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Management of Mucorales Infections in Transplant Patients

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Emerging Transplant Infections

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Abstract

Infections due to Mucorales fungi in hematopoietic stem cell transplantation (HSCT) and solid organ transplant (SOT) recipients may be increasing. Disease is severe and rapidly progressive and carries high mortality. Both the prevalence and species epidemiology vary with geography. Rhizopus species is the most common pathogen followed by Mucor species. Risk factors in SOT patients include renal failure, diabetes mellitus, and immunosuppression to prevent rejection. Additional risks in HSCT patients include corticosteroid use, neutropenia, iron overload, newer immunomodulating therapies, and graft-versus-host disease Breakthrough mucormycosis has occurred in patients receiving voriconazole and caspofungin as well as with posaconazole oral solution. Outbreaks of infection occur.

The lung is the commonest site of mucormycosis followed by disseminated infection, sinus, and skin. Clinical features are non-specific as are radiological findings. In lung disease, the finding of the reversed halo sign and/or >10 nodular infiltrates on chest computed tomography scan supports the diagnosis. Histopathology/direct microscopy of clinical specimens is key to diagnosis as is culture. Molecular assays to detect Mucorales DNA in tissue, blood, and other body fluids are increasingly used. MALDI-TOF MS and molecular identification methods are used to confirm species identity.

There are no specific antifungal prophylaxis measures against mucormycosis. Randomized controlled treatment efficacy trials are lacking. Surgical debridement is essential where feasible. The drug of choice remains liposomal amphotericin B (≥5 mg/kg/day). In severe extensive disease, addition of isavuconazole or posaconazole may be considered. Both azoles are widely used in maintenance therapy. The use of iron chelators is not recommended.

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Authors and Affiliations

  1. Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW, Australia

    Sharon C.-A. Chen

  2. Marie Bashir Institute for Emerging Infections and Biosecurity, The University of Sydney, Sydney, NSW, Australia

    Sharon C.-A. Chen

  3. The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia

    Sharon C.-A. Chen & Monica A. Slavin

Authors
  1. Sharon C.-A. Chen
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  2. Monica A. Slavin
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Corresponding author

Correspondence to Sharon C.-A. Chen .

Editor information

Editors and Affiliations

  1. Immunocompromised Host Service Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA

    Michele I. Morris

  2. Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Camille Nelson Kotton

  3. Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA

    Cameron R. Wolfe

Section Editor information

  1. Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA

    Michele I. Morris

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Chen, S.CA., Slavin, M.A. (2021). Management of Mucorales Infections in Transplant Patients. In: Morris, M.I., Kotton, C.N., Wolfe, C.R. (eds) Emerging Transplant Infections. Springer, Cham. https://doi.org/10.1007/978-3-030-25869-6_45

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  • DOI: https://doi.org/10.1007/978-3-030-25869-6_45

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