Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium

Gastrointestinal mucormycosis by Mucor indicus: A report of two cases

Mucormycosis is an invasive infection caused by fungi of the order Mucorales, typically affecting immunocompromised individuals, and rarely involving the gastrointestinal tract. We report two cases of gastrointestinal mucormycosis by Mucor indicus: a 77-year-old woman with a gastric ulcer and a 25-year-old man with liver lesions. Both were treated with surgery and liposomal amphotericin B; only one survived. Recognizing gastrointestinal mucormycosis in the correct clinical context is essential and requires timely surgical and antifungal treatment. 2012 Elsevier Ltd. All rights reserved.

Coronavirus Disease 2019 and Emerging Lung Infections in the Immunocompromised Patient

The immunocompromised are at higher risk of COVID-19 and lung infections, and these are associated with more severe presentations and greater risk of complication, increasing the risks of intensive care unit admission and poor outcomes. However, only limited high-quality data are available about the diagnosis and management of lung infections in this population, with many clinical trials and other large studies excluding the immunocompromised. Well-designed studies are needed to better understand the optimal diagnostic and management options to improve outcomes in the increasingly heterogeneous group of immunocompromised patients.

Non-Candida mycosis in Gulf Cooperation Council (GCC) countries: perspective of a low-incidence region

BACKGROUND

Fungal pathogens are ubiquitous microorganisms that are implicated in a wide range of infections, affecting individuals with underlying health conditions and immune suppression therapy; however, immunocompetent individuals may also be at risk. Among these infections, many are caused by molds and yeasts other than Candida and are recognized in clinical practice, such as aspergillosis, mucormycosis, fusariosis, phaeohyphomycosis, and basidiobolomycosis, among others, each presents different clinical manifestations and requires clinical management specific to the site of involvement. Although pathogenic fungal contaminants and potential sources of mycosis in humans are plentiful in Gulf Cooperation Council (GCC) countries, epidemiological reports regarding mycosis in the region are scarce.

AIM

The aim of this review is to shed some light on the epidemiology of clinically associated molds and yeasts other than Candida and to survey all related case reports and epidemiological studies conducted in the GCC over the past 10 years.

METHODS

A comprehensive search of the Medline (PubMed) and Scopus databases was conducted using the following keywords: Aspergillosis, Mycosis, Mucormycosis, Fusarium, Kuwait, Bahrain, Saudi Arabia, Qatar, Oman and the United Arab Emirates. A timeframe was set to include only articles that were published from 2014 to 2024.

RESULTS

One hundred thirty-five of the 1563 articles examined fulfilled the purpose of this review. Most studies were in Saudi Arabia (45%), Qatar (18%) and Kuwait (16%). Mucormycosis, aspergillosis, phaeohyphomycosis and basidiobolomycosis were among the most commonly reported fungal infections in the GCC, with corresponding mortality rates of 53%, 37%, 69% and 24%, respectively. The average estimations of non-Candida fungal infections indicate a low regional incidence in comparison with global estimations.

CONCLUSION

Awareness and a high index of suspicion are warranted in successfully managing non-Candida mycosis. More specific immunological and molecular markers are needed for differential diagnosis to rule out fungal infections. Additionally, incorporating non-Candida mycosis-related antifungal resistance surveys in GCC national surveillance efforts should be enforced, especially when considering the increase in global mycosis rates.

Antifungal Policy and Practice Across Five Countries: A Qualitative Review

The burden of invasive fungal infections (IFIs) is increasing worldwide. National, regional, and local policies on IFI management should respond to the changing landscape. We assessed antifungal policies from five countries of varying size, IFI burden, and geography: the Netherlands, Italy, South Korea, China, and India. These countries were selected as a representative sample reflecting different types of economic and health systems that patients and providers access worldwide. This assessment focused on a comprehensive range of antifungal policy elements, including recognition and prioritization, awareness and education, prevention and monitoring, diagnosis and coordinated care, access to appropriate treatment, and diagnostic and treatment innovation. Although countries in this analysis all have some form of policy for IFI management, we have identified substantial gaps, including low prioritization of IFI diagnostics, omission of fungal pathogens from antimicrobial resistance policies, and a general lack of awareness and healthcare professional (HCP) training on IFI management. The gaps identified are intended to inform HCPs and policy- and decision-makers about aspects to consider in reducing the IFI burden for patients and health systems while demonstrating responsible antifungal stewardship.

Interlaboratory assays from the fungal PCR Initiative and the Modimucor Study Group to improve qPCR detection of Mucorales DNA in serum: one more step toward standardization

The aim of this study was to identify parameters influencing DNA extraction and PCR amplification efficiencies in an attempt to standardize Mucorales qPCR. The Fungal PCR Initiative Mucorales Laboratory Working Group distributed two panels of simulated samples to 26 laboratories: Panel A (six sera spiked with Mucorales DNA and one negative control serum) and Panel B (six Mucorales DNA extracts). Panel A underwent DNA extraction in each laboratory according to the local procedure and were sent to a central laboratory for testing using three different qPCR techniques: one in-house qPCR assay and two commercial assays (MucorGenius and Fungiplex). Panel B DNA extracts were PCR amplified in each laboratory using local procedures: nine in-house qPCR assays and two commercial kits (MucorGenius and MycoGENIE). All data were compiled and anonymously analyzed at the central laboratory. For Panel A, a total of six different automated platforms and five manual extraction methods were used. Positive rates were 64%, 70%, and 89%, for the MucorGenius, Fungiplex, and the in-house qPCR assay, respectively. Using a large volume of serum for DNA extraction provided the highest analytical sensitivity (82.5% for 1 mL compared with 62.7% for smaller volumes, P < 0.01). For Panel B, five in-house qPCR assays and two commercial kits had >78% positivity. Using larger PCR input volumes (≥7 µL) was associated with the highest sensitivity at 95.5% compared to 58.3% when lower input volumes were used (P < 0.01). Using larger sample volumes for nucleic acid extraction and DNA template volumes for PCR amplification significantly improves the performance of Mucorales qPCR when testing serum.

IMPORTANCE

Mucormycosis is a life-threatening mold infection affecting immunosuppressed patients but also other patients with diabetes or trauma. Better survival is linked to shorter delays in diagnosis and treatment initiation. Detection of Mucorales-free DNA in serum or plasma using quantitative PCR allows a prompt diagnosis and earlier treatment. Several techniques and protocols of quantitative Mucorales PCR are used in Europe, and improving performance remains a common objective of laboratories participating in the fungal PCR Initiative Working Group. This study, which combined results from 26 laboratories in Europe, showed that the main parameters underpinning sensitivity are the preanalytical variables (volume of serum used for DNA extraction and DNA template volume), irrespective of the extraction platforms and qPCR assay/platform.

[Diagnosis of mucormycosis in three children following hematopoietic stem cell transplantation using metagenomic next-generation sequencing]

This article reports the clinical characteristics and treatment processes of three cases of mucormycosis occurring after hematopoietic stem cell transplantation in children, along with a review of relevant literature. All three patients presented with chest pain as the initial symptom, and metagenomic next-generation sequencing (mNGS) confirmed the mucycete infection early in all cases. Two patients recovered after treatment, while one succumbed to disseminated infection. mNGS has facilitated early diagnosis and treatment, reducing mortality rates. Additionally, surgical intervention is an important strategy for improving the prognosis of this condition.

