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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: 1] [Impact Index Per Article: 1.0] [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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Zhou Y. Survival of a Rhino-Orbital-Cerebral Mucormycosis Patient after Localized Combination Liposomal Amphotericin B Medications: A Case Report. Case Rep Ophthalmol 2024; 15:122-128. [PMID: 38322311 PMCID: PMC10846874 DOI: 10.1159/000536185] [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: 07/13/2023] [Accepted: 01/05/2024] [Indexed: 02/08/2024] Open
Abstract
Introduction The aim of this study was to report a case of ROCM related to nasogastric intubation who was survived by liposomal amphotericin B (LAmB) combination therapy in situ without orbital exenteration. Case Presentation A 44-year-old woman presented with a 1-week history of rapidly enlarging swelling on the right nose, cheek, and lower eyelid after underwent gastrointestinal decompression. The lesions were derived from the nasal area where the nasogastric tube had been placed. Based on the biopsy results and clinical manifestations, ROCM was diagnosed. Immediate combination therapy with intravenous LAmB and micafungin and multisection debridement of the right facial region were applied. Postoperative treatment included cleaning, irrigating, and local dressing of the wound area using LAmB. LAmB was also used daily as binocular eye drops against deep infection on the eyeballs. The patient recovered well 4 months later and remained free of disease after 40 months of follow-up. Conclusion This case adds to our knowledge on the potential risk of nasogastric intubation for mucormycosis infection. Nasogastric tube may be the source of infection associated with ROCM. This report evaluates the beneficial effect of LAmB combination therapy in situ for cleaning, irrigating, local wound dressing, and eye drops on lesion areas. The combination of LAmB as cleaning, irrigating, local dressing solution, and eye drops to control intraocular and intraorbital ROCM infection has not been previously reported to our knowledge. These methods provide multiple choices to substitute for orbital exenteration on the survival of ROCM patients.
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Affiliation(s)
- Yang Zhou
- Department of Ophthalmology, Qingdao Qingda Zhengda Guangming Eye Hospital, Zhengda Guangming Eye Group, Qingdao, China
- Zhengda Guangming International Eye Research Center, Qingdao University, Qingdao, China
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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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Redzuwan NS, Barr Kumarakulasinghe AL, W Md Kasim WM, Mohd Khialdin S. COVID-19-Related Rhino-Orbital-Cerebral Mucormycosis With Angioinvasion: A Lethal Sequelae. Cureus 2023; 15:e40483. [PMID: 37461781 PMCID: PMC10349690 DOI: 10.7759/cureus.40483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
A middle-aged man with multiple comorbidities including uncontrolled diabetes mellitus presented with shortness of breath and lethargy for six days. He was treated for COVID-19 pneumonia, requiring high cumulative steroid therapy. After 15 days of treatment, he developed right orbital apex syndrome with central retinal artery occlusion secondary to invasive mucormycosis. The infection progressed rapidly despite aggressive medical treatment, systemic anti-fungal therapy along with local transcutaneous retrobulbar amphotericin B injection. We report our battle in fighting this vicious disease. Judicious use of immunomodulators in COVID-19 treatment and close monitoring is crucial, especially in high-risk patients.
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Affiliation(s)
- Nur Syazwani Redzuwan
- Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
- Ophthalmology, Hospital Tengku Ampuan Rahimah, Klang, MYS
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5
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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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Saluja G, Bhari A, Pushker N, Agrawal S, Meel R, Thakar A, Xess I, Khandelwal A, Narwal A, Bajaj MS. Experience on rhino-orbital mucormycosis from a tertiary care hospital in the first wave of COVID-19: An Indian perspective. Med J Armed Forces India 2022; 79:S0377-1237(22)00009-0. [PMID: 35400798 PMCID: PMC8975717 DOI: 10.1016/j.mjafi.2022.01.009] [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: 12/05/2021] [Accepted: 01/18/2022] [Indexed: 12/27/2022] Open
Abstract
Background To highlight the clinical presentations and management outcomes of rhino-orbital mucormycosis during first wave of COVID-19 pandemic in North India. Methods A retrospective observational study. 15 patients with mucormycosis (orbital disease) who presented during short span of 3 months (October-December 2020) in a tertiary-care referral institution were analysed. Results At presentation, 13 of 15 patients had uncontrolled diabetes. Four had history of COVID-19 infection. All patients had advanced orbital disease with sinusitis; cavernous sinus involvement was in nine and intracranial spread in three patients. Liposomal amphotericin-B was started and prompt orbital exenteration with sinus surgery was performed in 12 patients. All 12 patients survived with an average follow-up of 4.8 months. Conclusion In the present series, cases with orbital spread of mucormycosis were mostly found in non-COVID uncontrolled diabetics. Exenteration was done in 80% of cases with advanced orbital disease. Prevention and early detection of infection at the stage of sino-nasal involvement might help to prevent spread and/or halt the orbital disease.
