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Diabetes mellitus and other underlying conditions in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis: a systematic review and meta-analysis. J Laryngol Otol 2022; 136:788-798. [PMID: 35514092 PMCID: PMC9203420 DOI: 10.1017/s0022215122001074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE This study aimed to compute the pooled prevalence of diabetes mellitus and other underlying conditions in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis. METHOD A systematic literature review was performed in PubMed, Scopus, Web of Science, Embase and Google Scholar. The cross-sectional studies that reported the frequency of diabetes mellitus in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis were included. RESULTS Eighteen eligible studies with a total number of 3718 patients were included in the current study. The pooled prevalence of diabetes in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis was 89 per cent and with new-onset diabetes was 32 per cent. The pooled prevalence of steroid use was high (79 per cent) too. The all-cause mortality rate was 24 per cent. CONCLUSION Diabetes mellitus was the most frequent underlying condition in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis. The second most frequent underlying condition was steroid use during coronavirus disease 2019 infection. The appropriate control of hyperglycaemia and rational prescription of steroids during the treatment of coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis is recommended.
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Infections fongiques invasives chez l’enfant immunodéprimé en hématologie pédiatrique : recommandations de prise en charge au sein des centres de la SFCE. Bull Cancer 2022; 109:1109-1124. [DOI: 10.1016/j.bulcan.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/08/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022]
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Maassarani D, Bassil GF, Nehme M, Nassar A, Ghanime G, Sleiman Z. Rhinocerebral Mucormycosis: An Emerging Threat in the Era of COVID-19. Cureus 2022; 14:e28057. [PMID: 36127989 PMCID: PMC9477555 DOI: 10.7759/cureus.28057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 11/05/2022] Open
Abstract
Mucormycosis is a rare but aggressive and fatal infection that is prevalent in immunocompromised patients. The variation in its clinical presentation and the lack of specificity are misleading and lead to a delay in the diagnosis and management. However, the era of coronavirus disease 2019 (COVID-19) is marked by the increasing emergence of Mucor infections, now identified as coronavirus-associated mucormycosis (CAM). Although many clinical forms exist, the most encountered in CAM is rhino-orbito-cerebral, as already reported in India. We present a case of a 56-year-old male patient with uncontrolled diabetes mellitus and a history of recent SARS-CoV-2 infection treated with IV steroids, presenting for maxillary teeth pain and instability on day 16 of COVID-19 infection. Early diagnosis of CAM is crucial and will help decrease mortality in COVID-19 patients, especially those with comorbidities such as diabetes mellitus. Increasing cases of CAM should prompt clinicians to have a high index of suspicion for rhinocerebral mucormycosis, especially in patients with risk factors receiving steroid therapy. In such patients, baseline glycosylated hemoglobin level and strict glycemic control by frequently measuring blood glucose levels and strictly adhering to insulin protocols would be rational but its efficacy in limiting the numbers of CAM in developing countries still needs to be confirmed.
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He GQ, Xiao L, Pan Z, Wu JR, Liang DN, Guo X, Jiang MY, Gao J. Case report: A rare case of pulmonary mucormycosis caused by Lichtheimia ramosa in pediatric acute lymphoblastic leukemia and review of Lichtheimia infections in leukemia. Front Oncol 2022; 12:949910. [PMID: 36046038 PMCID: PMC9421258 DOI: 10.3389/fonc.2022.949910] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Mucormycosis caused by Lichtheimia ramosa is an emerging and uncommon opportunistic infection in patients with hematological malignancies, with high mortality rates. Herein, we first report a case of pulmonary mucormycosis with Lichtheimia ramosa in a 3-year-old girl recently diagnosed with B-cell acute lymphoblastic leukemia. The diagnosis was made using computerized tomography of the lung, metagenomic next-generation sequencing (mNGS) of blood and sputum specimens, and microscopic examination to detect the development of Lichtheimia ramosa on the surgical specimen. She was effectively treated after receiving prompt treatment with amphotericin B and posaconazole, followed by aggressive surgical debridement. In our case, the fungal isolates were identified as Lichtheimia ramosa using mNGS, which assisted clinicians in quickly and accurately diagnosing and initiating early intensive treatment. This case also indicated the importance of strong clinical suspicion, as well as aggressive antifungal therapy combined with surgical debridement of affected tissues.
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Affiliation(s)
- Guo-qian He
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | | | - Zhen Pan
- Sichuan University, Chengdu, China
| | - Jian-rong Wu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Dong-ni Liang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pathology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xia Guo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Ming-yan Jiang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- *Correspondence: Ming-yan Jiang,
| | - Ju Gao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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Mohapatra S, Barik MR, Rath S, Sharma S, Mohapatra A, Behera S, Acharya S, Pattjoshi DR, Padhi RK, Behera HS. Diagnostic Performance and Clinical Utility of Conventional PCR Assay in Early Diagnosis of COVID-19 Associated Rhino-Orbito-Cerebral Mucormycosis. J Fungi (Basel) 2022; 8:jof8080844. [PMID: 36012832 PMCID: PMC9409716 DOI: 10.3390/jof8080844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/08/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Early diagnosis and treatment of rhino-orbital-cerebral mucormycosis (ROCM) are crucial. Potassium hydroxide with Calcofluorwhite (KOH + CFW) smears can demonstrate the fungal hyphae, but mixed infections caused by both mucorales and non-mucorales pose a diagnostic challenge. Polymerase chain reaction (PCR) can detect mixed infections and differentiate mucorales from non-mucorales. This study aimed to evaluate the utility of a single reaction PCR in the diagnosis of ROCM and the efficacy of nasal biopsy and endonasal swab in the detection of fungus. Sixty-six clinical samples were collected from 33 patients and were subjected to KOH + CFW smear, culture and PCR. PCR was performed using pan-fungal primers targeting the 28S large subunit rRNA gene, and the amplified products were further sequenced to identify the fungi. KOH + CFW smear, culture and PCR detected mucorales in 54.6%, 27.3% and 63.6% patients, respectively. PCR detected mixed infection in 51.5% patients compared to 9.1% by KOH + CFW smear. PCR detected fungus in 90% of nasal biopsies and 77.8% of endonasal swabs. Rhizopus spp. was the most common fungi identified in 43.2% of PCR-positive samples. PCR is effective in detecting mixed infection and in the diagnosis of ROCM. Nasal biopsies had better fungal detection rates than endonasal swabs.
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Affiliation(s)
- Samir Mohapatra
- Department of Ophthalmic Plastic and Reconstructive Surgery Service, L V Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar 751024, Odisha, India
| | - Manas Ranjan Barik
- Ocular Microbiology Service, L V Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar 751024, Odisha, India
| | - Suryasnata Rath
- Department of Ophthalmic Plastic and Reconstructive Surgery Service, L V Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar 751024, Odisha, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad 500034, Telangana, India
| | - Archisman Mohapatra
- Department of Biostatistics, Generating Research Insights for Development (GRID) Council, Noida 201307, Delhi NCR, India
| | | | - Souvagini Acharya
- Department of Ear, Nose and Throat, VSSIMSAR, Burla 768017, Odisha, India
| | - Dipti Ranjan Pattjoshi
- Department of Ear, Nose and Throat, SCB Medical College and Hospital, Cuttack 753007, Odisha, India
| | - Rajesh Kumar Padhi
- Department of Ear, Nose and Throat, Sparsh Hospitals Pvt Ltd., Bhubaneswar 751007, Odisha, India
| | - Himansu Sekhar Behera
- Ocular Microbiology Service, L V Prasad Eye Institute, Mithu Tulsi Chanrai Campus, Bhubaneswar 751024, Odisha, India
- Correspondence:
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Ghelfenstein-Ferreira T, Verdurme L, Alanio A. Analytical Performance of the Commercial MucorGenius® Assay as Compared to an In-House qPCR Assay to Detect Mucorales DNA in Serum Specimens. J Fungi (Basel) 2022; 8:jof8080786. [PMID: 36012775 PMCID: PMC9410016 DOI: 10.3390/jof8080786] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 11/18/2022] Open
Abstract
Standardized, reproducible and validated Mucorales quantitative PCR (qPCR) assays are needed in the context of routine testing in diagnostic labs. We, therefore, compared the commercial MucorGenius® assay (PathoNostics, Maastricht) targeting five genera of Mucorales to our in-house qPCR targeting Rhizomucor spp., Lichtheimia spp. and Mucor/Rhizopus spp. To assess their analytical sensitivity, 25 frozen leftover serum specimens, which had already tested positive based on our in-house assay, were selected. These sera were from 15 patients with probable or proven mucormycosis. For analytical specificity, 0.5 pg from 15 purified fungal DNAs from nine different Mucorales genera were spiked into pooled qPCR-negative leftover serum specimens. All samples were tested in parallel with both assays and the quantitative cycles (Cq) were compared. A total of 13/25 (52%) serum samples were amplified by one of the two assays with only four of them detected with the MucorGenius® assay. In spiked specimens, all targeted strains were successfully amplified by our in-house qPCR. The MucorGenius® assay was not able to detect Lichtheimia corymbifera but successfully amplified all other species targeted by the kit and two additional non-targeted species (Syncephalastrum monosporum and Saksenaea vasiformis). The MucorGenius® assay showed lower analytical sensitivity compared to our in-house assay. Indeed, the MucorGenius® assay amplified more species, as expected, but showed a decreased detection of the frequent species Lichtheimia corymbifera.
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Affiliation(s)
- Théo Ghelfenstein-Ferreira
- Laboratoire de Parasitologie-Mycologie, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, 75010 Paris, France;
| | - Laura Verdurme
- Laboratoire Cerba, Saint-Ouen-l’Aumône, 95310 Paris, France;
| | - Alexandre Alanio
- Laboratoire de Parasitologie-Mycologie, AP-HP, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, 75010 Paris, France;
- Institut Pasteur, Université Paris Cité, Centre National de la Recherche Scientifique (CNRS), Molecular Mycology Unit, Unité Mixte de Recherche UMR2000, CEDEX 15, 75724 Paris, France
- Correspondence: ; Tel.: +33-140613255
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Davies GE, Thornton CR. Development of a Monoclonal Antibody and a Serodiagnostic Lateral-Flow Device Specific to Rhizopus arrhizus (Syn. R. oryzae), the Principal Global Agent of Mucormycosis in Humans. J Fungi (Basel) 2022; 8:jof8070756. [PMID: 35887511 PMCID: PMC9325280 DOI: 10.3390/jof8070756] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/01/2022] [Accepted: 07/20/2022] [Indexed: 12/04/2022] Open
Abstract
Mucormycosis is a highly aggressive angio-invasive disease of humans caused by fungi in the zygomycete order, Mucorales. Though a number of different species can cause mucormycosis, the principal agent of the disease worldwide is Rhizopus arrhizus, which accounts for the majority of rhino-orbital-cerebral, pulmonary, and disseminated infections in immunocompromised individuals. It is also the main cause of life-threatening infections in patients with poorly controlled diabetes mellitus, and in corticosteroid-treated patients with SARS-CoV-2 infection, where it causes the newly described disease, COVID-19-associated mucormycosis (CAM). Diagnosis currently relies on non-specific CT, a lengthy and insensitive culture from invasive biopsy, and a time-consuming histopathology of tissue samples. At present, there are no rapid antigen tests for the disease that detect biomarkers of infection, and which allow point-of-care diagnosis. Here, we report the development of an IgG1 monoclonal antibody (mAb), KC9, which is specific to Rhizopus arrhizus var. arrhizus (syn. Rhizopus oryzae) and Rhizopus arrhizus var. delemar (Rhizopus delemar), and which binds to a 15 kDa extracellular polysaccharide (EPS) antigen secreted during hyphal growth of the pathogen. Using the mAb, we have developed a competitive lateral-flow device (LFD) that allows rapid (30 min) and sensitive (~50 ng/mL running buffer) detection of the EPS biomarker, and which is compatible with human serum (limit of detection of ~500 ng/mL) and bronchoalveolar lavage fluid (limit of detection of ~100 ng/mL). The LFD, therefore, provides a potential novel opportunity for the non-invasive detection of mucormycosis caused by Rhizopus arrhizus.
