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Mucormycosis

Updated : May 7, 2024





Background

Mucormycosis is an invasive fungal infection. It is caused by common environmental organisms. They are often non-pathologic in immunocompromised patients. The infection causes tissue necrosis due to blood vessel invasion and thrombosis. This usually occurs quickly. The treatment of this disease is early and thorough surgery and large doses of intravenous antifungal medication.  These organisms may cause catastrophic and severe complications. 

 

Epidemiology

Mucorales are temperature-sensitive fungi. It is found in decomposing debris and soil. It is rarely pathogenic because of the poor virulence. Mucormycosis is a common condition in general populations. Mucormycosis cases increasing as the cases of immunosuppression in cancer and transplant patients increases, survival rates improve, and immunosuppressive medicines is used for autoimmune diseases. 

Anatomy

Pathophysiology

Mucorales present in decaying waste and compost. It enters into respiratory track via nasal mucus. It is released by sneezing and swallowing. When mucous membrane is damaged, polymorphonuclear neutrophils damage the fungus formations. Patients with neutrophil malfunction or neutropenia mainly in bone marrow transplants and leukemia are at the highest risk of this disease. Diabetes patients with uncontrolled diabetes and high glucose levels provide a perfect environment to grow the filamentous structure. It binds to the blood vessels and infiltrate them. This causes ischemic necrosis. 

Etiology

Mucormycosis is an infectious fungus disease. It is caused by the Zygomycetes and Mucorales groups. They are inhaled by air spores. The associated conditions are like diabetes, malnutrition, lymphomas, leukemias, renal failure, organ transplants, burns, immunosuppressive medication, cirrhosis, and AIDS. Patients who have diabetic ketoacidosis and dialysis using deferoxamine are at high risks. Patients who have overt immunosuppression, transplants, HIV, chronic steroids, or using disease-modifying anti-rheumatic drugs may develop a necrotizing infection. 

Genetics

Prognostic Factors

The prognosis of the patient is dependent on the treatment time and presented immunodeficiency. The death ratio is about 25 to 87 %. Spread of the infection, kidney damage, dysfunction of central nervous system and limited response to the treatment are the bad signs of the prognosis. The most important factor is to gain the normal immune system.  

Clinical History

Mucormycosis disease is caused by a weak immune system. The associated diseases are diabetes, hematological malignancies, organ transplantation or immunosuppressive therapy. When the skin or mucous raptured after the trauma, this condition also led to this disease. The symptoms of od this disease depend on the type and severity of the infection. In cases of rhinocerebral mucormycosis, the symptoms occur very rapidly. 

 

Physical Examination

Cutaneous mucormycosis is a primary or secondary disease. It is caused by infection by direct contact to skin or other places. This infection occurs to those individuals who have burn or traumatic skin injuries. It appears as a single and a hard cellulitis that develops to necrotic tissue. The symptoms include abscess formation, skin swelling and tissue necrosis. 

Gastrointestinal mucormycosis is cause by infection through contaminated food or herbal medicines. The related symptoms are like nausea, vomiting, ulceration, thrombosis, diarrhea, hematemesis, melena, necrotizing ulcers, perforation, and peritonitis. Gastrointestinal symptoms are rare. It is rare in the individuals with an immunodeficiency like leukemia or intestinal transplant because of the high level of immune tissue in the GI tract. 

Pulmonary mucormycosis is a fast outbreak of bilateral pneumonia. It is caused by inhalation of infectious material. The symptoms include are like fever, dyspnea, hemoptysis and cough. This is common patient with hematological disease. It is associated with the diseases like bronchopneumonia, bronchitis or pulmonary embolism. The infection can spread to the nearby tissue like mediastinum and heart. It causes cavity lesions and lead to tuberculosis and severe allergic fungal diseases. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Orbital cellulitis  

Aspergillosis  

Nocardiosis  

Cavernous sinus thrombosis 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

An integrated approach to control and management is necessary to treat the disease. Early detection of the disease is crucial. It includes the image study, microbiological cultures and tissue examination. Antifungal treatment mainly with amphotericin B is used to treat the disease. It is a first line agent.  

