microsporus in a diabetic patient with COVID-19

COVID-19 disease caused by the SARS-CoV-2 coronavirus causes a wide range of clinical manifestations, ranging from mild to severe, with the main ones affecting the respiratory tract, such as pneumonia. In patients with greater severity, the high frequency of bacterial and fungal coinfection stands out, a situation related both to the patient's pre-existing comorbidities and due to the hospitalization itself. Cases of mucormycosis associated with COVID-19 were highlighted in the lay and scientific media, with the increase in mycosis cases being directly and indirectly attributed to the viral infection. This report describes a case of rhino-orbito-cerebral mucormycosis in a diabetic patient hospitalized for COVID-19, whose diagnosis was confirmed by identifying the agent Rhizopus microsporus var. microsporus through culture for fungi and PCR examination.

Resurgence of mucormycosis during COVID-19 pandemic

Objective

To explore the literature on corona-associated mucormycosis and explain its relevance to dentists and oral surgeons.

Methods

A literature search was carried out to identify reported cases on corona-associated mucormycosis since the start of COVID-19 pandemic.

Results

A review of literature identified 265 published papers on CAM between March 2020 and September 2021. Careful screening of abstracts and full texts revealed 29 studies reporting case series of CAM and, 27 case reports on CAM.

Conclusions

A multitude of factors may be responsible for the alarming rise in the incidence of corona-associated mycosis including reduced access to routine medical services during the pandemic, injudicious use of antibiotics, steroids and nutritional supplements. Risk factors contributing to corona-associated mucormycosis need to be recognized. Dentists and oral surgeons can contribute to early recognition of corona-associated mucormycosis involving the maxilla, and palate. Prioritizing research focus on optimal management of mucormycosis may reduce the morbidity and mortality associated with this debilitating infection.

Coronavirus Disease 2019 (COVID-19)-Associated Rhino-Orbito-Cerebral Mucormycosis: A Multi-Institutional Retrospective Study of Imaging Patterns

BACKGROUND

Mucormycosis infection of the maxillofacial region and brain has been associated with coronavirus disease 2019 (COVID-19) infection. Mucormycosis was relatively a rare infection before COVID-19, and imaging findings are not very well described.

MATERIALS AND METHODS

A retrospective imaging study of 101 patients diagnosed with COVID-19-associated mucormycosis by histopathology and/or culture was performed. All patients underwent computed tomography and/or magnetic resonance imaging based on the clinical condition of the patient and on consensus decision by the team of treating physicians. A simple 3-stage classification system based on imaging findings was adopted.

RESULTS

One hundred one cases were included in the final analysis (mean age = 55.1 years; male/female ratio = 67:34). The affected patients had diabetes in 94% of the instances (n = 95), 80.1% (n = 81) received steroids), whereas 59.4% (n = 60) patients received supplemental oxygen. The majority underwent surgical intervention, whereas in 6 cases, patients were treated with antibiotic regimens. Sixty subjects improved following therapy, whereas 18 eventually succumbed to the illness. We noted a significant positive correlation between the imaging stage and outcomes. No association was seen between other clinical parameters and final clinical outcomes. Salient imaging findings include lack of normal sinonasal mucosal enhancement, perisinus inflammation, ischemic optic neuropathy, perineural spread, pachymeningeal enhancement, and presence of strokes.

CONCLUSIONS

We describe the imaging findings in the largest cohort of patients with rhino-orbito-cerebral mucormycosis in the context of the current COVID-19 pandemic. A simplified staging system described here is helpful for standardized reporting and carries prognostic information.

Survival in rhino-orbito-cerebral mucormycosis: An international, multicenter ID-IRI study

BACKGROUND

Mucormycosis is an emerging aggressive mold infection. This study aimed to assess the outcome of hospitalized adults with rhino-orbito-cerebral mucormycosis (ROCM). The secondary objective was to identify prognostic factors in this setting.

METHODS

This study was an international, retrospective, multicenter study. Patients' data were collected from 29 referral centers in 6 countries. All qualified as "proven cases" according to the EORTC/MSGERC criteria.

RESULTS

We included 74 consecutive adult patients hospitalized with ROCM. Rhino-orbito-cerebral type infection was the most common presentation (n = 43; 58.1%) followed by rhino-orbital type (n = 31; 41.9%). Twenty (27%) had acquired nosocomial bacterial infections. A total of 59 (79.7%) patients (16 in combination) received appropriate antifungal treatment with high-doses of liposomal amphotericin B. Fifty-six patients (75.7%) underwent curative surgery. Thirty-five (47.3%) required intensive care unit admission (27; 36.5% under mechanical ventilation). Hospital survival was 56.8%, being reduced to 7.4% in patients with invasive mechanical ventilation. A multivariate binary backward logistic regression model identified confusion at admission (OR 11.48), overlapping hospital-acquired infection (OR 10.27), use of antifungal treatment before diagnosis (OR 10.20), no surgical debridement (OR 5.92), and the absence of prior sinusitis (OR 6.32) were independently associated with increased risk for death.

CONCLUSION

Today, ROCM still has high mortality rate. Improving source control, rational therpy, and preventing nosocomial infections may improve survival in this severe infection.

Pneumonitis and Pulmonary Mucormycosis in a Covid-19 Positive Patient-A Case Report

In the wake of second wave of coronavirus disease (Covid-19), an increased number of mucormycosis cases were reported by the Ministry of Health and Family Welfare in India. A total of 45 432 cases of mucormycosis were reported till mid-July 2021, with 4252 fatalities. Mucormycosis and other fungal infections are most commonly seen as an opportunistic infection. They are found in those with low underlying immunity either due to a diabetes, cancers particularly hematological malignancies, and so on, or as a side effect of prolonged/irrational use of certain drugs like steroids, immunosuppressive drugs for management of other disorders including Covid-19. The Health Authorities in India stated that although it is not a new disease, its true incidence during the beginning of the second wave was unknown as it was not a notifiable disease. As per reports, the most common presentations of mucormycosis included rhinocerebral (77.6%), cutaneous (4.3%), and pulmonary (3.0%). We present a case of pulmonary mucormycosis and pneumonitis in a Covid-19 positive patient brought for autopsy. The patient was an under trial prisoner sent for treatment to our facility who was reported Covid positive.

Mucormycosis, one month after recovery from COVID-19: A case report

Introduction

and importance: There are increasing case reports of mucormycosis in patient with coronavirus disease 2019 (Covid-19). Herein, we describe the case of mucormycosis after recovery from Covid-19.

Case presentation

The patient was a 73 years old woman with a history of chronic kidney disease, diabetes mellitus, hypertension, and dyslipidemia that referred to the emergency department with clinical presentation of Covid-19. On the third day of admission, the Covid-19 PCR test was negative, but the patient presented headache and pain in her upper jaw. Physical examination showed fever, erythema, and tenderness in the right cheek. Emergency biopsy and culture from sinus by subsection to mucormycosis conducted. and the diagnosis of mucormycosis was confirmed by the positive result of biopsy and culture. Despite anti-fungal treatment with Amphotericin B, patient developed severe diarrhea and became hemodynamically unstable. In the stool analysis, Strongyloides stercoralis was reported. Unfortunately, patient was expired on day thirty-two of this admission.

Clinical discussion

Mucormycosis is a dangerous infection, and its rapid diagnosis is so important. On the other hand, Covid-19 may associated with many nonspecific sign and symptoms. These finding may overlap with other infections.

