Epidemiology and clinical manifestations of mucormycosis

Clinical evaluation of a Mucorales-specific real-time PCR assay in tissue and serum samples

Molecular diagnostic assays can accelerate the diagnosis of fungal infections and subsequently improve patient outcomes. In particular, the detection of infections due to Mucorales is still challenging for laboratories and physicians. The aim of this study was to evaluate a probe-based Mucorales-specific real-time PCR assay (Muc18S) using tissue and serum samples from patients suffering from invasive mucormycosis (IMM). This assay can detect a broad range of clinically relevant Mucorales species and can be used to complement existing diagnostic tests or to screen high-risk patients. An advantage of the Muc18S assay is that it exclusively detects Mucorales species allowing the diagnosis of Mucorales DNA without sequencing within a few hours. In paraffin-embedded tissue samples this PCR-based method allowed rapid identification of Mucorales in comparison with standard methods and showed 91 % sensitivity in the IMM tissue samples. We also evaluated serum samples, an easily accessible material, from patients at risk from IMM. Mucorales DNA was detected in all patients with probable/proven IMM (100 %) and in 29 % of the possible cases. Detection of IMM in serum could enable an earlier diagnosis (up to 21 days) than current methods including tissue samples, which were gained mainly post-mortem. A screening strategy for high-risk patients, which would enable targeted treatment to improve patient outcomes, is therefore possible.

Risk factors and prophylaxis against invasive fungal disease for haematology and stem cell transplant recipients: an evolving field

INTRODUCTION

Due to increasing intensity and complexity of therapies and longer survivorship, many patients with haematologic malignancy (HM) are at risk of invasive fungal disease (IFD). Mortality from IFD is high and treatment of an episode of IFD results in an excess length of hospital stay and costs and delays delivery of curative therapy of the underlying haematologic condition. Therefore, prevention and early recognition and treatment of IFD are crucial. Areas covered: Risk factors particular to certain HMs and haematopoietic stem cell transplantation, as well as those risk factors universal to all HM groups are examined. Expert commentary: Risk stratification identifies those patients who would benefit most from mould active versus yeast active prophylaxis and those who can be safely managed with monitoring and clinically driven interventions for IFD. This approach aids in antifungal stewardship.

Management of rhinomaxillary mucormycosis with Posaconazole in immunocompetent patients

Mucormycosis is an opportunistic, uncommon and serious systemic fungal infection mostly presenting in immunocompromised patients. The combination of surgical debridement, parenteral therapy with Amphotericin B and management of the underlying systemic disease is the standard treatment modality for mucormycosis. The drawback of this regime is the need for long hospitalization due to the serious side effects of Amphotericin B requiring regular monitoring. Oral Posaconazole is one of the newer antifungals that have shown promising results. This paper highlights a case series of rhinomaxillary mucormycosis in immunocompetent patients diagnosed and managed successfully with surgical debridement and oral Posaconazole administration on out-patient basis.

A case of rhino-orbital mucormycosis in diabetes with haematogenous cerebral spread

We document the first case of haematogenous cerebral spread in Rhizopus arrhizus rhino-orbital mucormycosis, and of posaconazole related adrenal insufficiency. A patient presenting with diabetic ketoacidosis and sinusitis was treated with right medial maxillectomy, ethmoidectomy and IV liposomal amphotericin. Orbital exenteration was performed after intraorbital spread of infection. IV caspofungin and posaconazole was added but complicated by adrenal insufficiency. MRI revealed a new left lentiform nucleus and thalamus rim-enhancing lesion indicating haematogenous cerebral spread.

Is It Time to Include CT "Reverse Halo Sign" and qPCR Targeting Mucorales in Serum to EORTC-MSG Criteria for the Diagnosis of Pulmonary Mucormycosis in Leukemia Patients?

In 23 leukemia patients with proven (n = 17) or possible (n = 6) pulmonary mucormycosis (PM), the presence of reversed halo sign on computed tomography was strongly associated with the positivity of quantitative polymerase chain reaction assays targeting Mucorales in the serum, confirming the value of these two tools for the diagnosis of PM in this setting.

Detection of the Dimorphic Phases of Mucor circinelloides in Blood Cultures from an Immunosuppressed Female

Mucormycosis fungemia is rarely documented since blood cultures are nearly always negative. We describe a case of Mucor circinelloides fungemia in a patient with a history of a sinus infection, sarcoidosis, and IgG deficiency. The identity of the isolate was supported by its microscopic morphology and its ability to convert into yeast forms under anaerobic conditions. The early detection, initiation of liposomal amphotericin B treatment, and reversal of underlying predisposing risk factors resulted in a good outcome.

Mucormycosis of the Forehead and Sinuses in a Trauma Patient

Mucormycosis is a rare fungal infection in immunocompetent patients. It is not commonly seen in trauma patients who sustain multisystem injuries and are often exposed to numerous infectious sources. A multidisciplinary approach between medical and surgical specialties is crucial to ensuring timely diagnosis and treatment as morbidity and mortality can be high once acquired. In addition to antifungal therapy, radical debridement and reconstruction by plastic surgery is often necessary. Review of the literature shows that there is no definitive reconstructive technique for mucormycosis of the forehead and sinuses because the amount of tissue destruction may be varied in location and depth, therefore requiring varying extents of debridement. However, other reconstructive techniques commonly used for oncologic and trauma reconstructions can be used to achieve functionality and a satisfactory cosmetic result. Few facial reconstructions after infection with mucormycosis have been documented in the literature.