Surgical treatment can lower the infection and increases the treatment efficacy. In cases of resistance or sensitive disease, other medicines like posaconazole and isavuconazole is used. Supportive care like acid base management, imbalance in electrolytes and organ failure is necessary. 

Close monitoring of clinical response, laboratory data and image study is necessary to treat the disease. Contact with infectious disease specialists, critical care physicians, surgeons and healthcare providers is important to treat the disease correctly. The important factors to treat the fungal infections are early detection, immediate antifungal treatment and correct surgical treatment. 

 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

The procedure of debridement is a surgical treatment. It removes the infected and necrotic tissue to reduce the fungal infection. It prevents the spread of fungus. This treatment removes the affected skin, soft tissue, bone or other parts. It increases the penetration of antifungal medicines at the infection site. It is mainly work on the deep-seated tissues or where antifungal medicines can not each. Surgical treatment with the antifungal medicines can lower the risk of the bacterial infection. It prevents the other disease complications like tissue necrosis, organ dysfunction and systemic spread. 

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Role of Amphotericin

Amphotericin B is a strong fungicidal drug. It kills many kinds of fungi like Mucorales. It damages the cell membrane. It is a first line of treatment. It administered intravenously. Lipid formulations is suggested as there is increased tolerability and lower nephrotoxicity. In some cases, it is used with antifungal medicines or adjunctive therapy like surgical debridement. It is considered in severe or refractory cases. 

Role of Posaconazole

Posaconazole is the most studies to treat the mucormycosis. It is used in patients who are resistant to the amphotericin B treatment. It is used as a salvage treatment. It is used as alone or with antifungal medicines in refractory or intolerance mucormycosis. 

Role of Isavuconazole

Isavuconazole is an alternative treatment to amphotericin B or posaconazole. In vitro studies and clinical trials prove that it is effective against mucormycosis. It is widely used in the clinical practice instead of to amphotericin B. It is mainly used for the patient who is under risk of renal impairment or other disease.  

Management of Hyperglycemia

Hyperglycemia is a major risk factor for mucormycosis. It increases the level of glucose. Glucose is necessary to grow the fungi. By controlling the blood glucose level, the fungal infection can be inhibited and severity of infection can be reduced. Uncontrolled blood glucose level can lead to poor wound healing and tissue necrosis. Insulin therapy is used to control the glycemic index.  

 

Identifying and addressing the underlying causes of hyperglycemia is crucial for long-term management and prevention of recurrence. Patients with mucormycosis and hyperglycemia should be closely monitored for complications like diabetic ketoacidosis or hyperosmolar hyperglycemic state. Medication-induced diabetes or stress hyperglycemia can lead to the hyperglycaemia. It is important to identify and treat the diseases. Patients who have mucormycosis and hyperglycemia are at the risk of the diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). They are closely monitored. 

Management of Acidosis

Management of acidosis is important to stabilize the condition of patient and to improve the result. Acidosis is caused by the factors like tissue hypoperfusion, respiratory issue and metabolic abnormalities. Increase hemodynamics by resuscitation of fluids and vascular support is necessary. Treat the respiratory issue with oxygen, ventilation and administration of intravenous fluids to rebuild the intravascular volume. 

Medication

 

isavuconazonium sulfate 

Initial dose: take a dose of 372 mg orally or intravenously every 8 hours up to 6 doses for two days
Maintenance dose: take a dose of 372 mg orally or intravenously daily
Dosage Modifications
Renal impairment
Mild, moderate and severe: dose modification not required
Hepatic impairment
Mild or moderate: dose modification not required
Severe: study not performed



isavuconazonium sulfate 

Initial dose: 372 mg orally/Intravenous every 8 hours for 6 doses (48 hours)
Maintenance dose: 372 mg orally/Intravenous daily



Dose Adjustments

Dosage Modifications
Renal impairment

Mild, moderate and severe (including End Stage Renal Disease): dose adjustment is not necessary
Hepatic impairment
Mild-moderate: dose adjustment is not necessary
Severe: Not studied

 
 

Media Gallary

Mucormycosis

Updated : May 7, 2024




Mucormycosis is an invasive fungal infection. It is caused by common environmental organisms. They are often non-pathologic in immunocompromised patients. The infection causes tissue necrosis due to blood vessel invasion and thrombosis. This usually occurs quickly. The treatment of this disease is early and thorough surgery and large doses of intravenous antifungal medication.  These organisms may cause catastrophic and severe complications. 

