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Treatment of localized mucormycosis using nasal amphotericin B irrigation in pediatric oncology

To the Editor: Despite advances in supportivemanagement, invasivemucormycosis in pediatric oncology patients remains a life-threatening condition.1 Approximately 22-59% of these patients experience significant morbidity or mortality despite aggressive treatment.1–3 Timely diagnosis of mucormycosis is critical in decreasing mortality.2,4,5 Current treatment involves a multimodal approach of aggressive surgical debridement, antifungal therapy, and correcting underlying risk factors such as neutropenia and immunosuppression.4,6–8 In this report, we describe a pediatric oncology patient who developedmucormycosis. In addition to the usual components of therapy, he was also treated with nasal amphotericin B as an innovative treatment modality. A 13-year old male presented with a necrotizing, erosive gum lesion while receiving chemotherapy for a late isolated bone marrow relapse of pre-B acute lymphoblastic leukemia. He had received his first cycle of reinduction chemotherapy based on the standard protocol UKR3ALL.9 Antimicrobial prophylaxis included levofloxacin and caspofungin. Trimethoprim-sulfamethoxazole was given for Pneumocystis jirovecii prophylaxis. The patient was otherwise healthy. A maxillary biopsy was performed for the necrotizing gum lesion and cultures grew Rhizopus oryzae on day 23 of incubation. Bloodwork at that time was as follows: white blood cells 0.06 × 109/L, absolute neutrophil count 0.0 × 109/L, hemoglobin 84 g/L, platelets 51 × 109/L, and lactate 1.3 mmol/L. Imaging revealed marked mucosal thickening within the rightmaxillary sinuswith extension to the right osteomeatal complex. A brainmagnetic resonance imaging (MRI), computed tomography (CT) chest/sinus, and abdominal/pelvic ultrasound did not reveal any lesions suspicious for fungal infection. Liposomal amphotericinBwas started at 7mg/kg/dose IVdaily. Five weeks after the original lesionwas noted, the lesions progressed in size and the liposomal amphotericin was increased to 10 mg/kg/dose. Systemic liposomal amphotericin B treatment was complicated by renal impairment, high blood pressure, potassium wasting, increased ionized calcium and phosphate, and nausea/vomiting. Posaconazole was started in an effort to transition to oral therapy but discontinued after 4 weeks due to peripheral neuropathy. In conjunction with medical therapy, surgical intervention was performed when the lesion was first noted in the form of debridement of the discoloredmucosa and gingiva on themedial and lateral aspects of the alveolar ridge as shown in Figure 1A and B.When progression was F IGURE 1 A, B, medial and lateral aspects of the dental alveolus upon initial presentation displaying a necrotizing lesion. C, D, Oral cavity following 13months of treatment