Difference between revisions of "Mucormycosis"

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*Opportunistic invasive fungal infection, typically affecting immunocompromised patients (esp 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>
 
*Opportunistic invasive fungal infection, typically affecting immunocompromised patients (esp 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>
 
*Caused by saprophytic fungi (''Mucorales'')
 
*Caused by saprophytic fungi (''Mucorales'')
 +
**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>
 
*Fungal spores are dispersed in air → route of entry is inhalation<ref name="Selvamani" />
 
*Fungal spores are dispersed in air → route of entry is inhalation<ref name="Selvamani" />
 
**Infection typically begins in nose and paranasal sinuses
 
**Infection typically begins in nose and paranasal sinuses
 
**Can also affect pulmonary, GI and CNS systems
 
**Can also affect pulmonary, GI and CNS systems
*Fungi have vascular proclivity, and can cause thrombosis → tissue and bone necrosis
+
*''Mucorales'' fungi have vascular proclivity, and can cause thrombosis → tissue and bone necrosis
 
*Prognosis is poor, with 30-90% mortality
 
*Prognosis is poor, with 30-90% mortality
  
 
===Clinical Types===
 
===Clinical Types===
*6 clinical types, based on location of infection<ref name="Selvamani" />
+
*6 clinical types, based on location of infection<ref name="Selvamani" /><ref name="Motaleb" />
 
*#Rhino-orbital-cerebral (most common form)
 
*#Rhino-orbital-cerebral (most common form)
 
*#Pulmonary
 
*#Pulmonary
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==Clinical Features==
 
==Clinical Features==
*Rhinocerebral form 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" />
**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
+
**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==
 
==Differential Diagnosis==
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==Diagnostic Evaluation==
 
==Diagnostic Evaluation==
*Can be clinical diagnosis
+
*Can be clinical diagnosis - early diagnosis is critical to limiting spread of disease
*CT scan of sinuses with IV contrast can assist with diagnosis
+
*CT scan of sinuses with IV contrast can assist with diagnosis and surgical planning
  
 
==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 1 mg/kg IV<ref name="Motaleb" /> '''OR'''
 +
**Liposomal Amphotericin B 5-7.6 mg/kg
 
*Aggressive resuscitation, airway management, and supportive care while in ED.
 
*Aggressive resuscitation, airway management, and supportive care while in ED.
 +
*Hyperbaric oxygen therapy and iron chelation (iron is required for fungal growth) may also help.<ref name="Motaleb" />
 +
**Do not use deferoxamine (can worsen disease) - deferiprone is preferred
  
 
==See Also==
 
==See Also==

Revision as of 05:01, 8 September 2015

Background

  • Opportunistic invasive fungal infection, typically affecting immunocompromised patients (esp 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 30-90% mortality

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

Diagnostic 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

Management

  • Emergent ENT consult for OR debridement (definitive treatment)
  • Start Amphotericin B 1 mg/kg IV[2] OR
    • Liposomal Amphotericin B 5-7.6 mg/kg
  • Aggressive resuscitation, airway management, and supportive care while in ED.
  • Hyperbaric oxygen therapy and iron chelation (iron is required for fungal growth) may also help.[2]
    • Do not use deferoxamine (can worsen disease) - 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.