Mucormicosis bronquial, un hallazgo inusual en la broncoscopia / Bronchial mucormycosis, an unusual finding on bronchoscopy

La mucormicosis es una infección causada por hongos oportunistas pertenecientes al orden de los mucorales. Desde la aparición de la pandemia por SARS-CoV-2 se han emitido alertas sobre el incremento en la presentación de esta infección. La presentación de mucormicosis traqueo-bronquial representa el 37% de la afectación pulmonar. A continuación, se desarrolla el caso clínico de una pa-ciente diabética con neumonía severa por SARS-CoV-2, con evolución desfavorable, quien es llevada a broncoscopia, encontrando pseudomembranas blanquecinas que obs-truían la luz del bronquio fuente izquierdo, confirmándose histopatológicamente la presencia de mucorales. Se realiza reporte del presente caso para reconocer la apa-rición de infecciones fúngicas en pacientes que presen-tan diabetes mal controlada e infección por SARS-CoV-2 que tienen una evolución tórpida. La presencia de seudo membranas blancas puede ser un signo de alarma para tener este tipo de infecciones dentro de las posibilidades diagnósticas

Mucormycosis is an infection caused by opportunistic fungi belonging to the order Mucorales. Since the SARS CoV 2 pandemic, warnings have been issued about the increase in the presentation of this infection. The presentation of tracheobronchial mucormycosis represents 37% of pulmonary involvement.We present the clinical case of a diabetic patient with severe pneumonia due to SARS VOC 2, with unfavorable evolution, who was taken to bronchoscopy and found whitish pseudomembranes obstructing the lumen of the left main bronchus, confirming histopathologically the presence of mucormycosis.A report of the present case is made to recognize the appearance of fungal infections in patients with poorly controlled diabetes and SARSe COV 2 infection, who have a torpid evolution. The presence of white pseudomembranes should be an alarm sign to have this type of infections within the diagnostic possibilities

Eficacia y seguridad de las formulaciones lipídicas de amfotericina B para el tratamiento de primera línea de pacientes adultos con diagnóstico de mucormicosis / Efficacy and safety of lipid formulations of amphotericin B for the first-line treatment of adult patients diagnosed with mucormycosis

INTRODUCCIÓN: Antecedentes: El presente dictamen expone la evaluación de tecnología de la eficacia y seguridad de las formulaciones lipídicas de amfotericina B para el tratamiento de primera líena de pacientes con diagnóstico de mucormicosis. Aspectos Generales: La mucormicosis es una infección causada por hongos del orden Mucorales (clase Zigomycetes). Esta micosis afecta preferentemente a pacientes inmunocomprometidos o con diabetes mellitus, y se manifiesta por una variedad de síndromes, siendo los más comunes las infecciones de tipo rino-orbital-cerebral y pulmonar. Además, se recnonocen cinco formas clínicas adicionales de la infección: gastrointestinal, cutánea, renal, diseminada y con complicación del sistema central nervioso. Tecnología Sanitaria de Interés: El grupo de las formulaciones lipídicas abarca dos formulaciones disponibles, las cuales fueron desarrolladas para maximizar la utilidad terapéutica de la terapia estándar con amfotericina B y a su vez reducir la frecuencia de eventos adversos. Los compuestos considerados son: Amfotericina B Complejo Lipídico (ABCL/Marca Registrada Abelcet; Enzon Pharmaceuticals); Amfotericina B Liposomal (L-AMB/Marca Registrada AmBisome; Gilead). METODOLOGÍA: Estrategia de Búsqueda: Se realizó una búsqueda de la literatura con respecto a la eficacia y seguridad de la amfotericina B liposomal o la amfotericina B complejo lipídico para el tratamiento de mucormicosis. Esta búsqueda se realizó utilizando los meta-fuscadores: Translating Research into Practice (TRIPDATABASE), National Library of Medicine (Pubmed-Medline) y Health Systems Evidence. RESULTADOS: Sinopsis de la Evidencia: Se llevó a cabo una búsqueda de evidencia científica con respecto a la eficacia y seguridad de amfotericina B liposomal o amfotericina B complejo lipídico para el tratamiento de mucormicosis. CONCLUSIONES: En la presente evaluación de tecnología sanitaria no se encontraron estudios primarios de tipo ensayos clínicos que muestren diferencias entre las formulaicones lipídicas de amfotericina B y amfotericina B desoxicolato en cuanto a la eficacia y seguridad en pacientes con mucormicosis. El Instituto de Evaluación de Tecnologías Sanitarias e Investigación-IETSI, no aprueba el uso de las formulaciones lipídicas de la amfotericina B como primera línea de tratamiento de la mucormicosis.

