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Patil R, Ajagunde J, Khan S, Kannuri S, Gandham N, Mukhida S. Rhino-orbital cerebral mycosis: a case series of non-mucorales in COVID patients. Access Microbiol 2023; 5:000575.v4. [PMID: 37970091 PMCID: PMC10634496 DOI: 10.1099/acmi.0.000575.v4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/18/2023] [Indexed: 11/17/2023] Open
Abstract
Introduction Rhino-Orbito-cerebral mycoses are not only caused by Aspergillus spp. and Zygomycetes spp. but also can be associated with other rare species such as Neurospora spp., Cladosporium spp. and Fusarium spp. Mucormycosis is associated causatively with immunocompromised states, for example patients with comorbidities such as diabetes mellitus. Clinical symptoms of coronavirus disease (COVID) and mucormycosis in tandem are critical and relentless, frequently with no life-saving treatment. Case series We report three patients with COVID-19 infection, who during the course of treatment developed rhino-orbital-cerebral mycosis including oral cavity involvement. Rhinocerebral mycosis along with oral cavity involvement was diagnosed by radiological investigations and preliminary screening for fungal infection (KOH mount) in all three cases. Empirical treatment was started but patients did not respond to treatment. All patients died even after debridement and maxillectomy. On culture, rare species of fungi were isolated in all three cases which, with the help of a reference laboratory, were identified as Neurospora, Cladosporium and Fusarium. Neurospora is considered nonpathogenic to humans. Cladosporium is a dematiaceous fungus found in soil in all climates, associated with disseminated or cerebral infections; and Fusarium, though considered a saprophytic colonizer of skin and respiratory mucosa along with other bacteria, is a common cause of mycotic keratitis worldwide. Conclusion Immune system modifications due to COVID-19 with/without other risk factors can result in fungal co-infections that prove to be fatal for the patients. It is vital to be aware that COVID-19 patients, particularly those who are critically ill, may acquire secondary fungal infections and early detection is critical.
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Affiliation(s)
- Rajashri Patil
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411018, Maharashtra, India
| | - Jyoti Ajagunde
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411018, Maharashtra, India
| | - Sameena Khan
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411018, Maharashtra, India
| | - Sriram Kannuri
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411018, Maharashtra, India
| | - Nageswari Gandham
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411018, Maharashtra, India
| | - Sahjid Mukhida
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune 411018, Maharashtra, India
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Management of Invasive Infections in Diabetes Mellitus: A Comprehensive Review. BIOLOGICS 2023. [DOI: 10.3390/biologics3010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Patients with diabetes often have more invasive infections, which may lead to an increase in morbidity. The hyperglycaemic environment promotes immune dysfunction (such as the deterioration of neutrophil activity, antioxidant system suppression, and compromised innate immunity), micro- and microangiopathies, and neuropathy. A greater number of medical interventions leads to a higher frequency of infections in diabetic patients. Diabetic individuals are susceptible to certain conditions, such as rhino-cerebral mucormycosis or aspergillosis infection. Infections may either be the primary symptom of diabetes mellitus or act as triggers in the intrinsic effects of the disease, such as diabetic ketoacidosis and hypoglycaemia, in addition to increasing morbidity. A thorough diagnosis of the severity and origin of the infection is necessary for effective treatment, which often entails surgery and extensive antibiotic use. Examining the significant issue of infection in individuals with diabetes is crucial. Comprehensive research should examine why infections are more common amongst diabetics and what the preventive treatment strategies could be.
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Patil C, Kumar A, Battula V, Kumar P, Kollu R, Kotamraju S, Nethi Balingari BL, Reddy S, Ravula S, Reddy AR. Radiological Manifestations of Rhino-Orbito-Cranial Mucormycosis in COVID-19 Patients Correlated With Pathological and Clinical Outcomes and Emphasis on Magnetic Resonance Imaging-Based Scoring System. Cureus 2023; 15:e35745. [PMID: 37020477 PMCID: PMC10069717 DOI: 10.7759/cureus.35745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 03/07/2023] Open
Abstract
There was tremendous increase in the number of cases of mucormycosis among patients affected by coronavirus disease 2019 (COVID-19) during the second wave of pandemic in South Asian countries. This invasive fungal infection primarily affects paranasal sinuses and can have orbito-facial and intracranial extension. We are presenting the radiological findings of invasive mucormycosis with pathological and clinical outcome correlation. It is important for radiologists to have the knowledge of various presentations of this opportunistic infection for early diagnosis and helping clinicians in planning the appropriate line of management. The study also emphasizes on the correlation between the extent of involvement with clinical outcome and we proposed a magnetic resonance imaging (MRI) based scoring system to standardize and prognosticate the patients affected with mucormycosis. MATERIALS AND METHODS We utilized GE 1.5 tesla, 16-channeled MRI machine for scanning the clinically suspected mucormycosis patients and did plain and contrast study of the paranasal sinuses, orbito-facial study and included brain as and when required. Images were acquired in axial, coronal, and sagittal planes using T1, T2, and fat-saturated short tau inversion recovery sequences (STIR), fat-saturated contrast sequences for better evaluation of the extent of the disease. Diffusion-weighted sequence was also acquired to detect ischemic changes in optic nerve or brain parenchyma. Contrast study was used to detect any major vessel occlusion or cavernous sinus thrombosis in the study population. RESULTS Total number of cases (n) included in the study were 32. The mean age group was 41-50 years with the median age was 47 years. Out of 32 cases (n=32), in 16 cases (50%) the disease was limited only to the paranasal sinuses and in remaining 16 (50%) cases, disease has spread to other regions such as orbits, facial soft tissues, optic nerve, and brain parenchyma. All the 18 cases with Mild score (MRI ROCM score 1-3) survived and all those with severe score (2 cases) (MRI ROCM score 7-10) did not survive. CONCLUSION During the second wave of COVID-19 pandemic, we observed a significant rise in acute invasive mucormycosis infection primarily involving the paranasal sinuses and spread to orbito-facial, cerebral parenchyma causing related complications and hence increased morbidity and death. Radiologically, using MRI, it was effectively possible to detect early extrasinonasal spread and other fatal complications thereby guiding the physicians and surgeons in the proper early aggressive management of the disease. Here, we have described the radiological characteristics of paranasal sinus mucormycosis and its spread to other regions. We also proposed an MRI-based Scoring System for standardized assessment of the disease severity. We observed in our study that the extent of disease on MRI is directly correlating with mortality.
