mucormycosis ( mcm ) is a devastating infection with high mortality rates despite recent advances in its diagnosis and treatment .
it is caused by the filamentous fungi of the mucorales order of the class of zygomycetes .
although it is classically defined as an opportunistic infection , preferentially affecting patients with diabetes mellitus ( dm ) , neutropenia , malignancy , chronic renal failure , and acquired immunodeficiency syndrome and those who have received organ or hematopoietic stem cell transplants , it can affect immunocompetent hosts as well ( such as trauma patients ) [ 1 , 2 ] .
the incidence of mcm worldwide appears to be increasing , particularly in oncological patients and those with dm . along with aspergillus , it is one of the most common invasive fungal infections affecting immunosuppressed individuals . despite aggressive surgical and polyene antifungal therapy , overall mortality for mcm infection remains high , with figures ranging from 20 to 50% [ 46 ] .
depending on patient characteristics ( such as critically ill or immunocompromised patients ) and site of infection , mortality rises markedly , nearing 7090% for cases of disseminated mucormycosis [ 46 ] .
inhalation of sporangiospores is the most common route of transmission , although ingestion of spores , direct implantation into injured skin ( burns ) , trauma with contaminated soil , or intravenous ( drug users ) transmission have also been described .
after nasal inoculation it takes a rapidly progressive course extending to neighboring tissues , including the orbit , and sometimes to the brain .
lipid formulations of amphotericin b are the mainstay of treatment , along with aggressive surgical therapy . however , such drug formulations are not available worldwide due to their elevated costs .
most of the information on the epidemiology and clinical characteristics of mcm comes from case series and small studies on specific populations , such as those in oncology centers .
considering the high mortality associated with mcm and the increasing recognition of the importance of this disease in latin american countries , we set out to describe the demographic and clinical characteristics of mcm patients in a tertiary - care teaching hospital in mexico .
we received approval from the ethics committee of our institution to carry out this study . from 2007 to 2012
jose eleuterio gonzalez ,  and their records were obtained to analyze the cases retrospectively .
demographic characteristics , presentation , signs , and symptoms as well as treatment and outcomes were analyzed .
cases were sought through manual and electronic searches in hospital records ( using discharge diagnoses ) .
we used the 2008 european organization for research and treatment of cancer / mycoses study group ( eortc / msg ) criteria for the diagnosis of mcm , but only proven cases were retained .
descriptive statistical methods were used to analyze demographic characteristics , and differences between groups were calculated using student 's  t - test for independent samples or fisher 's exact test , where appropriate . statistical significance was established at p < 0.05 .
data were analyzed using an spss statistical package ( spss statistics 15.0 , spss inc .
the mean age of the patients was 39.9 + / 20.3 years ( range 565 years ) , with men presenting the majority ( 64.3% ) .
the most common underlying disease was dm ( 71.4% ) , followed by hematological malignancy ( 42.8% ) and chronic renal insufficiency on hemodialysis ( 21.4% ) .
five patients with hematological malignancy had all and only one had acute myelocytic leukemia ; they had all received chemotherapy , including steroids , and two were neutropenic on diagnosis .
patients also complained of headache , ocular pain , facial edema , and when ocular involvement was present , visual abnormalities .
all patients had rhinocerebral involvement ( figure 1 ) . on presentation , 4 patients had overt orbital involvement . all patients received medical treatment with conventional ( deoxycholate ) amphotericin b at 11.5 
amphotericin b was administered through a central line , with a median duration of treatment of 11.5 days .
medical treatment was initiated empirically in 10 patients and after microbiological identification in the remaining cases .
hypokalemia and creatinine elevations appeared in 6 patients after treatment , but these alterations did not ultimately require switching or modifying therapy .
all of the patients that presented with diabetic ketoacidosis died , and all nonsurvivors underwent surgery . some routine laboratory tests on admission were also analyzed .
no differences were found in hemoglobin , white blood count , or serum electrolytes ( data not shown ) between survivors and nonsurvivors .
mean creatinine was 3.68 + / 3.15  mg / dl in nonsurvivors and 1.69 + / 1.15  mg / dl in survivors , with no statistical difference between groups .
serum albumin levels were significantly lower on admission in nonsurvivors ( 2.3 + / 0.23  g / dl ) in comparison with survivors ( 3.15 + / 0.46  g / dl ) , with a p = 0.03 .
there was no difference in the time of initiation of treatment between survivors and nonsurvivors ( data not shown ) .
the majority of the patients in our series were male , a trend that has been consistently reported in case series from different countries [ 1012 ] .
dm is associated with impaired neutrophil function , microvascular insufficiency , and in the case of ketoacidosis , other metabolic abnormalities that promote fungal growth [ 1113 ] .
rhizopus species have an active ketone reductase system and thrive in high glucose and acidotic conditions .
