Outcomes of early anti-fungal therapy with aggressive surgical resection in pulmonary mucormycosis

Abstract

Objectives: The standard management protocols are lacking in the management of pulmonary mucormycosis (PM). The present study aims at reporting our clinical experience and proposing an algorithm for the management of PM. Materials and Methods: This is a retrospective analysis of a prospectively maintained database at a dedicated thoracic surgical unit in New Delhi, India, over 7 years. An analysis of demographic characteristics and perioperative variables including complications was carried out. Various parameters were analyzed to assess the factors affecting mortality after surgical intervention. Results: Out of total 19 patients, 15 were males (78.9%) and 4 females (21.1%), with a mean age of 43.8 years (range, 19–72 years). Chronic kidney disease (status postrenal transplant on immunosuppressant therapy) was the most common predisposing factor in 11 patients (57.8%). All patients were initially started on antifungal therapy, and after 7–8 days, the response was assessed by computed tomography scan of the chest, and based on that, 15 patients (78.9%) were operated (surgical group) and the rest 4 (21.1%) were not (nonsurgical group). In the surgical group, lobectomy was required in 12 (80%) and pneumonectomy in 3 patients (20%). Postoperative complications occurred in 5 patients (33.3%). There were 3 perioperative deaths (within 90 days of surgery) (20%). Poor Eastern Cooperative Oncology Group performance status (>2) and longer duration of symptoms (>2 weeks) were independent predictors of mortality after surgery. The survivors in the surgical group are doing well. However, all four patients in the nonsurgical group died due to disease progression. Conclusion: After few days of initiation of antifungal therapy, aggressive surgical resection must be performed (wherever feasible) to improve survival outcome in patients with PM.

COVID associated pulmonary mucormycosis: Outcomes of surgical therapy

“…The present experience of 33 cases undergoing surgical resection for CAPM was compared with our previously reported experience of 15 cases of non-COVID pulmonary Mucormycosis. 11 The mean age was significantly higher ( P = 0.01) in CAPM group. Cavitation was the most common radiological presentation in CAPM group whereas pneumonia was most common in non-COVID group.…”

“…A protocolised approach (Figure 1) to the management of this complex entity was reported by the same authors in non-COVID pulmonary mucormycosis. 11 The same principles were extrapolated in CAPM as well. Similar recommendations have been reported by other authors as well.…”

Clinical characteristics, outcome, and factors associated with mortality of pulmonary mucormycosis: a retrospective single-center study from Pakistan

“…Disseminated disease, voriconazole use at clinical suspicion for invasive mold pneumonia, prolonged neutropenia, high APACHE II score, severe lymphocytopenia, thrombocytopenia, high lactate dehydrogenase (LDH) levels, steroid use, and longer duration of disease are predictor of poor outcomes in pulmonary mucormycosis. 15 , 33 – 35 …”

COVID-19-Associated Pulmonary Mucormycosis

“…Surgery should always be considered in patients with CAPM, though in some patients there might be issues with technical difficulties due to involvement of large vessels or mediastinal structures or in very sick patients with multiple co-morbidities. Surgery either in the form of resection, lobectomy or pneumonectomy improves survival when combined with appropriate medical therapy [ 48 , 49 ]. Surgical resection was a major factor associated with survival in multivariate analysis in a subgroup of patients with hematologic malignancies (odds ratio = 0.71) [ 50 ].…”