Systemic Antifungal Treatment Research Articles

Improvement in onychomycosis after initiation of combined antiretroviral therapy

Onychomycosis is frequent in patients with late and advanced HIV disease; immunocompromised patients may develop atypical clinical presentations that can be difficult to control. Current treatment for onychomycosis is based on the prolonged administration of antifungal therapies that may have significant interactions with combined antiretroviral therapy (cART). An improvement in certain HIV-associated opportunistic infections has been associated with initiation of cART. The aim of this study was to analyze the influence of cART on the outcome of onychomycosis in HIV-infected patients. HIV-infected patients with dermatologic lesions attending the National Institute of Respiratory Diseases were asked to undergo physical examination. Detailed clinical histories were recorded. Routine laboratory tests, CD4 T cell count, and HIV viral load were performed. Onychomycosis was diagnosed on the basis of clinical appearance. Nail scrapings were collected from toenails and fingernails. Specimens were analyzed using direct microscopy. Nail changes after cART initiation were assessed by clinical examination. Improvement in onychomycosis was observed in six patients with late and advanced HIV disease after initiation of cART. Complete resolution of onychomycosis was observed in one patient without the use of antifungal therapy; one patient required topical antifungal treatment, and two patients required systemic antifungal treatment to achieve complete resolution. Onychomycosis should be included in the group of pathologies that improve with cART-induced immune reconstitution. The pathogenesis of onychomycosis in HIV disease warrants investigation in the context of cell-mediated immunity restoration.

Indications and outcomes of antifungal therapy in French patients with haematological conditions or recipients of haematopoietic stem cell transplantation

Invasive fungal disease (IFD) remains a major concern in patients with haematological conditions. We describe diagnoses, therapeutic management and outcomes in unselected consecutive patients from haematological facilities treated for suspected or documented IFD. In this observational prospective study, children/adults with haematological conditions or haematopoietic stem cell transplantation (HSCT) were recruited upon start of non-prophylactic systemic antifungal treatment in 37 French haematological facilities (December 2007 to December 2008). IFD episodes were classified according to the 2008 EORTC/MSG criteria. The cohort included 419 patients (298 adults and 121 children): 88% haematological malignancies, 28% HSCT recipients and 68% neutropenic. Patients had 423 IFD episodes: 21% mycologically documented (59% probable/proven aspergillosis, 32% proven candidiasis and 9% probable/proven other IFD) and 20% classified as possible IFD. The remaining cases were assigned to two groups: febrile neutropenia (34%) and unclassified (25%), 9% of which were classified as possible/probable/proven IFD by day 7. Treatment was thus initiated early in 59% of patients; liposomal amphotericin B and caspofungin were the most common single-agent therapies. The 12 week mortality was 18% for probable/proven aspergillosis, 15% for proven candidiasis, 10% for probable/proven other IFD, 9% for possible IFD, 3% for febrile neutropenia and 12% for unclassified episodes (log rank P = 0.016); it was dependent on age, complete remission of underlying haematological disease and mechanical ventilation. In this comprehensive sample of haematological patients receiving antifungal treatment, we observe a widespread resort to early therapy and a low mortality rate, including in patients with probable or proven IFD.

Outcomes associated with amphotericin B lipid complex (ABLC) prophylaxis in high-risk liver transplant patients

Antifungal prophylaxis with liposomal amphotericin B in high-risk liver transplant recipients is recommended, but experience with amphotericin B lipid complex (ABLC, Abelcet(®)) in this setting is limited. Data from 615 liver transplants performed during 1999-2005 were analyzed retrospectively. High-risk patients (n = 146) received a mean cumulative ABLC dose of 955 ± 609 mg (mean duration of 23.3 ± 11.9 days). Low-risk patients (n = 469) received no prophylaxis. During a mean follow-up of 43.8 ± 29.2 months, fungal infections occurred in 32.2% of ABLC patients versus 43.5% of non-prophylaxis patients (P = 0.015). The overall rate of invasive fungal infection was 12.3% in the ABLC group versus 15.6% in the non-prophylaxis patients (P = 0.34). Any Candida infection (ABLC 29.5%, non-prophylaxis 41.2%, P = 0.011), probable or proven invasive Candida infection requiring systemic antifungal treatment (ABLC 18.5%, non-prophylaxis 32.4%, P = 0.001) and invasive abdominal candidiasis during the first 3 months (ABLC 4.1%, non-prophylaxis 9.2%, P = 0.049) were significantly less frequent in the ABLC group. There was no significant difference between groups in the incidence of Aspergillus infections. The ABLC group showed no evidence of nephrotoxicity. In conclusion, the marked and significant differences in infection rates and requirement for systemic treatment in this large population suggest that targeted use of low-dose ABLC therapy to high-risk patients is a valid prophylactic strategy following liver transplantation.

