Mucor is a disease with protean findings and diverse outcomes. These infections are often fatal, although patients with limited sinonasal disease may have a better prognosis, especially with early diagnosis, aggressive surgical resection, and aggressive antifungal therapy. There is a markedly poorer prognosis for those patients with hemiplegia, facial necrosis, and nasal deformity (12). Among patients with RCM, 70% of survivors are left with residual defects (14). In a meta-analysis by Yohai et al, it was believed that the survival rate declines when interval from diagnosis to treatment is longer than six days (6).
Once the patient is stable, amphotericin should be continued in the outpatient setting, administered either as a home infusion or in an ambulatory infusion center. At this point, the frequency of amphotericin infusion is often reduced to every other day or more, depending on renal function. Follow-up MRI or CT scans at the end of therapy should demonstrate significant improvement and lack of inflammation (15). Physicians have observed chronic presentations and late sequelae after successful therapy; therefore, patients require long-term monitoring to detect recurrence or signs of indolent residual infection (16).
Measures to decrease the incidence of zygomycosis in patients at risk are difficult, at best. There is no routine antifungal prophylaxis available, and with the low prevalence of zygomycosis, there is no real indication to provide it. With rare exception, mycoses are not transmissible from patient to patient. Gown, glove, or mask isolation of hospitalized patients with mycoses is not indicated. The most common preventive interventions attempted consist of modifications and controls in the environment that reduce the risk of exposure to airborne spores. Most of these control measures are focused on easily identified patients at risk, i.e., those expected to be profoundly neutropenic for prolonged periods. The most effective, and expensive, method of protection is to confine the patient to a hospital room supplied with sterile laminar airflow. Although this measure reduces the risk of disease to an insignificant level, infection can still develop if patients are moved from the protected environment to other areas of the hospital for performance of essential procedures. Transplantation and chemotherapeutic wards are often isolated with Hepafilter treatment of the air supply and positive pressure to exclude the recruitment of dust into the ward, which provides significant protection. Dust should be kept to a minimum in the environment that houses these neutropenic patients. Additionally, flower arrangements and live plants are often excluded from such wards since they may harbor a variety of fungal agents. Patients, when neutropenic below 1000/mL, are asked to wear masks when leaving the cancer or transplant wards, particularly when going outside. The monitoring of air quality, particularly during times of building renovation and excavation in the vicinity of transplant centers, is also an important infection-control measure.
Preventive measures for patients other than the transplant and chemotherapy population require addressing the underlying risk factors for developing zygomycosis. Adequate control of diabetes, the use of iron chelators other than deferoxamine (such as substitution of hydroxypyridinone chelators for deferoxamine in patients who require such therapy), limitation of the use of aluminum-containing buffers in dialysis, and aggressive direct and culture-based detection of zygomycosis are among the best preventive measures. Keeping a high level of suspicion for zygomycosis in patients at risk can aid in early diagnosis and implementation of appropriate therapy.
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