eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Mucormycosis: Treatment & Medication

Author: Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University Medical Center
Coauthor(s): Debra Whaley, MD, Staff Physician, Department of Pediatrics, University of Nebraska Medical Center, Creighton University Joint Pediatric Residency Program; Mary Carmen Y Mancao, MD, Associate Professor, Department of Pediatrics, University of South Alabama College of Medicine; Christine A Reyes, MD, Medical Director, Medical Technology School, Methodist Hospital; Consulting Staff, Department of Pathology, Methodist Hospital, Children's Hospital
Contributor Information and Disclosures

Updated: Nov 20, 2008

Treatment

Medical Care

A combination of a high index of suspicion with prompt diagnosis and medical and surgical care are vital in the management of mucormycosis.

Regarding medical care, underlying comorbidities such as hyperglycemia, acidosis in diabetic patients, nutritional problems, neutropenia, lymphopenia, and immunosuppression must be addressed.

The drug of choice for treating mucormycosis is amphotericin B, with a dosage of 1-1.5 mg/kg/d. Liposomal amphotericin B at dosages higher than these have also been used to treat disseminated disease. Some authors have suggested doses as high as 10-15 mg/kg. A term neonate who was diagnosed with facial mucormycosis after liver and small bowel transplantation survived after wide excision and 26 weeks' treatment with liposomal amphotericin B.3  

Azoles (eg, fluconazole, itraconazole) are not helpful in the treatment of mucormycosis. Among new triazoles, posaconazole are effective against mucormycosis. It has oral formulation and undergoes liver metabolism. Studies are being conducted to evaluate combination antifungal therapies. Posaconazole may be effective compared with other azoles against molds, including mucormycosis.4

Hyperbaric oxygen has been noted to reduce the morbidity and mortality when given in combination with medical and surgical therapy, with a 50% survival rate.5

Surgical Care

Surgical debridement should be undertaken early in the course of the illness, especially in cases of rhinocerebral mucormycosis. Instilling amphotericin B into abscess cavities after debridement has been suggested. Repeat surgery may be necessary to effectively eliminate all necrotic tissue in patients who survive. Reconstructive surgery is inevitable for those who have disfigurement due to severe rhinocerebral mucormycosis.

Consultations

Care of a pediatric patient with mucormycosis should involve several pediatric subspecialists, depending on the patient's underlying risk factors and the extent of disease. Therefore, if the child has an underlying malignancy, the following physicians should be involved in the child's care: oncologist, infectious disease specialist, surgeon (ear, nose, and throat [ENT] specialist and neurosurgeon if the patient has rhinocerebral disease), and critical care specialists.

Medication

The drug of choice for the treatment of mucormycosis is amphotericin B. Posaconazole has been rarely used in combination with amphotericin B as a salvage therapy in severe cases of mucormycosis in adults and children.

Antifungal agents

High-dose liposomal amphotericin B have been used to treat disseminated disease. Azoles (eg, fluconazole, itraconazole) are not helpful in the treatment of mucormycosis.


Amphotericin B (Fungizone)

Produced by Streptomyces nodosus. Mechanism of action is binding of sterols in fungal cytoplasmic membrane, resulting in membrane permeability that impairs survival of fungus and leading to loss of intracellular potassium. Administered IV when used to treat mucormycosis.

Adult

Pediatric

1-1.5 mg/kg/d IV in 5% dextrose solution (incompatible in NaCl solutions) for 6 wk or longer

Antineoplastic agents may enhance potential to cause renal toxicity, bronchospasm, or hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; cyclosporine increases risk of renal toxicity

Pregnancy

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

Precautions

Medical personnel should closely monitor IV initial doses in infants and children; fever and chills not uncommon after first few doses; rare acute reactions include hypotension, bronchospasm, arrhythmias, and shock

More on Mucormycosis

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

  1. Kline MW. Mucormycosis in children: review of the literature and report of cases. Pediatr Infect Dis. Nov-Dec 1985;4(6):672-6. [Medline].

  2. Simbli M, Hakim F, Koudieh M, Tleyjeh IM. Nosocomial post-traumatic cutaneous mucormycosis: a systematic review. Scand J Infect Dis. 2008;40(6-7):577-82. [Medline].

  3. Dave SP, Vivero RJ, Roy S. Facial cutaneous mucormycosis in a full-term infant. Arch Otolaryngol Head Neck Surg. Feb 2008;134(2):206-9. [Medline].

  4. Scheinfeld N. A review of the new antifungals: posaconazole, micafungin, and anidulafungin. J Drug Dermatol. 2007;12:1249-51. [Medline].

