Mucormycosis and Entomophthoramycosis

Authors: Authors: Samantha Jacobs, M.D., M.S, Corina E Gonzalez, M.D., Thomas J Walsh, M.D., FACP, FCCP

Authors (Second Edition, 2002): Corina E Gonzalez, M.D., Thomas J Walsh, M.D., FACP, FCCP


The taxonomy of the fungi previously classified as Zygomycetes has recently been revised (79). Mucormycosis and entomophthoramycosis describe infections due to the agents of the subphyla Mucormycotina and Entomophthormycotina, respectively. Most cases of human infection are due to Mucorales fungi, most commonly from the Rhizopus, Mucor, and Lichtheimia genera. In contrast, the Entomophthorales fungi are uncommon pathogens and are primarily found in tropical areas. Although the organisms of the Entomophthorales cause specific syndromes distinct from those due to the Mucorales, they may rarely cause opportunistic pulmonary and disseminated infection similar to that of the Mucorales. This chapter will primarily focus on mucormycosis.

Organisms with the Mucorales and Entomophthorales are ubiquitous in soil and are commonly found in decaying organic matter such as fruit and bread (123, 124, 141). They grow rapidly on virtually any carbohydrate substrate and produce large numbers of hyphae, sporangiospores, and asexual sporangiospores that permit the organism to propagate into the environment. Although species-specific spores may form in vitro as a result of heterothallic sexual reproduction, a microbiologic diagnosis of a particular species is usually made from the morphologic features of the asexual structures, with increasing use of direct DNA sequencing for more diagnostically challenging organisms. Many of these organisms are able to grow at temperatures above 37°C. These properties of wide ecological distribution, rapid growth, and thermotolerance are of particular importance in developing human disease. Culture on Sabouraud glucose agar yields large fluffy white, gray, or brownish colonies in 2 to 3 days that rapidly fill the medium container.


Most commonly, mucormycosis develops as a nosocomial infection (22, 26, 28, 46, 89, 95, 98, 104, 110, 112-114, 121, 123) affecting a wide range of susceptible hosts. Prediposing conditions include hematologic malignancy, prolonged and profound neutropenia, poorly controlled diabetes mellitus, prolonged corticosteroid use, iron overload, malnutrition, illicit intravenous drug use, and premature birth (117). Breakthrough infection in neutropenic patients receiving voriconazole is an increasingly recognized risk factor for mucormycosis (80, 91, 125). The major mode of disease transmission is through inhalation of spores from environmental sources (75, 77, 82, 89). Cutaneous routes of infection are particularly important in surgical, trauma, and burn patients (16, 18, 39, 59, 71, 85, 93, 95, 110, 119, 121, 130, 160). The development of mucormycosis in areas of skin breakdown (104, 114, 121) has been associated with a variety of contaminated adhesive products, elastic bandages, and tongue depressors used in the hospital setting (57, 71, 83, 97, 151). The ingestion of contaminated milk, vegetables, bread, may play a role in promoting gastrointestinal mucormycosis.

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Classically there are five clinical presentations of mucormycosis: rhinocerebral, pulmonary, gastrointestinal, cutaneous, and disseminated (141). Notably, certain clinical manifestations of mucormycosis occur in hosts with a particular underlying condition, such as rhinocerebral mucormycosis in diabetic patients or pulmonary mucormycosis in neutropenic hosts (Table 1). There are no specific signs or symptoms of the disease; however, suggestive clinical manifestations in the appropriate clinical setting should alert physicians for the possibility of mucormycosis. By comparison, entomophthoramycosis most commonly causes chronic cutaneous and subcutaneous infections

Rhinocerebral disease is the most common form of mucormycosis (35, 36, 100, 107, 122, 129, 132, 135, 140, 159, 162). The infection originates in the paranasal sinuses following inhalation of fungal spores and may progress into the orbit (sino-orbital) or brain parenchyma (rhinocerebral).

In sinus disease, nasal endoscopy typically reveals necrotic black ulcers along the nasal mucosa and turbinates. Orbital involvement occurs when the organism extends from the ethmoid sinus through the lamina papyracea or from the roof of the maxillary sinus. An ominous complication is orbital apex syndrome in which organisms extend posteriorly to the optic foramen, threatening the ophthalmic artery, vein and nerve. Most commonly, this presents as a painful ophthalmoplegia that progresses to proptosis and loss of visual acuity. Cerebral infection results from several potential pathways: invasion along the optic nerve, direct extension from the frontal, sphenoid, and ethmoid sinuses, or drainage from the ethmoidal and orbital veins into the cavernous sinus (35,43,48,68) see photos .

