Discussion:
Zygomycosis was first described as a cause of human disease in 1885 [1].Unlike other fungal opportunist infections which affect patients with cancer, recipients of organ transplant or with compromised immunity, mucormycosis can touch patients with diabetes mellitus [1-3], renal insufficiency, alcoholism [4-6]or even with an intact immunity system [7-9]. These underlying conditions not only predispose to the disease but also worsen the outcome of patients. Our first patient had diabetes and renal insufficiency as a risk factors of mucormycosis [9].
The mode of transmission of mucormycosis involves inhalation or ingestion of spores and direct inoculation into damaged mucocutaneous surfaces [8].
The common sites of infection are sinuses(39%) which constitue the predilected infection site in diabetic patients, skin (19%) in particular in patients with no risk factor and lungs (24%) in patients with cancer [1,10].
The gastrointestinal tract is less commonlyaffected (7%) with67% of stomach infection and 25% of intestine infection [1,9].Factors predisposing for gastrointestinal mucormycosis (GIM) include malnutrition, typhoid fever, uremia and penetrating trauma [8,11].
The clinical manifestations of GIM include fever, abdominal pain, nausea, vomiting, diarrhea, hemorrhage, or gastrointestinal perforation [8,12]. Our first patient presented only vomiting and the second patient presented withfever, abdominal pain and vomiting. The confirmation of diagnosis is based on anatomopathological examination of tissue samples showing fungal hyphae [8,13].
GIM is usually fatal with 85% of mortality [1,10,14],.The mainstay of therapy in GIM is a combination of surgical debridement and intravenous antifungal therapy. Early initiation of antifungal therapy improves survival and can even exempt the patient from surgery in case of non-invasive form of the disease [10].A delayintreatmentgreaterthan6daysworsens the prognosis and seems to double the mortality rates [8]. The cornerstone of drug-therapy is amphotericin B which constitutes the first line treatment at a daily dose of 1 to 1.5 mg/kg for a duration of 4-6 weeks [4,8,15]. The liposomal form is prefered for its lower risk of nephrotoxicity and the possibility to administrate higher dosesĀ : 5 to 10 mg/kg/day [1,16,17]. Posaconazole and isavuconazole are also effective agents and can be used as second line therapy. Surgical debridement of necrotic tissue is often required for invasive mucormycosis [17]. In our first patient, liposomal form of amphotericin B was not available in our country thus we started treatment with conventional amphotericin B at low doses which was stopped at day 5 because of worsening of renal dysfunction and we opted for the surgical debridment. As for the second patient, he did not receive this treatment since he was in a septic shock.