eMedicine Specialties > Infectious Diseases > HEENT Infections

Rhinocerebral Mucormycosis: Follow-up

Author: William P Baugh, MD, Assistant Clinical Professor of Dermatology, University of California Irvine School of Medicine and Western School of Medicine; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center
Coauthor(s): Cynthia L Chen, Western University of Health Sciences College of Osteopathic Medicine of the Pacific
Contributor Information and Disclosures

Updated: Feb 11, 2009

Follow-up

Further Inpatient Care

  • Among patients who survive the initial presentation of rhinocerebral mucormycosis (RCM), the extent of disease dictates additional inpatient care. Further surgical debridement, surgical repair, and wound care may be required. Continued medical therapy with close monitoring for drug toxicity or recurrence of disease is recommended. If eye enucleation is necessary to surgically clear the infection, postoperative reconstruction of the orbit and fitting of an eye prosthesis can be highly valuable in restoring the patient's psychosocial health. Dhiman et al (2007) reported on the use of a neodymium-iron-boron magnetic-based silicone eye prosthetic in the rehabilitation of a 17-year-old boy with diabetes who lost his eye to rhinocerebral mucormycosis.22

Further Outpatient Care

  • Once the patient is stable, continue amphotericin therapy in the outpatient setting, administered either as a home infusion or in an ambulatory infusion center. At this point, the frequency of amphotericin infusion is often reduced to every other day or more, depending on renal function.
  • Follow-up MRI or CT scanning at the end of therapy should demonstrate significant improvement and lack of inflammation.
  • Treatment may require 7 months of therapy or more.
  • Chronic presentations and late sequelae after successful therapy have been observed; therefore, patients require long-term monitoring to detect recurrence or signs of indolent residual infection.

Complications

  • Rhinocerebral mucormycosis progresses rapidly and can result in carotid artery occlusion, cavernous sinus thrombosis, CNS infarction secondary to fungal thrombosis leading to hemiparesis, hemiplegia, coma, and death.
  • Other complications of rhinocerebral mucormycosis include CNS hemorrhage, abscess, and cerebritis.
  • Postsurgical disfigurement is likely.
  • Neurologic function can be recovered if no irreversible damage has occurred, but morbidity is very common.

Prognosis

  • Rhinocerebral mucormycosis carries a prognosis of high morbidity and mortality; survival depends on reversibility of underlying risk factors and early surgical intervention.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • The available medicolegal information in the literature is minimal, with the main discussion by Bullock and Warwar (1999).23 Bullock relates his personal experience and discusses the controversy of exenteration. The authors aptly state that patients, family members, and all involved health care personnel must understand that the physical and psychological morbidity of disfiguring wide surgical debridement must be weighed against the life-threatening nature of the disease.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Kenneth C Earhart, MD, FACP, to the development and writing of this article.



More on Rhinocerebral Mucormycosis

Overview: Rhinocerebral Mucormycosis
Differential Diagnoses & Workup: Rhinocerebral Mucormycosis
Treatment & Medication: Rhinocerebral Mucormycosis
Follow-up: Rhinocerebral Mucormycosis
Multimedia: Rhinocerebral Mucormycosis
References
[ CLOSE WINDOW ]

References

  1. McLean FM, Ginsberg LE, Stanton CA. Perineural spread of rhinocerebral mucormycosis. AJNR Am J Neuroradiol. Jan 1996;17(1):114-6. [Medline].

  2. Margo CE, Linden C, Strickland-Marmol LB, Denietolis AL, McCaffrey JC, Kirk N. Rhinocerebral mucormycosis with perineural spread. Ophthal Plast Reconstr Surg. Jul-Aug 2007;23(4):326-7. [Medline].

  3. Anaissie EJ, Shikhani AH. Rhinocerebral mucormycosis with internal carotid occlusion: report of two cases and review of the literature. Laryngoscope. Sep 1985;95(9 Pt 1):1107-13. [Medline].

  4. Delbrouck C, Jacobs F, Fernandez Aguilar S. Carotid artery occlusion due to fulminant rhinocerebral mucormycosis. Acta Otorhinolaryngol Belg. 2004;58(2):135-40. [Medline].

  5. Shah PD, Peters KR, Reuman PD. Recovery from rhinocerebral mucormycosis with carotid artery occlusion: a pediatric case and review of the literature. Pediatr Infect Dis J. Jan 1997;16(1):68-71. [Medline].

  6. Balch K, Phillips PH, Newman NJ. Painless orbital apex syndrome from mucormycosis. J Neuroophthalmol. Sep 1997;17(3):178-82. [Medline].

  7. Sheth SM, Talwalkar NC, Desai AP. Rhinocerebral mucormycosis in a case of renal failure. J Postgrad Med. Jul 1981;27(3):190b-193. [Medline].