Acute Necrotizing Fasciitis Caused by Rhizopus Infection in a Patient with Diabetes and Pulmonary Tuberculosis: A Case Report

Background

Zygomycosis, also termed mucormycosis, is a rare yet highly fatal fungal infection caused by Mucorales species, notably Rhizopus spp.

Case Presentation

This case study details a 72-year-old man with diabetes, pulmonary tuberculosis, and nephrotic syndrome who developed acute necrotizing fasciitis attributable to R. oryzae. Despite initial empirical antibiotic therapy, the infection progressed rapidly. Metagenomic next-generation sequencing (mNGS) facilitated a swift diagnosis, identifying R. oryzae in blood and drainage samples. The treatment included amphotericin B and isavuconazole, along with aggressive surgical debridement. The patient exhibited substantial improvement, and he was discharged after stabilization.

Conclusion

This case highlights the critical role of early diagnosis through mNGS and the need for a multidisciplinary approach to manage severe mucormycosis in immunocompromised patients.

Invasive Fungal Disease After Chimeric Antigen Receptor-T Immunotherapy in Adult and Pediatric Patients

Invasive fungal diseases (IFDs) have been documented among the causes of post-chimeric antigen receptor-T (CAR-T) cell immunotherapy complications, with the incidence of IFDs in CAR-T cell therapy recipients being measured between 0% and 10%, globally. IFDs are notorious for their potentially life-threatening nature and challenging diagnosis and treatment. In this review, we searched the recent literature aiming to examine the risk factors and epidemiology of IFDs post-CAR-T infusion. Moreover, the role of antifungal prophylaxis is investigated. CAR-T cell therapy recipients are especially vulnerable to IFDs due to several risk factors that contribute to the patient's immunosuppression. Those include the underlying hematological malignancies, the lymphodepleting chemotherapy administered before the treatment, existing leukopenia and hypogammaglobinemia, and the use of high-dose corticosteroids and interleukin-6 blockers as countermeasures for immune effector cell-associated neurotoxicity syndrome and cytokine release syndrome, respectively. IFDs mostly occur within the first 60 days following the infusion of the T cells, but cases even a year after the infusion have been described. Aspergillus spp., Candida spp., and Pneumocystis jirovecii are the main cause of these infections following CAR-T cell therapy. More real-world data regarding the epidemiology of IFDs and the role of antifungal prophylaxis in this population are essential.

Infection by Saksenaea vasiformis in Spain: Case report and literature review

INTRODUCTION

Saksenaea vasiformis is a filamentous fungus from the Mucorales family, responsible for isolated infections with high morbidity and mortality, especially in tropical or subtropical areas. The objective is to describe the clinical characteristics of the cases reported in Spain.

METHODS

In addition to presenting a case of S. vasiformis infection treated at Hospital Universitario Cruces in 2023, a systematic literature review was conducted on 17/04/2024, analyzing a total of 11 cases. Epidemiological and clinical data were obtained, and a descriptive analysis was performed.

RESULTS

The average age was 64.9 years, with most being male (72.7%) and immunocompetent. Acquisition was related to severe trauma (45.5%) or insect bites (36.4%). 90.1% suffered from skin and soft tissue infections. The diagnostic process was complex, with the following being useful: direct staining (36.4%), culture in specific media (27.3%), molecular techniques (54.5%), and histopathological findings (90.9%). MICs of antifungals was determined in 3 cases, with low MICs for liposomal amphotericin B (L-AMB) and posaconazole, and variable MICs for voriconazole. L-AMB was the most commonly used antifungal, combined in all cases with extensive surgical debridement. Mortality was 45.5%.

CONCLUSION

Infection by S. vasiformis is rare in our environment but clinically significant due to its severity and difficult diagnosis. Rapid recognition, along with early and aggressive debridement and appropriate antifungal treatment, are essential.

Invasive fungal rhinosinusitis: current evidence and research opportunities

PURPOSE OF REVIEW

To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs.

RECENT FINDINGS

New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed.

SUMMARY

Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.

The Black Fungus: A Rare Case of Pulmonary Mucormycosis

Background

Mucormycosis, commonly known as the "black fungus," is a severe infection affecting multiple organ systems, including the skin, brain, lungs, and gastrointestinal tract. This case report is focused on pulmonary mucormycosis, which is frequently observed in organ transplant recipients. Diagnostic challenges arise from nonspecific symptoms.

Case Presentation

Our case involved a 61-year-old male with a history of renal transplantation. The patient initially presented with a persistent cough and bloody sputum and was treated unsuccessfully for a presumed fungal infection. A lung biopsy confirmed pulmonary mucormycosis, emphasizing the heightened vulnerability of immunocompromised individuals.

Conclusion

This case highlights the intricate nature of mucormycosis diagnosis and management, particularly in post-organ transplantation patients. It underscores the importance of awareness and collaboration among medical specialists, including infectious disease experts, pulmonologists, and transplant teams, to optimize outcomes in the face of this life-threatening infection.

An Immunocompetent 56-Year-Old Woman With Multiple Enlarged Lymph Nodes and Recurrent Fevers

CASE PRESENTATION

A 56-year-old woman was admitted to our hospital, presenting with a history of recurrent fevers persisting for over 2 months. The febrile episode was self-limiting, accompanied by cough without significant expectoration, with the fever predominantly manifesting during the afternoon and evening hours. Furthermore, there were no concurrent symptoms indicative of chest tightness, wheezing, dyspnea, or hemoptysis. A CT scan in a local hospital demonstrated multifocal lymphadenopathy in the mediastinum and bilateral supraclavicular regions. The patient had neither a history of tobacco usage nor of alcohol consumption. Furthermore, there was no familial history of oncologic conditions. The patient's medical records revealed no evidence of hypertension, diabetes mellitus, coronary artery disease, infectious diseases, or immunologic disorders.

Sjogren's Syndrome Complicated by Naso-Orbito-Cerebral Mucormycosis: A Case Report

Background: Sjogren's syndrome (SS) is a chronic inflammatory autoimmune disease characterized by exocrine gland dysfunction. Mucormycosis is a rare yet life-threatening opportunistic fungal infection caused by Mucor species, with a high mortality rate. In patients undergoing long-term immunosuppressive therapy or corticosteroid use, especially when compounded by conditions such as diabetes or hyperlipidemia, Mucor can become pathogenic. Medical Record Description: We retrospectively analyzed the clinical data of a patient with Sjogren's syndrome complicated by rhinocerebral mucormycosis, focusing on its clinical presentation and progression. The patient was admitted to the hospital 20 days prior with symptoms of a "nasal infection" caused by a furuncle on the nose. The condition progressively worsened, resulting in nasofacial skin ulceration and necrosis, with black eschar formation around the affected area. Upon admission, comprehensive evaluations, including rapid histopathological and fungal tests, confirmed the diagnosis of mucormycosis. Despite surgical intervention under general anesthesia and antifungal therapy, the clinical outcome was ultimately fatal. Conclusion: Mucor infections commonly occur in patients with immunodeficiency and severe underlying diseases. The clinical manifestations are diverse, often presenting with skin tissue necrosis and the formation of black eschar. Fungal culture and histopathological examination remain the gold standards for diagnosing mucormycosis, while imaging studies are crucial for evaluating the extent of fungal dissemination and bone involvement. Given the rapid progression of the disease, early diagnosis and prompt treatment are critical for improving survival rates.