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Mahalaxmi I, Jayaramayya K, Venkatesan D, Subramaniam MD, Renu K, Vijayakumar P, Narayanasamy A, Gopalakrishnan AV, Kumar NS, Sivaprakash P, Sambasiva Rao KRS, Vellingiri B. Mucormycosis: An opportunistic pathogen during COVID-19. ENVIRONMENTAL RESEARCH 2021; 201:111643. [PMID: 34237335 PMCID: PMC8258024 DOI: 10.1016/j.envres.2021.111643] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 05/06/2023]
Abstract
The pandemic of coronavirus disease 2019 (COVID-19) still remains on an upsurge trend. The second wave of this disease has led to panic in many countries, including India and some parts of the world suffering from the third wave. As there are no proper treatment options or remedies available for this deadly infection, supportive care equipment's such as oxygen cylinders, ventilators and heavy use of steroids play a vital role in the management of COVID-19. In the midst of this pandemic, the COVID-19 patients are acquiring secondary infections such as mucormycosis also known as black fungus disease. Mucormycosis is a serious, but rare opportunistic fungal infection that spreads rapidly, and hence prompt diagnosis and treatment are necessary to avoid high rate of mortality and morbidity rates. Mucormycosis is caused by the inhalation of its filamentous (hyphal form) fungi especially in the patients who are immunosuppressed. Recent studies have documented alarming number of COVID-19 patients with mucormycosis infection. Most of these patients had diabetes and were administered steroids for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and were consequently more prone to mucormycosis. Hence, the present review emphasizes mucormycosis and its related conditions, its mechanism in normal and COVID-19 affected individuals, influencing factors and challenges to overcome this black mold infection. Early identification and further investigation of this fungus will significantly reduce the severity of the disease and mortality rate in COVID-19 affected patients.
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Affiliation(s)
- Iyer Mahalaxmi
- Livestock Farming and Bioresource Technology, Tamil Nadu, India
| | - Kaavya Jayaramayya
- Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore, 641-046, India
| | - Dhivya Venkatesan
- Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore, 641-046, India
| | - Mohana Devi Subramaniam
- SN ONGC, Department of Genetics and Molecular Biology, Vision Research Foundation, Chennai, 600 006, Tamil Nadu, India
| | - Kaviyarasi Renu
- Department of Biomedical Sciences, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, 632 014, Tamil Nadu, India
| | - Padmavathi Vijayakumar
- Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore, 641-046, India
| | - Arul Narayanasamy
- Disease Proteomics Laboratory, Department of Zoology, Bharathiar University, Coimbatore, 641046, Tamil Nadu, India
| | - Abilash Valsala Gopalakrishnan
- Department of Biomedical Sciences, School of Biosciences and Technology, Vellore Institute of Technology, Vellore, 632 014, Tamil Nadu, India
| | - Nachimuthu Senthil Kumar
- Department of Biotechnology, Mizoram University (A Central University), Aizawl, 796 004, Mizoram, India
| | - Palanisamy Sivaprakash
- Centre for Environmental Awareness, Dr. N.G.P. Institute of Technology, Coimbatore, 641048, Tamil Nadu, India
| | | | - Balachandar Vellingiri
- Human Molecular Cytogenetics and Stem Cell Laboratory, Department of Human Genetics and Molecular Biology, Bharathiar University, Coimbatore, 641-046, India.
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Coronavirus disease 2019 associated mucormycosis meandering its way into the orbit: a pictorial review. The Journal of Laryngology & Otology 2021; 135:942-946. [PMID: 34523395 PMCID: PMC8476927 DOI: 10.1017/s0022215121002450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background There has been a recent deluge of coronavirus disease 2019 associated mucormycosis in our country. It affects the paranasal sinuses; however, it has a rapid extrasinus progression (the orbit being most common), which can be fatal if not detected early. It may meander into the orbit through various foramina without frank bone destruction. Methods This paper reviews the various gateways of the spread of coronavirus disease 2019 associated mucormycosis to the orbit, even before advent of bone destruction or ocular symptoms. Plausible pathways of invasion and subtle imaging findings are depicted, to enable an early diagnosis. Results Relevant anatomy and imaging examples have been illustrated to familiarise the surgeons with various routes of coronavirus disease 2019 associated mucormycosis spread to the orbit. Emphasis is laid on searching for subtle imaging findings for the detection of early orbital invasion. Conclusion Early detection and extension of coronavirus disease 2019 associated mucormycosis is facilitated by knowledge of its gateways of spread, which aids the surgeon in prognostication and planning of the surgical approach.
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Sutradhar J, Sarkar B. Manifestations and risk factors of COVID-19 and mucormycosis: A mini-review. JOURNAL OF ACUTE DISEASE 2021. [DOI: 10.4103/2221-6189.330739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Cervantes-Arslanian AM, Anand P. Infectious Vasculitides of the Central Nervous System. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00815-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Challa S. Invasive Fungal Infections of the Central Nervous System in Immune-Competent Hosts. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00384-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Corzo-León DE, Chora-Hernández LD, Rodríguez-Zulueta AP, Walsh TJ. Diabetes mellitus as the major risk factor for mucormycosis in Mexico: Epidemiology, diagnosis, and outcomes of reported cases. Med Mycol 2018; 56:29-43. [PMID: 28431008 DOI: 10.1093/mmy/myx017] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Indexed: 12/16/2022] Open
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.
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Affiliation(s)
- Dora E Corzo-León
- Department of Epidemiology and Infectious Diseases, Hospital General Dr. Manuel Gea González, Mexico City, Mexico.,Medical Mycology and Fungal immunology / Wellcome Trust Strategic Award Program. Aberdeen Fungal Group, University of Aberdeen, Aberdeen, UK
| | - Luis D Chora-Hernández
- Department of Epidemiology and Infectious Diseases, Hospital General Dr. Manuel Gea González, Mexico City, Mexico.,Department of Infectious Diseases. Hospital General No. 1 Instituto Mexicano del Seguro Social. Morelia Michoacan
| | - Ana P Rodríguez-Zulueta
- Department of Epidemiology and Infectious Diseases, Hospital General Dr. Manuel Gea González, Mexico City, Mexico
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program and Infectious Diseases Translational Research Laboratory, Departments of Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine of Cornell University, New York, NY, USA
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Jevalikar G, Sudhanshu S, Mahendru S, Sarma S, Farooqui KJ, Mithal A. Cutaneous mucormycosis as a presenting feature of type 1 diabetes in a boy - case report and review of the literature. J Pediatr Endocrinol Metab 2018; 31:689-692. [PMID: 29672274 DOI: 10.1515/jpem-2017-0404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/05/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mucormycosis is a potentially fatal complication of diabetes. The rhino-orbito-cerebral form is the most common presentation, however, rarely other types can also be seen. CASE PRESENTATION We describe the case of a 4½ -year-old boy not previously known to be a diabetic who presented to the plastic surgery department for gangrene of the left middle finger with surrounding erythema and induration. After the diagnosis of diabetes and initial treatment, pus from the wound showed broad aseptate hyphae suggestive of mucormycosis which was further confirmed on culture. Aggressive surgical debridement including amputation, antifungal treatment and glycemic control achieved a complete cure. CONCLUSIONS Cutaneous mucormycosis is a rare complication of type 1 diabetes mellitus and can even be seen at the onset of diabetes. High index of suspicion, timely antifungal treatment and aggressive surgical debridement usually lead to recovery in the localized form of the disease.
