1. Results: Thirty four patients (16) males and (20) females (Male: Female ratio 0.8:1) aged (1-18) years were diagnosed with fungal sinusitis. Of them 5 patients had intracranial extension in addition (15%). Three patients with intracranial extension had facial edema and necrotic patches. Focal neurologic deficits was present in on of them in addition. Three patients had histopathologically proven mucormycosis and two had aspergillosis with positive β – D glucan test. Empirical treatment with liposomal Amphothericin B was started for all patients, those with aspergillosis were shifted to voriconazole.
The remaining 29 (85%) patients who had fungal sinusitis without intracranial extension had fever, 17 of them (58.6%) were neutropenic, 8 patients (27.5%) had facial edema, 18 patients (62%) had necrotic tissue. Three patients (10.3%) had perforated hard palate and another three (10.3%) had bone erosion on imaging. Mucormycosis was documented in 15 patients (51.7%) , in 4 cases it was coupled with Aspergillus infection and in one case it was mixed with Candida . Isolated aspergillosis was present in 9 patients (31%), while mixed aspergillus and candida was documented in 2 patients (6.9%). All patients received liposomal amphotheicin -B empirically till result of pathology and those who were diagnosed with aspergillosis were shifted to therapeutic voriconazole.
Comparison of both groups is presented in the table.
Clinical Charecterestics and Outcome of rhino-cerebral fungal infection in pediatric cancer patients
Comprison
Patinets with fungal sinusitis AND intracranial extension
(N=5)
Patients with fungal sinusitis and NO intrcranial extnesion
(N=29)
Underlying malignancy
ALL
AML
NHL
MPAL
5 (100%)
---
16(64%)
11(44%)
1(3%)
Treatment phase at time of fungal infection diagnosis
Induction/consolidation
Salvage chemotherapy
24 (28%)
5(17%)
Underlying host factors
Fever
Neutropenia (neutrophils: < 0.5*109 /L)
Iron overload
Hyperglycemia
ICU admission
29(100%)
17(58%)
7(24%)
3 (10 %)
6(20%)
Pathology
Mucormyciosis
Aspergillosis
Mixed fungal infection
3(60%)
2(40%)
15 (51%)
9(31%)
Other organs affected
Lungs
Retina
11(37%)
Surgical debridement
Complete
Incomplete --
5(100%)
15 (51.7%)
Death due to fungal infection
4 (80%)
7 (24%)
Shaimaa Samir Mostafa Abdallah*1 , Youssef Madney2 , Mervat G. Elanany3 , Marwa Romeih3 , Lama Halaby3 Lobna Shalaby4
1Children's Cancer Hospital-Egypt; Hematology/Oncology 2NCI; Pediatric Oncology 3Children's Cancer Hospital-Egypt (57357); 4National Cancer Institute/ Children's Cancer Hospital
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CT maxillofaical showing left maxillary sinusitis, bone erosion and premaxillary cellulitis with inflammatory process and air loculi into the left masticator space/infratemporal fossa. It is extended –in other cuts- into oral cavity the left tonsil and downwards in the left lateral laryngeal space.
Background: Children with hematologic malignancies are especially vulnerable to contract fungal infection; not only by virtue of their disease process but also by the intensive chemotherapy they receive. Rhino-cerebral fungal infection is a rare entity that requires careful attention and prompt management due to its almost deadly outcome.
Material/methods: Retrospective analysis of the medical records of patients with hematologic malignancies who were treated at Children's Cancer Hospital - Egypt through the period from July 2007 to December 2015 who had pathologically proven fungal infection.
Analysis included patients’ demographic data, underlying disease and its status, microbiologic, histopathologic, radiologic and surgical data. .
Conclusion: Patients with hematologic malignancies are immunocompromised and are highly susceptible to invasive fungal infection. The mortality due to rhino-cerebral fungal infection is very high. Reversal of the underlying risk factors, proper broad spectrum antifungal therapy and early surgical debridement is of paramount importance to improve outcome..
Mortality: Four out of 5 patients (80%) with intracranial extension died out of fungal infection. On the other hand , of the 29 patients without intracranial extension, 15 patients (51.7%) had surgical debridement, one died due to disseminated fungal infection. Fourteen patients (48.3%) were not eligible for surgical debridement, of them 6 patients died despite maximal supportive care
Contact information:
Shaimaa Samir Eissa
Childrens Cancer Hospital-Egypt (57357)
References :
Devi Dayal , Jaimanti Bakshi: Early Diagnosis and Surgery is Crucial to Survival Outcome in Rhinocerebral Mucormycosis. Indian Journal of Otolaryngology and head and neck surgery. 2016
Lewis RE, Kontoyiannis DP. Epidemiology and treatment of mucormycosis. Future microbiology Sep;8(9):
Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis Feb;54 Suppl 1:S23-34.