Pulmonary mucormycosis most commonly occurs in profoundly neutropenic patients and in hematopoietic stem cell transplant recipients who have graft-versus-host disease (7, 22, 42, 75, 76, 82, 112, 113, 143). Usually patients present with persistent fever despite broad-spectrum antibiotics. The characteristics of the pulmonary infiltrates on chest imaging are indistinguishable from those of invasive aspergillosis. Common findings include consolidation, cavitation, nodules, pleural effusions and hilar or mediastinal lymphadenopathy (82, 112, 117, 156). If treatment is not implemented promptly, the infection typically progresses to pulmonary vascular invasion, infarction, followed by dissemination to both thoracic and distant extrapulmonary tissues (21, 72, 82, 112, 156). The isolation of the fungi from respiratory secretions in susceptible hosts should be considered strong evidence for invasive mucormycosis (4, 47).

Cutaneous and soft tissue involvement occurs most frequently from primary inoculation (16, 18, 20, 85, 95, 104, 110, 114, 121). The lesions initially appear red and indurated but often progress to necrotic eschars (61, 114). Primary cutaneous disease may be very invasive locally, involving not only cutaneous and subcutaneous tissue but also underlying fat, muscle, fascial layers and bone (93, 110) see photos .

Gastrointestinal disease is rare and encountered mainly in immunocompromised patients and malnourished or premature children (26, 60, 98, 136, 164). Complications include perforation of the intestinal wall, peritonitis, and sepsis. The disease is often fatal; most of the reported cases were diagnosed post-mortem.

Disseminated mucormycosis is associated with an exceedingly high mortality rate, and generally occurs in profoundly immunocompromised patients or in patients undergoing deferoxamine therapy (13, 38, 68, 75, 76). It may originate from any of the primary sites of infection (26, 98, 102, 131, 152, 161); however; the lung is the single most common site associated with disseminated mucormycosis (38, 49, 75, 76, 139).

Less common forms of mucormycosis include endocarditis, osteomyelitis, and isolated cerebral, renal, and peritoneal disease (27, 39, 59, 68, 103, 119, 131, 152, 158, 160, 163).

Entomophthoramycosis in immunocompetent humans is limited to the skin and subcutaneous tissues and presents in two clinically distinct forms: basidiobolomycosis (subcutaneous mucormycosis) and conidiobolomycosis (rhinofacial mucormycosis) (32). This infection can be disfiguring through progressive scarring, and lymphatic obstruction can result in lymphedema. The disease most commonly occurs in warm climates (24, 108). By contrast, when Entomophthorales fungi infect immunocompromised hosts, they cause an infection with similar clinical, histopathological, and epidemiological features as that caused by Mucorales fungi (21, 69, 144, 158, 164).


Diagnosis of mucormycosis relies on direct morphologic identification of mycotic elements and recovery of Mucorales organisms in culture from specimens obtained from the site of presumed involvement. Presence of broad (6-16μm), ribbon-like, somewhat irregular nonseptate hyphae that branch in perpendicular angles facilitates identification of the fungus (124, 154) see photos. Tissue samples may show hyphae invading tissue and blood vessels with or without thrombosis. Histologic detection of Mucorales organisms is enhanced by use of periodic acid-Schiff and Gomori methanamine silver stains. The diagnosis of entomophthoramycosis is usually made on clinical presentation. Culture and identification of fungal elements on biopsy is frequently hampered by the intense reactive fibrosis. The Splendore-Hoepli phenomenon may be evident within the chronic inflammatory infiltrate. Final species identification requires culture and should be attempted whenever possible as it bears important therapeutic implications (124). The recovery rate of Mucorales organisms in culture is enhanced if the tissue is sliced into small pieces instead of grinded. Molecular methods to improve diagnosis and identification of clinically relevant Mucorales organisms are under development (10, 56, 70, 157).

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Most commonly, mucormycosis presents as an opportunistic disease in patients with underlying risk factors (13, 75, 76, 102, 112-114) (Table 2). Host defenses include monocyte/macrophages and neutrophils (15, 30, 31, 86, 87). In fact, an increased risk for developing mucormycosis appears to involve functional and/or quantitative deficiencies of these cells (38, 60, 75, 76, 112, 113, 136, 161). The paucity of reports of mucormycosis in HIV-infected patients who do not inject intravenous illicit drugs indicates that T-cell dysfunction alone is not a major determinant in the development of the disease (27, 58, 102, 130, 158).