Fungal septic arthritis in an immunocompetent girl

Results A 14-year-old girl was referred with pain and swelling in her right knee. This was first noticed 3 months earlier after she banged the knee while swimming. There was no involvement of other joints or systemic symptoms. There was no history of significant illness in the past. Examination confirmed active arthritis of the right knee. Other joints were normal with no systemic signs. With a provisional diagnosis of oligoarticular Juvenile Idiopathic Arthritis, her right knee was injected with Triamcinolone hexactonide. The knee did not respond to the steroid injection and she had significant bruising around the injection site. She underwent further blood tests including tests for Lyme disease and Tuberculosis which were negative, after which her right knee was injected again with steroid after aspirating synovial fluid. The MRI scan confirmed knee effusion with some erosive areas. The synovial aspirate was negative for tuberculosis but grew a fungus of doubtful significance on prolonged culture, later identified as Phaeoacremonium spp. It was revealed that during horse riding while on holiday in Dominican Republic a year earlier, she had scraped her right knee against a tree sustaining an abrasion, but there was no swelling of the knee till the swimming pool accident. The arthritis progressively got worse along with systemic symptoms like high temperature. Her CRP was 39mg/L and ESR 48mm/hr. Her joint was aspirated again, which drained pus. She underwent arthroscopic lavage and debridement. The lateral tibial and femoral condyles were autodigested and she underwent partial synovectomy. She was commenced on intravenous antibiotics with Voriconazole because of the growth of the fungus in April. The aspirates grew Phaeoacremonium again and the bacterial cultures were negative confirming the diagnosis of fungal septic arthritis. She was tested extensively for immunodeficiencies, the results of which were normal. She was continued on systemic antifungal treatment for over one year and the knee improved steadily.

Outbreak of cutaneous zygomycosis associated with the use of adhesive tape in haematology patients

We report an outbreak of cutaneous Rhizopus oryzae infection associated with adhesive polyethylene tapes used to stabilize peripheral venous catheters in four patients. All patients were suffering from haematological diseases; the infection severity was proportional to the duration of neutropenia. Intervention with systemic antifungal treatment and surgical debridement was required for resolution of the infection. The entire batch of tapes was withdrawn and the outbreak subsided.

Diagnosis and treatment of postpartum Candida endophthalmitis

The occurrence of endogenous Candida endophthalmitis is rare in immunocompetent patients. We report a case of a 29-year-old healthy woman who developed endogenous Candida endophthalmitis after normal spontaneous vaginal delivery. The patient was diagnosed with Candida endophthalmitis by positive vitreous culture obtained by diagnostic vitrectomy. After vitrectomy, she was treated with systemic and intravitreal antifungal therapy, and subsequently, her visual acuity recovered to 20/20 without other complications. Normal spontaneous vaginal delivery may cause endogenous Candida endophthalmitis in young healthy women. Diagnostic vitrectomy with systemic and intravitreal antifungal treatment can be useful in diagnosis and treatment of Candida endophthalmitis.

Clinical analysis of deep cutaneous mycoses: a 12‐year experience at a single institution

Deep cutaneous mycoses can cause significant morbidity and mortality, especially in immunocompromised patients. There have been few studies focusing on deep cutaneous mycoses and there are no data from Asian countries. This study aimed to investigate clinical characteristics, underlying predisposing factors, aetiological organisms and outcomes in patients with deep cutaneous mycoses. A retrospective medical record review of patients with deep cutaneous mycoses treated at a tertiary referral centre in Korea from 1999 to 2010. Forty-one cases of deep cutaneous mycosis were identified (median age: 49). Most patients (32/41) had impaired immunological status, and seven of the remaining nine had a history of physical trauma. Neutropenia and long-term use of antibiotics were detected in 13 and 12 patients respectively. Nodular skin lesions were the most common type (17/41) and the morphology of the lesions varied. Fungal organisms were identified by culture and histopathology of skin specimens. Candida (16/41) was the most common organism, followed by Aspergillus, Alternaria, Fusarium (4/41 each). Systemic antifungal treatment was successful in 28 patients, while nine patients died from the fungal infection. Our study may lead to improved insights into deep cutaneous mycoses as their incidence is increasing and they vary in different clinical settings.