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MESH Headings
- Amputation, Surgical
- Antifungal Agents/therapeutic use
- Child, Preschool
- Debridement
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/surgery
- Diagnosis, Differential
- Fingers/microbiology
- Fingers/pathology
- Fingers/surgery
- Hand Deformities, Acquired/drug therapy
- Hand Deformities, Acquired/microbiology
- Hand Deformities, Acquired/pathology
- Hand Deformities, Acquired/surgery
- Humans
- Male
- Mucormycosis/diagnosis
- Mucormycosis/drug therapy
- Mucormycosis/etiology
- Mucormycosis/surgery
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Affiliation(s)
- Ganesh Jevalikar
- Division of Endocrinology and Diabetes, Medanta Medicity Hospital, Gurugram (Haryana), India
| | - Siddhnath Sudhanshu
- Department of Endocrinology, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow (Uttar Pradesh), India
| | - Sanjay Mahendru
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medanta Medicity Hospital, Gurugram (Haryana), India
| | - Smita Sarma
- Department of Microbiology, Medanta Medicity Hospital, Gurugram (Haryana), India
| | - Khalid J Farooqui
- Division of Endocrinology and Diabetes, Medanta Medicity Hospital, Gurugram (Haryana), India
| | - Ambrish Mithal
- Division of Endocrinology and Diabetes, Medanta Medicity Hospital, Gurugram (Haryana), India
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[Rhino-orbito-cerebral mucormycosis from dental origin: Case report]. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2018; 38:27-31. [PMID: 29668130 DOI: 10.7705/biomedica.v38i0.3383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 04/11/2017] [Indexed: 12/26/2022]
Abstract
Rhino-orbito-cerebral mucormycosis from dental origin is an acute infection caused by opportunistic fungi belonging to the order of Mucorales, which affects mainly diabetic and immunocompromised patients.We report the case of a 63-year old diabetic man who performed a dental extraction on himself by his own means and subsequently developed a rhino-orbito-cerebral mucormycosis with cutaneous and palatal affection. The species isolated in the mycological culture was Rhizopus sp.
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Morales-Avalos R, Santos-Martínez AG, Ávalos-Fernández CG, Mohamed-Noriega K, Sánchez-Mejorada G, Montemayor-Alatorre A, Martínez-Fernández DA, Espinosa-Uribe AG, Mohamed-Noriega J, Cuervo-Lozano EE, Mohamed-Hamsho J, Quiroga-García O, Lugo-Guillen RA, Guzmán-López S, Elizondo-Omaña RE. Clinical and surgical implications regarding morphometric variations of the medial wall of the orbit in relation to age and gender. Eur Arch Otorhinolaryngol 2015; 273:2785-93. [PMID: 26683469 DOI: 10.1007/s00405-015-3862-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
Abstract
The ethmoidal foramens are located on the medial wall of the orbit and are key reference points for intraoperative orientation. Detailed knowledge of the anatomy, bony landmarks and morphometric characteristics of the medial wall of the orbit is essential for various surgical procedures. The aim of this study was to determine the morphometric variations in the medial wall of the orbit and establish significant variations regarding age and gender. A total of 110 orbits were analyzed and subdivided by age (over or under 40 years) and gender. The distances of the medial wall of the orbit between the anterior lacrimal crest, the ethmoidal foramen, the optic canal and the interforamina were determined. Safe surgical areas were sought. Statistical tests were used to determine the differences between groups. In men, there is a safe surgical area proximal to the anterior and posterior ethmoidal foramen. In women, this area is in the posterior third of the medial wall of the orbit between the posterior ethmoidal foramen and the optic canal. Regarding variation according to age, the results of this study suggested that the anteroposterior diameter of the medial wall increases with age. This study showed that the anteroposterior total length of the medial orbit wall is similar between genders of similar age, increases with age, and has significant variations in the distances between the various structures that make up the medial orbit wall with regard to gender and age.
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Affiliation(s)
- Rodolfo Morales-Avalos
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico.
| | - Arlette Gabriela Santos-Martínez
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
| | - Cesia Gisela Ávalos-Fernández
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
| | - Karim Mohamed-Noriega
- Department of Ophthalmology, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, Mexico
| | - Gabriela Sánchez-Mejorada
- Laboratory of Physical Anthropology, Department of Anatomy, Faculty of Medicine, Universidad Nacional Autónoma de México (U.N.A.M.), Mexico, Distrito Federal, Mexico
| | - Adolfo Montemayor-Alatorre
- Service of Otolaryngology and Head and Neck Surgery, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, Mexico
| | - David A Martínez-Fernández
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
| | - Abraham G Espinosa-Uribe
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
| | - Jibran Mohamed-Noriega
- Department of Ophthalmology, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, Mexico
| | - Edgar E Cuervo-Lozano
- Department of Ophthalmology, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, Mexico
| | - Jesús Mohamed-Hamsho
- Department of Ophthalmology, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Monterrey, Nuevo León, Mexico
| | - Oscar Quiroga-García
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
| | - Roberto A Lugo-Guillen
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
| | - Santos Guzmán-López
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
| | - Rodrigo E Elizondo-Omaña
- Anatomy Research Group (GIA), Department of Human Anatomy, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León (U.A.N.L.), Ave. Madero s/n Col. Mitras Centro, C.P.64460, Monterrey, Nuevo León, Mexico
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Clinical features and outcome of mucormycosis. Interdiscip Perspect Infect Dis 2014; 2014:562610. [PMID: 25210515 PMCID: PMC4158140 DOI: 10.1155/2014/562610] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 07/15/2014] [Accepted: 08/07/2014] [Indexed: 12/28/2022] Open
Abstract
Mucormycosis (MCM) is a life-threatening infection that carries high mortality rates despite recent advances in its diagnosis and treatment. The objective was to report 14 cases of mucormycosis infection and review the relevant literature. We retrospectively analyzed the demographic and clinical data of 14 consecutive patients that presented with MCM in a tertiary-care teaching hospital in northern Mexico. The mean age of the patients was 39.9 (range 5-65). Nine of the patients were male. Ten patients had diabetes mellitus as the underlying disease, and 6 patients had a hematological malignancy (acute leukemia). Of the diabetic patients, 3 had chronic renal failure and 4 presented with diabetic ketoacidosis. All patients had rhinocerebral involvement. In-hospital mortality was 50%. All patients received medical therapy with polyene antifungals and 11 patients underwent surgical therapy. Survivors were significantly younger and less likely to have diabetes than nonsurvivors, and had higher levels of serum albumin on admission. The clinical outcome of patients with MCM is poor. Uncontrolled diabetes and age are negative prognostic factors.