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Affiliation(s)
- Gunjan Saluja
- Senior Resident, Oculoplastics, Tumor & Pediatric Ophthalmology Services, Dr R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Anju Bhari
- Senior Resident, Oculoplastics, Tumor & Pediatric Ophthalmology Services, Dr R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Neelam Pushker
- Professor, Oculoplastics, Tumor & Pediatric Ophthalmology Services, Dr R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Sahil Agrawal
- Senior Research Officer, Oculoplastics, Tumor & Pediatric Ophthalmology Services, Dr R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Rachna Meel
- Professor, Oculoplastics, Tumor & Pediatric Ophthalmology Services, Dr R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Alok Thakar
- Professor (Otolaryngology), AIIMS, New Delhi, India
| | | | | | | | - Mandeep S. Bajaj
- Professor, Oculoplastics, Tumor & Pediatric Ophthalmology Services, Dr R. P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
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Chiou CA, Yoon MK. An Update on Fungal Orbital Infections. Int Ophthalmol Clin 2022; 62:55-69. [PMID: 35325910 DOI: 10.1097/iio.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Murthy R, Bagchi A, Gote Y, Desai S. Retrobulbar injection of amphotericin B using intravenous cannula for post-COVID-19 rhino-orbital mucormycosis. Indian J Ophthalmol 2021; 70:302-305. [PMID: 34937263 PMCID: PMC8917598 DOI: 10.4103/ijo.ijo_1511_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Rhino-orbital mucormycosis has seen a huge resurgence in patients post COVID-19 infection. In patients with minimal orbital disease and especially with preserved vision, retrobulbar injections of amphotericin B can be of great help in controlling the disease. Instead of giving daily injections of amphotericin B using needles every time, we used an 18-gauge intravenous (IV) cannula with injection port and suture holes to deliver the amphotericin into the orbital space for a period of 5 days. Patients were more compliant and less distressed with this method compared with being given an injection with a needle daily. We got a good response in terms of orbital disease regression with this method. In our review of the literature, we did not come across any such case of amphotericin B injection using an IV cannula. Injection of amphotericin B into the orbit using an IV cannula is a viable and easy treatment option for cases of rhino-orbital mucormycosis.
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Affiliation(s)
- Ramesh Murthy
- Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Aadhyaa Bagchi
- Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Yogita Gote
- Department of Ophthalmology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Sanjay Desai
- Department of Radiology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
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9
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Nair AG, Dave TV. Transcutaneous retrobulbar injection of amphotericin B in rhino-orbital-cerebral mucormycosis: a review. Orbit 2021; 41:275-286. [PMID: 34720026 DOI: 10.1080/01676830.2021.1990351] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Mucormycosis is an aggressive and potentially fatal invasive fungal infection. The most common form of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). While it is commonly seen in immunocompromised patients, it is also known to affect healthy individuals. The global disease burden of ROCM has increased significantly following the surge in cases during the COVID-19 pandemic. Endoscopic sinus debridement, systemic antifungal therapy, and control of the underlying immunosuppressive condition are essential for the management of ROCM. Orbital involvement, however, presents a challenge to clinicians. Intervention strategies that have been described to treat orbital disease include orbital exenteration, conservative orbital debridement with or without irrigation with amphotericin B and transcutaneous retrobulbar injection of amphotericin B (TRAMB). Currently, there is a lack of clarity regarding the indications and outcomes of TRAMB as a treatment modality. In this review, the drug formulations used, the complications, and outcomes of previously described cases that have used TRAMB in cases of ROCM are discussed. Favorable outcomes following TRAMB depend on appropriate patient selection and radiological evidence of the orbital burden of the disease. This review aims to familiarize clinicians with objective parameters for patient selection for TRAMB, namely the extent of the disease, the clinical features, and radiological findings; viz. the clinical interpretation of areas of contrast uptake and those of necrosis. TRAMB can be considered as a viable option in select cases of orbital mucormycosis where exenteration or debridement are not indicated, or when there is limited orbital disease.
