Opportunistic fungal infections caused by Aspergillus and Candida followed by infections with Fusarium, Rhizopus, Mucor, and Alternaria species are an important cause of morbidity and mortality in patients with hematological malignancies. Cutaneous mucormycosis infections are rare, and the incidence, outcomes, and factors associated with survival in the setting of hematological malignancies are not clear.
Methods
A literature search was conducted for all cases of primary cutaneous mold infections in patients with hematological malignancy, of which 50 cases were found. Our case of a patient with a hematological malignancy who sustained a cat bite that in turn caused a primary cutaneous mold infection is also included.
Results
In the 51 cases identified, 66.7% were neutropenic upon presentation, and 54.9% were male with an average age of 32 years. Aspergillus species (33.3%) was the most cited followed by Rhizopus species (19.6%). Overall mortality rate was 29.4% and was observed more frequently in patients with neutropenia (60.0%) and without surgical intervention (73.3%). Survival rate was higher (35.3%) for cases utilizing both antifungal and surgical intervention. The antifungal agent with the highest survival rate was amphotericin B and its formulations (58.8%).
Conclusions
Neutropenia within hematological malignancies demonstrate a risk for developing severe cutaneous fungal infections, of which primary cutaneous mucormycosis can carry significant mortality. Combination antifungal therapy and surgical debridement appears to be associated with higher survival outcomes and warrants further investigation.
References
1.
HoffmannK., PawłtowskaJ., WaltherG.The family structure of the Mucorales: a synoptic revision based on comprehensive multigenegenealogies.Persoonia.2013; 30: 57–76.
2.
TianB-Y, HuangQ-G, XuY.Microbial community structure and diversity in a native forest wood-decomposed hollow-stump ecosystem.World J Microbiol Biotechnol.2010; 26(2): 233–240.
3.
KokluE., AkcakusM., TorunY.A.Primary gangrenous cutaneous mucormycosis of the scalp in a child: a case report.Pediatr Emerg Care.2008 Feb;24(2): 102–104.
4.
MaysS.R., BogleM.A., BodeyG.P.Cutaneous fungal infections in the oncology patient: recognition and management.Am J Clin Dermatol.2006; 7(1): 31–43.
5.
ChangY.H., HuangL.M., HsuehP.R.Acremonium pyomyositis in a pediatric patient with acute leukemia.Pediatr Blood Cancer.2005; 44(5): 521–524.
6.
KnappC.F., TucciV.T., KeelerJ.A.Primary cutaneous Acremonium infection in a neutropenic patient after trauma.Infect Dis Clin Pract.2010; 18(4): 277–278.
7.
FincherR.M., FisherJ.F., LovellR.D.Infection due to the fungus Acremonium (cephalosporium).Medicine (Baltimore).1991; 70(6): 398–409.
8.
VasiloudesP., MorelliJ.G., WestonW.L.Painful skin papules caused by concomitant Acremonium and Fusarium infection in a neutropenic child.J Am Acad Dermatol.1997; 37(6): 1006–1008.
IwenP.C., TarantoloS.R., SuttonD.A.Cutaneous infection caused by Cylindrocarpon lichenicola in a patient with acute myelogenous leukemia.J Clin Microbiol.2000; 38(9): 3375–3378.
14.
TorreloA., Hernandez-MartínA., ScaglioneC.Primary cutaneous aspergillosis in a leukemic child.Actas Dermosifiliogr.2007; 98(4): 276–8.
15.
GalimbertiR., KowalczukA., HidalgoP.I.Cutaneous aspergillosis: a report of six cases.Br J Dermatol.1998; 139(3): 522–526.
16.
GrossmanM.E., FithianE.C., BehrensC.Primary cutaneous aspergillosis in six leukemic children.J Am Acad Dermatol.1985; 12(2 pt 1): 313–318.
17.
EstesS.A., HendricksA.A., MerzW.G.Primary cutaneous aspergillosis.J Am Acad Dermatol.1980; 3(4): 397–400.