  8. Stern LE, Kagan RJ. Rhinocerebral mucormycosis in patients with burns: case report and review of the literature. J Burn Care Rehabil. Jul-0Aug 1999;20(4):303-6. [Medline].

  9. Webb M, Dowdy L, Bundschu C. Cerebral mucormycosis after liver transplantation: a case report. Clin Transplant. Dec 1998;12(6):596-9. [Medline].

  10. Apaydin S, Ataman R, Cansiz H. Rhinocerebral mucormycosis in a kidney transplant recipient. Nephron. 1998;79(1):117-8. [Medline].

  11. Maertens J, Demuynck H, Verbeken EK. Mucormycosis in allogeneic bone marrow transplant recipients: report of five cases and review of the role of iron overload in the pathogenesis. Bone Marrow Transplant. Aug 1999;24(3):307-12. [Medline].

  12. Penalver FJ, Romero R, Fores R. Rhinocerebral mucormycosis following donor leukocyte infusion: successful treatment with liposomal amphotericin B and surgical debridement. Bone Marrow Transplant. Oct 1998;22(8):817-8. [Medline].

  13. Ferguson AD. Rhinocerebral mucormycosis acquired after a short course of prednisone therapy. J Am Osteopath Assoc. Nov 2007;107(11):491-3. [Medline].

  14. Salinas-Lara C, Rembao-Bojórquez D, de la Cruz E, Márquez C, Portocarrero L, Tena-Suck ML. Pituitary apoplexy due to mucormycosis infection in a patient with an ACTH producing pulmonary tumor. J Clin Neurosci. Jan 2008;15(1):67-70. [Medline].

  15. Bengel D, Susa M, Schreiber H, Ludolph AC, Tumani H. Early diagnosis of rhinocerebral mucormycosis by cerebrospinal fluid analysis and determination of 16s rRNA gene sequence. Eur J Neurol. Sep 2007;14(9):1067-70. [Medline].

  16. Deshpande AH, Munshi MM. Rhinocerebral mucormycosis diagnosis by aspiration cytology. Diagn Cytopathol. Aug 2000;23(2):97-100. [Medline].

  17. Nair M, Kapila K, Verma K. Fine-needle aspiration: another diagnostic modality for rhinocerebral mucormycosis. Diagn Cytopathol. Oct 1999;21(4):300-1. [Medline].

  18. Garner D, Machin K. Investigation and management of an outbreak of mucormycosis in a paediatric oncology unit. J Hosp Infect. Sep 2008;70(1):53-9. [Medline].

  19. Gonzalez CE, Couriel DR, Walsh TJ. Disseminated zygomycosis in a neutropenic patient: successful treatment with amphotericin B lipid complex and granulocyte colony-stimulating factor. Clin Infect Dis. Feb 1997;24(2):192-6. [Medline].

  20. Avet PP, Kline LB, Sillers MJ. Endoscopic sinus surgery in the management of mucormycosis. J Neuroophthalmol. Mar 1999;19(1):56-61. [Medline].

  21. Adler DE, Milhorat TH, Miller JI. Treatment of rhinocerebral mucormycosis with intravenous interstitial, and cerebrospinal fluid administration of amphotericin B: case report. Neurosurgery. Mar 1998;42(3):644-8; discussion 648-9. [Medline].

  22. Dhiman R, Arora V, Kotwal N. Rehabilitation of a rhinocerebral mucormycosis patient. J Indian Prostheodont Soc. 2007;7:88-91.

  23. Bullock JD, Warwar RE. Three patients with presumed rhino-orbital-cerebral mucormycosis. J Neuroophthalmol. Jun 1999;19(2):120-1. [Medline].

  24. Abedi E, Sismanis A, Choi K, Pastore P. Twenty-five years' experience treating cerebro-rhino-orbital mucormycosis. Laryngoscope. Aug 1984;94(8):1060-2. [Medline].

  25. Akoz T, Civelek B, Akan M. Rhinocerebral mucormycosis: report of two cases. Ann Plast Surg. Sep 1999;43(3):309-12. [Medline].

  26. Bakr A, Wafa E, Fouda A, Elagroudy A, Gheith O, Sobh M, et al. Successful treatment of mucormycosis in a renal allograft recipient. Clin Exp Nephrol. Jun 2008;12(3):207-10. [Medline].

  27. Bhargava P. Survival in rhinocerebral mucormycosis: Is iron the key?. Neurol India. Oct-Dec 2007;55(4):416. [Medline].

  28. Blitzer A, Lawson W, Meyers BR. Patient survival factors in paranasal sinus mucormycosis. Laryngoscope. Apr 1980;90(4):635-48. [Medline].

