Local Infiltration Anesthesia for Orbital Exenteration in Patients With Rhino-Orbital Cerebral Mucormycosis: A Case Series.

Orbital exenteration is occasionally required for rhino-orbital cerebral mucormycosis. Multiple associated comorbidities can pose a risk for general anesthesia. There is only 1 report of exenteration being performed under trigeminal nerve block. We describe 5 patients who underwent orbital exenteration under local infiltration anesthesia with sedation. Patients and surgeons reported satisfactory conditions, with stable hemodynamics and successful day care management. Orbital exenteration under local infiltration anesthesia can be a safe and effective alternative for patients with rhino-orbital mucormycosis who are at risk with use of general anesthesia.

Successful Treatment of Rhino-Orbital-Cerebral Mucormycosis in a Child With Leukemia.

Rhino-orbital-cerebral mucormycosis (ROCM) is a rare fulminant opportunistic fungal infection that despite relevant treatment has high mortality. We present a case of a 3-year-old girl with acute lymphoblastic leukemia and ROCM, who was treated successfully with excessive surgery, systemic antifungal treatment with amphotericin B (AmB), posaconazole, and terbinafine as well as hyperbaric oxygen. Surgery included, beside extracranial and intracranial removal of infected areas, endoscopic sinus and skull base surgery with local AmB installation and in addition placement of an Ommaya reservoir for 114 intrathecal administrations of AmB. In addition, we review the literature of ROCM in pediatric patients with hematological diseases.

A successful combined endovascular and surgical treatment of a cranial base mucormycosis with an associated internal carotid artery pseudoaneurysm.

OBJECTIVE: We report a rare case of internal carotid artery pseudoaneurysm owing to rhinocerebral mucormycosis and review 40 reported cases from 1980 to present. CLINICAL PRESENTATION: A 38-year-old Caucasian man presented with a 3-day history of headache, diplopia, and numbness in the distribution of the left ophthalmic and maxillary branches of the trigeminal nerve. A complete left cavernous syndrome was discovered upon neurological examination. Magnetic resonance imaging scans revealed an inflammatory process involving the paranasal sinuses with extension into the left cavernous sinus, temporal fossa, and petrous bone. INTERVENTION: The patient was immediately treated with amphotericin B, atorvastatin, and daily hyperbaric oxygen sessions before surgical intervention. The patient underwent endovascular treatment of the associated mycotic pseudoaneurysm after carotid test occlusion in addition to a radical bilateral debridement of the paranasal sinuses and infratemporal and temporal fossa. CONCLUSION: Aggressive multimodal therapy is imperative for late-stage rhinocerebral mucormycosis. Extensive resection of infected tissue combined with amphotericin B, atorvastatin, and hyperbaric oxygen seems to be the best course of management. If the internal carotid artery is involved, endovascular intervention is clearly an option to attain this goal. Further research and longer follow-up periods are required to better understand the long-term implications of endovascular coiling and hyperbaric oxygen therapy for rhinocerebral mucormycosis.

Intraabdominal zygomycosis caused by Syncephalastrum racemosum infection successfully treated with partial surgical debridement and high-dose amphotericin B lipid complex.

Invasive zygomycosis rarely complicates trauma. We describe the first recorded case of invasive infection of the anterior abdominal wall and omentum with the zygomycete Syncephalastrum racemosum, which was successfully treated with partial surgical debridement and amphotericin B lipid complex.

Resolution of rhinocerebral zygomycosis associated with adjuvant administration of granulocyte-macrophage colony-stimulating factor.

We successfully treated 3 consecutive patients who had nonneutropenic rhinocerebral zygomycosis, by use of subcutaneous granulocyte-macrophage colony-stimulating factor therapy combined with traditional surgical and medical treatment. All patients are currently free of disease. Granulocyte-macrophage colony-stimulating factor should be considered as adjuvant therapy for rhinocerebral zygomycosis; however, optimum dose and length of therapy are unknown.

Mucormycosis.

Mucormycosis refers to the disease caused by a growing number of members of the Mucorales. Typically an airborne infection, primary disease is initiated in the upper or lower airways and is associated with the clinical development of sinusitis, rhinocerebral mucormycosis, or pulmonary infection. Dissemination of infection to skin, brain, and other sites is less common, but direct extension of the infection to contiguous sites is common if patients do not receive aggressive surgical and medical therapy. Risk factors for the development of mucormycosis include diabetic ketoacidosis; neutropenia; protein-calorie malnutrition; and iron overload, with or without the concomitant use of deferoxamine. This last association has only recently been recognized and has emerged as a major life-threatening complication for patients who are undergoing hemodialysis. Intravenous drug abusers may inject spores of Mucorales with their drugs and may present with space-occupying lesions of the CNS. The underlying immunologic defects that are responsible for predisposing different populations of patients to the development of mucormycosis are not well understood, and there is no unifying theory to explain why most individuals have innate immunity to this group of fungi. Patients with mucormycosis who are managed aggressively (i.e., those who undergo surgical debridement and who receive therapy with iv amphotericin B) may have increased rates of survival. The role of new azole derivatives in the treatment of mucormycosis is unknown.

Adjunctive hyperbaric oxygen for treatment of rhinocerebral mucormycosis.

The therapy of rhinocerebral mucormycosis includes aggressive surgical debridement, administration of high-dose amphotericin B, and control of underlying predisposing conditions, especially diabetes and immunosuppression or immunodeficiency. Hyperbaric oxygen suppresses fungal growth in vitro and has theoretical value in treating mucormycosis because it reduces the tissue hypoxia and acidosis that accompany vascular invasion by the fungus. In a retrospective review of patients at Duke University Medical Center with rhinocerebral mucormycosis, six patients were treated with hyperbaric oxygen and seven cases (involving six patients) were treated without hyperbaric oxygen. All patients received surgical debridement and amphotericin B. Two of six patients receiving hyperbaric oxygen therapy died, and four of seven patients not receiving hyperbaric oxygen therapy died. Adverse effects from hyperbaric oxygen were minimal. Because mucormycosis occurs infrequently, this retrospective review involved a small number of patients. Despite this limitation, adjunctive hyperbaric oxygen appears to be a promising clinical modality for the treatment of rhinocerebral mucormycosis and warrants further investigation.