In patients with prolonged mucormycosis infection, the development of strongyloidiasis should not be neglected. A single dose of ivermectin as strongyloidiasis prophylaxis should be given if the duration of the illness is prolonged.

Conclusion

Clinicians should consider mucormycosis and its complications after Covid-19 treatment in diabetic and immunocompromised patients.

•

COVID-19 may be associated with bacterial or fungal co-infections.

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Nonspecific sign and symptoms of COVID-19, may overlap with other infections.

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Mucormycosis may occur following COVID-19, especially in patients with risk factors.

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We report a case of mucormycosis, one month after recovery from COVID-19 in a patient with poor diabetic control.

Mucromycosis in India: Pathophysiology and Perspectives on Treatment and Management

Mucormycosis, also known as "black fungus," is a potentially fatal disorder that causes blurred or double vision, chest pain, and breathing problems. The introduction of novel risk factors and causative agents, as well as the problems with controlling the disease, are all significant problems with mucormycosis in India. It is most common among COVID-19 patients. Mucormycosis is an invasive fungal disease that primarily affects immunosuppressant patients, mainly caused by mold fungi of the genus mucor, rhizopus, rhizomucor, and absidia, which are in the zygomycetes class and the mucorales order. The most common risk factor is diabetes mellitus, followed by haematological malignancy and solid-organ transplantation. Reversal of underlying predisposing factors, surgical debridement of infected tissues, and proper antifungal therapy are all required for the treatment of mucormycosis. In this review, the epidemiology, pathogenesis, and symptoms of black fungus and its association with covid-19, treatment and diagnosis are discussed.

Adjunctive use of saturated solution of potassium iodide (SSKI) with liposomal amphotericin B (L-AMB) in mucormycosis achieves favorable response, shortened dose and duration of amphotericin: A retrospective study from a COVID-19 tertiary care center

Purpose

Second wave of COVID-19 pandemic was associated with an unprecedented rise in cases of mucormycosis, treatment of which has been challenging owing to the availability and side effects associated with amphotericin.

Methods

All patients presenting with rhino-orbital cerebral mucormycosis (ROCM) following COVID-19 infection between April 2021 to June 2021 were included in this retrospective interventional study. Primary objective was to assess the clinical response with combination of intravenous liposomal amphotericin B (4–5 mg/kg/day) and saturated solution of potassium iodide (SSKI) given orally along with surgical debridement.

Results

Twenty-five patients of ROCM were treated with the regimen. Mean age and fasting blood sugar levels were 53.48 years and 239.64 mg/dL respectively. All patients had history of intake of steroids with a mean daily dose of 86.39 mg of prednisolone equivalent. 88% of patients had a “proven” diagnosis of mucormycosis. Cultures were positive in 52% of patients with Rhizopus arrhizus as the predominant species. The mean daily dose of amphotericin received was 268 mg/day with a mean duration of 9.52 days. Mean daily dose of SSKI was 2.57 g. 21 patients (84%) had stabilization of disease at week 8 and achieved cure at the end of treatment whereas the mortality rate was 16%. Factors that significantly affected outcome were eye and central nervous system (CNS) involvement on presentation.

Conclusion

SSKI, with its remarkably low cost and safety profile, makes it a potential adjuvant drug that may help achieve the twin benefits of shortened duration and dose of LAMB.

A rare case of cutaneous mucormycosis in the forearm: A case report

INTRODUCTION AND IMPORTANCE

Cutaneous Mucormycosis (CM) is a less frequent type of fungal infection that can present with different skin lesions. Although these lesions appear to be benign and silent, CM rapidly progresses into the deeper layers. Given that no specific laboratory or imaging finding is described for the disease, the diagnosis is mainly based on history and physical examination. In addition, immediate debridement and antifungal agents must be commenced.

CASE PRESENTATION

We present a 43-year-old septic man who was hospitalized for his forefoot infection. During his admission, he developed a necrotic-like ulcer in his antecubital fossa. After initial debridement, pathology examination revealed the infection with mucormycosis. We administered intravenous liposomal Amphotericin B, and also multiple surgeries were performed. Unfortunately, the sepsis progressed to multiorgan failure, and the patient passed away.

CONCLUSION

CM requires emergent diagnosis and treatment. Early surgical interventions like extensive debridement and repetitive wound irrigation alongside systemic antifungal therapy are the key steps to preventing the progression of the disease.

Post COVID-19 Head and Neck Mucormycosis: MR Imaging Spectrum and Staging

Objective

To develop a systematic approach for magnetic resonance imaging (MRI) analysis, imaging spectrum, and classification system for the staging of post-COVID-19 head and neck mucormycosis.

Method

The study included 63 post-COVID-19 patients with pathologically proven mucormycosis who underwent head and neck MR imaging. Three independent radiologists assessed the imaging spectrum of mucormycosis, MRI characteristics of sino-nasal mucormycosis, and extra-sinus extension, and submitted a final staging using a systematic approach and a proposed categorization system. A consensus reading was considered the reference imaging standard. The kappa statistics were used to assess the categorization system's diagnostic reliability.

Results

The overall interreader agreement of the MR staging system was very good (k-score = 0.817). MR imaging spectrum involved localized sino-nasal mucormycosis (n = 7 patients, 11.1%), sino-nasal mucormycosis with maxillo-facial soft tissue extension (n = 28 patients, 44.5 %), sino-nasal mucormycosis with maxillo-facial bony extension (n = 7 patients, 11.1%), sino-naso-orbital mucormycosis (n = 13 patients, 20.6%), and sino-nasal mucormycosis with cranium or intracranial extension (n = 8 patients, 12.7%). Extra-sinus extension to the orbit and brain did not have significant association with involvement of the posterior ethmoid/sphenoid sinuses and maxillo-facial regions (p > 0.05). MRI-based staging involved four stages: stage 1 (n = 7, 11.1%); stage 2 (n = 35, 55.6%), and stage 3 (n = 13, 20.6%), and stage 4 (n = 8, 12.7%). Involvement of the bone and MR-based staging were significant predictors of patients’ mortality p = 0.012 and 0.033, respectively.

Conclusion

This study used a diagnostic-reliable staging method to define the imaging spectrum of post-COVID-19 head and neck mucormycosis and identify risk variables for extra-sinus extension.

Novel 2-aryl-4-aryloxyquinoline-based fungistatics for Mucor circinelloides. Biological evaluation of activity, QSAR and docking study

Zygomycetes are ubiquitous saprophytes in natural environments which transform organic matter. Some zygomycetes of gender Mucor have attracted interest in health sector. Due to its ability as opportunistic microorganisms infecting immuno-compromised people and to the few available pharmacological treatments, the mucormycosis is receiving worldwide attention. Concerning to the pharmacological treatments, some triazole-based compounds such as fluconazole are extensively used. Nevertheless, we focused in the quinolines since they are broadly used models for the design and development of new synthetic antifungal agents. In this study, the fungistatic activity on M. circinelloides of various 2-aryl-4-aryloxyquinoline-based compounds was discovered, and in some cases, it resulted better than reference compound fluconazole. These quinoline derivatives were synthesized via the C_sp²-O bond formation using diaryliodonium(III) salts chemistry. A QSAR study was carried out to quantitatively correlate the chemical structure of the tested compounds with their biological activity. Also, a docking study to identify a plausible action target of our more active quinolines was carried out. The results highlighted an increased activity with the fluorine- and nitro-containing derivatives. In light of the few mucormycosis pharmacological treatments, herein we present some non-described molecules with excellent in vitro activities and potential use in the mucormycosis treatment.

