Cutaneous Mucormycosis of the Eyelid Treated With Subcutaneous Liposomal Amphotericin B Injections

Abstract

Cutaneous mucormycosis is a rare, opportunistic fungal infection that typically affects immunocompromised hosts. Current treatment consists of systemic antifungal therapy, surgical debridement, and when applicable, restoration of immune function. Despite intervention, the morbidity and mortality of invasive fungal disease remains high. There are few reports of primary or secondary cutaneous mucormycosis involving the ocular adnexa. The authors describe the course of 2 children with cutaneous mucormycosis of the eyelid treated with subcutaneous liposomal amphotericin B (LAmB) injections (3.5 mg/ml) in an off-label application as an adjunct to debridement and systemic antifungal therapy. To the authors' knowledge, these are the first 2 cases of invasive fungal disease involving the eyelid treated with subcutaneous LAmB injections, and the first reported case of disseminated fungal infection with secondary cutaneous involvement of the eyelid.

Figure 1.

Case 1. A 4-year-old male with Stage IV metastatic neuroblastoma presenting with cutaneous mucormycosis of the left maxilla from primary inoculation. A – Progressive enlarging soft tissue lesion of the left maxilla at the site of endotracheal tube (ET) taping. The appearance of the initial lesion is demonstrated (inset). B – Magnetic resonance imaging (MRI) demonstrating subcutaneous fat stranding in the left mid-face. C – Left maxilla following surgical debridement with persistent fungal elements seen on histopathology at the left lower eyelid tissue margin. Note, there is no evidence of gross necrosis of the eyelid. D – Fourteen months later following reconstruction with split thickness skin graft.

Figure 2.

Case 2. A 4-year-old female with acute lymphoblastic leukemia (ALL) presenting with cutaneous mucormycosis of the right lower eyelid from disseminated pulmonary disease. A – Right lower eyelid edema, erythema, duskiness of the eyelid margin, and necrosis of the inferior palpebral conjunctiva. B – Magnetic resonance imaging (MRI) demonstrating enhancement of the right preseptal tissue. C – Right lower eyelid palpebral conjunctiva and pretarsal orbicularis histopathology demonstrating broad, ribbon-like, non-septate fungal hyphae (hematoxylin-eosin stain, original magnification 60x). D – Twenty months following treatment, the right lower eyelid maintains adequate protection of the ocular surface without further intervention.