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Affiliation(s)
- Genna E. Davies
- ISCA Diagnostics Ltd., B12A, Hatherly Laboratories, Prince of Wales Road, Exeter EX4 4PS, UK;
| | - Christopher R. Thornton
- MRC Centre for Medical Mycology, Geoffrey Pope Building, University of Exeter, Stocker Road, Exeter EX4 4QD, UK
- Correspondence:
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Zareshahrabadi Z, Emami A, Pakshir K, Roudgari A, Ghaffari B, Rezaei T, Shekarkhar G, Zomorodian K. COVID
‐19‐associated facial cutaneous mucormycosis superinfection: A potentially life‐threatening disease. Clin Case Rep 2022; 10:e6103. [PMID: 35898729 PMCID: PMC9307887 DOI: 10.1002/ccr3.6103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 12/11/2022] Open
Abstract
A 49‐year‐old male was involved in an accident and an abdominal computer tomographic examination revealed papillary renal cell carcinoma of the right kidney. During hospitalization, the patient was infected with COVID‐19. In the following COVID‐19 treatment, a black dot developed on the right side of the head and face. Antifungal therapy and surgical debridement were initiated and gradual improvement was observed. COVID‐19 infection is spreading rapidly and mucormycosis is an invasive fungal infection which causes a high rate of mortality. Early diagnosis and prompt treatment can result in better outcome of the patient.
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Affiliation(s)
- Zahra Zareshahrabadi
- Basic Sciences in Infectious Diseases Research Center Shiraz University of Medical Sciences Shiraz Iran
| | - Amir Emami
- Microbiology Department, Burn & Wound Healing Research Center Shiraz University of Medical Sciences Shiraz Iran
| | - Keyvan Pakshir
- Basic Sciences in Infectious Diseases Research Center Shiraz University of Medical Sciences Shiraz Iran
- Department of Parasitology and Mycology, School of Medicine Shiraz University of Medical Sciences Shiraz Iran
| | - Amir Roudgari
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital Shiraz University of Medical Sciences Shiraz Iran
| | - Behzad Ghaffari
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital Shiraz University of Medical Sciences Shiraz Iran
| | - Tahere Rezaei
- Vice Chancellor for Treatment Shiraz University of Medical Sciences Shiraz Iran
| | - Golsa Shekarkhar
- Department of Pathology, School of Medicine Shiraz University of Medical Sciences Shiraz Iran
| | - Kamiar Zomorodian
- Basic Sciences in Infectious Diseases Research Center Shiraz University of Medical Sciences Shiraz Iran
- Department of Parasitology and Mycology, School of Medicine Shiraz University of Medical Sciences Shiraz Iran
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Deb AK, Singh R, Kaliaperumal S, Alexander A, Gokhale T, Sarkar S. Rhino-orbito-cerebral mucormycosis: aetiopathology, clinical features, outcome and the factors associated with outcome- a retrospective hospital record-based study. KOREAN JOURNAL OF OPHTHALMOLOGY 2022; 36:356-365. [PMID: 35766047 PMCID: PMC9388891 DOI: 10.3341/kjo.2022.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Mucormycosis is a multisystemic, aggressive, and an opportunistic fungal infection. The most common type is rhino-orbito-cerebral mucormycosis (ROCM) accounting for almost 40% of the cases. In this study, we analyzed the etiopathology, clinical features, treatment outcome, and the factors associated with outcome in ROCM. Methods Case records of 52 patients of ROCM were analyzed. Clinical parameters, laboratory parameters, imaging findings, treatment regime, and treatment outcome details were retrieved from each case record. The outcome measures were evaluated as treatment success and treatment failure. Univariate and logistic regression analyses were performed to identify factors associated with treatment outcome. Results On univariate analysis, factors associated with poor treatment outcome were uncontrolled blood sugar, blood urea, diabetic ketoacidosis, duration of ocular symptoms, no perception of light at presentation, ptosis, conjunctival chemosis, relative afferent pupillary defect, two or more sinus involvement, bony erosion of orbital wall, intracranial extension, intraconal invasion, etc. On subsequent logistic regression analysis, factors that maintained significant association with poor treatment outcome were uncontrolled blood sugar (adjusted odds ratio [aOR], 1.17; p = 0.018), no perception of light at presentation (aOR, 10.67; p = .006), ptosis at presentation (aOR, 3.90; p = 0.03), conjunctival chemosis (aOR, 7.11; p = 0.024), relative afferent pupillary defect (aOR, 10.60, p = 0.01), central retinal artery occlusion at presentation (aOR, 3.54; p = 0.021) and two or more sinus involvement (aOR, 4.90; p = 0.009). Conclusions The current study identified newer factors in the form of presenting ocular and radiological features as predictors for aggressive systemic disease and poor treatment outcome. Future prospective studies are, however, needed to substantiate these associations.
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Affiliation(s)
- Amit Kumar Deb
- Department of Ophthalmology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry, India
| | - Rakesh Singh
- Department of Microbiology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry, India
| | - Subashini Kaliaperumal
- Department of Ophthalmology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry, India
| | - Arun Alexander
- Department of Otorhinolaryngology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry, India
| | - Tanmay Gokhale
- Department of Ophthalmology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry, India
| | - Sandip Sarkar
- Department of Ophthalmology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry, India
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Clinical Manifestations of Pulmonary Mucormycosis in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation: A 21-Case Series Report and Literature Review. Can Respir J 2022; 2022:1237125. [PMID: 35692949 PMCID: PMC9184213 DOI: 10.1155/2022/1237125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Mucormycosis is a rare, invasive disease caused by opportunistic pathogens related to the Mucorales order with high fatality rates in immunocompromised hosts, especially in recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Diagnosis and treatment of pulmonary mucormycosis in recipients of allo-HSCT remains challenging. Purpose The aim of this study is to summarize and analyze the clinical features of pulmonary mucormycosis in recipients of allo-HSCT to explore further clinical research directions for this rare fungal infection in the particular populations. Methods We retrospectively reviewed pulmonary mucormycosis in patients who received allo-HSCT in our hospital from January 2010 to December 2020. A total of 21 patients fulfilled the diagnostic criteria for pulmonary mucormycosis according to the European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG) criteria. Demographic and clinical data, mycological and histopathological records, and treatment and prognosis data were collected. Clinical variables were compared between survivors and nonsurvivors. The survival days of patients with and without graft-versus-host disease (GVHD) and hemoptysis were compared separately. Results Most of the recipients of allo-HSCT were male patients with a mean age of 43 years. Acute myeloid leukemia (AML) was the most common primary hematologic malignancy. Extrapulmonary involvement accounted for 28.6%, of the cases, including central nervous system (n = 5) and skin and soft tissue (n = 1). The median time to infection was 96 days after allo-HSCT. Clinical presentations were nonspecific, including fever (76.2%) and cough (85.7%), as well as dyspnea (19.0%), chest pain (38.1%), and hemoptysis (61.9%). Ground-glass infiltrates (95.0%) and nodules/masses (80%) were the most common radiographic patterns on chest CT. The most common pathogen was Rhizopus (63.2%), and breakthrough infection accounted for 90.5%. Fifteen of the patients died within one year, and the median time from diagnosis to death was 47 days. Conclusion Mucormycosis is a fatal infection disease. Opportunistic infections in recipients of allo-HSCT are mainly breakthrough infections and may have a seasonal distribution (summer and autumn) and more cases of death in autumn. The marked reversed halo sign can be seen both in the initial stage of infection and after antifungal treatment. In our case series, patients with pulmonary mucormycosis with extrapulmonary involvement 100% died within one year. There are more patients with GVHD before infection and hemoptysis in nonsurvivors than survivors within 100 days. Patients with GVHD before infection and hemoptysis have a shorter survival time than those without.
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Sharma A, Goel A. Mucormycosis: risk factors, diagnosis, treatments, and challenges during COVID-19 pandemic. Folia Microbiol (Praha) 2022; 67:363-387. [PMID: 35220559 PMCID: PMC8881997 DOI: 10.1007/s12223-021-00934-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Mucormycosis is a deadly opportunistic disease caused by a group of fungus named mucormycetes. Fungal spores are normally present in the environment and the immune system of the body prevents them from causing disease in a healthy immunocompetent individual. But when the defense mechanism of the body is compromised such as in the patients of diabetes mellites, neustropenia, organ transplantation recipients, and other immune-compromised states, these fungal spores invade our defense mechanism easily causing a severe systemic infection with approximately 45-80% of case fatality. In the present scenario, during the COVID-19 pandemic, patients are on immunosuppressive drugs, glucocorticoids, thus are at high risk of mucormycosis. Patients with diabetes mellitus are further getting a high chance of infection. Usually, the spores gain entry through our respiratory tract affecting the lungs and paranasal sinuses. Besides, they can also enter through damage into the skin or through the gastrointestinal route. This review article presents the current statistics, the causes of this infection in the human body, and its diagnosis with available recent therapies through recent databases collected from several clinics and agencies. The diagnosis and identification of the infection were made possible through various latest medical techniques such as computed tomography scans, direct microscopic observations, MALDI-TOF mass spectrometry, serology, molecular assay, and histopathology. Mucormycosis is so uncommon, no randomized controlled treatment studies have been conducted. The newer triazoles, posaconazole (POSA) and isavuconazole (ISAV) (the active component of the prodrug isavuconazonium sulfate) may be beneficial in patients who are refractory to or intolerant of Liposomal Amphotericin B. but due to lack of early diagnosis and aggressive surgical debridement or excision, the mortality rate remains high. In the course of COVID-19 treatments, there must be more vigilance and alertness are required from clinicians to evaluate these invasive fungal infections.
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Affiliation(s)
- Ayushi Sharma
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India
| | - Anjana Goel
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India.
