[Successful treatment of a persistent rhino-cerebral mucormycosis in a pediatric patient with a debut of acute lymphoblastic leukemia]

Diagnosis and rehabilitation of an infant with palatal mucormycosis: A clinical report and systematic literature review

STATEMENT OF PROBLEM

Oral mucormycosis is uncommon in pediatric patients with hematolymphoid diseases. Prosthetic rehabilitation is challenging, and protocols are scarce in the literature.

PURPOSE

The purpose of this clinical report and systematic literature review of case reports and case series was to describe the clinicopathologic aspects of oral mucormycosis and the interim prosthetic rehabilitation of an affected infant.

MATERIAL AND METHODS

The clinical lesions were ulcerative and necrotic with underlying bone exposure that affected the hard palate. The affected area underwent surgical debridement, and histopathologic analysis was performed. A literature search in PubMed/MEDLINE, Embase, Scopus, and Web of Science up to October 2023 was performed.

RESULTS

The histopathological features were consistent with mucormycosis. Topical and systemic antifungals were prescribed. Tooth eruption was insufficient, and an acetate plate without clasp retention, but still with adequate retention, was fabricated. Articulatory, masticatory, and swallowing functions were restored, preventing the passage of food and fluids into the oroantral cavities. Twenty-five articles describing 26 patients with oral mucormycosis related to hematolymphoid disorders affecting the pediatric population were identified. None of the authors of these articles provided information about oral rehabilitation.

CONCLUSIONS

Early diagnosis and treatment are essential to increasing the chances of survival for infants affected by oral mucormycosis. Custom-made rehabilitation should be provided to restore oral function and improve the patient's general health.

Pediatric invasive fungal rhinosinusitis

Pediatric invasive fungal rhinosinusitis (PIFR) is a rapidly progressive, potentially fatal disease. Previous medical literature demonstrates that its early diagnosis significantly reduces the risk of mortality in these patients. This study aims to present an updated clinical algorithm for optimized diagnosis and management of PIFR. A comprehensive review was conducted with only original, full-text articles published in English and Spanish from Cochrane Library, Pub-Med/MEDLINE, Embase, Scopus, and Google Scholar between January 2010 and June 2022. Relevant information was extracted and then integrated to develop a clinical algorithm for a proper diagnosis and management of PIFR.

Molecular Mechanisms of Antifungal Resistance in Mucormycosis

Mucormycosis is one among the life-threatening fungal infections with high morbidity and mortality. It is an uncommon and rare infection targeting people with altered immunity. This lethal infection induced by fungi belonging to the Mucorales family is very progressive in nature. The incidence has increased in recent decades owing to the rise in immunocompromised patients. Disease management involves a multimodal strategy including early administration of drugs and surgical removal of infected tissues. Among the antifungals, azoles and amphotericin B remain the gold standard drugs of choice for initial treatment. The order Mucorales are developing a high level of resistance to the available systemic antifungal drugs, and the efficacy still remains below par. Deciphering the molecular mechanisms behind the antifungal resistance in Mucormycosis would add vital information to our available antifungal armamentarium and design novel therapies. Therefore, in this review, we have discussed the mechanisms behind Mucormycosis antifungal resistance. Moreover, this review also highlights the basic mechanisms of action of antifungal drugs and the resistance landscape which is expected to augment future treatment strategies.

Rhino-orbito-cerebral mucormycosis in an acute lymphoblastic leukemia pediatric patient. Case report and review of literature

Mucormycosis is a disease caused by opportunistic fungi of the order Mucorales that generally affects immunocompromised patients or those with underlying disease. It has a high mortality rate and is the third most common invasive fungal infection. The following is a case report of a 12-year-old pediatric patient diagnosed with B-cell acute lymphoblastic leukemia, who presented an aggressive infectious disease two months after beginning chemotherapy, which began in the right frontal and maxillary sinuses, with subsequent progression and extension, progressively deteriorating the patient's clinical status. Culture and biopsy of the affected areas were performed, confirming by histopathology and isolation a rhino-orbito-cerebral mucormycosis due to Actinomucor elegans. The patient was treated with specific antifungal therapy as an inpatient and left the service after obtaining negative cultures, continuing with outpatient antifungal treatment.

Factors associated with all-cause mortality in pediatric invasive fungal rhinosinusitis

INTRODUCTION

Pediatric invasive fungal rhinosinusitis (PIFR) is a potentially lethal infection seen in immunocompromised pediatric patients. Even with timely treatments, mortality ranges between 18 and 80% of the cases.

OBJECTIVE

To analyze the factors associated with all-cause mortality in pediatric patients with acute invasive fungal rhinosinusitis.

SETTING

Tertiary pediatric referral center.

RESULTS

A total of 18 patients were included, 12 male and 6 female. The average age at diagnosis was 8.7 years (range 4 months-17 years), with 56% overall mortality and 44% survival after 60 months. The most common cause of immunosuppression was acute lymphoblastic leukemia. The only factor found affecting mortality was a time between diagnosis and surgery greater than 7 days.

CONCLUSION

PIFR is an aggressive entity with high mortality. An appropriate diagnosis with an opportune surgical debridement followed by systemic antifungal therapy is essential to improve survival. Delay in surgical treatment is associated with higher mortality.