Mucormycosis

Health

Mucormycosis

What is mucormycosis?

Mucormycosis (sometimes called zygomycosis) is a serious but rare fungal infection caused by a group of molds called mucormycetes.  These fungi live throughout the environment, particularly in soil and in decaying organic matter, such as leaves, compost piles, or rotten wood. 1

People get mucormycosis by coming in contact with the fungal spores in the environment. For example, the lung or sinus forms of the infection can occur after someone breathes in spores. These forms of mucormycosis usually occur in people who have health problems or take medicines that lower the body’s ability to fight germs and sickness. 3,6 Mucormycosis can also develop on the skin after the fungus enters the skin through a cut, scrape, burn, or other type of skin trauma.

Types of mucormycosis

• Rhinocerebral (sinus and brain) mucormycosis is an infection in the sinuses that can spread to the brain. This form of mucormycosis is most common in people with uncontrolled diabetes and in people who have had a kidney transplant. 7-8
• Pulmonary (lung) mucormycosis is the most common type of mucormycosis in people with cancer and in people who have had an organ transplant or a stem cell transplant.
• Gastrointestinal mucormycosis is more common among young children than adults, especially premature and low birth weight infants less than 1 month of age, who have had antibiotics, surgery, or medications that lower the body’s ability to fight germs and sickness. 9-10
• Cutaneous (skin) mucormycosis: occurs after the fungi enter the body through a break in the skin (for example, after surgery, a burn, or other type of skin trauma). This is the most common form of mucormycosis among people who do not have weakened immune systems.
• Disseminated mucormycosis occurs when the infection spreads through the bloodstream to affect another part of the body. The infection most commonly affects the brain, but also can affect other organs such as the spleen, heart, and skin.

Types of fungi that most commonly cause mucormycosis

Examples are: Rhizopus species, Mucor species, Rhizomucor species, Syncephalastrum species, Cunninghamella bertholletiae, Apophysomyces species, and Lichtheimia (formerly Absidia) species. 2

References

1. Richardson M. The ecology of the Zygomycetes and its impact on environmental exposureexternal icon. Clin Microbiol Infect. 2009 Oct;15 Suppl 5:2-9.
2. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported casesexternal icon. Clin Infect Dis. 2005 Sep 1;41(5):634-53.
3. Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosisexternal icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S23-34.
4. Lewis RE, Kontoyiannis DP. Epidemiology and treatment of mucormycosisexternal icon. Future Microbiol. 2013 Sep;8(9):1163-75.
5. Spellberg B, Edwards Jr. J,, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and managementexternal icon. Clin Microbiol Rev. 2005 Jul;18(3):556-69.
6. Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human diseaseexternal icon. Clin Microbiol Rev 2000; 13:236-301.
7. Song Y, Qiao J, Giovanni G, Liu G, Yang H, Wu J, Chen J. Mucormycosis in renal transplant recipients: review of 174 reported casesexternal icon. BMC Infect Dis. 2017 Apr; 17(1): 283.
8. Abdalla A, Adelmann D, Fahal A, Verbrugh H, Van Belkum A, De Hoog S. Environmental occurrence of Madurella mycetomatis, the major agent of human eumycetoma in Sudanexternal icon. J Clin Microbiol. 2002 Mar; 40(3): 1031–1036.
9. Vallabhaneni S, Mody RK. Gastrointestinal mucormycosis in neonates: a reviewexternal icon. Current Fungal Infect Rep. 2015.
10. Francis JR, Villanueva P, Bryant P, Blyth CC. Mucormycosis in children: review and recommendations for managementexternal icon. J Pediatric Infect Dis Soc. 2018 May 15;7(2):159-164.

Symptoms 

The symptoms of mucormycosis depend on where in the body the fungus is growing. 1,4 Contact your healthcare provider if you have symptoms that you think are related to mucormycosis.

