Subcutaneous Mucormycosis in an Immunocompetent Patient

Rhinocerebral Mucormycosis

Background/Objectives: Mucormycosis is a rapidly progressive invasive fungal infection that commonly involves the sinonasal region and skull base in patients with systemic comorbidities, yet robust ENT data from middle-income settings are scarce. Methods: We performed a single-center retrospective review of all patients with histopathologically confirmed mucormycosis treated in the Otorhinolaryngology Department of Dicle University between 2010 and 2023, covering a 14-year period. Eligible patients had paranasal sinus computed tomography at presentation and received surgical and/or systemic antifungal therapy. Demographic data, comorbidities, disease subtype, radiological extent, treatment modality and survival were extracted from records. Survival was estimated using Kaplan–Meier analysis, and group differences were tested with chi-square statistics (p ≤ 0.05). Results: Fifty-two patients met the inclusion criteria (mean age 56.5 ± 15.2 years; 57.7% male); 73.1% had at least one systemic comorbidity, most frequently diabetes mellitus (65.4%) and hematological malignancy (19.2%). Disease was sinonasal in 42.3%, rhino-orbital in 28.8% and rhino-orbito-cerebral in 28.8%. Baseline CT showed intracranial extension in 26.9%. Overall survival was 59.6% and differed markedly by subtype, highest in isolated sinonasal disease (81.8%) and lowest in rhino-orbito-cerebral disease (26.7%). Intracranial extension was associated with higher mortality (71.4% vs. 28.9%). Combined surgical debridement plus systemic antifungal therapy, used in 84.6% of patients, yielded lower mortality than antifungal therapy alone (31.8% vs. 87.5%). Conclusions: In this ENT cohort, prognosis was mainly determined by anatomical extent and treatment strategy. Our findings suggest that timely combined surgical and antifungal management, when feasible and in appropriately selected patients, is associated with improved survival outcomes.

There are two main types of fungal infections in the oncology patient: primary cutaneous fungal infections and cutaneous manifestations of fungemia. The main risk factor for all types of fungal infections in the oncology patient is prolonged and severe neutropenia; this is especially true for disseminated fungal infections. Severe neutropenia occurs most often in leukemia and lymphoma patients exposed to high-dose chemotherapy. Fungal infections in cancer patients can be further divided into five groups: (i) superficial dermatophyte infections with little potential for dissemination; (ii) superficial candidiasis; (iii) opportunistic fungal skin infections with distinct potential for dissemination; (iv) fungal sinusitis with cutaneous extension; and (v) cutaneous manifestations of disseminated fungal infections. In the oncology population, dermatophyte infections (i) and superficial candidiasis (ii) have similar presentations to those seen in the immunocompetent host. Primary cutaneous mold infections (iii) are especially caused by Aspergillus, Fusarium, Mucor, and Rhizopus spp. These infections may invade deeper tissues and cause disseminated fungal infections in the neutropenic host. Primary cutaneous mold infections are treated with systemic antifungal therapy and sometimes with debridement. The role of debridement in the severely neutropenic patient is unclear. In some patients with an invasive fungal sinusitis (iv) there may be direct extension to the overlying skin, causing a fungal cellulitis of the face. Aspergillus, Rhizopus, and Mucor spp. are the most common causes. We also describe the cutaneous manifestations of disseminated fungal infections (v). These infections usually occur in the setting of prolonged neutropenia. The most common causes are Candida, Aspergillus, and Fusarium spp. Therapy is with systemic antifungal therapy. The relative efficacies of amphotericin B, fluconazole, itraconazole, voriconazole, and caspofungin are discussed. Recovery from disseminated fungal infections is unlikely, however, unless the patient's neutropenia resolves.

Recurrent cutaneous Geomyces pannorum infection in three brothers with ichthyosis

Cutaneous mucormycosis is a rare, opportunistic fungal infection that typically affects immunocompromised hosts. Current treatment consists of systemic antifungal therapy, surgical debridement, and when applicable, restoration of immune function. Despite intervention, the morbidity and mortality of invasive fungal disease remains high. There are few reports of primary or secondary cutaneous mucormycosis involving the ocular adnexa. The authors describe the course of 2 children with cutaneous mucormycosis of the eyelid treated with subcutaneous liposomal amphotericin B (LAmB) injections (3.5 mg/ml) in an off-label application as an adjunct to debridement and systemic antifungal therapy. To the authors' knowledge, these are the first 2 cases of invasive fungal disease involving the eyelid treated with subcutaneous LAmB injections, and the first reported case of disseminated fungal infection with secondary cutaneous involvement of the eyelid.

