Diabetes mellitus as the major risk factor for mucormycosis in Mexico: Epidemiology, diagnosis, and outcomes of reported cases

Abstract

Mucormycosis is an emerging infectious disease with high rates of associated mortality and morbidity. Little is known about the characteristics of mucormycosis or entomophthoromycosis occurring in Mexico. A search strategy was performed of literature published in journals found in available databases and theses published online at Universidad Nacional Autónoma de México (UNAM) library website reporting clinical cases or clinical case series of mucormycosis and entomophthoromycosis occurring in Mexico between 1982 and 2016. Among the 418 cases identified, 72% were diabetic patients, and sinusitis accounted for 75% of the reported cases. Diabetes mellitus was not a risk factor for entomophthoromycosis. Mortality rate was 51% (125/244). Rhizopus species were the most frequent isolates (59%, 148/250). Amphotericin B deoxycholate was used in 89% of cases (204/227), while surgery and antifungal management as combined treatment was used in 90% (172/191). In diabetic individuals, this combined treatment approach was associated with a higher probability of survival (95% vs 66%, OR = 0.1, 95% CI, 0.02-0.43' P = .002). The most common complications were associated with nephrotoxicity and prolonged hospitalization due to IV antifungal therapy. An algorithm is proposed to establish an early diagnosis of rhino-orbital cerebral (ROC) mucormycosis based on standardized identification of warning signs and symptoms and performing an early direct microbiological exam and histopathological identification through a multidisciplinary medical and surgical team. In summary, diabetes mellitus was the most common risk factor for mucormycosis in Mexico; combined antifungal therapy and surgery in ROC mucormycosis significantly improved survival.

Diabetic versus non‐diabetic rhino‐orbito‐cerebral mucormycosis

“…Although, white blood cell and neutrophil counts were not significantly lower in diabetic group in this series, impaired function could be the main reason for impaired immunity. Almost half of the diabetic patients (46.5%) were initially in the ketoacidosis state which is consistent with large series of ROCM 4,6,15 …”

“…The frequency of mucormycosis in patients with neoplastic diseases and bone marrow or solid organ transplant has increased during the last decades 2,6 . Renal failures, HIV and severe burn are the other non‐diabetic predisposing conditions 2,9 .…”

“…Renal failures, HIV and severe burn are the other non‐diabetic predisposing conditions 2,9 . Typical presentations of mucormycosis in non‐diabetics are pulmonary and disseminated types, even though some present with ROCM 2,4,6,9 . Malignancy has been the most common cause of non‐diabetic ROCM 2,7,10,16,17 .…”

“…Therefore, some series specifically evaluated the clinical pictures and outcomes of diabetic ROCM 3,4 . Nearly half of the patients with mucormycosis die 2,5,6 . Some reported better 7,8 and some worse 9‐11 outcomes for diabetic ROCM as compared with the other immunocompromised patients.…”

Mucormicosis diseminada en un paciente diabético: un reporte de caso

“…Finalmente, la cetoacidosis disminuye la permeabilidad de la barrera hematoencefálica contribuyendo a la predilección por la enfermedad rinocerebral en esta población [14] . En un estudio descriptivo de 221 casos de mucormicosis en México, se encontró que en pacientes diabéticos con cetoacidosis la mortalidad fue mayor que en diabéticos sin cetoacidosis [15] .…”