Detection of Circulating Mucorales DNA in Critically Ill Burn Patients: Preliminary Report of a Screening Strategy for Early Diagnosis and Treatment

BACKGROUND

 Invasive wound mucormycosis (IWM) is associated with an extremely poor outcome among critically ill burn patients. We describe the detection of circulating Mucorales DNA (cmDNA) for the early diagnosis of IWM in those patients and report the potential value of detecting cmDNA for treatment guidance.

METHODS

 Severely ill burn patients admitted to our tertiary referral center between October 2013 and February 2016 were included. Retrospective plasma samples were tested for the presence of cmDNA by quantitative real-time polymerase chain reaction (qPCR). Patients were then prospectively screened twice a week, and liposomal amphotericin-B therapy initiated based on a positive qPCR. The primary endpoint was the time between cmDNA detection and standard diagnosis. Secondary endpoints were the time from cmDNA detection and treatment initiation and mortality.

RESULTS

 Seventy-seven patients (418 samples) were included. The average age was 46 (28-60) years, abbreviated burn severity index was 8 (7-10), and simplified acute physiology score was 33 (23-46). The total body surface area was 33% (22%-52%). cmDNA was detected 11 (4.5-15) days before standard diagnosis. The in-hospital mortality was 62% for patients with IWM and 24% for those without (P = .03). The mortality due to IWM was 80% during period A and 33% during period B (P = .46).

CONCLUSIONS

 This study suggests that the detection of cmDNA allows earlier diagnosis of IWM in severely ill burn patients and earlier initiation of treatment. Further studies are needed to confirm the impact of earlier treatment initiation on patient outcome.

Primary cutaneous mucormycosis in an immunocompetent patient

Mucormycosis is most common in immunocompromised patients, but it can also occur in healthy hosts, most frequently as primary cutaneous mucormycosis (PCM) and predominantly as a result of skin trauma. We present an uncommon case of PCM in a healthy, young man with no previous history of local trauma. Despite rapid progression of the infection, the patient was successfully treated through surgical intervention and by administering liposomal amphotericin B and posaconazole. He made a full recovery without the need for skin grafting.

Early Differential Diagnosis of Rhino-Orbito-Cerebral Mucormycosis and Bacterial Orbital Cellulitis: Based on Computed Tomography Findings

PURPOSE

To identify significant clinical and radiological findings that distinguish rhino-orbito-cerebral mucormycosis (ROCM) from bacterial orbital cellulitis (BOC).

METHODS

This study was retrospective, multicenter, case-control study that enrolled 34 cases; 14 cases were diagnosed with ROCM and 20 cases were diagnosed with BOC at three different tertiary hospitals between 2005 and 2013. The medical records of all 34 cases were reviewed. The initial clinical manifestations (eyelid swelling, ptosis, extraocular muscle [EOM] limitation, conjunctival injection, and chemosis) and computed tomography (CT) findings (sinus mucosal thickening, full opacification, and air-fluid level) of both diseases were compared.

RESULTS

Patients with diabetes mellitus (DM) and hypertension (HTN) showed higher incidence rates of ROCM than BOC (DM: p < 0.001, HTN: p = 0.036). ROCM cases exhibited more frequent EOM limitation than cases with BOC (100.0% vs. 66.7%, p = 0.024) but less frequent eyelid swelling (35.7% vs. 90.0%, p = 0.002). However, the incidence rates of ptosis, conjunctival injection, and chemosis exhibited no differences between the diseases. Abnormal CT findings were observed in the sinuses of all patients with ROCM, whereas 12 patients with BOC had sinus abnormalities (100.0% vs. 60.0%, p = 0.011). Thickening of the sinus mucosa was more frequent in patients with ROCM than in those with BOC (92.9% vs. 45.0%, p = 0.009). No significant differences in full opacification or air-fluid level were detected between the groups.

CONCLUSIONS

The differential diagnosis of ROCM and BOC is difficult. Nevertheless, physicians should consider ROCM when a patient with suspected orbital cellulitis presents with EOM limitation without swollen eyelids or thickening of the sinus mucosa on a CT scan.

