign on the initial CT scan followed by a decreased extent of surrounding ground-glass opacities with the development of internal necrosis during follow-up.
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Affiliation(s)
- Ji Yung Choo
- From the Department of Radiology (J.Y.C., C.M.P. e-mail: , H.J.L., C.H.L., J.M.G. J.G.I.) Seoul National University College of Medicine, and Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea; the Department of Radiology (J.Y.C.), Korea University Ansan Hospital, Ansan, Korea
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Forrester JD, Chandra V, Shelton AA, Weiser TG. Gastrointestinal mucormycosis requiring surgery in adults with hematologic malignant tumors: literature review. Surg Infect (Larchmt) 2014; 16:194-202. [PMID: 25405775 DOI: 10.1089/sur.2013.232] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Gastrointestinal mucormycosis is associated with high mortality rates. Appropriate and early antifungal therapy and prompt surgical intervention are essential. METHOD Case report and literature review. RESULTS Nineteen case reports were reviewed describing adults with hematologic malignant tumors who developed intestinal mucormycosis and underwent surgery. The overall survival rate was 50%. CONCLUSION Intestinal mucormycosis is an infection associated with a high mortality rate although adults with underlying hematologic malignant have improved outcomes compared with other groups.
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Starkey J, Moritani T, Kirby P. MRI of CNS Fungal Infections: Review of Aspergillosis to Histoplasmosis and Everything in Between. Clin Neuroradiol 2014; 24:217-30. [DOI: 10.1007/s00062-014-0305-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 03/26/2014] [Indexed: 11/28/2022]
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Grant P, Skilbeck CJ. Rhinocerebral mucormycosis: a devastating rhinological condition. PRACTICAL DIABETES 2014. [DOI: 10.1002/pdi.1826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Invasive fungal infections (IFI) have become a leading cause of morbidity and mortality in cancer patients. Infections with these organisms are often difficult to diagnose and treat. Appropriate and timely diagnosis requires a high index of suspicion and invasive procedures, including biopsy, to confirm the diagnosis. Treatment may be difficult, secondary to variable susceptibility and difficulty with exact and specific characterization of the fungal pathogen. The pathogens that are seen range from yeasts to invasive molds. Fortunately newer, noninvasive diagnostic techniques are available to aid in the diagnosis and treatments have become better tolerated and more efficacious.
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Affiliation(s)
- Michael Angarone
- Division of Infectious Disease, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave, Suite 900, Chicago, IL, 60611, USA,
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Mucormycosis in a Patient with Acute Myeloid Leukemia Successfully Treated with Liposomal Amphotericin B Associated with Deferasirox and Hyperbaric Oxygen. Mycopathologia 2013; 175:295-300. [DOI: 10.1007/s11046-013-9629-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 02/18/2013] [Indexed: 10/27/2022]
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Cervicofacial tissue infarction in patients with acute invasive fungal sinusitis: prevalence and characteristic MR imaging findings. Neuroradiology 2013; 55:467-73. [PMID: 23377235 DOI: 10.1007/s00234-013-1147-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 01/22/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Tissue infarction is known as one of the characteristic features of invasive fungal sinusitis (IFS). The purpose of this study was to investigate the prevalence and characteristic MR imaging findings of cervicofacial tissue infarction (CFTI) associated with acute IFS. METHODS We retrospectively reviewed MR images in 23 patients with histologically or microbiologically proven acute IFS. CFTI was defined as an area of lack of enhancement in and around the sinonasal tract on contrast-enhanced T1-weighted images. We divided CFTI into two groups, i.e., intrasinonasal and extrasinonasal. Particular attention was paid to the location of extrasinonasal CFTI and the signal intensity of CFTI on T1- and T2-weighted images. The presence of bone destruction on CT scans was also recorded. RESULTS CFTI was found in 17 (74%) of 23 patients. All of these 17 patients had intrasinonasal CFTI, and 13 patients also had extrasinonasal CFTI. All 13 patients with extrasinonasal CFTI died of disease directly related to IFS. Various locations were involved in the 13 patients with extrasinonasal CFTI, including the orbit (n = 8), infratemporal fossa (n = 7), intracranial cavity (n = 3), and oral cavity and/or facial soft tissue (n = 4). Various signal intensities were noted at the area of CFTI on T1- and T2-weighted images. Bone destruction was found on CT scans in only 3 of 17 patients with CFTI. CONCLUSION CFTI with preservation of the bony wall of the involved sinonasal tract may be a characteristic MR imaging finding of acute IFS. The mortality is very high once the lesion extends beyond the sinonasal tract.
