Case # 1. 60/M with h/o refractory neutropenia secondary to large granular cell lymphoma, h/o kidney transplantation, who p/w acute mental status change, new-onset left axillary skin lesion, and progressive lung nodules and cavity formation secondary to disseminated mucormycosis.
1. Remember the most commonly encountered causes of mucormycosis: Rhizopus, Mucor, and Rhizomucor; Cunninghamella, Absidia, Saksenaea, and Apophysomyces.
2. The three most common disease presentations associated with mucormycosis are: rhinocerebral, pulmonary, and cutaneous mucormycosis.
3. Cutaneous mucromycosis can arise from direct inoculation. Reverse dissemination (from skin to other organ systems) rarely occurs (3%).
4. Treatment of choice is amphotericin. Posaconazole is an alternative agent. Not backed up by randomized controlled trials but combination therapy (amphotericin plus echinocandin, amphotericin plus posaconazole) has also been used for refractory cases. Use of adjunct deferasirox for refractory cases has also been reported.
5. This patient's treatment course was complicated by development of torsades de pointes while receiving a quinolone and posaconazole. QT prolongation persisted despite discontinuation of drugs. In this situation, intermittent amphotericin (once weekly) can be tried. This is supported by a small study where once weekly amphotericin was comparable to other prophylaxis for invasive fungal infection (see here).
Case # 2. A 10 year old girl with cystic fibrosis, s/p bilateral lung transplant, h/o post-transplant lymphoproliferative disorder who p/w persistent abdominal pain and fever; PET scan revealed diffuse uptake in the pancreas; multiple infectious disease work-up were negative; pancreas biopsy showed necrotizing granulomas and yeasts on Giemsa stain; beta glucan was elevated; believed to be secondary to Candida pancreatitis
1. Remember that Cryptococcus and the agents responsible for mucormycosis will test negative for beta glucan. Maybe helpful to distinguish cryptococcal versus candidal infection especially if cultures are negative and yeasts are evident on tissue biopsy.
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