The Importance of MRI in the Early Diagnosis of Acute Invasive Fungal Rhinosinusitis

Acute invasive fungal rhinosinusitis (AIFR) is a rare, severe, and life-threatening opportunistic infection associated with high mortality and morbidity. Rapid and accurate diagnosis and treatment are crucial for survival and effective disease management. Diagnosing AIFR is challenging because no single pathognomonic feature exists other than surgical biopsy showing fungal angioinvasion and necrosis. This narrative review focuses on the diagnostic challenges and pitfalls, emphasizing the critical clinical value of magnetic resonance imaging (MRI) for early diagnosis of AIFR. It includes selected cases that illustrate the significance of MRI. When AIFR is suspected, clinical symptoms, nasal endoscopy, blood samples, and facial computed tomography all provide non-specific information. In contrast, MRI can identify signs of devitalized sinonasal mucosa consistent with AIFR. The absence of mucosal enhancement on T1-weighted images, combined with restricted diffusivity, are characteristic MRI features of AIFR. The cases presented underscore the usefulness of MRI in supporting clinical suspicion of AIFR and accurately determining its topography, thereby guiding early surgical biopsies and debridement. In suspected cases of AIFR, MRI serves as a valuable supplementary, non-invasive tool to help determine whether prompt surgical biopsy or debridement is necessary, thereby enhancing early diagnosis and improving survival rates. Therefore, the threshold for conducting an MRI in these cases should be low.

Impact of an institutional antifungal stewardship program on antifungal usage and outcomes in patients with invasive fungal infections

Therapeutic and prophylactic use of antifungals is rising continuously. However, inadequate awareness of diagnostic and treatment guidelines and limited laboratory modalities lead to inappropriate use. This study assessed the impact of an institutional antifungal stewardship program on antifungal use practices and patient outcomes. In the pre-intervention phase, data was collected regarding antifungal therapy among patients with invasive fungal infections. Appropriateness of antifungal prescription was assessed. In the intervention phase, simple algorithms for diagnosis and management of fungal infections were prepared from international guidelines and incorporated into a booklet for distribution. Monthly training sessions were conducted. New serological and molecular tests and therapeutic drug monitoring were introduced. In the post-intervention phase, an antifungal stewardship team was constituted for clinical advisory on demand and ongoing training. Data regarding antifungal therapy was collected and compared with pre-intervention data. Untreated patients decreased from 25% to 18.9% post-intervention (P = .28). Appropriate antifungal use increased from 72.6% to 77.9% (P = .4) among patients with a single fungal infection, and from 57.1% to 88.5% (P = .04) for at least one infection among those with dual fungal infections. 49 incidents of inappropriate use in various categories were seen among 75 patients receiving antifungals pre-intervention, decreasing to 42 incidents among 94 patients post-intervention (P = .06), particularly evident among patients with dual infections (P = .002). Mortality increased from 51% to 75.86% post-intervention (P = .0001). Overall, the small improvement noticed in antifungal usage pattern can still be considered significant, given the limited study period.

Utility of Mucorales polymerase chain reaction to diagnose Rhizomucor infections in neutropenic patients

Mucormycoses are life-threatening infections related to fungi from the Mucorales order. Based on fungal culture, the most frequently involved genera are Rhizopus spp., Mucor spp., or Lichtheimia spp. However, since the introduction of Mucorales polymerase chain reaction (PCR), many diagnoses have been made without positive fungal culture, biasing mucormycosis epidemiology. We conducted a single-centre retrospective observational study on invasive mucormycosis cases diagnosed between April 2020 and December 2022. Cases were classified according to EORTC/MSGERC definitions, adding a 'PCR-only' category for patients with a positive Mucorales PCR as the only mycological evidence. Genus/species identification was obtained by sequencing the Mucorales 18S rDNA directly on Mucorales PCR-positive samples. We identified 35 cases of mucormycosis, including 6 proven, 7 probable, and 22 'PCR-only'. Genus/species identification was achievable in 34 cases and surprisingly revealed the genus Rhizomucor as the main aetiological agent (n = 14, 41.2%). Interestingly, all the Rhizomucor infections, except one, were classified as 'PCR-only', while fungal culture was positive in 11/20 (55%) for other Mucorales genera (P <.001). Moreover, in comparison with other genera, the genus Rhizomucor was significantly more associated with neutropenia (11/14 [78.6%] vs. 2/20 [10%], P < .0001) and pulmonary localizations (11/14 [78.6%] vs. 6/20 [30%], P = .01). Our study reveals the changing epidemiology of mucormycosis in our centre with the use of Mucorales PCR and underlines the importance of the genus Rhizomucor, especially in neutropenic patients. This highlights the benefits of using Mucorales PCR in clinical practice for mucormycosis diagnosis in high-risk patients and the need to include it in diagnostic criteria.

Violaceous Nodules on the Left Forearm of an Immunosuppressed Patient Following Heart Transplantation for Cardiac Amyloidosis

We present the case of a 60-year-old immunocompromised man who presented with two pruritic pink-red indurated nodules with overlying scale and focal areas of ulceration on his left dorsal and left medial forearm, which evolved over a 2-month period. The pathology showed numerous fungal hyphae present that were pauci-septate with various branched angles and variable hyphal thickness. Fungal cultures grew Rhizopus species and a universal fungal PCR detected the Rhizopus oryzae complex. Based on the clinicopathologic correlation, the diagnosis of cutaneous mucormycosis was made. Cutaneous mucormycosis is an aggressive fungal infection of the Mucorales family occurring after the inoculation of fungal spores in disrupted skin. It usually presents as a necrotic eschar but can also present as cellulitis that evolves into a necrotic ulcer. A prompt diagnosis is critical for the effective management of cutaneous mucormycosis. The treatment includes an immediate systemic treatment with amphotericin B and a surgical debridement of the necrotic regions. Given the wide range of presenting symptoms, clinical suspicion for this emergent condition must remain high in immunocompromised and diabetic patients.

Diagnostic Approach to Pneumonia in Immunocompromised Hosts

In immunocompromised patients, pneumonia presents a diagnostic challenge due to diverse etiologies, nonspecific symptoms, overlapping radiological presentation, frequent co-infections, and the potential for rapid progression to severe disease. Thus, timely and accurate diagnosis of all pathogens is crucial. This narrative review explores the latest advancements in microbiological diagnostic techniques for pneumonia in immunocompromised patients. It covers major available microbiological tools for diagnosing both community-acquired and hospital-acquired pneumonia, encompassing a wide spectrum of pathogens including bacterial, viral, fungal, and parasitic. While traditional culture methods remain pivotal in identifying many pneumonia-causing etiologies, their limitations in sensitivity and time to results have led to the rise of non-invasive antigen tests and molecular diagnostics. These are increasingly employed alongside cultures and microscopy for more efficient diagnosis, mainly in viral and fungal infections. Lastly, we report the future of pneumonia diagnostics, exploring the potential of metagenomics and CRISPR/Cas13a for more precise and rapid pathogen detection in immunocompromised populations.

Use of isavuconazole in mucormycosis: a systematic review

BACKGROUND

Mucormycosis is an opportunistic fungal infection which is associated with poor prognosis. Only a few antifungals are available in the arsenal against mucormycosis. The global guidelines for diagnosing and managing mucormycosis recommend high doses of liposomal amphotericin B (LAmB) as the first-line treatment. Isavuconazole is another potential treatment option for mucormycosis.