Role of isavuconazole in the treatment of invasive fungal infections

Despite recent advances in both diagnosis and prevention, the incidence of invasive fungal infections continues to rise. Available antifungal agents to treat invasive fungal infections include polyenes, triazoles, and echinocandins. Unfortunately, individual agents within each class may be limited by spectrum of activity, resistance, lack of oral formulations, significant adverse event profiles, substantial drug–drug interactions, and/or variable pharmacokinetic profiles. Isavuconazole, a second-generation triazole, was approved by the US Food and Drug Administration in March 2015 and the European Medicines Agency in July 2015 for the treatment of adults with invasive aspergillosis (IA) or mucormycosis. Similar to amphotericin B and posaconazole, isavuconazole exhibits a broad spectrum of in vitro activity against yeasts, dimorphic fungi, and molds. Isavuconazole is available in both oral and intravenous formulations, exhibits a favorable safety profile (notably the absence of QTc prolongation), and reduced drug–drug interactions (relative to voriconazole). Phase 3 studies have evaluated the efficacy of isavuconazole in the management of IA, mucormycosis, and invasive candidiasis. Based on the results of these studies, isavuconazole appears to be a viable treatment option for patients with IA as well as those patients with mucormycosis who are not able to tolerate or fail amphotericin B or posaconazole therapy. In contrast, evidence of isavuconazole for invasive candidiasis (relative to comparator agents such as echinocandins) is not as robust. Therefore, isavuconazole use for invasive candidiasis may initially be reserved as a step-down oral option in those patients who cannot receive other azoles due to tolerability or spectrum of activity limitations. Post-marketing surveillance of isavuconazole will be important to better understand the safety and efficacy of this agent, as well as to better define the need for isavuconazole serum concentration monitoring.

Gastrointestinal mucormycosis after abdominal aortic aneurysm repair and prolonged hospitalization: A case report and review of the literature

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Mucormycosis is an opportunistic fungal infection which can sometimes affect the gastrointestinal tract.

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Infection causes thrombosis and necrosis of affected tissue and carries a high mortality rate.

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A high index of suspicion is necessary to diagnose and begin treatment with amphotericin B.

Introduction

Mucormycosis is a rare fungal infection typically affecting immunocompromised hosts. One form of the disease affects the gastrointestinal tract.

Presentation of case

We present the case of a 70-year old patient with no recognized risk factors that developed gastrointestinal mucormycosis after urgent abdominal aortic aneurysm repair.

Discussion

There are several risk factors for this infection, such as hematological malignancies, solid organ or stem cell transplants and diabetes. The infectious agent causes thrombosis and necrosis of involved tissues and organs and carries a high mortality rate.

Conclusion

Mucormycosis is an opportunistic infection which can sometimes affect the gastrointestinal tract. A high index of suspicion is necessary in order to make an early diagnosis and promptly start an appropriate treatment regimen.

Posaconazole: an emerging therapeutic option for invasive rhino-orbito-cerebral mucormycosis

Posaconazole has significant activity against the Mucormycetes. However, data are limited on the clinical efficacy of posaconazole for treating rhino-orbito-cerebral mucormycosis (ROCM). The aim of this study is to assess the efficacy and safety of posaconazole in patients with ROCM. We included 12 consecutive adult patients admitted with ROCM and treated with posaconazole between January 2010 and February 2015. The main outcome of the study was the overall success rate (i.e. either complete or partial response) at the end of treatment. We also assessed serum posaconazole concentrations in a subgroup of patients. Of the 12 patients who received posaconazole, eight patients (66.6%) had complete resolution with median follow-up of 6.5 months (range 2-24 months). Two patients (16.6%) had significant reduction of disease and two (16.6%) had marked residual disease on follow-up. Uncontrolled diabetes was the predisposing factor in all except one patient. One patient developed diarrhoea on posaconazole, which settled without discontinuation of the drug. Posaconazole appears to be a safe and effective antifungal agent in diabetic patients with ROCM, especially in those who have toxicity with polyene therapy.

Disseminated mucormycosis (DM) after pneumonectomy: a case report

BACKGROUND

Mucormycosis is a kind of rare opportunistic fungal disease and the incidence of which has gradually increased. Disseminated mucormycosis (DM) is a life-threatening infection that mostly occurs in immunocompromised patients. The lung and brain are usually involved in disseminated mucormycosis, and other sites are scare. We report the first case of disseminated mucormycosis whose infection sites included lung, skin, liver, vertebra, and spinal cord that ensued after a right lung pneumonectomy in an immunocompetent patient.

CASE PRESENTATION

A 20-year-old female underwent a right lung pneumonectomy for "lung cancer" presented with an intermittent fever for two years. A computed tomography (CT) scan showed an enclosed outstanding mass in the right chest wall. The patient also suffered from lower limb numbness and weakness, difficulty walking, and dysuria. Medical examination showed superficial feeling of the abdominal wall was decreased from the T7 and T8 level; muscle strength for both lower limbs was decreased; muscle tension of both lower limbs was also diminished. A biopsy through the right chest wall mass and thoracic mass by fistula of chest wall showed broad nonseptate hyphae with right-angle branching, consistent with mucormycosis. With titration of amphotericin B and its lipid complex, the patient recovered.

CONCLUSIONS

Our case showed an unusual clinical presentation of disseminated mucormycosisin an immunocompetent patient.