Increased iron availability in tissue and serum is a unique risk factor for mucormycosis as demonstrated in patients with diabetic ketoacidosis, those receiving iron chelation therapy (13), and those with iron overload due to frequent blood transfusions in the setting of underlying hematologic malignancy (66). Fungi secure iron from the host by using high-affinity iron permeases or low-molecular-weight iron chelators (66).

Metabolic acidosis is also a key factor in predisposing patients to mucormycosis (34, 36). It has been demonstrated that low serum pH diminishes the phagocytic and chemotactic ability of neutrophils (19, 61, 101). Furthermore, as noted above, lower blood pH disrupts transferrin binding of iron, leading to increased iron availability.


Single Drug

In vitro susceptibility testing for filamentous fungi, including Mucorales is under ongoing consideration and results should be interpreted with caution. Interpretive breakpoints for in vitro susceptibility to amphotericin B have not been determined. However, amphotericin B has proven efficacy in robust laboratory and clinical studies and remains the mainstay of mucormycosis therapy. Among the triazoles, isavuconazole is the newest second-generation triazole that has demonstrated promising activity against Mucorales in vitro as well as in immunosuppressed mice (90). Posaconazole has more variable in vitro and in vivo activity against Mucorales depending on the species (33). In experimental infections, posaconazole is more active against Mucor species than Rhizopus species (43). Experience with other azole and triazole compounds is limited to few in vitro susceptibility studies, experimental animal models, and case reports (8, 16, 25, 42, 73, 109, 111, 127, 134, 142, 148). Pneumocandin and echinocandin derivatives as well as allylamine compounds have showed no efficacy in in vitro susceptibility studies against Mucorales (111, 118).

Combination Drugs

Although the echinocandins do not have in vitro activity against Mucorales organisms using standard susceptibility tests, synergy with lipid formulations of amphotericin B has been demonstrated in murine models of disseminated mucormycosis (64, 137). In comparison, the addition of posaconazole to polyenes has not shown any survival benefit in preclinical studies (65, 126). Combination polyene-deferasirox acted synergistically and improved survival in mice with diabetic ketoacidosis and disseminated mucormycosis (63). However, these results were not replicated in a phase 2 randomized clinical trial (138). Therefore, the combination cannot be routinely recommended outside of a clinical trial.

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Antfungal therapy for mucormycosis is considered an essential and equally important part of a combined therapeutic approach also involving surgical debridement of all devitalized tissue and reversal of underlying predisposing conditions Figure 1), (Table 2).

Drug of Choice

Amphotericin B

Lipid formulations of amphotericin B have generally replaced amphotericin B as the drugs of choice for the treatment of mucormycosis in high resource environments (23). They appear to be clinically efficacious and have a favorable safety profile with less nephrotoxicity than conventional amphotericin B, allowing the administration of higher doses of the drug (88). Liposomal amphotericin B (LAmB) may be superior to amphotericin B lipid complex (ABLC) for central nervous system (CNS) infection as evidenced by higher CNS concentrations and more rapid clearance of fungus in animal models (52, 64). The optimal dosage of lipid formulations is unknown. Based on in vivo and in vitro data, the initial dosage may be 5.0mg/kg/day. Higher dosages (e.g. 7.5 to 10mg/kg/day) may be appropriate for CNS mucormycosis. When conventional amphotericin B is used, prompt administration of dosages ranging from 1 to 1.5mg/kg/day is warranted given the relative microbiological and clinical resistance of some Mucorales to the drug. Gradual dose escalation of amphotericin B is discouraged in this rapidly evolving infection. Daily high dose therapy with amphotericin B or its lipid derivatives should be continued for as long as possible in order to control the infection and facilitate surgical debridement. Duration of therapy is not clearly defined but prolonged treatment until resolution of symptoms and signs is recommended. Therapy should be individualized according to patient's response and underlying condition. This is particularly important in immunocompromised patients that may require a chronic suppressive course with amphotericin B for as long as the profound immunosuppression lasts.

