Mucormycosis


Epidemiology

Incidence

  • Incidence is Difficult to Quantify
  • Decreasing Incidence of Diabetes-Related Mucormycosis Since the 1990’s
    • May Be Related to the Widespread Use of Statins
    • Statins Have In Vitro Inhibitory Activity Against Organisms Which Cause Mucormycosis

Environmental Risk Factors for Mucormycosis

  • Combat-Associated Mucormycosis
    • Cases Have Been Reported in Association with Blast Injuries in Aghanistan
  • Healthcare-Associated Mucormycosis
    • Cases Have Been Reported in Association with Intravenous and Other Catheters, Adhesive Tape, surgical wounds, Wooden Tongue Depressors, Adjacent Building Construction, and Hospital Linens
  • Natural Disaster-Associated Mucormycosis
    • Cases Have Been Reported in Association with Tornado, Tsunami, and Volcanic Eruption

Clinical Risk Factors

General Comments

  • All Human Mucormycosis Infections Occur in the Presence of Some Underlying Immunocompromising Condition

Malignancy

  • General Comments
    • Hematologic Malignancy is a Common Risk Factor for Mucormycosis
    • Voriconazole Prophylaxis Appears to Increase the Risk of Mucormycosis
      • Possibly Due to Increased Selective Pressure for the Organisms Which Cause Mucormycosis
  • Carcinoma
  • Leukemia
  • Lymphoma (see Lymphoma, [[Lymphoma]])

Organ Transplantation

  • General Comments
    • Transplantation is a Common Risk Factor for Mucormycosis
  • Hematopoietic Stem Cell Transplant (HSCT) (Bone Marrow Transplant (see Hematopoietic Stem Cell Transplant, [[Hematopoietic Stem Cell Transplant]])
    • Graft vs Host Disease Increases the Risk of Mucormycosis (see Graft vs Host Disease, [[Graft vs Host Disease]])
    • Voriconazole Prophylaxis Increases the Risk of Mucormycosis (see Voriconazole, [[Voriconazole]])
      • Possibly Due to Increased Selective Pressure for the Organisms Which Cause Mucormycosis
  • Solid Organ Transplant
    • Risk Factors for Mucormycosis in Patients with Solid Organ Transplant

Pharmacologic Immunosuppression

  • Corticosteroids (see Corticosteroids, [[Corticosteroids]])
    • Corticosteroids Inhibit Neutrophil and Alveolar Macrophage Function
  • Cytotoxic Therapy
    • Cytotoxics Inhibit Neutrophil and Alveolar Macrophage Function

Other

  • Burns (see Burns, [[Burns]])
  • Chronic Kidney Disease (CKD) (see Chronic Kidney Disease, [[Chronic Kidney Disease]])
  • Deferoxamine (Desferal, DFO) (Deferoxamine, [[Deferoxamine]])
    • Deferoxamine-Iron Chelate Acts as Siderophore for Rhizopus: increases Rhizopus iron uptake, stimulating fungal growth and tissue invasion
    • In Contrast, Deferasirox and Deferipone Do Not Act as Siderophores for Rhizopus and Do Not Increase the Risk of Mucormycosis
    • Highest Risk for Deferoxamine-Related Mucormycosis is Observed in Those Who Have Received Multiple Blood Transfusions with Subsequent Deferoxamine Treatment
    • Mortality rate is almost 90% in deferoxamine-associated mucormycosis cases
  • Diabetes Mellitus (DM) (see Diabetes Mellitus, [[Diabetes Mellitus]])
    • Diabetes Mellitus is Probably the Most Common Risk Factor for Mucormycosis
    • Risk of Mucormycosis is Especially High with Diabetic Ketoacidosis (DKA): due to impaired neutrophil function and elevated free iron present in diabetic ketoacidosis
      • Free Iron Enhances the Growth of Rhizopus at Acidic (But Not Alkaline) pH
    • Mucormycosis May Occur as the Initial Presentation of Diabetes Mellitus
  • Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus, [[Human Immunodeficiency Virus]])
  • Intravenous Drug Abuse (IVDA) (see Intravenous Drug Abuse, [[Intravenous Drug Abuse]])
  • Iron Overload (see Iron Overload, [[Iron Overload]])
    • Iron Overload Itself Increases the Risk of Mucormycosis
  • Malnutrition (see Malnutrition, [[Malnutrition]])
  • Prematurity (Neonates)
  • Trauma

Etiology

General Comments

Zygomycetes (see Zygomycetes, [[Zygomycetes]])


Physiology

Entry and Infection

Unique Features of Rhizopus


Diagnosis

Direct Microscopy/Histopathology (Preferably with Optical Brighteners)

Characteristics of Mucorales

Recommendations (ESCMID/ECMM Mucormycosis Guidelines) (Clin Microbiol Infect, 2014) [MEDLINE]

Immunohistochemistry

Recommendations (ESCMID/ECMM Mucormycosis Guidelines) (Clin Microbiol Infect, 2014) [MEDLINE]

Fungal Culture

Recommendations (ESCMID/ECMM Mucormycosis Guidelines) (Clin Microbiol Infect, 2014) [MEDLINE]

Quantitative PCR

Recommendations (ESCMID/ECMM Mucormycosis Guidelines) (Clin Microbiol Infect, 2014) [MEDLINE]

Serum/Bronchoalveolar Lavage (BAL) Galactomannan (see Serum Galactomannan, [[Serum Galactomannan]])

Recommendations (ESCMID/ECMM Mucormycosis Guidelines) (Clin Microbiol Infect, 2014) [MEDLINE]

Serum (1–3)-β-D-Glucan (see Serum (1–3)-β-D-Glucan, [[Serum (1–3)-β-D-Glucan]])

Recommendations (ESCMID/ECMM Mucormycosis Guidelines) (Clin Microbiol Infect, 2014) [MEDLINE]

ELISPOT

Recommendations (ESCMID/ECMM Mucormycosis Guidelines) (Clin Microbiol Infect, 2014) [MEDLINE]


Clinical Manifestations

Central Nervous System (Isolated) Mucormycosis

Cutaneous Mucormycosis

Gastrointestinal Mucormycosis

Pulmonary Mucormycosis

Renal Mucormycosis

Rhino-Orbital-Cerebral Mucormycosis

Disseminated Mucormycosis


Treatment

Elimination of Predisposing Factors

Surgery

Antifungal Treatment

General Comments

Liposomal Amphotericin (see Amphotericin, [[Amphotericin]]): drug of choice for initial treatment

Posaconazole (Noxafil, Posanol) (see Posaconazole, [[Posaconazole]])

Isavuconazole (Cresemba) (see Isavuconazole, [[Isavuconazole]])

Duration of Anti-Fungal Therapy

Other


References