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Ziaka M, Papakonstantinou E, Vasileiou E, Chorafa E, Antachopoulos C, Roilides E. Pediatric cutaneous mucormycosis: case report and review of the literature. Mycoses 2022; 65:674-682. [PMID: 35514044 DOI: 10.1111/myc.13452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mucormycosis has emerged as an increasingly important fungal disease for immunocompromised children and neonates, with the cutaneous form being one of its most common presentations. METHODS We present a cutaneous mucormycosis case in a 10-year-old girl and analyze reports of single cases and case series of cutaneous mucormycosis in ≤16-year-old patients, recorded in PUBMED from 1953 to 2020, for epidemiology, risk factors, diagnostic and therapeutic procedures and outcome. RESULTS 113 cases were enrolled. Median age was 5 years [Interquartile Range (IQR) 10.9], without gender predominance. Underlying conditions were hematologic malignancies/disorders (25.7%), prematurity (23%), solid organ transplantation (3.5%), diabetes mellitus type 1 (4.4%), immunodeficiency and other diseases (14.2%), and no underlying conditions (29.2%). Inoculation occurred through major trauma (12.4%), including surgery and motor vehicle accidents, catheter sites (27.4%), dressings, patches and probes (11.5%), burns and farm-related accidents (8.8%). Rhizopus spp. was most frequently isolated (43.4%), followed by Lichtheimia corymbifera (9.7%), Saksenaea vasiformis (8%), Mucor and Rhizomucor spp. (5.3% each), other species/combinations (7.2%) and unspecified isolates (21.2%). Surgery was combined with antifungals in 62.8%. Each was performed solely in 27.4% and 6.2%, respectively. Amphotericin B was used in 78% (alone in 55.8% and combined with other antifungals in 22.2%) of the cases. Overall mortality was 26.5%. In regression analysis, prematurity and hematologic malignancies/disorders were associated with increased mortality, whereas combination of antifungals and surgery with improved survival. CONCLUSION Cutaneous mucormycosis mainly affects premature infants and children with hematologic malignancies/disorders. Outcome is improved when active antifungal therapy and surgery are combined.
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Affiliation(s)
- Maria Ziaka
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Aristotle University, Thessaloniki, Greece
| | - Eugenia Papakonstantinou
- Department of Pediatric Hematology and Oncology, Hippokration General Hospital, Thessaloniki, Greece
| | | | - Elisavet Chorafa
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Aristotle University, Thessaloniki, Greece
| | - Charalampos Antachopoulos
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Aristotle University, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Aristotle University, Thessaloniki, Greece
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63
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Active Surveillance Program to Increase Awareness on Invasive Fungal Diseases: the French RESSIF Network (2012 to 2018). mBio 2022; 13:e0092022. [PMID: 35499498 PMCID: PMC9239099 DOI: 10.1128/mbio.00920-22] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The French National Reference Center for Invasive Mycoses and Antifungals leads an active and sustained nationwide surveillance program on probable and proven invasive fungal diseases (IFDs) to determine their epidemiology in France. Between 2012 and 2018, a total of 10,886 IFDs were recorded. The incidence increased slightly over time (2.16 to 2.36/10,000 hospitalization days, P = 0.0562) in relation with an increase of fungemia incidence (1.03 to 1.19/10,000, P = 0.0023), while that of other IFDs remained stable. The proportion of ≥65-year-old patients increased from 38.4% to 45.3% (P < 0.0001). Yeast fungemia (n = 5,444) was due mainly to Candida albicans (55.6%) with stable proportions of species over time. Echinocandins became the main drug prescribed (46.7% to 61.8%), but global mortality rate remained unchanged (36.3% at 1 month). Pneumocystis jirovecii pneumonia (n = 2,106) was diagnosed mostly in HIV-negative patients (80.7%) with a significantly higher mortality than in HIV-positive patients (21.9% versus 5.4% at 1 month, P < 0.0001). Invasive aspergillosis (n = 1,661) and mucormycosis (n = 314) were diagnosed mostly in hematology (>60% of the cases) with a global mortality rate of 42.5% and 59.3%, respectively, at 3 months and significant changes in diagnosis procedure over time. More concurrent infections were also diagnosed over time (from 5.4% to 9.4% for mold IFDs, P = 0.0115). In conclusion, we observed an aging of patients with IFD with a significant increase in incidence only for yeast fungemia, a trend toward more concurrent infections, which raises diagnostic and therapeutic issues. Overall, global survival associated with IFDs has not improved despite updated guidelines and new diagnostic tools.
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64
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Ahn H, Lee R, Cho SY, Lee DG. Advances in prophylaxis and treatment of invasive fungal infections: perspectives on hematologic diseases. Blood Res 2022; 57:101-111. [PMID: 35483934 PMCID: PMC9057668 DOI: 10.5045/br.2022.2022036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/26/2022] Open
Abstract
Invasive fungal infections (IFIs) are common causes of mortality and morbidity in patients with hematologic diseases. Delayed initiation of antifungal treatment is related to mortality. Aspergillus sp. is the leading cause of IFI followed by Candida sp. Diagnosis is often challenging owing to variable conditions related to underlying diseases. Clinical suspect and prompt management is important. Imaging, biopsy, and non-culture-based tests must be considered together. New diagnostic procedures have been improved, including antigen-based assays and molecular detection of fungal DNA. Among hematologic diseases, patients with acute myeloid leukemia, myelodysplastic syndrome, recipients of hematopoietic stem cell transplantation are at high risk for IFIs. Antifungal prophylaxis is recommended for these high-risk patients. There are continuous attempts to achieve ideal management of IFIs. Scoring system for quality control has been developed with important recommendations of current guidelines. Higher adherence to guidelines is related to decreased mortality in IFIs.
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Affiliation(s)
- Hyojin Ahn
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Raeseok Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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65
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Disseminated Cunninghamella spp. Endocarditis in a Beta-Thalassemia Patient after Asymptomatic COVID-19 Infection. Diagnostics (Basel) 2022; 12:diagnostics12030657. [PMID: 35328209 PMCID: PMC8946993 DOI: 10.3390/diagnostics12030657] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 02/05/2023] Open
Abstract
Cunninghamella spp. is a group of fungi belonging to the Mucorales order. Cases of fungal endocarditis are sporadic, but more frequent in immunocompromised patients. COVID-19 (SARS-CoV-2 Infection Disease 2019) infections, prematurity, deferoxamine treatment, iron overload, neutropenia, diabetes, and malignant hemopathies proved to be risk factors for mucormycosis. We present the case of a 7-year-old boy who was treated every three weeks with blood transfusion for major beta-thalassemia, receiving deferoxamine for secondary hemochromatosis. After two weeks with nonspecific respiratory and digestive symptoms, he was admitted for fever, followed by lower limb ischemia and neurological signs. Echocardiography revealed massive endocarditis affecting the mitral and tricuspid valves with embolization phenomena in the brain, lungs, kidney, spleen, and lower limbs. As a particular finding, IgG antibodies for COVID-19 were positive. Emergency cardiac surgery was performed. The mitral valve necessitated replacement with CarboMedics prosthesis. Unfortunately, the patient did not survive. Cunninghamella spp. was confirmed via the PCR analysis of vegetations. Cunninghamella endocarditis in the context of a systemic infection presented as an opportunistic infection affecting a child who had several risk factors. Mucormycosis is challenging to treat, with high mortality. Prophylactic treatment in beta-thalassemia patients with iron-chelator deprivation drugs, such as deferiprone, may help in preventing these particular fungal infections.
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66
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Hepatic failure and malnutrition as predisposing factors of cutaneous mucormycosis in a pediatric patient. Med Mycol Case Rep 2022; 35:26-29. [PMID: 35059283 PMCID: PMC8760179 DOI: 10.1016/j.mmcr.2021.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 12/30/2022] Open
Abstract
The genus Lichtheimia is the third-most frequent genus isolated in mucormycosis. We report a cutaneous case caused by Lichtheimia ramosa, localized on the face of a pediatric patient, in the context of acute liver failure and caloric malnutrition. Several surgeries and treatment with liposomal amphotericin B enabled the patient's favorable evolution.
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67
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Successful treatment of Mucor circinelloides in a Burn patient. BURNS OPEN 2022. [DOI: 10.1016/j.burnso.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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68
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Bigot J, Godmer A, Prudenté L, Angebault C, Brissot E, Bige N, Voiriot G, Leger PL, Petit-Hoang C, Atallah S, Gouache E, Senghor Y, Valot S, Hennequin C, Guitard J. Diagnosis of mucormycosis using an intercalating dye-based quantitative PCR. Med Mycol 2022; 60:6533518. [DOI: 10.1093/mmy/myac015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
PCR-based methods applied to various body fluids emerged in recent years as a promising approach for the diagnosis of mucormycosis. In this study, we set up and assess the value of a qPCR to detect a wide variety of Mucorales species in a single tube. A pair of degenerated primers targeting the rDNA operon was used in a qPCR utilizing an intercalating fluorescent dye. Analytical assessment, using a wide variety of both Mucorales strains (8 genera, 11 species) and non-Mucorales strains (9 genera, 14 species), showed 100% sensitivity and specificity rates with a limit of detection at 3 rDNA copy/ qPCR reaction. Subsequently, 364 clinical specimens from 166 at-risk patients were prospectively tested with the assay. All the seven patients classified as proven/probable mucormycosis using the EORTC-MSG criteria had a positive qPCR as well as a patient with a proven uncharacterized invasive mould infection. In addition, 3 out of 7 patients with possible mould invasive infections had at least one positive qPCR test. Sensitivity was calculated between 73.33% to 100% and specificity between 98.10% to 100%. The qPCR method proposed showed excellent performances and would be an important adjunctive tool for the difficult diagnosis of mucormycosis diagnosis.
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Affiliation(s)
- Jeanne Bigot
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, AP-HP, Hôpital Saint-Antoine, Service de Parasitologie-Mycologie, F-75012 Paris, France
| | - Alexandre Godmer
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI-Paris, F-75013, Paris, France
- Sorbonne-Université, Hôpital Saint-Antoine, Département de Bactériologie, Paris, France
| | - Lysa Prudenté
- APHP, Hôpital St Antoine, Laboratoire de parasitologie mycologie, F-75012 Paris, France
| | - Cécile Angebault
- Univ-Paris-Est-Créteil (UPEC), Faculté de Santé, EA DYNAMiC 7380 ; AP-HP, CHU Henri Mondor, Unité de Parasitologie-Mycologie, Département de Prévention, Diagnostic et Traitement des Infections, F-94010, France
| | - Eolia Brissot
- Sorbonne Université, INSERM U938, APHP, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, F-75012 Paris, France
| | - Naike Bige
- APHP, Hôpital Saint Antoine, Service de Réanimation Médicale, F-75012 Paris, France
| | - Guillaume Voiriot
- APHP, Hôpital Tenon, Service de Médecine Intensive et Réanimation, F-75020 Paris, France
| | - Pierre-Louis Leger
- APHP, Hôpital Saint Trousseau, Service de Réanimation Pédiatrique, F-75012 Paris, France
| | - Camille Petit-Hoang
- APHP, Hôpital Tenon, Service de Urgences Néphrologiques et Transplantation Rénale, F-75020 Paris
| | - Sarah Atallah
- APHP, Hôpital Tenon, Service de Oto-Rhino-Laryngologie, F-75012 Paris, France
| | - Elodie Gouache
- APHP, Hôpital Trousseau, Département d'Hématologie et d'Oncologie Pédiatrique, F-75012 Paris, France
| | - Yaye Senghor
- APHP, Hôpital St Antoine, Laboratoire de parasitologie mycologie, F-75012 Paris, France
| | - Stéphane Valot
- Laboratoire de Parasitologie-Mycologie, Plateforme de Biologie Hospitalo-Universitaire, F-21070 Dijon, France
| | - Christophe Hennequin
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, AP-HP, Hôpital Saint-Antoine, Service de Parasitologie-Mycologie, F-75012 Paris, France
| | - Juliette Guitard
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, AP-HP, Hôpital Saint-Antoine, Service de Parasitologie-Mycologie, F-75012 Paris, France
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69
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Global Cutaneous Mucormycosis: A Systematic Review. J Fungi (Basel) 2022; 8:jof8020194. [PMID: 35205948 PMCID: PMC8878367 DOI: 10.3390/jof8020194] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/10/2022] [Accepted: 02/15/2022] [Indexed: 01/27/2023] Open
Abstract
Cutaneous mucormycosis is the third most common clinical type of mucormycosis. The signs and symptoms vary widely, and it is important to make the diagnosis as early as possible in order to achieve a better outcome. We present a systematic review of its epidemiology, clinical presentation, diagnosis, and treatment, analyzing cases published from 1958 until 2021. The review was conducted according to the PRISMA guidelines and included 693 cases from 485 articles from 46 countries. Most publications were from North America (256 cases, 36.9%) and Asia (216 cases, 31.2%). The most common risk factors were diabetes mellitus (20%) and hematological malignancies (15.7%). However, a large proportion of published cases (275, 39.6%) had no identified underlying disease. The most common mode of transmission was trauma (54%), and 108 (15.6%) cases were healthcare-associated. In this review, 291 (42.5%) patients had localized infection, and 90 (13%) had disseminated mucormycosis. In Europe, N. America and S. America, the most common genus was Rhizopus spp., while in Asia it was Apophysomyces spp. (34.7%). Treatment was performed with antifungals, mainly amphotericin B, and/or surgery. Mortality was significantly lower when both antifungals and surgery were applied (29.6%).
