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Drogari-Apiranthitou M, Skiada A, Panayiotides I, Vyzantiadis TA, Poulopoulou A, Christofidou M, Antoniadou A, Roilides E, Iosifidis E, Mamali V, Argyropoulou A, Sympardi S, Charalampaki N, Antonakos N, Mantzana P, Mastora Z, Nicolatou-Galitis O, Orfanidou M, Pana ZD, Pavleas I, Pefanis A, Sakka V, Spiliopoulou A, Stamouli M, Tofas P, Vagiakou E, Petrikkos G. Epidemiology of Mucormycosis in Greece; Results from a Nationwide Prospective Survey and Published Case Reports. J Fungi (Basel) 2023; 9:425. [PMID: 37108880 PMCID: PMC10142618 DOI: 10.3390/jof9040425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
Mucormycosis has emerged as a group of severe infections mainly in immunocompromised patients. We analysed the epidemiology of mucormycosis in Greece in a multicentre, nationwide prospective survey of patients of all ages, during 2005-2022. A total of 108 cases were recorded. The annual incidence declined after 2009 and appeared stable thereafter, at 0.54 cases/million population. The most common forms were rhinocerebral (51.8%), cutaneous (32.4%), and pulmonary (11.1%). Main underlying conditions were haematologic malignancy/neutropenia (29.9%), haematopoietic stem cell transplantation (4.7%), diabetes mellitus (DM) (15.9%), other immunodeficiencies (23.4%), while 22.4% of cases involved immunocompetent individuals with cutaneous/soft-tissue infections after motor vehicle accident, surgical/iatrogenic trauma, burns, and injuries associated with natural disasters. Additionally, DM or steroid-induced DM was reported as a comorbidity in 21.5% of cases with various main conditions. Rhizopus (mostly R. arrhizus) predominated (67.1%), followed by Lichtheimia (8.5%) and Mucor (6.1%). Antifungal treatment consisted mainly of liposomal amphotericin B (86.3%), median dose 7 mg/kg/day, range 3-10 mg/kg/day, with or without posaconazole. Crude mortality was 62.8% during 2005-2008 but decreased significantly after 2009, at 34.9% (p = 0.02), with four times fewer haematological cases, fewer iatrogenic infections, and fewer cases with advanced rhinocerebral form. The increased DM prevalence should alert clinicians for timely diagnosis of mucormycosis in this patient population.
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Affiliation(s)
- Maria Drogari-Apiranthitou
- Infectious Diseases Research Laboratory, 4th Department of Internal Medicine, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Anna Skiada
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Ioannis Panayiotides
- 2nd Department of Pathology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, 12462 Athens, Greece
| | | | - Aikaterina Poulopoulou
- Department of Microbiology, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Myrto Christofidou
- Department of Microbiology, University Hospital of Patras, 26504 Patras, Greece
| | - Anastasia Antoniadou
- Infectious Diseases Research Laboratory, 4th Department of Internal Medicine, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3nd Department of Paediatrics, School of Medicine, Aristotle University and Hippokration General Hospital, 54642 Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Diseases Unit, 3nd Department of Paediatrics, School of Medicine, Aristotle University and Hippokration General Hospital, 54642 Thessaloniki, Greece
| | - Vassiliki Mamali
- Department of Microbiology, Tzaneio General Hospital, 18536 Piraeus, Greece
| | - Athina Argyropoulou
- Department of Clinical Microbiology, Evangelismos General Hospital, 10676 Athens, Greece
| | - Styliani Sympardi
- 1st Department of Internal Medicine, Thriasio General Hospital of Eleusis, 19600 Eleusis, Greece
| | - Nikoletta Charalampaki
- Clinical Microbiology Laboratory, Thriasio General Hospital of Eleusis, 19600 Eleusis, Greece
| | - Nikolaos Antonakos
- Infectious Diseases Research Laboratory, 4th Department of Internal Medicine, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Paraskevi Mantzana
- Department of Microbiology, AHEPA University Hospital, 54636 Thessaloniki, Greece
| | - Zafeiria Mastora
- 1st Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 10676 Athens, Greece
| | | | - Maria Orfanidou
- Clinical Microbiology Laboratory, General Hospital of Athens Georgios Gennimatas, 11527 Athens, Greece
| | - Zoi-Dorothea Pana
- School of Medicine, European University of Cyprus, Nicosia 2404, Cyprus
| | - Ioannis Pavleas
- Intensive Care Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Angelos Pefanis
- Department of Internal Medicine, Sotiria General and Chest Diseases Hospital of Athens, 11527 Athens, Greece
| | - Vissaria Sakka
- 3rd Department of Internal Medicine, Sotiria General and Chest Diseases Hospital of Athens, 11527 Athens, Greece
| | | | - Maria Stamouli
- 2nd Department of Internal Medicine, Propaedeutic, Haematology Unit, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | | | - Eleni Vagiakou
- Clinical Microbiology Laboratory, General Hospital of Athens Georgios Gennimatas, 11527 Athens, Greece
| | - George Petrikkos
- Infectious Diseases Research Laboratory, 4th Department of Internal Medicine, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
- School of Medicine, European University of Cyprus, Nicosia 2404, Cyprus
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Abstract
Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.
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Affiliation(s)
- R A Yohai
- Wright State University School of Medicine, Dayton, Ohio
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