Invasive mould infections in patients from floodwater-damaged areas after hurricane Harvey - a closer look at an immunocompromised cancer patient population

OBJECTIVES

Extensive floodwater damage following hurricane Harvey raised concerns of increase in invasive mould infections (IMIs), especially in immunocompromised patients. To more comprehensively characterize the IMI landscape pre- and post-Harvey, we used a modified, less restrictive clinical IMI (mcIMI) definition by incorporating therapeutic-intent antifungal drug prescriptions combined with an expanded list of host and clinical features.

METHODS

We reviewed 103 patients at MD Anderson Cancer Center (Houston, Texas), who lived in Harvey-affected counties and had mould-positive cultures within 12 months pre-/post-Harvey (36 and 67 patients, respectively). Cases were classified as proven or probable IMI (EORTC/MSG criteria), mcIMI, or colonization/contamination. We also compared in-hospital mortality and 42- day survival outcomes of patients with mcIMI pre-/post-Harvey.

RESULTS

The number of patients with mould- positive cultures from Harvey-affected counties almost doubled from 36 pre- Harvey to 67 post- Harvey (p < 0.01). In contrast, no significant changes in (mc)IMI incidence post-Harvey nor changes in the aetiological mould genera were noted. However, patients with mcIMIs from flood affected areas had significantly higher in-hospital mortality (p = 0.01).

CONCLUSIONS

We observed increased colonization but no excess cases of (mc)IMIs in immunosuppressed cancer patients from affected areas following a large flooding event such as hurricane Harvey.

Antibody responses and CNS pathophysiology of Mucormycosis in Chronic SARS CoV-2 infection: Current Therapies against Mucormycosis

The incidence rate of opportunistic secondary infections through invasive fungi has been observed to be 14.5% to 27% in the SARS CoV pandemic during the year 2003. But, the incidence of SARS CoV-2 is accompanied by the substantial rise in secondary opportunistic infections like mucormycosis (black fungus) mainly in the immunocompromised individuals, and diabetic patients taking steroids. Substantial rates of COVID-19 cases with mucormycosis were reported in India and other parts of the world. Previous research reports delineated the ability of Mucorales in invading the various tissues like lungs, brain, sinus through the GRP78 and subsequently this infection could invoke crusting, edema, and necrosis of brain parenchyma, ptosis, proptosis, and vision loss due to intraorbital & intracranial complications. Similarities of these pathophysiological complications with already existing diseases are causing clinicians to face several challenges in order to diagnose and treat this disease effectively at the early stage. This minireview depicts the mucormycosis-induced immune, and pathophysiological alterations in COVID-19 patients comorbid with diabetes, immunosuppression, and also reported the various clinical manifestations, and the therapeutic modalities and the failures of anti-fungal vaccines. Therefore, the emerging mucormycosis in COVID-19 patients need a rapid investigation and selective optimization of the effective therapeutic modalities including antifungal vaccines to minimize mortality rate.

Sensitivity of liquid-based cytology in the diagnosis of mucormycosis in COVID-19 treated patients

BACKGROUND

The coronavirus disease 2019 (COVID-19) infection caused by the novel severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is associated with a wide range of disease patterns, ranging from mild to life-threatening pneumonia. COVID-19 can be associated with a suppressed immune response and/or hyperinflammatory state due to cytokine storm. Reduced immunity, combined with steroid usage to prevent cytokine storm along with various pre-existing co morbidities can prove to be a fertile ground for various secondary bacterial and fungal infection, including mucormycosis. Diagnosis of mucor is a challenging task given high negativity rate of various detection methods. While histopathology is considered the gold standard, the acquisition of necessary tissue biopsy specimens requires invasive procedures and is time consuming.

METHOD

In this study various methods of mucor detection, like conventional cytopathology (CCP), liquid-based cytology (LBC, BD SurepathTM ), potassium hydroxide mount (KOH) preparation, culture and histopathology were analysed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for various methods.

RESULTS

This study showed that LBC has sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 72.4%,100%,100% and 38.4% respectively.

CONCLUSION

This study showed that, liquid-based cytology (LBC) can be a rapid and effective alternative to histopathology in mucor diagnosis.

COVID 19 associated Rhino- Orbital- Cerebral Mucormycosis: A proposed Classification and Treatment Strategies

OBJECTIVE

Mucormycosis is a rare fungal disease and was known to affect only immunocompromised hosts, but in the COVID 19 pandemic, a surge in the cases of Rhino- Orbital-Cerebral Mucormycosis have been reported, and the cause still unknown. As the disease was a rare entity there was no classification considering the sprerad and proper management at various stages of spread.

METHOD

Extensive literature search with the terms " Mucormycosis", "Invasive Fungal Sinusitis" and "COVID 19 associated Mucormycosis", "Mucormycosis in COVID" was made on Pubmed, Scopus and Embase database, taking into consideration case histories revealing the site of involvement and treatment according to the extension of the disease.

RESULTS

Relevant articles were analysed and it was found that there is no specific classification of the disease entity and proper surgical and medical management guidelines to date and the disease spread followed a pattern related to the first site of involvement and few reports also suggested skip lesions.

CONCLUSION

This review is an attempt through which, we elaborate the pathophysiology of Mucormycosis and its spread and propose a classification which will be helpful in determining policies for control and prevent complications, morbidity, and mortality.

COVID-19 and Co-infections: A Serious Health Threat Requires Combination Diagnosis and Therapy

Since the advent of the COVID-19 pandemic in 2019, a mammoth research activity targeting the etiological features of COVID-19 has commenced. Many aspects of the disease have been studied, and various others are under consideration. The secondary microbial co-infections with COVID-19 have generated some serious concerns across the globe. This review mainly focuses on the notable secondary co-infections. The co-infection of influenza, tuberculosis, and typhoid may mimic the original COVID-19 symptoms. Physicians and clinicians must focus on the secondary co-infections which may aggravate the disease progression towards acute respiratory disorder syndrome (ARDS). Diagnostic strategies must also be redefined to determine the actual underlying secondary co-infection. There is a need for combination therapy and diagnostic approaches to minimize the risks associated with the COVID-19 pandemic effectively.

Antifungal Activity of Endophytic Aspergillus terreus Extract Against Some Fungi Causing Mucormycosis: Ultrastructural Study

Endophytes fungi are applied as favorable safe antifungal agents as well as natural bioactive compounds reservoir. In the current study, the inhibitory effect of endophytic fungus was explained by direct antifungal activity against fungi causing mucormycosis, ultrastructural, and determination of active compounds in fungal extract. Endophytic Aspergillus terreus was isolated from healthy Moringa oleifera leaves and identified morphologically and genetically, and was recorded in gene bank with accession number MW444551.1. Phytochemical analysis and gas chromatography-mass spectroscopy (GC–MS) of ethyl acetate crude extract (EACE) of A. terreus were performed. GC–MS results of EACE of A. terreus revealed that fungal extract contains 16 major bioactive compounds with extensive pharmaceutical activities. Furthermore, EACE of A. terreus revealed a promising antifungal activity against fungi causing mucormycosis as Rhizopus oryzae, Mucor racemosus, and Syncephalastrum racemosum, where inhibition zones of EACE (10 mg/ml) were 20, 37, and 18 mm, respectively. Minimum inhibitory concentration (MIC) of EACE was 0.3125 toward M. racemosus, while 1.25 and 2.5 mg/ml against R. oryzae and S. racemosum, respectively. In the same context, treated R. oryzae, M. racemosus, and S. racemosum with EACE of A. terreus revealed elevation of membrane lipid peroxidation which approves membrane leakage. Furthermore, ultrastructure changes were observed which established alteration in both sporangium and hyphal structures; cell membrane and cytoplasm leakage. In conclusion, endophytic A. terreus has an outstanding antifungal activity against fungi causing mucormycosis.

