Mucormycosis in India: unique features

Outbreak of Mucormycosis in Coronavirus Disease Patients, Pune, India

We provide an overview of the epidemiology and clinical course of mucormycosis in the coronavirus disease (COVID-19) pandemic era. We conducted a retrospective chart review of 178 patients with clinical or diagnostic, endoscopically or histopathologically confirmed rhino-sino-orbital or cerebral mucormycosis after COVID-19 treatment during the second wave of COVID-19 in Pune, India. Median time to symptom onset from COVID-19 detection was 28 days. Moderate or severe COVID-19 was seen in 73% of patients and diabetes in 74.2%. A total of 52.8% received steroids. Eschar over or inside the nose was seen in 75%, but baseline clinical and laboratory parameters were mostly unremarkable. Bone penetration was present in ≈90% of cases, 30% had soft-tissue swelling of the pterygopalatine fossa and 7% had cavernous sinus thrombosis, and 60% had multifocal mucormycosis. Of the 178 study cases, 151 (85%) underwent surgical debridement. Twenty-six (15%) died, and 16 (62%) of those had multifocal mucormycosis.

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

Background

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

Objective

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

Methodology.

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

Results

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

Conclusion

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

Consensus guidelines for the diagnosis and management of invasive fungal disease due to moulds other than Aspergillus in the haematology/oncology setting, 2021

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.

Pulmonary Mucormycosis as the Leading Clinical Type of Mucormycosis in Western China

The aim was to better understand the clinical characteristics of patients with mucormycosis in western China. We retrospectively investigated the clinical, laboratory, radiological and treatment profiles of mucormycosis patients during a 10-year period (2010–2019). As a result, 59 proven mucormycosis were enrolled in this study. It was found that 52.5% of patients had worse clinical outcomes. Pulmonary mucormycosis (PM) was the most common clinical manifestation. The most frequent risk factor was diabetes mellitus (38, 64.4%) for mucormycosis patients. Cough (43, 93.5%), fever (24, 52.2%) and hemoptysis/bloody phlegm (21, 45.7%) were the most common manifestations of PM. There were no differences in clinical manifestations, risk factors and laboratory tests between different clinical outcome groups (P>0.05). Lymph node enlargement (30, 65.2%), patchy shadows (28, 60.9%), cavitation (25, 53.3%) and bilateral lobe involvement (39, 84.8%) were the most common on chest CT. Nodule was more common in good outcome group (P <0.05). A total of 48 cases (81.4%) were confirmed by histopathological examination, 22 cases (37.3%) were confirmed by direct microscopy. PM patients were treated with amphotericin B/amphotericin B liposome or posaconazale had better clinical outcomes (P <0.05). In conclusion, PM was the most common clinical type of mucormycosis in China. Diabetes mellitus was the most common risk factor. PM has diverse imaging manifestations and was prone to bilateral lobes involvement. Early diagnosis and effective anti-mucor treatment contribute to successful treatment.

The rise in cases of mucormycosis, candidiasis and aspergillosis amidst COVID19

The Coronavirus outbreak globally has changed the medical system and also led to a shortage of medical facilities in both developing and underdeveloped countries. The COVID19 disease, being novel in nature along with high infectivity and frequent mutational rate, has been termed to be fatal across the globe. The advent of infection by SARS-CoV-2 has brought a myriad of secondary complications and comorbidities resulting in additional challenges to the health care system induced by novel therapeutic procedures. The emerging variant with respect to the Indian subcontinent and the associated genetic mutations have worsened the situation at hand. Proper clinical management along with epidemiological studies and clinical presentations in scientific studies and trials is necessary in order to combat the simultaneous waves of emerging strains. This article summarizes three of the major fungal outbreaks in India namely mucormycosis, candidiasis and aspergillosis, and elaborates their subtypes, pathogenesis, symptoms and treatment and detection techniques. A detail of future therapeutics under consideration are also elaborated along with a general hypothesis on how COVID19 is related to immunological advances leading to major widespread fungal infection in the country. The factors that contribute in promoting virus proliferation and invasive fungal infections include cell-mediated immunity, associated immunocompromised conditions and treatment protocols that slows down immune mechanisms. To better comprehend a fungal or bacterial outbreak, it is very important to conduct audits mediated through multicenter national and state research teams for recognizing patterns and studying current cases of fungal infection in both healthy and comorbid groups of COVID19 patients.

COVID-19-associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic's second wave in India

Coronavirus Disease 2019 (COVID-19), during the second wave in early 2021, has caused devastating chaos in India. As daily infection rates rise alarmingly, the number of severe cases has increased dramatically. The country has encountered health infrastructure inadequacy and excessive demand for hospital beds, drugs, vaccines, and oxygen. Adding more burden to such a challenging situation, mucormycosis, an invasive fungal infection, has seen a sudden surge in patients with COVID-19. The rhino-orbital-cerebral form is the most common type observed. In particular, approximately three-fourths of them had diabetes as predisposing comorbidity and received corticosteroids to treat COVID-19. Possible mechanisms may involve immune and inflammatory processes. Diabetes, when coupled with COVID-19-induced systemic immune change, tends to cause decreased immunity and an increased risk of secondary infections. Since comprehensive data on this fatal opportunistic infection are evolving against the backdrop of a major pandemic, prevention strategies primarily involve managing comorbid conditions in high-risk groups. The recommended treatment strategies primarily included surgical debridement and antifungal therapy using Amphotericin B and selected azoles. Several India-centric clinical guidelines have emerged to rightly diagnose the infection, characterise the clinical presentation, understand the pathogenesis involved, and track the disease course. Code Mucor is the most comprehensive one, which proposes a simple but reliable staging system for the rhino-orbital-cerebral form. A staging system has recently been proposed, and a dedicated registry has been started. In this critical review, we extensively analyse recent evidence and guidance on COVID-19-associated mucormycosis in India.