Azole Derivatives

Isavuconazole: Isavuconazole is the first antifungal agent to receive FDA approval in nearly one half-century for primary treatment of mucormycosis. In a phase 2 single arm study of isavuconazole for treatment of mucormycosis in which approximately 90% of patients had hematologic malignancy or were transplant recipients, 63% of 21 patients receiving isavuconazole for primary therapy had a complete, partial or stable response at end of therapy. The 84-day overall survival was 57% (40). In clinical trials, the following dosage regimen is used in adult patients: loading dose of 200 mg every 8 hours intravenously or orally for the first two days followed by 200 mg/day intravenous or oral.

Posaconazole: Posaconazole has more in vitro and in vivo activity against Mucorales than the above triazoles. Data from case reports and large case series suggest a role for posaconazole as salvage therapy in some patients who are refractory to or intolerant of amphotericin B and its lipid derivatives (51, 148, 149). Three formulations of posaconazole are currently available; oral suspension, delayed release tablets and intravenous injection. Most clinical experience is with the oral suspension, where optimal exposure is achieved in adults when 800mg divided in two to four doses daily is given with food or a nutritional supplement. The delayed release tablets and intravenous formulation are both given at 300 mg twice on the 1st day as loading, followed by 300 mg daily thereafter. Therapeutic drug monitoring should be implemented to support the use of posaconazole for treatment of mucormycosis. Drug absorption is erratic, particularly in patients with mucositis or malabsorption. The target drug trough concentration should be at least 1μg/ml as an extrapolation from aspergillosis (74). Posaconazole is generally well-tolerated with nausea, vomiting, and headache as the most common side effects.

Ketoconazole, fluconazole, itraconazole, voriconazole: Among the antifungal triazoles, fluconazole, itraconazole and voriconazole have little to no activity in vitro or in vivo against Mucorales. There exist few case reports of successful treatment of mucormycosis with azole derivatives (8, 16, 25, 42, 73, 127, 134). By comparison, ketoconazole and itraconazole have been used in successful treatment of entomophthoramycosis. Given the hepatotoxicity of ketoconazole, itraconazole should be the preferred agent.

Specific Infections

Cerebral Mucormycosis

Cerebral mucormycosis is a devastating infection with high mortality. Lipid formulation of amphotericin B (> 5 mg/kg/day) or high dose deoxycholate amphotericin B (1.0-1.5 mg/kg/day) have been used extensively in treatment of this infection. Amphotericin B deoxycholate may be the only formulation available in resource-limited settings. Among the different lipid formulations of amphotericin B, LAmB achieves the greatest degrees of penetration and antifungal efficacy in cerebral tissue. Higher dosages of LAmB (7.5-10mg/kg/day) may allow for greater CNS penetration and may be safely achieved in immunocompromised patients (155). Despite this aggressive medical approach, surgical resection of infected CNS tissue is usually necessary. Reversal of immunosuppression, recovery from neutropenia and control of diabetes mellitus are also important cornerstones of therapy of cerebral mucormycosis.

Local irrigation as well as intracavitary/interstitial, and intrathecal administration of amphotericin B have been attempted in cases unresponsive to conventional therapy (2, 3, 22, 39, 45, 50, 55, 81, 96, 110, 115). Intrathecal amphotericin B is not indicated in treatment of cerebral mucormycosis due to complications that outweigh any putative benefits.

Rhinofacial Entomophthoramycosis

Therapeutic recommendations for the treatment of entomophthoramycosis can be made only based on empiric observations; complicating this is the fact that some cases of entomophthoramycosis may resolve spontaneously. In vitro antifungal susceptibility testing for entomophthorales is highly variable. However, in general, Basidiobolus spp display low MICs for triazoles; whereas, Conidiobolus spp are resistant to all antifungals tested (53). Potassium iodide, imidazoles, triazoles (particularly itraconazole), terbinafine, and amphotericin B have been all used for therapy (41, 54). In addition, trimethoprim-sulfamethoxazole, despite its unknown antifungal effect, has been implemented in few cases. In patients with chronic disease, potassium iodide (10gtt orally three times daily or 40mg/kg/day) and itraconazole is considered to be the preferred approach (3, 28, 32, 99, 105, 150). In addition, surgical removal of accessible nodules and reconstructive surgery may be required.

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Underlying Conditions

Diabetes Mellitus

In patients with diabetes mellitus, hyperglycemia and ketoacidosis should be rapidly corrected. Several laboratory, as well as clinical, observations have supported the rationale for correction of the metabolic disarrangement as an integral part of therapy (162).


Reversal of immunosuppression is also essential for resolution of mucormycosis (23). Spontaneous or cytokine-induced neutrophil recovery has paramount importance in the final outcome of the infection (49, 84, 113, 128). In addition, reducing or temporarily withholding corticosteroids or other immunosuppressive drugs until the infection has stabilized or improved also improves outcome.