Disseminated Candidiasis Developing during Prophylaxis with Fluconazole in a Small-Intestine Transplant Recipient

A 31-year-old man underwent immunosuppressive treatment and was treated with 150 mg per day of prophylactic oral fluconazole after receiving a small-intestine transplant. The patient had acute rejection by the end of the first week after the transplant. Endoscopic examination showed white plaques. In blood and urine cultures, growth of Candida albicans was detected. Biopsy specimens showed high levels of conidia and hyphae in all regions. Intravenous treatment with caspofungin was started for the patient. Candidal findings had regressed on follow-up endoscopy. However, the patient died 3 months after transplant because of the effects of immunosuppression on his bone marrow and the development of disseminated intravascular coagulation. Candida species are the most common cause of invasive fungal infections that develop after solid-organ transplant. Following transplant, candidemia may develop during systemic antifungal treatment with a high level of mortality.

Bola fúngica por Aspergillus fumigatus em cavidade pleural

To report the cases of 6 patients with fungus ball caused by Aspergillus fumigatus (aspergilloma) in the pleural cavity. Between 1980 and 2009, 391 patients were diagnosed with aspergilloma at the Santa Casa Hospital Complex in Porto Alegre, Brazil. The diagnosis of aspergilloma in the pleural cavity was made through imaging tests revealing effusion and pleural thickening with air-fluid level; direct mycological examination revealing septate hyphae, consistent with Aspergillus sp.; and positive culture for A. fumigatus in the surgical specimen from the pleural cavity. Of the 391 patients studied, 6 (2%) met the established diagnostic criteria. The mean age of those 6 patients was 48 years (range, 29-66 years), and 5 (83%) were male. The most common complaints were cough, expectoration, and hemoptysis. Four patients (67%) had a history of tuberculosis that had been clinically cured. All of the patients were submitted to surgical removal of the aspergilloma, followed by intrapleural instillation of amphotericin B, in 4; and 2 received systemic antifungal treatment p.o. There was clinical improvement in 5 patients, and 1 died after the surgery. In adult patients with a history of cavitary lung disease or pleural fistula, a careful investigation should be carried out and fungal infection, especially aspergilloma, should be taken into consideration. In such cases, laboratory testing represents the most efficient use of the resources available to elucidate the diagnosis.

Endogenous Fungal Endophthalmitis Developing in a Myasthenia Gravis Individual Treated with High Dose Methylprednisolone

Background: To report a successful treatment case of endogenous fungal endophthalmitis caused by corticosteroid impulse therapy and the cultures are always negative for fungi. Methods: Systemic antifungal treatment and full ophthalmic examination including B-scan ultrasonography, fundus photograph and indocyanine green angiography. Results: The visual acuity recovered from 0.2 to 0.8. B-scan ultrasonography revealed the largest irregular apophysis which disappeared finally. Both fundus photograph and indocyanine green angiography showed the chorioretinal lesions disappearing. Conclusion: Endogenous fungal endophthalmitis caused by corticosteroid impulse therapy is noteworthy and under this situation antifungal treatment should be considered even if the culture is negative for fungi.

Successful Treatment of Fanconi Anemia and T-Cell Acute Lymphoblastic Leukemia

Fanconi anemia is associated with an increased risk of malignancy. Patients are sensitive to the toxic effects of chemotherapy. We report the case of a patient with Fanconi anemia who developed T-cell acute lymphoblastic leukemia. He experienced chemotherapy-related complications including prolonged neutropenia, grade IV vincristine neuropathy, and disseminated aspergillosis. He was successfully treated with modified dosing of cytarabine and intrathecal methotrexate followed by allogeneic bone marrow transplant. The aspergillosis was treated with systemic antifungal treatment and surgical resection. Now 30 months after bone marrow transplant the patient is without evidence of aspergillosis or leukemia.

