Diabetes mellitus as the major risk factor for mucormycosis in Mexico: Epidemiology, diagnosis, and outcomes of reported cases

Rhinocerebral mucormycosis in a diabetes type 2 patient: A fatal case report from northern Tanzania

Mucormycosis is an acute and aggressive fungal infection usually, but not exclusively, occurring in immunocompromised individuals. Lack of knowledge and awareness in developing countries hinders timely management. This case highlights the importance of a prompt index of suspicion for the timely and aggressive intervention of mucormycosis to the Tanzanian community. We report a case of fatal rhino-orbital-cerebral mucormycosis in a diabetic patient presenting at a tertiary hospital in the Kilimanjaro region, Tanzania. Nasal deformity, proptosis, chemosis and left-sided hemiplegia were evident on physical examination. Nasoendoscopy revealed extensive necrosis of the nasal septum, inferior turbinate and involvement of the frontal recess. Computed tomography and magnetic resonance imaging of the paranasal sinuses and head revealed necrosis and ischemic changes due to fungal invasion. The patient deceased due to intracranial complications of advanced fungal invasion. Late presentation and unacquainted with mucormycosis our patient had an unfavourable outcome. Early diagnosis, extensive surgical debridement and a multidisciplinary approach to treatment are of the essence in favour of a better prognosis.

Burden of serious fungal infections in Honduras

BACKGROUND

The burden of serious fungal infections in Honduras is unknown. The diagnosis of fungal diseases relies on almost exclusively on microscopy and culture limiting an accurate estimate of the burden of disease.

OBJECTIVES

The primary objective of the study was to estimate the burden of serious fungal infections in Honduras using previously described methods.

METHODS

National and international demographic data on population, HIV, tuberculosis, asthma, COPD and cancer were obtained. A thorough literature search was done for all epidemiological studies and case series of serious fungal diseases. Using these risk populations and whatever incidence and prevalence could be found that was most pertinent to Honduras, a burden estimate was derived.

RESULTS

The estimated number of serious fungal infection was estimated to be between 178,772 and 179,624 with nearly 2300 cases of these representing opportunistic infections in people living with HIV. The incidence of histoplasmosis and cryptococcosis in people living with HIV is high and estimated to be 4.3 and 4.6 cases per 100,000 population respectively. Approximately 12,247-13,099 cases of aspergillosis and 164,227 of other serious fungal infections were estimated to occur each year.

CONCLUSION

An accurate estimate of the burden of serious fungal infections in Honduras is unknown but based on our results, likely significant. Serious fungal infections represent an important public health problem in Honduras affecting approximately 1.8% of the population. There is a clear need for better access to diagnostic tools and antifungals to conduct research to better understand the impact of fungal diseases in Honduras.

New insights on mucormycosis and its association with the COVID-19 pandemic

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.

A surgical approach in the management of mucormycosis in trauma patients

Introduction:

Fungal infections are rare occurrence in the oral cavity. They are most often seen in other medical conditions such as the immunocompromised states, diabetes, on immunosuppressants, and more recently, among the COVID patients. There are various ways that are employed to manage these infections. The most usual of fungal infection in these conditions is mucormycosis, also called as zygomycosis. Hence, in our study, we aim to evaluate the management of the fungal infection mucormycosis in trauma patients by the surgical approach.

Materials and Methods:

We piloted a retrospective observational study among 50 subjects who were admitted to the department with oral fungal infections with mucormycosis. We analyzed various clinical and demographic parameters among the subjects. The data thus obtained were analyzed with proper statistical tools deliberating P < 0.05 as significant.

Results:

We observed that among the 50 subjects, the mean age was 41 ± 1.7 years. There was no significant difference between the genders and the age groups. The most common reason for the oral involvement was uncontrolled diabetes. This was followed by malignancy, specifically leukemia, AIDS, and COVID. The most common site of the involvement was the palate, followed by the mandibular region. All the subjects tested positive for the fungal hyphae of Rhizopus arrhizus which was the most common of the species. The surgical debridement along with the medical management showed satisfactory results, while one death was noted in our study.

Conclusion:

Although rare, oral involvement in the fungal infection with the mucormycosis is often easily managed when diagnosed early. The proper surgical debridement is the best method of treatment along with the appropriate medications. The management of the underlying medical conditions is the primary key for the success of the treatments.

Storm of a rare opportunistic life threatening mucormycosis among post COVID-19 patients: A tale of two pathogens

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.

Infectious diseases associated with pediatric type 1 diabetes mellitus: A narrative review

Diabetes mellitus (DM) has been frequently associated with an impaired immune response against infectious agents, making affected patients at risk for more severe disease and sometimes causing worse outcomes. The recent COVID-19 pandemic has seriously affected patients with both diabetes, in particular those carrying comorbidities or with poor glycemic control. As regards pediatric diabetes mellitus, the availability of more accurate and technological tools for glycemic management and the improved markers of metabolic control might mitigate the negative impact of infections. Notably, good metabolic control of diabetes since its diagnosis reduces not only the risk of microangiopathic complications but also of impaired immune response to infectious diseases. Therefore, vaccinations are strongly recommended. Our paper aims to provide the most updated evidence regarding infectious diseases in type 1 pediatric DM.

Dental and Oral Manifestations of COVID-19 Related Mucormycosis: Diagnoses, Management Strategies and Outcomes

It has been nearly two years since the pandemic caused by the novel coronavirus disease (COVID-19) has affected the world. Several innovations and discoveries related to COVID-19 are surfacing every day and new problems associated with the COVID-19 virus are also coming to light. A similar situation is with the emergence of deep invasive fungal infections associated with severe acute respiratory syndrome 2 (SARS-CoV-2). Recent literature reported the cases of pulmonary and rhino-cerebral fungal infections appearing in patients previously infected by COVID-19. Histopathological analysis of these cases has shown that most of such infections are diagnosed as mucormycosis or aspergillosis. Rhino-orbital-cerebral mucormycosis usually affects the maxillary sinus with involvement of maxillary teeth, orbits, and ethmoidal sinuses. Diabetes mellitus is an independent risk factor for both COVID-19 as well as mucormycosis. At this point, there is scanty data on the subject and most of the published literature comprises of either case reports or case series with no long-term data available. The aim of this review paper is to present the characteristics of COVID-19 related mucormycosis and associated clinical features, outcome, diagnostic and management strategies. A prompt diagnosis and aggressive treatment planning can surely benefit these patients.

