Disseminated Mucormycosis in Immunocompromised Children: Are New Antifungal Agents Making a Difference? A Multicenter Retrospective Study

BACKGROUND

Mucormycosis is a life-threatening infection with a tendency for angioinvasion that may lead to progressive dissemination. Disseminated mucormycosis, defined as the involvement of two or more non-contiguous sites, is rare in children, and data concerning its management and outcome are scarce. The aim of this study was to assess the contemporary management strategies and outcomes of disseminated mucormycosis in the pediatric population.

METHODS

We conducted a retrospective search in six large tertiary medical centers for all cases of disseminated mucormycosis that occurred between 2009-2020 in patients aged 1-20 years.

RESULTS

Twelve cases were identified. Underlying conditions included hematological malignancies (n = 10), solid tumor (post-autologous hematopoietic stem cell transplantations; n = 1), and solid organ (liver) transplantation (n = 1). In all cases, amphotericin B formulations were administered as first-line therapy; in eight cases, they were also administered in combination with an echinocandin or triazole. Seven patients underwent surgical debridement procedures. The six-week mortality was 58%. Among the patients diagnosed between 2009-2015, one of the six survived, and of those diagnosed between 2016-2020, four of the six were salvaged.

CONCLUSIONS

Disseminated mucormycosis is a life-threatening and often fatal disease, and improved diagnostic and therapeutic strategies are needed. Nevertheless, in this population-based study, five patients (42%) were salvaged through combined liposomal amphotericin/triazole treatment and extensive surgical interventions.

FDG PET/CT for Detection of Infectious Complications Following Solid Organ Transplantation

Infectious complications after solid organ transplantation (SOT) are often more severe and remain a diagnostic challenge due to vague and atypical clinical presentations. Diagnostic performance of conventional diagnostic tools is frequently inadequate which may lead to delayed diagnosis with the risk of poorer outcomes. This literature review aimed to investigate the current evidence on the use of ¹⁸F-fluoro-deoxy-glucose (FDG) Positron Emission Tomography (PET)/computer tomography (CT) in infectious complications after SOT. Based on search in PubMed, Medline, and Cochrane databases, 13 articles and 46 case reports were included. For inclusion, articles were to include data on patients with infectious complications after SOT, and where FDG PET/CT was part of the work-up. Final searches were conducted on 02 September 2020. Overall, in the absence of initial diagnostic clues, FDG PET/CT should be considered as the imaging technique of choice as it may guide further investigations and eventually reveal the diagnosis in most of the patients. However, the available literature of the role of FDG PET/CT in SOT recipients with infectious complications is scarce and well-designed prospective studies including control groups are warranted to establish the role of FDG PET/C/ in SOT recipients. The main drawback of FDG PET/CT is the lack of ability to differentiate between cancer and infectious diseases which are both highly prevalent in this patient group. Accordingly, the main reasons for "false" results of FDG PET/CT is the misdiagnosis of cancer in benign inflammatory or infectious processes, information which nonetheless can be useful.

Successful posaconazole salvage therapy for rhinocerebral mucormycosis in a child with leukemia. Review of the literature

BACKGROUND

Mucormycosis is a fungal infection caused by species of the Mucorales order. These microorganisms are angioinvasive, with rapid disease progression and potentially lethal in its rhinocerebral form.

CASE REPORT

We present the case of a 12-year-old female with trisomy 21, acute lymphoblastic leukemia and diabetes, with fever and neutropenia who developed rhinocerebral mucormicosis. After treatment with amphotericin B lipid complex and extensive surgery, disease progressed and posaconazole was added as salvage treatment with full remission of the infection. Four years after diagnosis the patient continues without relapse of mucormycosis or leukemia.

CONCLUSIONS

This case highlights the use of posaconazole as either monotherapy or combined therapy. Although it is still debated, it can be considered an option for salvage treatment in children with non-responding mucormycosis, despite lack of standard dosage in pediatric patients.

Simultaneous or sequential gastrectomy in pediatric liver transplant recipients

The association between LT and gastrectomy is not common. Only two studies reported the gastrectomy/LT association in children. Here, we report three children who underwent LT who required a concomitant or sequential gastrectomy for different reasons. Patient 1, a 16-yr-old boy, during the LT, underwent a partial gastrectomy due to extensive injury to the duodenum. He had a previous and unusual portoenterostomy performed in the duodenum. Bowel reconstruction was performed using an intestinal loop that was first used for the bilio-enteric anastomosis and then connected to the gastric stump. Patient 2, a 22-month-old female child, underwent a partial gastrectomy with a Roux-en-Y reconstruction during a retransplantation. She had a large perforated gastric ulcer blocked by the allograft liver. Patient 3, a 26-month-old male child, five yr after living donor LT, was submitted to a partial gastrectomy because of gastric outlet obstruction. The histopathology was compatible with eosinophilic gastritis. The association between LT and gastrectomy in the pediatric population is extremely rare. Appropriate knowledge of the previous transplantation technique is very important. Further studies are required to assess the outcomes of the different types of gastric reconstruction in pediatric recipients.

Mucormycosis in a renal transplant recipient: case report and comprehensive review of literature

Mucormycosis is a rare but devastating infection. We present a case of fatal disseminated mucormycosis infection in a renal transplant patient. Uncontrolled diabetes mellitus and immunosuppression are the major predisposing factors to infection with Mucorales. Mucorales are angioinvasive and can infect any organ system. Lungs are the predominant site of infection in solid organ transplant recipients. Prompt diagnosis is challenging and influences outcome. Treatment involves a combination of surgical and medical therapies. Amphotericin B remains the cornerstone in the medical management of mucormycosis, although other agents have been used. Newer agents are promising.