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Affiliation(s)
- Akshay Gopinathan Nair
- Ophthalmic Plastic Surgery and Ocular Oncology Services, Aditya Jyot Eye Hospital, Mumbai, India.,Advanced Eye Hospital & Institute, Navi Mumbai, India.,Department of Ophthalmology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.,Ophthalmic Plastic Surgery and Ocular Oncology Services, R. Jhunjhunwala Sankara Eye Hospital, Panvel, India
| | - Tarjani Vivek Dave
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, India
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10
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Use of topical amphotericin in a case of refractory sino-orbital angioinvasive mucormycosis. Med Mycol Case Rep 2021; 33:21-25. [PMID: 34295641 PMCID: PMC8282967 DOI: 10.1016/j.mmcr.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 12/29/2022] Open
Abstract
The standard of care for treatment of sino-orbital mucormycosis involves aggressive surgical debridement and liposomal amphotericin, and the roles of adjunctive and topical therapies are less clear. Here we describe a case of severe refractory sino-orbital mucormycosis in an immunocompetent patient who responded to combination therapy with liposomal amphotericin, isavuconazole, micafungin, and topical amphotericin deoxycholate after failing to achieve negative surgical margins.
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Invasive Fungal Sinusitis: Risk Factors for Visual Acuity Outcomes and Mortality. Ophthalmic Plast Reconstr Surg 2019; 35:535-542. [DOI: 10.1097/iop.0000000000001357] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Vaughan C, Bartolo A, Vallabh N, Leong SC. A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis-has anything changed in the past 20 years? Clin Otolaryngol 2018; 43:1454-1464. [PMID: 29947167 DOI: 10.1111/coa.13175] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 06/22/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Rhino-orbital-cerebral mucormycosis (ROCM) is an uncommon yet potentially lethal fungal infection. Although most cases originate from developing countries, an ageing population and increased prevalence of chronic illness may mean some clinicians practicing in developed countries will encounter ROCM cases in their careers. Yohai et al published a systematic review of 145 case reports from 1970 to 1993 assessing prognostic factors for patients presenting with ROCM. We present an updated review of the literature and assess whether survival outcomes have changed in the two decades since that seminal paper. SEARCH STRATEGY An extensive Medline literature search was performed for case reports published between 1994 and 2015. RESULTS In total, 210 published cases were identified from the literature review, of which 175 patients from 140 papers were included in this review. Fifty-five were female, with an overall mean age of 43 years. Overall survival rate was 59.5%, which was not significantly better than the previous series reported (60%) reported by Yohai et al. Survival rates in patients with chronic renal disease had improved, from 19% to 52%, and in patients with leukaemia (from 13% to 50%). Facial necrosis and hemiplegia remained poor prognostic indicators (33% and 39% survival rates, respectively). Early commencement of medical treatment related to better survival outcomes (61% if commenced within first 12 days of presentation, compared to 33% if after 13 days). Timing of surgery had less of an effect on overall survival. However, in 28 cases that did not receive any surgical treatment, survival was only 21%. CONCLUSIONS Although overall survival rates have not improved, survival in patients with renal disease were better, potentially due to the introduction of liposomal amphotericin B which is less nephrotoxic. Prompt recognition of ROCM, reversal of predisposing co-morbidities and aggressive medical treatment remain the cornerstone of managing this highly aggressive disease.
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Affiliation(s)
- Casey Vaughan
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Amanda Bartolo
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Nimisha Vallabh
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Samuel C Leong
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Abstract
A 68-year-old immunocompromised man with rhino-orbital-cerebral mucormycosis was treated with retrobulbar injections of amphotericin B deoxycholate in conjunction with intravenous antifungals and endoscopic sinus debridement. Transient episodes of orbital inflammation were noted after retrobulbar injections, but progression of orbital infection was halted and visual acuity restored with eventual hospital discharge. To the authors' knowledge, clearance of orbital mucormycosis with retrobulbar amphotericin B injections has not been previously reported. This intervention may be a viable therapeutic option in cases of orbital mucormycosis where aggressive orbital debridement is not favored and/or the burden of orbital disease is not substantial. However, physicians should be aware of the risk of transient orbital inflammation secondary to retrobulbar amphotericin B deoxycholate.