Mucormycosis – resurgence of a deadly opportunist during COVID-19 pandemic: Four case reports

BACKGROUND

Coronavirus disease 2019 (COVID-19) patients who suffer severe infection or comorbidities have an increased risk of developing fungal infections. There is a possibility that such infections are missed or misdiagnosed, in which case patients may suffer higher morbidity and mortality. COVID-19 infection, aggressive management strategies and comorbidities like diabetes render patients prone to opportunistic fungal infections. Mucormycosis is one of the opportunistic fungal infections that may affect treated COVID patients.

CASE SUMMARY

We present a case series of four adult males who were diagnosed with mucormycosis post-COVID-19 recovery. All the patients had diabetes and a history of systemic corticosteroids for treatment of COVID-19. The mean duration between diagnosis of COVID-19 and development of symptoms of mucor was 15.5 ± 14.5 (7–30) d. All patients underwent debridement and were started on antifungal therapy. One patient was referred to a higher center for further management, but the others responded well to treatment and showed signs of improvement at the last follow-up.

CONCLUSION

Early diagnosis and management of mucormycosis with appropriate and aggressive antifungals and surgical debridement can improve survival.

"Increasing Incidence of Mucormycosis in Spanish inpatients from 1997-2018"

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.

Aspergillosis: Emerging risk groups in critically ill patients

Information on invasive aspergillosis (IA) and other invasive filamentous fungal infections is limited in non-neutropenic patients admitted to the intensive care unit (ICU) and presenting with no classic IA risk factors. This review is based on the critical appraisal of relevant literature, on the authors' own experience and on discussions that took place at a consensus conference. It aims to review risk factors favoring aspergillosis in ICU patients, with a special emphasis on often overlooked or neglected conditions. In the ICU patients, corticosteroid use to treat underlying conditions such as chronic obstructive pulmonary disease (COPD), sepsis, or severe COVID-19, represents a cardinal risk factor for IA. Important additional host risk factors are COPD, decompensated cirrhosis, liver failure, and severe viral pneumonia (influenza, COVID-19). Clinical observations indicate that patients admitted to the ICU because of sepsis or acute respiratory distress syndrome are more likely to develop probable or proven IA, suggesting that sepsis could also be a possible direct risk factor for IA, as could small molecule inhibitors used in oncology. There are no recommendations for prophylaxis in ICU patients; posaconazole mold-active primary prophylaxis is used in some centers according to guidelines for other patient populations and IA treatment in critically ill patients is basically the same as in other patient populations. A combined evaluation of clinical signs and imaging, classical biomarkers such as the GM assay, and fungal cultures examination, remain the best option to assess response to treatment.

LAY SUMMARY

The use of corticosteroids and the presence of co-morbidities such as chronic obstructive pulmonary disease, acute or chronic advanced liver disease, or severe viral pneumonia caused by influenza or Covid-19, may increase the risk of invasive aspergillosis in intensive care unit patients.

Oral involvement in mucormycosis. A retrospective study of 55 cases

INTRODUCTION

Mucormycosis with oral involvement (OIM) is a rare opportunistic and lethal mycosis, which has increased in the last decade and is generally associated with uncontrolled diabetes and neutropenia.

METHODS

A retrospective study of cases with OIM was carried out in a tertiary-care center. Mycological and histological examinations were performed, and the isolated organisms were identified by morphology and molecular biology.

RESULTS

Fifty-five OIM patients were included, with a median age of 38 years (61.8% males). The most frequent associated disease was type-2 diabetes mellitus (61%), followed by neutropenia due to acute lymphocytic leukemia (27%). The main presentation was palatal and mandibular ulcers (92.7%) and, to a lesser extent, gingival and lingual necrosis. The diagnosis was established by mycological and histopathological studies. The most frequent fungi isolated was Rhizopus arrhizus (67.2%).

CONCLUSION

OIM is a rapidly progressing disease, therefore, an early diagnosis and the proper control of predisposing factors is necessary, and consequently, contributing to improve the outcome of mucormycosis.

Global Prevalence of COVID-19-Associated Mucormycosis (CAM): Living Systematic Review and Meta-Analysis

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.

Successful treatment of pulmonary mucormycosis caused by Rhizopus microsporus with posaconazole

Background

Mucormycosis is a rare fungal infection occurring chiefly in the lung or the rhino-orbital-cerebral compartment, particularly in patients with immunodeficiency or diabetes mellitus. Among Mucorales fungi, Rhizopus spp. are the most common cause of mucormycosis.

Case presentation

We report a case of pulmonary mucormycosis caused by Rhizopus microsporus in a young patient with diabetes but no other apparent risk factors. The diagnosis mainly relied on clinical manifestation, positive pulmonary tissue biopsy, and fungal culture. The patient was successfully treated with posaconazole oral suspension and remains asymptomatic at one-year follow-up.

Conclusions

Pulmonary mucormycosis is a life-threatening condition and posaconazole is an effective treatment for pulmonary mucormycosis caused by Rhizopus microspores.

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

BACKGROUND

Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

AIM

Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

DESIGN

This was a retrospective, single-centre, observational study.

METHODS

We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

RESULTS

Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

CONCLUSION

COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Newer Horizon of Mesenchymal Stem Cell-Based Therapy in the Management of SARS-CoV-2-Associated Mucormycosis: A Safe Hope for Future Medicine

SARS-CoV-2-infected patients are reported to show immunocompromised behavior that gives rise to a wide variety of complications due to impaired innate immune response, cytokine storm, and thrombo-inflammation. Prolonged use of steroids, diabetes mellitus, and diabetic ketoacidosis (DKA) are some of the factors responsible for the growth of Mucorales in such immunocompromised patients and, thus, can lead to a life-threatening condition referred to as mucormycosis. Therefore, an early diagnosis and cell-based management cosis is the need of the hour to help affected patients overcome this severe condition. In addition, extended exposure to antifungal drugs/therapeutics is found to initiate hormonal and neurological complications. More recently, mesenchymal stem cells (MSCs) have been used to exhibit immunomodulatory function and proven to be beneficial in a clinical cell-based regenerative approach. The immunomodulation ability of MSCs in mucormycosis patient boosts the immunity by the release of chemotactic proteins. MSC-based therapy in mucormycosis along with the combination of short-term antifungal drugs can be utilized as a prospective approach for mucormycosis treatment with promising outcomes. However, preclinical and in mucormyIn mucormycosis, the hyphae of clinical trials are needed to establish the precise mechanism of MSCs in mucormycosis treatment.

