Mucormycosis

Mucormycosis

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  Mucormycosis Presented by Dr:Abdulrahman Almalaq Internal Medicine PGY1
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  Content:- • Introduction. • Riskfactors. • Pathogenesis. • Clinical presentation. • Diagnosis. • Treatment. • Prognosis.
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  Introduction • Mucormycosis (sometimescalled zygomycosis) is a serious but rare fungal infection caused by a group of molds called mucormycetes. These fungi live throughout the environment, particularly in soil and in decaying organic matter, such as leaves, compost piles, or rotten wood.1 • People get mucormycosis through contact with fungal spores in the environment. By inhalation of fungal spores, ingestion or through the skin in case of burn or wounds.
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  Predisposing Factors - Diabetes,especially with diabetic ketoacidosis. - Organ transplant, Stem cell transplant and chemotherapy. - Neutropenia. - HIV/AIDS. - Long-term corticosteroid use. - Iron overload or hemochromatosis. - Skin injury due to surgery, burns, or wounds. - Prematurity and low birthweight.
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  1.Inhalation 2.Invasion 3.Dissemination
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  Clinical Presentation • Rhinocerebralmucormycosis: most common in people with uncontrolled diabetes and in people who have had a kidney transplant.2-3 - Acute sinusitis with fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. - Palatal eschars, destruction of the turbinates, perinasal swelling, and erythema and cyanosis of the facial skin overlying the involved sinuses and/or orbit. - Signs of orbital involvement include periorbital edema, proptosis, and blindness.
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  Rhinocerebral mucormycosis
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  Clinical Presentation cont. •Pulmonary mucormycosis: most common type of mucormycosis in people with cancer and in people who have had an organ transplant or a stem cell transplant. - Fever, cough, pleuritic chest pain and massive hemoptysis. • Gastrointestinal mucormycosis: more common among young children than adults . - Abdominal pain and hematemesis, perforation and peritonitis, Bowel infarctions and hemorrhagic shock. • Cutaneous mucormycosis: trauma or wounds. - Single, painful, indurated area of cellulitis rapidly progressing to necrotic tissue.
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  Work up • LaboratoryTests: - CBC, chemistry panel, ABG, Iron studies and CSF. - Beta-D-glucan or galactomannan are negative in mucormycosis. - KOH and fungal stain. • Imaging: (CT) of the brain, sinuses, chest, and abdomen. • Tissue biopsy is the gold standard. • Molecular : PCR • Other: sinus endoscopy and GI endoscopy.
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  Treatment • Correction ofthe underlying abnormality, initiation of antifungal therapy, and surgical debridement. • Antifungal drugs: Early initiation of antifungal therapy improves the outcome of infection with mucormycosis. - Amphotericin B is the drug of choice for initial therapy ( Liposomal amphotericin B – Ambisome 5 mg/kg daily - ). • Posaconazole and isavuconazole : Step-down therapy. - Posaconazole :300 mg every 12 hours on the first day, then 300 mg once daily. - Isavuconazole Loading doses of 200 mg, should be given every 8 hours for six doses, followed by 200 mg orally once daily starting 12 to 24 hours after the last loading dose.8
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  Treatment • Surgery: aggressivesurgical intervention (debridement or lobe- ectomy) of involved tissues once the diagnosis of any form of mucormycosis is suspected.6
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  Prognosis • Rhinocerebral diseasecauses significant morbidity in patients who survive, because treatment usually requires extensive, and often disfiguring, facial surgery. • Surviving mucormycosis requires rapid diagnosis and aggressive coordinated medical and surgical therapy. • Mucormycosis carries a mortality rate of 50-85%. The mortality rate associated with rhinocerebral disease is 50-70%. Pulmonary and gastrointestinal (GI) diseases carry an even higher mortality rate, because these forms are typically diagnosed late in the disease course. Disseminated disease carries a mortality rate that approaches 100%.
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  References: 1. Richardson M.The ecology of the Zygomycetes and its impact on environmental exposure. Clin Microbiol Infect. 2009 Oct;15 Suppl 5:2-9. 2. Song Y, Qiao J, Giovanni G, Liu G, Yang H, Wu J, Chen J. Mucormycosis in renal transplant recipients: review of 174 reported cases. BMC Infect Dis. 2017 Apr; 17(1): 283. 3. Abdalla A, Adelmann D, Fahal A, Verbrugh H, Van Belkum A, De Hoog S. Environmental Occurrence of Madurella mycetomatis, the Major Agent of Human Eumycetoma in Sudan. J Clin Microbiol. 2002 Mar; 40(3): 1031–1036. 4. Vallabhaneni S, Mody RK. Gastrointestinal Mucormycosis in Neonates: a Review. Current Fungal Infection Reports. 2015. 5. Francis JR, Villanueva P, Bryant P, Blyth CC. Mucormycosis in Children: Review and Recommendations for Management. J Pediatric Infect Dis Soc. 2018 May 15;7(2):159-164. 6. Tedder M, Spratt JA, Anstadt MP, et al. Pulmonary mucormycosis: results of medical and surgical therapy. Ann Thorac Surg 1994; 57:1044. 7. Di Carlo P, Pirrello R, Guadagnino G, et al. Multimodal surgical and medical treatment for extensive rhinocerebral mucormycosis in an elderly diabetic patient: a case report and literature review. Case Rep Med. 2014;2014:527062. 8. Cresemba (isavuconazonium sulfate) for oral administration, for injection for intravenous administration, prescribing information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/207500Orig1s000lbl.pdf (Accessed on March 09, 2015).
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  THANK YOU