Surgical Intervention

Surgical resection of infected lesions is a cornerstone of therapy for many forms of mucormycosis. The type of surgical procedure is dictated by the extent and type of the patient's infection. Procedures used for rhinocerebral mucormycosis include drainage of sinuses and abscesses, enucleation of necrotic orbital contents, palatectomy, and resection of cerebral lesions. Repeated debridements are often necessary. With advances in antifungal therapy and reversal of immunosuppression, less disfiguring surgery may be feasible. A recent strategy of guiding conservative surgical resection uses calcofluor microscopy for detection of organisms within resection margins (92). For localized pulmonary mucormycosis, the threat of fatal hemoptysis makes lobectomy the preferred therapy whenever surgery is feasible. Extensive surgical excision, which may necessitate amputation, is also key in the eradication of mucormycosis involving skin and soft tissue. Resection of necrotic bowel, nephrectomy, bone curettage, and valve replacement are among the surgical procedures of mucormycosis involving the gastrointestinal tract, kidneys, bone, and heart, respectively.

Hyperbaric Oxygen

This adjunctive intervention has a potential value in the treatment of mucormycosis since high partial pressures of oxygen have shown a fungicidal effect against Mucorales organisms in vitro (17), but rigorous laboratory and animal data and a randomized clinical trial are lacking (23). Hyperbaric oxygen has been used in rhinocerebral and cutaneous/soft tissue mucormycosis as adjunctive therapy to surgery and amphotericin B (5, 9, 25, 29, 37, 45, 46, 67, 94, 110, 115, 120, 135, 144). Most of the reported cases have been treated with 100% oxygen at 2 to 2.5 atmospheres absolute; at these pressures CNS toxicity is rare. The optimal duration of treatment is unknown.


The administration of the cytokines granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) to patients receiving myelosuppressive chemotherapy and hematopoietic stem cell transplant recipients has reduced the degree and duration of neutropenia and diminished the frequency of infections (6, 14, 133). Several reports using either G-CSF or GM-CSF as adjuvant therapy for invasive fungal infections and mucormycosis in particular have been published (9, 44, 45, 49, 84, 106, 113, 128). In general, these reports have demonstrated favorable outcomes, and use of G-CSF is strongly recommended in hematologic malignancy patients with prolonged neutropenia (23). Granulocyte transfusion is another modality for reversal of neutropenia and has been given sporadically to neutropenic patients for the treatment of progressive fungal infections (11, 116). In vitro data on an enhancing fungicidal effect on murine macrophages by Interferon-gamma has shown some clinical correlation (15, 110). It should be noted that the goal of these therapies is to stabilize disease in neutropenic patients until recovery from neutropenia occurs.

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Side Effects of Antifungal Therapy

Close follow-up of patients receiving amphotericin B is of paramount importance. Initiation of treatment with deoxycholate and lipid complex amphotericin B is frequently associated with acute infusion reactions including mild hemodynamic instability, fever, chills, and rigors. Use of acetaminophen, hydrocortisone, or meperidine before the infusion may control these symptoms. LAmB is associated with significantly fewer of these infusion-related reactions. However, LAmB may cause severe acute infusion-related reactions that are characterized by flank pain, dypnea, substernal chest discomfort, and urticaria. These symptoms disappear with discontinuation of the infusion and administration of diphenhydramine. Electrolyte abnormalities such as hypokalemia, hypomagnesemia, and metabolic acidosis may develop with all formulations. Careful monitoring and electrolyte replacement are required. A rise in serum creatinine concentration is expected with deoxycholate amphotericin B use and to a lesser extent, lipid formulations of amphotericin. Azotemia can usually be managed by prehydration with isotonic saline. Isavuconazole and posaconazole are generally well-tolerated. The most common side effects are gastrointestinal distress and nausea. Posaconazole inhibits CYP3A4; therefore, potential drug-drug interactions need careful assessment.

Monitoring Response to Treatment

Close clinical evaluation is essential in monitoring the response to treatment. Serial computerized tomography or magnetic resonance imaging studies help localize and define the extent of disease in order to perform adequate diagnostic procedures and surgical debridement when possible and repeatedly if needed. Pulmonary and CNS lesions are treated until radiographic resolution. Response of sinus infection to antifungal therapy is best monitored by nasal endoscopy. Cutaneous lesions are treated until complete healing. No laboratory test is specific, but resolution of leukocytosis, accelerated erythrocyte sedimentation rate, and recovery of organ function also suggest favorable response to treatment.


