Developments in identifying and managing mucormycosis in hematologic cancer patients

ABSTRACT

Introduction

Mucormycoses represent a rare but very aggressive class of mold infections occurring in patients with hematological malignancies (HMs). In the past, patients at high risk of invasive mucomycosis (IM) were those affected by acute myeloid leukemia but over the last ten years the prophylaxis with a very effective mold-active drug, such as posaconazole, has completely modified the epidemiology. In fact, IM is now observed more frequently in patients with lymphoproliferative disorders who do not receive antifungal prophylaxis.

Areas covered

The attention was focused on the epidemiology, diagnosis, prophylaxis and treatment of IM in HMs. Authors excluded pediatric patients considering the different epidemiology and differences in treatment given the limitation of the use of azoles in the pediatric field. A systematic literature review was performed using PubMed database listings between February 2014 and February 2020 using the following MeSH terms: leukemia, hematological malignancies, stem cell transplantation, mucormycosis, molds, prophilaxis, treatment.

Expert opinion

The epidemiology of mucormycosis in HMs is changing in the last years. The availability of drugs more effective than in the past against this infection has reduced the mortality; however, a timely diagnosis remains a relevant problem potentially influencing the outcome of hematologic patients with IM.

KEYWORDS:

• Acute leukemia
• prophylaxis
• fungal
• mucormycosis

Article highlights box

• The detection of mucormycosis cases remains challenging and relies on a multidisciplinary approach; besides the use of imaging techniques, biological specimens from clinically involved sites should always be collected for histopathology, culture, and molecular approaches.

• Despite a 50% of isolation rate, culture is essential to allow identification at the species level, to provide the isolate antifungal susceptibility and to confirm the diagnosis. Its sequencing is strongly supported or MALDI-TOF MS in the presence of an updated in-house database. PCR-based procedures can be performed to detect Mucorales DNA not only from tissue biopsies and BAL fluids but also in non-invasive samples like plasma and serum leading to an increase in diagnosed cases.

• At the present various antifungal drugs are available for both prophylaxis and treatment of hematologic patients with IM. As a consequence, in recent years a consistent reduction in the incidence of IM has been observed, along with a moderate reduction in the mortality rate.

Declaration of interest

A Busca has received honoraria from Gilead Sciences, MSD, Pfizer Pharmaceuticals, and Jazz Pharmaceuticals; has been a speaker for Gilead Sciences, Merck, Pfizer Pharmaceuticals, and Novartis and is part of an Advisory Board of GILEAD and Pfizer. L Pagano was a board member of Gilead Science, MSD, Pfizer, Basilea, Janssen, Novartis, Cidara and has been a speaker for Gilead Sciences, MSD, Pfizer Pharmaceuticals, Astellas Pharma.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.