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Abstract
Fungal infections of the orbit can lead to grave complications. Although the primary site of inoculation of the infective organism is frequently the sinuses, the patients can initially present to the ophthalmologist with ocular signs and symptoms. Due to its varied and nonspecific clinical features, especially in the early stages, patients are frequently misdiagnosed and even treated with steroids which worsen the situation leading to dire consequences. Ophthalmologists should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of this invasive sino-orbital infection. In this review, relevant clinical, microbiological, and imaging findings are discussed along with the current consensus on local and systemic management. We review the recent literature and provide a comprehensive analysis. In the immunocompromised, as well as in healthy patients, a high index of suspicion must be maintained as delay in diagnosis of fungal pathology may lead to disfiguring morbidity or even mortality. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly oral voriconazole and topical amphotericin B, may be beneficial in selected patients.
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Affiliation(s)
- Bipasha Mukherjee
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
| | - Nirav Dilip Raichura
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
| | - Md Shahid Alam
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
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Intraorbital Irrigation of Amphotericin B in the Treatment of Rhino-Orbital Mucormycosis. Ophthalmic Plast Reconstr Surg 2017; 33:e13-e16. [DOI: 10.1097/iop.0000000000000377] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The Role of Adjunctive Therapies in the Management of Invasive Sino-Orbital Infection. Ophthalmic Plast Reconstr Surg 2016. [PMID: 26207927 DOI: 10.1097/iop.0000000000000488] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Invasive sino-orbital fungal infections are life-threatening complications of immunonosupression that are difficult to treat. Currently there are no standard treatment guidelines. The most widely accepted therapy includes parenteral anti-fungal therapy and surgical debridement of sinuses with orbital exenteration, a procedure that is not only disfiguring, but may increase morbidity. Injection of retrobulbar Liposomal Amphotericin B (L-AMB) is an alternative approach that provides local administration to infected tissues. The adjunct use of anti-fungal retrobulbar injections not been extensively reviewed in treating sino-orbital infection. We are reporting the multimodal approach of using L-AMB retrobulbar injections in combination with sinus debridement, intravenous (IV) anti-fungal therapy, and hyperbaric oxygen (HBO) for the management of sino-orbital infection. METHOD & RESULTS Review of literature of 12 cases and retrospective evaluation of one patient with sino-orbital Aspergillus flavus infection on chemotherapy for T-cell acute lymphocytic leukemia treated with retrobulbar Amphotericin B, IV anti-fungal agents, and hyperbaric oxygen therapy. Clinical characteristics, radiographic features, management techniques, and clinical outcomes are described. CONCLUSION Retrobulbar Amphotericin B injection may be an effective adjunct to hyperbaric oxygen and parenteral anti-fungals in the control of sino-orbital fungal infections.
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Farooq AV, Patel RM, Lin AY, Setabutr P, Sartori J, Aakalu VK. Fungal Orbital Cellulitis: Presenting Features, Management and Outcomes at a Referral Center. Orbit 2015; 34:152-9. [PMID: 25906127 DOI: 10.3109/01676830.2015.1014512] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To report a series of patients with fungal orbital cellulitis who underwent exenteration surgery and describe presenting features, management and outcomes at a referral center. METHODS Retrospective case series. RESULTS From November 2011 to March 2014, four patients underwent orbital exenteration for fungal orbital cellulitis at the University of Illinois. Three patients had mucormycosis and one had aspergillosis. All patients were treated with intravenous antifungals and underwent orbital exenteration. Two patients were successfully treated with supplemental intra-orbital catheter delivery of amphotericin B. Presenting visual acuity in the affected eye ranged from 20/25 to no light perception. Some level of ophthalmoplegia was present in three patients. Significantly elevated intraocular pressure was found in two patients. All patients with mucormycosis were found to have uncontrolled diabetes mellitus. One patient had a history of myelodysplastic syndrome, chronic hepatitis C infection, polysubstance abuse and Crohn's disease. Another patient had a history of alcoholic liver cirrhosis, Crohn's disease treated with systemic immunosuppression and renal cell carcinoma. The patient with aspergillosis had myelodysplastic syndrome and portal hypertension, and the initial presentation resembled giant cell arteritis. Two of four patients died during their hospitalization. CONCLUSIONS Fungal orbital cellulitis has a high mortality rate despite aggressive antifungal treatment and orbital exenteration performed soon after the diagnosis is confirmed. Patients often have a history of immunosuppression and the onset may be insidious. There must be a high rate of suspicion for fungal orbital cellulitis given the appropriate signs and medical history in order to avoid treatment delay.