MAIN BODY

This systematic review aims to consolidate and analyse existing evidence concerning the efficacy and safety of isavuconazole in treating mucormycosis alone or in combination with LAmB. For data aggregation, comprehensive searches were conducted across various electronic databases, such as PubMed, Science Direct, Trip, Google Scholar, the Cochrane Library, and Open-Gray. Furthermore, we explored the gray literature, employing tailored keywords. The reference lists of the selected articles were scrutinized to identify additional pertinent publications. Articles reporting any studies, case series, or case reports on any form of mucormycosis exclusively involving human subjects published in English were included. There were no time restrictions involved. We extracted crucial data, such as publication year, country, disease form, isavuconazole dosage, frequency, duration, overall outcomes, and reported adverse effects. A total of 31 articles, which included four case series, 24 case reports, one open-label trial, one randomized controlled trial, and one non-interventional registry study, were included in the final analysis. 135 adult patients and 14 children were treated with isavuconazole as primary monotherapy, primary combination therapy, nonprimary monotherapy, or nonprimary combination therapy. The mortality rate following LAmB monotherapy, amphotericin B plus azole, amphotericin B followed with azole, posaconazole only and isavuconazole only was 32%, 6.6%, 13.7%, 17.2% and 24.6%, respectively. The heterogeneity of the studies did not allow for a comparison of the different treatment strategies (primary mono- vs. primary combination, etc.).

SHORT CONCLUSION

The use of isavuconazole in combination therapies during the acute phase via intravenous administration alongside LAmB or other triazoles, followed by long-term monotherapy via the oral route, has yielded promising recovery rates. Adverse events associated with the use of isavuconazole are infrequently reported.

New pharmacotherapeutic strategies for drug-resistant Candida infections: a review

INTRODUCTION

Candida species produce a wide array of infections ranging from mucocutaneous to systemic infections. Candida albicans remains the most common species identified; however, the non-albicans Candida species have continued to increase as the diagnosis and therapeutic regimens have progressed.

AREAS COVERED

This review with discussion of the various Candida species, especially the non-albicans species, some of the important mechanisms of resistance, and newer in vitro and clinical studies describing the recent and novel antifungal options such as rezafungin, ibrexafungerp, and oteseconazole, along with a novel antifungal, fosmanogepix.

EXPERT OPINION

Initial antifungal therapy is frequently obsolete due to the expansion of antifungal resistance. This is especially true with C. glabrata, C. krusei, and most recently with C. auris. The newer and novel antifungals discussed here will add valuable tools to our antifungal armamentarium to be able to appropriately and adequately treat and manage these difficult infections. Each of the antifungals has unique and novel properties that will expand the arsenal useful to treat these fungal infections in the years to come.

Endoscopic Orbital Clearance/Debridement: A Potential Substitute for Orbital Exenteration in Rhino-orbital Mucormycosis

Introduction  Mucormycosis is an aggressive, lethal fungal infection affecting the nasal and paranasal territory in immunocompromised patients. Orbital involvement is not uncommon and may require orbital exenteration. Objectives  The management of orbital involvement in invasive fungal sinusitis is challenging, ranging from conservative retrobulbar amphotericin B injection in the early stages to orbital exenteration in late stages. Endoscopic endonasal debridement is a minimally invasive technique used to manage orbital fungal involvement in the late stages. Methods  Endoscopic endonasal orbital clearance was performed to manage late-stage orbital invasive fungal infection (≥ stage 3c) or after failure of retrobulbar amphotericin B injection with no light perception. Removal of the lamina papyracea (LP) and incision of the periorbita were done to expose all the necrotic intraorbital content in the extra and intraconal spaces. A microdebrider was utilized to debride necrotic fungal infected tissue until a healthy vascularized plane was reached. Gelfoam (Pfizer Inc., New York, NY, United States) soaked in amphotericin B was applied as an adjunctive step to deliver antifungal medication to the orbital content. Results  Fourteen patients were included in the study, 9 of whom were male and 5 female, with a mean age of 58.5 years. Eleven patients showed no evidence of disease progression (complete recovery and cessation of medical treatment). Two patients died 15 days after the surgery. The last patient developed frontal lobe abscess but has been treated with double antifungal medication. Conclusion  Endoscopic endonasal orbital debridement could be an effective method to treat late-stage orbital fungal infection without jeopardizing the patient's life. Level of Evidence : 4.

Mucormycosis and COVID-19: Unraveling the Interplay of Fungal Infection in a Global Health Crisis: An Overview

The healthcare system has been greatly affected by the COVID-19 pandemic, resulting in an increase in secondary and co-infections among patients. Factors like pulmonary damage and weakened immune systems make patients more susceptible to fungal infections. Mucormycosis, an opportunistic fungal infection, prospers in environments with limited oxygen, and elevated glucose levels due to conditions such as diabetes and steroid use, as well as in acidic environments from metabolic acidosis and diabetic ketoacidosis, where it demonstrates heightened germination ability. Recognizing these complications is critical to minimize harm to patients. The insights gained from this review can improve our understanding of how fungal infections develop in connection to COVID-19, leading to better predictive algorithms, tailored care plans, enhanced antifungal treatments, quicker diagnostics, and improved management strategies.

Real-World Effectiveness and Safety of Isavuconazole Versus Amphotericin B for Patients with Invasive Mucormycosis

BACKGROUND

Invasive mucormycosis (IM) poses a substantial morbidity and mortality burden among immunocompromised patients.

OBJECTIVES

We aim to compare the real-world effectiveness and safety of isavuconazole with those of amphotericin B in patients with IM.

PATIENTS AND METHODS

In this observational cohort study, we enrolled patients who were diagnosed with IM and treated with either isavuconazole or amphotericin B.

RESULTS

A total of 106 patients met the study criteria. Of these, 47 received isavuconazole, and 59 received amphotericin B as the primary treatment. The two cohorts had similar baseline characteristics, including a history of malignancy, use of immunosuppressants, infection sites, and pathogens. The amphotericin B group demonstrated a significantly greater incidence of renal disorders (p < 0.001) and hypokalemia (p < 0.001) than the isavuconazole group. The proportion of patients who received salvage therapy was greater in the amphotericin B group than in the isavuconazole group (42% vs. 6%, p < 0.001). Eighteen patients in the amphotericin B group discontinued treatment because of adverse events, whereas no patients in the isavuconazole group discontinued treatment because of adverse events. A significant difference in the primary therapeutic response between the isavuconazole and amphotericin B groups was noted (p = 0.013), with a higher treatment failure rate in the amphotericin B group (68% vs. 36%, p = 0.001). However, there were no significant differences in all-cause mortality or mucormycosis-attributable mortality rates between the two groups.

CONCLUSIONS

Isavuconazole outperformed amphotericin B as a first-line treatment option for IM in terms of its clinical effectiveness and safety.

Mucormycosis Infection in Lung Transplant Patients: Experience in Andalusia, Spain

INTRODUCTION

Mucorales infections in the airways of lung transplant (LT) patients are rare but have a rising incidence in transplanted lungs.

OBJECTIVE

We present our experience with LT in immediate postoperative infections due to mucormycosis.

METHODS

Review of 767 LT performed in Andalusia between 2000 and 2023 identifying Mucorales through microbiological results and histological findings.

RESULTS

The incidence of Mucorales was less than 1% of all LTs performed at our institution but resulted in 100% mortality. In our series, all cases underwent LT for chronic obstructive pulmonary disease. They presented with pulmonary infection that progressed to disseminated infection. Major associated risk factors included prior corticosteroid treatment, malnutrition, solid organ transplantation, single lung transplantation, immunosuppression, and concomitant Aspergillus infection.