The use of combined PCR, fluorescence in situ hybridisation and immunohistochemical staining to diagnose mucormycosis from formalin-fixed paraffin-embedded tissues

OBJECTIVE

To develop a comprehensive diagnostic system for mucormycosis from formalin-fixed paraffin-embedded tissues, consisting of own-designed real-time polymerase chain reaction (PCR) assays, fluorescence in situ hybridisation, and immunohistochemical staining.

METHODS

We designed 11 primers and probes for specific real-time PCR assays based on genome sequences, and validated the specificity by Aspergillus, Fusarium, Scedosporium, Lomentospora, Cryptococcus and Candida species. Formalin-fixed paraffin-embedded (FFPE) tissues from forty-four mouse model infected by above fungi were collected and extracted DNA by laser capture microdissection (LCM) and direct extraction methods for real-time PCR assays. In addition, seventeen clinical specimens histopathologically proven for mucormycosis were included for specific detection with the new diagnostic system.

RESULTS

The real-time PCR assays allowed detection of a minimum of 10 CFU/ml equivalent gDNA of each species. No cross-reaction with gDNA among species was noted. From mouse model specimens, the sensitivity of real-time PCR in samples extracted with LCM versus direct extraction method was 100% versus 91.43% at Mucorales level and 80% versus 45.71% at species level, respectively. The specificity was 100%. From clinical samples, LCM combined with real-time PCR can test 88.24% (15/17) of Mucorales. Sensitivities of fluorescence in situ hybridisation (FISH) and immunohistochemical staining (IHC) were 70.59% and 41.18%, respectively. Combined LCM-RT-PCR, FISH and IHC yielded positive results in all samples.

CONCLUSIONS

The combination diagnostic system we developed is a culture-independent and robust method which enables rapid species identification from FFPE tissues for timely diagnosis of mucormycosis.

COVID-19-associated mucormycosis, diabetes and steroid therapy: Experience in a single centre in Western Mexico

Background

COVID‐19–associated mucormycosis (CAM) has emerged as a challenging complication as the current pandemic has increased the population requiring treatment with corticosteroids. CAM has caused a massive outbreak in India, reported to be causing cases in Iran, Egypt and The Netherlands.

Objectives

To describe CAM cases occurring in a single centre in Western Mexico.

Methods

Our group carried out a retrospective study from May 2020 to May 2021 to identify CAM cases in patients with previous COVID‐19 diagnosis.

Results

Six CAM cases occurred in a single centre in Western Mexico during the study period, most of them with diabetes (n = 5/6) and all received corticosteroid therapy even when only three had severe COVID‐19. After analysing local COVID‐19 burden, it was estimated that in this region, CAM was 300 times more frequent among COVID individuals than the estimates for general population.

Conclusion

Similar to large reports in India and other countries, CAM cases reported in this study were diagnosed in individuals with diabetes, hyperglycaemic status and with history of previous use of corticosteroids. Identifying these individuals at risk can help the early identification of CAM. In addition, strict glycaemic control and avoidance of unnecessary corticosteroid in non‐severe COVID‐19 cases could help in preventing this complicated fungal infection.

Mucormycosis: An opportunistic pathogen during COVID-19

The pandemic of coronavirus disease 2019 (COVID-19) still remains on an upsurge trend. The second wave of this disease has led to panic in many countries, including India and some parts of the world suffering from the third wave. As there are no proper treatment options or remedies available for this deadly infection, supportive care equipment's such as oxygen cylinders, ventilators and heavy use of steroids play a vital role in the management of COVID-19. In the midst of this pandemic, the COVID-19 patients are acquiring secondary infections such as mucormycosis also known as black fungus disease. Mucormycosis is a serious, but rare opportunistic fungal infection that spreads rapidly, and hence prompt diagnosis and treatment are necessary to avoid high rate of mortality and morbidity rates. Mucormycosis is caused by the inhalation of its filamentous (hyphal form) fungi especially in the patients who are immunosuppressed. Recent studies have documented alarming number of COVID-19 patients with mucormycosis infection. Most of these patients had diabetes and were administered steroids for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and were consequently more prone to mucormycosis. Hence, the present review emphasizes mucormycosis and its related conditions, its mechanism in normal and COVID-19 affected individuals, influencing factors and challenges to overcome this black mold infection. Early identification and further investigation of this fungus will significantly reduce the severity of the disease and mortality rate in COVID-19 affected patients.

Risk of Mucormycosis in Diabetes Mellitus: A Systematic Review

Hyperglycemia or diabetes mellitus (DM) is a disorder of the endocrine system. In this condition, the body is insulin-deficient or resistant to insulin. Due to insulin deficiency or resistance, the body is unable to process sugar. The worldwide prevalence of diabetes mellitus is rising substantially. Hyperglycemia makes the immune system weak, which increases the risk of infection in a diabetic patient. Fungal infection is more common in DM. Mucormycosis is a rare fungal infection in a healthy individual, but in DM, it can cause severe complications and even be fatal if not treated adequately and timely. In our literature review, a total of 19 published articles from the PubMed database and Google Scholar were included. We combed the PubMed database and Google Scholar by using various inclusion and exclusion criteria. The result of the review study shows the increased risk of mucormycosis in a diabetic patient.

COVID-19-Associated Mucormycosis (CAM): An Updated Evidence Mapping

Mucormycosis, a serious and rare fungal infection, has recently been reported in COVID-19 patients worldwide. This study aims to map all the emerging evidence on the COVID-19-associated mucormycosis (CAM) with a special focus on clinical presentation, treatment modalities, and patient outcomes. An extensive literature search was performed in MEDLINE (Ovid), Embase (Ovid), Cochrane COVID-19 Study Register, and WHO COVID-19 database till 9 June 2021. The primary outcome was to summarize the clinical presentation, treatment modalities, and patient outcomes of CAM. Data were summarized using descriptive statistics and presented in tabular form. This evidence mapping was based on a total of 167 CAM patients with a mean age of 51 ± 14.62 years, and 56.28% of them were male. Diabetes mellitus (73.65% (n = 123)), hypertension (22.75% (n = 38)), and renal failure (10.77% (n = 18)) were the most common co-morbidities among CAM patients. The most common symptoms observed in CAM patients were facial pain, ptosis, proptosis, visual acuity, and vision loss. Survival was higher in patients who underwent both medical and surgical management (64.96%). Overall mortality among CAM patients was found to be 38.32%. In conclusion, this study found a high incidence of CAM with a high mortality rate. Optimal glycemic control and early identification of mucormycosis should be the priority to reduce the morbidity and mortality related to CAM.

