An aggressive multidisciplinary approach reduces mortality in rhinocerebral mucormycosis

Abstract

Background:Rhinocerebral mucormycosis occurs in immunocompromised hosts with uncontrolled diabetes, solid organ transplants, and hematologic malignancies. Primary disease is in the paranasal sinuses but often progresses intracranially, via direct extension or angioinvasion. Rhinocerebral mucormycosis is rapidly fatal with a mortality rate of 85%, even when maximally treated with surgical debridement, antifungal therapy, and correction of underlying processes.Methods:We performed a retrospective chart review of patients with rhinocerebral mucormycosis from 2011 to 2014. These patients were analyzed for symptoms, surgical and medical management, and outcome. We found four patients who were diagnosed with rhinocerebral mucormycosis. All patients underwent rapid aggressive surgical debridement and were started on antifungal therapy on the day of diagnosis. Overall, we observed a mortality rate of 50%.Results:An early aggressive multidisciplinary approach with surgical debridement, antifungal therapy, and correction of underlying disease have been shown to improve survivability in rhinocerebral mucormycosis.Conclusion:A multidisciplinary approach to rhinocerebral mucormycosis with otolaryngology, neurosurgery, and ophthalmology, infectious disease and medical intensivists can help reduce mortality in an otherwise largely fatal disease. Even despite these measures, outcomes remain poor, and a high index of suspicion must be maintained in at-risk populations, in order to rapidly execute a multifaceted approach.

Posaconazole and isavuconazole induced hypomagnesaemia

“…Both hyperglycaemia and glucocorticoid use represent well-established risk factors for mucormycosis, probably due to impaired chemotaxis and neutrophil fungicidal activity and macrophage function respectively [1], [2], [6]. Once identified, aggressive surgical management as well as a multi-disciplinary approach has been shown to reduce mortality [7].…”

“…The mechanism of the hypomagnesaemia may be multifactorial, and part of a complex interplay between medications, cation channel receptors, intestinal absorption and urinary excretion of magnesium. Mutations in the transient receptor potential melastain 6 (TRPM6) genes that encodes a cation channel have been linked to familial hypomagnesaemia [7]. Nephrotoxic drugs like amphotericin B can produce urinary magnesium wasting, and the residual tissue effects of the amphotericin B may have compounded this effect when the azole was commenced [13].…”

Rapid and Low-Cost Culture-Based Method for Diagnosis of Mucormycosis Using a Mouse Model

“…A timely and efficient diagnosis, as well as an aggressive multimodal treatment approach, is critical in the management of this fulminant progressive and invasive disease, as delays may result in an increased mortality risk Jeong et al, 2016). Indeed, a delay of more than 5 days of an effective antifungal therapy in patients with hematological malignancies leads to approximately twofold increase in 12week mortality (Spellberg et al, 2005;Chamilos et al, 2008;Palejwala et al, 2016). Rapid mycological diagnostic methods may assist with timely initiation of appropriate antifungal therapy, which may prevent progressive tissue invasion, lead to decreased mortality, and overall improvement in healthcare utilization (i.e., shorter hospitalization duration and reduced costs).…”

Rhinocerebral mucormycosis with dissemination to pontine area in a diabetic patient: Treatment and management

“…They are found in rotting biological material and are thermotolerant. The disease has a global distribution, and Mucorales infection is influenced by seasonal variation . This disease, in developed countries, is rare and mostly affects diabetic or immunosuppressed patients or subjects undergoing chemotherapy.…”