There are no vaccines available.


Appropriate environmental control measures, in addition to careful metabolic control of the underlying condition, and judicious use of deferoxamine and immunosuppressive agents are important factors in preventing mucormycosis. Construction activity can increase the number of airborne Rhizopus organisms in the hospital air (77, 89). Control of environmental transmission during construction and renovation should be established. High-efficiency particulate filters (HEPA) used in hospital rooms for patients with profound immunosuppression have been shown to reduce the risks of aspergillosis and mucormycosis. Appropriate wound care and daily inspection of the portions of the skin covered by bandages or boards are also recommended.

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Table 1.  Risk Factors and Most Common Clinical Presentation of Zygomycosis 

Predisposing Conditions Clinical Presentation
Immunosuppression Respiratory tract infection
Disseminated infection
Metabolic Respiratory tract infection
Rhinocerebral infection
Deferoxamine therapy Disseminated infection
Skin/soft tissue breakdown Primary cutaneous and  soft tissue infection
Intravenous illicit drug use Endocarditis
Cerebral infection
Neonatal prematurity Gastrointestinal infection
Disseminated infection
Malnourishment Gastrointestinal infection


Table 2.  Predisposing Conditions and Therapeutic Approaches against Zygomycosis

Predisposing Conditions  Underlying Deficit Approaches for reverting the deficit
Corticosteroid therapy
Organ transplantation
Functional and/or numerical deficiencies of macrophages,
neutrophils, and monocytes
G-CSF, GM-CSF, Interferon g
Granulocyte transfusions
Withold/reduce dose of immunosuppressants
   Diabetic ketoacidosis
Chronic metabolic acidosis
Uncontrolled diabetes
Deferoxamine therapy
Functional deficiency of neutrophils, better availability of
iron for the fungus to enhance its growth
Correction of acidosis and
Hold deferoxamine therapy
Skin/soft tissue breakdown
   Burn wounds
Traumatic inoculation
Surgical wounds
Devitalized tissue Daily wound care and inspection
Surgical debridement
  Intravenous illicit drug use
  Cardiac surgery
  Neonatal prematurity
Direct inoculation in blood stream
Contaminated prosthetic valves

Table 3. Antifungal agents used in the treatment of mucormycosis

Mechanism of action Available formulations Clinical indications Dosage Adverse effects
Liposomal amphotericin B (LAmB) Binds to ergosterol, leading to the formation of ion channels and concentration-dependent cell death Intravenous Primary therapy 5mg/kg/day

*May consider higher doses (7.5-10mg/kg/day) in CNS infection
Acute infusion-related reaction
Electrolyte abnormalities
Lipid complex amphotericin B (ABLC) Binds to ergosterol, leading to the formation of ion channels and concentration-dependent cell death Intravenous Primary therapy 5mg/kg/day
*May consider higher doses (7.5-10mg/kg/day) in CNS infection
Acute infusion-related reaction

Electrolyte abnormalities
Deoxycholate amphotericin B Binds to ergosterol, leading to the formation of ion channels and concentration-dependent cell death Intravenous Primary therapy (lipid formulations of amphotericin B preferred when available) 1.0-1.5mg/kg/day Acute infusion-related reaction
Electrolyte abnormalities

Isavuconazole Inhibition of lanosterol 14-alpha-demethylase, disrupting ergosterol synthesis to alter cell membrane physiology Intravenous and oral Primary therapy IV and oral: loading dose of 200 mg every 8 hours for two days followed by 200 mg/day Elevated liver function tests
Posaconazole Inhibition of lanosterol 14-alpha-demethylase, disrupting ergosterol synthesis to alter cell membrane physiology Intravenous and oral (tablet and suspension) Salvage therapy IV and tablet: 300mg twice on the first day followed by 300mg daily
Suspension: 800mg divided 3-4 doses/day
Elevated liver function tests




Figure 1.  Combined Approach in the Treatment of Zygomycosis


Walsh TJ., Shoham S., Roilides E.Mucormycosis in Transplant Recipients.

Georgiadou S, et al. The Diagnostic Value of Halo and Reversed Halo Signs for Invasive Mold Infections in Compromised Hosts. Clin Infect Dis 2011;52(9):1144-1155.



Clinical Manifestation







Mucormycosis and Entomophthoramycosis