Mucormycosis of the head and neck

Early diagnosis and aggressive surgical resection matters to cure rhinocerebral mucormycosis: Six case reports

Rhino-cerebral mucormycosis (RM) is a rare and opportunistic fungal infection observed in immune-compromised patients and metabolic imbalances such as Diabetes Mellitus. RM rapidly infiltrates blood vessels, leading to vascular thrombosis, subsequent tissue necrosis, and high mortality rates (23.6-60%). Due to its fast advancement, RM is a life-threatening condition requiring accurate clinical decisions by the medical and surgical teams. Based on the report of six cases, we emphasize the need for an early diagnosis and starting antifungal pharmacological therapy at the slightest suspicion of RM. Moreover, the restitution of metabolic balance and aggressive surgical debridement are vital steps to control RM, reducing the possibility of fatal outcomes.

Fungal Necrotizing Fasciitis of Craniofacial Region: A Diagnostic Challenge

Necrotizing fasciitis is a rare rapidly progressive, devastating surgical emergency that results in necrosis of superficial fascia, and subcutaneous tissue. It most commonly affects the abdominal wall, extremities and perineum, while the involvement in the head and neck region is relatively rare. Here, we report a successfully treated case of necrotizing fasciitis of the craniofacial region caused by Mucor in an uncontrolled diabetic patient. Early diagnosis, early surgical intervention with radical excision of infected tissue, management of underlying predisposing medical condition and supportive therapy (antimicrobials, rehydration, proper rest and nutrition) can reduce the morbidity and mortality associated with this condition.

Is Single-stage Microvascular Reconstruction for Facial Mucormycosis Safe?

Introduction This is a retrospective therapeutic series of eight cases of facial mucormycosis treated over a 15-year period to determine the safety of simultaneous debridement and free-flap reconstruction in facial mucormycosis.

Methods Surgical debridement was done for three cases that presented acutely with systemic manifestations (group 1) and five cases that presented in the subacute phase without systemic manifestations (group 2). The debridement involved total maxillectomy with orbital exenteration in three cases, total maxillectomy with orbital preservation in two, and subtotal maxillectomy in three cases. A total of seven out of eight patients underwent reconstruction with free flap for defect closure; in one patient, only primary closure of mucosa was done.

Results The mean follow-up was 20.5 months. Two patients with acute disease, where reconstruction was done, died in the postop period (on the 27th and 6th day post reconstruction, respectively) due to continuing infection and septic shock. One of the three (group 1), who presented acutely and underwent debridement alone, survived. Four of five patients in group 2 underwent successful free-flap reconstruction. The patient with free-flap loss was salvaged with an extracorporeal radial forearm flap. All except one patient had a soft-tissue free-flap reconstruction. Three of the six living patients reported for secondary surgery. The inability to achieve clear nonnecrotic surgical margins due to extensive disease was the reason for mortality in two patients in group 1. There was no mortality in any of the group 2 patients, even when debridement and free-flap coverage was done simultaneously.

Conclusion Simultaneous debridement and free flap can be successfully implemented in select cases of facial mucormycosis

Mucormycosis: A rare entity with rising clinical presentation in immunocompromised hosts

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It is a case study of an immunocompromised patients affected by Mucormycosis which is - a profoundly mortal fungal infection.

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In order to restore the function, enhance the cosmetic appearance and quality of life of the patient, surgical intervention is often necessary to correct the various pathologies affecting the patients.

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This paper highlights the significance of prompt diagnosis and urgent treatment, especially among high-risk patients, of this potentially lethal phenomenon and the surgical procedure undertaken to remove the disease afecting the person and improve the patient's overall health.

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The management of our patient demonstrates the need for an early visual identification and diagnosis approach that is multidisciplinary, multi-factorial and multi-faceted.

