Mucormycosis, quick review

1. Mucormycosis
Presented by Dr: Abdulrahman Almalaq
Internal Medicine PGY1

2. Content:-
• Introduction.
• Risk factors.
• Pathogenesis.
• Clinical presentation.
• Diagnosis.
• Treatment.
• Prognosis.

3. Introduction
• Mucormycosis (sometimes called zygomycosis) is a serious but rare
fungal infection caused by a group of molds called
mucormycetes. These fungi live throughout the environment,
particularly in soil and in decaying organic matter, such as leaves,
compost piles, or rotten wood.1
• People get mucormycosis through contact with fungal spores in the
environment. By inhalation of fungal spores, ingestion or through the
skin in case of burn or wounds.

4. Predisposing Factors
- Diabetes, especially with diabetic ketoacidosis.
- Organ transplant, Stem cell transplant and chemotherapy.
- Neutropenia.
- HIV/AIDS.
- Long-term corticosteroid use.
- Iron overload or hemochromatosis.
- Skin injury due to surgery, burns, or wounds.
- Prematurity and low birthweight.

5. 1.Inhalation 2.Invasion 3.Dissemination

6. Clinical Presentation
• Rhinocerebral mucormycosis: most common in people with
uncontrolled diabetes and in people who have had a kidney
transplant.2-3
- Acute sinusitis with fever, nasal congestion, purulent nasal
discharge, headache, and sinus pain.
- Palatal eschars, destruction of the turbinates, perinasal swelling,
and erythema and cyanosis of the facial skin overlying the involved
sinuses and/or orbit.
- Signs of orbital involvement include periorbital edema, proptosis,
and blindness.

7. Rhinocerebral mucormycosis

8. Clinical Presentation cont.
• Pulmonary mucormycosis: most common type of mucormycosis in people
with cancer and in people who have had an organ transplant or a stem cell
transplant.
- Fever, cough, pleuritic chest pain and massive hemoptysis.
• Gastrointestinal mucormycosis: more common among young children than
adults .
- Abdominal pain and hematemesis, perforation and peritonitis, Bowel
infarctions and hemorrhagic shock.
• Cutaneous mucormycosis: trauma or wounds.
- Single, painful, indurated area of cellulitis rapidly progressing to necrotic
tissue.

9. Work up
• Laboratory Tests:
- CBC, chemistry panel, ABG, Iron studies and CSF.
- Beta-D-glucan or galactomannan are negative in mucormycosis.
- KOH and fungal stain.
• Imaging: (CT) of the brain, sinuses, chest, and abdomen.
• Tissue biopsy is the gold standard.
• Molecular : PCR
• Other: sinus endoscopy and GI endoscopy.

10. Treatment
• Correction of the underlying abnormality, initiation of antifungal therapy,
and surgical debridement.
• Antifungal drugs: Early initiation of antifungal therapy improves the
outcome of infection with mucormycosis.
- Amphotericin B is the drug of choice for initial therapy ( Liposomal
amphotericin B – Ambisome 5 mg/kg daily - ).
• Posaconazole and isavuconazole : Step-down therapy.
- Posaconazole :300 mg every 12 hours on the first day, then 300 mg once
daily.
- Isavuconazole Loading doses of 200 mg, should be given every 8 hours for
six doses, followed by 200 mg orally once daily starting 12 to 24 hours after
the last loading dose.8

11. Treatment
• Surgery: aggressive surgical intervention (debridement or lobe-
ectomy) of involved tissues once the diagnosis of any form of
mucormycosis is suspected.6

12. Prognosis
• Rhinocerebral disease causes significant morbidity in patients who
survive, because treatment usually requires extensive, and often
disfiguring, facial surgery.
• Surviving mucormycosis requires rapid diagnosis and aggressive
coordinated medical and surgical therapy.
• Mucormycosis carries a mortality rate of 50-85%. The mortality rate
associated with rhinocerebral disease is 50-70%. Pulmonary and
gastrointestinal (GI) diseases carry an even higher mortality rate,
because these forms are typically diagnosed late in the disease
course. Disseminated disease carries a mortality rate that approaches
100%.

13. References:
1. Richardson M. The ecology of the Zygomycetes and its impact on environmental exposure. Clin Microbiol Infect. 2009 Oct;15
Suppl 5:2-9.
2. Song Y, Qiao J, Giovanni G, Liu G, Yang H, Wu J, Chen J. Mucormycosis in renal transplant recipients: review of 174 reported
cases. BMC Infect Dis. 2017 Apr; 17(1): 283.
3. Abdalla A, Adelmann D, Fahal A, Verbrugh H, Van Belkum A, De Hoog S. Environmental Occurrence of Madurella mycetomatis,
the Major Agent of Human Eumycetoma in Sudan. J Clin Microbiol. 2002 Mar; 40(3): 1031–1036.
4. Vallabhaneni S, Mody RK. Gastrointestinal Mucormycosis in Neonates: a Review. Current Fungal Infection Reports. 2015.
5. Francis JR, Villanueva P, Bryant P, Blyth CC. Mucormycosis in Children: Review and Recommendations for Management. J
Pediatric Infect Dis Soc. 2018 May 15;7(2):159-164.
6. Tedder M, Spratt JA, Anstadt MP, et al. Pulmonary mucormycosis: results of medical and surgical therapy. Ann Thorac Surg
1994; 57:1044.
7. Di Carlo P, Pirrello R, Guadagnino G, et al. Multimodal surgical and medical treatment for extensive rhinocerebral
mucormycosis in an elderly diabetic patient: a case report and literature review. Case Rep Med. 2014;2014:527062.
8. Cresemba (isavuconazonium sulfate) for oral administration, for injection for intravenous administration, prescribing
information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/207500Orig1s000lbl.pdf (Accessed on March 09,
2015).

14. THANK YOU