Symptoms of rhinocerebral (sinus and brain) mucormycosis include:

• One-sided facial swelling
• Headache
• Nasal or sinus congestion
• Black lesions on nasal bridge or upper inside of mouth that quickly become more severe
• Fever

Symptoms of pulmonary (lung) mucormycosis include:

• Fever
• Cough
• Chest pain
• Shortness of breath

Cutaneous (skin) mucormycosis can look like blisters or ulcers, and the infected area may turn black. Other symptoms include pain, warmth, excessive redness, or swelling around a wound.

Symptoms of gastrointestinal mucormycosis include:

• Abdominal pain
• Nausea and vomiting
• Gastrointestinal bleeding

Disseminated mucormycosis typically occurs in people who are already sick from other medical conditions, so it can be difficult to know which symptoms are related to mucormycosis. Patients with disseminated infection in the brain can develop mental status changes or coma.

References

1. Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosisexternal icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S23-34.
2. Lewis RE, Kontoyiannis DP. Epidemiology and treatment of mucormycosisexternal icon. Future Microbiol. 2013 Sep;8(9):1163-75.
3. Spellberg B, Edwards Jr. J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and managementexternal icon. Clin Microbiol Rev. 2005 Jul;18(3):556-69.
4. Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human diseaseexternal icon. Clin Microbiol Rev 2000; 13:236-301.

RISK & PREVENTION 

Who gets mucormycosis?

Mucormycosis is rare, but it’s more common among people who have health problems or take medicines that lower the body’s ability to fight germs and sickness. Certain groups of people are more likely to get mucormycosis, ^1–3 including people with:

• Diabetes, especially with diabetic ketoacidosis
• Cancer
• Organ transplant
• Stem cell transplant
• Neutropenia pdf icon[PDF – 2 pages] (low number of white blood cells)
• Long-term corticosteroid use
• Injection drug use
• Too much iron in the body (iron overload or hemochromatosis)
• Skin injury due to surgery, burns, or wounds
• Prematurity and low birthweight (for neonatal gastrointestinal mucormycosis)

How does someone get mucormycosis?

People get mucormycosis through contact with fungal spores in the environment. For example, the lung or sinus forms of the infection can occur after someone inhales the spores from the air. A skin infection can occur after the fungus enters the skin through a scrape, burn, or other type of skin injury.

Is mucormycosis contagious?

No. Mucormycosis can’t spread between people or between people and animals.

How can I lower the risk of mucormycosis?

It’s difficult to avoid breathing in fungal spores because the fungi that cause mucormycosis are common in the environment. There is no vaccine to prevent mucormycosis. For people who have weakened immune systems, there may be some ways to lower the chances of developing mucormycosis.

• Protect yourself from the environment. 4,5 It’s important to note that although these actions are recommended, they haven’t been proven to prevent mucormycosis.
  • Try to avoid areas with a lot of dust like construction or excavation sites. If you can’t avoid these areas, wear an N95 respirator (a type of face mask) while you’re there. Click here for more information about respirators.
  • Avoid direct contact with water-damaged buildings and flood water after hurricanes and natural disasters. 6
  • Avoid activities that involve close contact to soil or dust, such as yard work or gardening. If this isn’t possible,
    • Wear shoes, long pants, and a long-sleeved shirt when doing outdoor activities such as gardening, yard work, or visiting wooded areas.
    • Wear gloves when handling materials such as soil, moss, or manure.
    • To reduce the chances of developing a skin infection, clean skin injuries well with soap and water, especially if they have been exposed to soil or dust.
• Antifungal medication. If you are at high risk for developing mucormycosis (for example, if you’ve had an organ transplant or a stem cell transplant), your healthcare provider may prescribe medication to prevent mucormycosis and other mold infections. 7,8 Doctors and scientists are still learning about which transplant patients are at highest risk and how to best prevent fungal infections.

For more information about indoor mold, including cleanup and remediation recommendations, please visit CDC’s Basic Facts about Mold webpage and Mold After a Disaster webpage.

If you are a healthcare provider or healthcare infection control practitioner, click here for prevention guidelines and other resources.