Case Report: Metagenomics Next-Generation Sequencing Can Be Performed for the Diagnosis of Disseminated Mucormycosis

Mucormycosis is an infection caused by a group of filamentous molds with in the order Mucorales. In developing countries, most cases of mucormycosis occur in persons with poorly controlled diabetes mellitus or subjects with normal post-traumatic immune function. Mucormycosis exhibits a marked propensity for invading blood vessels. The mortality rate of invasive mucormycosis is very high (>30-50%), and 90% of mortality is related to disseminated diseases. We report a 62-year-old man with underlying diseases, such as diabetes and psoriatic arthritis, with a history of trauma before admission. Chest CT showed multiple cavities. Based on the suspected clinical manifestation of mucormycosis infection, the patient received a microbiological culture of bronchoalveolar lavage fluid, and metagenomics next generation sequencing (mNGS) was performed. The results suggested Klebsiella pneumoniae infection. However, Rhizopus microsporus strains were shown by the mNGS of transpulmonary puncture tissue. Therefore, we report a case in which rare pathogens are identified by mNGS.

COVID-19-associated mucormycosis: Case report and systematic review

BACKGROUND

Increasing number of patients with COVID-19-associated mucormycosis have been reported, especially from India recently. We have described a patient with COVID-19-associated mucormycosis and, searched and analyzed current medical literature to delineate the characteristics of COVID-19-associated mucormycosis.

METHOD

We reported a patient developed mucormycosis during post-COVID period. We searched literature to describe the incidence, clinical features, and outcomes of COVID-19-associated mucormycosis. Demographic features, risk factors, clinical features, diagnostic methods, treatment and outcome were analyzed.

RESULTS

We describe a 54-year-old male, hospitalized due to severe COVID-19 pneumonia. He was given long-term, high doses of systemic steroids. He developed maxillo-fascial mucormycosis and died of sepsis. Our literature search found 30 publications describing 100 patients including present case report. The majority (n = 68) were reported from India. 76% were male. The most commonly seen risk factors were corticosteroid use (90.5%), diabetes (79%), and hypertension (34%). Also, excessive use of broad-spectrum antibiotics were noted in cases. Most frequent involvements were rhino-orbital (50%), followed by rhino-sinusal (17%), and rhino-orbito-cerebral (15%). Death was reported as 33 out of 99 patients (33,3%).

CONCLUSIONS

Steroid use, diabetes, environmental conditions, excessive use of antibiotics, and hypoxia are main risk factors. Despite medical and surgical treatment, mortality rate is high. A multidisciplinary approach is essential to improve the conditions facilitating the emergence of COVID-19-associated mucormycosis.

Mandibular mucormycosis following SARS-CoV-2 infection - A case report and review of literature

BACKGROUND

The second wave of COVID-19 pandemic has seen an unprecedented rise in the number of mucormycosis cases worldwide and in India particularly. This otherwise rare fungal infection has become an endemic among patients who have recovered from recent SARS-CoV-2 infection. Among the different types of mucormycosis, rhino-orbital-cerebral involvement has mainly been observed in the recent surge of cases. Very few cases of mucormycosis of mandible have been reported in literature and none in COVID-19 patients. We report a case of isolated mandibular mucormycosis in a COVID- 19 patient, with no other predisposing comorbidities.Case report.A 39 year old patient recently recovered from COVID-19 presented with typical symptoms of osteomyelitis which was confirmed using computed tomography of face. He underwent thorough debridement and curettage and tissue was sent for culture, special staining and biopsy.

RESULT

Diagnosis of mucormycosis was confirmed based on postoperative biopsy and special staining. He was further managed with complete course of appropriate antifungal therapy.

CONCLUSION

Mucormycosis is a fulminant and aggressive infection which requires prompt diagnosis and intervention. Early referral to a maxillofacial surgeon by physicians and general dental practitioners on seeing signs and symptoms of secondary fungal infections involving maxilla or mandible in patients with history of SARS-CoV-19 infection can improve prognosis.

The Statewide Epidemiology of Mucormycosis Among Trauma Patients in Florida

OBJECTIVES

Mucormycosis is a rare angioinvasive infection caused by filamentous fungi with a high lethality among the immunocompromised. In healthy people, the innate immune system is sufficient to prevent infection. The exception to this is deep tissue exposure seen during trauma. The purpose of this study is to evaluate the epidemiology of mucormycosis using a statewide population-based data set.

METHODS

This is a retrospective cohort study of all hospital admissions for mucormycosis within the state of Florida from 1997 through the beginning of 2020. A distribution map was created to evaluate for geographic variation. Botanical growth zones, based on plant hardiness, used by state environmental agencies and landscapers were also used to detect possible patterns based on climate conditions throughout Florida. A multivariable regression analysis was performed to account for confounders and limit bias.

RESULTS

A total of 1190 patients were identified for mucormycosis infection. Only 86 of these patients were admitted for trauma. Cutaneous infections were more prevalent among trauma patients while non-trauma patients had more pulmonary infections (P = .04). Trauma patients with infection tended to be younger and less likely to suffer from comorbidities such as immunosuppression (36% vs 46%, P = .07) and diabetes (22.1% vs 47.1%, P ≤ .0001) as compared to their non-trauma counterparts. Mortality was similar with 17.8% for non-trauma patients and 15.1% for traumatized patients (AOR .80 [.42, 1.52]). Length of stay was longer for trauma patients (37.3 vs 23.0, P < .0001). Infections were less prominent in plant hardiness Zone 9 and Zone 10 as compared to Zone 8 (AOR .71 [.61, .82]; AOR .54 [.46, .64], respectively).

CONCLUSION

Trauma patients who develop infection from mucormycosis are at high risk of death despite being a younger and healthier population. Mucormycosis infections were primarily soft tissue based among trauma patients. These infections are more prevalent in colder regions within Florida.

COVID-19-Associated Mucormycosis (CAM): Case-Series and Global Analysis of Mortality Risk Factors

BACKGROUND

Since the novel coronavirus disease (COVID-19) outbreak, the cases of COVID-19 co-infections have been increasingly reported worldwide. Mucormycosis, an opportunistic fungal infection caused by members of the Mucorales order, had been frequently isolated in severely and critically ill COVID-19 patients.

METHODS

Initially, the anamnestic, clinical, and paraclinical features of seven COVID-19-associated mucormycosis (CAM) cases from Egypt were thoroughly reported. Subsequently, an extensive review of the literature was carried out to describe the characteristics of CAM cases globally, aiming to explore the potential risk factors of mortality in CAM patients.