Breaking the Mold

Objective: To review the current literature for the pathogenesis of mucormycosis, discuss diagnostic strategies, and evaluate the efficacy of polyenes, triazoles, and echinocandins as pharmacological treatment options. Data Sources: An electronic literature search was conducted in PubMed using the MESH terms Rhizopus, zygomycetes, zygomycosis, Mucorales and mucormycosis, with search terms amphotericin B, micafungin, anidulafungin, caspofungin, extended infusion amphotericin B, liposomal amphotericin B, combination therapy, triazole, posaconazole, isavuconazole, diagnosis, and clinical manifestations.Study Selection and Data Extraction: Studies written in the English language from January 1960 to March 2016 were considered for this review article. All search results were reviewed, and the relevance of each article was determined by the authors independently. Data Synthesis: Mucormycosis is a rare invasive fungal infection with an exceedingly high mortality and few therapeutic options. It has a distinct predilection for invasion of endothelial cells in the vascular system, which is likely important in dissemination of disease from a primary focus of infection. Six distinct clinical syndromes can occur in susceptible hosts, including rhino-orbital-cerebral, pulmonary, gastrointestinal, cutaneous, widely disseminated, and miscellaneous infection. Conclusion: Diagnosis of mucormycosis is typically difficult to make based on imaging studies, sputum culture, bronchoalveolar lavage culture, or needle aspirate. Surgical debridement prior to dissemination of infection improves clinical outcomes. Surgery combined with early, high-dose systemic antifungal therapy yields greater than a 1.5-fold increase in survival rates. The Mucorales are inherently resistant to most widely used antifungal agents. Amphotericin B is appropriate for empirical therapy, whereas posaconazole and isavuconazole are best reserved for de-escalation, refractory cases, or patients intolerant to amphotericin B.

Gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy in the years 2000

AIM: To review gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy. To look at gut microflora features in oncology children.

METHODS: We selected studies published after year 2000, excluding trials on transplanted pediatric patients. We searched English language publications in MEDLINE using the keywords: “gastrointestinal infection AND antineoplastic chemotherapy AND children”, “gastrointestinal infection AND oncology AND children”, “liver infection AND antineoplastic chemotherapy AND children”, “liver abscess AND chemotherapy AND child”, “neutropenic enterocolitis AND chemotherapy AND children”, “thyphlitis AND chemotherapy AND children”, “infectious diarrhea AND children AND oncology”, “abdominal pain AND infection AND children AND oncology”, “perianal sepsis AND children AND oncology”, “colonic pseudo-obstruction AND oncology AND child AND chemotherapy”, “microflora AND children AND malignancy”, “microbiota AND children AND malignancy”, “fungal flora AND children AND malignancy”. We also analysed evidence from several articles and book references.

RESULTS: Gastrointestinal and liver infections represent a major cause of morbidity and mortality in children undergoing antineoplastic chemotherapy. Antineoplastic drugs cause immunosuppression in addition to direct toxicity, predisposing to infections, although the specific risk is variable according to disease and host features. Common pathogens potentially induce severe diseases whereas opportunistic microorganisms may attack vulnerable hosts. Clinical manifestations can be subtle and not specific. In addition, several conditions are rare and diagnostic process and treatments are not standardized. Diagnosis may be challenging, however early diagnosis is needed for quick and appropriate interventions. Interestingly, the source of infection in those children can be exogenous or endogenous. Indeed, mucosal damage may allow the penetrance of endogenous microbes towards the bowel wall and their translocation into the bloodstream. However, only limited knowledge of intestinal dysbiosis in oncology children is available.

CONCLUSION: The diagnostic work-up requires a multimodal approach and should be implemented (also by further studies on new biomarkers) for a prompt and individualized therapy.

The burden of mucormycosis in HIV-infected patients: A systematic review

OBJECTIVES

Mucormycosis is an invasive fungal infection afflicting immunocompromised patients, causing a significant degree of morbidity and mortality. The purpose of the study was to provide a comprehensive analysis describing the epidemiology and outcome of mucormycosis in the scenario of HIV infection.

METHODS

We systematically searched PubMed for reports about mucormycosis associated with HIV. Eligible studies describe the predisposing factor, clinical form, treatment, and survival outcome.

RESULTS

We included 61 articles from 212 reviewed abstracts, corresponding to 67 cases. Patients were mostly men (68.2%) with a median CD4(+) count of 47 [IQR 17-100] cells/mm(3). Intravenous drug use (50%), neutropenia (29.7%) and corticosteroid use (25%) were the predominant associated factors. The main clinical forms were disseminated (20.9%), renal (19.4%), and rhino-cerebral (17.9%). Rhizopus (45.5%) and Lichtheimia spp (30.3%) were the main fungal isolates. Treatment consisted of antifungal therapy and surgery in 38.8%. Overall mortality rate was 52.2%, and varied with the site of infection: 92.9% for disseminated disease, 62.5% for cerebral disease, 60% for pulmonary infection, and 36.4% for cutaneous infection. Survival was worse for those who did not initiate antifungals (p = .04), who were antiretroviral naïve (p = .01), who were admitted to ICU (p = .003) or had disseminated disease (p = .007).

CONCLUSIONS

Mucormycosis is a life-threatening infection in HIV patients and clinician should be aware of this co-infection in the differential diagnosis of HIV opportunistic infections.

Cutaneous mucormycosis secondary to penetrative trauma

INTRODUCTION

Mucormycosis is a rare but serious sequelae of penetrating trauma [1-5]. In spite of aggressive management, mortality remains high due to dissemination of infection. We completed a review of literature to determine the most optimal treatment of cutaneous mucormycosis which occurs secondary to penetrating trauma.

