Mucorales - Revision history

Aidan: /* Skin and Soft Tissue infection */

2022-02-12T21:05:25Z

Skin and Soft Tissue infection

← Older revision		Revision as of 21:05, 12 February 2022
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	*Less commonly associated with classic “halo sign” and may actually see '''“reverse halo sign”''' which is a focal round area of ground-glass attenuation surrounded by ring consolidation.		*Less commonly associated with classic “halo sign” and may actually see '''“reverse halo sign”''' which is a focal round area of ground-glass attenuation surrounded by ring consolidation.

	===Skin and Soft Tissue ~~infection~~===		===Skin and Soft Tissue Infection===

	*Usually occur as a result of contaminated trauma.		*Usually occur as a result of contaminated trauma.

Aidan: Text replacement - " species]]" to "]]"

2022-01-27T20:52:33Z

Text replacement - " species]]" to "]]"

← Older revision		Revision as of 20:52, 27 January 2022
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	*May or may not have rhizoids, depending on the species		*May or may not have rhizoids, depending on the species
	*Human pathogens within the order include:		*Human pathogens within the order include:
	**[[Rhizopus ~~species~~]]		**[[Rhizopus]]
	***[[Rhizopus oryzae]], the most common cause of mucormycosis		***[[Rhizopus oryzae]], the most common cause of mucormycosis
	***[[Rhizopus microsporus]]		***[[Rhizopus microsporus]]
	***[[Rhizopus stolonifer]]		***[[Rhizopus stolonifer]]
	**[[Mucor ~~species~~]]		**[[Mucor]]
	***[[Mucor circinelloides]]		***[[Mucor circinelloides]]
	**[[Rhizomucor ~~species~~]]		**[[Rhizomucor]]
	***[[Rhizomucor pusillus]]		***[[Rhizomucor pusillus]]
	**Others		**Others
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	*** Sporangiophores branching from stolon		*** Sporangiophores branching from stolon
	*** Sporangium at the end of the sporangiophore, and may be attached by an apophysis (a conical neck at the end of sporangiophore)		*** Sporangium at the end of the sporangiophore, and may be attached by an apophysis (a conical neck at the end of sporangiophore)
	**** May instead have a sporangiolum, which produces spores more discretely, so it there are countable spores then it's a sporangiolum, as seen in [[Cunninghamella ~~species~~]]		**** May instead have a sporangiolum, which produces spores more discretely, so it there are countable spores then it's a sporangiolum, as seen in [[Cunninghamella]]
	**** May instead have finger-like merosporangia, each finger of which has a countable number of spores		**** May instead have finger-like merosporangia, each finger of which has a countable number of spores
	*** May have columella at the neck		*** May have columella at the neck
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	** Histopathology		** Histopathology
	*** GMS or PAS are best stains, and should be requested STAT		*** GMS or PAS are best stains, and should be requested STAT
	** Galactomannan is usually negative; if positive, it can help rule in [[Aspergillus ~~species~~]] in the right clinical context, and therefore help to rule out mucormycosis		** Galactomannan is usually negative; if positive, it can help rule in [[Aspergillus]] in the right clinical context, and therefore help to rule out mucormycosis
	** β-D-glucan is usually negative, and guidelines recommended against use		** β-D-glucan is usually negative, and guidelines recommended against use
	*** [[Rhizopus species\|Rhizopus]] sometimes has enough to be detectable		*** [[Rhizopus species\|Rhizopus]] sometimes has enough to be detectable