Tratamiento exitoso de una mucormicosis rinocerebral persistente en un paciente pediátrico durante el debut de una leucemia aguda / Successful treatment of a persistent rhino-cerebral mucormycosis in a pediatric patient with a debut of acute lymphoblastic leukemia

The fungi of the order Mucorales cause mucormycosis, which usually presents as an invasive fungal disease with rapid angioinvasion in immunocompromised patients. Rhinocerebral is the most common presentation. The lipid formulations of amphotericin B are used as primary treatment in invasive mucormycosis; the combined use of posaconazole could allow a reduction in the dose of amphotericin B improving tolerance and adherence to treatment. Caspofungin and amphotericin B association has been shown to be synergistic in vitro and effective in murine models. We present the case of a preschool patient that during the debut of acute lymphoblastic leukemia developed a rhinocerebral mucormycosis successfully responding to antifungal treatment with the combination of liposomal amphotericin and caspofungin.

Los hongos del orden Mucorales causan la mucormicosis, que se presenta habitualmente como una enfermedad fúngica invasora con rápida angioinvasión en pacientes inmunocomprometidos. La presentación rino-cerebral es la más frecuente. Las formulaciones lipídicas de anfotericina B se usan como tratamiento primario en las mucormicosis invasoras; el uso combinado de posaconazol podría permitir reducir la dosis de anfotericina B generando una mejor tolerancia y adherencia al tratamiento. La asociación de caspofungina con anfotericina ha demostrado acción sinérgica in vitro y eficacia en modelos murinos. Se presenta el caso de una niña preescolar que durante el debut de una leucemia linfoblástica aguda evolucionó con una mucormicosis rino-cerebral persistente, que respondió en forma exitosa al tratamiento antifúngico combinado de anfotericina liposomal y caspofungina.

Gastrointestinal mucormycosis: a success story and appraisal of concepts

Mucormycosis is an opportunistic, life-threatening fungal infection caused by fungi of the class Zygomycetes. The disease has traditionally been reported in immunocompromised patients, premature infants, diabetics, transplant recipients, prolonged use of corticosteroids or in condition associated with increased availability of serum iron such as acidosis or deferoxamine administration. The infection is progressive and associated with a high mortality unless treatment is initiated promptly. The number of cases of gastrointestinal mucormycosis indexed on PubMed over the past 2 decades has shown an alarming rise. Moreover, the infection is being increasingly reported in patients without the traditional risk factors. We report successful management of an immunocompetent child with gastrointestinal mucormycosis who responded to aggressive treatment with surgical debridement and antifungal agents. The fungicidal activity of colistin [polymyxin E] has also been highlighted

Cutaneous mucormycosis in a leukemic patient

Mucormycosis is a fulminant and uncommon fungal infection of skin which mostly occurs in immunocompromised patients. Early diagnosis followed by aggressive debridement and administration of antifungal agents is the key to management. We report primary cutaneous mucormycosis in a 23 years old patient of acute leucocytic leukemia who developed this lesion over volar surface of right forearm at the site of intravenous cannulation during induction phase of chemotherapy. The condition was treated successfully by wide surgical debridement, amphotericin-B, wound care and definitive reconstruction with skin graft