References

1. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported casesexternal icon. Clin Infect Dis. 2005 Sep 1;41(5):634-53.
2. Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosisexternal icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S23-34.
3. Walsh TJ, Gamaletsou MN, McGinnis MR, Hayden RT, Kontoyiannis DP. Early clinical and laboratory diagnosis of invasive pulmonary, extrapulmonary, and disseminated mucormycosis (zygomycosis)external icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S55-60.
4. Avery RK, Michaels MG. Strategies for safe living after solid organ transplantationexternal icon. Am J Transplant. 2013 Mar;13 Suppl 4:304-10.
5. CDC. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recomm Rep. 2000 Oct;49(RR-10):1-125, CE1-7.
6. Davies BW, Smith JM, Hink EM, Durairaj VD. Increased incidence of rhino-orbital-cerebral mucormycosis after Colorado floodingexternal icon. Ophthalmic Plast Reconstr Surg. 2017 May;33(3S Suppl 1):S148-S151.
7. Brizendine KD, Vishin S, Baddley JW. Antifungal prophylaxis in solid organ transplant recipientsexternal icon. Expert Rev Anti Infect Ther. 2011 May;9(5):571-81.
8. Rogers TR, Slavin MA, Donnelly JP. Antifungal prophylaxis during treatment for haematological malignancies: are we there yet? external iconBr J Haemato. 2011 Jun;153(6):681-97.

Where it comes from ?

The fungi that cause mucormycosis live in the environment

Medical illustration of mucormycetes.

Mucormycetes, the group of fungi that cause mucormycosis, are present throughout the environment, particularly in soil and in association with decaying organic matter, such as leaves, compost piles, and animal dung. ¹  They are more common in soil than in air, and in summer and fall than in winter or spring. ^2-4 Most people come in contact with microscopic fungal spores every day, so it’s probably impossible to completely avoid coming in contact with mucormycetes. These fungi aren’t harmful to most people. However, for people who have weakened immune systems, breathing in mucormycete spores can cause an infection in the lungs or sinuses which can spread to other parts of the body.

Types of fungi that cause mucormycosis

Several different types of fungi can cause mucormycosis. These fungi are called mucormycetes and belong to the scientific order Mucorales. The most common types that cause mucormycosis are Rhizopus species and Mucor species. 5 Other examples include Rhizomucor species, Syncephalastrum species, Cunninghamella bertholletiae, Apophysomyces, Lichtheimia (formerly Absidia), Saksenaea, and Rhizomucor. 2

References

1. Richardson M. The ecology of the Zygomycetes and its impact on environmental exposureexternal icon. Clin Microbiol Infect. 2009 Oct;15 Suppl 5:2-9.
2. Al-Ajam, MR, Bizri, AR, Mokhbat, J, Weedon, J, Lutwick, L. Mucormycosis in the Eastern Mediterranean: a seasonal diseaseexternal icon. Epidemiol Infect. 2006 Apr 134(2):341-6.
3. Talmi, YP, Goldschmied-Reouven, A, Bakon, M, Barshack, I, Wolf, M, Horowitz, Z, et al. Rhino-orbital and rhino-orbito-cerebral mucormycosisexternal icon. Otolaryngology-Head and Neck Surgery, 2002 July 1;127(1):22–31.
4. Sivagnanam, S, Sengupta, DJ, Hoogestraat, D, Jain, R, Stednick, Z, Fredricks, DN, et al. Seasonal clustering of sinopulmonary mucormycosis in patients with hematologic malignancies at a large comprehensive cancer centerexternal icon. Antimicrob Resist Infect Control. 2017 November;6(1)
5. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported casesexternal icon. Clin Infect Dis. 2005 Sep 1;41(5):634-53.

DIAGNOSIS & Testing 

How is mucormycosis diagnosed?

Healthcare providers consider your medical history, symptoms, physical examinations, and laboratory tests when diagnosing mucormycosis. Healthcare providers who suspect that you have mucormycosis in your lungs or sinuses might collect a sample of fluid from your respiratory system to send to a laboratory. Your healthcare provider may perform a tissue biopsy, in which a small sample of affected tissue is analyzed in a laboratory for evidence of mucormycosis under a microscope or in a fungal culture. You may also need imaging tests such as a CT scan of your lungs, sinuses, or other parts of your body, depending on the location of the suspected infection.

