Rhinocerebral zygomycosis in a young girl undergoing allogeneic stem cell transplantation for severe aplastic anaemia

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.

Antifungal combinations in Mucorales: A microbiological perspective

Mucormycosis mostly affects immunocompromised patients and is associated with a high morbidity and mortality despite currently available treatments. In that context, combination therapy might be the key to a better outcome for these patients. Purpose of this review is to summarise and to discuss the current combination data obtained in vitro, in vivo in animal models of mucormycosis, and in patients. In vitro combination studies showed that most of the interactions between antifungal drugs were indifferent, even though that some synergistic interactions were achieved for the combination of echinocandins with either azoles or amphotericin B. Importantly, antagonism was never observed. Animal models of mucormycosis focused on infections caused by Rhizopus arrhizus, neglecting most other species responsible for human disease. In these experimental animal models, no strong interactions have been demonstrated, although a certain degree of synergism has been reported in some instances. Combinations of antifungals with non-antifungal drugs have also been largely explored in vitro and in animal models and yielded interesting results. In patients with ketoacidosis and rhino-orbito-cerebral infection, combination of polyene with caspofungin was effective. In contrast, despite promising experimental data, adjunctive therapy with the iron chelator deferasirox was unfavourable and was associated with a higher mortality than monotherapy with liposomal amphotericin B. More combinations have to be tested in vitro and a much larger panel of Mucorales species has to be tested in vivo to give a valuable statement if antifungal combination therapy could be an effective treatment strategy in patients with mucormycosis.

Rare Orbital Infections ~ State of the Art ~ Part II

Infections of the orbit and periorbita are relatively frequent. Identifying unusual organisms is crucial because they can cause severe local and systemic morbidity, despite their rarity. Opportunistic infections of the orbit should be considered mainly in debilitated or immunocompromised patients. The key to successful management includes a high index of suspicion, prompt diagnosis, and addressing the underlying systemic disease. This review summarizes unusual infectious processes of the orbit, including mycobacterial, fungal, and parasitic infections, as well as their pathophysiology, symptoms, signs, and treatment.

Successful Treatment of Rhino-Orbital-Cerebral Mucormycosis in a Child With Leukemia

Rhino-orbital-cerebral mucormycosis (ROCM) is a rare fulminant opportunistic fungal infection that despite relevant treatment has high mortality. We present a case of a 3-year-old girl with acute lymphoblastic leukemia and ROCM, who was treated successfully with excessive surgery, systemic antifungal treatment with amphotericin B (AmB), posaconazole, and terbinafine as well as hyperbaric oxygen. Surgery included, beside extracranial and intracranial removal of infected areas, endoscopic sinus and skull base surgery with local AmB installation and in addition placement of an Ommaya reservoir for 114 intrathecal administrations of AmB. In addition, we review the literature of ROCM in pediatric patients with hematological diseases.

Safety, Tolerability, and Pharmacokinetics of Liposomal Amphotericin B in Immunocompromised Pediatric Patients

The safety, tolerability, and pharmacokinetics of the liposomal formulation of amphotericin B (L-AMB) were evaluated in 40 immunocompromised children and adolescents. The protocol was an open-label, sequential-dose-escalation, multidose pharmacokinetic study with 10 to 13 patients in each of the four dosage cohorts. Each cohort received daily dosages of 2.5, 5.0, 7.5, or 10 mg of amphotericin B in the form of L-AMB per kg of body weight. Neutropenic patients between the ages of 1 and 17 years were enrolled to receive empirical antifungal therapy or treatment of documented invasive fungal infections. The pharmacokinetic parameters of L-AMB were measured as those of amphotericin B by high-performance liquid chromatography and calculated by noncompartmental methods. There were nine adverse-event-related discontinuations, four of which were related to infusions. Infusion-related side effects occurred for 63 (11%) of 565 infusions, with 5 patients experiencing acute infusion-related reactions (7.5- and 10-mg/kg dosage levels). Serum creatinine levels increased from 0.45 ± 0.04 mg/dl to 0.63 ± 0.06 mg/dl in the overall population (P = 0.003), with significant increases in dosage cohorts receiving 5.0 and 10 mg/kg/day. At the higher dosage level of 10 mg/kg, there was a trend toward greater hypokalemia and vomiting. The area under the concentration-time curve from 0 to 24 h (AUC_0-24) values for L-AMB on day 1 increased from 54.7 ± 32.9 to 430 ± 566 μg · h/ml in patients receiving 2.5 and 10.0 mg/kg/day, respectively. These findings demonstrate that L-AMB can be administered to pediatric patients at dosages similar to those for adults and that azotemia may develop, especially in those receiving ≥5.0 mg/kg/day.