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Husain N, Kumar P. Pathology of tropical diseases. Neuroimaging Clin N Am 2011; 21:757-75, vii. [PMID: 22032498 DOI: 10.1016/j.nic.2011.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Tropical diseases affecting the central nervous system include infections, infestations, and nutritional deficiency disorders. This article discusses the commonly encountered diseases. The infections include bacterial, mycobacterial, fungal, parasitic, and viral infections with varied clinical manifestations. Imaging sensitivity and specificity for the prediction of the cause of infections has improved with application of advanced techniques. Microbial demonstration and histology remain the gold standard for diagnosis. Understanding the basis of imaging changes is mandatory for better evaluation of images. Nutritional disorders present with generalized and nonspecific imaging manifestations. The pathology of commonly encountered vitamin deficiencies is also discussed.
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Affiliation(s)
- Nuzhat Husain
- Department of Pathology, Dr Ram Manohar Lohia Institute of Medical Sciences, Gomti Nagar, Lucknow, Uttar Pradesh, India.
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De Yao JT, Al-Ameri A, Garcia-Manero G, Quintás-Cardama A. Infrequent presentations of mucormycosis in patients with myelodysplastic syndrome and acute leukemia: case series and review of literature. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2011; 11:446-51. [PMID: 21820986 DOI: 10.1016/j.clml.2011.05.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 05/19/2011] [Accepted: 05/31/2011] [Indexed: 02/03/2023]
Affiliation(s)
- Jocelyn T De Yao
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
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Ruhnke M, Böhme A, Buchheidt D, Cornely O, Donhuijsen K, Einsele H, Enzensberger R, Hebart H, Heussel CP, Horger M, Hof H, Karthaus M, Krüger W, Maschmeyer G, Penack O, Ritter J, Schwartz S. Diagnosis of invasive fungal infections in hematology and oncology--guidelines from the Infectious Diseases Working Party in Haematology and Oncology of the German Society for Haematology and Oncology (AGIHO). Ann Oncol 2011; 23:823-33. [PMID: 21948809 DOI: 10.1093/annonc/mdr407] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Invasive fungal infections (IFIs) are a primary cause of morbidity and mortality in patients with hematological malignancies. Establishing a definite diagnosis of IFI in immunocompromised patients is particularly challenging and time consuming, but delayed initiation of antifungal treatment increases mortality. The limited overall outcome has led to the strategy of initiating either 'empirical' or 'preemptive' antifungal therapy before the final diagnosis. However, diagnostic procedures have been vastly improved in recent years. Particularly noteworthy is the introduction of newer imaging techniques and non-culture methods, including antigen-based assays, metabolite detection and molecular detection of fungal DNA from body fluid samples. Though varying widely in cancer patients, the risk of IFI is highest in those with allogeneic stem cell transplantation and those with acute leukemia. The AGIHO presents recommendations for the diagnosis of IFIs with risk-adapted screening concepts for febrile episodes in patients with haemato-oncological disorders.
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Affiliation(s)
- M Ruhnke
- Department of Internal Medicine, Charité University Medicine, Campus Charité Mitte, Berlin, Germany.
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Kim HJ, Rha SE, Kang WK. A patient with neutropenic fever and abdominal pain showing absent bowel wall on CT. Br J Radiol 2011; 84:478-80. [PMID: 21511752 DOI: 10.1259/bjr/13586512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- H J Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic, University of Korea, 505, Banpo-dong, Seocho-gu Seoul, South Korea
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Abstract
We report three cases of ileocolic mucormycosis in adult immunocompromised patients presenting as acute abdomen. All patients underwent laparotomy but two of them died from multiorgan failure before the diagnoses were confirmed. The diagnosis of gastrointestinal mucormycosis is rarely suspected, and antemortem diagnosis is made in only 25%-50% of cases. These cases illustrate the difficulty encountered by surgeons in managing acute abdomen in neutropenic patients with hematological malignancy. The management of colonic mucormycosis in the published literature is also reviewed.
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Safder S, Carpenter JS, Roberts TD, Bailey N. The "Black Turbinate" sign: An early MR imaging finding of nasal mucormycosis. AJNR Am J Neuroradiol 2009; 31:771-4. [PMID: 19942703 DOI: 10.3174/ajnr.a1808] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Rhinocerebral mucormycosis is a rare angioinvasive fungal infection that has a strong predilection for patients with poorly controlled diabetes and immunosuppression. Initial presenting symptoms are nonspecific and frequently are attributed to more mundane sinonasal and orbital pathologies. Early diagnosis and treatment are essential for survival and minimizing neurologic sequelae. CT and MR imaging are often used in the diagnostic work-up; however, CT findings are nonspecific.
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Affiliation(s)
- S Safder
- Department of Radiology, West Virginia University Hospital, Morgantown, USA.
