Updated: 12/19/2019

Mucormycosis

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Snapshot
  • A 50-year-old man is brought to the emergency room via ambulance from a fire. He has extensive burns over his arms, torso, and legs. His past medical history is significant for uncontrolled diabetes. On exam, he has periorbital swelling and rhinorrhea. There is a black eschar over his nares and palate. A CT of his sinuses show air fluid levels in his maxillary and frontal sinuses. Biopsy of the black eschar reveals nonseptate hyphae branching at wide angles.
Introduction
  • Classification
    • Mucor and Rhizopus spp.
      • fungi with irregular, broad, and nonseptate hyphae branching at wide or right angles
      • found in soil and decomposed material
      • transmission via inhalation of spores or direct inoculation (through trauma)
  • Epidemiology
    • risk factors
      • ketoacidosis 
      • uncontrolled diabetes
      • neutropenia
      • hematologic malignancies
      • immunocompromised status
      • trauma
      • burns
  • Pathogenesis
    • inhalation of spores causes germination in nares, sinuses, or lungs, and spread in blood vessel walls
    • invasion into blood vessels cause hemorrhage, thrombosis, and hematogenous spread
    • fungi can penetrate cribriform plate to enter the brain and sinuses
  • Prognosis
    • high mortality
    • rapidly progressive
Presentation
  • Symptoms
    • headache
    • congestion
    • facial pain
    • sinus pressure
  • Physical exam
    • fevers
      • may be only presenting symptom in immunocompromised patients with pulmonary infections
    • soft tissue swelling
    • black necrotic eschar on face, particularly nares or palate
    • may affect cranial nerves
      • blurry vision
      • loss of ocular motility
    • may have erythematous and necrotic papules and plaques if skin is affected
Imaging
  • Computed tomography (CT) head/sinuses
    • indication
      • all patients
    • findings
      • air-fluid levels in sinuses
      • mucosal thickening
      • bony destruction
Studies
  • Labs
    • culture yield is often low and not useful
  • Biopsy of affected tissue
    • nonseptate hyphae with right-angle or wide-angle branching
  • Making the diagnosis
    • based on clinical presentation and demonstration of fungus in affected tissue
    • high level of suspicion in patients with sinusitis-like symptoms and appropriate risk factors who do not respond to broad-spectrum antibiotics
Differential
  • Bacterial sinusitis
    • distinguishing factor
      • does not present with black eschar or rapid progression to brain and cranial nerves
Treatment
  • Medical
    • amphotericin B
      • indication
        • first-line
    • isavuconazole
      • indication
        • second-line
  • Operative
    • surgical debridement
      • indications
        • all patients
        • in addition to antifungals
Complications
  • Death

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Questions (1)

(M2.ID.17.4766) A 54-year-old male presents to the emergency department with facial pain. He reports feeling well until yesterday, when he developed a headache that has gotten progressively worse. The pain has now spread to the right side of his face. This morning he also developed lacrimation of the right eye and double vision. His past medical history is significant for hypertension, hyperlipidemia, type II diabetes mellitus, and end stage renal disease secondary to diabetic nephropathy. The patient’s most recent HbA1c was 12.7%. His home medications include furosemide, lisinopril, pravastatin, metformin, glipizide, and insulin. His temperature is 101.8°F (38.8°C), blood pressure is 155/92 mmHg, pulse is 103/min, and respirations are 16/min. On physical exam, he has proptosis and chemosis of the right eye. Physical exam of the hard palate can be seen in Figure A.

In addition to surgical debridement, which of the following is the treatment of choice for this patient?

QID: 109050
FIGURES:
1

Amphotericin

50%

(13/26)

2

Caspofungin

12%

(3/26)

3

Penicillin

4%

(1/26)

4

Trimethoprim-sulfamethoxazole

19%

(5/26)

5

Voriconazole

15%

(4/26)

M 7 E

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