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70
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Darwish RM, AlMasri M, Al‐Masri MM. Mucormycosis: The Hidden and Forgotten Disease. J Appl Microbiol 2022; 132:4042-4057. [DOI: 10.1111/jam.15487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/14/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rula M. Darwish
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy The University of Jordan Amman Jordan
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71
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Chavan RP, Ingole SM, Nazir HA, Desai WV, Kanchewad GS. Mucormycosis in COVID-19 pandemic: study at tertiary hospital in India. Eur Arch Otorhinolaryngol 2022; 279:3201-3210. [PMID: 35122509 PMCID: PMC8817651 DOI: 10.1007/s00405-022-07282-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/21/2022] [Indexed: 02/01/2023]
Abstract
Aim During the second wave of COVID-19, cases of mucormycosis were increased suddenly over a period of 3 months in Maharashtra, India. An attempt was made to study the clinical profile and risk factors associated with mucormycosis. Materials and methods A retrospective descriptive study was carried out at a tertiary hospital during May 2021–July 2021. After obtaining informed written consent from the participants, various details of all participants, such as diabetes mellitus, use of steroids in COVID-19 treatment, use of immunosuppressant drugs, oxygen therapy, use of ventilators, complications that occurred during treatment, etc., were noted. All mucormycosis patients were treated with amphotericin B and aggressive surgical treatment. Results In the present study, 74.7% of mucormycosis patients were male. 77.4% of mucormycosis patients were above 40 years of age. 6.7% of mucormycosis patients were partially vaccinated. Among risk factors, 86.6% had diabetes mellitus, 84% had COVID-19 infection, 44% had received steroids, and 54.7% had received oxygen. 80% of patients were present during and within 1 month of COVID-19 infection. 52% of patients were presented in stage III and 41.3% were presented in stage II. Despite aggressive surgical debridement along with amphotericin B, mortality was 25.33%. 5.3% of patients had brain abscesses, 8% of patients had cavernous sinus thrombosis, 4% of patients had facial nerve palsy and 1.3% of patients had meningitis. Conclusion Mucormycosis was predominantly seen in male above the age of 40 years COVID-19 infection and diabetes mellitus was common risk factor for mucormycosis.
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Affiliation(s)
| | - Shivraj M. Ingole
- Department of Radiology, GGMC and Sir J.J. Group of Hospitals, Mumbai, Maharashtra India
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72
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New insights on mucormycosis and its association with the COVID-19 pandemic. Future Sci OA 2022; 8:FSO772. [PMID: 35059222 PMCID: PMC8686842 DOI: 10.2144/fsoa-2021-0122] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/10/2021] [Indexed: 11/23/2022] Open
Abstract
COVID-19 continues to cause significant fatality worldwide. Glucocorticoids prove to play essential roles in COVID-19 management; however, the extensive use of steroids together with the virus immune dysregulation may increase the danger of secondary infections with mucormycosis, an angioinvasive fungal infection. Unfortunately, a definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. In this review, we discuss the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response, risk factors, clinical presentation, diagnosis and treatment. Special emphasis is given to its association with the current COVID-19 pandemic, including latest updates on COVID-19-associated mucormycosis cases globally, with recommendations for efficacious management. A definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. This article can be used as comprehensive tool to help clinicians and the healthcare team in getting a clearer look on the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response. Risk factors, clinical presentation, diagnosis, treatment options and also the latest updates on COVID-19-associated mucormycosis are also discussed, which will help in the understanding of the fatal mucormycosis infection.
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73
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Improved In Vitro Anti-Mucorales Activity and Cytotoxicity of Amphotericin B with a Pegylated Surfactant. J Fungi (Basel) 2022; 8:jof8020121. [PMID: 35205875 PMCID: PMC8876526 DOI: 10.3390/jof8020121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to evaluate the effect of the combination of amphotericin B (AmB) and various non-ionic surfactants on the anti-Mucorales activity of AmB, the toxicity of the combination on eukaryotic cells and the modification of AmB aggregation states. Checkerboards were performed on five genera of Mucorales (12 strains) using several combinations of different surfactants and AmB. These data were analyzed by an Emax model. The effect of surfactants on the cytotoxic activity of AmB was then evaluated for red blood cells and two eukaryotic cell lines by absorbance and propidium iodide internalization. Finally, the effect of polyethylene glycol (15)-hydroxystearate (PEG15HS) on the aggregation states of AmB was evaluated by UV-visible spectrometry. PEG15HS increased the efficacy of AmB on four of the five Mucorales genera, and MICs of AmB were decreased up to 68-fold for L. ramosa. PEG15HS was the only surfactant to not increase the cytotoxic activity of AmB. Finally, the analysis of AmB aggregation states showed that the increased efficacy of AmB and the absence of toxicity are related to an increase in monomeric and polyaggregated forms of AmB at the detriment of the dimeric form. In conclusion, PEG15HS increases the in vitro efficacy of AmB against Mucorales at low concentration, without increasing its toxicity; this combination could therefore be evaluated in the treatment of mucormycosis.
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74
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Danion F, Letscher-Bru V, Guitard J, Sitbon K, Dellière S, Angoulvant A, Desoubeaux G, Botterel F, Bellanger AP, Gargala G, Uhel F, Bougnoux ME, Gerber V, Michel J, Cornu M, Bretagne S, Lanternier F. Coronavirus Disease 2019-Associated Mucormycosis in France: A Rare but Deadly Complication. Open Forum Infect Dis 2022; 9:ofab566. [PMID: 35071681 PMCID: PMC8773954 DOI: 10.1093/ofid/ofab566] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/04/2021] [Indexed: 11/14/2022] Open
Abstract
We studied COVID-19 associated mucormycosis based on 17 cases reported nationwide and assessed the differences with India. They differed by frequencies of diabetes mellitus (47% in France versus up to 95% in India), hematological malignancies (35% versus 1%), anatomical sites (12% versus >80% rhino-orbito-cerebral) and prognosis (88% mortality versus <50%).
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Affiliation(s)
- François Danion
- Université de Strasbourg, Hôpitaux Universitaires de Strasbourg, Service de Maladies Infectieuses et Tropicales, Strasbourg, France.,Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM Unité Mixte de Recherche_S 1109, Strasbourg, France
| | - Valérie Letscher-Bru
- Université de Strasbourg, Hôpitaux Universitaires de Strasbourg, Laboratoire de Mycologie-Parasitologie, Strasbourg, France
| | - Juliette Guitard
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, CRSA, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Parasitologie-Mycologie, Paris, France
| | - Karine Sitbon
- Institut Pasteur, CNRS, Université de Paris, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et des Antifongiques, Paris, France
| | - Sarah Dellière
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Laboratoire de Mycologie-Parasitologie, Paris, France
| | - Adela Angoulvant
- Université Paris Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service des Maladies Infectieuses et Tropicales, Le Kremlin-Bicêtre, France.,Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Centre National de Recherche Scientifique, AgroParisTech, GQE-Le Moulon, Gif-sur-Yvette, France
| | - Guillaume Desoubeaux
- Centre Hospitalier Universitaire de Tours, Laboratoire de Mycologie-Parasitologie, Tours, France
| | - Francoise Botterel
- Assistance Publique-Hôpitaux de Paris, CHU Henri-Mondor, Laboratoire de Mycologie-Parasitologie, Créteil, France
| | | | - Gilles Gargala
- CHU de Rouen, Laboratoire de Mycologie-Parasitologie, Rouen, France
| | - Fabrice Uhel
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis-Mourier, Service de Médecine Intensive et Réanimation, Département Médical Universitaire ESPRIT, Colombes, France
| | - Marie-Elisabeth Bougnoux
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Laboratoire de Mycologie-Parasitologie, Paris, France
| | - Victor Gerber
- Hôpitaux Civils de Colmar, Service de Réanimation Médicale, Colmar, France
| | - Justin Michel
- Université Aix Marseille, AP-HM, Hôpital de La Conception, Service Oto-Rhino-Laryngologie et Chirurgie Cervico-faciale, Marseille, France
| | - Marjorie Cornu
- Université de Lille, Inserm U1285, CHU Lille, Laboratoire Parasitologie-Mycologie.,CNRS, UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Stéphane Bretagne
- Institut Pasteur, CNRS, Université de Paris, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et des Antifongiques, Paris, France.,Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Laboratoire de Mycologie-Parasitologie, Paris, France
| | - Fanny Lanternier
- Institut Pasteur, CNRS, Université de Paris, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et des Antifongiques, Paris, France.,Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Service de Maladies Infectieuses et Tropicales, Paris, France
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75
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Millon L, Caillot D, Berceanu A, Bretagne S, Lanternier F, Morio F, Letscher-Bru V, Dalle F, Denis B, Alanio A, Boutoille D, Bougnoux ME, Botterel F, Chouaki T, Charbonnier A, Ader F, Dupont D, Bellanger AP, Rocchi S, Scherer E, Gbaguidi-Haore H, Herbrecht R. Evaluation of serum Mucorales PCR for the diagnosis of Mucormycoses: The MODIMUCOR prospective trial. Clin Infect Dis 2022; 75:777-785. [PMID: 34986227 DOI: 10.1093/cid/ciab1066] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early diagnosis and prompt initiation of specific antifungal treatment is essential for improving the prognosis of mucormycosis. We aimed to assess the performance of serum Mucorales quantitative PCR (qPCR) for the early diagnosis and follow-up of mucormycosis. METHODS We prospectively enrolled 232 patients with suspicion of invasive mold disease, evaluated using standard imaging and mycological procedures. Thirteen additional patients with proven or probable mucormycosis were included to analyze DNA load kinetics. Serum samples were collected twice-a-week for Mucorales qPCR tests targeting the Mucorales species Lichtheimia, Rhizomucor and Mucor/Rhizopus. RESULTS The sensitivity was 85·2%, specificity 89·8%, and positive and negative likelihood ratios 8·3 and 0·17, respectively in this prospective study. The first Mucorales qPCR-positive serum was observed a median of four days (IQR, 0-9) before sampling of the first mycological or histological positive specimen and a median of one day (IQR, (-2)-6) before the first imaging was performed. Negativity of Mucorales qPCR within seven days after liposomal-amphotericin B initiation was associated with an 85% lower 30-day mortality rate (adjusted hazard Ratio = 0·15, 95%CI [0·03-0·73], p = 0·02). CONCLUSION Our study argues for the inclusion of qPCR for the detection of circulating Mucorales DNA for mucormycosis diagnosis and follow-up after treatment initiation. Positive results should be added to the criteria for the consensual definitions from the European Organization for the Research and Treatment of Cancer/ Mycoses Study Group Education and Research Consortium (EORTC/MSGERC), as already done for Aspergillus PCR.
