eMedicine Specialties > Ophthalmology > Infectious Disease

Mucormycosis: Treatment & Medication

Author: Kimberly G Yen, MD, Assistant Professor of Ophthalmology, Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine
Coauthor(s): Michael T Yen, MD, Associate Professor of Ophthalmology, Department of Ophthalmology, Division of Ophthalmic Plastic, Lacrimal, and Orbital Surgery, Cullen Eye Institute, Baylor College of Medicine
Contributor Information and Disclosures

Updated: Dec 31, 2008

Treatment

Medical Care

  • Complete treatment of underlying medical disease. Correct hypoxia, acidosis, hyperglycemia, and electrolyte abnormalities.
  • Any steroid medication, antimetabolites, or immunosuppressants that the patient is on should be addressed and discontinued if appropriate.
  • The use of systemic amphotericin B is important in treating mucormycosis; its use, along with increased awareness of the disease, has decreased the mortality. The highest possible tissue levels should be achieved. Remember to assess for nephrotoxicity. Other systemic toxicities include fever, nausea and vomiting, phlebitis, anemia, and electrolyte abnormalities. Liposomal amphotericin B may be more efficacious; it is less toxic, allowing higher doses of the medication to be given.10,11,12
  • Frontal sinus involvement and older patients have lower rates of survival.
  • Consider local irrigation and packing of the areas to aid delivery of amphotericin to necrotic and poorly perfused tissues. Because poor vascular supply may prevent systemic therapy from reaching the fungus, local irrigation of infected tissue has been reported as an important adjunct to treatment and may even prevent disfiguring surgery.
  • Hyperbaric oxygen has been suggested as a potential treatment, but its exact role remains unclear.

Surgical Care

  • Aggressive surgical debridement of all necrotic tissue is necessary, sometimes requiring multiple debridements.
    • Because of the vasoocclusive effect of mucormycosis, the involved tissue rarely bleeds, so debridement until normal, well-perfused, bleeding tissue is encountered is ideal.
    • Surgery often may be disfiguring.
  • Intraorbital irrigation of amphotericin B may be considered as an adjunct treatment.13,14,10
  • Orbital exenteration, along with removal of the sinuses, may be necessary.  No standard exists to guide physicians on the best timing of exenteration.15,16,17,18
  • Consider reconstructive surgery only after complete resolution of infection.19

Consultations

  • A multidisciplinary approach is the best. Specialties to consider include the following:
    • Ophthalmology for evaluation of ophthalmoplegia and optic neuropathy
    • Oculoplastic surgery for orbital evaluation, debridement, and reconstruction
    • Otolaryngology for biopsy or debridement of nasal/sinus cavities
    • Infectious disease, internal medicine, and endocrinology for medical management of underlying systemic etiologies
    • Neurosurgery if intracranial involvement present
    • Pharmacotherapy consult to assist with dosing of amphotericin B

Diet

Control diabetes if it is an underlying disease.

Medication

Although aggressive surgical intervention is required, patients also should receive adjuvant antifungal therapy.

Antifungals

Their mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.


Amphotericin B, liposomal (Amphocin, Fungizone)

Intravenous liposomal amphotericin B is produced from Streptomyces nodosus. Provided as a sterile suspension containing 100 mg/20 mL of amphotericin B. Acts by binding to sterols in the cell membrane of the fungi, resulting in a change in permeability of the membrane. Drug resistant species of have been isolated in patients receiving prolonged therapy.

Adult

Recommended daily dose is 5 mg/kg IV infusion at a rate of 2.5 mg/kg/h; if infusion time exceeds 2 h, then shake infusion bag to mix contents q2h

Pediatric

Administer as in adults

Antineoplastic agents may enhance the potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; risk of renal toxicity is increased with cyclosporine

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer under close clinical observation for acute reactions, usually more common with the first few doses; laboratory analyses should include serum creatine, liver profile, serum electrolytes, and CBC counts

More on Mucormycosis

Overview: Mucormycosis
Differential Diagnoses & Workup: Mucormycosis
Treatment & Medication: Mucormycosis
Follow-up: Mucormycosis
Multimedia: Mucormycosis
References
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References

  1. Gilbard SM, Della Rocca RC. Paranasal sinus disease and the orbit. In: Nesi FA, et al, ed. Smith's Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. 1998:896-930.

  2. Rocha G, Garza G, Font RL. Orbital pathology associated with diabetes mellitus. Int Ophthalmol Clin. Spring 1998;38(2):169-79. [Medline].

  3. Yohai RA, Bullock JD, Aziz AA, et al. Survival factors in rhino-orbital-cerebral mucormycosis. Surv Ophthalmol. Jul-Aug 1994;39(1):3-22. [Medline].

