Multiple major cerebral artery thromboses with profound thrombocytopenia in acute leukaemia

The surgical management of rhinocerebral mucormycosis

BACKGROUND

Rhinocerebral mucormycosis is a rare, rapidly progressive life threatening opportunistic fungal disease that usually occurs in immunocompromised patients.

AIM

The aim of the study is to present a case series of six immunocompromised patients who were diagnosed with rhinocerebral mucormycosis, review the diagnostic criteria and treatment approach.

PATIENTS AND MATERIALS

Six patients were treated in our department between the years 2005-2010. Their diagnostic criteria, surgical treatment and mortality rate are analyzed and discussed.

RESULTS

All six immunocompromised patients suffered from a primary hematological malignancy and received chemotherapy to treat their primary disease. Symptoms such as pain mimicking sinusitis, facial swelling, oral or dental pain, and fever were found in most patients. The diagnosis was based on both clinical signs and a biopsy for microbiological culture and histological examination. All patients underwent aggressive surgical resection and were treated simultaneously with anti fungal therapy. Four patients died from their primary illness. One patient died due to uncontrolled spreading of mucormycosis and one patient, the youngest and with the most extensive form of the disease (brain invasion) survived and clinically recovered with no evidence of recurrent disease following the surgical management.

CONCLUSIONS

Rhinocerebral mucormycosis is a rapidly progressing disease with a high mortality rate, which requires immediate surgical and medical intervention. It seems from the data presented that the presence of mucormycosis is an ominous sign in immunocompromised patients. The extent of the disease is of less prognostic value, since the only patients in our series who survived had the most extensive disease, yet his primary haemato-oncological disease was under control. Controlling the underlying disease with early diagnosis and aggressive surgical intervention appears to be the most important factor for survival.

Zygomycetes infections in pediatric hematology oncology patients: a case series and review of the literature

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.

Role of infection in the death of children with acute lymphoblastic leukaemia

Twenty-four consecutive deaths from a total of 70 children receiving treatment for acute lymphoblastic leukaemia (ALL) have been reviewed. An attempt has been made to ascribe the cause of death to either infection, haemorrhage, the leukaemia itself, or a combination of these factors. No child was free of infection at death. Infection, with or without haemorrhage, was responsible for the deaths of all 15 children whose leukaemia had not relapsed. Although infection was present at death in all 9 children whose leukaemia had relapsed, the leukaemia process itself was also a major contributing factor. Viruses were associated with death in many of the children and may be emerging as important pathogens in children with ALL. Familiarity with a protocol may be an important factor in the prevention of fatal infections in such children. Centralization of treatment is necessary if this expertise is to be acquired.