How I treat mucormycosis

Abstract

Unlike invasive aspergillosis, the prognosis and outcome of hematologic malignancy patients who develop invasive mucormycosis have not significantly improved over the past decade as a majority of patients who develop the infection still die 12 weeks after diagnosis. However, early recognition and treatment of invasive mucormycosis syndromes, as well as individualized approaches to treatment and secondary prophylaxis, could improve the odds of survival, even in the most persistently immunosuppressed patient receiving chemotherapy and/or of stem cell transplantation. Herein, we describe the subtle clinical and radiographic clues that should alert the hematologist to the possibility of mucormycosis, and aggressive and timely treatment approaches that may limit the spread of infection before it becomes fatal. Hematology patients with this opportunistic infection require integrated care across several disciplines and frequently highly individualized and complex sequence of decision-making. We also offer perspectives for the use of 2 antifungals, amphotericin B products and posaconazole, with activity against Mucorales. The availability of posaconazole in an oral formulation that can be administered safely for prolonged periods makes it an attractive agent for long-term primary and secondary prophylaxis. However, serum drug concentration monitoring may be required to minimize breakthrough infection or relapsing mucormycosis associated with inadequate blood concentrations. (Blood. 2011;118(5):1216-1224) IntroductionMucormycosis is the unifying term used to describe infections caused by fungi belonging to the order Mucorales. Zygomycosis, an alternative term used to describe these life-threatening infections, has become less accurate based on a recent taxonomic reclassification (based on molecular identification) that abolished Zygomycetes as a class. [1][2][3][4] Rhizopus, Mucor, and Rhizomucor species account for up to 75% of mucormycosis cases encountered in hematologic malignancy patients. [5][6][7] Mucorales typically cause acute, aggressive, and frequently angioinvasive infections, especially in immunosuppressed hosts with hematologic malignancy and/or stem cell transplantation (SCT). 8,9 This opportunistic, geographically broad mycosis was highlighted as a sporadic cause of death in leukemia patients in the 1950s 10 until the mid 1990s where there has been an apparent increase in the documented cases in hematology units throughout the Westernized world ( Figure 1). [4][5][6][7]11 These cases are typically considered community-acquired, as nosocomial cases are less common in modern SCT and transplant units. 12 However, the true incidence of mucormycosis is not known and probably underestimated because of difficulties in antemortem diagnosis and the low autopsy rates in contemporary patients who die in the setting of leukemia or SCT. 13 The predisposing factors for mucormycosis in patients with hematologic cancer are similar to ones encountered in other opportunistic mold infections, such as aspergillosis, includi...

Rhizopus Laryngitis Post Allogenic Stem Cell Transplantation

“…Advanced age, diabetes, long-term steroid therapy, low CD4 lymphocyte cells, leukemia, HIV infection and other causes leading to immunsuppressed state are generally the etiological factors (Liu et al, 2010). The iron overload in thalassemic patients also contributes to increased risk of mucormycosis in such patients (Kontoyiannis and Lewis, 2011).…”

Rhinomaxillary Mucormycosis in a Renal Transplant Recipient: Case Report

“…These products are usually recommended in patients who are refractory to, or intolerant of, commercial amphotericin B deoxycholate. 14,15 Because amphotericin B cannot distribute itself through necrotic tissues, local debridement of infected structures is necessary. 15 Our patient was a kidney allograft recipient with a predisposing factor of immunosuppression.…”

“…14,15 Because amphotericin B cannot distribute itself through necrotic tissues, local debridement of infected structures is necessary. 15 Our patient was a kidney allograft recipient with a predisposing factor of immunosuppression. He was treated with amphotericin B and aggressive surgical debridement.…”

Mucormycosis and acute kidney injury

“…The four cornerstones of successful therapy are 1) rapid initiation of therapy, 2) reversal of the patient's underlying predisposing condition, 3) administration of appropriate antifungal agents, and 4) surgical debridement of infected tissues i.e. nephrectomy (27). Only 2 systemic antifungal drugs are currently available with good activity against mucorales; Amphotericin B (including the lipid formulations) and the triazole, Posaconazole.…”