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15
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Abstract
Most infectious pathogens have anecdotal evidence to support a link with stroke, but certain pathogens have more robust associations, in which causation is probable. Few dedicated prospective studies of stroke in the setting of infection have been done. The use of head imaging, a clinical standard of diagnostic care, to confirm stroke and stroke type is not universal. Data for stroke are scarce in locations where infections are probably most common, making it difficult to reach conclusions on how populations differ in terms of risk of infectious stroke. The treatment of infections and stroke, when concomitant, is based on almost no evidence and requires dedicated efforts to understand variations that might exist. We highlight the present knowledge and emphasise the need for stronger evidence to assist in the diagnosis, treatment, and secondary prevention of stroke in patients in whom an infectious cause for stroke is probable.
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Abstract
The epidemiology of invasive fungal infections in immunocompromised patients is rapidly changing. Several of the fungi have worldwide distribution. However, some have specific geographical distribution. Sinocranial aspergillosis, mostly described from countries with temperate climates, occurs mostly in otherwise immunocompetent individuals Most of the systemic fungal pathogens have been associated with central nervous system (CNS) involvement. The major advances in CNS fungal infections are in the pathobiology, new diagnostic tools, and new therapies. In spite of these developments, there is still considerable delay in the diagnosis of CNS fungal infection. CNS fungal infections are associated with considerable morbidity and mortality. To achieve good outcomes early diagnosis and early institution of appropriate therapies are the key issues.
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Affiliation(s)
- J M K Murthy
- Continental Institute of Neurosciences & Rehabilitation, Continental Hospitals, IT & Financial District, Gachibowli, Hyderabad, India.
| | - C Sundaram
- Department of Pathology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, India
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17
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Alsuhaibani AH, Al-Thubaiti G, Al Badr FB. Optic nerve thickening and infarction as the first evidence of orbital involvement with mucormycosis. Middle East Afr J Ophthalmol 2013; 19:340-2. [PMID: 22837632 PMCID: PMC3401808 DOI: 10.4103/0974-9233.97957] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a 53-year-old female with uncontrolled diabetes mellitus who presented with decreased vision in the right eye for a few hours duration. Orbital computed tomography and magnetic resonance imaging were performed at presentation and showed a thickening and infarction of the right optic nerve with no other orbital abnormalities. A few days later, the patient developed necrosis in the region of the right medial canthus and nasal mucosa. Tissue biopsy confirmed the diagnosis of mucormycosis.
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Affiliation(s)
- Adel H Alsuhaibani
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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18
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Chaudhry A, Hirano SA, Hayes TJ, Torosky C. Fatal rhino-orbito-cerebral mucormycosis in a patient with liver disease. J Am Acad Dermatol 2011; 65:241-3. [PMID: 21679839 DOI: 10.1016/j.jaad.2010.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 12/29/2009] [Accepted: 01/03/2010] [Indexed: 10/18/2022]
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19
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Herrera DA, Dublin AB, Ormsby EL, Aminpour S, Howell LP. Imaging findings of rhinocerebral mucormycosis. Skull Base 2011; 19:117-25. [PMID: 19721767 DOI: 10.1055/s-0028-1096209] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study was to describe common radiographic patterns that may be useful in predicting the diagnosis of rhinocerebral mucormycosis. METHODS We retrospectively evaluated the imaging and clinical data of four males and one female, 3 to 72 years old, with rhinocerebral mucormycosis. RESULTS All the patients presented with sinusitis and ophthalmological symptoms. Most of the patients (80%) had isointense lesions relative to brain in T1-weighted images. The signal intensity in T2-weighted images was more variable, with only one (20%) patient showing hyperintensity. A pattern of anatomic involvement affecting the nasal cavity, maxillary sinus, orbit, and ethmoid cells was consistently observed in all five patients (100%). Our series demonstrated a mortality rate of 60%. CONCLUSION Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents is the usual evolution of rhinocerebral mucormycosis. In the context of immunosupression, a pattern of nasal cavity, maxillary sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormycosis. Multiplanar magnetic resonance imaging shows anatomic involvement, helping in surgery planning. However, the prognosis is grave despite radical surgery and antifungals.
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Affiliation(s)
- Diego A Herrera
- Department of Radiology, Neuroradiology Section, Universidad de Antioquia, Medellin, Colombia
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20
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Lee EJ, Chung JW, Choi S, Kim YS, Woo JH. [Forefront of diagnosis and treatment of deep-steam mycology in Korea--rhinoorbitocerebral zygomycosis]. ACTA ACUST UNITED AC 2010; 50:229-33. [PMID: 19942794 DOI: 10.3314/jjmm.50.229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mucor is a mold which exists in nature, but mucor infections of humans, even in immunocompromised hosts, are rare. Clinical manifestations of mucormycosis are nonspecific and diagnosis is based on microscopic examination and culture of biopsy specimens. Serologic test or molecular methods of speciation are used only as research tools. We investigated medical records especially for underlying diseases, clinical findings, treatment, and prognosis of patients diagnosed with rhinocerebral mucormycosis retrospectively in the Asan Medical Center. The underlying diseases were diabetes mellitus in 8 patients, acute leukemia in 2, kidney transplantation in 2, and myelodysplastic syndrome in 1 of the total 13 patients. Six patients complained of nasal symptoms including stuffy nose, rhinorrhea, 5 patients complained of ophthalmic symptoms such as decreased visual acuity, diplopia, and ophthalmic pain and 2 of hard palate ulcer. The mortality was 23%(3/13; the two patients with kidney transplant, and one patient with acute leukemia). In summary, mucormycosis should be considered in an uncontrolled DM and an immunocompromised host. The combined modality of early surgical debridement and antifungal agents was used for better treatment of rhinocerebral mucormycosis.
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Affiliation(s)
- Eun Jung Lee
- Department of Infectious Diseases, University of Ulsan College of Medicine, Asan Medical Center
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21
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Fungal infections of the nervous system: Current perspective and controversies in management. Int J Surg 2010; 8:591-601. [DOI: 10.1016/j.ijsu.2010.07.293] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 06/06/2010] [Accepted: 07/21/2010] [Indexed: 01/23/2023]
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22
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Dehority W, Willert J, Pong A. Zygomycetes infections in pediatric hematology oncology patients: a case series and review of the literature. J Pediatr Hematol Oncol 2009; 31:911-9. [PMID: 19855304 DOI: 10.1097/mph.0b013e3181bbc516] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Fungi from the Zygomycetes class are increasingly recognized causes of infection in immunosuppressed children, but no comprehensive literature review and few case series have been published on the topic. A case series of 6 pediatric oncology patients with Zygomycetes infections cared for at our institution was constructed, and a concurrent search of the English language literature for Zygomycetes infections in children with oncologic disorders was undertaken. Our case series described 6 patients (5 male) between the ages of 2.5 and 19.5 years. One patient was diagnosed with rhinocerebral disease, 2 with rhinosinusitis, 2 with pulmonary involvement, and 1 with a gastrointestinal presentation. Five patients survived. Our literature review identified 82 cases from 61 studies. The mean subject age was 10.8 years (1.4 to 21.0 y). About 92.7% of all patients suffered from some form of leukemia, with 70.7% suffering from acute lymphoblastic leukemia. Overall, 58.5% of reported patients survived, with individuals with disseminated disease showing the worst prognosis (68.2% mortality) and those with cutaneous disease the best (14.3% mortality). Survival is increasingly reported in the literature, perhaps as a result of improved diagnostic capabilities, increased physician awareness and increased reliance on adjunctive surgical therapy.