Rhino-Orbital-Cerebral Mycosis and Cavernous Thrombosis

Rhino-orbital-cerebral mycosis (ROCM) is a life-threatening fungal disease associated mostly with Mucoralean fungi. The infection presents as headache, vision loss, proptosis, ptosis, painful ophthalmoplegia, and peripheral face palsy, with a high mortality (>80% for infections that spread to the brain) and severe morbidity, such as eyeball exenteration and vision loss. In our hospital, a 61-year-old woman with diabetes was diagnosed with rhino-orbital-cerebral infection caused by Alternaria infectoria. Cavernous sinus thromboses (CST) were seen in surgery, pathology, and MRI. She did not respond to potent antifungal therapy until the adding of anti-thrombosis drugs. By analyzing our case, together with the ones that have been published, we realized that fungal thrombosis in the cavernous sinus is the main pathophysiological problem in ROCM that typically shows mass enhancement within the cavernous sinus in radiographic images, thrombosis with characteristics of ischemia and infarction in pathology. Anticoagulation/antithrombus therapy might be helpful in the management of ROCM if potent antifungal treatment does not have effect.

Rhinocerebral zygomycosis with pansinusitis in a 14-year-old girl with type 1 diabetes: a case report and review of the literature

Background

Zygomycosis is a rare life-threatening fungal infection affecting mostly patients with predisposing conditions such as diabetes mellitus, immunodeficiency, haemochromatosis or major trauma.

Methods

We describe a case of rhinocerebral zygomycosis in a girl with type 1 diabetes and review previous published cases and treatment options.

Results

A 14-year-old girl with type 1 diabetes mellitus occurred with dental pain, facial swelling, ecchymosis and left eye decreased visual acuity, unresponsive to antibiotic therapy. The coltures of the sinusal mucosa were positive for fungal species belonging to the Zygomycetes. She performed antifungal therapy with posaconazole (POS) with a very slow improvement and a poor glycemic control, leading to blindness of the left eye.

Conclusion

Our report adds further awareness on rhinocerebral zygomycosis and emphasizes on urgent diagnosis and timely management of this potentially fatal fungal infection through an adequate treatment.

Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation

PURPOSE

To develop an evidence-based guideline for the empiric management of pediatric fever and neutropenia (FN).

METHODS

The International Pediatric Fever and Neutropenia Guideline Panel is a multidisciplinary and multinational group composed of experts in pediatric oncology and infectious disease as well as a patient advocate. The Panel was convened for the purpose of creating this guideline. We followed previously validated procedures for creating evidence-based guidelines. Working groups focused on initial presentation, ongoing management, and empiric antifungal therapy. Each working group developed key clinical questions, conducted systematic reviews of the published literature, and compiled evidence summaries. The Grades of Recommendation Assessment, Development, and Evaluation approach was used to generate summaries, and evidence was classified as high, moderate, low, or very low based on methodologic considerations.

RESULTS

Recommendations were made related to initial presentation (risk stratification, initial evaluation, and treatment), ongoing management (modification and cessation of empiric antibiotics), and empiric antifungal treatment (risk stratification, evaluation, and treatment) of pediatric FN. For each recommendation, the strength of the recommendation and level of evidence are presented.

CONCLUSION

This guideline represents an evidence-based approach to FN specific to children with cancer. Although some recommendations are similar to adult-based guidelines, there are key distinctions in multiple areas. Implementation will require adaptation to the local context.