 

Mucorales are temperature-sensitive fungi. It is found in decomposing debris and soil. It is rarely pathogenic because of the poor virulence. Mucormycosis is a common condition in general populations. Mucormycosis cases increasing as the cases of immunosuppression in cancer and transplant patients increases, survival rates improve, and immunosuppressive medicines is used for autoimmune diseases. 

Mucorales present in decaying waste and compost. It enters into respiratory track via nasal mucus. It is released by sneezing and swallowing. When mucous membrane is damaged, polymorphonuclear neutrophils damage the fungus formations. Patients with neutrophil malfunction or neutropenia mainly in bone marrow transplants and leukemia are at the highest risk of this disease. Diabetes patients with uncontrolled diabetes and high glucose levels provide a perfect environment to grow the filamentous structure. It binds to the blood vessels and infiltrate them. This causes ischemic necrosis. 

Mucormycosis is an infectious fungus disease. It is caused by the Zygomycetes and Mucorales groups. They are inhaled by air spores. The associated conditions are like diabetes, malnutrition, lymphomas, leukemias, renal failure, organ transplants, burns, immunosuppressive medication, cirrhosis, and AIDS. Patients who have diabetic ketoacidosis and dialysis using deferoxamine are at high risks. Patients who have overt immunosuppression, transplants, HIV, chronic steroids, or using disease-modifying anti-rheumatic drugs may develop a necrotizing infection. 

The prognosis of the patient is dependent on the treatment time and presented immunodeficiency. The death ratio is about 25 to 87 %. Spread of the infection, kidney damage, dysfunction of central nervous system and limited response to the treatment are the bad signs of the prognosis. The most important factor is to gain the normal immune system.  

Mucormycosis disease is caused by a weak immune system. The associated diseases are diabetes, hematological malignancies, organ transplantation or immunosuppressive therapy. When the skin or mucous raptured after the trauma, this condition also led to this disease. The symptoms of od this disease depend on the type and severity of the infection. In cases of rhinocerebral mucormycosis, the symptoms occur very rapidly. 

 

Cutaneous mucormycosis is a primary or secondary disease. It is caused by infection by direct contact to skin or other places. This infection occurs to those individuals who have burn or traumatic skin injuries. It appears as a single and a hard cellulitis that develops to necrotic tissue. The symptoms include abscess formation, skin swelling and tissue necrosis. 

Gastrointestinal mucormycosis is cause by infection through contaminated food or herbal medicines. The related symptoms are like nausea, vomiting, ulceration, thrombosis, diarrhea, hematemesis, melena, necrotizing ulcers, perforation, and peritonitis. Gastrointestinal symptoms are rare. It is rare in the individuals with an immunodeficiency like leukemia or intestinal transplant because of the high level of immune tissue in the GI tract. 

Pulmonary mucormycosis is a fast outbreak of bilateral pneumonia. It is caused by inhalation of infectious material. The symptoms include are like fever, dyspnea, hemoptysis and cough. This is common patient with hematological disease. It is associated with the diseases like bronchopneumonia, bronchitis or pulmonary embolism. The infection can spread to the nearby tissue like mediastinum and heart. It causes cavity lesions and lead to tuberculosis and severe allergic fungal diseases. 

Orbital cellulitis  

Aspergillosis  

Nocardiosis  

Cavernous sinus thrombosis 

An integrated approach to control and management is necessary to treat the disease. Early detection of the disease is crucial. It includes the image study, microbiological cultures and tissue examination. Antifungal treatment mainly with amphotericin B is used to treat the disease. It is a first line agent.  