METHODS

We completed a review regarding the management of mucormycosis in trauma patients. We selected a total of 36 reports, of which 18 were case-based, for review.

RESULTS

Surgical debridement is a primary predictor of improved outcomes in the treatment of mucormycosis [3,6,7]. Anti-fungal therapy, especially lipid soluble formulation of Amphotericin B, is helpful as an adjunct or when surgical debridement has been maximally achieved. Further research is needed to fully evaluate the impact of topical dressings; negative pressure wound therapy is helpful.

CONCLUSION

An aggressive and early surgical approach, even at the expense of disfigurement, is necessary to reduce mortality in the setting of cutaneous mucormycosis that results from penetrating trauma [4,8,9]. Anti-fungal therapy and negative pressure wound therapy are formidable adjuncts.

Recent developments in the management of invasive fungal infections in patients with oncohematological diseases

Patients with hematological cancer have a high risk of invasive fungal diseases (IFDs). These infections are mostly life threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly, Aspergillus and Candida species are involved. However, other non-Aspergillus molds are increasingly be identified in cases of documented IFDs. Important risk factors are long lasting granulocytopenia with neutrophil counts below 500/μl for more than 10 days or graft-versus-host disease resulting from allogeneic stem-cell transplantation. For definite diagnosis of IFD, various diagnostic tools have to be applied, including conventional mycological culture and nonconventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. In the last few years, various laboratory methods, like the Aspergillus GM immunoassay (Aspergillus GM EIA), 1,3-ß-D-glucan (BG) assay or polymerase chain reaction (PCR) techniques have been developed for better diagnosis. Since no single indirect test, including radiological methods, provides the definite diagnosis of an invasive fungal infection, the combination of different diagnostic procedures, which include microbiological cultures, histological, serological and molecular methods like PCR together with the pattern of clinical presentation, may currently be the best strategy for the prompt diagnosis, initiation and monitoring of IFDs. Early start of antifungal therapy is mandatory, but clinical diagnostics often do not provide clear evidence of IFD. Integrated care pathways have been proposed for management and therapy of IFDs with either the diagnostic driven strategy using the preemptive antifungal therapy as opposed to the clinical or empirical driven strategy using the 'traditional' empirical antifungal therapy. Antifungal agents preferentially used for systemic therapy of invasive fungal infections are amphotericin B preparations, fluconazole, voriconazole, posaconazole, caspofungin, anidulafungin, micafungin, and most recently isavuconazole. Clinical decision making must consider licensing status, local experience and availability, pharmacological and economic aspects.

Gastric mucormycosis: Diagnosis by imprint cytology

The fungi in the order of Mucorales commonly target diabetics and other immunocompromised hosts, producing fatal respiratory and or CNS infections. Gastrointestinal mucormycosis is uncommon and seldom diagnosed in living patients due to nonspecific clinical manifestations. We report a case of gastric mucormycosis in an immmunocompetent male patient, diagnosed by imprint cytology-a rare site and a rare setting. To the best of our knowledge, this is only the second report of gastric mucormycosis being diagnosed on cytology. As the disease is rapidly progressive and often fatal, early diagnosis is critical to the patient survival. Imprint cytology or brush cytology is extremely useful for the rapid diagnosis of gastric mucormycosis as these organisms are morphologically distinct. Familiarity with the cytomorphology of these organisms assists in the correct diagnosis of this disease. Diagn. Cytopathol. 2016;44:820-822. © 2016 Wiley Periodicals, Inc.

Temporal Bone Mucormycosis

CASE DETAILS

We present a case of temporal bone mucormycosis in a 71-year-old female with diabetes mellitus who presented to the emergency department with facial nerve paresis, otorrhea, and contralateral hemiparesis. After undergoing a tympanomastoidectomy, the patient's pathology exhibited fungal hyphae consistent with mucormycosis.

DISCUSSION

To our knowledge, there have been 9 reported cases of temporal bone mucormycosis, 3 of which presented with facial nerve paresis, all with some subsequent improvement. In this case, facial paralysis persisted at the time of last follow-up (2 months) despite surgery and intravenous antifungals. We also review and summarize the temporal bone mucormycosis literature.

CONCLUSION

Temporal bone mucormycosis is a rare and morbid infectious disease, though its outcomes appear to be different for patients who present with isolated temporal bone disease as compared to those individuals who develop temporal bone mucormycosis secondary to a rhinologic source.

Primary breast mucormycosis: FNAC diagnosis of a rare entity

Mucormycosis is the common name given to several different diseases caused by fungi in the order of mucorales. The clinical hallmark of these opportunistic pathogens in invasive mucormycosis is tissue necrosis resulting from angioinvasion and subsequent thrombosis. Rarely the disease may affect immunocompetent individuals. In addition, the breast involvement in this disease is very rare. Herein, we describe a case of primary breast mucormycosis diagnosed on fine needle aspiration cytology (FNAC), in an immunocompetent young female, which is extremely rare. Diagn. Cytopathol. 2016;44:761-763. © 2016 Wiley Periodicals, Inc.

