Multimodal Treatment of Rhinocerebral Mucormycosis in a Pediatric Patient With Relapsed Pre-B Acute Lymphoblastic Leukemia

Abstract

A 17-year-old girl developed invasive rhinocerebral mucormycosis during intensive re-induction chemotherapy for relapsed pre-B acute lymphoblastic leukemia. Due to the high case fatality rate for invasive mucormycosis in profoundly immunosuppressed patients, an aggressive treatment regimen was pursued. In addition to the standard of care treatments with intravenous amphotericin and aggressive surgical debridements, she received intraventricular amphotericin to the brain via an Ommaya reservoir, hyperbaric oxygen treatments, filgrastim, intravenous immunoglobulin and antifungal in vitro synergy testing to allow for more targeted antifungal therapy with the addition of micafungin. After a 3-month treatment course, it was determined that her mucormycosis was under appropriate control, allowing her to continue treatment for her leukemia with hematopoietic stem cell transplant with a plan for continued intravenous antifungal therapy through engraftment.

Rhinocerebral mucormycosis, risk factors and the type of oral manifestations in patients referred to a University Hospital in Tabriz, Iran 2007‐2017

“…In the present study, the mean age of the subjects was 60.6 ± 14.2 years; 52.5% of the patients were male which was older than in a recent systematic review of mucormycosis in Iran (mean age 39.8 years) and a study of 929 mucor cases in the US (mean age 38.8 years) (Table ) Possible reasons for the different age prevalence in our study can be the difference in nutritional culture and the high prevalence of diabetes at old ages in Iran compared with other countries.…”

“…The most important predisposing factor in the present study was diabetes (90%) (Table ). Diabetes was more frequently found as underlying condition in our study compared to previous studies . Seven cases (17.5%) of those evaluated in the present study, all with diabetes, developed rhinocerebral mucormycosis after extraction of a maxillary tooth; compromised immune response in diabetic patients and the high vascularity of the maxilla give rise to the spread of mucormycosis in this area .…”

“…In the present study, the general symptoms and signs of the patients in descending order consisted of oedema, ptosis, facial pain, headache, blindness, nasal discharge, a decrease in facial sensation, nausea and vomiting, visual deficiency, ptosis, fever and nasal necrosis; the oral manifestations in these patients consisted of palatal necrosis, palatal ulcers, aphthous and lesions on the tongue, respectively (Table ). The clinical symptoms include fever, malaise, headache, pain in the orbital area, sinusitis, sudden loss of vision, proptosis, ptosis, diplopia, nasal discharge and facial anesthesia . The incidence of fever is variable and not be seen in half of the patients …”

“…Mucormycosis is an invasive and potentially fatal mycosis . Mucormycosis is caused by Rhizopus and Mucor species in humans . The most common classic form of this mycosis is its rhinocerebral form .…”

Pain in child patients: A review on managements

“…They might assist to decrease the requirement for opioid treatments and these medications are harmless and useful analgesia and sedation. 3,[36][37][38][39][40] For acute pain management in children, presence of a psychologist or child life specialist into the therapy team reduces post-operative pain and anxiety by educating the Pediatric about therapeutic procedures, a plan of pain management, and implementing behavioral pain management interventions (e.g., distraction, play, active relaxation training) in the perioperative period. 41,42 Another person who manages pediatric pain is an acupuncturist or massage therapist during therapeutic plans and operations.…”