18.
D'AntonioD., PaganoL., GirmeniaC.Cutaneous aspergillosis in patients with haematological malignancies.Eur J Clin Microbiol Infect Dis.2000; 19(5): 362–365.
19.
LucasG.M., TuckerP., MerzW.G.Primary cutaneous Aspergillus nidulans infection associated with a Hickman catheter in a patient with neutropenia.Clin Infect Dis.1999; 29(6): 1594–1596.
20.
GeneJ., Azon-MasoliverA., GuarroJ.Cutaneous infection caused by Aspergillus ustus, an emerging opportunistic fungus in immunosuppressed patients.J Clin Microbiol.2001; 39(3): 1134–1136.
21.
KnappC.F., TucciV.T., SandinR.L.Cutaneous Curvularia infection in a neutropenic patient.Asian Biomed.2008; 2: 393–395.
22.
IoannidouD., MarakiS., Kruger KrasagakisS.Cutaneous alternariosis revealing acute myeloid leukaemia in an adult patient.Mycoses.2004; 47(5-6): 227–230.
23.
SrinivasanA., WickesB.L., RomanelliA.M.Cutaneous infection caused by Macrophomina phaseolina in a child with acute myeloid leukemia.J Clin Microbiol.2009; 47(6): 1969–1972.
24.
WanessA., DawsariG.A., Al JahdaliH.The rise of an opportunistic infection called “invasive zygomycosis.”J Glob Infect Dis.2009; 1(2): 131–138.
25.
MoraceG., BorghiE.Invasive mold infections: virulence and pathogenesis of mucorales.Int J Microbiol.2012; 2012: 349278.
26.
TapiaE.O., ChahínA.C., ConchaF.C.Primary cutaneous mucormycosis: two case reports and review of the literature.Rev Chilena Infectol.2011; 28(3): 269–273.
27.
ElsiesyH., SaadM., ShormanM.Invasive mucormycosis in a patient with liver cirrhosis: case report and review of the literature.Hepat Mon.2013; 13(8): e10858.
28.
BoxerL.A.How to approach neutropenia.Hematol Am Soc Hematol Educ Program.2012; 2012: 174–182.
29.
IbrahimA.S., SpellbergB., WalshT.J.Pathogenesis of mucormycosis.Clin Infect Dis.2012; 54(suppl 1): S16–S22.
30.
BaraiaJ., MunozP., Bernaldo de QuirosJ.C.Cutaneous mucormycosis in a heart transplant patient associated with a peripheral catheter.Eur J Clin Microbiol Infect Dis.1995; 14(9): 813–815.
Cantatore-FrancisJ.L., ShinH.T., HeilmanE.Primary cutaneous zygomycosis in two immunocompromised children.Pediatr Dermatol.2007; 24(3): 257–262.
35.
SankarJ., ArunS., SankarM.J.Primary cutaneous mucormycosis during induction chemotherapy in a child with acute lymphoblastic leukemia.Indian J Pediatr.2009; 76(11): 1161–1163.
36.
SalatiS.A., RabahS.M.Cutaneous mucormycosis in a leukemic patient.J Coll Physicians Surg Pak.2011; 21(2): 109–110.
37.
MuellerB.U., PabstT.Cutaneous zygomycosis at catheter insertion site in AML-M4Eo.Ann Hematol.2006; 85(3): 194–195.
38.
Arnaiz-GarciaM.E., Alonso-PenaD., Gonzalez-Vela MdelC.Cutaneous mucormycosis: report of five cases and review of the literature.J Plast Reconstr Aesthet Surg.2009; 62(11): e434–e441.
39.
BethgeW.A., SchmalzingM., StuhlerG.Mucormycoses in patients with hematologic malignancies: an emerging fungal infection.Haematologica.2005; 90(suppl): ECR22.
40.
KaramA., IanottoJ.C., MetgesJ.P.Ulceration of the penis due to Absidia corymbifera.Br J Dermatol.2003; 148(6): 1286–1287.
41.