Filamentous Fungi

Filamentous mycoses are often associated with significant morbidity and mortality. Prompt diagnosis and aggressive treatment are essential for good clinical outcomes in immunocompromised patients. The host immune response plays an essential role in determining the course of exposure to potential fungal pathogens. Depending on the effectiveness of immune response and the burden of organism exposure, fungi can either be cleared or infection can occur and progress to a potentially fatal invasive disease. Nonspecific cellular immunity (i.e., neutrophils, natural killer [NK] cells, and macrophages) combined with T-cell responses are the main immunologic mechanisms of protection. The most common potential mold pathogens include certain hyaline hyphomycetes, endemic fungi, the Mucorales , and some dematiaceous fungi. Laboratory diagnostics aimed at detecting and differentiating these organisms are crucial to helping clinicians make informed decisions about treatment. The purpose of this chapter is to provide an overview of the medically important fungal pathogens, as well as to discuss the patient characteristics, antifungal-therapy considerations, and laboratory tests used in current clinical practice for the immunocompromised host.

Pulmonary mucormycosis: A case report and review of the literature

The current study reports the case of a 15-year-old male who presented to The First Affiliated Hospital of Soochow University (Suzhou, Jiangsu, China) with a 3-day history of anergy and epistaxis. The patient was diagnosed with T-cell acute lymphoblastic leukemia according to the results of a bone marrow examination and received chemotherapy. During the agranulocytosis period, the patient developed pneumonia of the right upper lung (RUL). Once complete remission was achieved, the patient underwent a lobectomy of the RUL, together with amphotericin B therapy, following the confirmation of pulmonary mucormycosis by the histopathological results. The patient experienced 12 months of uneventful follow-up post-surgery.

Detection of human pathogenic Fusarium species in hospital and communal sink biofilms by using a highly specific monoclonal antibody

The fungus Fusarium is well known as a plant pathogen, but has recently emerged as an opportunistic pathogen of humans. Habitats providing direct human exposure to infectious propagules are largely unknown, but there is growing evidence that plumbing systems are sources of human pathogenic strains in the Fusarium solani species complex (FSSC) and Fusarium oxysporum species complex (FOSC), the most common groups infecting humans. Here, a newly developed Fusarium-specific monoclonal antibody (mAb ED7) was used to track FSSC and FOSC strains in sink drain biofilms by detecting its target antigen, an extracellular 200 kDa carbohydrate, in saline swabs. The antigen was detectable in 52% of swab samples collected from sinks across a University campus and a tertiary care hospital. The mAb was 100% accurate in detecting FSSC, FOSC, and F. dimerum species complex (FDSC) strains that were present, as mixed fungal communities, in 83% of sink drain biofilms. Specificity of the ELISA was confirmed by sequencing of the internally transcribed spacer 1 (ITS1)-5.8S-ITS2 rRNA-encoding regions of culturable yeasts and molds that were recovered using mycological culture, while translation elongation factor (TEF)-1α analysis of Fusarium isolates included FSSC 1-a, FOSC 33, and FDSC ET-gr, the most common clinical pathotypes in each group.

Rhinocerebral mucormycosis in a 5-month heart transplant recipient

Mucormycosis is an opportunistic acute fungal infection with a high mortality rate seen in immunocompromised patients. It is extremely rare in heart transplant recipients. Rhinocerebral mucormycosis (RM) is the most frequently observed presentation. We report a case of RM in a heart transplant recipient 5-month after the procedure, with a fatal outcome.

Isavuconazole as salvage therapy for mucormycosis

Mucormycosis carries a high mortality rate with few therapeutic options available. We describe a man with pulmonary/splenic mucormycosis complicating hypoplastic myelodysplastic syndrome on a background of chronic kidney disease, who achieved a complete response with salvage isavuconazole therapy following intolerance of consecutive courses of liposomal amphotericin and posaconazole therapy.

Mucorales-Specific T Cells in Patients with Hematologic Malignancies

Background

Invasive mucormycosis (IM) is an emerging life-threatening fungal infection. It is difficult to obtain a definite diagnosis and to initiate timely intervention. Mucorales-specific T cells occur during the course of IM and are involved in the clearance of the infection. We have evaluated the feasibility of detecting Mucorales-specific T cells in hematological patients at risk for IM, and have correlated the detection of such cells with the clinical conditions of the patients.

Methods and Findings

By using an enzyme linked immunospot assay, the presence of Mucorales-specific T cells in peripheral blood (PB) samples has been investigated at three time points during high-dose chemotherapy for hematologic malignancies. Mucorales-specific T cells producing interferon-γ, interleukin-10 and interleukin-4 were analysed in order to detect a correlation between the immune response and the clinical picture. Twenty-one (10.3%) of 204 patients, accounting for 32 (5.3%) of 598 PB samples, tested positive for Mucorales-specific T cells. Two groups could be identified. Group 1, including 15 patients without signs or symptoms of invasive fungal diseases (IFD), showed a predominance of Mucorales-specific T cells producing interferon-gamma. Group 2 included 6 patients with a clinical picture consistent with invasive fungal disease (IFD): 2 cases of proven IM and 4 cases of possible IFD. The proven patients had significantly higher number of Mucorales-specific T cells producing interleukin-10 and interleukin-4 and higher rates of positive samples by using derived diagnostic cut-offs when compared with the 15 patients without IFD.