Primary breast mucormycosis, a case report

Mucormycosis is a rare fungal infection caused by organisms of the order Mucorales often occurring in diabetics or immunologically compromised patients. To date, only one case of primary mucormycosis of breast has been reported in the English literature. We describe a further case of mucormycosis that was localized to the breast in a patient with no underlying disease and was successfully treated with a simple mastectomy and intravenous antifungal therapy

Mucormicosis en una paciente diabética: caso clínico y revisión de la literatura / Mucormycosis in a diabetic patient: case report and literature review

Presentamos un caso de Mucormicosis Rinoorbitaria en una mujer de 48 años, diabética, en cetoacidosis, a quien se hizo el diagnóstico por histopatología. Tratada con anfotericina B intravenosa y un agresivo debridamiento quirúrgico para eliminar tejidos infartados y necróticos de gran parte de la hemicara y ojo derecho, logra sobrevivir a esta catastrófica infección. La mucormicosis es una infección aguda y extremadamente grave causada por hongos oportunistas y ubicuos del orden Mucoroles pertenecientes a la clase Phycomycetes, que afecta principalmente a un grupo de pacientes cuyas condiciones inmunológicas y metabólicas favorecen el desarrollo del hongo. Hacemos una definición del grupo de "pacientes en riesgo", lo que es extremadamente importante, ya que de la sospecha clínica se puede abordar un diagnóstico precoz para evitar la alta mortalidad y morbilidad que esta enfermedad provoca. Analizamos la patogenia de la enfermedad, así como una revisión de la literatura sobre modalidades de diagnóstico y terapéutica. El diagnóstico de urgencia sigue siendo de responsabilidad del patólogo, y el tratamiento de mayor éxito es la anfotericina B.

We present a case of rhinoorbital mucormycosis in a diabetic, developing ketoacidose, 48-year old woman. Diagnosis was established through histopathology. The patient was successfully treated and survives with a combination of anphotericin B and an aggressive surgery in order to eliminate all the ischemic and necrotic tissues affecting almost the entire right side of the face and intraorbital structures surviving to this catastrophic infection. Mucormycosis is an acute and often fatal infection caused by opportunistic fungus of the class Zygomycetes, order Mucoroles that affects a select group of patients associated with underlying metabolic and immunological disorders. A definition of "risk-group" is proposed. This definition is of extreme importance for a prompt diagnosis avoiding the high rate of morbidity and mortality associated with this condition. We review both pathogenic mechanism and literature related to diagnostic modalities and new therapeutical approaches. Emergency diagnosis is still in hands of pathologists and the most successful treatment is with anphotericin B.

Liver cirrhosis and rhino-orbital mucormycosis, a possible but rare association: description of a clinical case and literature review

Only few cases of rhino-orbital mucormycosis in patients with liver cirrhosis are described in the literature and most of these patients showed an associated diabetes mellitus. We describe a case of rhino-orbital mucormycosis in a patient with liver cirrhosis without other risk factors.

Mucormicose: estudo clínico / Mucormycosis: clinical study

A mucormicose é uma infecção fúngica oportunista, habitualmente fulminante, que acomete, principalmente, imunodeprimidos. Pode apresentar-se sob as formas rinocerebral, pulmonar, gastrintestinal, cerebral, cutânea, subcutânea e disseminada. O diagnóstico é estabelecido a partir da biopsia de tecido com envio de material para cultura de fungos, podendo-se usar exames de imagem para quantificar a área acometida. O tratamento é cirúrgico, devendo ser associado à anfotericina B.

Murcomicosis is a fungal opportunistic infection that is usually fatal, which attacks, essentially, immunodeficient people. It usually presents itself in: rinocerebral, pulmonary, gastrointestinal, cerebral, cutaneous, subcutaneous and disseminated forms. The diagnosis is established by tissue biopsy after fungal culture, and image exams. Can be used to calculate the surgical treatment should be associated with anfotericin B.