CONCLUSIONS

Mucormycosis infection in grafts after lung transplantation is a lethal complication poorly documented in the literature. Vigilance for Mucorales in these patients is crucial for early diagnosis.

Exploring the interaction between Fe3+ and REGLE motif of the high-affinity iron permease (Ftr1): An in silico approach

Mucormycosis is an invasive fungal infection with high mortality rate in immunocompromised individuals. Due to COVID-19 pandemic, the disease has resurfaced recently and lack of appropriate antifungals resulted in a poor outcome in patients. The iron uptake mechanism in Rhizopus delemar, the predominant causal agent, is crucial for its survival and pathogenesis in human host. The current study is first of its kind to focus on structural dynamics of high affinity iron permease (Ftr1), a virulence factor for Mucormycosis. Ftr1 is a transmembrane protein which is responsible for transport of Fe3+ ion from extracellular milieu to cytoplasm under iron starving conditions in Rhizopus. In this work, the three-dimensional modelling of Ftr1 was carried out. The Ftr1 possessed seven transmembrane helices with N- & C-termini in extracellular and intracellular regions respectively. Moreover, the present study delineates interaction of glutamic acid residues, found in the REGLE motif of fourth transmembrane helix with Fe3+. The molecular dynamics simulation study revealed that the glycine present in the motif destabilizes the helix thereby bringing E157 closer to positively charged ion. Understanding the interaction between Fe3+ ion and Ftr1 would be helpful in designing effective small molecule drugs against this novel therapeutic target for treating mucormycosis.

Fatal hepatic mucormycosis in an allogeneic hematopoietic-stem cell transplanted patient: Case report of a rare presentation and review of the literature

Hepatic mucormycosis is a rare condition. Our objective is to report a case in a HSCT patient and to perform a review of the literature. A 36-year-old man with acute myeloid leukemia, performed a haploidentical HSCT. In D+132, when treating acute GVHD with methylprednisolone and etanercept, a hepatic abscess was diagnosed. Puncture of the abscess was performed, and fungal hyphae were visualized. The culture of the aspirate identified Mucor sp. Sequencing confirmed the isolate as Mucor indicus. The patient died despite the use of Amphotericin B. Our search identified 24 hepatic mucormycosis reports. Fifteen (62.5 %) were male and 79.1 % were immunocompromised. Fever accompanied with abdominal pain was present in 41.6 %. Twelve (50.0 %) had multiple hepatic lesions. Mortality rate was 45.8 % (n = 11/24). In conclusion, the most common clinical presentation of hepatic mucormycosis in immunocompromised patients might be abdominal pain and fever, along with hepatic abscess findings in abdominal imaging exams.

Pulmonary mucormycosis in an immunocompetent young female: a case report and literature review

Mucormycosis is considered a rare but highly lethal fungal infection, often occurring in patients with poorly controlled diabetes or immunosuppression. Pulmonary mucormycosis progresses rapidly and is often associated with pulmonary infarction and hemoptysis. In this case report, we presented a young, immunocompetent female patient with newly diagnosed diabetes who was diagnosed early with Rhizopus delemar infection through metagenomic next-generation sequencing. Despite early diagnosis, the infection progressed rapidly, invading the tracheal cartilage and upper mediastinal soft tissue, ultimately leading to the patient's unfortunate demise.

Severe dual fungal infection after bispecific antibody therapy: A case of invasive aspergillosis and mucormycosis in immunocompromised patient

Bispecific antibody is a new treatment for hematological disease, especially for lymphoma, myeloma and acute lymphoblastic leukemia. This class of treatment presents the same kind of side effect as CAR-T cell which are immune-mediated. Nevertheless, infectious complication remains a major concerns with related mortality. Fungal infection are rarely reported in clinical trial but remains a major concern. We report a case of a co-infection of Aspergillus and Mucorales in a patient with diffuse large B-cell lymphoma (DLBCL) following treatment with the bispecific antibody epcoritamab. The patient developed severe cytokine release syndrome (CRS) and subsequent fungal infections, which were challenging to diagnose and treat due to the complexities of managing immunocompromised patients and co-infection. Advanced diagnostics, including PET-CT, and a combination of antifungal therapies were crucial in achieving remission. The case underscores the need for early diagnosis, multidisciplinary management, and innovative treatment strategies in similar high-risk patients.

Epidemiology, Clinical, Radiological and Biological Characteristics, and Outcomes of Mucormycosis: A Retrospective Study at a French University Hospital

PURPOSE

Mucormycosis is a rare but emerging and life-threatening infection caused by environmental mold, with a mortality rate of 30-70% despite progress in management. A better understanding could improve its management.

METHOD

We conducted a single-center retrospective study of all cases of mucormycosis observed over a decade at the University Hospital of Caen.

RESULTS

Between 2014 and 2024, 18 cases of mucormycosis were identified, predominantly in males (n = 11, 65%). Most patients had hematological malignancies (n = 16, 89%). Seven cases were proven, and eleven were classified as probable. The main locations of infection were pulmonary (n = 12, 67%). Since 2021, we have observed an increase in the number of cases, rising from three between 2014 and 2021 to fifteen between 2021 and 2024. Among the 12 patients with pulmonary mucormycosis, all presented with fever except 1, and 67% required oxygen therapy. Chest computed tomography scans revealed an inverse halo sign in one-third of the patients. The first-line treatment consisted of amphotericin B in seventeen patients, posaconazole in one patient, and isavuconazole in one patient. Surgery was performed on seven patients. In cases of cutaneous mucormycosis, all patients underwent surgery, and none died within three months after the diagnosis. Overall, the three-month mortality rate was 39%. Surgical management was associated with a reduction in mortality (0% vs. 64%, p = 0.013).

CONCLUSIONS

This study highlights the role of PCR for early diagnosis and the key role of surgery in improving clinical outcomes while underscoring the need for better-adapted therapeutic protocols for these rare infections.

Application of Metagenomics Next-Generation Sequencing on Diagnosis of Disseminated Infection Caused by Rhizomucor pusillus in an Acute Lymphoblastic Leukemia Patient

Background

Rhizomucor pusillus is one of the major pathogens in mucormycosis. Infection due to R. pusillus is rare and has a high mortality rate, especially disseminated mucormycosis infections. Rapid and accurate pathogen identification is important for the development of targeted antifungal therapies.

Case Presentation

We presented a case of disseminated R. pusillus infection, identified through metagenomics next-generation sequencing (mNGS), in a 4-year-old patient with acute lymphoblastic leukemia. On days 22, 23, and 28, R. pusillus was detected in bronchoalveolar lavage fluid, blood, and hydrothorax, respectively, through mNGS. The patient developed lung, pleural, and blood disseminated lesions caused by R. pusillus infection. Subsequently, the patient was treated with antifungal therapy, including posaconazole, amphotericin B, and isacconazole, with supportive treatment. However, with the continuous deterioration of symptoms, the patient's family decided to give up treatment. The patient eventually died of multiple-organ failure on day 34.

Conclusion

mNGS facilitates prompt diagnosis of disseminated R. pusillus infections. The successful application of mNGS provided a new perspective for the clinician, underscoring the technique's potential for rapid diagnostic etiology. mNGS has the capability to identify pathogens at the species level, which is a significant asset in guiding clinical medication decisions.