Aidan at 16:01, 24 September 2020

2020-09-24T16:01:08Z

← Older revision		Revision as of 16:01, 24 September 2020
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	***[[Cunninghamella bertholletiae]], which is associated with higher mortality		***[[Cunninghamella bertholletiae]], which is associated with higher mortality
	***[[Apophysomyces elegans]]		***[[Apophysomyces elegans]]
	***[[Saksenaea vasiformis]]		***[[Saksenaea vasiformis]], which has a flask-shaped sporangium
	***[[Absidia corymbifera]]		***[[Absidia corymbifera]]
	***[[Syncephalastrum racemosum]]		***[[Syncephalastrum racemosum]]
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	*Ubiquitous environmental fungi often found in decaying organic substances i.e. bread, fruits, vegetables, soil, compose and animal feces.		*Ubiquitous environmental fungi often found in decaying organic substances i.e. bread, fruits, vegetables, soil, compose and animal feces.
	*It can infect anyone, but highest prevalence risk factors are:		*It can infect anyone, but highest prevalence risk factors are:
	**Poorly-controlled diabetes - especially susceptible to the rhinocerebral form		**Poorly-controlled [[diabetes]], especially susceptible to the rhinocerebral form
	**Metabolic acidosis, e.g. DKA, which also changes the iron into a form that is more readily absorbed.		**[[Metabolic acidosis]], e.g. [[DKA]], which also changes the iron into a form that is more readily absorbed.
	**High-dose steroids/TNF-~~alpha~~ inhibitors		**[[Corticosteroids\|High-dose steroids]]/[[Tumour necrosis factor-α inhibitors\|TNF-α inhibitors]]
	**Penetrating trauma/burns		**Penetrating trauma/[[Burn infections\|burns]]
	**Persistent neutropenia		**Persistent [[neutropenia]]
	**Chronic transfusion dependence		**Chronic transfusion dependence
	**Chelation therapy with deferoxamine in patients on dialysis, which increases free iron availability.		**Chelation therapy with [[deferoxamine]] in patients on dialysis, which increases free iron availability.
	**Hemochromatosis - ~~mucorales~~ ~~species~~ ~~require~~ iron in the tissue or bloodstream ~~for invasive growth~~		**[[Hemochromatosis]], since invasive growth requires iron in the tissue or bloodstream
	**Malnutrition: can cause necrotizing enterocolitis.		**Malnutrition, where it can cause [[necrotizing enterocolitis]]

	===Pathogenesis===		===Pathogenesis===
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	**Vascular occlusion sign: termination of a vessel at the edge of a focal lesion, seen on CTPA		**Vascular occlusion sign: termination of a vessel at the edge of a focal lesion, seen on CTPA
	*For suspected rhinocerebral disease, a CT or MRI, with MRI preferred for eye or brain involvement		*For suspected rhinocerebral disease, a CT or MRI, with MRI preferred for eye or brain involvement

			== Diagnosis ==

			* Culture is gold standard
			** Mincing, not grinding, is recommended for tissue samples
			** False negatives in 50%
			** Growth at 30ºC, since some strains do not grow at 37ºC
			*** Temperature tolerance can help differentiate, with [[Mucor species\|Mucor]] at ≤37ºC, [[Rhizopus species\|Rhizopus]] 40-50ºC, and [[Rhizomucor species\|Rhizomucor]] 38-58ºC
			** Cyclohexamide susceptible, so need to be careful with selection of media
			** Microscopy
			*** Wide, aseptate or pauci-septate hyaline mold with non-dichotomous branching
			*** Sporangiophores branching from stolon
			*** Sporangium at the end of the sporangiophore, and may be attached by an apophysis (a conical neck at the end of sporangiophore)
			**** May instead have a sporangiolum, which produces spores more discretely, so it there are countable spores then it's a sporangiolum, as seen in [[Cunninghamella species]]
			**** May instead have finger-like merosporangia, each finger of which has a countable number of spores
			*** May have columella at the neck
			*** May have rhizoids at base of sporangiophore
			* Non-culture methods
			** Histopathology
			*** GMS or PAS are best stains, and should be requested STAT
			** Galactomannan is usually negative; if positive, it can help rule in [[Aspergillus species]] in the right clinical context, and therefore help to rule out mucormycosis
			** β-D-glucan is usually negative, and guidelines recommended against use
			*** [[Rhizopus species\|Rhizopus]] sometimes has enough to be detectable
			** Molecular methods are not standardized, and guidelines recommend against use
			*** May be available in Canada through Hospital for Sick Children in Toronto

	==Management==		==Management==
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	*'''Hyperbaric oxygen:''' may have benefit in diabetic patients with rhinocerebral disease, but only for the duration of hyperbaric oxygen.		*'''Hyperbaric oxygen:''' may have benefit in diabetic patients with rhinocerebral disease, but only for the duration of hyperbaric oxygen.