 

Treatment

How is mucormycosis treated?

Mucormycosis is a serious infection and needs to be treated with prescription antifungal medicine, usually amphotericin B, posaconazole, or isavuconazole. These medicines are given through a vein (amphotericin B, posaconazole, isavuconazole) or by mouth (posaconazole, isavuconazole). Other medicines, including fluconazole, voriconazole, and echinocandins, do not work against fungi that cause mucormycosis. Often, mucormycosis requires surgery to cut away the infected tissue.

Health professionals 

Clinical features 

There are five major clinical forms of mucormycosis; of these, rhinocerebral and pulmonary infections are the most common. 1–3 A classic clinical sign of mucormycosis is the rapid onset of tissue necrosis with or without fever. Necrosis is the result of invasion of blood vessels and subsequent thrombosis.

• Rhinocerebral mucormycosis is the most common form in patients with diabetes and with renal transplants. 4 It also occurs in neutropenic cancer patients and hematopoietic stem cell transplant or solid organ transplant recipients. Symptoms may include unilateral facial swelling, headaches, nasal or sinus congestion or pain, serosanguinous nasal discharge, and fever. As the infection spreads, ptosis, proptosis, loss of extraocular muscle function, and vision disturbance may occur. Necrotic black lesions on the hard palate or nasal turbinate and drainage of black pus from eyes are useful diagnostic signs.
• Pulmonary mucormycosis generally occurs in patients with hematologic malignancy or profound neutropenia. The symptoms are non-specific and include fever, cough, chest pain, and dyspnea. Angioinvasion results in tissue necrosis, which may ultimately lead to cavitation and/or hemoptysis.
• Cutaneous mucormycosis may be primary or secondary. Primary infection is usually caused by direct inoculation of the fungus into disrupted skin and is most often seen in patients with burns or other forms of local skin trauma,  and can occur in patients who are not immunosuppressed. Primary infection produces an acute inflammatory response with pus, abscess formation, tissue swelling, and necrosis. The lesions may appear red and indurated and often progress to black eschars. Secondary cutaneous infection is generally seen when the pathogen spreads hematogenously; lesions typically begin as an erythematous, indurated, and painful cellulitis and then progress to an ulcer covered with a black eschar.
• Gastrointestinal mucormycosis is less common than the other clinical forms and is believed to result from ingestion of the organism. It typically occurs in malnourished patients or premature infants. The stomach, colon, and ileum are most commonly affected. Non-specific abdominal pain and distension, nausea, and vomiting are the most common symptoms, and gastrointestinal bleeding can occur. It is the most common form of mucormycosis among neonates and is challenging to diagnose partly because of its clinical resemblance to necrotizing enterocolitis, a far more common disease. 5
• Disseminated mucormycosis may follow any of the forms of mucormycosis described above but is usually seen in neutropenic patients with a pulmonary infection. The most common site of spread is the brain, but the spleen, heart, skin, and other organs can also be affected.

Etiologic agent

Molds belonging to the order Mucorales, most commonly Rhizopus species. Others include Mucor species, Cunninghamella bertholletiae, Apophysomyces species, and Lichtheimia (formerly Absidia) species. 6

Reservoir

Mucormycetes are thermotolerant molds that are found in the environment. 7 Environmental sampling studies indicate that Mucormycetes are commonly found in soil, but are rarely found in air samples targeting fungal spores. 8-11 Specific environmental niches vary among genera and species.