Mucormycosis Causing Splenic Infarction, Gastric Fistula, and Brain Abscess in a Patient With Acute Myeloid Leukemia: A Case Report

Invasive mucormycosis is an aggressive fungal infection characterized by rapid progression, primarily impacting immunocompromised individuals. Herein, we report a case of splenic infarction in association with gastrointestinal fistula and brain abscess as a rare presentation of mucormycosis biopsy, proven in a 56-year-old patient diagnosed with acute myeloid leukemia. The patient initially sought medical attention with a 3-week history of fever, night sweats, and malaise. Considering the chest computed tomography findings compatible with fungal disease and neutropenia, he underwent broad-spectrum antifungal therapy. Following the occurrence of splenic infarctions and a gastric fistula, the patient underwent a partial gastrectomy and splenectomy. Despite the interventions, the patient did not have a successful outcome and died on the second postoperative day. This case highlights the importance of timely suspicion, immediate antifungal therapy, and surgical intervention to improve the survival prospects of patients with multifaceted manifestations of mucormycosis.

A case report of successful treatment of pulmonary mucormycosis caused by Cunninghamella bertholletiae infection in a patient with T-lymphoblastic lymphoma

Mucormycosis caused by Cunninghamella bertholletiae (C. bertholletiae) is a rare opportunistic infection in patients with hematological malignancies (HM), with high mortality rates. Herein, we first report a case of pulmonary mucormycosis (PM) with C. bertholletiae in a 25-year-old male recently diagnosed with T-lymphoblastic lymphoma (T-LBL). The diagnosis was established through chest computed tomography (CT), metagenomic next-generation sequencing (mNGS) of blood and bronchoalveolar lavage fluid (BALF), as well as histopathological examination. Hematoxylin and eosin (HE) staining of the surgical specimen revealed the presence of fungal hyphae. He was effectively treated with liposomal amphotericin B (L-AmB) and posaconazole enteric-coated tablets, followed by aggressive surgical debridement. In our case, the fungal infection was initially identified as C. bertholletiae using mNGS, which facilitated rapid and accurate diagnosis, enabling clinicians to initiate early intensive treatment. The case also emphasizes the importance of surgical debridement in addressing affected tissues and underscores the significance of a multidisciplinary approach in implementing this treatment strategy.

Nomenclature for human and animal fungal pathogens and diseases: a proposal for standardized terminology

Medically important pathogenic fungi invade vertebrate tissue and are considered primary when part of their nature life cycle is associated with an animal host and are usually able to infect immunocompetent hosts. Opportunistic fungal pathogens complete their life cycle in environmental habitats or occur as commensals within or on the vertebrate body, but under certain conditions can thrive upon infecting humans. The extent of host damage in opportunistic infections largely depends on the portal and modality of entry as well as on the host's immune and metabolic status. Diseases caused by primary pathogens and common opportunists, causing the top approximately 80% of fungal diseases [D. W. Denning, Lancet Infect Dis, 24:e428-e438, 2024, https://doi.org/10.1016/S1473-3099(23)00692-8], tend to follow a predictive pattern, while those by occasional opportunists are more variable. For this reason, it is recommended that diseases caused by primary pathogens and the common opportunists are named after the etiologic agent, for example, histoplasmosis and aspergillosis, while this should not be done for occasional opportunists that should be named as [causative fungus] [clinical syndrome], for example, Alternaria alternata cutaneous infection. The addition of a descriptor that identifies the location or clinical type of infection is required, as the general name alone may cover widely different clinical syndromes, for example, "rhinocerebral mucormycosis." A list of major recommended human and animal disease entities (nomenclature) is provided in alignment with their causative agents. Fungal disease names may encompass several genera of etiologic agents, consequently being less susceptible to taxonomic changes of the causative species, for example, mucormycosis covers numerous mucormycetous molds.

Safety, outcomes, and pharmacokinetics of isavuconazole as a treatment for invasive fungal diseases in pediatric patients: a non-comparative phase 2 trial

Invasive aspergillosis (IA) and mucormycosis (IM) cause significant morbidity and mortality in immunocompromised and/or hospitalized patients. Isavuconazonium sulfate, a prodrug of the antifungal triazole isavuconazole, has been approved for treatment of IA and IM in adults; and was recently approved in children. This study describes the outcomes, safety, and pharmacokinetics of isavuconazole for the treatment of proven, probable, or possible IA or IM in children. In this phase 2, open-label, non-comparative study, patients aged 1 to <18 years with at least possible invasive mold disease were enrolled across 10 centers in the US, Spain, and Belgium from 2019 to 2022. Patients received 10 mg/kg isavuconazonium sulfate daily (maximum 372 mg; equivalent to 5.4 mg/kg or 200 mg isavuconazole) for up to 84 (IA) or 180 days (IM). Outcomes included rates of all-cause case fatality, overall response, treatment-emergent adverse events (TEAEs), and pharmacokinetics. Of 31 patients enrolled, 61.3% were 1-<12 years old; 58.1% had underlying hematologic malignancies. The successful overall response rate at the end of treatment was 54.8%. Day 42 all-cause case fatality was 6.5%; 93.5% experienced TEAEs, and two patients discontinued treatment due to drug-related TEAEs. Dosing at 10 mg/kg (maximum dose: 372 mg) met the pre-defined exposure threshold of above the 25th percentile for the area under the concentration-time curve (≥60 mg·h/L). Simulated doses of 15 mg/kg improved drug exposures in patients aged 1-<3 years. Isavuconazole was well tolerated in children, with exposure consistent with adult studies. Successful response was documented in 54.8% of patients.CLINICAL TRIALSThis study is registered at ClinicalTrials.gov as NCT03816176.

Mono-N-alkylation of Amphotericin B and Nystatin A1 and Its Amides: Effect on the In Vitro Activity, Cytotoxicity and Permeabilization of Model Membranes

Objectives: In 2022, the World Health Organization highlighted the necessity for the development of new antifungal agents. Polyene antibiotics are characterized by a low risk of drug resistance; however, their use is limited by low solubility and severe side effects. Methods: A series of N-alkylated derivatives of amphotericin B and nystatin A1 as well as their N-(2-hydroxyethyl)amides were synthesized. Their antifungal activity was evaluated against various Candida strains and Aspergillus fumigatus using the broth microdilution method. Cytotoxicity was assessed using an MTT assay on human embryonic kidney cells HEK293 and human skin fibroblast cells hFB-hTERT6, as well as a hemolysis assay on erythrocytes. Membrane activity was analyzed by fluorimetric measurement of calcein leakage from model liposomes. Results: Derivatives containing the N-(hydroxyethyl)amino)ethyl fragment (compounds 3 and 4) exhibited relatively high antifungal activity, as did N-(2-hydroxyethyl)amides 5 and 9. Bis-modified compounds 6 and 10 did not outperform their mono-modified analogues in terms of activity or cytotoxicity. The mono-N-alkylated compound 3 showed the highest activity/toxicity ratio, which correlated well with its selectivity for ergosterol-containing model membranes. Discussion: Combining two successful modifications does not necessarily improve the activity/toxicity ratio of polyenes. Further studies can be performed for the optimization of carboxyl group of 3.

Epidemiology, pathogenesis, clinical characteristics, and treatment of mucormycosis: a review

AIM

This review aims to summarize the epidemiology, etiology, pathogenesis, clinical manifestations, and current diagnostic and therapeutic approaches for mucormycosis. The goal is to improve understanding of mucormycosis and promote early diagnosis and treatment to reduce mortality.

