Difference between revisions of "Mucormycosis"

 
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==Background==
 
==Background==
#Infection of fungal hyphae in immunocompromised hosts
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*Opportunistic invasive [[fungal infection]], typically affecting immunocompromised patients (especially uncontrolled diabetics)<ref name="Selvamani">Selvamani M, Donoghue M, Bharani S, Madhushankari GS. Mucormycosis causing maxillary osteomyelitis. Journal of Natural Science, Biology, and Medicine. 2015;6(2):456-459. doi:10.4103/0976-9668.160039.</ref>
##DM
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*Caused by saprophytic fungi (''Mucorales'')
##HIV
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**Found in soil, bread mold, decaying fruits<ref name="Motaleb">Motaleb HYA, Mohamed MS, Mobarak FA. A Fatal Outcome of Rhino-orbito-cerebral Mucormycosis Following Tooth Extraction: A Case Report. Journal of International Oral Health : JIOH. 2015;7(Suppl 1):68-71.</ref>
##Neutropenic
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*Fungal spores are dispersed in air → route of entry is inhalation<ref name="Selvamani" />
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**Infection typically begins in nose and paranasal sinuses
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**Can also affect pulmonary, GI and CNS systems
 +
*''Mucorales'' fungi have vascular proclivity, and can cause thrombosis → tissue and bone necrosis
 +
*Prognosis is poor, with 17-51% mortality<ref name="Bellazreg" />, higher in cerebral involvement<ref name="Mohamed">Mohamed MS, Abdel-Motaleb HY, Mobarak FA. Management of rhino-orbital mucormycosis. Saudi Medical Journal. 2015;36(7):865-868. doi:10.15537/smj.2015.7.11859.</ref>
  
'''Locations'''
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===Clinical Types===
#Most commonly affects paranasal sinuses (rhinocerebral mucormycosis)
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*6 clinical types, based on location of infection<ref name="Selvamani" /><ref name="Motaleb" />
#Pulmonary
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*#Rhino-orbital-cerebral (most common form)
#GI
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*#Pulmonary
#CNS
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*#Gastrointestinal
 +
*#Cutaneous
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*#Disseminated
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*#Miscellaneous
  
==Diagnosis==
+
==Clinical Features==
Rhinocerebral: mimics acute bacterial sinusitis, however a much more rapid, extensive expansion of the fungus to the surrounding anatomy is classic
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*Rhinocerebral form initially mimics acute bacterial [[sinusitis]] (pain/swelling of cheeks and periorbital region)<ref name="Motaleb" />
 +
**A much more rapid, extensive expansion of the fungus to the surrounding anatomy is classic
 +
**Can spread to orbits, oropharynx, nasopharynx, brain, nearby vasculature leading to → [[vision loss|vision changes]], nasopharyngeal and oropharyngeal ulceration or eschars, facial edema/pain, [[cranial nerve palsies|cranial nerve deficits]], [[headache]]
 +
**Black palatal discoloration indicates palatal necrosis
  
Can spread to orbits, oropharynx, nasopharynx, brain, nearby vasculature leading to:
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==Differential Diagnosis==
#Vision changes
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{{Rhinorrhea}}
#Nasopharyngeal and oropharyngeal ulceration or eschars
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{{Headache DDX}}
#Facial edema, pain
 
#Cranial nerve deficits
 
#Headache
 
  
==Workup==
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==Evaluation==
CT scan of sinuses
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*Can be clinical diagnosis - early diagnosis is critical to limiting spread of disease
 +
*CT scan of sinuses with IV contrast can assist with diagnosis and surgical planning
 +
*Histopathology is confirmatory
  