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Affiliation(s)
- Walter Dehority
- Department of Pediatrics, The University of New Mexico Health Sciences Center, Albuquerque, NM 87131-0001, USA.
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23
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Elinav H, Zimhony O, Cohen MJ, Marcovich AL, Benenson S. Rhinocerebral mucormycosis in patients without predisposing medical conditions: a review of the literature. Clin Microbiol Infect 2009; 15:693-7. [PMID: 19624514 DOI: 10.1111/j.1469-0691.2009.02884.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Rhinocerebral mucormycosis is a rare disease, affecting almost exclusively patients with known predisposing conditions such as diabetes mellitus, immunocompromised status, haemochromatosis or major trauma. Subsequent to a case of rhinocerebral mucormycosis in a 78-year-old woman without any known risk factor, we reviewed the published English-language literature and found an additional 72 cases. Reviewing all the published case series of mucormycosis involving any site, the proportion of apparently normal hosts among cases of rhinocerebral mucormycosis was found to be 9.06% (95% confidence interval 6.7-11.8). These findings suggest that rhinocerebral mucormycosis in patients without known predisposing factors is more prevalent than was previously believed.
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Affiliation(s)
- H Elinav
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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24
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Castón-Osorio JJ, Rivero A, Torre-Cisneros J. Epidemiology of invasive fungal infection. Int J Antimicrob Agents 2009; 32 Suppl 2:S103-9. [PMID: 19013332 DOI: 10.1016/s0924-8579(08)70009-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Invasive fungal infection is a growing cause of morbidity and mortality in immunosuppressed patients. Furthermore, the use of azole prophylaxis against Candida species has coincided with an increase in the incidence of invasive aspergillosis and infections by other filamentous fungi such as Mucorales. New risk factors and different timescales for onset have been identified. Knowledge of changes in the epidemiology of, and risk factors for, invasive fungal infection is particularly important when developing therapeutic strategies and effective prophylaxis to improve the prognosis of immunosuppressed patients.
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Affiliation(s)
- J J Castón-Osorio
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain.
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25
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Post-traumatic Lethal Form of Primary Cutaneous Zygomycosis in a Healthy Young Patient and Review of the Literature. J Taibah Univ Med Sci 2009. [DOI: 10.1016/s1658-3612(09)70105-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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26
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27
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Osorio JJC, Román AR, Torre-Cisneros J. [Spectrum and risk factors of invasive fungal infection]. Enferm Infecc Microbiol Clin 2007; 25:467-76. [PMID: 17692214 DOI: 10.1157/13108710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In recent years, invasive fungal infection has become a growing problem in immunosuppressed patients. Simultaneously, changes in medical practice, such as the use of anti-Candida prophylaxis with azoles, has led to a shift in the epidemiology of these infections from Candida spp. to Aspergillus and other filamentous molds. Moreover, new risk factors for invasive fungal infection have been identified and the time of onset is different from that seen a decade ago. Recognition of these trends in patients receiving novel immunosuppressive regimens has important implications for the clinical management of fungal infection in this population.
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Affiliation(s)
- Juan José Castón Osorio
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, España.
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28
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Bengel D, Susa M, Schreiber H, Ludolph AC, Tumani H. Early diagnosis of rhinocerebral mucormycosis by cerebrospinal fluid analysis and determination of 16s rRNA gene sequence. Eur J Neurol 2007; 14:1067-70. [PMID: 17718704 DOI: 10.1111/j.1468-1331.2007.01878.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 40-year-old diabetic woman was diagnosed with rhinocerebral mucormycosis. Cerebral mucormycosis is an acute life-threatening disease, which is caused by fungi of the class Phycomycetae. Clinical suspicion and detection of the fungal hyphae in cerebrospinal fluid (CSF) led to early diagnosis, subsequently confirmed by immunohistochemistry and molecular analysis of fungal RNA. Early infiltration of the infectious agent into the central nervous system resulted in septic thrombosis of the cavernous sinus, mycotic meningoencephalitis, brain infarctions as well as intracerebral and subarachnoidal hemorrhages. Despite immediate high-dose antimycotic treatment, surgical debridement of necrotic tissue, and control of diabetes as a predisposing factor, the woman died 2 weeks after admission. Although fungal organisms are rarely detectable in CSF specimens from patients with mycotic infections of the central nervous system, comprehensive CSF examination is beneficial in the diagnosis of rhinocerebral mucormycosis. Furthermore, a concerted team approach, systemic antifungal agents and early surgical intervention seem to be crucial for preventing rapid disease progression.
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Affiliation(s)
- D Bengel
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
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29
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Diwakar A, Dewan RK, Chowdhary A, Randhawa HS, Khanna G, Gaur SN. Zygomycosis ? a case report and overview of the disease in India. Mycoses 2007; 50:247-54. [PMID: 17576314 DOI: 10.1111/j.1439-0507.2007.01382.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A case of zygomycosis caused by Rhizopus oryzae in a diabetic patient previously misdiagnosed as invasive pulmonary aspergillosis and an overview of the disease in India are presented. The case was diagnosed by direct microscopy, histopathologic examination and culture. Following surgical resection of pulmonary cavity under cover of amphotericin B administration, the patient recovered completely. Of 461 cases reported to-date, approximately 70% had been diagnosed at the Postgraduate Institute of Medical Education and Research, Chandigarh, in north India. This may be attributed to better awareness, expertise and infrastructural facilities for mycological diagnosis than to any particular regional preponderance of the disease. Rhino-orbito-cerebral manifestations were the most common feature of zygomycosis (269 cases), followed by cutaneous disease (66 cases), which is in conformity with the pattern prevalent worldwide. The etiologic agents encountered were Rhizopus oryzae, Apophysomyces elegans, Saksenaea vasiformis, Cunninghamella bertholletiae, Absidia corymbifera, Basidiobolus ranarum and Conidiobolus coronatus. In contrast to cases from the developed world where transplant recipients and patients with haematological malignancies seem to be most vulnerable to zygomycosis, the most common risk factor in India was uncontrolled diabetes mellitus. Amphotericin B was the mainstay of various treatment modalities employed. The relevance of a strong clinical suspicion and early diagnosis of zygomycosis for favourable prognosis can hardly be over-emphasised.