Actualización en terapia antifúngica: nuevos fármacos e indicaciones

Increases in the rates of fungal infections, as well as their associated morbidity and mortality has led to a need for additional antifungal agents. The most common serious fungal agents in immunosuppressed and critically ill patients are Candida spp. and Aspergillus spp., although other emerging fungi must be considered. Rational, early systemic antifungal treatment should be based on diagnostic imaging techniques and conventional mycological and non-culture-based procedures. While the availability of new therapeutic options is an important advance, antifungal therapy has become increasingly complex. In addition to the available antifungal armamentarium, recent research has resulted in the introduction of three new antifungal agents: micafungin, anidulafungin, and posaconazole. This article provides an update, based on the latest scientific evidence, of the clinical efficacy, pharmacokinetics, safety and dosing of antifungal drugs administered in the management of Candida spp., Aspergillus spp., Cryptococcus spp., Zygomycetes, Scedosporium spp. and Fusarium spp.

Palifermin In High Dose Chemotherapy and Autologous Stem Cell Transplantation: Reduction of Infections and of Resources Utilization with No Increase in Overall Cost

Abstract 4568Forty patients affected by various haematological malignancies who underwent high dose chemotherapy and autologous stem cell transplant (ASCT) were treated with Palifermin, this group was compared to 80 control subjects not assuming this drug. Controls were selected on the basis of being matched for length of neutropenia after ASCT and for Diagnosis. Primary end point was occurrence of “infections not CVC-related” (FUO/pneumonia/gram-negative bacteremia) and secondary end point was the “severe oral mucositis”.Patients and controls resulted to be comparable for many pre-transplant and transplant features. Patients treated with Palifermin displayed a lower rate of “infections not CVC-related” when compared to controls (25% versus 50%, P=0.01) and the protective effect of Palifermin on this outcome remained significant also in a multiple logistic regression model [odds ratio: 0.34, 95% CI: 0.12–0.92, P=0.03] adjusting for a series of potential confounders. The odds ratio of severe mucositis was 30% lower in Palifermin treated patients than in controls (odds ratio: 0.70, 95% CI: 0.33–1.51) but this difference did not attain the statistical significance (P=NS). A stratified analysis by conditioning therapy showed that in patients who received Palifermin after BEAM/BU-CY conditioning, the proportion of patients experiencing severe mucositis was significantly lower than that observed in controls (14% versus 56%, P=0.008) while no such difference was found in those who underwent HD-PAM conditioning (65% versus 56%, P=NS). This result indicates that the conditioning therapy modifies the effect of Palifermin on severe mucositis, a finding fully confirmed in a multiple logistic regression model (P for the effect modification=0.018). Palifermin treated patients had also lower severe gastrointestinal toxicity (12% versus 65%, P<0.001), lower morphine utilization (12% versus 40%, P<0.001), lower total parental nutrition (10% versus 71%, P<0.001) and lower PLT and RBC transfusions (P=0.04) when compared to controls. Average economical costs related to the sum of some resources (inpatient stay, TPN, systemic antifungal treatment and blood products transfusions) were lower in Palifermin treated patients than in controls (11.985 EUROs versus 15.717 EUROs, P=0.002) so that the economical saving in Palifermin treated patients (about 3.700 EUROs) fully compensated for the cost of this drug.Remarkably, in patients treated by “BEAM/BU-CY” conditioning therapy and receiving Palifermin, the overall costs (sum of the above mentioned resources and including also cost of the study drug) was lower in Palifermin treated group in respect to group of patients not treated. In fact, in BEAM/BU-CY stratum overall cost in group treated by Palifermin was 15990±2789 EUROs versus 19276±10946 EUROs in group treated by the same conditioning but not receiving Palifermin (P=0.11).In conclusion this controlled study shows that Palifermin, after ASCT using conditioning not containing TBI, significantly reduces rate of “infections not related to CVC” and ameliorates several indicators of resource consumption, without economical overburden. Disclosures:No relevant conflicts of interest to declare.