==Treatment==
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==Management==
#Adjunctive: Amphotericin B (1mgkg/d IV)
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*Emergent ENT consult for OR debridement (definitive treatment)
#Definitive: Prompt surgical consultation --> debridement
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*Start [[Amphotericin B]] 1mg/kg IV<ref name="Motaleb" /> '''OR'''
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**Liposomal [[Amphotericin B]] 5-10mg/kg<ref name="Bellazreg">Bellazreg F, Hattab Z, Meksi S, et al. Outcome of mucormycosis after treatment: report of five cases. New Microbes and New Infections. 2015;6:49-52. doi:10.1016/j.nmni.2014.12.002.</ref>
 +
*Aggressive resuscitation, airway management, and supportive care while in ED.
 +
*Hyperbaric oxygen therapy<ref name="Mohamed" /> and iron chelation (iron is required for fungal growth) may also help.<ref name="Motaleb" />
 +
**Do not use deferoxamine (can worsen disease caused by certain fungal genera) - deferiprone is preferred
  
==Prognosis==
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==See Also==
Mortality 30-90%
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*[[Fungal Infections]]
  
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==External Links==
 +
 +
 +
==References==
 +
<references/>
 +
 +
[[Category:ENT]]
 
[[Category:ID]]
 
[[Category:ID]]

Latest revision as of 21:17, 30 September 2019

Background

  • Opportunistic invasive fungal infection, typically affecting immunocompromised patients (especially uncontrolled diabetics)[1]
  • Caused by saprophytic fungi (Mucorales)
    • Found in soil, bread mold, decaying fruits[2]
  • Fungal spores are dispersed in air → route of entry is inhalation[1]
    • Infection typically begins in nose and paranasal sinuses
    • Can also affect pulmonary, GI and CNS systems
  • Mucorales fungi have vascular proclivity, and can cause thrombosis → tissue and bone necrosis
  • Prognosis is poor, with 17-51% mortality[3], higher in cerebral involvement[4]

Clinical Types

  • 6 clinical types, based on location of infection[1][2]
    1. Rhino-orbital-cerebral (most common form)
    2. Pulmonary
    3. Gastrointestinal
    4. Cutaneous
    5. Disseminated
    6. Miscellaneous

Clinical Features

  • Rhinocerebral form initially mimics acute bacterial sinusitis (pain/swelling of cheeks and periorbital region)[2]
    • A much more rapid, extensive expansion of the fungus to the surrounding anatomy is classic
    • Can spread to orbits, oropharynx, nasopharynx, brain, nearby vasculature leading to → vision changes, nasopharyngeal and oropharyngeal ulceration or eschars, facial edema/pain, cranial nerve deficits, headache
    • Black palatal discoloration indicates palatal necrosis

Differential Diagnosis

Rhinorrhea

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation

  • Can be clinical diagnosis - early diagnosis is critical to limiting spread of disease
  • CT scan of sinuses with IV contrast can assist with diagnosis and surgical planning
  • Histopathology is confirmatory

Management

  • Emergent ENT consult for OR debridement (definitive treatment)
  • Start Amphotericin B 1mg/kg IV[2] OR
  • Aggressive resuscitation, airway management, and supportive care while in ED.
  • Hyperbaric oxygen therapy[4] and iron chelation (iron is required for fungal growth) may also help.[2]
    • Do not use deferoxamine (can worsen disease caused by certain fungal genera) - deferiprone is preferred

See Also

External Links

References

  1. 1.0 1.1 1.2 Selvamani M, Donoghue M, Bharani S, Madhushankari GS. Mucormycosis causing maxillary osteomyelitis. Journal of Natural Science, Biology, and Medicine. 2015;6(2):456-459. doi:10.4103/0976-9668.160039.
  2. 2.0 2.1 2.2 2.3 2.4 Motaleb HYA, Mohamed MS, Mobarak FA. A Fatal Outcome of Rhino-orbito-cerebral Mucormycosis Following Tooth Extraction: A Case Report. Journal of International Oral Health : JIOH. 2015;7(Suppl 1):68-71.
  3. 3.0 3.1 Bellazreg F, Hattab Z, Meksi S, et al. Outcome of mucormycosis after treatment: report of five cases. New Microbes and New Infections. 2015;6:49-52. doi:10.1016/j.nmni.2014.12.002.
  4. 4.0 4.1 Mohamed MS, Abdel-Motaleb HY, Mobarak FA. Management of rhino-orbital mucormycosis. Saudi Medical Journal. 2015;36(7):865-868. doi:10.15537/smj.2015.7.11859.