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Pediatric Mucormycosis Treatment & Management

  • Author: Meera Varman, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Jul 28, 2016
 

Approach Considerations

Mucormycosis is often life threatening. A combination of a high index of suspicion with prompt diagnosis and medical and surgical care are vital in the management of mucormycosis.[8] Patients' survival rates also depend on resolution of their underlying condition. If mucormycosis progresses and if the underlying condition remains uncontrolled, death usually ensues.

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.

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Clinical Management

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.[9, 10] 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 of treatment with liposomal amphotericin B.[11]

Azoles (eg, fluconazole, itraconazole) are not helpful in the treatment of mucormycosis. Among relatively new triazoles, posaconazole is effective against mucormycosis. This agent has an oral formulation and undergoes liver metabolism. Posaconazole may be effective compared with other azoles against molds, including mucormycosis.[12, 13] Studies are being conducted to evaluate combination antifungal therapies.

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.[14]

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Surgical Intervention

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.

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Long-Term Monitoring

Close observation of patients who were treated and who survived the acute mucormycosis infection is important, because chronic manifestation of mucormycosis or late sequelae is possible.

In patients with rhinocerebral mucormycosis, cerebral abscess formation, cavernous sinus thrombosis, and thromboembolism of the internal carotid artery should be suspected as complications.

Studies in adults have demonstrated some benefit with the use of high-efficiency particulate air (HEPA) filters and different chelating agents instead of deferoxamine to decrease the risk of mucormycosis.

No method to prevent mucormycosis is recognized.

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Contributor Information and Disclosures
Author

Meera Varman, MD Associate 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, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America

Disclosure: Received honoraria from phamaceutical companies for speaking and teaching; Received grant/research funds from phamaceutical companies for clinical trials research.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD Minnesota American Legion and Auxiliary Heart Research Foundation Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Mary Carmen Y Mancao, MD, Christine A Reyes, MD, and Debra Whaley, MD, to the development and writing of the source article.

References
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  2. Sugar A. Agents of mucormycosis and related species. Mandell GL, Bennet JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Churchill Livingstone; 2009. Chapter 259.

  3. Wiedermann BL. Zygomycosis. Feigen RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, Pa: Saunders; 2009.

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

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

  8. Walsh TJ, Skiada A, Cornely OA, Roilides E, Ibrahim A, Zaoutis T, et al. Development of new strategies for early diagnosis of mucormycosis from bench to bedside. Mycoses. 2014 Dec. 57 Suppl 3:2-7. [Medline].

  9. Garbino J, Myers C, Ambrosioni J, Gumy-Pause F. Report of a successful treatment of pulmonary Cunninghamella bertholletiae infection with liposomal amphotericin and posaconazole in a child with GvHD and review of the literature. J Pediatr Hematol Oncol. 2010 Mar. 32(2):85-7. [Medline].

  10. Rüping MJ, Heinz WJ, Kindo AJ, Rickerts V, Lass-Flörl C, Beisel C, et al. Forty-one recent cases of invasive zygomycosis from a global clinical registry. J Antimicrob Chemother. 2010 Feb. 65(2):296-302. [Medline].

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  13. Ullmann AJ, Lipton JH, Vesole DH, Chandrasekar P, Langston A, Tarantolo SR, et al. Posaconazole or fluconazole for prophylaxis in severe graft-versus-host disease. N Engl J Med. 2007 Jan 25. 356(4):335-47. [Medline].

  14. Kaide CG, Khandelwal S. Hyperbaric oxygen: applications in infectious disease. Emerg Med Clin North Am. 2008 May. 26(2):571-95, xi. [Medline]. [Full Text].

  15. Garg PK, Gupta N, Gautam V, Hadke NS. Gastric zygomycosis: unusual cause of gastric perforation in an immunocompetent patient. South Med J. 2008 Apr. 101(4):449-50. [Medline].

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  19. Katragkou A, Walsh TJ, Roilides E. Why is mucormycosis more difficult to cure than more common mycoses?. Clin Microbiol Infect. 2014 Jun. 20 Suppl 6:74-81. [Medline].

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Black eschar on the skin of an immunocompromised patient.
Mucormycosis with broad, aseptate hyphae (hematoxylin and eosin, original magnification ×40).
Angioinvasion (hematoxylin and eosin, original magnification ×10).
Perineural invasion (hematoxylin and eosin, original magnification ×20).
 
 
 
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