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Affiliation(s)
- Laurence Millon
- Laboratoire de Parasitologie-Mycologie, CHU Besançon, Besançon, France.,UMR 6249 CNRS Chrono-Environnement, Univ Bourgogne Franche-Comté, Besançon, France
| | - Denis Caillot
- Department of Clinical Hematology, CHU Dijon, Dijon, France
| | - Ana Berceanu
- Service d'Hematologie, CHU Besançon, Besançon, France
| | - Stéphane Bretagne
- Institut Pasteur, CNRS, Molecular Mycology Unit, National Reference Center for Invasive Mycoses & Antifungals, UMR2000, Paris, France.,Laboratoire de Parasitologie-Mycologie, Hôpital Saint Louis, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - Fanny Lanternier
- Institut Pasteur, CNRS, Molecular Mycology Unit, National Reference Center for Invasive Mycoses & Antifungals, UMR2000, Paris, France.,Université de Paris, Paris, France.,Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants malades, AP-HP, IHU Imagine, Paris, France
| | - Florent Morio
- Laboratoire de Parasitologie-Mycologie, CHU Nantes, Nantes, France.,Département de Parasitologie et Mycologie Médicale, EA1155 - IICiMed, Nantes Université, Nantes, France
| | - Valérie Letscher-Bru
- Laboratoire de Parasitologie et de Mycologie Médicale, Hôpitaux Universitaires de Strasbourg Strasbourg, France
| | - Frédéric Dalle
- Laboratoire de Parasitologie-Mycologie, Plateforme de Biologie Hospitalo-Universitaire Gérard Mack, Dijon France.,UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
| | - Blandine Denis
- Infectious Diseases Department, APHP, Saint-Louis Hospital, Paris, France
| | - Alexandre Alanio
- Institut Pasteur, CNRS, Molecular Mycology Unit, National Reference Center for Invasive Mycoses & Antifungals, UMR2000, Paris, France.,Laboratoire de Parasitologie-Mycologie, Hôpital Saint Louis, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - David Boutoille
- Unité Maladies Infectieuses et Tropicales, CHU Nantes, Nantes, France
| | - Marie-Elisabeth Bougnoux
- Parasitology-Mycology Unit, Necker Enfants Malades Hospital, APHP, Paris, France.,Fungal Biology and Pathogenicity Unit - INRA USC 2019. Institut Pasteur, Paris, France
| | - Françoise Botterel
- EA Dynamyc 7380 UPEC, ENVA, Faculté de Médecine, Créteil, France.,Unité de Parasitologie - Mycologie, Département de Virologie, Bactériologie-Hygiène, Mycologie-Parasitologie, DHU VIC, CHU Henri Mondor, Créteil, France
| | - Taieb Chouaki
- Laboratoire de Parasitologie et Mycologie Médicales, Centre de Biologie Humaine, CHU Amiens Picardie, Amiens, France.,Equipe AGIR : Agents Infectieux, Résistance et Chimiothérapie UR4294, Université de Picardie Jules Verne, Amiens, France
| | - Amandine Charbonnier
- Department of Clinical Hematology and Cellular Therapy, Amiens University Medical Center, Amiens, France
| | - Florence Ader
- Hospices Civils de Lyon, Département des Maladies Infectieuses et Tropicales, F-69004, Lyon, France
| | - Damien Dupont
- Institut des Agents Infectieux, Parasitologie Mycologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Anne-Pauline Bellanger
- Laboratoire de Parasitologie-Mycologie, CHU Besançon, Besançon, France.,UMR 6249 CNRS Chrono-Environnement, Univ Bourgogne Franche-Comté, Besançon, France
| | - Steffi Rocchi
- Laboratoire de Parasitologie-Mycologie, CHU Besançon, Besançon, France.,UMR 6249 CNRS Chrono-Environnement, Univ Bourgogne Franche-Comté, Besançon, France
| | - Emeline Scherer
- Laboratoire de Parasitologie-Mycologie, CHU Besançon, Besançon, France.,UMR 6249 CNRS Chrono-Environnement, Univ Bourgogne Franche-Comté, Besançon, France
| | - Houssein Gbaguidi-Haore
- UMR 6249 CNRS Chrono-Environnement, Univ Bourgogne Franche-Comté, Besançon, France.,Infection Control Department, CHU Besançon, Besançon, France
| | - Raoul Herbrecht
- Université de Strasbourg, INSERM, IRFAC UMR-S1113, Strasbourg, France.,Service d'Hématologie, Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
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76
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Ghosh D, Dey S, Chakraborty H, Mukherjee S, Halder A, Sarkar A, Chakraborty P, Ghosh R, Sarkar J. Mucormycosis: A new threat to Coronavirus disease 2019 with special emphasis on India. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2022; 15:101013. [PMID: 35342843 PMCID: PMC8934183 DOI: 10.1016/j.cegh.2022.101013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/10/2021] [Accepted: 03/10/2022] [Indexed: 01/03/2023] Open
Abstract
The main reason for the growth of mucormycosis in people with Coronavirus disease-2019 (COVID-19) is mainly produced by Rhizopus spp. The infective mechanisms and issues recognized in Rhizopus spp. are the cell wall, germination proteins, and enzymes assisted to iron sequestration, CotH protein, and positive regulation of the GRP78 cell receptor. Mucormycosis is mainly caused by the Rhizopus spp. such as R. oryzae, R. microsporus, R. arrhizus, R. homothallicus, etc. that are gifted to numerous host defense mechanisms and attribute to the endothelium via specific receptors, GRP78 simplifying their endocytosis and angio-invasion. Factors such as hyperglycemia, elevated iron concentrations, and ketoacidosis have been shown to contribute to the pathogenesis in the tentative situation. The analytical data of 'black fungus disease' or 'mucormycosis', specify India reported for about 42.3% of published cases, followed by the USA about 16.9%, Iraq, Bangladesh, Iran, Paraguay, and 1 case each from Brazil, Mexico, Italy, UK, China, France, Uruguay, Turkey, and Austria. The COVID-19 infection is maybe a predisposing factor for mucormycosis and is related to a high mortality rate. Early recognition and restriction of hyperglycemia, liposomal amphotericin B, and surgical debridement are the bases in the successful managing of mucormycosis.
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Affiliation(s)
- Deganta Ghosh
- Department of Botany, Dinabandhu Andrews College, Garia, Kolkata, West Bengal, India, 700084
| | - Sagardeep Dey
- Department of Botany, Dinabandhu Andrews College, Garia, Kolkata, West Bengal, India, 700084
| | - Himanko Chakraborty
- Department of Botany, Dinabandhu Andrews College, Garia, Kolkata, West Bengal, India, 700084
| | - Sneha Mukherjee
- Department of Botany, Dinabandhu Andrews College, Garia, Kolkata, West Bengal, India, 700084
| | - Ankita Halder
- Department of Botany, Dinabandhu Andrews College, Garia, Kolkata, West Bengal, India, 700084
| | - Akash Sarkar
- Department of Botany, Dinabandhu Andrews College, Garia, Kolkata, West Bengal, India, 700084
| | - Pallab Chakraborty
- Department of Botany, Acharya Prafulla Chandra College, New Barrakpur, Kolkata, West Bengal, India, 700131
| | - Rajdeep Ghosh
- GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India, 533296
| | - Joy Sarkar
- Department of Botany, Dinabandhu Andrews College, Garia, Kolkata, West Bengal, India, 700084,Corresponding author
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77
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Sannathimmappa MB, Nambiar V, Aravindakshan R. Storm of a rare opportunistic life threatening mucormycosis among post COVID-19 patients: A tale of two pathogens. Int J Crit Illn Inj Sci 2022; 12:38-46. [PMID: 35433396 PMCID: PMC9008285 DOI: 10.4103/ijciis.ijciis_48_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/12/2021] [Accepted: 09/01/2021] [Indexed: 11/22/2022] Open
Abstract
Mucormycosis is a rare but life-threatening opportunistic fungal infection caused by a group of molds that belong to Zygomycetes of the order Mucorales. These fungi are found in the environment such as soil, decaying vegetation, and organic matters. Sporangiospores present in the environment enter the human body through inhalation or direct skin inoculation by trauma or ingestion and result in pulmonary, cutaneous, and gastrointestinal mucormycosis, respectively, in immunocompromised hosts. Patients with uncontrolled diabetes, hematological malignancies, high-dose glucocorticoid therapy, iron overload, and organ transplantation are at high risk of acquiring mucormycosis. The second wave of severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] affected India severely with the highest number of cases and deaths compared to all other countries. Additionally, the country was affected by emergence of rare but life-threatening mucormycosis. Currently, many coronavirus disease 2019 patients with underlying risk factors such as uncontrolled diabetes, high-dose steroid therapy, and exposure to mechanical ventilation have developed mucormycosis. Inhalation is the most common mode of transmission that results in colonization of sporangiospores in the nose. In immunocompromised host, sporangiospores germinate, and subsequently form hyphae. These hyphae invade into tissues, and produce tissue infarction, necrosis, and thrombosis. Angioinvasion causes hematogenous dissemination to many organs, predominantly to brain, that result in rhino-orbital-cerebral mucormycosis. Clinical characteristics, radio imaging, fungal culture, histopathology, and molecular techniques are the key diagnostic methods. Surgical intervention and aggressive antifungal therapy are the main management strategies. Amphotericin B is the drug of choice for treatment of mucormycosis, whereas posaconazole or isavuconazole is used for step-down therapy and salvage therapy.