Mucormicosis rino-orbito-cerebral: experiencia en doce años / Rhino-orbital-cerebral mucormycosis: a twelve-year experience

Introducción: La mucormicosis rino-órbito-cerebral (MROC) es una infección poco frecuente y de alta mortalidad, causada por hongos pertenecientes al orden Mucorales. Afecta excepcionalmente a individuos sanos, siendo mucho más frecuente que se produzca en sujetos inmunodeprimidos. Objetivo: Presentar la casuística de 12 años en mucormicosis del Hospital Barros Luco Trudeau. Material y método: El estudio incluye a 16 pacientes con MROC atendidos en el Hospital Barros Luco Trudeau, entre los años 1993 y 2004, detallando características clínicas de presentación de la enfermedad, procedimientos diagnósticos y terapéuticos realizados, efectos adversos de la terapia y mortalidad. Resultados: Sólo un paciente de la serie era inmunocompetente. El síntoma más frecuente fue dolor facial y el hallazgo más frecuente al examen físico, fue la presencia de una escara negra o grisácea en la mucosa nasal. El estudio micológico directo fue positivo en 11 casos, mientras que el cultivo de hongos resultó positivo sólo en 10 pacientes. Del total de pacientes, 15 recibieron tratamiento combinado de cirugía y terapia antifúngica intravenosa (anfotericina B). Once pacientes fueron debridados por medio de una cirugía abierta (8 maxilectomías parciales y 3 totales). Cuatro pacientes fueron debridados mediante una técnica endoscópicay todos ellos necesitaron mßs de un procedimiento. Discusión y Conclusión: Se discuten las causas y el hallazgo más consistente al examen físico y la conducta del hospital ante los casos sospechosos. También se comenta la importancia de las imágenes, el compromiso orbitario, la invasión cutánea y especialmente el tratamiento médico y quirúrgico. Se destaca la sobrevida general de la serie que fue de 62,5 por ciento

Introduction: Rhino-orbital-cerebral mucormycosis (MROC) is a rare, high mortality infection, produced by fungi belonging to the order Mucorales. It exceptionally affects healthy individuals, being much more prevalent in immunocompromised patients. Aim: To present the 12year experience in mucormycosis at the Barros Luco Trudeau Hospital. Material and Method: This study involves 16 MROC patients that were treatedatthe Barros Luco Trudeau Hospital between 1993 and 2004. We present detailed clinical characteristics of the disease, diagnostic and therapeutic procedures performed, adverse therapy effects and mortality. Results: Only one of the patients was immunocompetent. The most frequent symptom was facial pain and the most frequent finding at physical examination was a black or grayish scab on the nasal mucosa. Direct mycological study was positive in 11 cases, whereas fungal culture was positive in only 10 patients. Of all patients, 15 received combined surgical and intravenous antifungal therapy (amphotericin B). Eleven patients had debridement by open surgery (8 partial and 3 total maxillectomies). Four patients had endoscopic debridement; all of them required more than one procedure. Discussion and Conclusion: Possible causes are discussed as well as the more consistent findings at physical examination and the institution behavior when suspecting a case. In addition, imaging importance, orbital involvement, cutaneous invasion and medical and surgical treatments are discussed. The series survival rate of 62 percent is underscored

[Mucormycosis: four case reports]

Mucormycosis is a rare and invasive fungal infection, but frequently fatal when it occurs. It commonly affects patients with diabetes mellitus. The aim of this study is to assess the clinical presentation, radiological findings, management and prognosis of mucormycosis. This retrospective study was conducted in the department of infectious diseases of Rabta hospital between January 1988 and December 2004 and included patients hospitalized for mucormycosis confirmed by mycological and/or histological findings. The study is about four diabetic patients with mucormycosis [3 men and a woman]. Three of them had diabetic ketoacidosis at the time of diagnosis. The infection was sinusal in 2 cases and rhinocerebral in the other two cases. Treatment consisted in systemic amphotericin B combined with surgical debridement in 3 cases. A fatal outcome was noted in 2 cases. Mucormycosis remains a severe infectious disease in diabetic patients. Early diagnosis and treatment is mandatory for a successful management of this infection