  29. Bongiovanni M, Ranieri R, Ferrari D, Codecà C, Tartaro T, Uziel L. Prolonged survival of an HIV-infected subject with severe lymphoproliferative disease and rhinocerebral mucormycosis. J Antimicrob Chemother. Jul 2007;60(1):192-3. [Medline].

  30. Brown SR, Shah IA, Grinstead M. Rhinocerebral mucormycosis caused by Apophysomyces elegans. Am J Rhinol. Jul-Aug 1998;12(4):289-92. [Medline].

  31. Cagatay AA, Oncü SS, Calangu SS, Yildirmak TT, Ozsüt HH, Eraksoy HH. Rhinocerebral mucormycosis treated with 32 gram liposomal amphotericin B and incomplete surgery: a case report. BMC Infect Dis. 2001;1:22. [Medline].

  32. Damante JH, Fleury RN. Oral and rhinoorbital mucormycosis: case report. J Oral Maxillofac Surg. Feb 1998;56(2):267-71. [Medline].

  33. 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].

  34. Dismukes WE. Introduction to antifungal drugs. Clin Infect Dis. Apr 2000;30(4):653-7. [Medline].

  35. Ericsson M, Anniko M, Gustafsson H. A case of chronic progressive rhinocerebral mucormycosis treated with liposomal amphotericin B and surgery. Clin Infect Dis. Apr 1993;16(4):585-6. [Medline].

  36. Feeley MA, Righi PD, Davis TE. Mucormycosis of the paranasal sinuses and septum. Otolaryngol Head Neck Surg. May 1999;120(5):750. [Medline].

  37. Funada H, Miyake Y, Kanamori K, Okafuji K, Machi T, Matsuda T. Fluconazole therapy for pulmonary mucormycosis complicating acute leukemia. Jpn J Med. Mar-Apr 1989;28(2):228-31. [Medline].

  38. Gaviria JM, Grohskopf LA, Barnes R. Successful treatment of rhinocerebral zygomycosis: a combined-strategy approach. Clin Infect Dis. Jan 1999;28(1):160-1. [Medline].

  39. Gonis G, Starr M. Fatal rhinoorbital mucormycosis caused by Saksenaea vasiformis in an immunocompromised child. Pediatr Infect Dis J. Jul 1997;16(7):714-6. [Medline].

  40. Hopkins MA, Treloar DM. Mucormycosis in diabetes. Am J Crit Care. Sep 1997;6(5):363-7. [Medline].

  41. Kameh DS, Gonzalez OR, Pearl GS. Fatal rhino-orbital-cerebral zygomycosis. South Med J. Nov 1997;90(11):1133-5. [Medline].

  42. Koçak R, Tetiker T, Koçak M, Baslamisli F, Zorludemir S, Gönlüsen G. Fluconazole in the treatment of three cases of mucormycosis. Eur J Clin Microbiol Infect Dis. Jun 1995;14(6):559-61. [Medline].

  43. Langford JD, McCartney DL, Wang RC. Frozen section--guided surgical debridement for management of rhino- orbital mucormycosis. Am J Ophthalmol. Aug 1997;124(2):265-7. [Medline].

  44. Lee EJ, Lee MY, Hung YC. Orbital rhinocerebral mucormycosis associated with diabetic ketoacidosis: report of survival of a 10-year-old boy. J Formos Med Assoc. Oct 1998;97(10):720-3. [Medline].

  45. Lehrer RI, Howard DH, Sypherd PS. Lehrer, RI, moderator. Mucormycosis. Ann Intern Med. Jul 1980;93(1):93-108. [Medline].

  46. McNab AA, McKelvie P. Iron overload is a risk factor for zygomycosis. Arch Ophthalmol. Jul 1997;115(7):919-21. [Medline].

  47. McNulty JS. Rhinocerebral mucormycosis: predisposing factors. Laryngoscope. Oct 1982;92(10 Pt 1):1140-3. [Medline].

  48. Mohindra S, Mohindra S, Gupta R, Bakshi J, Gupta SK. Rhinocerebral mucormycosis: the disease spectrum in 27 patients. Mycoses. Jul 2007;50(4):290-6. [Medline].

  49. Moses AE, Rahav G, Barenholz Y. Rhinocerebral mucormycosis treated with amphotericin B colloidal dispersion in three patients. Clin Infect Dis. Jun 1998;26(6):1430-3. [Medline].

  50. Nenoff P, Kellermann S, Schober R. Rhinocerebral zygomycosis following bone marrow transplantation in chronic myelogenous leukaemia. Report of a case and review of the literature. Mycoses. Nov 1998;41(9-10):365-72. [Medline].

