Posaconazole for bone-invading rhinomaxillary mucormycosis

Mucormycosis has been increasingly diagnosed owing to the growing numbers of patients with impaired immunity. Rhinocerebral is the most common and most fatal manifestation, which is further divided into three subtypes: rhinomaxillary, rhinoorbital, and rhinoorbitocerebral. It is encountered in 60 to 80 percent of mucormycosis cases. In isolated rhinomaxillary infections, the survival rate is 82 percent, whereas prognosis is markedly poor in cerebral involvement, with a survival rate of 38 percent. 1 Diagnosis is made histologically because invasion and tissue reaction, rather than the mere presence of such ubiquitous fungi, characterize this disease. To date, the mainstay of treatment includes extensive local debridement, reversal or reduction of the immunosuppressive state, and the debated hyperbaric oxygen therapy. Intravenous amphotericin B, or its liposomal variant, has been considered the drug of choice at the highest tolerable dose. However, it has substantial toxicity (mostly infusionrelated and renal failure) and has little changed the high mortality rates of disseminated infections. Several new broad-spectrum agents have been recently introduced, following successful reports of in vitro activity against Mucor. 2 Posaconazole, an orally absorbed triazole, was first reported to cure rhinocerebral mucormycosis in a poorly controlled diabetic 8-year-old girl, which was complicated by internal carotid artery and cavernous sinus thromboses. 3 This work received the approval of the institutional review board.