Risk Factors for Mucormycosis in COVID-19 Patients

: Opportunistic infections, such as mucormycosis, in coronavirus disease 2019 (COVID-19) patients has become a new health challenge. Since opportunistic infections can exacerbate COVID-19 patients' status, it is vital to identify the risk factors to prevent, diagnose, and treat them as soon as possible. Viral, fungal, environmental, and host factors may be responsible for this situation. Long hospital stays, impaired host immune system function due to viral infection, and excessive consumption of glucocorticoids in managing COVID-19 patients are the main risk factors for the increased risk of mucormycosis in COVID-19 patients. Educating health care workers and considering the association between mucormycosis of the paranasal sinuses and different strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as the cause of COVID-19 can help prevent invasive fungal sinusitis in COVID-19 patients.

First report of COVID-19-associated rhino-orbito-cerebral mucormycosis in pediatric patients with type 1 diabetes mellitus

Coronavirus disease 2019 (COVID-19) is a major public health problem worldwide. These patients are at increased risk of developing secondary infections due to a combination of virus- and drug-induced immunosuppression. Recently, several countries have reported an emergence of COVID-19 associated mucormycosis (CAM), particularly among patients with uncontrolled diabetes, with India reporting an alarming increase in rhino-orbito-cerebral mucormycosis (ROCM) in post-COVID cases. Hyperglycemia and diabetic ketoacidosis (DKA) are the major underlying risk factors. So far, case reports and review articles have reported CAM only in adult patients. Here, we describe the first cases of COVID-19-associated ROCM in two pediatric patients with Type 1 diabetes mellitus (DM). Both the cases had asymptomatic infection with SARS-CoV-2 and developed ROCM during the course of treatment of DKA. None of them had exposure to systemic steroids. Imaging findings in both cases revealed involvement of orbit, paranasal sinuses, and brain with cavernous sinus thrombosis. The patients underwent craniotomy with evacuation of abscess. Microbiological and histopathological findings were consistent with the diagnosis of mycormycosis, with fungal culture growing Rhizopus arrhizus. Post-operatively, the patients received liposomal amphotericin B (LAMB) and systemic antibiotics. Retrobulbar injection of LAMB was given in an attempt to halt orbital disease progression. However, it wasn't successful and both of them had to undergo orbital exenteration eventually. ROCM is a rapidly progressive disease and prompt diagnosis with aggressive surgery and timely initiation of antifungal therapy can be life-saving. Physicians should have a high index of suspicion, so as to avoid a delayed diagnosis, particularly in post-COVID patients with uncontrolled diabetes.

COVID-19 and fatal renal mucormycosis: Contributory or coincidental?

Association of mucormycosis with COVID-19 disease is emerging as a matter of concern, with multiple reports of rhino-cerebral-orbital and pulmonary involvement. The association of isolated renal mucormycosis in a patient with a history of COVID-19 infection is unknown. The immune dysregulation associated with COVID, along with the use of steroids, mechanical ventilation, and interleukin-6-directed therapies, predisposes to the development of mucormycosis. We report a rare case of primary renal mucormycosis in a young male following recovery from COVID-19. The unusual mode of presentation, rapidly progressive disease course, and the ensuing dilemmas in diagnosis and treatment merit critical analysis.

COVID-19 associated mucormycosis: Staging and management recommendations (Report of a multi-disciplinary expert committee)

Even before the onslaught of COVID-19 pandemic could settle, the unprecedented rise in cases with COVID-19 associated mucormycosis pushed the medical health to the fringe. Hyperglycaemia and corticosteroids appear to be the most consistent associations leading to the commonest manifestation of mucormycosis, Rhino-Orbito-Cerebral Mucormycosis. To address challenges right from categorisation and staging of the disease to the management of relentless progression, a multi-disciplinary expert committee was formed to handle the task in an evidence-based format to enforce best practices. The report of the committee on one hand attempts to succinctly present the currently available evidence while at the other also attempts to bridge the evidence-deficient gaps with the specialty-specific virtuosity of experts.

Increased incidence of rhino-orbital mucormycosis in an educational therapeutic hospital during the COVID-19 pandemic in western Iran: An observational study

Background

COVID‐19 patients, especially the patients requiring hospitalisation, have a high risk of several complications such as opportunistic bacterial and fungal infections. Mucormycosis is a rare and opportunistic fungal infection that mainly affects diabetic and immunocompromised patients. An increase has been observed in the number of rhino‐orbital mucormycosis in patients with COVID‐19 admitted to Imam Khomeini Hospital, Kermanshah, Iran, since October 2020. This is a report of the frequency, risk factors, clinical manifestations, treatment and prognosis of COVID‐19 associated with mucormycosis infection.

Methods

The medical records of COVID‐19 patients with rhino‐orbital mucormycosis who were diagnosed in an educational therapeutic hospital in Kermanshah, west of Iran were surveyed. Several parameters were analysed including demographic, clinical, therapeutic and laboratory characteristics.

Results

Twelve patients with COVID‐19–associated rhino‐orbital mucormycosis were identified from 12 October to 18 November 2020. All cases reported as proven mucormycosis had a history of hospitalisation due to COVID‐19. Comorbidities mainly included diabetes mellitus (83.33%) and hypertension (58.33%). Seventy‐five per cent of patients received corticosteroids for COVID‐ 19 treatment. The sites of involvement were rhino‐sino‐orbital (83%) and rhino‐sino (17%). Amphotericin B/liposomal amphotericin B alone or in combination with surgical debridement or orbital exenteration was used as the first‐line therapy. The overall mortality rate was 66.7% (8/12).

Conclusions

We found a high incidence of mucormycosis among COVID‐19 patients. Diabetes mellitus and corticosteroid use were the dominant predisposing factor of mucormycosis. Mucormycosis is a life‐threatening and opportunistic infection; therefore, physicians should know the signs and symptoms of the disease so that a timely diagnosis and therapy can be performed.