Conclusions

Mucorales-specific T cells can be detected and monitored in patients with hematologic malignancies at risk for IM. Mucorales-specific T cells polarized to the production of T helper type 2 cytokines are associated with proven IM and may be evaluated as a surrogate diagnostic marker for IM.

In vitro antifungal susceptibility of clinical species belonging to Aspergillus genus and Rhizopus oryzae

OBJECTIVE

Among filamentous fungal pathogens, Aspergillus spp. and zygomycetes account for highest rates of morbidity and mortality among immunocompromised patients. Recently developed antifungal drugs offer the potential to improve management and therapeutic outcomes of fungal infections. The aim of this study was to analyse the in vitro activities of voriconazole, itraconazole, amphotericin B and caspofungin against clinical isolates of Aspergillus spp. and Rhizopus oryzae.

MATERIAL AND METHODS

The in vitro antifungal susceptibility of 54 isolates belonging to different clinical isolates of Aspergillus spp. and R. oryzae was tested for four antifungal agents using a microdilution reference method (CLSI, M38-A2). All isolates were identified by typical colony and microscopic characteristics, and also characterized by molecular methods.

RESULTS

Caspofungin (MEC range: 0.008-0.25 and MEC50: 0.0023μg/mL) was the most active drug in vitro against Aspergillus spp., followed by voriconazole (MIC range: 0.031-8 and MIC50: 0.5μg/mL), itraconazole (MIC range: 0.031-16 and MIC50: 0.25μg/mL), and amphotericin B (MIC range: 0.125-4 and MIC50: 0.5μg/mL), in order of decreasing activity. The caspofungin, voriconazole, and itraconazole demonstrated poor in vitro activity against R. oryzae isolates evaluated, followed by amphotericin B.

CONCLUSION

This study demonstrates that caspofungin had good antifungal activity and azole agents had better activity than amphotericin B against Aspergillus species. Although, azole drugs are considered ineffective against R. oryzae. This result is just from a small scale in vitro susceptibility study and we did not take other factors into consideration.

Emergency and elective pulmonary surgical resection in haematological patients with invasive fungal infections: a report of 50 cases in a single centre

Invasive fungal infections (IFI) remain life-threatening complications in haematological patients. The aim of the study was to present the experience of a single centre in the surgical treatment of pulmonary IFI. Between 1992 and 2014, 50 haematological patients with IFI underwent pulmonary resection. In 27 cases it was an emergency procedure to avoid haemoptysis (if the lesion threatened pulmonary vessels). The remaining 23 patients underwent elective surgery before new chemotherapy or stem-cell transplantation. Among these patients (median age: 54 years; range: 5-70 years), 92% had acute leukaemia and 68% were on haematological first-line therapy (receiving induction or consolidation chemotherapies). Invasive pulmonary aspergillosis and pulmonary mucormycosis were diagnosed in 37 and 12 patients, respectively. One patient had IFI due to Trichoderma longibrachiatum. All of the patients received antifungal agents. In the month preceding IFI diagnosis, 94% of patients had been neutropenic. At the time of surgery, 30% of patients were still neutropenic and 54% required platelet transfusions. Lobectomy or segmentectomy were performed in 80% and 20% of cases, respectively. Mortality at 30 and 90 days post-surgery was 6% and 10%, respectively. After surgery, median overall survival was 21 months; median overall survival was similar between patients with emergency or elective surgery and between the types of IFI (invasive pulmonary aspergillosis or pulmonary mucormycosis). However, overall survival was far better in haematological first-line patients or in those achieving a haematological complete response than in other patients (p <0.001). In pulmonary IFI, lung resection could be an effective complement to medical treatment in selected haematological patients.

Trilogy of sequential infections in a diabetic male

Uncontrolled diabetes is a known immunosuppressive state. It predisposes individuals to bacterial and fungal infections. The present case report demonstrates sequential infections by Klebsiella followed by tuberculosis and later development of mucormycosis in a poorly controlled diabetic patient. Timing of diagnosis is of essence because of high mortality seen with such pulmonary infections. High index of suspicion needs to be maintained as the same individual may harbor multiple infections as highlighted in this case.

Development and application of two independent real-time PCR assays to detect clinically relevant Mucorales species

PCR-based detection of Mucorales species could improve diagnosis of suspected invasive fungal infection, leading to a better patient outcome. This study describes two independent probe-based real-time PCR tests for detection of clinically relevant Mucorales, targeting specific fragments of the 18S and the 28S rRNA genes. Both assays have a short turnaround time, allow fast, specific and very sensitive detection of clinically relevant Mucorales and have the potential to be used as quantitative tests. They were validated on various clinical samples (fresh and formalin-fixed paraffin-embedded specimens, mainly biopsies, n = 17). The assays should be used as add-on tools to complement standard techniques; a combined approach of both real-time PCR assays has 100 % sensitivity. Genus identification by subsequent sequencing is possible for amplicons of the 18S PCR assay. In conclusion, combination of the two independent Mucorales assays described in this study, 18S and 28S, detected all clinical samples associated with proven Mucorales infection (n = 10). Reliable and specific identification of Mucorales is a prerequisite for successful antifungal therapy as these fungi show intrinsic resistance to voriconazole and caspofungin.

