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.