The burden of mucormycosis in HIV-infected patients
July 28 2016
A comprehensive analysis of mucormycosis in HIV has been carried out using data from 61 eligible studies published from 1988 - 2016, describing a total of 67 cases. The review describes predisposing factors, clinical form, treatment, and survival outcome of the disease in HIV-infected patients. Mucormycosis is a cause of extreme morbidity and mortality in both adult and pediatric immunocompromised patients; however, HIV has not previously been considered a significant risk factor. As such, there has been no previous attempt to review the epidemiology and outcomes of the condition in HIV-positive patients.
Moreira and colleagues from the National Institute of Infectology (IPEC), Brazil found that the most common co-morbidities with HIV-associated mucormycosis were: a history of intravenous drug use (50%), neutropenia (29.7%) and corticosteroid use (25%). Diabetes was present in 15.6% of cases and 3 cases of acute ketoacidosis were reported. Disseminated mucormycosis was the most common clinical form, followed by renal and rhino-cerebral. Cases of cutaneous, rhino-cerebral and pulmonary mucormycosis were also found. 77.6% of patients underwent some form of antifungal therapy, the remainder did not due to either disease severity at the time of hospitalisation or because they died prior to diagnosis. Amphotericin B was the main therapy, used alone in 84.6% of cases. In 7 additional cases, amphotericin B was administered in combination with flucytosine, itraconazole, fluconazole or posaconazole. In 27 cases, surgical intervention was performed, including elective nephrectomy, sinus surgery and skin debridement.
Mortality rate over all cases included was 52.2%. The most important determinant of prognosis was choice of therapy. Mortality rate in patients on no antifungal therapy was 93%, with no surgery, it was 75% and in those with combined antifungal and surgical therapy, mortality was 20%. The clinical form of the disease was also an important determinant of outcome: 92.9% of cases with disseminated disease ended with the death of the patient, compared to 62.5% of those with isolated cerebral mucormycosis and 60% of those with pulmonary infection. Admission to an ICU was a further predictor of poor outcomes.
In this first attempt to describe the burden of mucormycosis in HIV-infected patients, the authors found that mucormycosis in HIV positive patients is frequently fatal and associated with a number of comorbidities; e.g. severe immunosuppression, a history of intravenous drug use, neutropenia and corticosteroid use. Mortality is particularly high in those admitted to ICU or with disseminated disease.
The authors hope that this review will help to raise awareness amongst HIV physicians, that mucormycosis should be included in the differential diagnosis of opportunistic fungal infection in late stage HIV patients.
Note: Isavuconazole was approved by FDA and EMa for invasive mucormycosis in 2015