A Multicenter, Randomized, Open-Label Study to Evaluate Safety and Efficacy of Posaconazole Vs Fluconazole in the Prophylaxis of Invasive Fungal Infection in a Chinese Population

Abstract 4916 BackgroundInvasive fungal infection (IFI) is a common and fatal complication in neutropenic patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). MethodsIn this multicenter, randomized study, we enrolled patients with persistent neutropenia resulting from chemotherapy for the treatment of AML and MDS. Prophylaxis with either posaconazole or fluconazole was given to the patients to compare the efficacy and safety of the 2 drugs. The treatment was given with each cycle of chemotherapy until the patient recovered from neutropenia and had complete remission, an IFI occurred, or until the patient had received a maximum of 12 weeks of treatment. The primary end point was the incidence of possible, proven, or probable diagnosis of IFI during the treatment phase in *the 2 groups; clinical failure rate, all-cause mortality, and time to first systemic antifungal treatment were secondary end points. ResultsA total of 252 patients were included in this study, and 7 patients were excluded due to withdrawal of informed consent or deviation of eligible criteria. Finally, 124 patients from the posaconazole group and 121 patients from the fluconazole group were included; and 234 patients (117 in each group) entered into statistical analysis, respectively. The incidence of proven, probable, and possible IFI was 9.4% (11/117) and 22.2% (26/117) in the posaconazole and fluconazole groups, respectively (P = 0.0114). The clinical failure rate was lower in the posaconazole group (31.6% [95% CI: 23.3–40.9], 37/117) than in the fluconazole group (41.88% [95% CI: 32.8–51.4], 49/117); however, statistical significance was not reached (P = 0.168). The patients receiving posaconazole had a later onset of first systematic antifungal therapy than those receiving fluconazole (P = 0.0139). The most common clinical adverse reactions were liver function abnormalities, with 11 cases (9.4%) in the posaconazole group and 6 cases (5.1%) in the fluconazole group (P = 0.221). ConclusionsPosaconazole demonstrates efficacy as prophylaxis against IFI in high-risk neutropenic patients with AML and MDS undergoing chemotherapy and is well tolerated during long-term use. (ClinicalTrials.gov number, NCT00811928) Disclosures:No relevant conflicts of interest to declare.

Risk factors for persistent candidemia infection in a neonatal intensive care unit and its effect on mortality and length of hospitalization

Candida infections cause substantial morbidity and mortality in neonates. Persistent candidemia has not been associated with increased risk of mortality compared with candidemia of shorter duration. This study sought to determine whether persistent candidemia was associated with increased length of hospitalization or mortality in neonates. A chart review was conducted of neonates with Candida bloodstream infections (n=37). Demographic, laboratory, pharmacy, nutrition and discharge data were abstracted. Contingency table analysis and logistic regression were used to analyze variables associated with persistent candidemia and mortality. The relationship between length of hospitalization and persistent candidemia was assessed with k-sample equality of medians test. Nine patients (24%) had persistent candidemia. Increased time between blood culture draw and initial antifungal therapy was associated with increased incidence of persistent candidemia (P=0.03). Five patients (14%) died before hospital discharge; however, no deaths were attributed to persistent candidemia. Length of hospitalization was not increased with persistent candidemia. A decrease in the ratio of enteral feeding days to hyperalimentation days before collection of the first positive blood culture was significantly associated with an increase in all-cause mortality (P=0.03) and death attributed to candidemia (P=0.04). The risk of all-cause mortality decreased with a history of receiving any enteral feedings before the first positive blood culture (P=0.04), as did death attributed to candidemia (P=0.02). A duration of >1 day between the time of blood culture and the initial dose of systemic antifungal treatment places neonates at increased risk for developing persistent candidemia; however, this is not associated with increased mortality.

Salmonellal acute acalcular cholecystitis complicated by biliary candidal obstruction: An unusual presentation

Acute acalcular cholecystitis is a disease that mainly affects the immune compromised and severely ill patients. More often than not, the condition has a subtle presentation, yet it follows an aggressive course. Here, we present a case of acalcular salmonellal cholecystitis, which was further complicated by candidal biliary obstruction. Cholecystostomy and biliary irrigation with amphotericin B solution, in addition to systemic antifungal treatment, helped to resolve the grave situation.