RESULTS

Out of the seven reported patients in the case series, five (71.4%) were males, six (85.7%) had diabetes mellitus, and three (42.9%) had cardiovascular disease. All patients exhibited various forms of facial deformities under the computed tomography scanning, and two of them tested positive for Mucorales using the polymerase chain reaction (PCR) testing. Liposomal amphotericin B (LAmB) was prescribed to all cases, and none of them died until the end of the follow-up. On reviewing the literature, 191 cases were reported worldwide, of which 74.4% were males, 83.2% were from low-middle income countries, and 51.4% were aged 55 years old or below. Diabetes mellitus (79.1%), chronic hypertension (30%), and renal disease/failure (13.6%) were the most common medical comorbidities, while steroids (64.5%) were the most frequently prescribed medication for COVID-19, followed by Remdesivir (18.2%), antibiotics (12.7%), and Tocilizumab (5.5%).

CONCLUSIONS

As the majority of the included studies were observational studies, the obtained evidence needs to be interpreted carefully. Diabetes, steroids, and Remdesivir were not associated with increased mortality risk, thus confirming that steroids used to manage severe and critical COVID-19 patients should not be discontinued. Lung involvement, bilateral manifestation, and Rhizopus isolation were associated with increased mortality risk, thus confirming that proactive screening is imperative, especially for critically ill patients. Finally, surgical management and antimycotic medications, e.g., amphotericin B and posaconazole, were associated with decreased mortality risk, thus confirming their effectiveness.

COVID19 associated mucormycosis: Is GRP78 a possible link?

This review aimed to study molecular mechanisms for high incidence of life-threatening mucormycosis infection in COVID19 cases during second wave of SARS CoV2 pandemic in India. Hyperglycaemia, impaired immunity, acidosis, raised ferritin, glucocorticoid therapy, and COVID19 specific other factors have been implicated in pathogenesis of COVID19 associated mucormycosis (CAMM). Endoplasmic reticulum chaperone 'Glucose Related Protein 78' (GRP78), also involved in SARS CoV2 entry, is the host receptor for invasion by Mucorales. GRP78 is over-expressed by SARS CoV2, hyperglycaemia and ferritin. Delta variant of SARS CoV2 and indiscriminate use of steroids were distinguishing features of second wave and appear to upregulate GRP78 through intricate interplay between internal and external milieu. Common invasive fungal infections like candidiasis and aspergillosis, not utilizing GRP78 as receptor, were inconspicuous. Further molecular research to unravel mechanisms involved in the pathogenesis of CAMM shall effectively complement existing strategies for its prevention and treatment.

Rhino-Orbital Mucormycosis in a COVID-19 Patient Co-Infected With Klebsiella Pneumoniae

We present a case of a 34-year-old male with coronavirus disease 2019 (COVID-19) and uncontrolled blood sugar with right orbital cellulitis and right ethmoidal and maxillary sinusitis. Histopathology of a middle meatus tissue biopsy collected via diagnostic nasal endoscopy (DNE) revealed the presence of Mucor and Klebsiella pneumoniae (K. pneumoniae). After the administration of intravenous (IV) insulin, cefoperazone-sulbactam, and posaconazole (due to the non-availability of amphotericin B), he underwent surgical debridement and functional endoscopic sinus surgery (FESS). After being on antibiotics and antifungals for two weeks post-surgery, the patient had a favorable outcome and further tests revealed improved blood counts and inflammatory markers.

Current Understanding in the Pathophysiology of SARS-CoV-2-Associated Rhino-Orbito-Cerebral Mucormycosis: A Comprehensive Review

AIM

Recently, with the second wave of COVID-19, the Indian subcontinent has witnessed a dramatic rise in mucormycosis infection in patients recovered from COVID-19. This association has been documented in various case reports/case series and institutional experiences, and the mortality associated with this fungal infection is emerging as a cause of concern. The aim of the present paper is to provide a scientific overview on the pathogenesis of mucormycosis in COVID-19 beyond the conventional understanding of the disease process, which may not otherwise explain the increased incidence of mucormycosis in SARS-CoV-2.

METHODOLOGY

This paper is structured as a narrative review of the published literature on the pathogenesis of COVID-19 which contributes to the development of mucormycosis. Apart from the acknowledged role of ketoacidosis, high blood sugar, and iron metabolism in the pathogenesis of mucormycosis, other factors involved in pathophysiology of COVID-19 which might alter or enhance the mucormycosis infection such as (1) the role of ferritin, (2) high serum iron, (3) free radical-induced endothelitis, (4) hepcidin activation, (5) upregulation of glucose receptor protein (GRP78) are discussed in the pathophysiology of COVID-19-associated mucormycosis.

CONCLUSION

A new proposal for the pathogenesis based on the ferritin, viral mimicry of hepcidin and GRP78-CotH3 interaction, which clearly explains the surge in mucormycosis in SARS-CoV-2 infection, has been explained.

COVID-19 associated Mucormycosis (CAM): risk factors and mechanisms of disease

The severe surge of COVID-19 cases in the Indian subcontinent in early 2021 was marked by an unusually high number of cases of COVID-19 associated mucormycosis (CAM) reported during this period. This is significantly higher than predicted based on available data about prevalence or risk factors for this condition. This may be from an unusual alignment of multiple risk factors for this condition. There is high background prevalence of mucormycosis in India probably from high prevalence of risk factors, including undiagnosed or poorly controlled diabetes. COVID-19 induced immune dysregulation, and immune suppression from steroid therapy increase the risk. The role of environmental exposure is unclear. System factors like lack of access to healthcare during a pandemic may result in delayed diagnosis or suboptimal management with potentially poor outcomes. This is a review of currently identified risk factors and pathogenesis of CAM in a pandemic surge.

Epidemiology and Antifungal Susceptibilities of Mucoralean Fungi in Clinical Samples from the United States

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.

Nasal Microbiota Imbalance as a Contributory Link in the Emergence of COVID-19 Associated Mucormycosis

COVID-19 associated mucormycosis (CAM) is being reported at an elevated frequency and has been declared an ongoing epidemic in India. A huge diabetic population, inappropriate corticosteroid usage and environmental mucoralean spore count, along with COVID-19 associated glycemic imbalance, hypoxemia, increased iron levels, vascular endothelial injury, as well as the immunosuppressive impact are being considered as important risk factors for CAM. The present viewpoint aims to discuss the plausible role of another important facet, the nasal microbiota imbalance, in the emergence of mucormycosis under the prevailing COVID-19 pandemic conditions.