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Affiliation(s)
- Amit Diwakar
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
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30
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Sundaram C, Umabala P, Laxmi V, Purohit AK, Prasad VSSV, Panigrahi M, Sahu BP, Sarathi MV, Kaul S, Borghain R, Meena AK, Jayalakshmi SS, Suvarna A, Mohandas S, Murthy JMK. Pathology of fungal infections of the central nervous system: 17 years' experience from Southern India. Histopathology 2006; 49:396-405. [PMID: 16978203 DOI: 10.1111/j.1365-2559.2006.02515.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To describe the pathology of central nervous system (CNS) fungal infections with particular reference to India. METHODS AND RESULTS This was a retrospective study from 1988 to 2004 constituting 130 cases. The diagnosis was based on morphology of biopsy/autopsy material. These included aspergillosis (n=73), zygomycosis (n=40), cryptococcosis (n=2), rhodotorulosis (n=1), candidiasis (n=5), maduramycosis (n=1), pheohyphomycosis (n=3) and mixed infections (n=5). Predisposing risk factors were present in 49 (38%) patients only. The majority of the patients were immunocompetent. The commonest risk factor was diabetes mellitus, the commonest route of infection was from a contiguous site and the commonest pathology was granuloma. Culture positivity was seen in only 31%. CONCLUSION Environmental factors in tropical countries such as India play a significant role in the pathogenesis of CNS fungal infections.
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Affiliation(s)
- C Sundaram
- Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India.
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31
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Subarachnoid and Intracerebral Hemorrhage: Unusual Complications of Rhinocerebral Mucormycosis. ACTA ACUST UNITED AC 2006. [DOI: 10.1097/01.wnq.0000214022.47237.7c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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32
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Horger M, Hebart H, Schimmel H, Vogel M, Brodoefel H, Oechsle K, Hahn U, Mittelbronn M, Bethge W, Claussen CD. Disseminated mucormycosis in haematological patients: CT and MRI findings with pathological correlation. Br J Radiol 2006; 79:e88-95. [PMID: 16940368 DOI: 10.1259/bjr/16038097] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Disseminated mucormycosis is a rare, mostly fatal infectious complication in immunocompromised haematological patients. The purpose of our study was to describe the multiorgan manifestations of disseminated mucormycosis documented at CT and MRI in four patients and correlate these with the pathological findings and patient outcome. Irrespective of the site of infection, infarction or haemorrhage are the constant features of invasive mycosis. Identification of one or both of these two major imaging findings in immunocompromised patients should be regarded as an indicator of possible infection by angiotropic fungi, including the genre Mucorales.
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Affiliation(s)
- M Horger
- Department of Diagnostic Radiology, Eberhard-Karls-University, Hoppe-Seyler-Str.3, 72076 Tübingen, Germany
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33
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Saalwachter AR, Hedrick T, Sawyer RG. The Other Fungi: It's Not Just Candida albicans Anymore. Surg Infect (Larchmt) 2006; 7:143-50. [PMID: 16629604 DOI: 10.1089/sur.2006.7.143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Candida albicans continues to be the fungus most often causing disease in surgical patients, but with the treatment of an increasing number of critically ill and immunosuppressed patients, other candidal and non-candidal fungal pathogens are becoming more common. METHODS Review of current practice and guidelines. RESULTS The presentation and management of non-C. albicans fungal infections differs depending on the genus and species. The availability of newer anti-fungal agents has in many cases improved outcomes or decreased toxicities associated with these diseases. CONCLUSIONS Although such infections are still relatively uncommon, a working knowledge of infections with non-C. albicans fungi may be beneficial for surgeons, who are likely to encounter such patients both primarily and in consultation. Prompt recognition and treatment of these diseases should improve outcomes.
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Affiliation(s)
- Alison R Saalwachter
- Department of Surgery, University of Virginia, Charlottesville, Virginia 22901, USA
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34
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O'Neill BM, Alessi AS, George EB, Piro J. Disseminated rhinocerebral mucormycosis: a case report and review of the literature. J Oral Maxillofac Surg 2006; 64:326-33. [PMID: 16413907 DOI: 10.1016/j.joms.2005.10.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2004] [Indexed: 10/25/2022]
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35
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Sundaram C, Mahadevan A, Laxmi V, Yasha TC, Santosh V, Murthy JMK, Purohit AK, Mohandas S, Shankar SK. Cerebral zygomycosis. Mycoses 2005; 48:396-407. [PMID: 16262876 DOI: 10.1111/j.1439-0507.2005.01167.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fifty-six patients with cerebral zygomycosis (mucormycosis) were seen during the period 1971-2001 in two tertiary care hospitals located in south India with tropical climate and catering to neurological diseases. Forty-four patients had rhinocerebral and twelve patients had isolated central nervous system (CNS) zygomycosis. Of these, ten were culture proven (Rhizopus oryzae in eight and Mucor in two); 30 were diagnosed as probable and 16 were diagnosed possible; mixed infections were seen in three patients. Diabetes mellitus was the predisposing condition in a majority (31/44) of patients with the rhinocerebral form of zygomycosis. The tissue obtained at biopsy/autopsy in either form showed necrotic/infarcted tissue with neutrophilic infiltration with broad non-septate hyphae showing irregular branching. The outcome was poor despite surgical excision and antifungal therapy. The high concentration of spores in a mouldy environment, the bird population and improper disposal of hospital waste may facilitate healthy hosts presenting with primary CNS disease.
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Affiliation(s)
- C Sundaram
- Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India.
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36
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Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, Sein M, Sein T, Chiou CC, Chu JH, Kontoyiannis DP, Walsh TJ. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis 2005; 41:634-53. [PMID: 16080086 DOI: 10.1086/432579] [Citation(s) in RCA: 1886] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Accepted: 04/18/2005] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease. METHODS We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described. RESULTS The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively). CONCLUSIONS Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.
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Affiliation(s)
- Maureen M Roden
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD 20892, USA
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Abstract
More yeasts and molds are now recognized to cause more human disease than ever before. This development is not due to a change in the virulence of these fungi, but rather to changes in the human host. These changes include immunosuppression secondary to the pandemic of HIV, the use of life-saving advances in chemotherapy and organ transplantation, and the use of corticosteroids and other immunosuppressive agents to treat a variety of diseases. Fungi that were once considered common saprophytes are now recognized as potential pathogens in these patients. This situation necessitates better communication than ever between the clinician, pathologist, and clinical mycologist to ensure the prompt and accurate determination of the cause of fungal diseases.
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Affiliation(s)
- Gary W Procop
- Section of Clinical Microbiology, The Cleveland Clinic Foundation, L40, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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38
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Abstract
We report a case of a rhinocerebral mucormycosis with extensive cavernous sinus thrombophlebitis and internal carotid artery thrombosis. This case illustrates the usual clinical and imaging features of the disease, which is a potentially devastating infection in immunocompromised patients.
