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Diabetes mellitus + new sinusitis = red flag for mucormycosis – highlighted by 418 cases in Mexico

July 20 2017

In a diabetic patient, RED FLAG warning signs of mucormycosis are: any of periorbital swelling, propotosis, sinus pain, diplopia or cranial nerve palsy, visual impairment or an ulcer on the palate, emphasise Dora Corza-Leon and colleagues from Mexico.

Mucormycosis is an emerging fungal disease with high rates of associated mortality and morbidity. A full review of the scientific literature focused in Mexican population has recently been published in Medical Mycology. The authors evaluated 418 cases of mucormycosis published between 1982 and 2016. Diabetes mellitus was identified as the major risk factor for mucormycosis (found in 78% of patients) and rhinosinusitis the commonest presentation (75%).

The authors have developed a clinical diagnostic algorithm to improve recognition of rhino-orbital cerebral (ROC) mucormycosis in diabetic patients with sinusitis. The algorithm is intended to provide guidance for early diagnostic assessment, which should be done as an emergency (ie same day). Any “warning signs” should trigger cranial and sinus CT scan or MRI is the initial diagnostic tool, combined with nasal endoscopy, and serve as well to delimit the infected zone and plan the boundaries of surgery.

Perioperative samples for direct exam, KOH smear, cytology, culture and histopathology are key to confirm ROC mucormycosis. The use of molecular diagnostic technology has notably increased in Mexico as a useful tool for early identification of species causing mucormycosis. Rhizopus spp. were the most frequent isolated genus (59%) in Mexico followed by Mucor spp. Only one case of the newly described (2014) species Apophysomyces mexicanus was found.

The algorithm reflects the multidisciplinary medical and surgical approach needed for successful management of mucormycosis. Amphotericin B formulations, posacoazole and isavuconazole are primary antifungal therapies and glycemic control is also a key factor in the management of patients with mucorcmycosis.