RouxB.G., MechinaudF., Gay-AndrieuF.Successful triple combination therapy of disseminated Absidia corymbifera infection in an adolescent with osteosarcoma.J Pediatr Hematol Oncol.2010; 32(2): 131–133.
42.
BeckerB.C., SchusterF.R., GansterB.Cutaneous mucormycosis in an immunocompromised patient.Lancet Infect Dis.2006; 6(8): 536.
43.
HadithiM., LeemansC.R., JonkhoffA.R.Cutaneous mucormycosis in acute myeloid leukemia; hit hard and quickly.Haematologica.2001; 86(12): 1320.
44.
HansenJ.P., KristjanssonA.K., StoneM.S.A neutropenic child with a purple lesion on the thigh.Pediatr Dermatol.2007; 24(5): 560–561.
45.
KhardoriN., HayatS., RolstonK.Cutaneous Rhizopus and Aspergillus infections in five patients with cancer.Arch Dermatol.1989; 125(7): 952–956.
46.
RubinA.I., GrossmanM.E.Bull's-eye cutaneous infarct of zygomycosis: a bedside diagnosis confirmed by touch preparation.J Am Acad Dermatol.2004; 51(6): 996–1001.
47.
DurandC.M., AlonsoC.D., SubhawongA.P.Rapidly progressive cutaneous Rhizopus microsporus infection presenting as Fournier's gangrene in a patient with acute myelogenous leukemia.Transpl Infect Dis.2011; 13(4): 392–396.
48.
SundararajanT., KumarC.P., MenonT.Cutaneous zygomycosis due to Rhizopus oryzae in a patient with acute lymphoblastic leukemia.Mycoses.2004; 47(11-12): 521–523.
49.
MiyamotoH., HayashiH., NakajimaH.Cutaneous mucormycosis in a patient with acute lymphocytic leukemia.J Dermatol.2005; 32(4): 273–277.
JohnsonK.E., LeahyK., OwensC.An atypical case of fatal zygomycosis: simultaneous cutaneous and laryngeal infection in a patient with a non-neutropenic solid prostatic tumor.Ear Nose Throat J.2008; 87(3): 152–155.
52.
WirthF., PerryR., EskenaziA.Cutaneous mucormycosis with subsequent visceral dissemination in a child with neutropenia: a case report and review of the pediatric literature.J Am Acad Dermatol.1997; 36(2 pt 2): 336–341.
53.
HockerT.L., WadaD.A., BridgesA.Disseminated zygomycosis heralded by a subtle cutaneous finding.Dermatol Online J.2010; 16(9): 3.
54.
MotohashiK., ItoS., HagiharaM.Cutaneous zygomycosis caused by Cunninghamella bertholletiae in a patient with chronic myelogenous leukemia in blast crisis.Am J Hematol.2009; 84(7): 447–448.
ConstantinidesJ., MisraA., NassabR.Absidia corymbifera fungal infection in burns: a case report and review of the literature.J Burn Care Res.2008; 29(2): 416–419.
WollsteinR., PalekarA.Mucormycosis infection following intravenous access in the forearm.Can J Plast Surg.2010; 18(2): e30–e32.
59.
ZacharyD., ChapinK., BinnsL.Cutaneous mucormycosis complicating a polymicrobial wound infection following a dog bite.Case Rep Infect Dis.2011; 2011: 348046.
60.
RaizmanN.M., ParisienM., GrafeM.W.Mucormycosis of the upper extremity in a patient with alcoholic encephalopathy.J Hand Surg Am.2007; 32(3): 384–388.
61.
LarchéJ., MachouartM., BurtonK.Diagnosis of cutaneous mucormycosis due to Rhizopus microsporus by an innovative PCR-restriction fragment-length polymorphism method.Clin Infect Dis.2005; 41(9): 1362–1365.
62.
NosariA., OresteP., MontilloM.Mucormycosis in hematologic malignancies: an emerging fungal infection.Haematologica.2000; 85(10): 1068–1071.