Challenges in the diagnosis of pulmonary mucormycosis in a diabetic with a review of literature

Diabetes Mellitus appears to be the most common underlying condition associated with mucormycosis; a rare opportunistic fungal infection associated with high morbidity and mortality. Pulmonary mucormycosis may mimic pneumonia and thus pose challenges in achieving a timely diagnosis critical to successful outcomes. We present a case of a 65-year-old diabetic who presented with fever and haemoptysis that was managed as pneumonia. A bronchial alveolar lavage grew Rhizopus mould that was thought to be a contaminant as he responded well to antibiotics. He required another admission in 4 weeks due to worsening symptoms. Failure to respond to antibiotics and ongoing clinical and radiological deterioration led to a lobectomy that confirmed a diagnosis of pulmonary mucormycosis. He responded well to surgical resection and antifungal therapy with a complete recovery. Elusive clinical presentation and insensitive conventional diagnostic techniques may make the diagnosis of mucormycosis challenging. Our case reports highlight the issues involved in the diagnosis and management of pulmonary Mucormycosis mimicking as pneumonia.

COVID-19-associated mucormycosis: An updated systematic review of literature

In its wake, the COVID-19 pandemic has ushered in a surge in the number of cases of mucormycosis. Most cases are temporally linked to COVID-19; hence, the entity is described as COVID-19-associated mucormycosis (CAM). The present systematic review was undertaken to provide an up-to-date summary of the hitherto available literature on CAM. PubMed, Scopus and Google Scholar databases were systematically searched using appropriate keywords till 14 May 2021, to identify case reports/case series pertaining to mucormycosis in patients with COVID-19. Relevant data extracted included demographic characteristics, comorbidity profile, clinical category of mucormycosis, glucocorticoid use, treatment offered and patient outcome. We identified 30 case reports/case series, pooling data retrieved from 99 patients with CAM. Most cases were reported from India (72%). The majority of the patients was male (78%) and had diabetes mellitus (85%). A prior history of COVID-19 was present in 37% patients with mucormycosis developing after an initial recovery. The median time interval between COVID-19 diagnosis and the first evidence of mucormycosis infection or CAM diagnosis was 15 days. Glucocorticoid use was reported in 85% of cases. Rhino-orbital mucormycosis was most common (42%), followed by rhino-orbito-cerebral mucormycosis (24%). Pulmonary mucormycosis was observed in 10 patients (10%). The mortality rate was 34%; the use of adjunct surgery, which was undertaken in 81% of patients, was associated with better clinical outcomes (p < .001). In conclusion, CAM is an emerging problem necessitating increased vigilance in COVID-19 patients, even those who have recovered. CAM portends a poor prognosis and warrants early diagnosis and treatment.

The Role of Noncommunicable Diseases in the Pursuit of Global Health Security

Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap.

Rhinocerebral mucormycosis secondary to severe acute pancreatitis and diabetic ketoacidosis: a case report

INTRODUCTION

Rhinocerebral mucormycosis is a rare and severe form of opportunistic fungal infection that can develop rapidly and cause significant mortality, particularly among diabetic patients suffering from ketoacidosis. Diagnosing rhinocerebral mucormycosis during the early stages of infection is challenging.

CASE PRESENTATION

We describe a case of rhinocerebral mucormycosis secondary to severe acute pancreatitis in a patient suffering from diabetic ketoacidosis. In this case, the condition was not diagnosed during the optimal treatment window. we therefore provide a thorough overview of related clinical findings and histopathological characteristics, and we discuss potential differential diagnoses.

CONCLUSIONS

In summary, we described a case of rhinocerebral mucormycosis secondary to severe acute pancreatitis in a patient suffering from diabetic ketoacidosis, with the optimal treatment window for this condition having been missed. This report suggests that a definitive mucormycosis diagnosis can be made based upon tissue biopsy that reveals the presence of characteristic hyphae. Early diagnosis and treatment are essential in order to improve patient prognosis.

The double-edged sword of systemic corticosteroid therapy in viral pneumonia: A case report and comparative review of influenza-associated mucormycosis versus COVID-19 associated mucormycosis

Acute respiratory distress syndrome is a common complication of severe viral pneumonia, such as influenza and COVID‐19, that requires critical care including ventilatory support, use of corticosteroids and other adjunctive therapies to arrest the attendant massive airways inflammation. Although recommended for the treatment of viral pneumonia, steroid therapy appears to be a double‐edged sword, predisposing patients to secondary bacterial and invasive fungal infections (IFIs) whereby impacting morbidity and mortality. Mucormycosis is a fungal emergency with a highly aggressive tendency for contiguous spread, associated with a poor prognosis if not promptly diagnosed and managed. Classically, uncontrolled diabetes mellitus (DM) and other immunosuppressive conditions including corticosteroid therapy are known risk factors for mucormycosis. Upon the background lung pathology, immune dysfunction and corticosteroid therapy, patients with severe viral pneumonia are likely to develop IFIs like aspergillosis and mucormycosis. Notably, the combination of steroid therapy and DM can augment immunosuppression and hyperglycaemia, increasing the risk of mucormycosis in a susceptible individual. Here, we report a case of sinonasal mucormycosis in a 44‐year‐old woman with hyperglycaemia secondary to poorly controlled diabetes following dexamethasone therapy on a background of influenza pneumonia and review 15 available literatures on reported cases of influenza and COVID‐19 associated mucormycosis.

A Case of Fatal Rhino-Orbital Mucormycosis Associated With New Onset Diabetic Ketoacidosis and COVID-19

Mucormycosis is an invasive fungal infection, often acute and extremely severe, occurring in patients with an underlying condition. Coinfection in patients with coronavirus disease 2019 (COVID-19) has been reported, often bacterial. A 24-year-old female is presented with acute fatal rhino-orbital mucormycosis and COVID-19. We report one of the first cases of rhino-orbital mucormycosis and COVID-19. With this case, we highlight the importance of considering mycotic coinfection in COVID-19 patients with diabetes.