	== Further Reading ==		==Further Reading==

	* Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. ''Lancet Infect Dis''. 2019;19(12):e405-e421. doi: [https://doi.org/10.1016/S1473-3099(19)30312-3 10.1016/S1473-3099(19)30312-3].		*Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. ''Lancet Infect Dis''. 2019;19(12):e405-e421. doi: [https://doi.org/10.1016/S1473-3099(19)30312-3 10.1016/S1473-3099(19)30312-3].

	[[Category:Microbiology]]		[[Category:Microbiology]]

Aidan: /* Management */

2020-08-26T10:49:26Z

Management

← Older revision		Revision as of 10:49, 26 August 2020
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	== Background ==		==Background==

	* Order of ubiquitous environmental fungi that are rare causes of aggressive necrotizing infections		*Order of ubiquitous environmental fungi that are rare causes of aggressive necrotizing infections

	=== Microbiology ===		===Microbiology===

	* Large, aseptate dematiaceous molds with ribbon-like appearance on microscopy		*Large, aseptate dematiaceous molds with ribbon-like appearance on microscopy
	* May or may not have rhizoids, depending on the species		*May or may not have rhizoids, depending on the species
	* Human pathogens within the order include:		*Human pathogens within the order include:
	** [[Rhizopus species]]		**[[Rhizopus species]]
	*** [[Rhizopus oryzae]], the most common cause of mucormycosis		***[[Rhizopus oryzae]], the most common cause of mucormycosis
	*** [[Rhizopus microsporus]]		***[[Rhizopus microsporus]]
	*** [[Rhizopus stolonifer]]		***[[Rhizopus stolonifer]]
	** [[Mucor species]]		**[[Mucor species]]
	*** [[Mucor circinelloides]]		***[[Mucor circinelloides]]
	** [[Rhizomucor species]]		**[[Rhizomucor species]]
	*** [[Rhizomucor pusillus]]		***[[Rhizomucor pusillus]]
	** Others		**Others
	*** [[Cunninghamella bertholletiae]], which is associated with higher mortality		***[[Cunninghamella bertholletiae]], which is associated with higher mortality
	*** [[Apophysomyces elegans]]		***[[Apophysomyces elegans]]
	*** [[Saksenaea vasiformis]]		***[[Saksenaea vasiformis]]
	*** [[Absidia corymbifera]]		***[[Absidia corymbifera]]
	*** [[Syncephalastrum racemosum]]		***[[Syncephalastrum racemosum]]
	*** [[Actinomucor elegans]]		***[[Actinomucor elegans]]
	*** [[Cokeromyces recurvatus]]		***[[Cokeromyces recurvatus]]
	*** [[Mortierella wolfii]]		***[[Mortierella wolfii]]

	==== Identification ====		====Identification====

	* Microscopy:		*Microscopy:
	** Sporangia on an apophysis on a sporangiophore that comes off of a stolon. May have rhizoids at base.		**Sporangia on an apophysis on a sporangiophore that comes off of a stolon. May have rhizoids at base.
	** Sporangia may be globose (round) or pyriform (teardrop-shaped), may have collarettes.		**Sporangia may be globose (round) or pyriform (teardrop-shaped), may have collarettes.

	{\| class="wikitable"		{\| class="wikitable"
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	*Diagnosis is almost always made too late		*Diagnosis is almost always made too late

	=== Prognosis and Complications ===		===Prognosis and Complications===

	* Overall mortality ranges from 40 to 80% depending on underlying risk factors, but is even higher in disseminated or CNS disease		*Overall mortality ranges from 40 to 80% depending on underlying risk factors, but is even higher in disseminated or CNS disease