Mucormicosis renal aislada / Isolated renal mucormicosis

La mucormicosis es una infección causada por hongos de la clase Zygomycetes. Existen varias formas de presentación clínica, siendo las más comunes la rinocerebral y la pulmonar. La mucormicosis renal aislada es un tipo de mucormicosis muy poco frecuente hasta el momento; se han reportado 25 casos en la literatura. Se presenta el caso de una paciente con leucemia aguda que desarrolló mucormicosis renal aislada, y se revisa la literatura.

Mucormycosis is an infection caused by a class Zygomycetes fungi. The rhinocerebral and pulmonary are the most common clinical presentations. Renal mucormycosis is a very rare form. To date, only 25 cases have been reported in the literature. We describe the case of a patient with leukemia who developed isolated renal mucormycosis and review the literature.

Cutaneous mucormycosis in children.

Cutaneous mucormycosis is a rare fungal infection in children. It is commonly found in immunocompromised children. Early diagnosis is difficult and requires a very high degree of suspicion. Recommended mainstay of treatment has been amphotericin B and extensive surgical debridement which may at times require amputation if limb is involved. The authors share their experience of two cases of successfully treated cutaneous mucormycosis.

[Another look at the cases of Mucormycosis at Emam Reza hospital]

Mucormycosis or Zygomycosis is a rare opportunistic and fulminated fungal infection with high mortality. It occurs most often in diabetic and immuno-compromised patients, including those with hematological malignancy. There are several forms of disease that rhinocerebral is the most common form. Early diagnosis plays an important role in prognosis of the disease. Since, previous papers were mainly focused on pathologic aspects and case reports, we decided to review the cases on the basis of etiologic agents, predisposing factors, Clinical signs on admission and the role of early diagnosis in golden time on prognosis. This is a retrospective and cross sectional study of 18 cases of approved Mucormycosis that diagnosed in Imam Reza hospital during 12 years during 1312-1384. In addition to those, four recent cases studied prospectively. The study population was 15 men and 7 women. The cases were from 1 to 80 years old. Diabetes mellitus was the most common Predisposing factor [54.4%]. Most of the cases were rhinocerebral form. Mortality rate was more than 75%. Prognosis was good in less than 25% of the cases who received early diagnosis and treatment. Early diagnosis and correct Treatment [surgical and medical intervention] are critical because they could improve the prognosis for survival

Experiencia en mucormicosis Hospital Clinico Universidad de Chile / Experience in mucormycosis Hospital Clínico Universidad de Chile

Revisamos los hallazgos clínicos, patológicos y tratamiento en 12 pacientes con mucormicosis en el Hospital Clínico de la Universidad de Chile entre los años 1990 y 2004. Del total de pacientes estudiados, 7 eran hombres y 5 mujeres. La edad promedio fue de 54 años, con un rango de 29 a 79 años. El diagnóstico de mucormicosisse realizó por biopsia en 10 pacientes y por estudio directo en 2 pacientes. Los factores predisponentes presentes en los pacientes estudiados fueron, diabetes mellitus, HIV en etapa SIDA y enfermedades hematológicas en tratamiento oncológico. La histología demostró necrosis e infarto con invasión de vasos sanguíneos y trombosis micótica. Todos los pacientes estudiados recibieron tratamiento con Anfotericina B y 6 fueron intervenidos quirúrgicamente. Del total de 12 pacientes, 4 fallecieron (33 por ciento) y 8 permanecen vivos (66 por ciento).