Host-Pathogen Molecular Factors Contribute to the Pathogenesis of Rhizopus spp. in Diabetes Mellitus

Purpose of Review

Infectious diseases represent up to 12% of all deaths in people with diabetes mellitus (DM). The development and progression of DM generate a chronic inflammatory state with unique characteristics that have been exploited by some pathogens; one of them is Rhizopus spp., a fungus considered the causative agent of mucormycosis. This disease has a poor prognosis with high mortality rates, and the apparition of resistant isolates each year has become a worrying concern. DM is an actual and continuing health problem, and for that reason, it is of foremost importance to study the pathogenesis of mucormycosis to generate new prevention and treatment strategies.

Recent Findings

The worldwide incidence of mucormycosis has increased in recent years. The pathogenic mechanisms and factors identified in Rhizopus spp. are the cell wall, spore germination, proteins, and enzymes related to iron sequestration, CotH fungal protein, positive regulation of the GRP78 cell receptor, and immune evasion due to survival within phagocytes, among others. The physiopathology of DM offers favorable conditions for the successful replication of Rhizopus spp.

Summary

The main reason for increase of incidence of mucormycosis caused by Rhizopus spp. has been associated with the rise of worldwide prevalence of DM. Knowing the fungal pathogenic mechanisms as well as the relationships between Rhizopus with the microenvironment found in the human body will undoubtedly help generate better antifungals to enhance treatment outcomes. Nowadays, some strategies to combat the fungus are based on the knowledge of its proteins, cellular interactions, and iron metabolism.

Comparative host transcriptome in response to pathogenic fungi identifies common and species-specific transcriptional antifungal host response pathways

Candidiasis, aspergillosis, and mucormycosis cause the majority of nosocomial fungal infections in immunocompromised patients. Using an unbiased transcriptional profiling in PBMCs exposed to the fungal species causing these infections, we found a core host response in healthy individuals that may govern effective fungal clearance: it consists of 156 transcripts, involving canonical and non-canonical immune pathways. Systematic investigation of key steps in antifungal host defense revealed fungal-specific signatures. As previously demonstrated, Candida albicans induced type I and Type II interferon-related pathways. In contrast, central pattern recognition receptor, reactive oxygen species production, and host glycolytic pathways were down-regulated in response to Rhizopus oryzae, which was associated with an ER-stress response. TLR5 was identified to be uniquely regulated by Aspergillus fumigatus and to control cytokine release in response to this fungus. In conclusion, our data reveals the transcriptional profiles induced by C. albicans, A. fumigatus, and R. oryzae, and describes both the common and specific antifungal host responses that could be exploited for novel therapeutic strategies.

Mucormycosis at a tertiary-care center in Mexico. A 35-year retrospective study of 214 cases

BACKGROUND

Mucormycosis is a rare, invasive disease associated with high mortality rates, produced by opportunistic pathogens related to the Mucorales order and characterised by a diverse range of clinical forms; acute rhino-orbital-cerebral and pulmonary symptoms are the most reported ones.

OBJECTIVES

To report the experience of mucormycosis observed in a tertiary-care hospital in Mexico for 35 years.

METHODS

This was a retrospective, descriptive and observational study on mucormycosis at a tertiary-care hospital in Mexico from January 1985 to December 2019. Demographic and clinical data and mycological and histopathological records were selected.

RESULTS

Two hundred fourteen proven cases of mucormycosis for 35 years at a tertiary-care hospital in Mexico were included. Most of the cases were male patients with a median age of 45 years. The two most associated underlying diseases were diabetes mellitus (76.6%) and haematologic malignancy (15.4%). The three primary clinical forms were as follows: rhino-orbito-cerebral (75.9%), cutaneous (8.41%) and pulmonary (7.47%) mucormycosis. The most isolated agents were Rhizopus arrhizus (58.4%) and Lichtheimia corymbifera (12.3%). The overall therapeutic response was 58.5%, and the best response was observed with amphotericin B deoxycholate and surgical debridement.

CONCLUSION

Mucormycosis is an emerging disease, and its incidence has increased at our hospital over the years. In this study, the rhino-cerebral clinical type was the most frequent in patients with uncontrolled diabetes; the main aetiological agent was R. arrhizus. Early diagnosis, control of the underlying disease and prompt management may increase the survival rate.

Mucormycosis with cutaneous involvement. A retrospective study of 115 cases at a tertiary care hospital in Mexico

BACKGROUND/OBJECTIVES

Cutaneous mucormycosis is an emerging opportunistic mycosis caused by Mucorales. It can be divided into primary caused by trauma and secondary by extension of rhino-cerebral and disseminated cases. The objective is to present a retrospective study of cases of mucormycosis with cutaneous involvement.

METHODS

A retrospective and descriptive study was carried out. Mucormycosis patients were included and divided into two groups: a) Primary Cutaneous and b) Secondary Cutaneous. Mycological tests were performed; the agents were identified by morphology and molecular studies (PCR and sequencing); some cases underwent histopathology. Clinical data and response to treatment were collected.

RESULTS

115 cases were included, 18 of primary, and 97 of secondary cutaneous mucormycosis. Primary cutaneous mucormycosis was most associated with adhesive bands (44.4%) and trauma from traffic accidents (33.3%). The principal clinical form was extensive and deep necrotic ulcers. Secondary cutaneous mucormycosis cases were rhino-cerebral with uncontrolled diabetes (81.4%) The most frequent clinical presentation was necrosis of the eyelid and the nose (65.9%). In both groups, the principal agent was Rhizopus arrhizus, 38.8% and 74.2% respectively. The most effective treatment was the combination of amphotericin B with surgical debridement. The clinical and mycological cure was achieved in 31.0% of primary cases, and 44.4% for secondary cases.

CONCLUSION

Primary cutaneous mucormycosis is caused by implantation of the Mucorales due to trauma or rupture of the cutaneous barrier-breach, and secondary cutaneous mucormycosis develops as part of the rhino-cerebral process. The response to treatment depends on the extension and depth, as well as the predisposing factors.

Oral involvement in mucormycosis. A retrospective study of 55 cases

INTRODUCTION

Mucormycosis with oral involvement (OIM) is a rare opportunistic and lethal mycosis, which has increased in the last decade and is generally associated with uncontrolled diabetes and neutropenia.

METHODS

A retrospective study of cases with OIM was carried out in a tertiary-care center. Mycological and histological examinations were performed, and the isolated organisms were identified by morphology and molecular biology.