Transmission

Transmission occurs through inhalation, inoculation, or ingestion of spores from the environment. Although most cases are sporadic, healthcare-associated outbreaks have been linked to adhesive bandages, wooden tongue depressors, hospital linens, negative pressure rooms, water leaks, poor air filtration, non-sterile medical devices, and building construction. 12-20  Community-onset outbreaks have been associated with trauma sustained during natural disasters. 21-22

Diagnosis

A definitive diagnosis of mucormycosis typically requires histopathological evidence or positive culture from a specimen from the site of infection. Specimens from sterile body sites offer stronger evidence of invasive infection compared to colonization. 23,24 Culture of non-sterile sites (e.g., sputum) may be helpful in patients with infection that is clinically consistent with mucormycosis. Mucormycetes may be difficult to differentiate from other filamentous fungi in tissue; experienced pathological and microbiological assistance is often helpful. No routine serologic tests for mucormycosis are currently available, and blood tests such as beta-D-glucan or Aspergillus galactomannan do not detect mucormycetes. DNA-based techniques for detection are promising but are not yet fully standardized or commercially available. 25

Treatment

Early recognition, diagnosis, and prompt administration of appropriate antifungal treatment are important for improving outcomes for patients with mucormycosis. 2 Amphotericin B, posaconazole, and isavuconazole are active against most mucormycetes. Lipid formulations of amphotericin B are often used as first-line treatment. 2 Medications active against Aspergillus such as voriconazole are not active against mucormycetes, and there is some evidence to suggest that pre-exposure to voriconazole may be associated with increased incidence of mucormycosis in some patients. 26,27 In addition, surgical debridement or resection of infected tissue is often necessary, particularly for rhinocerebral, cutaneous, and gastrointestinal infections. 2,4 Control of the underlying immunocompromising condition should be attempted when possible. 2 The efficacy of other treatments such as hyperbaric oxygen therapy is uncertain but have been useful in certain situations. 28

Sequelae

The overall prognosis depends on several factors, including the rapidity of diagnosis and treatment, the site of infection, and the patient’s underlying conditions and degree of immunosuppression. The overall mortality rate is approximately 50%, 6 although early identification and treatment can lead to better outcomes. 23

Risk groups

Risk groups for mucormycosis include persons with uncontrolled diabetes; malignancy; hematopoietic stem cell transplant or solid organ transplant; persistent neutropenia; prolonged corticosteroid therapy; skin trauma, burns, or surgical wounds; iron overload; intravenous drug use; malnourishment; and premature infants.

Surveillance and statistics

National surveillance for mucormycosis does not exist. Healthcare providers who are concerned about an unusual number of new cases should contact their state or local public health agency. Click here for mucormycosis statistics.