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Affiliation(s)
- A L Brun
- Service de Neuroradiologie diagnostique et interventionnelle, Hôpital Lariboisière, Paris
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39
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Abstract
Fungi may infect the cornea, orbit and other ocular structures. Species of Fusarium, Aspergillus, Candida, dematiaceous fungi, and Scedosporium predominate. Diagnosis is aided by recognition of typical clinical features and by direct microscopic detection of fungi in scrapes, biopsy specimens, and other samples. Culture confirms the diagnosis. Histopathological, immunohistochemical, or DNA-based tests may also be needed. Pathogenesis involves agent (invasiveness, toxigenicity) and host factors. Specific antifungal therapy is instituted as soon as the diagnosis is made. Amphotericin B by various routes is the mainstay of treatment for life-threatening and severe ophthalmic mycoses. Topical natamycin is usually the first choice for filamentous fungal keratitis, and topical amphotericin B is the first choice for yeast keratitis. Increasingly, the triazoles itraconazole and fluconazole are being evaluated as therapeutic options in ophthalmic mycoses. Medical therapy alone does not usually suffice for invasive fungal orbital infections, scleritis, and keratitis due to Fusarium spp., Lasiodiplodia theobromae, and Pythium insidiosum. Surgical debridement is essential in orbital infections, while various surgical procedures may be required for other infections not responding to medical therapy. Corticosteroids are contraindicated in most ophthalmic mycoses; therefore, other methods are being sought to control inflammatory tissue damage. Fungal infections following ophthalmic surgical procedures, in patients with AIDS, and due to use of various ocular biomaterials are unique subsets of ophthalmic mycoses. Future research needs to focus on the development of rapid, species-specific diagnostic aids, broad-spectrum fungicidal compounds that are active by various routes, and therapeutic modalities which curtail the harmful effects of fungus- and host tissue-derived factors.
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Affiliation(s)
- Philip A Thomas
- Department of Ocular Microbiology, Institute of Ophthalmology, Joseph Eye Hospital, Tiruchirapalli 620001, India.
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40
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Abstract
OBJECTIVE To describe a case of mucormycosis in systemic lupus erythematosus (SLE) and to review other patients reported in the English literature. METHOD A Medline search for articles about mucormycosis in SLE published between 1970 and 2002 was performed by using the key words "lupus," "mucormycosis," "zygomycosis," "Mucorales," "Rhizopus," and "Mucor." Cases were pooled for analysis, and the mycology, diagnosis, treatment, and outcome of mucormycosis in SLE was reviewed. RESULTS Eight cases of mucormycosis in SLE were identified (female:male = 7:1). The mean age at the time of infection was 31.8 +/- 7.6 years and the mean duration of SLE was 6.3 +/- 3.9 years. All except 1 patient had active lupus and all were receiving high-dose corticosteroids. Concomitant cytotoxic agents were used in 4 patients. Additional predisposing factors for opportunistic infection included hypocomplementemia, nephrotic syndrome, uremia, leukopenia, and diabetes mellitus. The disseminated form of mucormycosis was the most common presentation and the diagnosis often was made only at autopsy (63%). For cases with positive culture results, Rhizopus was the causative species. In 4 patients, manifestations of the fungal infection mimicked those of active SLE. The overall mortality of mucormycosis was very high (88%) and, in most cases, was probably a function of delayed diagnosis and treatment. The cutaneous form appeared to have the best prognosis with combined medical and surgical treatment. CONCLUSIONS Mucormycosis is a rare but usually fatal fungal infection in SLE. Judicious use of immunosuppressive agents, a high index of suspicion, early diagnosis, and combination treatment with amphotericin B and surgical debridement may improve the prognosis of this serious infection.
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Affiliation(s)
- Chi Chiu Mok
- Departments of Medicine, Microbiology, Radiology, and Pathology, Tuen Mun Hospital, Hong Kong, China.
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41
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Kofteridis DP, Karabekios S, Panagiotides JG, Bizakis J, Kyrmizakis D, Saridaki Z, Gikas A. Successful treatment of rhinocerebral mucormycosis with liposomal amphotericin B and surgery in two diabetic patients with renal dysfunction. J Chemother 2003; 15:282-6. [PMID: 12868556 DOI: 10.1179/joc.2003.15.3.282] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The zygomycetes are a class of fungi that can cause a variety of infections in humans. Rhinocerebral mucormycosis is a rare disease and usually affects diabetic or immunosuppressed patients. The disease progresses rapidly and is usually fatal despite aggressive surgical and medical therapy. We report the management of two cases of rhino-sinusal and orbital mucormycosis in diabetic patients on treatment with corticosteroids, and mild renal impairment, successfully treated with a combination of aggressive surgical debridement and liposomal amphotericin B.
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Affiliation(s)
- D P Kofteridis
- Department of Internal Medicine, University of Crete School of Medicine, University Hospital Heraklion, Crete, Greece.
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42
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Abstract
Zygomycosis, an uncommon but frequently fatal mycosis caused by fungi of the class Zygomycetes, develops most commonly as an opportunistic disease. Successful therapy involves a combined approach based on early diagnosis, prompt institution of medical therapy, and extensive surgical debridement of all devitalized tissue. Given the rarity of this condition, novel therapeutic strategies have been limited and only tested on an individual basis. The use of high-dose lipid formulations of amphotericin B, prompt reversal of the underlying predisposing condition, and hyperbaric oxygen are the most common strategies that have shown potential value in the treatment of zygomycosis.
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Affiliation(s)
- Corina E Gonzalez
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA.
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43
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Talmi YP, Goldschmied-Reouven A, Bakon M, Barshack I, Wolf M, Horowitz Z, Berkowicz M, Keller N, Kronenberg J. Rhino-orbital and rhino-orbito-cerebral mucormycosis. Otolaryngol Head Neck Surg 2002; 127:22-31. [PMID: 12161726 DOI: 10.1067/mhn.2002.126587] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating infection of immunocompromised hosts. We present our experience with 19 ROCM cases and attempt to define preferred diagnostic and treatment protocols. METHODS All had tissue biopsies obtained studied by direct smear, histologic studies, and cultures. Imaging was obtained in 14 cases. RESULTS Sixteen patients presented between August and November. Six had mixed fungal infections. Seven patients had end-stage underlying disease or infection and did not undergo surgery and 4 had an indolent form of disease. Patients were treated by surgery and by amphotericin B. The overall survival was 47%. CONCLUSIONS ROCM may have seasonal incidence peaking in the fall and early winter. The therapeutic approach should be unchanged in cases of mixed fungal infections. Amphotericin B with aggressive debridement remains the mainstay of treatment. Early recognition and treatment are essential. A presentation and survival-dependent classification of ROCM are offered.
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Affiliation(s)
- Yoav P Talmi
- Departments of Otolaryngology-Head and Neck Surgery, The Chaim Sheba Medical Center, Israel.
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Mondy KE, Haughey B, Custer PL, Wippold FJ, Ritchie DJ, Mundy LM. Rhinocerebral mucormycosis in the era of lipid-based amphotericin B: case report and literature review. Pharmacotherapy 2002; 22:519-26. [PMID: 11939688 DOI: 10.1592/phco.22.7.519.33679] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Rhinocerebral mucormycosis (RCM) is an invasive fungal infection that necessitates, in most cases, aggressive surgical debridement and high cumulative, often nephrotoxic doses of amphotericin B. A 50-year-old woman with RCM was treated successfully with amphotericin B lipid complex as primary therapy. The patient previously had displayed progressive intracranial involvement and rising serum creatinine levels while receiving the conventional (nonlipid) form of amphotericin B. A literature review identified only a few cases where systemic antifungal therapy was administered, with minimal or no surgery. Our case further supports that amphotericin B lipid complex can be used as primary therapy in selected patients with RCM, without the need for surgical exenteration.