METHODS

A comprehensive literature review was conducted, focusing on recent studies and data on mucormycosis. The review includes an analysis of the disease's epidemiology, etiology, and pathogenesis, as well as current diagnostic techniques and therapeutic strategies.

RESULTS

Mucormycosis is increasingly prevalent due to the growing immunocompromised population, the COVID-19 pandemic, and advances in detection methods. The pathogenesis is closely associated with the host immune status, serum-free iron levels, and the virulence of Mucorales. However, the absence of typical clinical manifestations complicates diagnosis, leading to missed or delayed diagnoses and higher mortality.

CONCLUSION

An enhanced understanding of the epidemiology, pathogenesis, and clinical presentation of mucormycosis, along with the adoption of improved diagnostic and therapeutic approaches, is essential for reducing mortality rates associated with this opportunistic fungal infection. Early diagnosis and prompt treatment are critical to improving patient outcomes.

Update on methods used for mycological testing: wide diversity and opportunities for improvement persist

Past analysis of laboratory methods used for mycology specimens revealed significant variation in practices, many of which fell short of recommended procedures. In 2016 these findings led to a set of recommendations for laboratories to consider modification of their methods where appropriate, to analyse current laboratory methods used by participants in the Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) Mycology module, and to compare these to the 2016 recommendations. Seven test items, with 105-107 participants each, were analysed. Several laboratories (7-12%) did not handle specimens as recommended in an appropriate biological safety cabinet. Direct microscopy was not performed on tissue specimens 23-25% of the time. The most used staining method was potassium hydroxide with an optical brightener for fluorescent microscopy (49%) followed by Gram stain (33%). While 17-25% of laboratories used three or more media, use of four or more was uncommon (<3%). Between 9-13% of participants used only a single non-inhibitory medium for cultures. Urine specimens were incubated longer than recommended with 57% of laboratories incubating for >7days and 24% >21 days. Duration of incubation was shorter than recommended for several specimen types with 36% of skin specimens and 37-48% of tissue specimens being kept ≤21 days. For cultures kept >7 days, 13% were inspected daily, but for those incubating >14 days only 3%. The methods of several laboratories remain outside recommended practice. An updated set of recommendations are made.

Approaches for posaconazole therapeutic drug monitoring and their clinical benefits

OBJECTIVE

This review examines the progress of research on posaconazole therapeutic drug monitoring (TDM) that has focused on differences in the TDM of posaconazole after clinical application in different formulations and in different populations, the factors that affect posaconazole concentrations, the advantages of posaconazole TDM in terms of clinical efficacy and cost savings, and measurement methods.

METHODS

A literature search (2006 to 2024) was performed in PubMed and Embase with the following search terms: noxafil, posaconazole hydrate, posaconazole, drug monitoring, therapeutic drug monitoring, and TDM. Abstracts of review articles, prospective studies, and retrospective studies were reviewed.

RESULTS

TDM should be implemented earlier for posaconazole tablets and injections than for oral posaconazole suspensions. Posaconazole TDM is beneficial for improving clinical efficacy, and the incidence of breakthrough invasive fungal infections (IFIs) can be significantly reduced by gradually adjusting the posaconazole dose in response to TDM in patients with inadequate trough concentrations. Early TDM allows more patients to achieve target therapeutic posaconazole concentrations. TDM can also facilitate dose adjustments, which reduce the cost of this expensive drug. Different assay techniques, including chromatography, microbiological detection, chemofluorimetry, paper spray mass spectrometry, and capillary electrophoresis, can be used for posaconazole TDM.

CONCLUSIONS

Posaconazole TDM has potential clinical utility and cost-saving benefits and could improve the outcomes of IFI treatment.

Mucormycosis after liver transplant: Case series and literature review

We describe two cases of possible healthcare-associated mucormycosis in liver transplant recipients. Mucorales may be acquired from environmental sources such as contaminated medical equipment, grafts or procedure related. Gastrointestinal mucormycosis is the second most common presentation in healthcare-associated infections. The high mortality rate of mucormycosis is due to low suspicion, insensitive diagnostic tests and rapid angioinvasion. Early antifungal treatment and surgical debridement are imperative to improve survival.

Effectiveness, Safety, and Patterns of Real-World Isavuconazole Use in Europe (2015-2019)

INTRODUCTION

Real-world data from multinational observational studies are required to better understand the role and performance of isavuconazole in real-world practice in Europe.

METHODS

A retrospective medical record review was conducted at 16 sites in Europe (France, Germany, Italy, Spain, and the United Kingdom). Eligible records were from patients aged ≥ 18 years at the time of isavuconazole initiation and received at least one dose of isavuconazole for suspected or confirmed invasive aspergillosis (IA) or invasive mucormycosis (IM) during the eligibility period (October 15, 2015 to June 30, 2019). Data were descriptively analysed. Success rates, overall survival, and times to these events were descriptively analysed.

RESULTS

Data were abstracted from 218 patients (201, IA; 17, IM) who received isavuconazole as monotherapy (initiated as infusion, 52%; oral, 46%). Isavuconazole was initiated as primary therapy in 92 patients (42.2%) and salvage therapy in 121 patients (55.5%) (unknown for five patients). Mean (standard deviation) age was 56.8 (15.6) years, 66% were men and 62% had at least three comorbidities, most frequently haematologic malignancy (62%). Estimated clinical response rate at week 24 was 54.5% (95% confidence interval [CI], 38.2-66.5%) for primary treatment and 73.5% (95% CI, 62.7-81.1%) for salvage therapy. Overall, 45 patients (21%) experienced at least one adverse event (AE). Serious AEs were experienced by 37 patients (17%), with seven related to isavuconazole; five patients (2.3%) discontinued isavuconazole monotherapy due to the serious AE. A total of 137 patients (63%) died, with 17 deaths (12.4%) related to their invasive fungal infection, 11 of whom initiated isavuconazole as salvage therapy.

CONCLUSIONS

This study adds to the growing body of evidence that whether used as first-line therapy or after the failure of other antifungal therapies, isavuconazole appears to have a promising clinical response and a good safety profile as an antifungal agent in patients with varied underlying conditions.

Laboratory practices for the diagnosis and management of mucormycosis in France, 2024

This study investigates the diagnostic practices for mucormycosis among 30 French University Hospital mycology laboratories, in 2024. All laboratories perform both direct examination and culture, with fluorescent brighteners being the most commonly used method for direct examination. While 77 % of the participating laboratories routinely identify Mucorales to the species level, with 70 % having adopted Mucorales-specific quantitative PCR, primarily for the diagnosis of invasive fungal infections. Antifungal susceptibility testing practices varied between centers, with 36.7 % of laboratories consistently performing these tests, primarily using gradient concentration strips. Amphotericin B, posaconazole, and isavuconazole were the most frequently tested antifungals. These findings highlight variations in laboratory practices and emphasize the importance of establishing uniform diagnostic and susceptibility testing methods to optimize mucormycosis management.

Brain abscess following solid organ transplantation: A 21-year retrospective study

BACKGROUND

Development of brain abscess following solid organ transplantation is associated with significant morbidity and mortality. We undertook a descriptive study to evaluate the etiology, clinical manifestations, diagnosis, management, and outcomes of brain abscess in solid organ transplant (SOT) recipients at three major transplant centers in the United States.

METHODS

This is a retrospective study of adults with brain abscess following SOT between January 2000 and June 2021 at Mayo Clinic sites in Arizona, Minnesota, and Florida.