To exenterate or not? An unusual case of pediatric rhinocerebral mucormycosis

Mucormycosis is a highly invasive, devastating and usually fatal fungal infection of the sinuses, brain, or lungs that occurs primarily in people with immune disorders. Despite advances in diagnosis and treatment, a high mortality still exists. We present a middle aged diabetic male with this serious fungal infection involving nose, paranasal area and adjacent periorbital regions with a high risk of progressing further towards the dura mater. He was promptly diagnosed and managed with serial surgical debridements with systemic antifungals and was later fitted with a nasal prosthesis.

This investigation was conducted to determine if a correlation exists between wound healing outcomes and serial debridement in chronic venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs). We retrospectively analyzed the results from two controlled, prospective, randomized pivotal trials of topical wound treatments on 366 VLUs and 310 DFUs over 12 weeks. Weekly wound surface area changes following debridement and 12-week wound closure rates between centers and patients were evaluated. VLUs had a significantly higher median wound surface area reduction following clinical visits with surgical debridement as compared with clinical visits with no surgical debridement (34%, p=0.019). Centers where patients were debrided more frequently were associated with higher rates of wound closure in both clinical studies (p=0.007 VLU, p=0.015 DFU). Debridement frequency per patient was not statistically correlated to higher rates of wound closure; however, there was some minor evidence of a positive benefit of serial debridement in DFUs (odds ratio-2.35, p=0.069). Our results suggest that frequent debridement of DFUs and VLUs may increase wound healing rates and rates of closure, though there is not enough evidence to definitively conclude a significant effect. Future clinical research in wound care should focus on the relationship between serial surgical wound debridement and improved wound healing outcomes as demonstrated in this study.

Endemic Fungal Infections in Solid Organ Transplant Recipients

Invasive fungal wound infections (IFIs) were an unexpected complication associated with blast-related wounds during Operation Enduring Freedom. Between 2010 and 2012, IFI incidence rates were as high as 10-12% for patients injured during Operation Enduring Freedom and admitted to the intensive care unit at the Landstuhl Regional Medical Center. Independent risk factors for the development of IFIs include dismounted blast injuries, above knee amputations and massive (>20 units) packed red blood cell transfusions within 24 hours after injury. The Joint Trauma System developed a Clinical Practice Guideline on IFI prevention, identification and management. Aggressive and frequent surgical debridement remains the primary therapy accompanied by topical antifungal therapy (e.g., Dakins solution). Empiric systemic antifungal therapy with both liposomal amphotericin B and an intravenous broad-spectrum triazole (e.g., voriconazole or posaconazole) should be administered when there is strong suspicion of IFI based on the occurrence of recurrent wound necrosis following serial surgical debridements, since many cases involve multiple fungal species. Other recommendations include: (1) early tissue sampling for wound histopathology and fungal cultures, (2) early consultation with infectious disease specialists, and (3) coordination with surgical pathology and clinical microbiology.

A case report of cutaneous mucormycosis of the hand after minor trauma in a patient with acute myeloid leukaemia

Using free flaps for reconstruction during infections by mucormycosis: A case report and a structured review of the literature

Commentary: Pneumonectomy for resection of pulmonary mucormycosis: Enough is never too much.

Successful treatment of rhino-orbital mucormycosis by a new combination therapy with liposomal amphotericin B and micafungin

Rhinocerebral mucormycosis, also known as zygomycosis, is an acute opportunistic fungal infection with high associated mortality rates. There are some predisposing factors for mucormycosis such as hematological malignancies, severe burns, neutropenia, diabetes mellitus, and the use of corticosteroids. Treatment of rhinocerebral mucormycosis consists of treating the predisposing disease, aggressive surgical debridement and systemic antifungal therapy. We present the case of a 55-year-old diabetic patient treated with insulin who was admitted to the emergency department for headache and left purulent rhinorrhea for 3 days. The patient was hospitalized for diabetic ketoacidosis, and intravenous insulin infusion therapy and intravenous antibiotherapy were administered. The day after hospitalization the patient developed a ptosis of the left eye associated with edema of the upper eyelid and the left cheek. The nasal endoscopy showed necrotic tissue in the left middle meatus and the middle turbinate associated withprofuse purulent discharge. The culture of the nasal swab identified a Rhizopusoryzae and the diagnosis of rhino-cerebral mucormycosis was retained.The patient was put on amphotericin B (1 mg/kg/daily) under medical care in hospital. The patient underwent a functional endoscopic sinus surgery with debridement of sinuses, ethmoidectomy and bilateral antrotomie. Histopathological findings from biopsy of the maxillary sinus presented aseptate hyphae in necrotic tissue. The outcome was fatal on the third day of hospitalization, despite appropriate reanimation measures.