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Affiliation(s)
- Kristin E Mondy
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri 63110, USA
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45
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Singh J, Burr B, Stringham D, Arrieta A. Commonly used antibacterial and antifungal agents for hospitalised paediatric patients: implications for therapy with an emphasis on clinical pharmacokinetics. Paediatr Drugs 2002; 3:733-61. [PMID: 11706924 DOI: 10.2165/00128072-200103100-00003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Due to normal growth and development, hospitalised paediatric patients with infection require unique consideration of immune function and drug disposition. Specifically, antibacterial and antifungal pharmacokinetics are influenced by volume of distribution, drug binding and elimination, which are a reflection of changing extracellular fluid volume, quantity and quality of plasma proteins, and renal and hepatic function. However, there is a paucity of data in paediatric patients addressing these issues and many empiric treatment practices are based on adult data. The penicillins and cephalosporins continue to be a mainstay of therapy because of their broad spectrum of activity, clinical efficacy and favourable tolerability profile. These antibacterials rapidly reach peak serum concentrations and readily diffuse into body tissues. Good penetration into the cerebrospinal fluid (CSF) has made the third-generation cephalosporins the agents of choice for the treatment of bacterial meningitis. These drugs are excreted primarily by the kidney. The carbapenems are broad-spectrum beta-lactam antibacterials which can potentially replace combination regimens. Vancomycin is a glycopeptide antibacterial with gram-positive activity useful for the treatment of resistant infections, or for those patients allergic to penicillins and cephalosporins. Volume of distribution is affected by age, gender, and bodyweight. It diffuses well across serous membranes and inflamed meninges. Vancomycin is excreted by the kidneys and is not removed by dialysis. The aminoglycosides continue to serve a useful role in the treatment of gram-negative, enterococcal and mycobacterial infections. Their volume of distribution approximates extracellular space. These drugs are also excreted renally and are removed by haemodialysis. Passage across the blood-brain barrier is poor, even in the face of meningeal inflammation. Low pH found in abscess conditions impairs function. Toxicity needs to be considered. Macrolide antibacterials are frequently used in the treatment of respiratory infections. Parenteral erythromycin can cause phlebitis, which limits its use. Parenteral azithromycin is better tolerated but paediatric pharmacokinetic data are lacking. Clindamycin is frequently used when anaerobic infections are suspected. Good oral absorption makes it a good choice for step-down therapy in intra-abdominal and skeletal infections. The use of quinolones in paediatrics has been restricted and most information available is in cystic fibrosis patients. High oral bioavailability is also important for step-down therapy. Amphotericin B has been the cornerstone of antifungal treatment in hospitalised patients. Its metabolism is poorly understood. The half-life increases with time and can be as long as 15 days after prolonged therapy. Oral absorption is poor. The azole antifungals are being used increasingly. Fluconazole is well tolerated, with high bioavailability and good penetration into the CSF. Itraconazole has greater activity against aspergillus, blastomycosis, histoplasmosis and sporotrichosis, although it's pharmacological and toxicity profiles are not as favourable.
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Affiliation(s)
- J Singh
- Division of Infectious Disease, Children's Hospital of Orange County, Orange, California 92868, USA
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Schoen C, Reichard U, Monod M, Kratzin HD, Rüchel R. Molecular cloning of an extracellular aspartic proteinase from Rhizopus microsporus and evidence for its expression during infection. Med Mycol 2002; 40:61-71. [PMID: 11860014 DOI: 10.1080/mmy.40.1.61.71] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
An extracellular aspartic proteinase (Rmap) from Rhizopus microsporus var. rhizopodiformis was detected in the culture supernatant of a fungal isolate from a case of rhinocerebral mucormycosis (case HA). The proteinase was purified to near homogeneity by ion exchange and affinity chromatography on pepstatin agarose. Based on its N-terminus the RMAP gene was cloned and found to code for 388 amino acids. The preproenzyme has an aminoterminal leader sequence of 65 amino acids, whereas the mature enzyme consists of 323 amino acids. The deduced amino-acid sequence of the preproenzyme was 82% homologous to an extracellular aspartic proteinase of Rhizopus niveus. Low stringency Southern blot analysis of R. microsporus DNA suggested the presence of other homologous genes. Expression of Rmap in Pichia pastoris was achieved, and the recombinant enzyme was active in the yeast culture supernatant. Both enzyme preparations exhibited a similar optimum of activity in the pH 2.5 region. Furthermore, Rmap was shown to activate bovine blood coagulation factor X at slightly acidic pH in vitro. Expression of the proteinase during mycosis was proven by a specific immune response of patient HA.
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Affiliation(s)
- C Schoen
- Department of Bacteriology, University of Göttingen, Germany
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47
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 3-2001. A 59-year-old diabetic man with unilateral visual loss and oculomotor-nerve palsy. N Engl J Med 2001; 344:286-93. [PMID: 11172157 DOI: 10.1056/nejm200101253440408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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48
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Abstract
Although Zygomycetes cause life-threatening, opportunistic infections in immunocompromised hosts, the first case of vaginitis caused by Mucor species in a healthy woman is reported. Mucor vaginitis, which caused mild symptoms only, was refractory to conventional azole therapy and resistant to flucytosine. Cure was achieved with topical amphotericin B.
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Affiliation(s)
- J D Sobel
- Division of Infectious Diseases, Detroit Medical Center, Wayne State University School of Medicine, MI, USA.
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49
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Zarei M, Morris J, Aachi V, Gregory R, Meanock C, Brito-Babapulle F. Acute isolated cerebral mucormycosis in a patient with high grade non-Hodgkins lymphoma. Eur J Neurol 2000; 7:443-7. [PMID: 10971606 DOI: 10.1046/j.1468-1331.2000.00089.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 57-year-old female in complete remission of grade IV non-Hodgkin lymphoma whilst on intensive chemotherapy, suddenly developed unilateral hemispheric stroke with a fatal outcome in 3 days. She was apyrexial and had received antifungal prophylaxis during her treatment. Post-mortem examination showed complete thrombosis of the internal carotid artery leading to infarction in the territory of the middle and anterior cerebral arteries. Microscopic examination of the brain showed involvement of intra-cranial vessel walls and brain parenchyma by mucormyces, with no evidence of systemic mucormycosis. Isolated cerebral mucormycosis is a rare occurrence, more commonly found in intravenous drug abusers, but can occur in patients with haematological malignancy.
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Affiliation(s)
- M Zarei
- Department Royal Berkshire Hospital, Reading, UK.
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50
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Cellulite quand tu nous tiens! Rev Med Interne 2000. [DOI: 10.1016/s0248-8663(00)89285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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