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Zygomycosis in Children: A Systematic Review and Analysis of Reported Cases

Zaoutis, Theoklis E. MD, MSCE*†; Roilides, Emmanuel MD‡; Chiou, Christine C. MD∥; Buchanan, Wendy L. MS§; Knudsen, Tena A. BSN§; Sarkisova, Tatyana A. MD§; Schaufele, Robert L. MS§; Sein, Michael BS§; Sein, Tin MD§; Prasad, Priya A. MPH†; Chu, Jaclyn H. MHS†; Walsh, Thomas J. MD§

Pediatric Infectious Disease Journal: August 2007 - Volume 26 - Issue 8 - pp 723-727
doi: 10.1097/INF.0b013e318062115c
Review Article

Background: Zygomycosis has emerged as an increasingly important infection with a high mortality especially in immunocompromised patients. No comprehensive analysis of pediatric zygomycosis cases has been published to date.

Methods: We used a PUBMED search for English publications of pediatric (0–18 years) zygomycosis cases and references from major books as well as single case reports or case series. Individual references were reviewed for additional cases. Data were entered into Filemaker-pro database and analyzed by logistic regression analysis.

Results: One hundred fifty-seven cases (64% male) were found with median age 5 years (range, 0.16–13). Underlying conditions included neutropenia (18%), prematurity (17%), diabetes mellitus (15%), ketoacidosis (10%), and no apparent underlying condition (14%). The most common patterns of zygomycosis were cutaneous (27%), gastrointestinal (21%), rhinocerebral (18%), and pulmonary (16%). Among 77 culture-confirmed cases, Rhizopus spp. (44%) and Mucor spp. (15%) were most commonly identified. Of 81 patients who were given antifungal therapy, 73% received an amphotericin B formulation only. The remaining patients received mostly amphotericin B in combination with other antifungal agents. Mortality in patients without antifungal therapy was higher than in those with therapy (88% versus 36%, P < 0.0001). Ninety-two (59%) patients underwent surgery. Cerebral, gastrointestinal, disseminated and cutaneous zygomycosis were associated with mortality rates of 100, 100, 88, and 0%, respectively. Independent risk factors for death were disseminated infection (OR: 7.18; 95% CI: 3.02–36.59) and age <1 year (OR: 3.85; 95% CI: 1.05–7.43). Antifungal therapy and particularly surgery reduced risk of death by 92% (OR: 0.07; 95% CI: 0.04–0.25) and 84% (OR: 0.16; 95% CI: 0.09–0.61), respectively.

Conclusions: Zygomycosis is a life-threatening infection in children with neutropenia, diabetes mellitus, and prematurity as common predisposing factors, and there is high mortality in untreated disease, disseminated infection, and age <1 year. Amphotericin B and surgery significantly improve outcome.

From the *Department of Pediatrics and the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA; †Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA; ‡3rd Department of Pediatrics, Aristotle University, Thessaloniki, Greece; §Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD; and ∥National Yang Ming University, Taipei, Taiwan.

Accepted for publication March 23, 2007.

Address for correspondence: Theoklis Zaoutis, MD, MSCE, The Children's Hospital of Philadelphia, Division of Infectious Diseases, 3535 Market Street, Room 1527, Philadelphia, PA 19104. E-mail: zaoutis@email.chop.edu.

© 2007 Lippincott Williams & Wilkins, Inc.