Survival of an immuno-competent patient from splenic and gastric mucormycosis-case report and review of the literature

Mucormycosis is a life-threatening disease responsible for a high mortality rate. The disease usually affects immuno-compromised patients. While all sites might be involved, gastrointestinal disease is rare, occurring for 5% to 13% of all mucormycosis cases. We report herein the fifth case of splenic and gastric mucormycosis revealed after gastric perforation and the first case occurring among an immuno-competent patient, and we review all reported cases of splenic mucormycosis by searching PubMed publications till October 2020. The literature search yielded 27 cases of splenic mucormycosis including our case. The majority of the cases had underlying immuno-compromised conditions, except for 6 cases, including ours. A male predominance was noted (22 cases). Involvement of the spleen and the stomach was rare, occurring among four immuno-compromised patients. The outcome was death in more than half of the cases. Splenic and gastric mucormycosis is a rare disease. The diagnosis of splenic mucormycosis should be considered in front of splenic lesions suggesting abscess or infarction, especially among immuno-compromised patients.

Nasal Mucormycosis: Our experience with 24 cases

&lt;b&gt;Background:&lt;/b&gt; Mucormycosis is a rare fungal infection affecting people with impaired immunity. The aim of this study is to shed light on the epidemiology, incidence, and outcome of patients with mucormycosis hospitalized at a tertiary care center in Pondicherry. &lt;br&gt;&lt;b&gt;Methods:&lt;/b&gt; We conducted a retrospective chart review between January 2008 and January 2018. All patients with proven or probable mucormycosis were included. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; A total of 24 patients were included. Their median age was 49 years and the majority were males. Comorbidities included mainly hematologic malignancy and diabetes mellitus. A liposomal amphotericin B formulation alone or in combination with other antifungals was used as a first line agent in all patients. &lt;br&gt;&lt;b&gt;Conclusion:&lt;/b&gt; The incidence of mucormycosis has significantly increased over the past 10 years at our institution, most likely due to increased risk factors.

The importance of mucormycosis infections on example of Rhino Orbital Cerebral Mucormycosis

Mucormycosis is an angioinvasive fungal infection, characterized by high morbidity and mortality and is strongly dependent on the patient’s general health condition, initial site of infection, and the time from diagnosis to treatment commencement. It has been reported that the occurrence of mucormycosis has increased rapidly, also among immunocompetent patients. Moreover, the rise in number is expected to continue. Among all clinical manifestations of mucormycosis, the rhino-orbital-cerebral type (ROCM) is the most common. The aim of this article is to increase the awareness of mucoral infections, especially ROCM, and to describe its first symptoms, as proper treatment requires immediate surgical and medical intervention.

Epidemiology of Mucormycosis in India

Mucormycosis is an angioinvasive disease caused by saprophytic fungi of the order Mucorales. The exact incidence of mucormycosis in India is unknown due to the lack of population-based studies. The estimated prevalence of mucormycosis is around 70 times higher in India than that in global data. Diabetes mellitus is the most common risk factor, followed by haematological malignancy and solid-organ transplant. Patients with postpulmonary tuberculosis and chronic kidney disease are at additional risk of developing mucormycosis in this country. Trauma is a risk factor for cutaneous mucormycosis. Isolated renal mucormycosis in an immunocompetent host is a unique entity in India. Though Rhizopus arrhizus is the most common etiological agent of mucormycosis in this country, infections due to Rhizopus microsporus, Rhizopus homothallicus, and Apophysomyces variabilis are rising. Occasionally, Saksenaea erythrospora, Mucor irregularis, and Thamnostylum lucknowense are isolated. Though awareness of the disease has increased among treating physicians, disease-associated morbidity and mortality are still high, as patients seek medical attention late in the disease process and given the low affordability for therapy. In conclusion, the rise in the number of cases, the emergence of new risk factors and causative agents, and the challenges in managing the disease are important concerns with mucormycosis in India.

One Health aspects & priority roadmap for fungal diseases : A mini-review

Fungal diseases have not been taken seriously in public health agendas as well as research priorities, despite of globally causing an estimated two million deaths every year, and the emergence of many troublesome fungal pathogens like Candida auris, azole resistant Aspergillus fumigatus, terbinafine and azole resistant dermatophytes, and zoonotic sporotrichosis in humans. Fungi are also responsible for huge losses of agricultural products and stored crops as well as recent massive and unexpected mortality in animals caused by white-nose syndrome in the bats and Chytridiomycosis in amphibians. This review aims to underscore the need for collaborative, multisectoral, and trans-disciplinary approach to include the One Health approach as an essential component of surveillance, prevention, and control of globally emerging fungal diseases. Rigorous evidence based surveillance of the environment as well as strengthening rapid and quality diagnosis of fungal diseases can save millions of lives and reduce significant morbidity.

Diabetes and rhino-orbito-cerebral mucormycosis - A deadly duo

Background

Rhino-orbito-cerebral mucormycosis(ROCM) is an uncommon yet potentially fatal fungal infection predominantly seen in immunocompromised individuals. However, there is very limited data available from India regarding outcome of patients with ROCM and diabetes mellitus.

Objective

To ascertain clinical parameters and factors in the final outcome of patients with diabetes mellitus and ROCM.

Materials and Methods

This series included retrospective analysis of medical records of 91 patients with diabetes mellitus who were diagnosed with ROCM from january 2007 to june 2019 at a tertiary care hospital in Punjab.

Results

The mean age of patients was 52.6 years (range 18-82 years), with men constituting the majority (71.4 %). Ophthalmoplegia was the most frequent presenting feature seen in 77 % of patients followed by proptosis (71 %). Intracranial involvement was seen in 20 % of the patients and cavernous sinus thrombosis was diagnosed in 9(10 %) patients. Out of 91 patients, 81 patients were subjected to appropriate surgical procedure depending upon site and extent of involvement by mucorales. A total of 53 (58.2 %) patients survived while 38(41.8 %) patients succumbed. Delay in presentation to hospital, intracranial extension and loss of vision at presentation adversely affected the outcome (p < 0.05). Aggressive surgical management in the form of multiple debridements was superior to single debridement (p < 0.05). Diabetic ketoacidosis did not significantly affect the outcome (p = 0.359).