  5. Kaide CG, Khandelwal S. Hyperbaric oxygen: applications in infectious disease. Emerg Med clin north Am. 2008;26:571-95. [Medline]. [Full Text].

  6. Boelaert JR, Van Cutsem J, de Locht M, et al. Deferoxamine augments growth and pathogenicity of Rhizopus, while hydroxypyridinone chelators have no effect. Kidney Int. Mar 1994;45(3):667-71. [Medline].

  7. Bogard BN. Pulmonary mucormycosis. N Engl J Med. Mar 16 1972;286(11):606. [Medline].

  8. Bradley JS, Nelson JD. Nelson's Pocket Book of Pediatric Antimicrobial Therapy 2002-2003. 15th ed. 2002:62-5.

  9. De Decker K, Van Poucke S, Wojciechowski M, et al. Successful use of posaconazole in a pediatric case of fungal necrotizing fasciitis. Pediatr Crit Care Med. Sep 2006;7(5):482-5. [Medline].

  10. Frater JL, Hall GS, Procop GW. Histologic features of zygomycosis: emphasis on perineural invasion and fungal morphology. Arch Pathol Lab Med. Mar 2001;125(3):375-8. [Medline].

  11. Gonzalez CE, Rinaldi MG, Sugar AM. Zygomycosis. Infect Dis Clin North Am. Dec 2002;16(4):895-914, vi. [Medline].

  12. Greenberg RN, Scott LJ, Vaughn HH, Ribes JA. Zygomycosis (mucormycosis): emerging clinical importance and new treatments. Curr Opin Infect Dis. Dec 2004;17(6):517-25. [Medline].

  13. Kontoyiannis DP, Lionakis MS, Lewis RE, et al. Zygomycosis in a tertiary-care cancer center in the era of Aspergillus-active antifungal therapy: a case-control observational study of 27 recent cases. J Infect Dis. Apr 15 2005;191(8):1350-60. [Medline].

  14. Parfrey NA. Improved diagnosis and prognosis of mucormycosis. A clinicopathologic study of 33 cases. Medicine (Baltimore). Mar 1986;65(2):113-23. [Medline].

  15. Rex JH, Ginsberg AM, Fries LF, et al. Cunninghamella bertholletiae infection associated with deferoxamine therapy. Rev Infect Dis. Nov-Dec 1988;10(6):1187-94. [Medline].

  16. Richardson M, Koukila-Kahkola P, Shankland G. Rhizopus, Rhizomucor, Absidia, and other agents of systemic and subcutaneous zygomycoses. In: Manual of Clinical Microbiology. 8th ed. Washington, DC: American Society of Microbiology; 2003:1761-80.

  17. Robertson AF, Joshi VV, Ellison DA, Cedars JC. Zygomycosis in neonates. Pediatr Infect Dis J. Aug 1997;16(8):812-5. [Medline].

  18. Sugar A. Agents of mucormycosis and related species. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa: Churchill Livingstone; 2005:2973-83.

  19. Wiedermann BL. Zygomycosis. In: Feigen RD, ed. Textbook of Pediatric Infectious Diseases. 5th ed. Philadelphia, PA: Saunders; 2004.

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Further Reading

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Keywords

mucormycosis, Mucorales infection, fungal infection, Rhizopus species infection, Rhizomucor species infection, Absidia corymbifera infection, A corymbifera infection, Apophysomyces elegans infection, A elegans infection, Cunninghamella bertholletiae infection, C bertholletiae infection, Mucor species infection, Saksenaea vasiformis infection, S vasiformis infection, burns, trauma, diabetes mellitus, leukemia, diabetic ketoacidosis, malnutrition

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Contributor Information and Disclosures

Author

Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University Medical Center
Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: phamaceutical companies Honoraria Speaking and teaching; phamaceutical companies Grant/research funds clinical trials

Coauthor(s)

Debra Whaley, MD, Staff Physician, Department of Pediatrics, University of Nebraska Medical Center, Creighton University Joint Pediatric Residency Program
Debra Whaley, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Mary Carmen Y Mancao, MD, Associate Professor, Department of Pediatrics, University of South Alabama College of Medicine
Mary Carmen Y Mancao, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Christine A Reyes, MD, Medical Director, Medical Technology School, Methodist Hospital; Consulting Staff, Department of Pathology, Methodist Hospital, Children's Hospital
Christine A Reyes, MD is a member of the following medical societies: Alpha Omega Alpha, American Society for Clinical Pathologists, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Medical Editor

Gary J Noel, MD, Department of Pediatrics, Clinical Associate Professor, Weill Medical College of Cornell University
Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota School of Medicine
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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