Original article
Clinical
Contemporary Treatment and Outcomes of Zygomycosis in a Non-oncologic Tertiary Care Center

https://doi.org/10.1016/j.arcmed.2006.06.009Get rights and content

Background

Zygomycosis is an emerging mycosis of increasing relevance. Limited data exist for outcomes with contemporary therapies.

Methods

A 6-year retrospective chart review was performed in a non-oncological tertiary care center for patients with zygomycosis.

Results

Sixteen episodes of proven (EORTC/MSG criteria) zygomycosis were identified. The average age was 49.2 years. Sites of infection were surgical/traumatic wound [5], rhinocerebral [4], disseminated [2], pulmonary [2], peritoneal [2], and localized skin [1]. Associated conditions included diabetes [7], ketoacidosis [2], end-stage renal disease [4], surgery/trauma [4], steroids [3], solid organ transplant [2], neutropenia [1], and intravenous drug use [1]. Twelve patients had surgical debridement. Medical therapy included liposomal amphotericin B, conventional amphotericin B (CAB), and amphotericin B lipid complex. Overall mortality was 4/16 (25%), occurring in a patient each with rhinocerebral, pulmonary, surgical wound infection, and disseminated disease. Mortality with surgical treatment was 2/12 (17%) vs. 2/4 (50%) without surgery. Mortality for patients treated with CAB was 1/3 vs. 3/12 for those treated with any lipid preparation. Serious morbidity occurred in 7/12 survivors.

Conclusions

In this limited study of contemporary therapies, patients with zygomycosis from a non-oncological tertiary care center have lower mortality than classically described. This disease and its treatments are still associated with severe morbidity, disfigurement, and disability.

Introduction

Zygomycosis is a term for a variety of fungal infections caused by members of the order Mucorales and are associated with a poor prognosis, having high morbidity and mortality. Infections by the Mucorales are infrequent, acute, and often fatal with a reported mortality rate of up to 80% in patients with hematologic malignancy 1, 2 and 41% in patients without malignancy (3). They involve pulmonary, rhinocerebral, cutaneous, gastrointestinal, and disseminated mycoses (4).

Zygomycetes have a wide geographic distribution, are all thermotolerant, and utilize a variety of nutritional substrates. In nature, they are found in the soil, on animal feces, and decaying plant materials. They spread by the production of sporangiospores that are released into the environment as airborne propagules. Inhalation of propagules causes the major clinical infections (rhinocerebral and pulmonary) with dissemination from the respiratory tract accounting for other infections. Direct inoculation into the skin with contaminated material during trauma is associated with cutaneous infection. Nosocomial infections can occur from sporangiospores released in contaminated air conditioning systems or contaminated wound dressings (5). Reports have also been made of peritonitis after peritoneal dialysis (6), disseminated infection after infusion of contaminated solutions, cutaneous infections after intravenous catheter use (7), and gastrointestinal infection after nasogastric administration of contaminated medicines (8).

Infections occur equally in both sexes irrespective of age. Classically described predisposing factors include poorly controlled diabetes, especially when associated with ketoacidosis, corticosteroid use, immunosuppression therapy for solid organ transplant or bone marrow transplant, neutropenia or neutrophil dysfunction associated with leukemia/lymphoma (9), deferoxamine therapy for iron overload (10), HIV/AIDS, and renal failure. Cases have been described in patients without underlying illness but usually in the setting of local injury (3).

Zygomycosis appears to represent an emerging clinical entity (3). This is likely due to increased solid organ transplantation with resulting long-term immunosuppression, increased incidence of diabetes, and as a breakthrough mycosis in bone marrow transplant and leukemia/lymphoma patients 1, 11.

Although the primary literature on therapy describes aggressive, early surgical debridement with concomitant amphotericin B deoxycholate use 12, 13, contemporary data on treatments and outcomes of zygomycosis are limited. There are case reports of the use of lipid preparations of amphotericin in zygomycosis, one case series summarizing Phase I and II studies of amphotericin B colloid dispersion mostly in leukemic and bone marrow transplant patients (14), and one case series in a subset of a larger review (3). There are no contemporary case series describing patient characteristics, therapies, or outcomes of zygomycosis with presently available therapies in non-oncologic patients. The purpose of our study was to systematically describe the characteristics and outcomes of patients with zygomycosis treated with contemporary treatment options in non-oncology patients in a tertiary care center.

Section snippets

Materials and Methods

A 6-year (1999–2004) retrospective contemporary chart review was performed in a non-oncological tertiary care center for patients with zygomycosis identified through microbiological and discharge data. Cases of contamination were excluded and only cases of microbiologically confirmed (EORTC/MSG criteria) (15) zygomycosis were evaluated. The charts were reviewed for demographics, underlying disease information, medical and surgical treatments, complications of therapy, and hospital course, as

Results

Sixteen episodes of zygomycosis were found in 15 patients. One patient with fungal peritonitis had a recurrence of disease 1 month after completing a 7-week course of liposomal amphotericin therapy. He was readmitted for more aggressive surgical debridement and treated with 4 more weeks of liposomal amphotericin with complete resolution. A summary of patient demographics, underlying medical conditions, and sites of infections are shown in Table 1. Six of the cases (38%) were diagnosed in

Discussion

The mortality rate in our series of patients was lower than previously reported rates. This may partly be explained by the high percentage of patients with traumatic wound infections who generally have fewer comorbid conditions and lower mortality in zygomycosis [31% in the largest series by Roden et al. (3)]. However, even if these four patients (who all survived) are removed from the analysis, the mortality increases only to 33% in this series. Our high rate of cutaneous and rhinocerebral

Acknowledgments

This study was supported by a grant from Gilead Sciences.

This study was partially presented as abstract #273 at the 43rd annual meeting of the Infectious Diseases Society of America, San Francisco, CA, October 2005.

C.R. Sims–No conflicts.

L. Ostrosky-Zeichner–No conflicts.

References (16)

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