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Meyerowitz EA, Sanchez S, Mansour MK, Triant VA, Goldberg MB. Isolated Cerebral Mucormycosis in Immunocompetent Adults who Inject Drugs: Case Reports and Systematic Review of the Literature. Open Forum Infect Dis 2020; 7:ofaa552. [PMID: 33409328 PMCID: PMC7765436 DOI: 10.1093/ofid/ofaa552] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 01/16/2023] Open
Abstract
Background Mucormycosis involves life-threatening rapidly progressive angioinvasion with infiltration across tissue planes, resulting in necrosis and thrombosis, most commonly seen in the setting of immunocompromised states. We describe 2 cases of isolated cerebral mucormycosis in immunocompetent adults and describe this syndrome in detail in the context of a systemic literature review. Methods Using the criteria (1) isolated cerebral disease, (2) mucormycosis (by polymerase chain reaction, culture, or pathology), and (3) affected an immunocompetent individual, we identified 53 additional cases from 1969 to 2020. Results Of these 55 cases, ~60% occurred in men, >70% were in patients under age 35, 92% were associated with intravenous drug use, and >85% had infection centered in the basal ganglia. Many presented with cranial nerve deficits, headache, focal weakness, or altered mental status. Conclusions No patient survived without amphotericin, and steroid administration was associated with worse outcomes. Given the current opioid crisis, this syndrome may be seen more frequently.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarimer Sanchez
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael K Mansour
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Virginia A Triant
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marcia B Goldberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Microbiology, Harvard Medical School, Boston, Massachusetts, USA
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Zhang GJ, Zhang SK, Wang Z, Zhu YX, Kong J, Huang LL, Guo YJ, Wang YJ, Zou RC, Xie CM. Fatal and Rapid Progressive Isolated Cerebral Mucormycosis Involving the Bilateral Basal Ganglia: A Case Report. Front Neurol 2020; 11:295. [PMID: 32373057 PMCID: PMC7187894 DOI: 10.3389/fneur.2020.00295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/30/2020] [Indexed: 12/30/2022] Open
Abstract
Isolated cerebral mucormycosis is a clinical type of mucormycosis that is estimated to account for 8% of all mucormycosis cases. The clinical symptoms of isolated cerebral mucormycosis are elusive, and thus conventional techniques often lake sensitivity and specificity. Moreover, cultures are often negative, even when direct microscopy examination is positive. Although histopathology will probably remain the gold standard for the diagnosis of mucormycosis, obtaining a biopsy specimen is not always feasible in most vulnerable populations. Thus, molecular approaches are currently used as an advantageous assistant examination method to improve the early identification of the causative agent and subsequently guide therapy to improve the prognosis of patients. Here, we report a case of isolated cerebral mucormycosis caused by Rhizopus microspores in a healthy young adult that was identified using next-generation sequencing technology.