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Skiada A, Vrana L, Polychronopoulou H, Prodromou P, Chantzis A, Tofas P, Daikos G. Disseminated zygomycosis with involvement of the central nervous system. Clin Microbiol Infect 2009; 15 Suppl 5:46-9. [DOI: 10.1111/j.1469-0691.2009.02980.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Kasai M, Harrington SM, Francesconi A, Petraitis V, Petraitiene R, Beveridge MG, Knudsen T, Milanovich J, Cotton MP, Hughes J, Schaufele RL, Sein T, Bacher J, Murray PR, Kontoyiannis DP, Walsh TJ. Detection of a molecular biomarker for zygomycetes by quantitative PCR assays of plasma, bronchoalveolar lavage, and lung tissue in a rabbit model of experimental pulmonary zygomycosis. J Clin Microbiol 2008; 46:3690-702. [PMID: 18845827 PMCID: PMC2576616 DOI: 10.1128/jcm.00917-08] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 06/29/2008] [Accepted: 09/02/2008] [Indexed: 01/01/2023] Open
Abstract
We developed two real-time quantitative PCR (qPCR) assays, targeting the 28S rRNA gene, for the diagnosis of zygomycosis caused by the most common, clinically significant Zygomycetes. The amplicons of the first qPCR assay (qPCR-1) from Rhizopus, Mucor, and Rhizomucor species were distinguished through melt curve analysis. The second qPCR assay (qPCR-2) detected Cunninghamella species using a different primer/probe set. For both assays, the analytic sensitivity for the detection of hyphal elements from germinating sporangiospores in bronchoalveolar lavage (BAL) fluid and lung tissue homogenates from rabbits was 1 to 10 sporangiospores/ml. Four unique and clinically applicable models of invasive pulmonary zygomycosis served as surrogates of human infections, facilitating the validation of these assays for potential diagnostic utility. For qPCR-1, 5 of 98 infarcted lung specimens were positive by qPCR and negative by quantitative culture (qCx). None were qCx positive only. Among 23 BAL fluid samples, all were positive by qPCR, while 22 were positive by qCx. qPCR-1 detected Rhizopus and Mucor DNA in 20 (39%) of 51 serial plasma samples as early as day 1 postinoculation. Similar properties were observed for qPCR-2, which showed greater sensitivity than qCx for BAL fluid (100% versus 67%; P = 0.04; n = 15). The assay detected Cunninghamella DNA in 18 (58%) of 31 serial plasma samples as early as day 1 postinoculation. These qPCR assays are sensitive and specific for the detection of Rhizopus, Mucor, Rhizomucor, and Cunninghamella species and can be used for the study and detection of infections caused by these life-threatening pathogens.
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Affiliation(s)
- Miki Kasai
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Building 10-CRC, Room 1-5740, Bethesda, MD 20892, USA
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Stelzmueller I, Lass-Floerl C, Geltner C, Graziadei I, Schneeberger S, Antretter H, Mueller L, Zelger B, Singh N, Pruett TL, Margreiter R, Bonatti H. Zygomycosis and other rare filamentous fungal infections in solid organ transplant recipients. Transpl Int 2008; 21:534-46. [DOI: 10.1111/j.1432-2277.2008.00657.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Automated and manual methods of DNA extraction for Aspergillus fumigatus and Rhizopus oryzae analyzed by quantitative real-time PCR. J Clin Microbiol 2008; 46:1978-84. [PMID: 18353931 DOI: 10.1128/jcm.02246-07] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Quantitative real-time PCR (qPCR) may improve the detection of fungal pathogens. Extraction of DNA from fungal pathogens is fundamental to optimization of qPCR; however, the loss of fungal DNA during the extraction process is a major limitation to molecular diagnostic tools for pathogenic fungi. We therefore studied representative automated and manual extraction methods for Aspergillus fumigatus and Rhizopus oryzae. Both were analyzed by qPCR for their ability to extract DNA from propagules and germinated hyphal elements (GHE). The limit of detection of A. fumigatus and R. oryzae GHE in bronchoalveolar lavage (BAL) fluid with either extraction method was 1 GHE/ml. Both methods efficiently extracted DNA from A. fumigatus, with a limit of detection of 1 x 10(2) conidia. Extraction of R. oryzae by the manual method resulted in a limit of detection of 1 x 10(3) sporangiospores. However, extraction with the automated method resulted in a limit of detection of 1 x 10(1) sporangiospores. The amount of time to process 24 samples by the automated method was 2.5 h prior to transferring for automation, 1.3 h of automation, and 10 min postautomation, resulting in a total time of 4 h. The total time required for the manual method was 5.25 h. The automated and manual methods were similar in sensitivity for DNA extraction from A. fumigatus conidia and GHE. For R. oryzae, the automated method was more sensitive for DNA extraction of sporangiospores, while the manual method was more sensitive for GHE in BAL fluid.
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