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Affiliation(s)
- Mohan Bilikallahalli Sannathimmappa
- Department of Microbiology, College of Medicine and Health Sciences, National University of Science and Technology, Sohar Campus, Andhra Pradesh, India
- Department of Microbiology, National University of Science and Technology, Sohar Campus, Sultanate of Oman
| | - Vinod Nambiar
- Department of Microbiology, College of Medicine and Health Sciences, National University of Science and Technology, Sohar Campus, Andhra Pradesh, India
- Department of Microbiology, National University of Science and Technology, Sohar Campus, Sultanate of Oman
| | - Rajeev Aravindakshan
- Department of Community Medicine, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
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78
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Three Cases of Gastrointestinal Mucor Colonization in Patients With Prolonged Neutropenia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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79
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Sami CA, Rashed HM, Khan AH, Barai L, Arafat SM. Disseminated mucormycosis: An unusual case of ascites with bone marrow invasion. IDCases 2022; 29:e01553. [PMID: 35845829 PMCID: PMC9278065 DOI: 10.1016/j.idcr.2022.e01553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/25/2022] [Accepted: 07/01/2022] [Indexed: 11/02/2022] Open
Abstract
Mucormycosis is a fatal invasive illness most frequently seen in immunocompromised hosts with uncontrolled diabetes, hematological malignancies, organ transplantation, or long-term steroid treatment. It has a poorer outcome than other fungal diseases due to its rapid spread and resistance to antifungal agents. We report a rare case of disseminated mucormycosis including the bone marrow, peritoneum, lung, and lymph nodes in an apparently immunocompetent 58-year-old gentleman who presented with two months of ascites and weight loss. After a thorough analysis, we found aseptate fungal hyphae in the bone marrow and ascitic fluid. In addition, a cottony white, woolly growth indicative of mucor species was seen in the ascitic fluid culture. CT scans of the chest and abdomen indicate characteristics consistent with mucor invasion. We began the patient on tablet posaconazole, but he died on the fifth day. The atypical presentation in an apparently immunocompetent patient and broad dissemination with rare bone marrow involvement emphasizes the disease's invasiveness.
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80
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Bupha-Intr O, Butters C, Reynolds G, Kennedy K, Meyer W, Patil S, Bryant P, Morrissey CO. Consensus guidelines for the diagnosis and management of invasive fungal disease due to moulds other than Aspergillus in the haematology/oncology setting, 2021. Intern Med J 2021; 51 Suppl 7:177-219. [PMID: 34937139 DOI: 10.1111/imj.15592] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Invasive fungal disease (IFD) due to moulds other than Aspergillus is a significant cause of mortality in patients with malignancies or post haemopoietic stem cell transplantation. The current guidelines focus on the diagnosis and management of the common non-Aspergillus moulds (NAM), such as Mucorales, Scedosporium species (spp.), Lomentospora prolificans and Fusarium spp. Rare but emerging NAM including Paecilomyces variotii, Purpureocillium lilacinum and Scopulariopsis spp. are also reviewed. Culture and histological examination of tissue biopsy specimens remain the mainstay of diagnosis, but molecular methods are increasingly being used. As NAM frequently disseminate, blood cultures and skin examination with biopsy of any suspicious lesions are critically important. Treatment requires a multidisciplinary approach with surgical debridement as a central component. Other management strategies include control of the underlying disease/predisposing factors, augmentation of the host response and the reduction of immunosuppression. Carefully selected antifungal therapy, guided by susceptibility testing, is critical to cure. We also outline novel antifungal agents still in clinical trial which offer substantial potential for improved outcomes in the future. Paediatric recommendations follow those of adults. Ongoing epidemiological research, improvement in diagnostics and the development of new antifungal agents will continue to improve the poor outcomes that have been traditionally associated with IFD due to NAM.
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Affiliation(s)
- Olivia Bupha-Intr
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
| | - Coen Butters
- Department of General Paediatric and Adolescent Medicine, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - Karina Kennedy
- Department of Infectious Diseases and Microbiology, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia.,ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Westmead Clinical School and Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, New South Wales, Australia
| | - Sushrut Patil
- Malignant Haematology and Stem Cell Transplantation Service, Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Penelope Bryant
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Catherine O Morrissey
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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81
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Parra Fariñas R, Alonso-Sardón M, Velasco-Tirado V, Galindo Pérez I, Carbonell C, Álvarez Artero E, Romero-Alegría Á, Pardo-Lledías J, Belhassen-García M. "Increasing Incidence of Mucormycosis in Spanish inpatients from 1997-2018". Mycoses 2021; 65:344-353. [PMID: 34951054 DOI: 10.1111/myc.13418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/07/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mucormycosis is a worldwide angio-invasive fungal infection that is associated with high morbidity and mortality. A few European studies have focused on the epidemiology. METHODOLOGY A retrospective longitudinal descriptive study was performed with inpatients diagnosed with mucormycosis (ICD-9-CM, code 117.7, cases 1997-2015; and ICD-10, code B46, cases 2016-2018; along with length of hospital stay) in Spanish public hospitals between 1 January 1997 and 31 December 2018. Data were obtained from the Minimum Basic Data Set (CMBD in Spanish). PRINCIPAL FINDINGS A total of 962 patients were recorded; 665 were men. The mean age (±SD) was 55±18.8 years. The annual incidence rate increased from 0.74 to 1.24 cases per million person-years. The lethality rate was 31.3%. Renal failure (41.6%) and hematological malignancy (36.3%) were the main factors involved. CONCLUSIONS Mucormycosis is a rare infectious disease in Spain, but it has had a significantly increased incidence in the last two decades. Being an adult male and having diabetes, neoplasm or renal failure are the main factors associated. High mortality is usually associated mainly with hematological malignancy and renal failure. CMBD studies could be an efficient tool for assessing changes in the epidemiology of mucormycosis.
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Affiliation(s)
- Raúl Parra Fariñas
- Servicio de Medicina Interna, Hospital Marques de Valdecilla, Universidad de Cantabria, Spain
| | - Montserrat Alonso-Sardón
- Area of Preventive Medicine and Public Health, University of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación de Enfermedades Tropicales de la Universidad de Salamanca (CIETUS), Salamanca, Spain
| | - Virginia Velasco-Tirado
- Servicio de Dermatología, Complejo Asistencial Universitario de Salamanca (CAUSA), CIETUS, IBSAL, Salamanca, Spain
| | | | | | - Elisa Álvarez Artero
- Servicio de Medicina Interna. Hospital Rio Carrión. Complejo Asistencial de Palencia (CAUPA), Avenida Donantes de Sangre S/N, 34005, Palencia, España
| | | | - Javier Pardo-Lledías
- Servicio de Medicina Interna, Hospital Marques de Vadecilla, Universidad de Cantabria, Instituto de Investigación Valdecilla (IDIVAL), Spain
| | - Moncef Belhassen-García
- Internal Medicine, Infectious Diseases Section, CAUSA, IBSAL, CIETUS, University of Salamanca, Paseo San Vicente 58-182, 37007, Salamanca, Spain
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82
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Ma X, Li A, Cao W, Li H, Zhang S, Li L, Xing H, Tian W, Jiao P, Chen J, Zhang Q, Xu A, Xing L. Characteristics of Mucormycosis in Hematological Patients and a Death Prediction Model. Front Microbiol 2021; 12:784974. [PMID: 34975805 PMCID: PMC8714886 DOI: 10.3389/fmicb.2021.784974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/18/2021] [Indexed: 11/18/2022] Open
Abstract
Mucormycosis is an angioinvasive fungal infection, associated with high mortality. The aim of our study was to explore the high-risk factors and predict the death of hematological disease complicated with mucormycosis. We retrospectively analyzed clinical data of 31 patients with hematological disease complicated with mucormycosis, adopted random forest to establish the death prediction model, and validated the model in another 15 patients. The median age of the 31 cases was 46 (28–51) years, male to female ratio 1.38:1, and 90-day mortality rate 54.8%. The most common underlying disease was acute myeloid leukemia (58.1%). The main clinical symptoms were fever (100%), cough (87.1%), sputum (80.6%), chest pain (61.3%), and hemoptysis (19.4%). Reversed halo sign (83.9%) was the most common computed tomography sign. A total of 48.4% of patients also had aspergillus or bacterial infections. Discriminative models were constructed by random forest with 17 non-survivors and 14 survivors. Procalcitonin, the duration of intravenous administration of amphotericin B or amphotericin B liposomes, and neutropenia at death or 90 days of survival were the leading risk factors for poor prognosis, with area under the curve of 0.975 (95% CI 0.934–1). We chose 0.6775 as death prediction threshold (with 82.3% sensitivity and 100% specificity) and validated the model successfully in another 15 patients. Chest pain and reversed halo sign are specific clinical and image signs of hematological disease complicated with mucormycosis. Neutropenia, elevated procalcitonin, and insufficient use time of amphotericin B or amphotericin B liposomes are risk factors for death.
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Affiliation(s)
- Xiaoxu Ma
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ang Li
- Gene Hospital of Henan Province, Precision Medicine Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weijie Cao
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huiling Li
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Suping Zhang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Li
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haizhou Xing
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenliang Tian
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengfei Jiao
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiajun Chen
- College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Qingxian Zhang
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aiguo Xu
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Aiguo Xu,
| | - Lihua Xing
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Lihua Xing,
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83
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Devaraja K, Krishnan NV, Bhat VK, Pujary K, Venkatagiri AM, Vijayasekharan K. Palatal mucormycosis in neutropenic children: A Case Report with Review of Literature. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1739188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractPalatal involvement in mucormycosis is mostly secondary to rhino-orbito-cerebral disease, but rarely can be a primary disease of the oral mucosa. This report presents two rare cases of the isolated palatal mucormycosis in neutropenic children and highlights some of the peculiar features of the primary palatal disease and management-related issues in children. A 12-year-old child, who had completed the dexamethasone-based induction phase of chemotherapy for Near Early T cell precursor acute lymphoblastic leukemia, and a 9-year-old boy with a Late Isolated Medullary relapse of B cell acute lymphoblastic leukemia, who was to receive salvage induction chemotherapy, developed palatal discoloration without any other major complaints. Both had neutropenia and were on antifungal prophylaxis. In vitro staining of the discolored mucosa suggested mucormycosis, which was confirmed by pathological examination of the debrided tissue. Computed tomography, done before debridement, showed no significant sinonasal disease enabling us to proceed with the transoral approach. With the help of adjuvant antifungal therapy, the infection could be contained in both cases. This report, along with the reviewed literature, shows that limited palatal mucormycosis can be effectively treated by early diagnosis and debridement and appropriate antifungal therapy. Also, the role of antifungal prophylaxis amongst neutropenic patients has been briefly discussed here.
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Affiliation(s)
- K. Devaraja
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Neethu V. Krishnan
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vasudeva K. Bhat
- Division of Pediatric Hematology and Oncology, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Kailesh Pujary
- Department of Otorhinolaryngology and Head and Neck Surgery, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Archana M. Venkatagiri
- Division of Pediatric Hematology and Oncology, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Kalasekhar Vijayasekharan
- Division of Pediatric Hematology and Oncology, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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84
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Mucormycosis in Mainland China: A Systematic Review of Case Reports. Mycopathologia 2021; 187:1-14. [PMID: 34855101 PMCID: PMC8637510 DOI: 10.1007/s11046-021-00607-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022]
Abstract
Background Mucormycosis is a lethal fungal infection with increasing incidence. The epidemiology of mucormycosis in current mainland China has not been fully elucidated.
Objectives To investigate the epidemiology, risk factors, manifestations, diagnosis, treatment and prognosis of mucormycosis in mainland China.