Mucormycosis in COVID-19 patients: predisposing factors, prevention and management

India is considered the diabetes capital of the world and has the highest burden of mucormycosis. Bacterial, viral and fungal co-infections are increasingly being reported in severe acute respiratory syndrome virus 2 (SARSCoV-2) infected patients. India is one of the worst affected countries during the second wave of the COVID-19 pandemic. This combination of diabetes mellitus, COVID-19 and mucormycosis has led to the drastic upsurge of COVID-19-associated mucormycosis (CAM) in India. Immunosuppression, iron disequilibrium, endothelial injury, ketoacidosis and hypoxia are some of the other COVID-19-related risk factors for CAM. There has been an increase in the proportion of mucormycosis affecting paranasal sinuses and central nervous system (CNS) in CAM compared to pre-COVID-19 literature due to the SARSCoV-2-related pathophysiological mechanisms, complications and treatment strategies. CAM is a medical and surgical emergency, and it can present with non-specific symptoms and signs initially resulting in diagnostic delay. High index of suspicion and regular screening for features of CAM are of paramount importance to prevent lethal consequences. Rapid action with a tripod approach consisting of withdrawal of immunomodulators, early antifungal therapy and extensive surgical debridement is considered the best possible treatment model. We review the published data to give a detailed account of the predisposing factors and their mechanisms, diagnostic work-up, treatment modalities and prevention strategies of CAM with special emphasis on CNS mucormycosis.

Changing Trends in the Survival of Immunosuppressed Children with Invasive Fungal Rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis has been associated with high mortality rates.

OBJECTIVE

We aimed to explore the contribution of novel detection and treatment methods on the outcome of immunosuppressed children with acute invasive fungal rhinosinusitis.

METHODS

The records of all children with a hematologic or oncologic disease who developed acute invasive fungal rhinosinusitis between 2005-2020 were reviewed.

RESULTS

Thirty-four patients were included. Aspergillosis and mucormycosis were diagnosed in 20 patients (59%) and 12 patients (35%), respectively. Panfungal polymerase chain reaction (PCR) was associated with a change of treatment in 36% of patients. A more aggressive surgical approach as well as treatment with liposomal amphotericin B and novel antifungals were adopted in recent years. Overall, 26% of patients died of disease, however no disease-specific death occurred since 2012. Diagnosis using panfungal PCR (p  =  .04) and treatment with novel antifungal medications (p  =  .017) were significantly associated with disease-specific survival.

CONCLUSION

Enhanced fungal detection using panfungal PCR and treatment with novel antifungal agents, combined with rapid diagnosis and treatment, aggressive surgical approach and better control over the underlying oncological disease, may significantly improve the outcome of immunosuppressed children with acute invasive fungal rhinosinusitis.

A case of isolated unilateral renal mucormycosis post COVID-19 pneumonia with fatal outcome

Mucormycosis is a rare disease. It is typically seen in immunocompromised patients. Isolated renal mucormycosis is an extremely rare disease. We here report a case of isolated renal mucormycosis who had recently recovered from COVID-19 pneumonia. The patient was a known case of diabetes mellitus and had already developed acute kidney injury when he reported to us. Despite aggressive medical and surgical management, the patient succumbed to the disease.

The cross-talk between mucormycosis, steroids and diabetes mellitus amidst the global contagion of COVID-19

Mucormycosis is an opportunistic fungal disease that targets individuals having an impaired immune system due to a wide array of risk factors including HIV-AIDS, immunosuppressive therapy, diabetes mellitus, etc. The current explosive outbreak of coronavirus disease 2019 (COVID-19) has become the latest threat to such patients who are already susceptible to secondary infections. Physiological outcomes of COVID-19 end up in a cascade of grave alterations to the immunological profile and irreparable harm to their respiratory passage, heart and kidneys. Corticosteroidal treatment facilitates faster recovery and alleviates the adverse pathological effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). But clinical reports lend this approach a darker perspective especially if these patients have pre-existing diabetes mellitus. The mucormycotic fungal genera belonging to the order Mucorales not only survive but thrive under the comorbidity of COVID-19 and diabetes, often staying undetected until they have inflicted irreversible damage. Steroidal usage has been noted to be a common thread in the sudden spurt in secondary fungal infections among COVID-19 cases. Once considered a rare occurrence, mucormycosis has now acquired a notoriously lethal status in mainstream medical hierarchy. We set out to investigate whether corticosteroidal therapy against COVID-19 emboldens the development of mucormycosis. We also assess the conditions brought forth by steroidal usage and uncontrolled progression of diabetes in COVID-19 cases and their effect on the susceptibility towards mucormycosis.

An overview of COVID-19 related to fungal infections: what do we know after the first year of pandemic?

In 2019, severe acute respiratory syndrome caused by CoV-2 virus became a pandemic worldwide, being the fast spread of the disease due to the movement of infected people from one country to another, from one continent to another, or within the same country. Associated comorbidities are important factors that predispose to any fungal coinfections. Because of the importance of fungal infections in COVID-19 patients, the aim of this work was to collect data of the more encountered mycoses related to patients undergoing this disease. Aspergillosis was the first COVID-19-related fungal infection reported, being A. fumigatus the most frequent species for CAPA. Other fungal infections related include mainly candidiasis and mucormycosis, being Rhizopus spp. the more prevalent species found. Influenza-associated pulmonary aspergillosis is well documented; thus, similar complications are expected in severe forms of COVID-19 pneumonia. Therefore, in patients with COVID-19, it is important to take special attention to the surveillance and suspicion of fungal coinfections that might worsen the patient's prognosis.

As the virus sowed, the fungus reaped! A Comparative Analysis of the Clinico-epidemiological Characteristics of Rhino-orbital Mucormycosis before and during Covid -19 Pandemic

Background

The sudden surge of mucormycosis cases which happened during the second wave of COVID‐19 pandemic was a significant public health problem in India.

Objectives

The aim of this study was to analyse the clinico‐epidemicological characteristics of the mucormycosis cases to determine the changes that had occurred due to COVID‐19 pandemic.

Methodology

A retrospective cross‐sectional study was conducted at the Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India. Patients diagnosed with rhino‐orbital mucormycosis were categorised into the following groups: Pre‐pandemic(May 2019 to April 2020), Pandemic Pre‐epidemic (May 2020 to April 2021) and Epidemic (1 May 2021 to 12 July 2021). The epidemiological, clinical and surgical data of all the patients were retrieved from the hospital records and analysed.