Epidemiology of invasive fungal infections and rationale for antifungal therapy in patients with haematological malignancies

Invasive fungal infections (IFIs) in patients with haematological malignancies are difficult to diagnose and outcome is often fatal. Over the 7-month study period, 117 cases with haematological malignancies receiving systemic antifungal treatment were included. Data regarding antifungal agents, dosage and reason for administration were recorded. Fungal infections in study patients were classified as possible, probable or proven according to recent European Organization for Research and Treatment of Cancer criteria. During the study period, 690 cases with haematological malignancies were admitted. A total of 117 cases received systemic antifungal therapy. Twenty-four of 117 patients (21%) had possible, six (5.1%) had probable and four (3.4%) had proven IFI. Seven of 10 probable and proven infections were caused by Candida spp., 2 by Aspergillus spp. and 1 by a fungus belonging to Zygomycetes. Fifty-two of 117 patients (44%) received antifungal prophylaxis, 81 of 117 (69%) received empirical (31/117; 26%) or pre-emptive (50/117; 43%) antifungal therapy and four of 117 patients (3.4%) directed antifungal therapy. Mostly, systemic antifungal therapy was administered empirically or pre-emptively. Twenty-nine per cent of cases receiving systemic antifungal treatment met the international consensus criteria of mostly possible IFI, whereas 71% did not. Proven invasive fungal infections were rare.

Topical and systemic antifungal therapy for the symptomatic treatment of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nose and sinuses. Since fungi were postulated as a potential cause of CRS in the late 1990s, there has been increasing controversy about the use of both topical and systemic antifungal agents in its management. Although interaction between the immune system and fungus has been demonstrated in CRS, this does not necessarily imply that fungi are the cause of CRS or that antifungals will be effective its management. To assess the effectiveness of topical or systemic antifungal therapy in the treatment of CRS. We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 8 March 2011. All randomised, placebo-controlled trials considering the use of topical or systemic antifungal therapy in the treatment of CRS and allergic fungal sinusitis (AFS). CRS was defined using either the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) or American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) criteria. We reviewed the titles and abstracts of all studies obtained from the searches and selected trials that met the eligibility criteria. We extracted data using a pre-determined data extraction form. There was significant heterogeneity of outcome data reporting with reports containing both parametric and non-parametric representations of data for the same outcomes. Means and standard deviations for change data were unavailable for a number of trials. Due to the limited reported data, we contacted authors and used original data for data analysis. Six studies were included (380 participants). Five studies investigated topical antifungals and one study investigated systemic antifungals. The risk of bias in all included studies was low, with all trials being double-blinded and randomised. Pooled meta-analysis showed no statistically significant benefit of topical or systemic antifungals over placebo for any outcome. Symptom scores in fact statistically favoured the placebo group. Adverse event reporting was statistically significantly higher in the antifungal group. On the basis of this meta-analysis, there is no evidence to support the use of either topical or systemic antifungal treatment in the management of CRS.

Intravitreal voriconazole for the treatment of Aspergillus chorioretinitis

The aim of this article is to report a case of Aspergillus chorioretinitis successfully treated with intravitreal voriconazole based on an interventional case report. An immunodeficient patient, 34 years old, receiving systemic antifungal treatment for 1month for invasive aspergillosis with necrotizing pneumonia and brain metastasis, who presented with blurred vision in his left eye. Visual acuity (VA) was 20/20 in his right eye, and 8/20 in his left eye. Ophthalmological examination showed a paramacular nodular yellowish chorioretinal lesion with intraretinal hemorrhages, in the absence of vitritis or anterior uveitis. The patient was treated with one dose of intravitreal voriconazole (100μg/0.1ml). One week after the intravitreal injection, the patient's VA was 10/20, the retinal lesions had diminished, and the hemorrhages had disappeared. At 3-month follow-up, his AV was 20/20 with a residual retinal scar. The significant and rapid improvement in this patient suggests that early injection of intravitreal voriconazole may be the first therapeutic option in Aspergillus chorioretinitis, obviating the need for vitrectomy.

Primary cutaneous mucormycosis in a premature neonate responding to antigfungal therapy alone: when surgery is not an option

BackgroundCutaneous mucormycosis is a rare opportunistic infection with a high morbidity and mortality. One case review reported a survival rate of only 39%.1 Survival depends upon early recognition, aggressive antifungal...