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Affiliation(s)
- Asim V Farooq
- Department of Ophthalmology, University of Illinois at Chicago College of Medicine , Chicago, Illinois , USA
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Endoscopic management of rhinocerebral mucormycosis with topical and intravenous amphotericin B. The Journal of Laryngology & Otology 2011; 125:807-10. [DOI: 10.1017/s0022215111001289] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AbstractObjective:Mucormycosis is an aggressive fungal infection which may still cause fatal complications. However, the rarity of this disease has made optimal treatment a controversial issue. This study aimed to evaluate the use of topical amphotericin B in endoscopic management of rhinocerebral mucormycosis.Subjects and methods:Thirty patients with infection limited to the nose and sinuses were selected. Patients underwent endoscopic debridement of all necrotic tissue; cottonoid pledgets soaked in amphotericin B solution were then placed in the nasal cavity. Subsequently, long-term antifungal therapy was administered.Results:The overall survival rate was 60 per cent (18 cases); survival rates in the diabetic and malignancy groups were 70.58 and 40 per cent, respectively. Apart from predisposing factors, orbital and maxillary sinus involvement also had a significant correlation with patient outcome.Conclusion:Topical use of amphotericin B combined with endoscopic surgical debridement, followed by intravenous amphotericin B treatment, may constitute acceptable management for selected patients, with less morbidity than conventional treatments.
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Rhinocerebral mucormycosis: experience in 14 patients. The Journal of Laryngology & Otology 2011; 125:e3. [DOI: 10.1017/s0022215111000843] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AbstractObjective:Mucormycosis is an opportunist, often lethal fungal infection which occurs in immunocompromised patients. We present our experience in 14 patients with this condition.Patients and methods:A retrospective chart review was conducted for 14 patients treated for rhinocerebral mucormycosis.Results:Nine patients had diabetes mellitus and six had a haematological malignancy. Nine patients had cutaneous and/or palatal necrosis. Eleven patients were treated with amphotericin B and five with liposomal amphotericin B. Endoscopic sinus surgery was performed in five patients with disease limited to the sinonasal cavity; nine patients underwent more extensive surgery. Five patients with disease limited to the sinonasal cavity survived, while nine patients with widely disseminated disease died. Five of the nine diabetic patients died, as did five of the six patients with haematological malignancy.Conclusion:Patients with rhinocerebral mucormycosis spreading outside the sinonasal cavity have a poor prognosis.
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Becker M, Masterson K, Delavelle J, Viallon M, Vargas MI, Becker CD. Imaging of the optic nerve. Eur J Radiol 2010; 74:299-313. [PMID: 20413240 DOI: 10.1016/j.ejrad.2009.09.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 09/01/2009] [Indexed: 10/19/2022]
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Songu M, Unlu HH, Gunhan K, Ilker SS, Nese N. Orbital Exenteration: A Dilemma in Mucormycosis Presented with Orbital Apex Syndrome. ACTA ACUST UNITED AC 2008; 22:98-103. [DOI: 10.2500/ajr.2008.22.3121] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Mucormycosis is an uncommon, rapidly progressive, commonly fatal, opportunistic, fungal paranasal sinus infection. The most critical decision in the management of rhino-orbital mucormycosis is whether the orbit should be exenterated. The literature fails to provide a broad base of information of how physicians determine the need for exenteration in daily practice. The decision for exenteration often depends on the judgment of the treating otolaryngologist. The authors report their experience and outline that orbital exenteration may not be mandatory in all cases of rhino-orbital mucormycosis. Methods The medical records from Celal Bayar University Medical Faculty Department of Otorhinolaryngology/Head and Neck Surgery were retrospectively searched from 1995 to 2007 for three cases with rhino-orbital mucormycosis, treated without orbital exenteration. Results All patients with rhino-orbital mucormycosis who were treated without exenteration survived. Conclusion The favorable outcome was attributable to rapid correction of the underlying medical condition; wide local excision and debridement of all involved and devitalized sinonasal and periorbital tissue, while establishing adequate sinus and orbital drainage; daily endoscopic assessment with multiple sinus debridement when necessary; daily irrigation of the involved areas; and high-dose i.v. amphotericin B.