	== Investigations ==		==Investigations==

	* For pulmonary disease, a CT chest can show:		*For pulmonary disease, a CT chest can show:
	** Halo sign: a nodular infiltrate surrounded by a ring of ground glass, representing ischemia and angioinvasive disease		**Halo sign: a nodular infiltrate surrounded by a ring of ground glass, representing ischemia and angioinvasive disease
	** Reversed halo signs: an area of ground glass surrounded by a ring of consolidation		**Reversed halo signs: an area of ground glass surrounded by a ring of consolidation
	** Vascular occlusion sign: termination of a vessel at the edge of a focal lesion, seen on CTPA		**Vascular occlusion sign: termination of a vessel at the edge of a focal lesion, seen on CTPA
	* For suspected rhinocerebral disease, a CT or MRI, with MRI preferred for eye or brain involvement		*For suspected rhinocerebral disease, a CT or MRI, with MRI preferred for eye or brain involvement

	==Management==		==Management==
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	**Duration is until immunosuppression is reversed and complete radiographical resolution of the infection		**Duration is until immunosuppression is reversed and complete radiographical resolution of the infection
	*'''Hyperbaric oxygen:''' may have benefit in diabetic patients with rhinocerebral disease, but only for the duration of hyperbaric oxygen.		*'''Hyperbaric oxygen:''' may have benefit in diabetic patients with rhinocerebral disease, but only for the duration of hyperbaric oxygen.

			== Further Reading ==

			* Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. ''Lancet Infect Dis''. 2019;19(12):e405-e421. doi: [https://doi.org/10.1016/S1473-3099(19)30312-3 10.1016/S1473-3099(19)30312-3].

	[[Category:Microbiology]]		[[Category:Microbiology]]

Aidan at 01:32, 26 August 2020

2020-08-26T01:32:10Z

Show changes

Aidan: /* Basidiobolus and Conidiobolus */ oops

2020-03-19T13:15:49Z

Basidiobolus and Conidiobolus: oops

← Older revision		Revision as of 13:15, 19 March 2020
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	== Basidiobolus and Conidiobolus ==		== Basidiobolus and Conidiobolus ==

	* Refer to '''[[[entomophthoromycosis]]]'''		* Refer to '''[[entomophthoromycosis]]'''

	[[Category:Microbiology]]		[[Category:Microbiology]]

Aidan: /* Basidiobolus and Conidiobolus */ moved to own page

2020-03-19T13:15:37Z

Basidiobolus and Conidiobolus: moved to own page

@@ Line 263: / Line 263: @@
 == Basidiobolus and Conidiobolus ==
-* Together, referred to as '''entomophthoromycosis'''
+* Refer to '''[[[entomophthoromycosis]]]'''
 [[Category:Microbiology]]

Aidan: /* Species identification */

2019-08-16T11:47:24Z

Species identification

← Older revision		Revision as of 11:47, 16 August 2019
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	** Sporangia may be globose (round) or pyriform (teardrop-shaped), may have collarettes.		** Sporangia may be globose (round) or pyriform (teardrop-shaped), may have collarettes.

			{\| class="wikitable"
	{\|
	! Characteristic		! Characteristic
	!align="center"\| ''Rhizopus''		!align="center"\| ''Rhizopus''

Aidan: /* Management */

2019-08-16T11:47:04Z

Management

← Older revision		Revision as of 11:47, 16 August 2019
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	** [[Posaconazole]] active (salvage therapy):		** [[Posaconazole]] active (salvage therapy):
	*** [https://doi.org/10.1007/s11046-014-9792-y 10.1007/s11046-014-9792-y]		*** [https://doi.org/10.1007/s11046-014-9792-y 10.1007/s11046-014-9792-y]
	*** Study from 2015 that looked at ~~Posaconazole~~ as salvage therapy. 4/10 patients had proven mucor, 1/10 had IFI of unknown origin. Duration of therapy ranged from 15-355 days, median 47 days. Efficacy of salvage therapy for mucor specifically in this study was 60%		*** Study from 2015 that looked at [[posaconazole]] as salvage therapy. 4/10 patients had proven mucor, 1/10 had IFI of unknown origin. Duration of therapy ranged from 15-355 days, median 47 days. Efficacy of salvage therapy for mucor specifically in this study was 60%
	*** There is a recommendation that for mucormycosis, can consider step down to oral therapy alone with posaconazole after 3 weeks of IV liposomal Amphotericin		*** There is a recommendation that for mucormycosis, can consider step down to oral therapy alone with posaconazole after 3 weeks of IV liposomal Amphotericin
	** [[Posaconazole]] as monotherapy: ([https://doi.org/10.1016/j.ijantimicag.2019.01.002 10.1016/j.ijantimicag.2019.01.002])		** [[Posaconazole]] as monotherapy: ([https://doi.org/10.1016/j.ijantimicag.2019.01.002 10.1016/j.ijantimicag.2019.01.002])