References

1. Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosisexternal icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S23-34.
2. Lewis RE, Kontoyiannis DP. Epidemiology and treatment of mucormycosisexternal icon. Future Microbiol. 2013 Sep;8(9):1163-75.
3. Spellberg B, Edwards Jr. J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and managementexternal icon. Clin Microbiol Rev. 2005 Jul;18(3):556-69.
4. Song Y, Qiao J, Giovanni G, Liu G, Yang H, Wu J, Chen J. Mucormycosis in renal transplant recipients: review of 174 reported casesexternal icon. BMC Infect Dis. 2017 Apr; 17(1): 283.
5. Vallabhaneni S, Mody RK. Gastrointestinal mucormycosis in neonates: a reviewexternal icon. Current Fungal Infect Rep. 2015 Sept
6. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported casesexternal icon. Clin Infect Dis. 2005 Sep 1;41(5):634-53.
7. Richardson M. The ecology of the Zygomycetes and its impact on environmental exposureexternal icon. Clin Microbiol Infect. 2009 Oct;15 Suppl 5:2-9.
8. Meklin T, Reponen T, McKinstry C, Cho SH, Grinshpun SA, Nevalainen A, et al. Comparison of mold concentrations quantified by MSQPCR in indoor and outdoor airs ampled simultaneouslyexternal icon. Sci Total Environ 2007 Sept. 382(1):130–134.
9. Calvo MA, Guarro J, Suarez G, Ramirez C. Airborne fungi in the air of Barcelona (Spain). IV. Various isolated generaexternal icon. Mycopathologia. 1980 Jul 1; 71(2):119–123.
10. Klaric MS, Pepeljnjak S. A year-round aeromycological study in Zagreb area, Croatiaexternal icon. Ann Agric Environ Med 2006; 13(1):55–64.
11. Ziaee A, Zia M, Bayat M, Hashemi. Identification of Mucorales isolates from soil using morphological and molecular methodsexternal icon. Curr Med Mycol. 2016 Mar;2(1):13-19.
12. Rammaert B, Lanternier F, Zahar JR, Dannaoui E, Bougnoux ME, Lecuit M, et al. Healthcare-associated mucormycosisexternal icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S44-54.
13. Duffy J, Harris J, Gade L, Sehulster L, Newhouse E, O’Connell H, et al. Mucormycosis outbreak associated with hospital linensexternal icon. Pediatr Infect Dis J. 2014 May;33(5):472-6.
14. Novosad SA, Vasquez AM, Nambiar A, Matthew AJ, Christensen E, Moulton-Meissner H, et al. Notes from the field: probable mucormycosis among adult solid organ transplant recipients at an acute care hospital – Pennsylvania, 2014-2015. MMWR Morb Mortal Wkly Rep. 2016;65(18):481-482.
15. Garner D, Machin K. Investigation and management of an outbreak of mucormycosis in a paediatric oncology unitexternal icon. J Hosp Infect. 2008 Sept;70(1):53-59
16. Mishra B, Mandal A, Kumar N. Mycotic prosthetic-valve endocarditisexternal icon. J Hosp Infect. 1992;20(2):122-125.
17. Del Palacio Hernanz A, Fereres J, Larregla Garraus S, Rodriguez-Noriega A, Sanz Sanz F. Nosocomial infection by Rhizomucor pusillus in a clinical haematology unitexternal icon. J Hosp Infect. 1983;4(1):45-49.
18. de Repentigny L, St-Germain G, Charest H, Kokta V, Vobecky S. Fatal zygomycosis caused by Mucor indicus in a child with an implantable left ventricular assist deviceexternal icon. Pediatr Infect Dis J. 2008;27(4):365-369.
19. Chaudhry R, Venugopal P, Chopra P. Prosthetic mitral valve mucormycosis caused by Mucor speciesexternal icon. Int J Cardiol. 1987;17(3):333-335.
20. Chaves MS, Franco D, Nanni JC, Basaldúa ML, Boleas M, Aphalo G, et al. Control of an outbreak of postoperative bone mucormycosis: an intervention study of contiguous cohortsexternal icon. Am J Infect Control. 2016;44(12):1715-1717.
21. Neblett Fanfair R, Benedict K, Bos J, Bennett SD, Lo YC, Adebanjo T, et al. Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011external icon. New Engl J Med. 2012 Dec 6;367(23):2214-25.
22. Patino JF, Castro D, Valencia A, Morales P. Necrotizing soft tissue lesions after a volcanic cataclysmexternal icon. World J Surg. 1991 Mar-Apr;15(2):240-7.
23. Walsh TJ, Gamaletsou MN, McGinnis MR, Hayden RT, Kontoyiannis DP. Early clinical and laboratory diagnosis of invasive pulmonary, extrapulmonary, and disseminated mucormycosis (zygomycosis)external icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S55-60.
24. De Pauw B, Walsh TJ, Donnelly JP, Stevens DA, Edwards JE, Calandra T, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Groupexternal icon. Clin Infect Dis. 2008 Jun 15;46(12):1813-21.
25. Dadwal SS, Kontoyjannis DP. Recent advances in the molecular diagnosis of mucormycosisexternal icon. Expert Rev of Mol Diagn. 2018 Oct; 18(10):845-854
26. Kontoyiannis P, Lewis RE. How I treat mucormycosisexternal icon. Blood. 2011;118(5):1216-1224.
27. Pongas GN, Lewis RE, 2009. Voriconazole-associated zygomycosis: a significant consequence of evolving antifungal prophylaxis and immunosuppression practices?external icon Clin Microb Infec. 2009 Oct; 15 Suppl 5:93-7.
28. John BV, Chamilos G, Kontoyiannis DP. Hyperbaric oxygen as an adjunctive treatment for zygomycosisexternal icon. Clin Microbiol Infect. 2005 Jul;11(7):515-7.

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