Methods We searched for published mucormycosis case reports/series in mainland China in the PubMed, WanFang and China National Knowledge Infrastructure databases from January 2001 to July 2020. Cases of proven/probable mucormycosis were included. Results A total of 390 cases were included in this review. Most of the patients were male (61.3%), and diabetes was the most common predisposing factor (37.2%). Pulmonary mucormycosis (42.1%) was the most common form followed by cutaneous infection (21.0%). Of 390 patients, 24 died before therapy. Among the remaining 366 patients, 208 (56.8%) received antifungal drugs alone, 16 (4.4%) received surgery alone, and 142 (38.8%) received a combination of drugs and surgery, the mortality of the last group is much lower (34/142, 23.9%). The overall mortality was 37.2%. A multivariate analysis indicated that factors associated with increased mortality included corticosteroid use alone as immunosuppressive therapy, rhino-orbito-cerebral or disseminated mucormycosis (compared with pulmonary mucormycosis), and drug administration other than amphotericin B (AmB), posaconazole (POS) and itraconazole (ITR) (compared with the use of conventional AmB), while factors associated with decreased mortality included cutaneous mucormycosis and surgical therapy. Combination or sequential antifungal therapy of AmB and POS or ITR did not reduce mortality compared with conventional AmB monotherapy. Conclusion In mainland China, mucormycosis is a serious fungal infection with high mortality. Corticosteroid use, rhino-orbito-cerebral and disseminated mucormycosis were adverse prognostic factors. Antifungal therapy combined with surgery could improve the prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s11046-021-00607-4.
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85
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COVID-19-associated mixed mold infection: A case report of aspergillosis and mucormycosis and a literature review. J Mycol Med 2021; 32:101231. [PMID: 34864498 PMCID: PMC8620017 DOI: 10.1016/j.mycmed.2021.101231] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/02/2021] [Accepted: 11/25/2021] [Indexed: 12/14/2022]
Abstract
COVID-19-associated mold infections have been increasingly reported, and the main entity is COVID-19-associated aspergillosis (CAPA). Similarly, COVID-19-associated mucormycosis has been reported in hematology, and its prevalence is high and has been increasing in the diabetic population in India during the third COVID-19 pandemic wave. Simultaneous infection with Mucorales and Aspergillus is rare and even rarer during COVID-19. Here, we report the case of a previously immunocompetent patient with severe SARS-CoV-2 infection complicated with probable CAPA and mucormycosis co-infection. Specific diagnostic tools for mucormycosis are lacking, and this case highlights the advantages of analyzing blood and respiratory samples using the quantitative polymerase chain reaction to detect these fungi. We further reviewed the literature on mixed Aspergillus/Mucorales invasive fungal diseases to provide an overview of patients presenting with both fungi and to identify characteristics of this rare infection.
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86
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Hussain S, Riad A, Singh A, Klugarová J, Antony B, Banna H, Klugar M. Global Prevalence of COVID-19-Associated Mucormycosis (CAM): Living Systematic Review and Meta-Analysis. J Fungi (Basel) 2021; 7:jof7110985. [PMID: 34829271 PMCID: PMC8624337 DOI: 10.3390/jof7110985] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 12/11/2022] Open
Abstract
Mucormycosis, a secondary fungal infection, gained much attention in the ongoing COVID-19 pandemic. This deadly infection has a high all-cause mortality rate and imposes a significant economic, epidemiological, and humanistic burden on the patients and healthcare system. Evidence from the published epidemiological studies showed the varying prevalence of COVID-19-associated mucormycosis (CAM). This study aims to compute the pooled prevalence of CAM and other associated clinical outcomes. MEDLINE, Embase, Cochrane COVID-19 Study Register, and WHO COVID-19 databases were scanned to retrieve the relevant articles until August 2021. All studies reporting the prevalence of mucormycosis among COVID-19 patients were eligible for inclusion. Two investigators independently screened the articles against the selection criteria, extracted the data, and performed the quality assessment using the JBI tool. The pooled prevalence of CAM was the primary outcome, and the pooled prevalence of diabetes, steroid exposure, and the mortality rate were the secondary outcomes of interest. Comprehensive Meta-Analysis software version 2 was used for performing the meta-analysis. This meta-analysis comprised six studies with a pooled sample size of 52,916 COVID-19 patients with a mean age of 62.12 ± 9.69 years. The mean duration of mucormycosis onset was 14.59 ± 6.88 days after the COVID-19 diagnosis. The pooled prevalence of CAM (seven cases per 1000 patients) was 50 times higher than the highest recorded background of mucormycosis (0.14 cases per 1000 patients). A high mortality rate was found among CAM patients with a pooled prevalence rate of 29.6% (95% CI: 17.2-45.9%). Optimal glycemic control and the judicious use of steroids should be the approach for tackling rising CAM cases.
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Affiliation(s)
- Salman Hussain
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic; (A.R.); (J.K.); (M.K.)
- Correspondence:
| | - Abanoub Riad
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic; (A.R.); (J.K.); (M.K.)
- Department of Public Health, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Ambrish Singh
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS 7000, Australia; (A.S.); (B.A.)
| | - Jitka Klugarová
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic; (A.R.); (J.K.); (M.K.)
| | - Benny Antony
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS 7000, Australia; (A.S.); (B.A.)
| | - Hasanul Banna
- International Clinical Research Center, Molecular Control of Cell Signaling Group, St. Anne’s University Hospital, 656 91 Brno, Czech Republic;
| | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic; (A.R.); (J.K.); (M.K.)
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87
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Mehrabi Z, Salimi M, Niknam K, Mohammadi F, Mamaghani HJ, Sasani MR, Ashraf MJ, Salimi A, Zahedroozegar MH, Erfani Z. Sinoorbital Mucormycosis Associated with Corticosteroid Therapy in COVID-19 Infection. Case Rep Ophthalmol Med 2021; 2021:9745701. [PMID: 34745674 PMCID: PMC8568553 DOI: 10.1155/2021/9745701] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/21/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Mucormycosis is a rare and invasive fungal infection, affecting almost exclusively immunocompromised individuals. Immunosuppressive effects of corticosteroids which are widely prescribed in COVID-19 patients might be a predisposing factor for opportunistic infections even though the other factors should also be considered. Case Presentation. A middle-aged man without any significant past medical history was admitted to the hospital due to a severe COVID-19 infection. He received a high dose of corticosteroids as a part of the treatment. Five days after discharge, he presents with a headache and fever. Eventually, orbital mucormycosis was diagnosed for him and he was treated with antifungal medications. CONCLUSION Opportunistic infections should be considered during the current pandemic of COVID-19, during which corticosteroids are widely prescribed.
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Affiliation(s)
- Zeinab Mehrabi
- Department of Internal Medicine, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Salimi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kianoush Niknam
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Hesan Jelodari Mamaghani
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Sasani
- Department of Radiology, Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Amirhossein Salimi
- Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Zohreh Erfani
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
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88
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Peng L, Feng J, Sun X. A Middle-Aged Man With Skin Lesions, Progressive Deterioration of Renal Function, and Pulmonary Cheerios. Clin Infect Dis 2021; 73:1545-1547. [PMID: 34669945 DOI: 10.1093/cid/ciab115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Liying Peng
- Department of Internal Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Jun Feng
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
| | - Xuefeng Sun
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China
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89
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Schwarz P. Mukormykosen - frühe Abgrenzung zur Aspergillose besonders wichtig. PNEUMO NEWS 2021; 13:36-44. [PMID: 34691275 PMCID: PMC8526098 DOI: 10.1007/s15033-021-2754-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Patrick Schwarz
- Klinik für Innere Medizin, Schwerpunkt Pneumologie, Universität Marburg, Baldingerstraße, 35043 Marburg, Germany
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90
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Rudramurthy SM, Hoenigl M, Meis JF, Cornely OA, Muthu V, Gangneux JP, Perfect J, Chakrabarti A. ECMM/ISHAM recommendations for clinical management of COVID-19 associated mucormycosis in low- and middle-income countries. Mycoses 2021; 64:1028-1037. [PMID: 34133816 PMCID: PMC8447004 DOI: 10.1111/myc.13335] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 12/11/2022]
Abstract
Reports are increasing on the emergence of COVID-19-associated mucormycosis (CAM) globally, driven particularly by low- and middle-income countries. The recent unprecedented surge of CAM in India has drawn worldwide attention. More than 28,252 mucormycosis cases are counted and India is the first country where mucormycosis has been declared a notifiable disease. However, misconception of management, diagnosing and treating this infection continue to occur. Thus, European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology (ISHAM) felt the need to address clinical management of CAM in low- and middle-income countries. This article provides a comprehensive document to help clinicians in managing this infection. Uncontrolled diabetes mellitus and inappropriate (high dose or not indicated) corticosteroid use are the major predisposing factors for this surge. High counts of Mucorales spores in both the indoor and outdoor environments, and the immunosuppressive impact of COVID-19 patients as well as immunotherapy are possible additional factors. Furthermore, a hyperglycaemic state leads to an increased expression of glucose regulated protein (GRP- 78) in endothelial cells that may help the entry of Mucorales into tissues. Rhino-orbital mucormycosis is the most common presentation followed by pulmonary mucormycosis. Recommendations are focused on the early suspicion of the disease and confirmation of diagnosis. Regarding management, glycaemic control, elimination of corticosteroid therapy, extensive surgical debridement and antifungal therapy are the standards for proper care. Due to limited availability of amphotericin B formulations during the present epidemic, alternative antifungal therapies are also discussed.
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Affiliation(s)
- Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Center of Expertise in Mycology, Radboud University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Oliver A Cornely
- Department of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Faculty of Medicine, University of Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jean Pierre Gangneux
- CHU Rennes, Inserm, EHESP, Irset (Institut de recherché en santé, environnement et travail) - UMR_S 1085, Université de Rennes, Rennes, France
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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91
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Mahalmani V, Sarma P, Prakash A, Medhi B. Role of Iron Chelators in Mucormycosis. Indian J Pharmacol 2021; 53:261-263. [PMID: 34414902 PMCID: PMC8411966 DOI: 10.4103/ijp.ijp_604_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Vidya Mahalmani
- Department of Pharmacology, Jawaharlal Nehru Medical College, Kaher, Belagavi, Karnataka, India
| | - Phulen Sarma
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Prakash
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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92
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Badali H, Cañete-Gibas C, McCarthy D, Patterson H, Sanders C, David MP, Mele J, Fan H, Wiederhold NP. Epidemiology and Antifungal Susceptibilities of Mucoralean Fungi in Clinical Samples from the United States. J Clin Microbiol 2021; 59:e0123021. [PMID: 34232068 PMCID: PMC8373021 DOI: 10.1128/jcm.01230-21] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/01/2021] [Indexed: 01/12/2023] Open
Abstract
The global incidence of mucormycosis has increased in recent years owing to higher numbers of individuals at risk for these infections. The diagnosis and treatment of this aggressive fungal infection are of clinical concern due to differences in species distribution in different geographic areas and susceptibility profiles between different species that are capable of causing highly aggressive infections. The purpose of this study was to evaluate the epidemiology and susceptibility profiles of Mucorales isolates in the United States over a 52-month period. Species identification was performed by combined phenotypic characteristics and DNA sequence analysis, and antifungal susceptibility testing was performed by CLSI M38 broth microdilution for amphotericin B, isavuconazole, itraconazole, and posaconazole. During this time frame, 854 isolates were included, representing 11 different genera and over 26 species, of which Rhizopus (58.6%) was the predominant genus, followed by Mucor (19.6%). The majority of isolates were cultured from the upper and lower respiratory tracts (55%). Amphotericin B demonstrated the most potent in vitro activity, with geometric mean (GM) MICs of ≤0.25 μg/ml against all genera with the exception of Cunninghamella species (GM MIC of 1.30 μg/ml). In head-to-head comparisons, the most active azole was posaconazole, followed by isavuconazole. Differences in azole and amphotericin B susceptibility patterns were observed between the genera with the greatest variability observed with isavuconazole. Awareness of the epidemiology of Mucorales isolates and differences in antifungal susceptibility patterns in the United States may aide clinicians in choosing antifungal treatment regimens. Further studies are warranted to correlate these findings with clinical outcomes.