  4. Guevara N, Roy D, Dutruc-Rosset C, et al. Mucormycosis--early diagnosis and treatment. Rev Laryngol Otol Rhinol (Bord). 2004;125(2):127-31. [Medline].

  5. Turunc T, Demiroglu YZ, Aliskan H, et al. Eleven cases of mucormycosis with atypical clinical manifestations in diabetic patients. Diabetes Res Clin Pract. Nov 2008;82(2):203-8. [Medline].

  6. Nithyanandam S, Jacob MS, Battu RR, et al. Rhino-orbito-cerebral mucormycosis. A retrospective analysis of clinical features and treatment outcomes. Indian J Ophthalmol. Sep 2003;51(3):231-6. [Medline].

  7. Bhansali A, Sharma A, Kashyap A, et al. Mucor endophthalmitis. Acta Ophthalmol Scand. Feb 2001;79(1):88-90. [Medline].

  8. Arndt S, Aschendorff A, Echternach M, et al. Rhino-orbital-cerebral mucormycosis and aspergillosis: differential diagnosis and treatment. Eur Arch Otorhinolaryngol. Jan 2009;266(1):71-6. [Medline].

  9. Doty CI, Lucchesi M. Mucormycosis manifesting as proptosis and unilateral blindness. Acad Emerg Med. Aug 2000;7(8):944-6. [Medline].

  10. Strasser MD, Kennedy RJ, Adam RD. Rhinocerebral mucormycosis. Therapy with amphotericin B lipid complex. Arch Intern Med. Feb 12 1996;156(3):337-9. [Medline].

  11. Tarani L, Costantino F, Notheis G, et al. Long-term posaconazole treatment and follow-up of rhino-orbital-cerebral mucormycosis in a diabetic girl. Pediatr Diabetes. Sep 17 2008;[Medline].

  12. Reed C, Bryant R, Ibrahim AS, et al. Combination polyene-caspofungin treatment of rhino-orbital-cerebral mucormycosis. Clin Infect Dis. Aug 1 2008;47(3):364-71. [Medline].

  13. Luna JD, Ponssa XS, Rodriguez SD, et al. Intraconal amphotericin B for the treatment of rhino-orbital mucormycosis. Ophthalmic Surg Lasers. Aug 1996;27(8):706-8. [Medline].

  14. Seiff SR, Choo PH, Carter SR. Role of local amphotericin B therapy for sino-orbital fungal infections. Ophthal Plast Reconstr Surg. Jan 1999;15(1):28-31. [Medline].

  15. Hargrove RN, Wesley RE, Klippenstein KA, et al. Indications for orbital exenteration in mucormycosis. Ophthal Plast Reconstr Surg. Jul-Aug 2006;22(4):286-91. [Medline].

  16. Pelton RW, Peterson EA, Patel BC, et al. Successful treatment of rhino-orbital mucormycosis without exenteration: the use of multiple treatment modalities. Ophthal Plast Reconstr Surg. Jan 2001;17(1):62-6. [Medline].

  17. Hargrove RN, Wesley RE, Klippenstein KA, et al. Indications for orbital exenteration in mucormycosis. Ophthal Plast Reconstr Surg. Jul-Aug 2006;22(4):286-91. [Medline].

  18. Croce A, Moretti A, D'Agostino L, et al. Orbital exenteration in elderly patients: personal experience. Acta Otorhinolaryngol Ital. Aug 2008;28(4):193-9. [Medline].

  19. Lari AR, Kanjoor JR, Vulvoda M, et al. Orbital reconstruction following sino-nasal mucormycosis. Br J Plast Surg. Jan 2002;55(1):72-5. [Medline].

  20. Dhiwakar M, Thakar A, Bahadur S. Improving outcomes in rhinocerebral mucormycosis--early diagnostic pointers and prognostic factors. J Laryngol Otol. Nov 2003;117(11):861-5. [Medline].

  21. Fairley C, Sullivan TJ, Bartley P, et al. Survival after rhino-orbital-cerebral mucormycosis in an immunocompetent patient. Ophthalmology. Mar 2000;107(3):555-8. [Medline].

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Further Reading

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Keywords

mucormycosis , Mucor, rhinocerebral mucormycosis, rhino-orbital cerebral mucormycosis

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Contributor Information and Disclosures

Author

Kimberly G Yen, MD, Assistant Professor of Ophthalmology, Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine
Kimberly G Yen, MD is a member of the following medical societies: Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Michael T Yen, MD, Associate Professor of Ophthalmology, Department of Ophthalmology, Division of Ophthalmic Plastic, Lacrimal, and Orbital Surgery, Cullen Eye Institute, Baylor College of Medicine
Michael T Yen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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