Mucormycosis treated with posaconazole: review of 96 case reports

Mucormycosis is an emerging invasive fungal infection, primarily affecting immunocompromised patients. The disease is difficult to diagnose and mortality reaches 40% even if treated adequately. Depending on site of infection and risk factors, surgical debridement in combination with systemically active antifungal drugs are the mainstay treatment strategies. Lipid-based amphotericin B is the treatment of choice for first-line therapy while posaconazole may be a promising alternative. We performed a PubMed search on reports of patients with mucormycosis treated with posaconazole. From 2003 to 2011, 96 cases have been published. Diagnosis was based on histology alone in 2 (2.1%) and microbiological evidence in 67 (69.8%), while no data on the diagnostic approach was reported in 27 (28.1%) patients. The most frequent pathogens were Rhizopus spp. (31.2%), followed by Mucor spp. (14.6%). The site of infection was predominantly rhino-orbital (38.5%, of which 43% also had central nervous system [CNS] involvement), followed by disseminated disease (22.1%). A complete response was achieved in 62 (64.6%), partial response in 7 (7.3%) patients, and stable disease in 1 (1%). Overall mortality was 24% (lacking data for three patients). In published case reports on posaconazole treatment for mucormycosis, the drug was frequently and successfully used in combination or as second line therapy.

Posaconazole for the treatment of mucormycosis

Posaconazole (PCZ) is an orally administered, extended-spectrum triazole antifungal agent with activity against the Mucorales. This article describes the clinical and laboratory data supporting its use against this rare group of pathogens. To date, PCZ has been mostly used for salvage therapy and at present there is no strong published clinical evidence to support its role as a single agent in the treatment of mucormycosis. Further studies are required to explore its role as a single agent and in combination therapy for the management of these infections.

Posaconazole: when and how? The clinician's view

Posaconazole is the newest triazole antifungal agent available as an oral suspension with an extended spectrum of activity against Candida species, Aspergillus species, Cryptococcus neoformans, Zygomycetes and endemic fungi. Among posaconazole advantages are the relatively low potential of cross-resistance with other azoles, few drug interactions compared with other azoles and its activity against Zygomycetes. Randomised, double-blind trials have shown that posaconazole is effective for prophylaxis against invasive fungal infections (IFI), especially aspergillosis, in high-risk patients. Results of Phase III clinical trials and case/series reports indicate that posaconazole is effective in treating oesophageal candidiasis, including azole-refractory disease, and other IFI refractory to standard antifungal therapies. To date, posaconazole has appeared to be well tolerated even in long-term courses; it has an excellent safety profile with gastrointestinal disturbances being the most common adverse events reported. The dose of posaconazole is 200 mg three times daily for prophylaxis, 800 mg daily in two or four divided doses for the treatment of IFI and 100 mg daily (200 mg loading dose) for the treatment of oropharyngeal candidiasis. On the basis of early clinical experience, it appears that posaconazole will be a valuable aid in the management of life-threatening fungal infections.

Zygomycosis presenting a major clinical challenge: case report on Rhizomucor pusillus infection in a stem-cell-transplant recipient

Zygomycoses are opportunistic infections caused by the Mucorales fungi. They are typically seen in immunosuppressed patients. The incidence of zygomycosis cases seems to be increasing. We report on zygomycosis in a pediatric, female stem-cell-transplant recipient. This case report underlines the difficulty of taking care of patients with zygomycosis. In fungal infections of immunosuppressive patients on broad-coverage antibiotics, foci of skin necrosis are unique and typical for zygomycoses, and may be helpful in this challenging diagnosis.

Posaconazole for paediatric patients: status of development and future perspectives

Posaconazole is a novel oral antifungal triazole with potent and broad-spectrum antifungal activity, favourable pharmacokinetic properties and a limited spectrum of adverse events. The compound has documented clinical efficacy in the settings of oropharyngeal candidiasis, refractory aspergillosis, fusariosis, zygomycosis, and as antifungal prophylaxis in high-risk patients with acute myeloblastic leukaemia or graft-vs.-host disease. Whereas, posaconazole is approved for use in adults, however, the appropriate dosage and the safety of the compound have not been systematically investigated in paediatric age groups. This paper reviews the relevant pharmacological characteristics of posaconazole, the published data on its use in paediatric patients without therapeutic alternative and perspectives for the clinical development in paediatric patients at risk for invasive fungal infections.

Alternaria species infection in nine domestic cats

A case series of nine domestic cats with culture-confirmed Alternaria species infection is presented, with conclusions drawn regarding signalment, clinical signs, treatment and outcome. Middle aged neutered males were over-represented and all presented with cutaneous lesions involving the extremities (nose, pinnae and digits). Lesions were mainly slow-growing, poorly circumscribed nodules or plaques but some also presented as non-healing wounds. A combination of surgical excision with adjunctive medical therapy appeared to be the most successful treatment option but long courses of medical therapy were generally required and recurrence was common.