Conclusions

ROCM in patients with diabetes mellitus, is a rapidly progressive disease with a high fatality rate and grave outcome unless diagnosed early and managed aggressively.

Thoracic mucormycosis in immunocompetent patients

BACKGROUND

Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes.

METHODS

We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm.

RESULTS

The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment.

CONCLUSION

Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

Fatal renal mucormycosis with Apophysomyces elegans in an apparently healthy male

Mucor is an angioinvasive fungus that was reported mainly in immunocompromised patients. It usually presents as rhino-orbital, pulmonary, gastrointestinal, and disseminated disease. Isolated renal mucormycosis is an extremely rare infection in immunocompetent patients and is associated with high fatality rate. Early diagnosis, prompt antifungal treatment, and surgery give the patient the best chance for cure and survival. We describe herein a case of renal zygomycosis caused by Apophysomyces elegans (A. elegans) in an immunocompetent host. To the best of our knowledge, this is the first case of renal A. elegans to be reported from Qatar and the Middle East.

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.

Developments in identifying and managing mucormycosis in hematologic cancer patients

INTRODUCTION

Mucormycoses represent a rare but very aggressive class of mold infections occurring in patients with hematological malignancies (HMs). In the past, patients at high risk of invasive mucomycosis (IM) were those affected by acute myeloid leukemia but over the last ten years the prophylaxis with a very effective mold-active drug, such as posaconazole, has completely modified the epidemiology. In fact, IM is now observed more frequently in patients with lymphoproliferative disorders who do not receive antifungal prophylaxis.

AREAS COVERED

The attention was focused on the epidemiology, diagnosis, prophylaxis and treatment of IM in HMs. Authors excluded pediatric patients considering the different epidemiology and differences in treatment given the limitation of the use of azoles in the pediatric field. A systematic literature review was performed using PubMed database listings between February 2014 and February 2020 using the following MeSH terms: leukemia, hematological malignancies, stem cell transplantation, mucormycosis, molds, prophilaxis, treatment.

EXPERT OPINION

The epidemiology of mucormycosis in HMs is changing in the last years. The availability of drugs more effective than in the past against this infection has reduced the mortality; however, a timely diagnosis remains a relevant problem potentially influencing the outcome of hematologic patients with IM.

Understanding Mucormycoses in the Age of "omics"

Mucormycoses are deadly invasive infections caused by several fungal species belonging to the subphylum Mucoromycotina, order Mucorales. Hallmarks of disease progression include angioinvasion and tissue necrosis that aid in fungal dissemination through the blood stream, causing deeper infections and resulting in poor penetration of antifungal agents to the site of infection. In the absence of surgical removal of the infected focus, antifungal therapy alone is rarely curative. Even when surgical debridement is combined with high-dose antifungal therapy, the mortality associated with mucormycoses is >50%. The unacceptably high mortality rate, limited options for therapy and the extreme morbidity of highly disfiguring surgical therapy provide a clear mandate to understand the molecular mechanisms that govern pathogenesis with the hopes of developing alternative strategies to treat and prevent mucormycoses. In the absence of robust forward and reverse genetic systems available for this taxonomic group of fungi, unbiased next generation sequence (NGS)-based approaches have provided much needed insights into our understanding of many aspects of Mucormycoses, including genome structure, drug resistance, diagnostic development, and fungus-host interactions. Here, we will discuss the specific contributions that NGS-based approaches have made to the field and discuss open questions that can be addressed using similar approaches.

Comparative immunopathogenesis in a murine model of inhalative infection with the mucormycetes Lichtheimia corymbifera and Rhizopus arrhizus

Pathogenic mucormycetes induce diseases with considerable morbidity and mortality in immunocompromised patients. Virulence data comparing different Mucorales species and various underlying risk factors are limited. We therefore compared the pathogenesis of inhalative infection by Rhizopus (R.) arrhizus and Lichtheimia (L.) corymbifera in murine models for predominant risk factors for onset of infection. Mice with diabetes or treated with cyclophosphamide or cortisone acetate were challenged via the intranasal route with an isolate of R. arrhizus or L. corymbifera, respectively. Clinical, immunological and inflammation parameters as well as efficacy of posaconazole prophylaxis were monitored over 14 days. Whereas immunocompetent mice showed no clinical symptoms after mucormycete infection, mice treated with either cyclophosphamide (CP) or cortisone acetate (CA) were highly susceptible. Animals infected with the isolate of R. arrhizus showed prolonged survival and lower mortality, compared to those exposed to the L. corymbifera isolate. This lower virulence of R. arrhizus was risk factor-dependent, since diabetic mice died only after infection with Rhizopus, whereas all Lichtheimia-infected diabetic animals survived. Under posaconazole prophylaxis, both mucormycetes were able to establish breakthrough infections in CA- and CP-treated mice, but the course of infection was significantly delayed. Detailed analysis revealed that susceptibility of CA- and CP-treated mice could not be mimicked by exclusive lack or downmodulation of neutrophils, platelets or complement, but can be supposed to be the consequence of a broad immunosuppressive effect induced by the drugs. Both Lichtheimia corymbifera and Rhizopus arrhizus induce invasive mycoses in immunocompromised hosts after inhalative infection. Key parameters such as virulence and immunopathogenesis vary strongly according to fungal species and underlying risk group. Selected neutropenia is no sufficient risk factor for onset of inhalative mucormycosis.

First Case of Rhinocerebral Mucormycosis Caused by Lichtheimia ornata, with a Review of Lichtheimia Infections

BACKGROUND

Lichtheimia species are emerging opportunistic fungal pathogens in the Mucorales, causing serious skin and respiratory infections in immunocompromised patients. Established agents are Lichtheimia corymbifera and L. ramosa, while L. ornata is a novel agent. Available data on a species-specific analysis of Lichtheimia infections are limited.