Results

The epidemic period had 370 cases, compared with 65 during pandemic period and 42 in the pre‐pandemic period. Diabetes mellitus was seen in 87% of cases during epidemic period, 92.9% in the pre‐pandemic period and 90.8% in the pre‐pandemic pre‐epidemic period. The proportion of patients suffering from vision loss, restricted extra‐ocular movements, palatal ulcer and nasal obstruction was higher in the pre‐epidemic groups, and the difference was significant (p, <.01). There was no history of oxygen use in 85.9% of patients and no steroid use in 76.5%. The death rates were the lowest during epidemic (10%).

Conclusion

COVID‐19 has caused a statistically significant increase in the number of mucormycosis infections. The mortality and morbidity which showed an increase during the first wave of COVID‐19 decreased significantly during the epidemic period.

Risk factors for Coronavirus disease-associated mucormycosis

BACKGROUND

The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies.

METHODS

We performed a case-control study comparing cases diagnosed with CAM and taking controls as recovered COVID 19 patients who did not develop mucormycosis. Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Multivariate regression analysis was used to identify independent predictors.

RESULTS

A total of 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean of 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases had conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95% CI 1.1-11), use of systemic steroids (aOR 7.7, 95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs. no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6, 95% CI 1.2-2.2). Zinc therapy was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM.

CONCLUSION

Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.

Risk factors for palatal and orbital involvement in mucormycosis epidemic-Report of a center in India

BACKGROUND

Mucormycosis of the nose and paranasal sinuses has emerged as an epidemic following COVID-19 pandemic. The management involves surgical debridement, the extent of which depends on the bulk of the disease. Extension to the orbit and palate depends on the involvement of specific sites in the nose and paranasal sinuses. This study intended to identify those sites.

MATERIALS AND METHODS

This was a single-center case-control study. There were 3 groups according to the region involved (Palate, orbit and both). The fourth group with neither involvement was the control. Scoring system was used to estimate the bulk of disease according to the site involved in MRI scan. Odds ratio and chi-square tests were used to study risk and association respectively. ROC curve was obtained for the MRI scores of the cases and controls.

RESULTS

214 patients were studied in all; 44.39% and 61.68% had palate and orbit involvement, respectively. Maxillary sinus roof had significant association and the highest risk for spread of disease into the palate. The risk for the orbit to be involved was increased when there was disease in the cavernous and sphenoid sinus. For the orbit, the site with the significant association was the ethmoid sinus, infratemporal fossa and roof of the maxillary sinus.

CONCLUSION

Due attention should be given for clearance during surgical debridement to the high-risk sites to prevent recurrences and reduce morbidity and mortality. MRI scores were most helpful to identify the bulk of disease when both palate and orbit were involved.

Epidemiological Mucormycosis treatment and diagnosis challenges using the adaptive properties of computer vision techniques based approach: a review

As everyone knows that in today's time Artificial Intelligence, Machine Learning and Deep Learning are being used extensively and generally researchers are thinking of using them everywhere. At the same time, we are also seeing that the second wave of corona has wreaked havoc in India. More than 4 lakh cases are coming in 24 h. In the meantime, news came that a new deadly fungus has come, which doctors have named Mucormycosis (Black fungus). This fungus also spread rapidly in many states, due to which states have declared this disease as an epidemic. It has become very important to find a cure for this life-threatening fungus by taking the help of our today's devices and technology such as artificial intelligence, data learning. It was found that the CT-Scan has much more adequate information and delivers greater evaluation validity than the chest X-Ray. After that the steps of Image processing such as pre-processing, segmentation, all these were surveyed in which it was found that accuracy score for the deep features retrieved from the ResNet50 model and SVM classifier using the Linear kernel function was 94.7%, which was the highest of all the findings. Also studied about Deep Belief Network (DBN) that how easy it can be to diagnose a life-threatening infection like fungus. Then a survey explained how computer vision helped in the corona era, in the same way it would help in epidemics like Mucormycosis.

Mucormycosis in COVID-19: A systematic review of literature

Coronavirus disease 2019 (COVID-19) is an acute viral illness caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Opportunistic infections such as mucormycosis have been reported among COVID-19 patients particularly in South Asian countries during the second wave of this pandemic. It is necessary to re-evaluate any changes in traditional risk factors associated with mucormycosis such as diabetes mellitus, organ transplant, etc in the precedent of ongoing COVID-19 pandemic. We conducted a systematic review using electronic databases. A total of 115 COVID-19 patients who were diagnosed with mucormycosis were included in this study. Diabetes mellitus was the most common co-morbidity with 77.1%, followed by hypertension (29.5%) and renal disease (14.3%). 55.2% of the patients had received dexamethasone for COVID-19 infection. Ten patients (11.5%) had received tocilizumab. Sinuses were the most common site of mucormycosis among COVID-19 patients at 79.4% with maxillary sinus (47.4%) being most commonly infected. Orbits were the second most prevalent site at 56.7% and lungs were infected with mucor at 11.3%. The mean duration between the diagnosis of COVID-19 infection and mucormycosis was 16.15 days (range 2-90 days). Cavernous sinus was either infiltrated or encased in 14 patients (14.4%). Cerebral involvement was seen in terms of abscess, infarcts, or edema in 12 patients (12.4%). Only 76 patients had data on the outcomes, out of which 37 (48.7%) patients had died. Diabetes mellitus is still the most common co-morbidity similar to non-COVID-19 patients. More than 90% of the patients with COVID-19 infection had received steroids. Complications such as cavernous sinus thrombosis, cerebral infarcts, abscesses were common. Indiscriminate use of steroids in patients needs to be avoided and focus needs to be put on tight blood sugar control in diabetic patients. Studies are needed to confirm the role of the SARS-CoV-2 virus in causing immune dysfunction and mucormycosis.

Mucormycosis in COVID-19 pandemic: study at tertiary hospital in India

Aim

During the second wave of COVID-19, cases of mucormycosis were increased suddenly over a period of 3 months in Maharashtra, India. An attempt was made to study the clinical profile and risk factors associated with mucormycosis.

Materials and methods

A retrospective descriptive study was carried out at a tertiary hospital during May 2021–July 2021. After obtaining informed written consent from the participants, various details of all participants, such as diabetes mellitus, use of steroids in COVID-19 treatment, use of immunosuppressant drugs, oxygen therapy, use of ventilators, complications that occurred during treatment, etc., were noted. All mucormycosis patients were treated with amphotericin B and aggressive surgical treatment.

Results

In the present study, 74.7% of mucormycosis patients were male. 77.4% of mucormycosis patients were above 40 years of age. 6.7% of mucormycosis patients were partially vaccinated. Among risk factors, 86.6% had diabetes mellitus, 84% had COVID-19 infection, 44% had received steroids, and 54.7% had received oxygen. 80% of patients were present during and within 1 month of COVID-19 infection. 52% of patients were presented in stage III and 41.3% were presented in stage II. Despite aggressive surgical debridement along with amphotericin B, mortality was 25.33%. 5.3% of patients had brain abscesses, 8% of patients had cavernous sinus thrombosis, 4% of patients had facial nerve palsy and 1.3% of patients had meningitis.

Conclusion

Mucormycosis was predominantly seen in male above the age of 40 years COVID-19 infection and diabetes mellitus was common risk factor for mucormycosis.

