Mucormycosis in Hematopoietic Cell Transplant Recipients and in Patients With Hematological Malignancies in the Era of New Antifungal Agents

Abstract

Background The survival benefit of combination antifungal therapy for invasive mucormycosis (IM) in patients with hematologic malignancy (HM) and hematopoietic cell transplant (HCT) is not well defined. Methods This multicenter, retrospective study included HM and HCT recipients with proven or probable IM between January 1, 2007 and December 31, 2017 from 10 transplant centers across North America. Results Sixty-four patients with proven (n = 47) or probable (n = 17) IM defined by 2008 European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) consensus definitions were included. Thirty-nine (61%) were HCT recipients (95% allogeneic). Sites of infection included rhino-orbital-cerebral (33), pulmonary (30%), disseminated (19%), gastrointestinal (3%), and cutaneous (3%). Surgical debridement was performed in 66%. Initial antifungal treatment consisted of the following: lipid formulation of amphotericin B (AmB) alone (44%), AmB + posaconazole (25%), AmB + echinocandin (13%), AmB + isavuconazole (8%), posaconazole alone (5%), and isavuconazole alone (3%). All-cause mortality at 30 days and 1 year were 38% and 66%, respectively. Initial treatment with AmB plus posaconazole or isavuconazole (n = 28) was associated with a trend toward lower treatment failure compared with AmB (n = 21) (42% vs 64%, P = .136). Conclusions Long-term survival with IM among HM and HCT populations remains poor. However, initial use of AmB + azole in conjunction with surgery may result in less treatment failure. More evidence from prospective controlled studies is needed to confirm this observation.

COVID-19 associated mucormycosis: the urgent need to reconsider the indiscriminate use of immunosuppressive drugs

“…A prompt diagnosis and treatment should be established because of the angioinvasive character and rapid disease progression leading to a high mortality. 48 , 49 This is especially true in India; with an increased incidence of COVID-19 cases, apparently thousands of CAM cases are reported. However, Nepal, Brazil, Colombia, the USA, and other severely affected nations should consider this fungal threat amid the pandemic.…”

Clinical Manifestations of Pulmonary Mucormycosis in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation: A 21-Case Series Report and Literature Review

“…Although our study did not show empirical antifungal treatment before the diagnosis of mucormycosis causing increased mortality limited by the number of cases, breakthrough infection still remains a serious issue in fungal infection after allo-HSCT. A recent study indicated that the overall prognosis in HSCT and HM populations remains extremely poor after diagnosis, with only a 37% survival rate at 1 year [ 39 ]. In our cases, the survival rate at 1 year is 28.6%.…”

Breakthrough Invasive Fungal Infections in Allogeneic Hematopoietic Stem Cell Transplantation

“…Actually, b-IFI following voriconazole prophylaxis has been reported in up to 7.9% of cases, primarily mucormycosis, due to the lack of in vitro activity against Mucorales [ 4 ]. Mucormycosis, including Rhizopus microsporus , mainly affects immunocompromised hosts and, after IA, represents the most frequent IFI in hematological patients and HSCT recipients [ 22 , 23 , 24 , 25 ]. Mucormycoses are characterized by rapid local spread, angioinvasion and tissue necrosis.…”

“…Most common presentations are rhino-orbito-cerebral, cutaneous, pulmonary and disseminated, the latter two being more frequent among neutropenic patients with acute leukemia and HSCT recipients. The latter two are also associated with high mortality rates (20–100%) [ 22 , 23 , 25 , 26 ]. The ESCMID-ECCM and ECIL-6 guidelines recommend surgery and first-line treatment with L-AMB at least 5 mg/kg/day.…”