Original articleClinicalContemporary Treatment and Outcomes of Zygomycosis in a Non-oncologic Tertiary Care Center
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)
- et al.
Mucormycosis and entomophthoramycosis: a review of the clinical manifestations, diagnosis and treatment
Clin Microbiol Infect
(2004) - et al.
Nosocomial infection with Rhizopus microsporus in preterm infants: association with wooden tongue depressors
Lancet
(1996) - et al.
Risk factor for invasive zygomycosis in patients with hematologic malignancies
Mycoses
(2002) - et al.
Improved outcome of zygomycosis in patients with hematological diseases?
Leuk Lymphoma
(2004) - et al.
Epidemiology and outcome of zygomycosis: a review of 929 reported cases
Clin Infect Dis
(2005) - et al.
Successful treatment of mucormycosis peritonitis with liposomal amphotericin B in a patient on long-term peritoneal dialysis
Am J Kidney Dis
(2003) - et al.
Mucormycosis in transplant patients
Am Surg
(1980) - et al.
Outbreak of gastric mucormycosis associated with the use of wooden tongue depressors in critically ill patients
Intensive Care Med
(2004)
Cited by (35)
Invasive Fungal Infections Secondary to Traumatic Injury
2017, International Journal of Infectious DiseasesCitation Excerpt :Accelerated organic decay during warm, dry periods may precipitate rapid fungal growth and higher atmospheric spore concentrations, explaining this observation. In contrast, a 6-year (1994-2004) retrospective Texan study of 16 patients, 4 with known trauma, reported a clustering of mucormycosis cases in February and March, prior to the rainy season and with average high temperatures rarely exceeding 25 °C (Sims and Ostrosky-Zeichner, 2007). Given that most fungi prefer temperatures in the range of 12 °C to 30 °C (Garcia-Solache and Casadevall, 2010), the relatively hot Texan climate may explain the shift in peak incidence.
Mucormycoses
2016, Infectious Disease Clinics of North AmericaCitation Excerpt :Outside of the HM patient population,37 risk factors for mucormycosis are poorly controlled diabetes, especially in the setting of ketoacidosis,38,39 high-dose glucocorticoids, penetrating trauma or burns, and chelation therapy with deferoxamine in hemodialysis or transfusion-dependent patients.16,36 Less frequently,16,36 mucormycosis occurs in the setting of renal failure, malnutrition in low-birth-weight infants, surgical wounds (from contaminated bandages),37,40,41 and blast combat injuries.42 In intravenous drug users, fatal cerebral mucormycosis has been described and should be considered in cases of rapidly progressing brain abscesses or in the absence of response to antibacterials.16,43
Agents of Mucormycosis and Entomophthoramycosis
2014, Mandell, Douglas, and Bennett's Principles and Practice of Infectious DiseasesSkull vault destruction after rhinocerebral mucormycosis
2012, World NeurosurgeryCitation Excerpt :Rhinocerebral is the commonest form of the disease, accounting for between one-third and one-half of all cases (12, 13). Most of these cases have occurred in poorly controlled diabetic patients; however, other conditions that have been reported predispose to infection are solid or hematologic malignancies (7, 8, 16), iron overload (5), extensive burns, or long-term corticosteroid usage (13, 15). The fungus enters the paranasal sinuses by inhalation and can spread either inferiorly into the palate, posteriorly into the sphenoid sinus, laterally into the orbit, or superiorly into the brain either through the orbital apex or the cribriform plate (12).
Seven years of experience with zygomycosis in Iran: A seasonal disease
2011, Brazilian Journal of Infectious DiseasesMortality risk factors in patients with zygomycosis: A retrospective and multicentre study of 25
2011, Enfermedades Infecciosas y Microbiologia Clinica