RESULTS

A total of 39 patients were diagnosed with a brain abscess following SOT. The most common pathogens were Nocardia sp. (24 cases, 61.5% [Nocardia farcinica, 37.5%]), followed by fungi (12 cases, 30.7% [Aspergillus sp., 83.3%]). The majority were kidney transplant recipients (59%). Median time to brain abscess diagnosis was 1.3 years (range, 29 days-12 years) after SOT; 10 of 12 patients (83%) with fungal brain abscess were diagnosed within 1 year after SOT. Twelve patients underwent brain biopsy for diagnosis (25% Nocardia vs. 50% fungal), eight (20.5%) underwent surgical resection of the abscess, and 31 (79.5%) received antimicrobial therapy alone. Median time to brain abscess resolution was 166 days for Nocardia and 356 days for fungal pathogens. Eleven of 39 patients (28.2%) died as a result of their brain abscess, including four of 24 patients (16%) with Nocardia and six of 10 patients (60%) with Aspergillus brain abscess. All-cause mortality was 43.6%.

CONCLUSION

Brain abscess remains an uncommon infectious complication following SOT. Nocardia and fungi accounted for 92% of pathogens in our cohort. Fungal brain abscess portends a poor prognosis.

New and emerging roles for inhalational and direct antifungal drug delivery approaches for treatment of invasive fungal infections

INTRODUCTION

The rising prevalence of difficult-to-treat, deep-seated invasive fungal diseases (IFD) has led to high mortality. Currently available antifungal treatments, administered predominantly orally or intravenously, may not sufficiently penetrate certain body sites, and/or are associated with systemic toxicity. Little is known about how to position alternative administration approaches such as inhalational and direct drug delivery routes.

AREAS COVERED

This review provides an updated overview of unconventional drug delivery strategies for managing IFD, focusing on inhalational (to target the lungs) and direct delivery methods to the central nervous system, bone/joint, and eyes. Novel compounds (e.g. opelconazole) and existing antifungals with innovative drug delivery systems currently undergoing clinical trials and/or used off-label in the clinical setting are discussed.

EXPERT OPINION

For both inhalational agents and direct delivery approaches, there are similar challenges that include the absence of: approved formulations for specific administration routes, delivery vehicles that are simple and safe to use whilst maintaining potency and efficiency of delivery, animal models suitable for investigating pharmacokinetic/pharmacodynamic profiles of inhaled antifungals, and consensus on the composite endpoints and intervals for of follow-up in clinical trials. To meet these challenges, cooperation of all stakeholders in drug development and regulation is required.

Antifungal susceptibility testing: applicability of methods and strategies for improving access in resource-constrained settings

Patients infected with antifungal-resistant fungi often do not respond to therapy, substantially increasing mortality risk. Some fungi are inherently resistant to particular antifungals, underscoring the importance of rapid genus identification or, ideally, rapid species identification. The past decade has seen an increase in variable antifungal resistance rates among human fungal pathogens, necessitating individual isolate testing. Various antifungal susceptibility testing (AFST) methods are most suitable for resource-constrained settings, including agar diffusion, gradient diffusion, broth microdilution, and automated tests, which all differ in speed, reliability, and cost; yet AFST remains largely unavailable in resource-constrained settings. This Personal View explores the feasibility of AFST implementation in resource-constrained settings and addresses broader accessibility concerns. We outline seven steps for implementation of AFST with an initial focus on accurate species identification (to predict intrinsic resistance) of Candida albicans, Candida parapsilosis, Candida glabrata, and Aspergillus fumigatus. New funding, laboratory and clinical training, clear protocols, access to media and reagents, acquisition and maintenance of quality control strains, and regular participation in an external quality assurance programme are all essential for sustainable AFST services. AFST is fundamental for patient care guidance, surveillance data generation, and strengthening antifungal stewardship programmes. Political commitment and international collaborations are crucial for enhanced AFST service delivery.

Complete central airway obstruction from aggressive mucormycosis in a patient with acute myeloid leukaemia

A woman in her 30s with type 2 diabetes and morbid obesity presented with flu-like symptoms, persistent cough and mild dyspnoea, unresponsive to pneumonia treatment. Diagnosed with acute myeloid leukaemia, she was started on induction chemotherapy. Despite prophylactic antifungal and antibacterial therapy, she developed a fever, a right upper lobe opacity and a complete airway obstruction by a large endobronchial mass in the right main stem. Bronchoscopy with biopsy and PCR confirmed mucormycosis. Although a combined antifungal regimen was started promptly, her condition worsened, leading to acute respiratory distress syndrome, tracheo-pleural fistulas and extensive necrotic mucosa in the airways. Surgical intervention was not feasible, and she was transitioned to hospice. Complete central airway obstruction and trachea-pleural fistula are rare manifestations of pulmonary mucormycosis. We conduct a literature review of endobronchial mucormycosis to highlight the importance of early recognition and a multimodal treatment approach to improve outcomes.

Epidemiological Trends of Mucormycosis in Europe, Comparison with Other Continents

Mucormycosis is an invasive fungal infection, caused by fungi of the order Mucorales, and it is associated with high morbidity and mortality. The epidemiology of mucormycosis is evolving. The incidence, underlying risk factors, clinical presentation, as well as the responsible mucoralean agents, vary by geographic region. The estimated incidence in developed countries ranges from less than 0.06 to 0.3 cases per 100,000 population per year, while in India, it reaches approximately 14 cases per 100,000 population per year, which is about 80 times higher. In European countries the estimated incidence ranges from less than 0.04 to 0.12 per 100,000 population per year. Diabetes mellitus (DM) is the leading underlying disease globally. In Europe, hematological malignancies are the most common risk factor for mucormycosis, while in Asia diabetes predominates. The rhino-cerebral form of mucormycosis is most commonly seen in patients with DM, whereas pulmonary mucormycosis in patients with hematological malignancies and transplants. The most common species globally is Rhizopus arrhizus, whereas new emerging species only occasionally cause infection in Europe. However, vigilance is required, as they may raise concerns-especially in light of climate change- due to their potential to cause serious infections in both immunocompetent and immunosuppressed individuals.

The Rising Threat of Mucormycosis: Oman's Experience Before and During the COVID-19 Pandemic

Mucormycosis is a rare, severe fungal infection mainly affecting immunocompromised individuals. Because of limited data on its epidemiology in Oman, we present this national, multicentric, retrospective review that includes all cases of proven mucormycosis between 2006 and 2022 in Oman. There were 51 cases of mucormycosis reported in Oman. The annual incidence of mucormycosis was 0.38-0.69 cases per million population before COVID-19. During the pandemic, the incidence rose significantly to 1.76 in 2020, 5.31 in 2021, then decreased to 0.87 per million population in 2022. Diabetes was observed in 82.4% (n = 42) of the cases, COVID-19 in 47.1% (n = 24), and other chronic diseases in 72.6%. The use of steroids was reported in 33.3% (n = 17) and many patients (64.7%, n = 33) had multiple risk factors. The overall mortality rate was 41.2% (n = 21) and most deaths occurred within a month of diagnosis. Mortality rate among patients diagnosed with COVID-19 was 58.3% (14/24). Survival analysis showed a statistically significant association between COVID-19 status and patient survival (p = 0.024). Annual incidence of mucormycosis in Oman rose during the pandemic. This study highlights the epidemiological features of mucormycosis and emphasizes the importance of its inclusion in the national notifiable communicable diseases priority list as well as the importance of enhancing diagnostic capacities to detect and improve patient outcomes.