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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | Mucormycosis

Mucormycosis

by Chris Nickson, Last updated July 29, 2015

Reviewed and revised 29 July 2015

OVERVIEW

  • Mucormycosis is the unifying term used to describe infections caused by fungi belonging to the order Mucorales (e.g. Rhizopus, Rhizomucor, Mucor, and Absidia).
  • Rhinocerebral mucormycosis is severe sinusitis with caused by a non-Aspergillus mold, most commonly Rhizopus arrhizus

CLINICAL FEATURES

Rhinocerebral mucormycosis

  • headache
  • facial pain
  • confusion
  • fever
  • purulent nasal discharge (black)

Other manifestations:

  • pneumonia (associated with prolonged neutropenia): dyspnea, cough, hemoptysis
  • cutaneous (black lesions)
  • GI
  • CNS

Complications

  • intraorbital extension
  • intracranial extension (e.g. leptomeningeal enhancement, intracranial granulomas, epidural abscess)
  • vascular invasion (e.g. cavernous or venous sinus thrombosis, mycotic aneurysm formation, cerebral infarction or haemorrhage, systemic dissemination)

RISK FACTORS

  • diabetes mellitus (especially wit ketoacidosis)
  • burns
  • chronic renal failure
  • cirrhosis
  • immunosuppression
  • iron overload and desferrioxime treatment (iron chelator)

INVESTIGATIONS

  • blood cultures
  • tissue biopsies

Pulmonary mucormycosis

  • CXR and CT Chest – lobar consolidation, isolated masses, nodular disease, cavitation, or wedge-shaped infarcts (angioinvasive disease); reversed halo sign on CT (a focus of ground glass surrounded by a solid ring of consolidation)
  • BAL

Rhinocerebral mucormycosis

  • CT:
    • mucosal thickening (hypoattenuating; e.g. black turbinate sign)
    • opacification of the sinus (in acute fungal sinusitis, unlike in chronic infection, hyperdense material may not be seen in the sinus cavity)
    • bone destruction
    • stranding of fat on the outside of the sinus
  • MRI is the modality of choice for demonstrating soft tissue involvement

MANAGEMENT

General

  • resuscitation
  • supportive care and monitoring
  • treat underlying cause and complications (e.g. DKA, immunosuppression, nutrition, GCSF)

Specific

  • surgical debridement
  • amphotericin B
  • consider hyperbaric oxygen

PROGNOSIS

  • depending on comorbidities and underlying immunosuppression, mortality may range from ~ 20-80%

References and Links

Journal articles

  • Kontoyiannis DP, Lewis RE. How I treat mucormycosis. Blood. 2011 Aug 4;118(5):1216-24. doi: 10.1182/blood-2011-03-316430. Epub 2011 May 26. Review. PubMed PMID: 21622653; PubMed Central PMCID: PMC3292433.
  • Pak J, Tucci VT, Vincent AL, Sandin RL, Greene JN. Mucormycosis in immunochallenged patients. J Emerg Trauma Shock. 2008 Jul;1(2):106-13. doi: 10.4103/0974-2700.42203. PubMed PMID: 19561989; PubMed Central PMCID: PMC2700608.
  • Quan C, Spellberg B. Mucormycosis, pseudallescheriasis, and other uncommon mold infections. Proc Am Thorac Soc. 2010 May;7(3):210-5. doi: 10.1513/pats.200906-033AL. Review. PubMed PMID: 20463250; PubMed Central PMCID: PMC3266012.

FOAM and web resources

  • Radiopaedia — Pulmonary mucormycosis, Rhinocerebral mucormycosis,
  • Radiology signs — Black turbinate sign

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About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

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