Clinical Advances in Hematology & Oncology Volume 3, Issue 10 October 2005 773 H&0 CLINICAL CASE STUDIES Treatment of Zygomycosis With Posaconazole in a Patient With Acute Myeloid Leukemia he incidence of systemic fungal infection caused by pathogenic and opportunistic organisms is increasing. 1-4 his increase may be explained in part by the growing number of people with compromised immune function as a consequence of intensive cancer chemotherapy, use of immunosuppressants for organ transplantation, and acquired immune deficiency syndrome. 2 Zygomycosis (mucormycosis) is the second most common mycosis, after aspergillosis, caused by filamentous fungi. 5 Although it is observed most often in neutropenic patients with hematologic disease, it also is a major complication of other chronic debilitating diseases, such as uncontrolled diabetes mellitus. 1,5 Species of Rhizopus, a filamentous mold found in soil, decaying food, and animal feces, account for most cases of zygomycosis. 6 Rhino-orbital-cerebral zygomycosis is the most com- mon type of zygomycosis, occurring in approximately 44% of patients. 6 Disease outcomes are often negative. 7 Disease management is multimodal and includes correc- tion of the underlying immunosuppression (eg, reversal of neutropenia and control of glucose levels in patients with diabetes mellitus), aggressive surgical debridement of the infected tissue (if possible), and prompt high-dose antifungal therapy. 7-9 Nevertheless, the mortality rate among patients with rhino-orbital-cerebral zygomycosis is approximately 40–50%, and survivors typically have significant morbidity. 9 he need for new antifungal agents is warranted by limitations of current antifungal therapy coupled with the changing spectrum of fungal disease over the past 2 decades. Posaconazole (Schering-Plough Corporation) is a new extended-spectrum triazole with activity against Helen L. Leather, BPharm Todd A. Correll, PharmD, BCPS Christine L. Meyer, PA-C Ilona M. Schmalfuss, MD John R. Wingard, MD University of Florida, Gainesville, Fla a wide range of fungal pathogens being investigated in phase III clinical trials for the prophylaxis and treatment of refractory invasive fungal infection. A recent report from Dannaoui et al 10 showed that posaconazole has in vitro activity against Rhizopus species at 24 hours (minimum inhibitory concentration for 90% of isolates [MIC 90 ], 0.5 mg/L), which is better than that of amphotericin (MIC 90 , 1 mg/L), itraconazole (MIC 90 , 4 mg/L), and voriconazole (MIC 90 , 64 mg/L). Although amphotericin B has been considered the standard of therapy for patients with zygomycosis, these data indicate that posacon- azole therapy should be studied for the treatment of this disease. he following is a case of rhino-orbital-cerebral zygomycosis in a patient with acute myeloid leukemia (AML) in whom posaconazole was effective in arresting the refractory fungal infection. Case Report In late May 2000, a 51-year-old man was admitted to a community hospital for induction chemotherapy for AML (French-American-British classification M1) with cytarabine 334 mg daily, given via continuous intra- venous (IV) infusion for 7 days, and idarubicin 20 mg daily, administered as an IV push for 3 days. In mid-June, right-eye proptosis developed and initially was diagnosed as bacterial sinusitis based on isolation of Enterobacter aerogenes and s Stenotrophomonas maltophilia from the sinus cultures. he patient was given fluconazole and broad- spectrum antibiotics, including piperacillin-tazobactam and vancomycin, as part of febrile neutropenia precau- tions. A biopsy of the ethmoid tissue revealed broad asep- tate ribbon-like fungal hyphae morphologically consistent with Mucor species. Associated vascular invasion and thrombosis were noted. An orbital biopsy and ethmoid- ectomy was performed the following day, revealing broad, irregularly shaped hyphae with right-angle branching and Address correspondence to: John R. Wingard, MD, University of Florida College of Medicine, Division of Hematology/Oncology, PO Box 100277, 1600 SW Archer Road, R4-165, Gainesville, FL 32610-0277; Tel: 352-273-8021; Fax: 352-392-8530; E-mail: wingajr@medicine.ufl.edu.