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Affiliation(s)
- Gao-Jia Zhang
- Department of Neurology, Nanjing Lishui People's Hospital, Nanjing, China
| | - Shao-Ke Zhang
- School of Medicine, Southeast University, Nanjing, China
| | - Zan Wang
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Yi-Xin Zhu
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Jun Kong
- Department of Neurosurgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Li-Li Huang
- Department of Intensive Care Unit, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Yi-Jing Guo
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Yan-Juan Wang
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
| | - Rong-Cheng Zou
- Department of Neurology, Nanjing Lishui People's Hospital, Nanjing, China
| | - Chun-Ming Xie
- Department of Neurology, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
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Kerezoudis P, Watts CR, Bydon M, Dababneh AS, Deyo CN, Frye JM, Kelley PC, Kemp AM, Palraj BV, Pupillo GT. Diagnosis and Treatment of Isolated Cerebral Mucormycosis: Patient-Level Data Meta-Analysis and Mayo Clinic Experience. World Neurosurg 2018; 123:425-434.e5. [PMID: 30415043 DOI: 10.1016/j.wneu.2018.10.218] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Isolated cerebral mucormycosis is a rare and serious infection associated with intravenous drug abuse. METHODS We performed a comprehensive meta-analysis of cases reported in studies and have included an unreported case from our institution. We searched PubMed/Medline, EMBASE, Scopus, Cochrane Databases, and our institution's electronic medical health records from inception through March 31, 2018. The cases were considered isolated (only affecting the cerebrum, cerebellum, or brainstem) if the absence of other primary sources of infection had been documented. Continuous variables were summarized using the median and interquartile range and categorical variables using frequencies and proportions. The relationships between variables were tested using the Wilcoxon rank sum and Pearson χ2 tests. RESULTS A total of 130 studies (141 patients) met the eligibility requirements and were screened; 68 patients were included. The median age was 28 years (interquartile range, 24-38); 57% were men. Most patients had a history of intravenous drug abuse (82%), and 20% had positive human immunodeficiency virus findings. The lesion location was mostly supratentorial (91%), especially in the basal ganglia (71.2%). The cultures were positive in 38%, with Rhizopus the most common organism (59%). The mortality rate was 65%. The survivors were significantly more likely to have received amphotericin B (92% vs. 43%; P < 0.001) or to have undergone stereotactic aspiration (58% vs. 25%; P < 0.01). CONCLUSIONS Isolated cerebral mucormycosis has a pooled mortality rate of 65%. The presence of lesions in the basal ganglia, rapidly progressive symptoms, and a history of intravenous drug abuse should raise suspicion for the early initiation of amphotericin B and stereotactic aspiration.
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Affiliation(s)
| | - Charles R Watts
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA.
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ala S Dababneh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Infectious Diseases, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Christopher N Deyo
- Department of Hospital Medicine, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Judson M Frye
- Department of Radiology, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Parker C Kelley
- Department of Neurosurgery, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Anna M Kemp
- Department of Pathology, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Bharath V Palraj
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Infectious Diseases, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
| | - Gregory T Pupillo
- Department of Neurology, Mayo Clinic Health System-Franciscan Healthcare, La Crosse, Wisconsin, USA
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Mashhadinezhad H, Abouei Mehrizi MA. Cerebellar Mucormycosis in a Young Man: A Case Report. Arch Clin Infect Dis 2017; 13. [DOI: 10.5812/archcid.62962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Al Barbarawi MM, Allouh MZ. Successful Management of a Unique Condition of Isolated Intracranial Mucormycosis in an Immunocompetent Child. Pediatr Neurosurg 2015; 50:165-7. [PMID: 25967858 DOI: 10.1159/000381750] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 03/18/2015] [Indexed: 11/19/2022]
Abstract
This report describes a unique case of isolated intracranial mucormycosis of a slowly progressive nature in a healthy immunocompetent child. A 4-year-old girl with a clear medical and surgical history presented with complaints of right side facial asymmetry and unsteady gait for a period of 10 months. Clinical and radiographic investigations revealed right-sided lower motor neuron facial palsy caused by an infiltrative lesion on the right cerebellopontine angle. Initial surgical debulking was performed, a biopsy was sent for histopathological examination, and a course of prophylactic antibiotic and antifungal drugs was prescribed. The pathological report confirmed the mucormycosis fungal infection, and intravenous amphotericin B was administered for 3 weeks. One month after admission, the patient left the hospital with complete recovery. Follow-ups after 4, 8 and 12 weeks revealed no sensory or motor neurological deficits. In conclusion, this is a unique case of mucormycosis with regard to the nature and location of the infection, along with the host being a healthy child. Initial surgical exploration is a very critical step in the early diagnosis and treatment of such rare conditions.
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Affiliation(s)
- Mohammed M Al Barbarawi
- Division of Neurosurgery, Department of Neuroscience, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Affiliation(s)
- Tanya P Lin
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA.
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