RESULTS

Fifty-five OIM patients were included, with a median age of 38 years (61.8% males). The most frequent associated disease was type-2 diabetes mellitus (61%), followed by neutropenia due to acute lymphocytic leukemia (27%). The main presentation was palatal and mandibular ulcers (92.7%) and, to a lesser extent, gingival and lingual necrosis. The diagnosis was established by mycological and histopathological studies. The most frequent fungi isolated was Rhizopus arrhizus (67.2%).

CONCLUSION

OIM is a rapidly progressing disease, therefore, an early diagnosis and the proper control of predisposing factors is necessary, and consequently, contributing to improve the outcome of mucormycosis.

Epidemiology and Diagnosis of Mucormycosis: An Update

Mucormycosis is an angioinvasive fungal infection, due to fungi of the order Mucorales. Its incidence cannot be measured exactly, since there are few population-based studies, but multiple studies have shown that it is increasing. The prevalence of mucormycosis in India is about 80 times the prevalence in developed countries, being approximately 0.14 cases per 1000 population. Diabetes mellitus is the main underlying disease globally, especially in low and middle-income countries. In developed countries the most common underlying diseases are hematological malignancies and transplantation. Τhe epidemiology of mucormycosis is evolving as new immunomodulating agents are used in the treatment of cancer and autoimmune diseases, and as the modern diagnostic tools lead to the identification of previously uncommon genera/species such as Apophysomyces or Saksenaea complex. In addition, new risk factors are reported from Asia, including post-pulmonary tuberculosis and chronic kidney disease. New emerging species include Rhizopus homothallicus, Thamnostylum lucknowense, Mucor irregularis and Saksenaea erythrospora. Diagnosis of mucormycosis remains challenging. Clinical approach to diagnosis has a low sensitivity and specificity, it helps however in raising suspicion and prompting the initiation of laboratory testing. Histopathology, direct examination and culture remain essential tools, although the molecular methods are improving. The internal transcribed spacer (ITS) region is the most widely sequenced DNA region for fungi and it is recommended as a first-line method for species identification of Mucorales. New molecular platforms are being investigated and new fungal genetic targets are being explored. Molecular-based methods have gained acceptance for confirmation of the infection when applied on tissues. Methods on the detection of Mucorales DNA in blood have shown promising results for earlier and rapid diagnosis and could be used as screening tests in high-risk patients, but have to be validated in clinical studies. More, much needed, rapid methods that do not require invasive procedures, such as serology-based point-of-care, or metabolomics-based breath tests, are being developed and hopefully will be evaluated in the near future.

Opportunistic invasive fungal disease in patients with type 2 diabetes mellitus from Southern China: Clinical features and associated factors

AIMS/INTRODUCTION

A retrospective study was carried out to investigate the clinical characteristics and associated factors for invasive fungal disease in patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

Demographic and clinical data were recorded. Associated factors were analyzed by logistic regression analysis.

RESULTS

Invasive fungal disease was diagnosed in 120 patients with type 2 diabetes mellitus (prevalence, 0.4%). Yeast infection (56/120, 46.7%), including candidiasis (31/56, 55.4%) and cryptococcosis (25/56, 44.6%), was the most common. The urinary tract was mainly involved in candidiasis (12/31, 38.7%). More than half of the cryptococcosis (16/25, 64.0%) presented as pneumonia. Mold infection accounted for 40.8% of the cases, and predominantly involved the lung (34/49, 69.4%). A total of 15 (12.5%) patients had mixed fungal infection. Candida albicans (24/111, 21.6%), Cryptococcus neoformans (19/111, 17.1%) and Aspergillus fumigatus (14/111, 12.6%) were the leading agents. Co-infection occurred in 58 (48.3%) patients, mainly presenting as pneumonia caused by Gram-negative bacteria. The inpatient mortality rate of invasive fungal disease was 23.3% (28/120). Glycated hemoglobin levels were higher in non-survivors than survivors (8.8 ± 2.5 vs 7.7 ± 2.1%, P = 0.02). Anemia (adjusted odds ratio, 3.50, 95% confidence interval 1.95-6.27, P < 0.001), hypoalbuminemia (adjusted odds ratio, 5.42, 95% confidence interval 3.14-9.36, P < 0.001) and elevated serum creatinine (adjusted odds ratio, 2.08, 95% confidence interval 1.07-4.04, P = 0.03) were associated with invasive fungal disease in type 2 diabetes mellitus patients.

CONCLUSIONS

Invasive fungal disease is a life-threatening complication in type 2 diabetes mellitus patients. C. a albicans, C. neoformans, and A. fumigatus are the leading agents. Prolonged hyperglycemia results in unfavorable outcomes. Correction of anemia and hypoalbuminemia might improve prognosis.

[Mucormycosis in patients with hematological diseases: seven cases reports and literature review]

目的

探讨血液病合并毛霉菌病患者的临床特征、诊治与转归，提高对该病的认识。

方法

回顾性分析2012年9月至2018年9月7例血液病合并毛霉菌病患者的临床资料，分析其临床特征、治疗过程和转归。

结果

7例血液病合并毛霉菌病患者中，男4例，女3例，中位年龄36（19~79）岁。基础疾病：急性髓系白血病2例，急性B淋巴细胞白血病、外周T细胞淋巴瘤、慢性髓性白血病急髓变、骨髓增殖性肿瘤及重型再生障碍性贫血（移植后）各1例。毛霉菌病临床类型：4例为肺型，1例为鼻眶脑型，1例为皮肤型，1例为播散型。7例患者均通过活检组织病理确诊。治疗药物为两性霉素B、两性霉素B脂质体及泊沙康唑。手术治疗4例，其中3例术中彻底清除病变组织，1例仅行局限性清除。治愈2例，好转1例，死亡4例。

结论

血液病合并毛霉菌病患者临床表现及影像学表现多样，死亡率高，确诊主要依赖于组织病理学。早期诊断、控制基础疾病、改善免疫抑制状态、尽早行有效的抗真菌药物治疗及彻底的手术清创治疗是提高血液病合并毛霉菌病患者生存率的关键。

A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India

OBJECTIVES

To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality.

METHODS

We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed.