Introduction

Mucormycosis is a rare, rapidly progressive and a fulminant, life-threatening, opportunistic infection. Although it most commonly manifests in diabetic patients, its presence in other immunologically compromised patients cannot be ruled out. Its etiology is saprophytic fungal organisms, with rhizopus being the most common causative organism. Clinically the disease is marked by a partial loss of neurological function and a progressive necrosis due to the invasion of the organisms into the blood vessels causing a lack of blood supply. The disease may progress to involve the cranium thereby increasing the mortality rate. The first line of management in mucormycosis is antifungal therapy which may extend and also include surgical management.

Presentation of case

Authors present here two patients with mucormycosis affecting the maxillofacial region, that were treated by including both medical and surgical lines of management.

Discussion

This report aims to highlight the importance of prompt diagnosis and urgent management of this potentially fatal phenomenon, particularly among high-risk individuals.

Conclusion

This case report intensifies the importance of considering mucormycosis as a possible diagnosis in spontaneous necrotic soft tissue lesions of the face, especially in an immunocompromised patient.

A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis-has anything changed in the past 20 years?

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.

Primary Oral Mucormycosis Due to Rhizopus microsporus after Allogeneic Stem Cell Transplantation

We herein report a rare case of oral mucormycosis following allogeneic hematopoietic stem cell transplantation. Oral mucormycosis due to Rhizopus microsporus manifested as localized left buccal mucositis with a 1-cm black focus before neutrophil recovery. Combination therapy with liposomal amphotericin B was initiated and surgical debridement was performed; however, the patient died due to progressive generalized mucormycosis. Considerable attention needs to be paid to the diagnosis and management of oral mucormycosis in post-transplant patients, thereby suggesting the importance of fully understanding the risk factors.

Early diagnosis and successful management of oral mucormycosis in a hematopoietic stem cell transplant recipient: case report and literature review

PURPOSE

Oral mucormycosis is a rare and high risk of infection in patients following hematopoietic cell transplantation few cases in the literature. We review the literature and present an additional case to emphasize the subtle changes that resulted in positive outcome when diagnosed and managed in a comprehensive transplant team.

RESULTS

A patient was diagnosed with gingival mucormycosis on day +25 following a hematopoietic stem cell transplant for lymphoblastic transformation of chronic myeloid leukemia. The patient was diagnosed with minor and nonspecific symptoms and was successfully treated with local dental extraction, a short course of liposomal amphotericin B and 4 months of oral posaconazole.

CONCLUSIONS

The good outcome of this case highlights the subtle clinical changes that present early in mucormycosis and the importance of early detection and treatment of post-transplant oral infections by an experienced multidisciplinary team.

Management of rhino-orbital mucormycosis

Mucormycosis is an uncommon acute invasive fungal infection that affects immunocompromised patients. It progresses rapidly and has poor prognosis if diagnosed late. Early detection, control of the underlying condition with aggressive surgical debridement, administration of systemic and local antifungal therapies, hyperbaric oxygen as adjunctive treatment improves prognosis and survivability.

Extranodal lymphomas of head and neck with emphasis on NK/T-cell lymphoma, nasal type

PURPOSE

To determine the occurrence, clinical course and outcome of our patients with natural killer/T-cell lymphoma (NKTCL), nasal type. The nasal type of natural killer/T-cell lymphoma (NKTCL), is rare in the European population but is more frequent in Asia, Central and South America where it accounts for 15-20% of all non-Hodgkin lymphomas (NHL). This type of lymphoma is characterized by tissue necrosis and destruction of the nasal cavity and upper aero-digestive tract. The disease is closely associated with Epstein-Barr virus (EBV) infection and has an aggressive clinical course, poor clinical outcome and high resistance to chemotherapy.

PATIENTS

63 patients with NHL were treated in our department between 2006 and 2011. Eleven patients were diagnosed with extranodal lymphoma, 6 in the area of head and neck. Three of them belonged to NKTCL, nasal type group (4.7%), 1 was diffuse large B cell lymphoma and 2 were marginal zone lymphomas.

CONCLUSION

Two out of 3 patients with nasal type NKTCL, had extremely aggressive disease resistant to applied chemotherapy (anthracycline containing regimen), while 1 patient remains in complete remission 6 years after diagnosis.