Risks of mucormycosis in the current Covid-19 pandemic: a clinical challenge in both immunocompromised and immunocompetent patients

Mucormycosis, also called "Black Fungus", is a new cause for worry in the current Coronavirus disease 2019 (covid-19) pandemic. Mucormycosis is devasting due to its high rate of morbidity and mortality which is a great cause of concern. Mucormycosis, in general, affects immunocompromised patients including diabetic, people with malignancies, organ and stem cell transplants and people affected with pandemic diseases like covid-19. Diagnosis of Mucormycosis is often delayed either due to clinical complications or misdiagnosed as symptoms of other diseases, especially covid-19. This could delay the treatment protocol which results in the failure of treatment. Mortality rate due to secondary infections in covid-19 patients with uncontrolled diabetics and who are on steroid therapy can soon reach 100% if diagnosis and treatment doesn't happen on timely basis. Risk of Mucormycosis is not just in immunosuppressed patients, but immunocompetent people with late diagnosis are also prone to infection. In view of this, we present a comprehensive review on risks of Mucormycosis in immunocompromised and immunocompetent patients highlighting the epidemiology, forms of Mucormycosis, immune response against Mucorales, difficulties in diagnosis and challenges in treatment of Mucormycosis, with emphasis on covid-19 associated Mucormycosis. Importantly, we have discussed the precautions and care to effectively manage Mucormycosis in immunocompromised and immunocompetent patients. Thus, current review helps clinicians in understanding various risk factors in both immunocompromised (especially covid-19 patients) and immunocompetent patients which is critical in managing Mucormycosis in current covid-19 pandemic.

Gastrointestinal mucormycosis: A periodic systematic review of case reports from 2015 to 2021

BACKGROUND

GI mucormycosis (GI) is a rare but highly lethal infection in patients. There is no single comprehensive review of the literature that demonstrates the various clinical aspects of this infection.

METHODS

A structured search of PubMed/Medline was used to collect case reports of GI mucormycosis in patients of all ages published between 2015 and November 2021.

RESULTS

Eighty-seven cases were identified through PubMed bibliographic database searches, and final analyses were conducted on 70 adults and ten neonatal patients with GI mucormycosis. Asia had the highest number of reported cases, with 46 (57.5%). Neonatal cases had a mortality rate of 70%, while other cases had a mortality rate of 44%. Corticosteroid therapy and diabetes were the most significant risk factors in patients, while 11% were immunocompetent with no apparent underlying condition. COVID-19 positivity was detected in four adult patients. Moreover, neonatal cases included premature and low-weight infants, metabolic acidosis, and malnutrition. Abdominal pain, fever, and GI perforation were the most common signs of infection, while vomiting occurred in 40% of neonatal cases. In 97% of patients, a histopathologic examination was used to detect infection, whereas culture and molecular methods were used in only 28% and 17% of patients, respectively. Surgery plus anti-infection therapy, anti-infection therapy alone, and surgery alone were used in 61%, 28%, and 11% of patients, respectively. Nonetheless, all neonatal patients underwent surgery. Although used in a small number of patients, posaconazole (30%) and isavuconazole (11%) demonstrated high efficacy in treating patients.

CONCLUSION

GI mucormycosis is a rare but highly lethal disease. Treatment of underlying conditions, the use of multiple diagnostic techniques, and appropriate antifungals in conjunction with surgery can all contribute to infection control.

In silico prediction and structure-based multitargeted molecular docking analysis of selected bioactive compounds against mucormycosis

BACKGROUND

During the second wave of the COVID-19 pandemic, an unusual increase in cases of mucormycosis was observed in India, owing to immunological dysregulation caused by the SARS-CoV-2 and the use of broad-spectrum antibiotics, particularly in patients with poorly controlled diabetes with ketoacidosis to have contributed to the rise, and it has been declared an epidemic in several states of India. Because of the black colouring of dead and dying tissue caused by the fungus, it was dubbed "black fungus" by several Indian media outlets. In this study, attempts were taken to unmask novel therapeutic options to treat mucormycosis disease. Rhizopus species is the primary fungi responsible for 70% of mucormycosis cases.

RESULTS

We chose three important proteins from the Rhizopus delemar such as CotH3, Lanosterol 14 alpha-demethylase and Mucoricin which plays a crucial role in the virulence of Mucorales. Initially, we explored the physiochemical, structural and functional insights of proteins and later using AutoDock Vina, we applied computational protein-ligand binding modelling to perform a virtual screening around 300 selected compounds against these three proteins, including FDA-approved drugs, FDA-unapproved drugs, investigational-only drugs and natural bioactive compounds. ADME parameters, toxicity risk and biological activity of those compounds were approximated via in silico methods. Our computational studies identified six ligands as potential inhibitors against Rhizopus delemar, including 12,28-Oxamanzamine A, vialinin B and deoxytopsentin for CotH3; pramiconazole and saperconazole for Lanosterol 14 alpha-demethylase; and Hesperidin for Mucoricin. Interestingly, 12,28-Oxamanzamine A showed a maximum binding affinity with all three proteins (CotH3: - 10.2 kcal/mol Lanosterol 14 alpha-demethylase: - 10.9 kcal/mol Mucoricin: - 8.6 kcal/mol).

CONCLUSIONS

In summary, our investigation identified 12,28-Oxamanzamine A, vialinin B, deoxytopsentin, pramiconazole, saperconazole and hesperidin as potent bioactive compounds for treating mucormycosis that may be considered for further optimisation techniques and in vitro and in vivo studies.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s42269-022-00704-4.

COVID-19 associated mucormycosis - An emerging threat

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly become a global threaten since its emergence in the end of 2019. Moreover, SARS-CoV-2 infection could also present with co-infection or secondary infection by other virus, bacteria, or fungi. Among them, mucormycosis is a rare but aggressive fungal disease and it mainly affects patients particularly with poorly controlled diabetes mellitus with diabetic ketoacidosis (DKA). We here did a comprehensive review of literature reporting COVID-19 associated with mucormycosis (CAM) cases, which have been reported worldwide. The prevalence is higher in India, Iran, and Egypt than other countries, particularly highest in the states of Gujarat and Maharashtra in India. Poor diabetic control and the administration of systemic corticosteroids are the common precipitating factors causing mucormycosis in the severe and critical COVID-19 patients. In addition, COVID-19 itself may affect the immune system resulting in vulnerability of the patients to mucormycosis. Appropriate treatments of CAM include strict glycemic control, extensive surgical debridement, and antifungal therapy with amphotericin B formulations.

Perception of mucormycosis infection among Bangladeshi healthcare workers: an exploratory cross-sectional study in the year following the COVID-19 pandemic

BACKGROUND

Mucormycosis, a severe fungal infection, is an emerging public health concern during the COVID-19 pandemic. This study aimed to investigate the perception of mucormycosis among Bangladeshi healthcare workers.

RESULTS

An exploratory cross-sectional study was carried out among the Bangladeshi healthcare workers from May 25, 2021, to June 5, 2021. The study found 422 responses from the healthcare workers of Bangladesh. Among the respondents, nearly half of them (45.26%) were doctors (n = 191). This study explored that the healthcare workers' mucormycosis perception scores were significantly associated with their age, gender, profession, monthly income, marital status, job type, and death of friends and family members due to COVID-19.

CONCLUSIONS

This study emphasized the healthcare workers' mucormycosis perception along with other associated factors. The findings could help policymakers to mitigate mucormycosis and related infectious diseases emergencies in the post-COVID-19 situation.