METHODS

The first case of a fatal rhino-orbital-cerebral infection in a hematopoietic stem cell transplantation recipient caused by L. ornata is reported; the agent was identified by sequencing the ITS ribosomal region. We reviewed the literature on mucormycosis due to Lichtheimia species between 2009 and 2018, with an analysis of risk factors and epidemiological and clinical data.

RESULTS

In addition to our Lichtheimia ornata case, 44 cases of human Lichtheimia were analyzed. Lichtheimia predominated in Europe (68.2%), followed by Asia (16%), and Africa (9%). The most common underlying condition was hematological malignancy (36.3%), followed by trauma/major surgery (27.3%), while diabetes mellitus was rare (11.4%). Site of infection was mostly skin and soft tissues (45.5%) and lung (25%), while relatively few cases were disseminated (13.6%) or rhinocerebral (11.4%). Mortality (36.4%) was mainly due to disseminated and rhinocerebral infections.

CONCLUSION

In contrast to Rhizopus, the most common agent of mucormycosis recorded in patients with diabetes mellitus, Lichtheimia infections were primarily associated with hematological malignancies and major skin barrier damage. Given the fact that classical rhinocerebral mucormycosis remains difficult to treat, independent of causative species, timely application of amphotericin B accessory to debridement may be required for patient survival.

Case of mucormycosis of mandible after self-extraction of teeth incidentally detected to have chronic granulomatous disease: Case report and literature review

Mucormycosis isolated to the mandible is a rare presentation occurring generally after dental procedures. The case we report presented with discharging sinuses over facial region with radiological appearance of isolated osteomyelitis of the mandible. The patient used to apply an addictive dental powder over his teeth leading to caries. Following this, he pulled out all his teeth, which probably led to his condition. Invasive sampling revealed mucormycosis. An extensive search for an underlying immunodeficiency revealed that the patient had chronic granulomatous disease (CGD). Despite a prolonged course of L-Amphotericin B, the patient continued to have intermittent pus discharge and surgical debridement and curettage was eventually required. The patient had a chronic course with minimal soft tissue involvement which initially did not raise the suspicion of mucormycosis. The main learning point is that an unusual invasive fungal infection in an otherwise healthy host can be the first symptom of an underlying primary immunodeficiency, like CGD. Invasive fungal infections in patients with CGD often have an indolent course.

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Mucormycosis isolated to the mandible is a rare presentation, occurring generally after dental procedures.

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Self-extraction of teeth as in our patient can result in isolated mucormycosis of the mandible.

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Isolated mucormycosis of the mandible can be a presenting symptom of chronic granulomatous disease.

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Combination of medical and surgical treatment is usually needed in mandibular mucormycosis.

Traumatic Mucormycosis of Auricular Cartilage in an Iranian Diabetic Patient

Mucormycosis is an uncommon and acute fungal infection, with high morbidity and mortality. Traumatic mucormycosis mainly occurs in military conflicts, civilian trauma, and vehicle accidents. Hurricanes, tornadoes, floods, and tsunamis also play a major role in causing mucormycosis by inoculation. Herein, we presented a case of trauma-related mucormycosis in a 70-year-old diabetic male. He referred to a specialty clinic due to the auricular swelling after having fallen and having a major trauma in his ear. Pathologic examination of necrotic cartilage revealed broad ribbon like aseptate hyphae. Antifungal therapy with amphotericin B deoxycholate (1.5 mg/kg/day) was administered for 6 weeks as an initial therapy, and the patient was discharged with a regimen of posaconazole oral solution (400 mg PO bid with meals) for 8 weeks. He followed up for one year and there was no recurrence of the infection. In conclusion, traumatic mucormycosis is a rare but potentially life-threatening fungal infection. Early diagnosis and surgical excision are essential regarding the management of this critical condition. Knowing the underlying diseases is preferable to early diagnosis and timely initiation of antifungal therapy in order to improve survival rates.

Rapid and Low-Cost Culture-Based Method for Diagnosis of Mucormycosis Using a Mouse Model

Prompt and targeted antifungal treatment has a positive impact on the clinical outcome of mucormycosis; however, current diagnostic tools used in histopathology laboratories often fail to provide rapid results. Rapid culture-based strategies for early diagnosis of Mucorales infections, which may influence treatment decisions, are urgently needed. Herein, we evaluated a microculture assay for the early diagnosis of mucormycosis in an immunocompetent murine model of disseminated infection, by comparing it with traditional diagnostic methods. The assay specificity was assessed using blood (n = 90) and tissue (n = 90) specimens obtained from mice infected with Rhizopus arrhizus using different inoculum sizes [1 × 10⁴, 1 × 10⁵, and 1 × 10⁶ colony forming units (CFUs)/mouse] and blood (n = 15) and tissue specimens (n = 15) from uninfected mice. Surprisingly, 26 of 90 (28.9%) blood samples revealed positive results by microculture, whereas all blood samples were negative when assayed by conventional culture. The overall positive conventional culture rate for the mouse tissue (kidney) samples was 31.1% (28/90). The calculated sensitivity for kidney microculture was 98.8% [95% confidence interval (CI) 96.6–100], with an assay specificity of 100%. Hence, the microculture assay may be useful for rapid culturing and diagnosis of mucormycosis caused by R. arrhizus directly in blood and tissue samples. Hence, this method may allow for the timely administration of an appropriate treatment.

Successful treatment of rhino-facial mucormycosis in a diabetic patient

Mucormycosis is a rapidly progressing and lethal infection caused by fungi of the order mucorales. The disease occurs mostly in patients with uncontrolled diabetes or other predisposing systemic conditions. We report a case of rhinofacial mucormycosis in a 39-year-old diabetic patient. The diagnosis was established by clinical examination, imaging, and confirmed by mycological examination. Rhizopus arrhizus was isolated. He was successfully treated with amphotericin B, surgical resection, diabetes control and hyperbaric oxygen therapy.