Surgical treatment can lower the infection and increases the treatment efficacy. In cases of resistance or sensitive disease, other medicines like posaconazole and isavuconazole is used. Supportive care like acid base management, imbalance in electrolytes and organ failure is necessary. 

Close monitoring of clinical response, laboratory data and image study is necessary to treat the disease. Contact with infectious disease specialists, critical care physicians, surgeons and healthcare providers is important to treat the disease correctly. The important factors to treat the fungal infections are early detection, immediate antifungal treatment and correct surgical treatment. 

 

The procedure of debridement is a surgical treatment. It removes the infected and necrotic tissue to reduce the fungal infection. It prevents the spread of fungus. This treatment removes the affected skin, soft tissue, bone or other parts. It increases the penetration of antifungal medicines at the infection site. It is mainly work on the deep-seated tissues or where antifungal medicines can not each. Surgical treatment with the antifungal medicines can lower the risk of the bacterial infection. It prevents the other disease complications like tissue necrosis, organ dysfunction and systemic spread. 

Amphotericin B is a strong fungicidal drug. It kills many kinds of fungi like Mucorales. It damages the cell membrane. It is a first line of treatment. It administered intravenously. Lipid formulations is suggested as there is increased tolerability and lower nephrotoxicity. In some cases, it is used with antifungal medicines or adjunctive therapy like surgical debridement. It is considered in severe or refractory cases. 

Posaconazole is the most studies to treat the mucormycosis. It is used in patients who are resistant to the amphotericin B treatment. It is used as a salvage treatment. It is used as alone or with antifungal medicines in refractory or intolerance mucormycosis. 

Isavuconazole is an alternative treatment to amphotericin B or posaconazole. In vitro studies and clinical trials prove that it is effective against mucormycosis. It is widely used in the clinical practice instead of to amphotericin B. It is mainly used for the patient who is under risk of renal impairment or other disease.  

Hyperglycemia is a major risk factor for mucormycosis. It increases the level of glucose. Glucose is necessary to grow the fungi. By controlling the blood glucose level, the fungal infection can be inhibited and severity of infection can be reduced. Uncontrolled blood glucose level can lead to poor wound healing and tissue necrosis. Insulin therapy is used to control the glycemic index.  

 

Identifying and addressing the underlying causes of hyperglycemia is crucial for long-term management and prevention of recurrence. Patients with mucormycosis and hyperglycemia should be closely monitored for complications like diabetic ketoacidosis or hyperosmolar hyperglycemic state. Medication-induced diabetes or stress hyperglycemia can lead to the hyperglycaemia. It is important to identify and treat the diseases. Patients who have mucormycosis and hyperglycemia are at the risk of the diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). They are closely monitored. 

Management of acidosis is important to stabilize the condition of patient and to improve the result. Acidosis is caused by the factors like tissue hypoperfusion, respiratory issue and metabolic abnormalities. Increase hemodynamics by resuscitation of fluids and vascular support is necessary. Treat the respiratory issue with oxygen, ventilation and administration of intravenous fluids to rebuild the intravascular volume. 

isavuconazonium sulfate 

Initial dose: take a dose of 372 mg orally or intravenously every 8 hours up to 6 doses for two days
Maintenance dose: take a dose of 372 mg orally or intravenously daily
Dosage Modifications
Renal impairment
Mild, moderate and severe: dose modification not required
Hepatic impairment
Mild or moderate: dose modification not required
Severe: study not performed



isavuconazonium sulfate 

Initial dose: 372 mg orally/Intravenous every 8 hours for 6 doses (48 hours)
Maintenance dose: 372 mg orally/Intravenous daily



Dose Adjustments

Dosage Modifications
Renal impairment

Mild, moderate and severe (including End Stage Renal Disease): dose adjustment is not necessary
Hepatic impairment
Mild-moderate: dose adjustment is not necessary
Severe: Not studied

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