Intraoperative Scoring Assessment as a Prognostic Tool in Covid-19 Associated Mucormycosis: A Short-Term Observational Study

To introduce an intraoperative scoring system for covid-19 associatedmucormycosis An observational study conducted among 43 cases of confirmed CAM whichincluded 35 males and 8 females, with an average age of 56 years. The surgicalapproach adopted in our cases included endoscopic surgical debridement withDenker’s approach including mandatory pterygopalatine and infratemporal fossaexploration. All cases were intraoperatively scored using our designed intraoperativescoring assessment tool for mucormycosis. Postoperatively patient recovery wasassessed using C reactive protein levels and weekly imaging. Although an early observation in the post op period we observed highermortality among cases reporting with high scores as per our intraoperative reportingsystem. At the end of 2 months of completed treatment we report 6 cases of mortalityamong whom 5 cases were found to have scores (> 25) and one reported with a scoreof 18. This assessment helped us in grading the disease severity and also gaveus an insight about the postoperative prognosis too. Global scientific collaboration andreporting of a validated tool for CAM is of paramount importance to increase theknowledge with regard to this emerging disease.

Anu taila, an herbal nasal-drop, suppresses mucormycosis by regulating host TNF-α response and fungal ergosterol biosynthesis

AIM

The intractable, mucormycosis, caused by Mucorales primarily targets immunocompromised individuals. The first-line therapy, intravenous liposomal Amphotericin B and surgical debridement of necrotic tissue, is contraindicative in individuals with compromised kidneys. This invokes a pressing need to identify safer treatment options.

METHODS AND RESULTS

Antifungal effect of the classical nasal drop, Anu taila, against Mucor spp. was investigated through microbiological, cytological, analytical chemical (HPLC and GS/MS/MS) and field emission scanning electron microscopic (FE-SEM) approaches. Anu taila pre-treated spores germinated late, resulting in reduced infectivity, observed as milder monocytic immune response. Conversely, Anu taila pre-treated THP-1 cells exhibited an improved immune response, through TNF-α, against Mucor spores. Repeated Anu taila application abolished fungal microarchitectures faster than Amphotericin B, evident from rapid replacement of hyphae, sporangiophores and sporangia with fused biomass, in the FESEM images. Anu taila downregulated sterol-C5-desaturase-coding ERG3 gene, crucial for ergosterol biosynthesis and resultant structural integrity, in Mucor spp.

CONCLUSION

Taken together, Anu taila was found effective against Mucor spp., with both prophylactic and curative implications, attributable to its phytochemical composition.

SIGNIFICANCE

Potential remedial effects of a classical nasal drop against an obdurate and challenging fungal infection are identified.

Are Low Serum Vitamin D Levels a Risk Factor for Advent of COVID-19 Associated Rhinocerebral Mucormycosis: A Preliminary Case Control Study

To determine whether low serum vitamin D level is a risk factor for development of Rhinocerebral mucormycosis in COVID-19 afflicted patients. A case control study was conducted in a tertiary care hospital utilizing the archived records of COVID-19 afflicted Rhinocerebral mucormycosis cases and age and gender matched controls. The mean value (± standard deviation) of vitamin D level in patients with Mucormycosis was 19.65 ± 13.07 ng/ml and in control subjects it was 27.88 ± 18.04 ng/ml.There was a significant difference between groups (p = 0.02). Thus, low Vitamin D level may be implicated as a risk factor for the advent of mucormycosis in a COVID-19 afflicted patient and therefore Vitamin D supplements may be provided to such patients to achieve normal serum levels.

Palatal Flap: An Optimistic Salvagable Option to Negate the Maxillectomy Defects in COVID Related Rhino-Orbito-Cerebral Mucormycosis

We present three cases diagnosed with COVID-19 associated Rhino-orbito-cerebral mucormycosis, managed by aggressive debridement and resection of the involved maxilla, followed by primary closure with preserved palatal flap, thus trying to establish its versatility for the closure of the maxillectomy defects.

Rhino-Cerebral Mucormycosis with Otologic Involvement

Mucormycosis is an opportunistic invasive fungal infection, recently been detected in Covid-19 due to several underlying conditions. Otologic involvement in such patients though exceptional, should not be simply ignored even when presented without any clinical signs or symptoms. This report manifests the need of evaluating otologic involvement in post-covid mucormycosis.

Evaluation of serum Mucorales PCR for the diagnosis of Mucormycoses: The MODIMUCOR prospective trial

BACKGROUND

Early diagnosis and prompt initiation of specific antifungal treatment is essential for improving the prognosis of mucormycosis. We aimed to assess the performance of serum Mucorales quantitative PCR (qPCR) for the early diagnosis and follow-up of mucormycosis.

METHODS

We prospectively enrolled 232 patients with suspicion of invasive mold disease, evaluated using standard imaging and mycological procedures. Thirteen additional patients with proven or probable mucormycosis were included to analyze DNA load kinetics. Serum samples were collected twice-a-week for Mucorales qPCR tests targeting the Mucorales species Lichtheimia, Rhizomucor and Mucor/Rhizopus.

RESULTS

The sensitivity was 85·2%, specificity 89·8%, and positive and negative likelihood ratios 8·3 and 0·17, respectively in this prospective study. The first Mucorales qPCR-positive serum was observed a median of four days (IQR, 0-9) before sampling of the first mycological or histological positive specimen and a median of one day (IQR, (-2)-6) before the first imaging was performed. Negativity of Mucorales qPCR within seven days after liposomal-amphotericin B initiation was associated with an 85% lower 30-day mortality rate (adjusted hazard Ratio = 0·15, 95%CI [0·03-0·73], p = 0·02).

CONCLUSION

Our study argues for the inclusion of qPCR for the detection of circulating Mucorales DNA for mucormycosis diagnosis and follow-up after treatment initiation. Positive results should be added to the criteria for the consensual definitions from the European Organization for the Research and Treatment of Cancer/ Mycoses Study Group Education and Research Consortium (EORTC/MSGERC), as already done for Aspergillus PCR.

Image challenge: A diabetic man with facial swelling following recent Covid-19 infection

A 68-year-old man with diabetes presented with shortness of breath, left sided facial swelling, and nasal discharge. He had recently returned from India and PCR was positive for SARS-CoV-2 Delta variant. CT head and diffusion-weighted MRI sinuses were performed and the patient underwent endoscopic sinus surgery before being transferred to a specialist skull base centre.

Gingival presentation of mucormycosis post infection with COVID-19: series of 3 cases

Through the evolution of this global pandemic, it became increasingly clear that patients with pre-existing conditions such as diabetes mellitus, chronic kidney diseases (CKD), chronic cardiovascular disease, underlying malignancies, organ transplant recipients, and chronic liver disease are at increased risk for developing severe post COVID-19 complications. One such complication seen after COVID-19 is mucormycosis. Oral mucormycosis is a rare but highly fatal disease. Early diagnosis and timely treatment of rhinomaxillary mucormycosis are necessary to limit the spread of infection, which otherwise can lead to high morbidity and mortality. Dental healthcare practitioners should be familiar with its initial presentation, which if left undiagnosed or ignored can rapidly spread to the orbital and cerebral region leading to death. The case series describes the gingival clinical presentation in its initial stage, relevant basic clinical investigations, treatment, and the importance of an inter-professional team approach in the early management of patients with mucormycosis after post covid-19 infection.