Outbreaks of Mucorales and the Species Involved

The order Mucorales is an ancient group of fungi classified in the subphylum Mucoromycotina. Mucorales are mainly fast-growing saprotrophs that belong to the first colonizers of diverse organic materials and represent a permanent part of the human environment. Several species are able to cause human infections (mucormycoses) predominantly in patients with impaired immune system, diabetes, or deep trauma. In this review, we compiled 32 reports on community- and hospital-acquired outbreaks caused by Mucorales. The most common source of mucoralean outbreaks was contaminated medical devices that are responsible for 40.7% of the outbreaks followed by contaminated air (31.3%), traumatic inoculation of soil or foreign bodies (9.4%), and the contact (6.2%) or the ingestion (6.2%) of contaminated plant material. The most prevalent species were Rhizopus arrhizus and R. microsporus causing 57% of the outbreaks. The genus Rhizomucor was dominating in outbreaks related to contaminated air while outbreaks of Lichtheimia species and Mucor circinelloides were transmitted by direct contact. Outbreaks with the involvement of several species are reported. Subtyping of strains revealed clonality in two outbreaks and no close relation in two other outbreaks. Based on the existing data, outbreaks of Mucorales can be caused by heterogeneous sources consisting of different strains or different species. Person-to-person transmission cannot be excluded because Mucorales can sporulate on wounds. For a better understanding and prevention of outbreaks, we need to increase our knowledge on the physiology, ecology, and population structure of outbreak causing species and more subtyping data.

Antagonistic Interaction of Staphylococcus aureus and Staphylococcus epidermidis with Rhizopus arrhizus Mediated by Phenol Soluble Modulins and Organic Acids

Rhizopus arrhizus (R. arrhizus) is a common causative agent of mucormycosis that usually enters the human body through the respiratory tract and skin. Both these sites harbor staphylococci as a part of the normal microflora, indicating the possibility of interspecies interactions. We aimed to elucidate this interaction and identify the molecular mechanisms involved. Both Staphylococcus aureus (S. aureus) and Staphylococcus epidermidis (S. epidermidis) substantially hindered R. arrhizus radial growth, spore germination, and liquid culture biomass. Secreted components in the stationary-phase supernatant were responsible for this activity. The active components, based on molecular weight-based fractionation, mass spectrometry, and ion exclusion chromatography, were identified as a truncated version of phenol soluble modulin α2 (Δ1Δ2PSMα2) and PSMα3 in S. aureus, PSMδ in S. epidermidis, and organic acids in both the species. Exposure to the phenol soluble modulins (PSMs) extensively damaged the fungal spores and pre-existing hyphae, leading to bleb formation, shriveling, hyphal shrinkage, and cell distortion.

Emerging Fungal Infections: New Patients, New Patterns, and New Pathogens

The landscape of clinical mycology is constantly changing. New therapies for malignant and autoimmune diseases have led to new risk factors for unusual mycoses. Invasive candidiasis is increasingly caused by non-albicans Candida spp., including C. auris, a multidrug-resistant yeast with the potential for nosocomial transmission that has rapidly spread globally. The use of mould-active antifungal prophylaxis in patients with cancer or transplantation has decreased the incidence of invasive fungal disease, but shifted the balance of mould disease in these patients to those from non-fumigatus Aspergillus species, Mucorales, and Scedosporium/Lomentospora spp. The agricultural application of triazole pesticides has driven an emergence of azole-resistant A. fumigatus in environmental and clinical isolates. The widespread use of topical antifungals with corticosteroids in India has resulted in Trichophyton mentagrophytes causing recalcitrant dermatophytosis. New dimorphic fungal pathogens have emerged, including Emergomyces, which cause disseminated mycoses globally, primarily in HIV infected patients, and Blastomyceshelicus and B. percursus, causes of atypical blastomycosis in western parts of North America and in Africa, respectively. In North America, regions of geographic risk for coccidioidomycosis, histoplasmosis, and blastomycosis have expanded, possibly related to climate change. In Brazil, zoonotic sporotrichosis caused by Sporothrix brasiliensis has emerged as an important disease of felines and people.

Anti-CotH3 antibodies protect mice from mucormycosis by prevention of invasion and augmenting opsonophagocytosis

Mucorales are fungal pathogens that cause mucormycosis, a lethal angioinvasive disease. Previously, we demonstrated that Rhizopus, the most common cause of mucormycosis, invades endothelial cells by binding of its CotH proteins to the host receptor GRP78. Loss of CotH3 renders the fungus noninvasive and attenuates Rhizopus virulence in mice. Here, we demonstrate that polyclonal antibodies raised against peptides of CotH3 protected diabetic ketoacidotic (DKA) and neutropenic mice from mucormycosis compared to mice treated with control preimmune serum. Passive immunization with anti-CotH3 antibodies enhanced neutrophil inlfux and triggered Fc receptor-mediated enhanced opsonophagocytosis killing of Rhizopus delemar. Monoclonal antibodies raised against the CotH3 peptide also protected immunosuppressed mice from mucormycosis caused by R. delemar and other Mucorales and acted synergistically with antifungal drugs in protecting DKA mice from R. delemar infection. These data identify anti-CotH3 antibodies as a promising adjunctive immunotherapeutic option against a deadly disease that often poses a therapeutic challenge.

A prospective multicenter study on mucormycosis in India: Epidemiology, diagnosis, and treatment

Mucormycosis due to Mucorales is reported at large numbers in uncontrolled diabetics across India, but systematic multicenter epidemiological study has not been published yet. The present prospective study was conducted at four major tertiary care centers of India (two in north and two in south India) during 2013-2015 to compare the epidemiology, treatment strategies and outcome of mucormycosis between the two regions. Molecular techniques were employed to confirm the identity of the isolates or to identify the agent in biopsy samples. A total of 388 proven/probable mucormycosis cases were reported during the study period with overall mortality at 46.7%. Uncontrolled diabetes (n = 172, 56.8%) and trauma (n = 31, 10.2%) were the common risk factors. Overall, Rhizopus arrhizus (n = 124, 51.9%) was the predominant agent identified, followed by Rhizopus microsporus (n = 30, 12.6%), Apophysomyces variabilis (n = 22, 9.2%) and Rhizopus homothallicus (n = 6, 2.5%). On multivariate analysis, the mortality was significantly associated with gastrointestinal (OR: 18.70, P = .005) and pulmonary infections (OR: 3.03, P = .015). While comparing the two regions, majority (82.7%) cases were recorded from north India; uncontrolled diabetes (n = 157, P = .0001) and post-tubercular mucormycosis (n = 21, P = .006) were significantly associated with north Indian cases. No significant difference was noted among the species of Mucorales identified and treatment strategies between the two regions. The mortality rate was significantly higher in north Indian patients (50.5%) compared to 32.1% in south India (P = .016). The study highlights higher number of mucormycosis cases in uncontrolled diabetics of north India and emergence of R. microsporus and R. homothallicus across India causing the disease.