Mucormycosis: a 10-year experience at a tertiary care center in Turkey

BACKGROUND/AIM

Mucormycosis is a rare invasive fungal infection most commonly encountered in the immunocompromised host. We analyzed 51 adult patients treated for mucormycosis between 2003 and 2013 and recorded at a tertiary university hospital in Turkey.

MATERIALS AND METHODS

We examined the following data for all patients: age, sex, predisposing disease, symptoms, treatment, surgical procedure, concomitant infections, intensive care requirement, and outcomes.

RESULTS

During the study period 51 cases of mucormycosis were documented; 54.9% of the patients were female. The mean age was 44.2 ± 18.2 years. Rhinocerebral presentation was reported in 94.1% of patients. Almost all patients (88.2%) had at least one risk factor. The common predisposing factors were hematologic malignancies (52.9%), diabetes mellitus (25.5%), and solid malignancies (5.8%). The most common initial symptoms were fever, cellulitis, and facial pain. The primary medication used was liposomal amphotericin B or conventional amphotericin B. Surgery was performed in 94.1% of patients. Mortality was 52.9%.

CONCLUSION

Our study revealed that mucormycosis continues to be a mortal disease in about half of the cases. Our findings indicate that treatment with L-AMB is associated with a favorable response. Also, in the case of facial pain, the low mortality rate may indicate the importance of early diagnosis.

Approach to the Solid Organ Transplant Patient with Suspected Fungal Infection

In solid organ transplant (SOT) recipients, invasive fungal infections (IFIs) are associated with significant morbidity and mortality. Detection of IFIs can be difficult because the signs and symptoms are similar to those of viral or bacterial infections, and diagnostic techniques have limited sensitivity and specificity. Clinicians must rely on knowledge of the patient's risk factors for fungal infection to make a diagnosis. The authors describe their approach to the SOT recipient with suspected fungal infection. The epidemiology of IFIs in the SOT population is reviewed, and a syndromic approach to suspected IFI in SOT recipients is described.

Early diagnosis and monitoring of mucormycosis by detection of circulating DNA in serum: retrospective analysis of 44 cases collected through the French Surveillance Network of Invasive Fungal Infections (RESSIF)

The main objective of this study was to assess the diagnostic performance of a set of three Mucorales quantitative PCR assays in a retrospective multicentre study. Mucormycosis cases were recorded thanks to the French prospective surveillance programme (RESSIF network). The day of sampling of the first histological or mycological positive specimen was defined as day 0 (D0). Detection of circulating DNA was performed on frozen serum samples collected from D-30 to D30, using quantitative PCR assays targeting Rhizomucor, Lichtheimia, Mucor/Rhizopus. Forty-four patients diagnosed with probable (n = 19) or proven (n = 25) mucormycosis were included. Thirty-six of the 44 patients (81%) had at least one PCR-positive serum. The first PCR-positive sample was observed 9 days (range 0-28 days) before diagnosis was made using mycological criteria and at least 2 days (range 0-24 days) before imaging. The identifications provided with the quantitative PCR assays were all concordant with culture and/or PCR-based identification of the causal species. Survival rate at D84 was significantly higher for patients with an initially positive PCR that became negative after treatment initiation than for patients whose PCR remained positive (48% and 4%, respectively; p <10^-6). The median time for complete negativity of PCR was 7 days (range 3-19 days) after initiation of l-AmB treatment. Despite some limitations due to the retrospective design of the study, we showed that Mucorales quantitative PCR could not only confirm the mucormycosis diagnosis when other mycological arguments were present but could also anticipate this diagnosis. Quantification of DNA loads may also be a useful adjunct to treatment monitoring.

Challenges and Strategies for Proteome Analysis of the Interaction of Human Pathogenic Fungi with Host Immune Cells

Opportunistic human pathogenic fungi including the saprotrophic mold Aspergillus fumigatus and the human commensal Candida albicans can cause severe fungal infections in immunocompromised or critically ill patients. The first line of defense against opportunistic fungal pathogens is the innate immune system. Phagocytes such as macrophages, neutrophils and dendritic cells are an important pillar of the innate immune response and have evolved versatile defense strategies against microbial pathogens. On the other hand, human-pathogenic fungi have sophisticated virulence strategies to counteract the innate immune defense. In this context, proteomic approaches can provide deeper insights into the molecular mechanisms of the interaction of host immune cells with fungal pathogens. This is crucial for the identification of both diagnostic biomarkers for fungal infections and therapeutic targets. Studying host-fungal interactions at the protein level is a challenging endeavor, yet there are few studies that have been undertaken. This review draws attention to proteomic techniques and their application to fungal pathogens and to challenges, difficulties, and limitations that may arise in the course of simultaneous dual proteome analysis of host immune cells interacting with diverse morphotypes of fungal pathogens. On this basis, we discuss strategies to overcome these multifaceted experimental and analytical challenges including the viability of immune cells during co-cultivation, the increased and heterogeneous protein complexity of the host proteome dynamically interacting with the fungal proteome, and the demands on normalization strategies in terms of relative quantitative proteome analysis.