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Affiliation(s)
- Murat Songu
- Department of Otorhinolaryngology/Head and Neck Surgery, Celal Bayar University Hospital, Manisa, Turkey
| | - H. Halis Unlu
- Department of Otorhinolaryngology/Head and Neck Surgery, Celal Bayar University Hospital, Manisa, Turkey
| | - Kivanc Gunhan
- Department of Otorhinolaryngology/Head and Neck Surgery, Celal Bayar University Hospital, Manisa, Turkey
| | - S. Sami Ilker
- Departments of Ophthalmology, Celal Bayar University Hospital, Manisa, Turkey
| | - Nalan Nese
- Department of Pathology, Celal Bayar University Hospital, Manisa, Turkey
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Mohindra S, Mohindra S, Gupta R, Bakshi J, Gupta SK. Rhinocerebral mucormycosis: the disease spectrum in 27 patients. Mycoses 2007; 50:290-6. [PMID: 17576322 DOI: 10.1111/j.1439-0507.2007.01364.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The variable forms of clinical complaints, findings and time interval of presentation in 27 cases of mucormycosis have been described, which were encountered over a span of 8 years. The previous concept about this fungal infection attacking chronic, debilitated, immunocompromised patients does not appear to hold true. Seven of the 27 patients (22.2%) did not reveal any predisposing factors and their outcome of 42.9% survival seems to be poorer than the total outcome (66.7%). 'Chronic form' of disease presentation, the definition of which is still not delineated, was encountered in four patients (14.8%). Again, the outcome was not significantly different from the total survival. Burr-hole tap of an intracranial abscess revealing mucor in a 2-month-old infant has been described. Even in the present era, extranasal exenteration of sinuses along with disfiguring orbital exenteration is required to ensure satisfactory surgical debridement. Control of the underlying predisposing illness, along with the aggressive surgical debridement and the parenteral administration of amphotericin B, remains the treatment essentials even today.
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Affiliation(s)
- Sandeep Mohindra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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24
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Cheema SA, Amin F. Five cases of rhinocerebral mucormycosis. Br J Oral Maxillofac Surg 2007; 45:161-2. [PMID: 16162369 DOI: 10.1016/j.bjoms.2005.06.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 06/29/2005] [Indexed: 11/17/2022]
Abstract
Rhinocerebral mucormycosis is a rare and often fatal fungal infection in immunocompromised patients. We encountered three women and two men with diabetes and mucormycosis in a period of 4 years. Two of the patients died.
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Affiliation(s)
- Saeed Ashraf Cheema
- Department of Plastic and Maxillofacial Surgery, Services Institute of Medical Sciences & Services Hospital, Lahore, Pakistan.
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Hosseini SMS, Borghei P. Rhinocerebral mucormycosis: pathways of spread. Eur Arch Otorhinolaryngol 2005; 262:932-8. [PMID: 15891927 DOI: 10.1007/s00405-005-0919-0] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Accepted: 12/17/2004] [Indexed: 10/25/2022]
Abstract
Rhinocerebral mucormycosis is an invasive, opportunistic fungal infection usually seen in immunocompromised patients, and particularly in the setting of diabetes or immune deficiency. It is assumed that the port of entry is colonization of the nasal mucosa, allowing the fungus to spread via the paranasal sinuses into the orbit. Involvement of the brain and cavernous sinus occurs by way of the orbital apex; therefore, spheno-ethmoidectomy with or without maxillectomy seems to be the definitive method to eradicate this infection. We conducted a prospective study of ten patients with rhinocerebral mucormycosis from February 2000 to April 2004. Rhinocerebral mucormycosis was clinically diagnosed in 11 patients, 10 of whom were included in our study upon histopathological confirmation. Diabetes was the most common underlying disorder seen in nine out of ten patients. In this study, the patients were assessed for predisposing factors, presenting signs and symptoms, sites of extension, the number and sites of surgical debridement, as well as the outcome. Ocular, sinonasal and facial soft tissue involvement was common. Involvement of the pterygopalatine fossa at the time of debridement was evident in all patients. No invasion through the lamina papiracea or the walls of the maxillary sinus was identified. At the time of this communication, six out of ten patients were alive. For the four who died, the causes were hypokalemia, cardiac arrythmia and refractory pneumonia. Pterygopalatine fossa is considered to be the main reservoir for rhinocerebral mucormycosis, and extension into the orbit and facial soft tissues usually follows this route. After proliferation in the nasal cavity, the mucor reaches the pterygo-palatine fossa, inferior orbital fissure and finally the retroglobal space of the orbit, resulting in ocular signs. The facial soft tissues, palate and infratemporal fossa can be infected through connecting pathways from the pterygo-palatine fossa; therefore, debridement of the pterygopalatine fossa seems to be the definitive method of managing this infection.
