Mucormycosis: Difference between revisions

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==Background==
==Background==
#Infection of fungal hyphae in immunocompromised hosts
*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
*Caused by saprophytic fungi (''Mucorales'')
##HIV
**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
*Fungal spores are dispersed in air → route of entry is inhalation<ref name="Selvamani" />
**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<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'''
===Clinical Types===
#Most commonly affects paranasal sinuses (rhinocerebral mucormycosis)
*6 clinical types, based on location of infection<ref name="Selvamani" /><ref name="Motaleb" />
#Pulmonary
*#Rhino-orbital-cerebral (most common form)
#GI
*#Pulmonary
#CNS
*#Gastrointestinal
*#Cutaneous
*#Disseminated
*#Miscellaneous


==Clinical Features==
==Clinical Features==
Rhinocerebral: mimics acute bacterial sinusitis, however a much more rapid, extensive expansion of the fungus to the surrounding anatomy is classic
*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:
**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]]
#Vision changes
**Black palatal discoloration indicates palatal necrosis
#Nasopharyngeal and oropharyngeal ulceration or eschars
#Facial edema, pain
#Cranial nerve deficits
#Headache


==Differential Diagnosis==
==Differential Diagnosis==
{{Rhinorrhea}}
{{Headache DDX}}


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


==Management==
==Management==
*Emergent ENT consult for OR debridement (definitive treatment)
*Emergent ENT consult for OR debridement (definitive treatment)
*Start Amphotericin B 1mg/kg IV
*Start [[Amphotericin B]] 1mg/kg IV<ref name="Motaleb" /> '''OR'''
**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.
*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" />
==Prognosis==
**Do not use deferoxamine (can worsen disease caused by certain fungal genera) - deferiprone is preferred
Mortality 30-90%


==See Also==
==See Also==

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.
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