Mucormycosis beyond the classic host: a case series and narrative literature review from a tertiary Greek hospital.
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BACKGROUND: Mucormycosis is an aggressive, angioinvasive mold infection that progresses rapidly and carries high mortality. Disease in non-classical hosts is readily mistaken for bacterial superinfection or the expected course of the underlying condition and the resulting delay in tissue biopsy and antifungal therapy may adversely affect outcome. METHODS: We report a retrospective case series at a tertiary referral center in northern Greece over a seven-year period. RESULTS: Nine patients (median age: 49 years, of whom 7 were male and 2 were female) with histopathologically confirmed mucormycosis were reviewed. Two previously healthy adolescents developed post-traumatic cutaneous disease and survived. Three patients reached craniofacial disease through the classic immunosuppressed route, one through poorly controlled type 1 diabetes, one through poorly controlled type 2 diabetes, and one through allogeneic transplantation for acute lymphoblastic leukemia (ALL). The remaining four developed infection on a background of barrier disruption or critical illness: two with major thermal burns (39% and 54% total body surface area), one with a cannulation-site eschar during high-dose corticosteroid therapy for dermatomyositis, and one intubated patient with prediabetes who developed forearm necrosis with local thrombosis. Rhizopus arrhizus predominated in the craniofacial and healthcare-associated cases, whereas the trauma and burn cases yielded a wider range of species. Liposomal amphotericin B (L-AmB) was the first-line agent in eight patients and one case with limited disease received isavuconazole monotherapy. Eight patients underwent surgery, ranging from debridement to orbital exenteration, maxillectomy, and in one case forequarter amputation. Eight of nine patients (89%) required admission to the Intensive Care Unit (ICU); among them, the median ICU stay was 37 days (IQR 7-57; range 2-123). Overall mortality was 67% (6/9). CONCLUSIONS: This series includes established metabolic and transplant-associated mucormycosis as well as trauma, burn, and healthcare-associated presentations. Only two patients had no documented systemic predisposition other than traumatic tissue disruption. While this small, heterogeneous patient sample cannot determine incidence, prognostic factors, or treatment effects, it may illustrate that this disease has the potential to affect patients beyond the classic host. Rapidly progressive necrosis or thrombosis should nevertheless prompt consideration of mucormycosis and tissue sampling for histopathology and culture.