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Pelton RW, Peterson EA, Patel BC, Davis K. Successful treatment of rhino-orbital mucormycosis without exenteration: the use of multiple treatment modalities. Ophthalmic Plast Reconstr Surg 2001; 17:62-6. [PMID: 11206749 DOI: 10.1097/00002341-200101000-00012] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the successful management of rhino-orbital mucormycosis without the use of orbital exenteration. METHOD Case report. RESULTS The patient had successful eradication of the fungal infection with retention of normal vision and ocular function. CONCLUSIONS The use of multiple treatment modalities including aggressive surgical debridement guided by intraoperative frozen section monitoring, intravenous liposomal amphotericin B, intraorbital regular amphotericin B and hyperbaric oxygen may allow complete resolution of orbital phycomycosis and spare the patient from the blindness and disfigurement associated with exenteration.
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Affiliation(s)
- R W Pelton
- Department of Ophthalmology, University of Utah Health Sciences Center, Salt Lake City, USA.
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Hong RH, Koch RJ. Possible role of anticoagulation in the treatment of rhinocerebral mucormycosis. Otolaryngol Head Neck Surg 2000; 122:577-8. [PMID: 10740183 DOI: 10.1067/mhn.2000.103168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- R H Hong
- Division of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, California 94305-5328, USA
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 22-1999. A 68-year-old woman with multiple myeloma, diabetes mellitus, and an inflamed eye. N Engl J Med 1999; 341:265-73. [PMID: 10413740 DOI: 10.1056/nejm199907223410408] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
A 48-year-old man presented to the emergency department with a 3-day history of decreased vision in a painful proptotic right eye. The patient was being treated with chemotherapy and radiation for non-small cell lung carcinoma. Examination showed visual acuity of hand motions, decreased motility, and an afferent pupillary defect on the right, consistent with an orbital apex syndrome. Neuroimaging revealed "dirty" orbital fat and no paranasal sinus disease. Orbital biopsy initially showed only fibrosis; however, on subsequent biopsies, nonseptate hyphae later identified as mucormycosis was recovered. The patient survived with exenteration and systemic amphotericin B.
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MESH Headings
- Amphotericin B/therapeutic use
- Antifungal Agents/therapeutic use
- Biopsy
- Carcinoma, Non-Small-Cell Lung/complications
- Carcinoma, Non-Small-Cell Lung/drug therapy
- Diagnosis, Differential
- Exophthalmos/diagnosis
- Exophthalmos/drug therapy
- Exophthalmos/etiology
- Eye Infections, Fungal/complications
- Eye Infections, Fungal/diagnosis
- Eye Infections, Fungal/drug therapy
- Follow-Up Studies
- Humans
- Lung Neoplasms/complications
- Lung Neoplasms/drug therapy
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Mucormycosis/complications
- Mucormycosis/diagnosis
- Mucormycosis/drug therapy
- Orbital Diseases/complications
- Orbital Diseases/diagnosis
- Orbital Diseases/drug therapy
- Tomography, X-Ray Computed
- Vision, Low/diagnosis
- Vision, Low/drug therapy
- Vision, Low/etiology
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Affiliation(s)
- D B Auerbach
- Neuro-Ophthalmology Service, Wills Eye Hospital, Philadelphia, PA, USA
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Abstract
Traditionally, amphotericin B has been the cornerstone of antifungal treatment. Toxicity, however, is a major dose-limiting factor of amphotericin B deoxycholate. Nevertheless, it continues to have a major role in the treatment of deep-seated mycotic infections. Recently, less nephrotic lipid formulations, including amphotericin B lipid complex, amphotericin B cholesteryl sulfate, and liposomal amphotericin B, have been introduced. The pharmacologic properties, main indications, recommended dosages, related costs, and adverse effects of these various preparations are summarized in this review. Orally administered flucytosine is useful in certain infections, particularly cryptococcal meningitis, but it should be used with caution in patients with renal insufficiency.