We made a review of the clinical and pathological findings and the treatment in 12 patients presenting mucormycosis in the Clinical Hospital of the University of Chile between 1990 and 2004. Of the whole studied patients, 7 were men and 5 women. The average age was 54 years, with a range from 29 to 79 years. The diagnosis of mucormycosis was performed by biopsy in 10 patients andby direct study in 2 patients. The predisposing factors in the studied patients were: Diabetes Mellitus, HIV at AIDS stage and hematological diseases in oncologic treatment. The histology demonstrated necrosis and infarction with blood vessels invasion and mycotic thrombosis. All the studied patientsreceived treatment with Anphotericine B and 6 required surgical intervention. Of the total of 12 patients, 4 died (33 percent) and 8 remain alive (66 percent).

Mucormycosis: a devastating fungal infection in diabetics

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

Mucormycosis causing palatal necrosis and orbital apex syndrome

A case of mucormycosis causing palatal necrosis and orbital apex syndrome is reported successfully treated with systemic antifungal therapy, surgical debridement and control of underlying disease process. After one year of followup patient is blind with anatomically preserved right eye and ptosis as well as having palatal obturator. Mucormycosis should be considered in differential diagnosis of palatal necrosis and orbital apex syndrome

Tratamiento adjunto con oxigenación hiperbárica en mucormicosis. Presentación de cinco casos tratados en la misma Institución y revisión de la literatura / Treatment of mucormycosis with adjunctive hyperbaric oxygen: five cases treated in the some institution and review of the literature

Introduction. Mucormycosis is an invasive fungal infection that affects decompensated diabetics, immunosupressed patients and occasionally healthy individuals. Despite advances in anti-fungal therapy and surgical techniques, the morbidity and mortality remain high. Adjuvant hyperbaric oxygen therapy (HBO) has been proposed based on pathophysiology and several favorable clinical reports. Material and methods. A chart review of mucormycosis patients referred to the HBO service was performed. Also an electronic search in Medline of relevant literature was undertaken. Results. Five mucormycosis patients referred for HBO had complete charts available. Four had craniofacial involvement and one had left upper extremity involvement. The predisposing diseases were leukemia (n = 3), diabetes mellitus plus sarcoidosis (n = 1), and trauma (n = 1). All patients were managed with amphotericin B, surgical debridement and HBO. Survival was 60% (3/5) three months after the diagnosis was established. The literature was scarce but favors HBO. Conclusion. Considering the pathophysiology of mucormycosis adjuvant HBO therapy seems reasonable. However, the clinical experience is still too limited to make HBO part of the standard of care. Prospective, randomized, controlled trials will help to define the role of HBO in this devastating infection.

Introducción. La mucormicosis es una infección micótica invasiva que se presenta principalmente en pacientes diabéticos descompensados, pacientes con afección del sistema inmune, e incluso en individuos previamente sanos. A pesar de los avances en medicamentos y técnicas quirúrgicas la morbimortalidad es todavía muy elevada. La terapia adjunta con oxígeno hiperbárico (OHB) ha sido sugerida con base en fundamentos fisiopatológicos y algunos reportes clínicos favorables. Material y métodos. Revisión de expedientes de pacientes referidos al Servicio de OHB con diagnóstico de infecciones micóticas invasivas. Búsqueda electrónica en Medline de literatura pertinente. Resultados. Cinco pacientes con diagnóstico clínico e histopatológico de mucormicosis con expediente completo fueron referidos a OHB para terapia adjunta. Cuatro presentaron afección craneofacial y uno afección de la extremidad superior izquierda. La enfermedad predisponente fue leucemia (n = 3), sarcoidosis y diabetes mellitus (n = 1) y trauma (n = 1). Todos fueron manejados con anfotericina B, debridación quirúrgica y OHB. La sobrevida fue 60% (3/5) tres meses después del diagnóstico. La literatura al respecto es escasa, pero favorece al OHB. Conclusión. Con base en la fisiopatología de la mucormicosis la terapia adjunta con OHB parece lógica. No obstante, la información clínica es todavía muy limitada para recomendar OHB rutinariamente en estos pacientes. Estudios prospectivos, aleatorios, controlados ayudarán a definir el papel del OHB en el manejo de esta devastadora infección.