  51. Ochi JW, Harris JP, Feldman JI. Rhinocerebral mucormycosis: results of aggressive surgical debridement and amphotericin B. Laryngoscope. Dec 1988;98(12):1339-42. [Medline].

  52. Odessey E, Cohn A, Beaman K, Schechter L. Invasive mucormycosis of the maxillary sinus: extensive destruction with an indolent presentation. Surg Infect (Larchmt). Feb 2008;9(1):91-8. [Medline].

  53. Pagano L, Ricci P, Tonso A, Nosari A, Cudillo L, Montillo M, et al. Mucormycosis in patients with haematological malignancies: a retrospective clinical study of 37 cases. GIMEMA Infection Program (Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto). Br J Haematol. Nov 1997;99(2):331-6. [Medline].

  54. Peterson KL, Wang M, Canalis RF. Rhinocerebral mucormycosis: evolution of the disease and treatment options. Laryngoscope. Jul 1997;107(7):855-62. [Medline].

  55. Radner AB, Witt MD, Edwards JE Jr. Acute invasive rhinocerebral zygomycosis in an otherwise healthy patient: case report and review. Clin Infect Dis. Jan 1995;20(1):163-6. [Medline].

  56. Reed C, Ibrahim A, Edwards JE Jr, Walot I, Spellberg B. Deferasirox, an iron-chelating agent, as salvage therapy for rhinocerebral mucormycosis. Antimicrob Agents Chemother. Nov 2006;50(11):3968-9. [Medline].

  57. Rinaldi MG. Zygomycosis. Infect Dis Clin North Am. Mar 1989;3(1):19-41. [Medline].

  58. Saltoglu N, Tasova Y, Zorludemir S. Rhinocerebral zygomycosis treated with liposomal amphotericin B and surgery. Mycoses. Jan-Feb 1998;41(1-2):45-9. [Medline].

  59. Schmidt JM, Poublon RM. Rhinocerebral mycosis in immunocompromised patients. A case report and review of the literature. Rhinology. Jun 1998;36(2):90-3. [Medline].

  60. Scully RE, Mark EJ, McNeely WF. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 22-1999. A 68-year-old woman with multiple myeloma, diabetes mellitus, and an inflamed eye. N Engl J Med. Jul 22 1999;341(4):265-73. [Medline].

  61. 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].

  62. Selcen D, Seçmeer G, Aysun S, Kanra G, Onerci M, Gököz A. Mucormycosis in a diabetic child and its treatment with fluconazole: a case report. Turk J Pediatr. Apr-Jun 1995;37(2):165-8. [Medline].

  63. Shetty S, Kini U, Joy R. Isolated lingual mucormycosis in an infant with Down syndrome. Ear Nose Throat J. Jan 2008;87(1):34-5, 43. [Medline].

  64. Shpitzer T, Keller N, Wolf M. Seasonal variations in rhino-cerebral Mucor infection. Ann Otol Rhinol Laryngol. Sep 2005;114(9):695-8. [Medline].

  65. Simmons JH, Zeitler PS, Fenton LZ, Abzug MJ, Fiallo-Scharer RV, Klingensmith GJ. Rhinocerebral mucormycosis complicated by internal carotid artery thrombosis in a pediatric patient with type 1 diabetes mellitus: a case report and review of the literature. Pediatr Diabetes. Dec 2005;6(4):234-8. [Medline].

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

  67. Uçkay I, Chalandon Y, Sartoretti P, Rohner P, Berney T, Hadaya K, et al. Invasive zygomycosis in transplant recipients. Clin Transplant. Jul-Aug 2007;21(4):577-82. [Medline].

  68. Weprin BE, Hall WA, Goodman J. Long-term survival in rhinocerebral mucormycosis. Case report. J Neurosurg. Mar 1998;88(3):570-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

rhinocerebral mucormycosis, RCM, phycomycosis, zygomycosis, rhinoorbital mucormycosis, rhino-orbital mucormycosis, Mucorales, Rhizopus, Absidia, Mucor, Rhizomucor, Saksenaea, Apophysomyces

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

William P Baugh, MD, Assistant Clinical Professor of Dermatology, University of California Irvine School of Medicine and Western School of Medicine; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center
William P Baugh, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Laser Medicine and Surgery, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Coauthor(s)

Cynthia L Chen, Western University of Health Sciences College of Osteopathic Medicine of the Pacific
Disclosure: Nothing to disclose.

Medical Editor

John M Leedom, MD, Professor of Medicine, Keck School of Medicine, University of Southern California; Chief, Division of Infectious Diseases, Department of Internal Medicine, Los Angeles County, University of Southern California Medical Center
John M Leedom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M Kerkering, MD, Chief of Infectious Diseases, Virginia Tech, Carilion School of Medicine, Roanoke, Virginia
Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.