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Affiliation(s)
- R Patel
- Division of Infectious Diseases and Internal Medicine, Mayo Clinic Rochester, Minnesota, USA
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Abstract
Rhino-orbital-cerebral mucormycosis (ROCM) is an acute, often fatal, fungal infection caused by members of the class Zygomycetes and the order Mucorales. The genus Rhizopus accounts for most cases of ROCM. The disease is characterized by fungal hyphal invasion of blood vessels resulting in thrombosis and infarction of the nasal, paranasal sinus, orbital, and cerebral tissues. The most commonly associated condition is diabetes mellitus; other associated conditions include immunocompromised states, renal disease, deferoxamine use, and acidotic states. Common clinical findings include rhinitis, periorbital and facial swelling, facial and mucosal necrosis, ophthalmoplegia, multiple cranial nerve palsies, facial pain, and headache. Definitive diagnosis is made by demonstration of fungal hyphae in tissue specimens. The mainstay of treatment is aggressive surgical debridement of infected tissue and administration of amphotericin B. ROCM has a mortality rate of 40-50%; 70% of survivors are left with residual defects. Early diagnosis and treatment are imperative in the successful management of patients afflicted with this devastating sight- and life-threatening disease.
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Affiliation(s)
- Ronald E. Warwar
- Department of Ophthalmology, Wright State University School of Medicine, Dayton, Ohio, U.S.A
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Adler DE, Milhorat TH, Miller JI. Treatment of rhinocerebral mucormycosis with intravenous interstitial, and cerebrospinal fluid administration of amphotericin B: case report. Neurosurgery 1998; 42:644-8; discussion 648-9. [PMID: 9527000 DOI: 10.1097/00006123-199803000-00037] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE Rhinocerebral mucormycosis is extremely difficult to treat. Approximately 70% of patients are poorly controlled diabetics, and many of the remainder are immunocompromised as a consequence of cytotoxic drugs, burn injuries, or end-stage renal disease. Despite standard treatment consisting of surgical debridement and the intravenous administration of amphotericin B, rhinocerebral mucormycosis is usually a fatal disease. CLINICAL PRESENTATION We describe the case of a 16-year-old male patient with juvenile onset diabetes mellitus who presented with fever, right-sided hemiparesis, and dysarthria. Axial view computed tomography revealed abscess formation in the left basal ganglia and frontal lobe, which was proven by stereotactic biopsy to contain Rhizopus oryzae. INTERVENTION Intravenous administration of amphotericin B (30-280 mg/dose) was begun on the day of admission. On hospital Day 20, after the occurrence of frank abscess formation, the lesion was aggressively debrided. Despite these therapies, there was neurological deterioration characterized by the development of hemiplegia and aphasia. Sequential computed tomographic scans enhanced with contrast medium demonstrated progressively enlarging lesions. Ommaya reservoirs were placed into the abscess cavity and the frontal horn of the contralateral lateral ventricle. The patient was then treated with intracavitary/interstitial injections of amphotericin B during the course of 80 days and three doses of intraventricular amphotericin B. Clinical and radiographic improvement was achieved after treatment. Two years after the initial diagnosis, magnetic resonance imaging of the brain showed no evidence of disease and an examination revealed a neurologically intact and fully functional patient. CONCLUSION We conclude that with an infection as morbid as rhinocerebral mucormycosis, it is advisable to use surgical debridement and all available routes for delivering amphotericin B to infected cerebral parenchyma, which include intravenous, intracavitary/interstitial, and cerebrospinal fluid perfusion pathways.
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Affiliation(s)
- D E Adler
- Department of Neurosurgery, State University of New York, Health Science Center at Brooklyn, 11203, USA
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