notably , in our series , 4 patients presented with diabetic ketoacidosis . in a series of 28 mcm cases ,
64% cases had dm and 55.6% of those cases had diabetic ketoacidosis , a proportion similar to our findings . however , in other series , complications associated with dm accounted for only 17% of cases of mcm .
chronic renal insufficiency is another condition that predisposes to mcm infection . in our series ,
patients with renal disease all had concomitant dm and were on hemodialysis . in a 1997 case series with patients from our institution , rhinocerebral mcm was diagnosed in 22 patients over 15 years .
in contrast with our study , hematologic malignancy was uncommon , with only one patient presenting with myelodysplastic syndrome .
this could indicate increasing number of patients with hematological malignancies admitted to our institution , the use of more aggressive immunosuppressive regimens in these patients , and improved control of dm complications in our population .
these trends have been recognized in other studies as well [ 12 , 16 ] . in the largest case series ,
patients with hematological malignancies ( mainly acute leukemia ) represent the group with the highest prevalence and with rapidly increasing rates of mcm [ 12 , 16 ] . in our series 6 of our patients had hematological malignancies , and in all cases these were acute leukemia ( all and aml ) . although neutropenia has also been hailed as an important factor in the development of mcm , only 2 of our patients with all presented with neutropenia .
mcm infection may have a rhinocerebral , rhinoorbital , pulmonary and soft - tissue extension , among others .
recent registries have reported conflicting data about the most common site of infection . in a global registry , the lung ( 58.5% ) was the main site of infection , followed by rhinocerebral or rhinoorbital involvement ( 19.5% ) . in an italian series ,
rhino - orbital - cerebral involvement was the most common site of infection ( 35% ) , followed by the lung ( 25% ) .
interestingly , we found no evidence of lung involvement or of disseminated disease in our series .
the most common signs and symptoms were fever , rhinorrhea , and headache , while the most ominous symptom was vision loss . despite aggressive medical and surgical treatment , in - hospital mortality in our patients was 50% , which is similar to rates reported in other case series .
although it is higher than the rate reported in a recent population - wide study ( 22% ) , our series is quite different in terms of infection site ( mainly rhinocerebral ) and treatment ( conventional amphotericin b ) .
all of our patients received conventional ( as opposed to liposomal ) amphotericin b at doses that ranged from 1 to 1.5  mg / kg / day .
although surgical therapy has been associated with improved outcome in some studies [ 5 , 6 ] , all of the nonsurvivors in our study underwent surgical treatment .
this could be explained by clinically milder forms of mcm infection in those patients that did not have to undergo surgery .
notwithstanding our small sample , we could identify factors that were significantly different in nonsurvivors when compared with survivors : these were older age , dm , and ketoacidosis at presentation .
ketoacidosis represents a severe complication of dm in its own right and indicates poor glycemic control , so along with old age it is not surprising that it would be associated with worse outcomes . of note ,
this accounts for the higher creatinine levels ( although not significant ) on admission in nonsurvivors .
serum albumin on admission was lower in nonsurvivors as well , which could indicate malnutrition , another predisposing factor for immunosuppression .
in conclusion , mcm is a life - threatening infection that most commonly affects immunocompromised individuals and that despite aggressive multimodal treatment carries a significant risk of mortality .
a high index of suspicion is required in order to begin the appropriate diagnostic workup and treatment .
our cases most commonly involved the rhino - orbital - cerebral cavities , and the main underlying disease was dm .
unfortunately , due to economic limitations , the use of liposomal amphotericin b in third world countries is often prohibitive , and our patients were instead treated with conventional amphotericin b. fortunately , there were no cases in our series where side effects ( such as renal injury or hypokalemia ) forced a change in therapy . in light of evidence suggesting that early and aggressive use of liposomal amphotericin b could improve outcomes ,
 mucormycosis ( mcm ) is a life - threatening infection that carries high mortality rates despite recent advances in its diagnosis and treatment . 
 the objective was to report 14 cases of mucormycosis infection and review the relevant literature . 
 we retrospectively analyzed the demographic and clinical data of 14 consecutive patients that presented with mcm in a tertiary - care teaching hospital in northern mexico . 
 the mean age of the patients was 39.9 ( range 565 ) . 
 nine of the patients were male . 
 ten patients had diabetes mellitus as the underlying disease , and 6 patients had a hematological malignancy ( acute leukemia ) . 
 of the diabetic patients , 3 had chronic renal failure and 4 presented with diabetic ketoacidosis . 
 all patients had rhinocerebral involvement . 
 in - hospital mortality was 50% . 
 all patients received medical therapy with polyene antifungals and 11 patients underwent surgical therapy . 
 survivors were significantly younger and less likely to have diabetes than nonsurvivors , and had higher levels of serum albumin on admission . 
 the clinical outcome of patients with mcm is poor . uncontrolled diabetes and age are negative prognostic factors . 
1. Introduction 
2. Materials and Methods
3. Results
4. Discussion
5. Conclusion