RESULTS

We included 465 patients. Rhino-orbital mucormycosis was the most common (315/465, 67.7%) presentation followed by pulmonary (62/465, 13.3%), cutaneous (49/465, 10.5%), and others. The predisposing factors included diabetes mellitus (342/465, 73.5%), malignancy (42/465, 9.0%), transplant (36/465, 7.7%), and others. Rhizopus species (231/290, 79.7%) were the most common followed by Apophysomyces variabilis (23/290, 7.9%), and several rare Mucorales. Surgical treatment was performed in 62.2% (289/465) of the participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. The 90-day mortality rate was 52% (242/465). On multivariate analysis, disseminated and rhino-orbital (with cerebral extension) mucormycosis, shorter duration of symptoms, shorter duration of antifungal therapy, and treatment with amphotericin B deoxycholate (versus liposomal) were independent risk factors of mortality. A combined medical and surgical management was associated with a better survival.

CONCLUSIONS

Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis. Combined surgical and medical management was associated with better outcomes. Several gaps surfaced in the management of mucormycosis. The rarer Mucorales identified in the study warrant further evaluation.

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

Mucormycosis is a difficult to diagnose rare disease with high morbidity and mortality. Diagnosis is often delayed, and disease tends to progress rapidly. Urgent surgical and medical intervention is lifesaving. Guidance on the complex multidisciplinary management has potential to improve prognosis, but approaches differ between health-care settings. From January, 2018, authors from 33 countries in all United Nations regions analysed the published evidence on mucormycosis management and provided consensus recommendations addressing differences between the regions of the world as part of the "One World One Guideline" initiative of the European Confederation of Medical Mycology (ECMM). Diagnostic management does not differ greatly between world regions. Upon suspicion of mucormycosis appropriate imaging is strongly recommended to document extent of disease and is followed by strongly recommended surgical intervention. First-line treatment with high-dose liposomal amphotericin B is strongly recommended, while intravenous isavuconazole and intravenous or delayed release tablet posaconazole are recommended with moderate strength. Both triazoles are strongly recommended salvage treatments. Amphotericin B deoxycholate is recommended against, because of substantial toxicity, but may be the only option in resource limited settings. Management of mucormycosis depends on recognising disease patterns and on early diagnosis. Limited availability of contemporary treatments burdens patients in low and middle income settings. Areas of uncertainty were identified and future research directions specified.

Mucormycosis in South America: A review of 143 reported cases

Mucormycosis is a rare but important invasive fungal disease that most often affects immunocompromised hosts. The incidence of mucormycosis appears to be increasing worldwide, as risk factors such as the use of immunosuppressive therapies become more common. We report the results of a literature review of 143 mucormycosis cases reported in South America between 1960 and 2018. The number of reported cases has increased by decade, from 6 in the 1960s to 51 in the 2010s. The most common underlying conditions associated with mucormycosis in South America were diabetes mellitus (42.0%) and penetrating trauma/burns (20.0%). Underlying conditions involving immunosuppression, including treatment of haematologic malignancy, solid organ transplant, and corticosteroid use, also accounted for a large proportion of cases (45.5%). Between 1960 and 2018, cases of mucormycosis associated with conditions involving immunosuppression accounted for the highest mortality rate (58.5%), followed by diabetes mellitus (45.0%), and penetrating trauma/burns (37.9%). Overall mortality decreased from 100% to 39.4% during this period, mainly driven by the increasing availability and use of antifungal therapies and surgical intervention. However, these treatments are not yet universally utilised across the region in the treatment of mucormycosis; efforts to improve availability of effective treatments would be likely to improve outcomes.

Animal Models to Study Mucormycosis

Mucormycosis is a rare but often fatal or debilitating infection caused by a diverse group of fungi. Animal models have been crucial in advancing our knowledge of mechanisms influencing the pathogenesis of mucormycoses, and to evaluate therapeutic strategies. This review describes the animal models established for mucormycosis, summarizes how they have been applied to study mucormycoses, and discusses the advantages and limitations of the different model systems.

Global Epidemiology of Mucormycosis

Mucormycosis is an angio-invasive fungal infection, associated with high morbidity and mortality. A change in the epidemiology of mucormycosis has been observed in recent years with the rise in incidence, new causative agents and susceptible population. The rise has been perceived globally, but it is very high in the Asian continent. Though diabetes mellitus overshadow all other risk factors in Asia, post-tuberculosis and chronic renal failure have emerged as new risk groups. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas, pulmonary mucormycosis in patients with haematological malignancy and transplant recipients. In immunocompetent hosts, cutaneous mucormycosis is commonly seen following trauma. The intriguing clinical entity, isolated renal mucormycosis in immunocompetent patients is only reported from China and India. A new clinical entity, indolent mucormycosis in nasal sinuses, is recently recognized. The causative agents of mucormycosis vary across different geographic locations. Though Rhizopusarrhizus is the most common agent isolated worldwide, Apophysomycesvariabilis is predominant in Asia and Lichtheimia species in Europe. The new causative agents, Rhizopus homothallicus, Mucor irregularis, and Thamnostylum lucknowense are reported from Asia. In conclusion, with the change in epidemiology of mucormycosis country-wise studies are warranted to estimate disease burden in different risk groups, analyse the clinical disease pattern and identify the new etiological agents.

Disease Entities in Mucormycosis

Mucormycosis is an emerging life-threatening fungal infection caused by Mucorales. This infection occurs mainly in immunocompromised patients, especially with hematological malignancy, transplantation, or diabetes mellitus. Rhino-orbito-cerebral and pulmonary mucormycosis are the predominant forms. Interestingly, location is associated with the underlying disease as pulmonary mucormycosis is more frequent in hematological malignancy patients whereas rhino-orbito-cerebral mucormycosis is associated with diabetes. Cutaneous mucormycosis results from direct inoculation, mainly after trauma or surgery. Gastro-intestinal mucormycosis occurs after ingestion of contaminated food or with contaminated device and involves the stomach or colon. Disseminated disease is the most severe form and is associated with profound immunosuppression. Uncommon presentations with endocarditis, osteoarticluar or isolated cerebral infections are also described. Finally, health-care associated mucormycosis is a matter of concern in premature newborns and burn units. Clinical symptoms and CT scan findings are not specific, only the early reversed halo sign is associated with pulmonary mucormycosis. Circulating Mucorales DNA detection is a recent promising diagnostic tool that may lead to improving the diagnosis and prompting therapeutic initiation that should include antifungal treatment, correction of the underlying disease and surgery when feasible.