Mucormycosis: A new threat to Coronavirus disease 2019 with special emphasis on India

The main reason for the growth of mucormycosis in people with Coronavirus disease-2019 (COVID-19) is mainly produced by Rhizopus spp. The infective mechanisms and issues recognized in Rhizopus spp. are the cell wall, germination proteins, and enzymes assisted to iron sequestration, CotH protein, and positive regulation of the GRP78 cell receptor. Mucormycosis is mainly caused by the Rhizopus spp. such as R. oryzae, R. microsporus, R. arrhizus, R. homothallicus, etc. that are gifted to numerous host defense mechanisms and attribute to the endothelium via specific receptors, GRP78 simplifying their endocytosis and angio-invasion. Factors such as hyperglycemia, elevated iron concentrations, and ketoacidosis have been shown to contribute to the pathogenesis in the tentative situation. The analytical data of 'black fungus disease' or 'mucormycosis', specify India reported for about 42.3% of published cases, followed by the USA about 16.9%, Iraq, Bangladesh, Iran, Paraguay, and 1 case each from Brazil, Mexico, Italy, UK, China, France, Uruguay, Turkey, and Austria. The COVID-19 infection is maybe a predisposing factor for mucormycosis and is related to a high mortality rate. Early recognition and restriction of hyperglycemia, liposomal amphotericin B, and surgical debridement are the bases in the successful managing of mucormycosis.

COVID associated mucormycosis: A preliminary study from a dedicated COVID Hospital in Delhi

Background

It is an incontrovertible fact that the Rhino Orbital Cerebral Mucormycosis (ROCM) upsurge is being seen in the context of COVID-19 in India. Briefly presented is evidence that in patients with uncontrolled diabetes, a dysfunctional immune system due to SARS-COV-2 and injudicious use of corticosteroids may be largely responsible for this malady.

Objective

To find the possible impact of COVID 19 infection and various co-morbidities on occurrence of ROCM and demonstrate the outcome based on medical and surgical interventions.

Methodology.

Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID-19 infection. Diagnostic nasal endoscopy (DNE) was performed on each patient and swabs were taken and sent for fungal KOH staining and microscopy. Medical management included Injection Liposomal Amphotericin B, Posaconazole and Voriconazole. Surgical treatment was restricted to patients with RT PCR negative results for COVID-19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow-up for survived patients was maintained regularly for the first postoperative month.

Results

Out of total 131 patients, 111 patients had prior history of SARS COVID 19 infection, confirmed with a positive RT-PCR report and the rest 20 patients had no such history. Steroids were received as a part of treatment in 67 patients infected with COVID 19. Among 131 patients, 124 recovered, 1 worsened and 6 died. Out of 101 known diabetics, 98 recovered and 3 had fatal outcomes. 7 patients with previous history of COVID infection did not have any evidence of Diabetes mellitus, steroid intake or any other comorbidity.

Conclusion

It can be concluded that ROCM upsurge seen in the context of COVID-19 in India was mainly seen in patients with uncontrolled diabetes, a dysfunctional immune system due to SARS-COV-2 infection and injudicious use of corticosteroids.

COVID-19 associated mucormycosis: evolving technologies for early and rapid diagnosis

The post-coronavirus disease (COVID-19) mucormycosis is a deadly addition to the pandemic spectrum. Although it’s a rare, aggressive, and opportunistic disease, the associated morbidity and mortality are significant. The complex interplay of factors aggravating CAM is uncontrolled diabetes, irrational and excessive use of antibiotics, steroids, and an impaired immune system. Recently, India has been witnessing a rapid surge in the cases of coronavirus disease-associated mucormycosis (CAM), since the second wave of COVID-19. The devastating and lethal implications of CAM had now become a matter of global attention. A delayed diagnosis is often associated with a poor prognosis. Therefore, the rapid and early diagnosis of infection would be life-saving. Prevention and effective management of mucormycosis depend upon its early and accurate diagnosis followed by a multimodal therapeutic approach. The current review summarizes an array of detection methods and highlights certain evolving technologies for early and rapid diagnosis of CAM. Furthermore, several potential management strategies have also been discussed, which would aid in tackling the neglected yet fatal crisis of mucormycosis associated with COVID-19.

Effect of Ayurvedic Intervention as an adjunct therapy in Post COVID-19 Mucormycosis (PCM): A non-randomized parallel group study

Background

The Ayurveda therapy is often used as an adjunct to conventional allopathic treatments for management of chronic disorders including life threatening infections such as post COVID-19 Mucormycosis (PCM).

Aims/objectives

The aim of the current study is to evaluate the role of adjunct Ayurveda therapy (AAT + CAT) over conventional Allopathic therapy (CAT) in the prevention of progression of oral/orbital/neural extension of PCM.

Material and methods

A non-randomised parallel group interventional study was on a sample of 92 cases of PCM, sorted into two groups i.e. group A (n = 46; AAT + CAT) and group B (n = 46; CAT/controls). The group A received AAT (lab-tested standardised regimen) while simultaneously receiving conventional antifungal measures (or CAT). The outcomes assessed were clinical symptomatic grading score, Nasal endoscopic examination for patency of sinuses, Progression or extension of disease from sinuses to maxilla, orbit and brain, need of additional surgical interventions and antifungal medication after study period, adverse drug reactions and mortality.

Results

The group A (AAT + CAT)) had shown extension free PCM in 86.96% (n = 40) as opposed to 41.3% (n = 19) in group B (CAT), No surgical interventions were needed in 89.13% (n = 41) in group A vs. 60.87% (n = 28) in group B. Around 69.5% (n = 32) in group A vs. 4.37% (n = 2) in group B did not need antifungal medication. The safety of both arms of the therapy has been determined by liver function and renal profile which are with in normal range in both groups.

Conclusion

Adjunct Ayurveda therapy (given along with routine medical therapy) for PCM showed a better cure and reduced disease progression after a trial period of 45 days and in the extended observational period of three months. AAT + CAT regimen is not only therapeutically effective, but also safe and economical option to consider for PCM.

COVID-19-associated opportunistic infections: a snapshot on the current reports

Treatment of the novel Coronavirus Disease 2019 (COVID-19) remains a complicated challenge, especially among patients with severe disease. In recent studies, immunosuppressive therapy has shown promising results for control of the cytokine storm syndrome (CSS) in severe cases of COVID-19. However, it is well documented that immunosuppressive agents (e.g., corticosteroids and cytokine blockers) increase the risk of opportunistic infections. On the other hand, several opportunistic infections were reported in COVID-19 patients, including Aspergillus spp., Candida spp., Cryptococcus neoformans, Pneumocystis jiroveci (carinii), mucormycosis, Cytomegalovirus (CMV), Herpes simplex virus (HSV), Strongyloides stercoralis, Mycobacterium tuberculosis, and Toxoplasma gondii. This review is a snapshot about the main opportunistic infections that reported among COVID-19 patients. As such, we summarized information about the main immunosuppressive agents that were used in recent clinical trials for COVID-19 patients and the risk of opportunistic infections following these treatments. We also discussed about the main challenges regarding diagnosis and treatment of COVID-19-associated opportunistic infections (CAOIs).

Mucormycosis in COVID-19: Is Zinc a Silent Killer in India?

How to cite this article: Nath S, Baidya DK. Mucormycosis in COVID-19: Is Zinc a Silent Killer in India? Indian J Crit Care Med 2021;25(9):1079-1080.