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Affiliation(s)
- Hamid Badali
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Connie Cañete-Gibas
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Dora McCarthy
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Hoja Patterson
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Carmita Sanders
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Marjorie P. David
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - James Mele
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Hongxin Fan
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Nathan P. Wiederhold
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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93
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Rothe K, Braitsch K, Okrojek R, Heim M, Rasch S, Verbeek M, Schmid RM, Busch DH, Lahmer T. Clinical and microbiological features and outcomes of mucormycosis in critically ill patients. Int J Infect Dis 2021; 109:142-147. [PMID: 34229089 DOI: 10.1016/j.ijid.2021.06.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/18/2021] [Accepted: 06/30/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Mucormycosis is a rare invasive fungal infection with high mortality in patients with severe underlying predisposing factors causing immunosuppression. The exact incidence of mucormycosis and the optimal therapeutic approach is difficult to determine, especially in severe cases, due to the rarity of the disease. The new second-generation triazole isavuconazole provides an alternative treatment option which may represent a potential benefit in severe cases. MATERIALS AND METHODS A retrospective case series was conducted of patients with a positive laboratory culture for Mucorales and consistent clinical findings who required intensive care treatment. Patient characteristics including demographics, comorbidities, microbiological analysis, specific antifungal therapy and clinical outcome were analysed. RESULTS Fifteen critically ill patients with Mucorales detected between 2016 and 2019 were included in this study; the crude mortality rate was 100%. At the time of diagnosis of mucormycosis, 80% of subjects had relevant medical immunosuppression and 53.3% of subjects had neutropenia. Manifestation of mucormycosis was pulmonary in 53.3% of subjects, rhino-orbital in 20% of subjects and disseminated in 26.7% of subjects. Notably, 40% of all patients had received antifungal prophylaxis prior to mucormycosis, mainly with posaconazole due to underlying haematological malignancy, thus possibly representing break-through infections. Antifungal therapy for invasive mucormycosis was administered in 80% of subjects for a median duration of 16 days. CONCLUSION In this retrospective cohort analysis of intensive care patients, the prognosis of mucormycosis was extremely poor. An aggressive strategy for diagnosis and treatment is essential for intensive care patients with mucormycosis. There is a need for further research to determine if combination therapy in higher dosages or prompt surgery is beneficial in severe critically ill patients.
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Affiliation(s)
- Kathrin Rothe
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, School of Medicine, Munich, Germany
| | - Krischan Braitsch
- Department of Internal Medicine III, Technical University of Munich, School of Medicine, Munich, Germany
| | - Rainer Okrojek
- Department of Internal Medicine I, Technical University of Munich, School of Medicine, Munich, Germany
| | - Markus Heim
- Department of Anaesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sebastian Rasch
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Mareike Verbeek
- Department of Internal Medicine III, Technical University of Munich, School of Medicine, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Dirk H Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, School of Medicine, Munich, Germany; German Centre for Infection Research, Partner Site Munich, Munich, Germany
| | - Tobias Lahmer
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany.
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94
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Coinfection pulmonary mucormycosis and aspergillosis with disseminated mucormycosis involving gastrointestinalin in an acute B-lymphoblastic leukemia patient. Braz J Microbiol 2021; 52:2063-2068. [PMID: 34218427 PMCID: PMC8254622 DOI: 10.1007/s42770-021-00554-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 11/06/2022] Open
Abstract
Pulmonary mucormycosis and aspergillosis with disseminated mucormycosis involving gastrointestinalin is a very rare but lethal infection leading to extreme mortality. Herein, we present a unique case of pulmonary coinfection with Cunninghamella bertholletiae and Aspergillus flavus, with disseminated mucormycosis involving the jejunum caused by C. bertholletiae in an acute B-lymphocytic leukemia (B-ALL) patient with familial diabetes. Early administration of active antifungal agents at optimal doses and complete resection of all infected tissues led to improved therapeutic outcomes.
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95
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Arfaj L, Aloqpi F, Elsayad W, Tayeb S, Rabie N, Samannodi M. A fatal case of disseminated mucormycosis in an immunocompetent patient post traumatic injury. IDCases 2021; 25:e01182. [PMID: 34168958 PMCID: PMC8209080 DOI: 10.1016/j.idcr.2021.e01182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 06/09/2021] [Indexed: 11/25/2022] Open
Abstract
Mucormycosis, is an invasive infection caused by fungi. Mainly it affects patients with immunosuppressive conditions but can occur in immuncompetent host in specific situation such us direct skin inoculation by traumatic injury. We present a 56-year-old patient who hospitalized due to left orbital cellulitis and necrotizing fasciitis post traumatic injury. A diagnosis of invasive mucormycosis was established by tissue histopathology and culture. Despite daily surgical debridement and amphotericin B, the infection disseminated to central nervous system led to fatal outcome. We conclude that mucormycosis can disseminate in immunocompetent population and leads to death.
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Affiliation(s)
- Lama Arfaj
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Fatinah Aloqpi
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Waleed Elsayad
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Sarah Tayeb
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Nada Rabie
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Mohammed Samannodi
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia.,Department of Medicine, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
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96
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Martín Gómez MT, Salavert Lletí M. [Mucormycosis: Current and future management perspective]. Rev Iberoam Micol 2021; 38:91-100. [PMID: 34144835 DOI: 10.1016/j.riam.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/20/2021] [Accepted: 04/08/2021] [Indexed: 02/06/2023] Open
Abstract
Infections caused by mucorales, with an increasing incidence after candidiasis and aspergillosis, are characterized by the fast angioinvasion of blood vessels and invasion of neighboring organs or structures. Mucorales most commonly cause rhinocerebral, pulmonary, cutaneous, digestive or disseminated infections, and their spread is favored by certain underlying diseases (diabetes, kidney failure) and risk factors (neutropenia, immunosuppression, iron overload). These infections have a high mortality rate, over 40% in many series, and the key to their cure depends on both an early diagnosis and an antifungal treatment, associated in most cases with extensive surgical debridement and other adjunctive therapies. Currently, there are international guidelines, not only local ones, for the management of mucormycosis, in which it is considered by consensus and with a strong recommendation that first-line treatment with high-dose liposomal amphotericin B is the best choice. The combined antifungal treatment of polyene agents with triazoles or candins remains in open debate.
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Affiliation(s)
- María Teresa Martín Gómez
- Sección de Micología, Servicio de Microbiología, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Miguel Salavert Lletí
- Unidad de Enfermedades Infecciosas (Área Clínica Médica), Hospital Universitario y Politécnico La Fe, Valencia, España.
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97
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Chao A, Vazquez JA. Fungal Infections of the Gastrointestinal Tract. Gastroenterol Clin North Am 2021; 50:243-260. [PMID: 34024440 DOI: 10.1016/j.gtc.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The thinking about fungi has evolved from unusual agents considered contaminants and colonizers to actual pathogens. Fungi are ubiquitous in nature and are found throughout in association with food, soil, mammals, and insects. Fungi have become important pathogens in animals and humans causing infections extending from superficial disease to disseminated infection. Because the gastrointestinal tract is continually exposed to fungi, it is frequently colonized and infected by numerous yeast and other fungi. It is also the origin of many disseminated fungal infections. The increased incidence of fungal infections has led to the approval and use of novel antifungals.
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Affiliation(s)
- Andrew Chao
- Division of Infectious Disease, Department of Medicine, Medical College of Georgia/Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Jose A Vazquez
- Division of Infectious Disease, Department of Medicine, Medical College of Georgia/Augusta University, 1120 15th Street, Augusta, GA 30912, USA.
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98
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Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
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Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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99
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Abstract
Mucormycosis is a rare but aggressive fungal disease that mainly affects patients with poorly controlled diabetes mellitus and those who are severely immunocompromised, including patients with hematological malignancies and solid organ transplant recipients. Early recognition of infection is critical for treatment success, followed by prompt initiation of antifungal therapy with lipid formulation amphotericin B. Posaconazole and isavuconazole should be used for stepdown and salvage therapy. Surgical debridement is key for tissue diagnosis and treatment and should be pursued urgently whenever possible. In addition to surgery and antifungal therapy, reverting the underlying risk factor for infection is important for treatment response.
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Affiliation(s)
- Julie M Steinbrink
- Division of Infectious Diseases, Department of Internal Medicine, Duke University Medical Center, Hanes House, Duke University Medical Center, 315 Trent Drive, Durham, NC 27710, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, F4005 UH-South- SPC 5226, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
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100
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Galletta K, Alafaci C, D'Alcontres FS, Maria ME, Cavallaro M, Ricciardello G, Vinci S, Grasso G, Granata F. Imaging features of perineural and perivascular spread in rapidly progressive rhino-orbital-cerebral mucormycosis: A case report and brief review of the literature. Surg Neurol Int 2021; 12:245. [PMID: 34221576 PMCID: PMC8247725 DOI: 10.25259/sni_275_2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Rhinocerebral mucormycosis (ROCM) is an opportunistic fungal infection originating from the paranasal sinuses with extension to the brain. A delayed diagnosis can rapidly result in a poor prognosis. ROCM commonly affects patients with diabetes or immunocompromised states with a variable progression. Case Description: We report the case of a 59-year old patient with an untreated diabetes who developed a ROCM with rapidly progressive neurological symptoms. From the onset of sinus pain, nasal congestion, he rapidly developed facial swelling and masticatory dysfunction. The patient underwent sinus surgery which allowed Rhizopus oryzae to be isolated. Accordingly, a systemic therapy by intensive intravenous amphotericin B was started. Nevertheless, the infection rapidly resulted in bilateral cavernous sinuses thrombosis and occlusion of the left internal carotid artery providing the subsequent patient death. Conclusion: Mucormycosis is a life-threatening fungal infection in diabetic and/or immunosuppressed patients. Our case demonstrates the three main mechanisms for infection spreading that are direct, perineural, and perivascular diffusion. Clear identification of the main risk factors, proper assessment of clinical features, and radiological findings may improve the chance for an early diagnosis and patient survival.
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Affiliation(s)
- Karol Galletta
- Department of Biomedical, Dental Science and Morphological and Functional Images, Messina, Italy
| | - Concetta Alafaci
- Department of Biomedical Sciences and Morphological and Functional Imaging, Section of Neurosurgery, Messina, Italy
| | | | - Mormina Enrico Maria
- Department of Biomedical, Dental Science and Morphological and Functional Images, Messina, Italy
| | - Marco Cavallaro
- Department of Biomedical, Dental Science and Morphological and Functional Images, Messina, Italy
| | - Giorgia Ricciardello
- Department of Biomedical, Dental Science and Morphological and Functional Images, Messina, Italy
| | - Sergio Vinci
- Department of Biomedical, Dental Science and Morphological and Functional Images, Messina, Italy
| | - Giovanni Grasso
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Section of Neurosurgery, University of Palermo, Palermo, Italy
| | - Francesca Granata
- Department of Biomedical, Dental Science and Morphological and Functional Images, Messina, Italy
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