Aidan: /* Management */

2019-08-16T11:46:49Z

Management

← Older revision		Revision as of 11:46, 16 August 2019
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	** Mucorales are inherently resistant to ketoconazole, fluconazole, voriconazole, flucytosine and echinocandins (since no beta-D glucan in cell wall)		** Mucorales are inherently resistant to ketoconazole, fluconazole, voriconazole, flucytosine and echinocandins (since no beta-D glucan in cell wall)
	** '''[[Amphotericin B]]''' active (first-line treatment), up to 10 mg/kg if CNS involvement.		** '''[[Amphotericin B]]''' active (first-line treatment), up to 10 mg/kg if CNS involvement.
	** Posaconazole active (salvage therapy):		** [[Posaconazole]] active (salvage therapy):
	*** [https://doi.org/10.1007/s11046-014-9792-y 10.1007/s11046-014-9792-y]		*** [https://doi.org/10.1007/s11046-014-9792-y 10.1007/s11046-014-9792-y]
	*** Study from 2015 that looked at Posaconazole as salvage therapy. 4/10 patients had proven mucor, 1/10 had IFI of unknown origin. Duration of therapy ranged from 15-355 days, median 47 days. Efficacy of salvage therapy for mucor specifically in this study was 60%		*** Study from 2015 that looked at Posaconazole as salvage therapy. 4/10 patients had proven mucor, 1/10 had IFI of unknown origin. Duration of therapy ranged from 15-355 days, median 47 days. Efficacy of salvage therapy for mucor specifically in this study was 60%
	*** There is a recommendation that for mucormycosis, can consider step down to oral therapy alone with posaconazole after 3 weeks of IV liposomal Amphotericin		*** There is a recommendation that for mucormycosis, can consider step down to oral therapy alone with posaconazole after 3 weeks of IV liposomal Amphotericin
	** Posaconazole as monotherapy: ([https://doi.org/10.1016/j.ijantimicag.2019.01.002 10.1016/j.ijantimicag.2019.01.002])		** [[Posaconazole]] as monotherapy: ([https://doi.org/10.1016/j.ijantimicag.2019.01.002 10.1016/j.ijantimicag.2019.01.002])
	*** Systematic review of contemporary management of mucormycosis infections		*** Systematic review of contemporary management of mucormycosis infections
	*** Posaconazole oral suspension monotherapy was prescribed as an initial antifungal in 11 cases. 1/11 died from disseminated infection and there was 1 case of infection recurrence.		*** [[Posaconazole]] oral suspension monotherapy was prescribed as an initial antifungal in 11 cases. 1/11 died from disseminated infection and there was 1 case of infection recurrence.
	*** The dose used was 800mg po daily of the oral suspension		*** The dose used was 800mg po daily of the oral suspension
	*** The posaconazole MR tablet achieves higher concentrations, but as of yet has only been used for cutaneous infections		*** The [[posaconazole]] MR tablet achieves higher concentrations, but as of yet has only been used for cutaneous infections
	** Synergy: may have some evidence for addition of rifampin to ~~ampho~~ or terbinafine and ~~ampho~~. Also some suggestion regarding use of caspofungin.		** Synergy: may have some evidence for addition of [[rifampin]] to [[amphotericin]] or [[terbinafine]] and [[amphotericin]]. Also some suggestion regarding use of [[caspofungin]].
	* '''Hyperbaric oxygen:''' may have benefit in diabetic patients with rhinocerebral disease, but only for the duration of hyperbaric oxygen.		* '''Hyperbaric oxygen:''' may have benefit in diabetic patients with rhinocerebral disease, but only for the duration of hyperbaric oxygen.