An aero mycological analysis of Mucormycetes in indoor and outdoor environments of northern India

Mucormycosis is an angio-invasive infection, predominantly acquired by inhalation of sporangiospores from the environment. However, the burden of Mucormycetes sporangiospores in the air is not well studied. We aimed to estimate the burden of Mucormycetes spores in the outdoor and indoor (hospital) environment across different seasons in north India. A total of 380 air samples from outdoor (n = 180) and indoor (n = 200) environment were included in the study. Air samples were suctioned using air sampler (100 l/min) and cultured on Dichloran Rose Bengal Chloramphenicol (DRBC) with benomyl for selective isolation of Mucormycetes. The isolates were identified by phenotypic and genotypic methods. The mean spore count (±SD) of Mucormycetes (cfu/m3) in outdoor samples varied from 0.73 (±0.96) to 8.60 (±5.70) across different seasons. In hospital, the mean spore count varied from 0.68 (±1.07) to 1.12 (±1.07) and 0.88 (±1.01) to 1.72 (±2.17) for air-conditioned wards and non-air-conditioned wards, respectively. Rhizopus arrhizus was the predominant agent isolated from both indoor and outdoor environment followed by Cunninghamella species. We also report a single isolate of the rare mucormycete agent, Apophysomyces variabilis from outdoor environment. The present study highlights the presence of low spore burden of Mucormycetes in outdoor and hospital settings in north India. This study also reports the first isolation of A. variabilis from air samples in the Indian subcontinent.

Mucormycosis-A clinicoepidemiological review of cases over 10 years

BACKGROUND

Limited data exist for epidemiology and outcomes of various agents causing mucormycosis in various clinical settings from developing countries like India.

OBJECTIVES

To study the epidemiology and outcomes of various agents causing mucormycosis in different clinical settings in a tertiary care hospital from South India.

PATIENTS AND METHODS

We reviewed details of 184 consecutive patients with culture-proven mucormycosis with consistent clinical syndrome and supporting features from September 2005 to September 2015.

RESULTS

The mean age of patients was 50.42 years; 70.97% were male. Unlike developed countries, R microsporus (29/184; 15.7%) and Apophysomyces elegans (20/184; 10.8%) also evolved as important pathogens in addition to R arrhizus in our setting. Paranasal sinuses (136/184; 73.9%) followed by musculoskeletal system (28/184; 15.2%) were the common areas of involvement. Apophysomyces elegans typically produced skin and musculoskeletal disease in immune-competent individuals with trauma (12/20; 60%) and caused significantly lower mortality (P = 0.03). R microsporus was more common in patients with haematological conditions (25% vs 15.7%) and was less frequently a cause for sinusitis than R arrhizus (27.58% vs 10.9%). The overall mortality was 30.97%. Combination therapy with surgery and antifungals offered the best chance for cure.

CONCLUSIONS

Agents causing mucormycosis may have unique clinical and epidemiological characteristics.

Epidemiology and clinical outcomes of invasive mould infections in Indian intensive care units (FISF study)

BACKGROUND AND AIM

Due to limited data on invasive mould infections (IMIs) in the intensive care units (ICUs) of developing countries, we ascertain epidemiology and management of IMIs at 11 ICUs across India.

METHODS

Consecutive patients with proven or probable/putative IMIs were enrolled during the study period. Subjects were categorized into classical (neutropenia, malignancy, transplant recipients on immunosuppression) and non-classical (chronic obstructive pulmonary disease, diabetes, liver disease and glucocorticoids) risk groups. We analyzed the demographic, laboratory variables and outcomes of these patients.

RESULTS

398 patients with IMIs (96 proven, 302 probable) were identified, amounting to a prevalence of 9.5 cases/1000 ICU admissions. The mean ± SD age of the participants was 45.6 ± 21.9 years. The mean ± SD APACHE II score was 14.3 ± 11.4. The IMIs were diagnosed at a median of 4 days after ICU admission. There were 145 and 253 subjects with classical and non-classical risk groups, respectively. Although Aspergillus spp. were the commonest (82.1%) isolates, Mucorales were detected in 14.4% subjects. A high APACHE II score and IMI due to mucormycosis were significant predictors of mortality.

CONCLUSIONS

The study highlights the distinct epidemiology of IMIs in India ICUs with high burden, new susceptible patient groups and considerable number of non-Aspergillus mould infections. [clinicaltrials.gov: NCT02683642].

Managing mucormycosis in a resource-limited setting: challenges and possible solutions

Mucormycosis is a potentially fatal fungal infection with high prevalence in poor-resource settings. Besides being an extremely expensive disease to treat, the challenges range from lack of experienced mycologists or mycology department to knowledge and availability of treatment regimes.

Mucormycotic Osteomyelitis Involving the Maxilla: A Rare Case Report and Review of the Literature

Osteomyelitis is an inflammatory process of bone and marrow contents. These changes in bone are primarily seen in soft tissue followed by calcified tissue. It is an opportunistic infection due to the complication of some other conditions rendering the host susceptible to disease. Consequences of this infection range from draining tract to malignant transformation. Various etiological factors are involved in origin of the disease; among them, fungal origin is rare. Specific feature in fungal osteomyelitis is the involvement of maxillary sinus with a complaint of sinusitis associated with diabetes mellitus. Here, we discuss a case of osteomyelitis with fungal infection involving the maxilla. The patient is under medication for the past five years due to diabetes.

Rhinocerebral Mucormycosis: A Prospective Analysis of an Effective Treatment Protocol

Objective:

The objective of this study was to prospectively analyze the effectiveness of a treatment protocol in patients diagnosed with rhinocerebral mucormycosis.

Materials and Methods:

This series included ten patients who reported with suspicious clinical signs of mucormycosis. The diagnosis was established by histopathology, and computed tomography imaging was used to assess the extent of spread. All patients were treated with immediate radical surgical debridement and antifungal chemotherapy with amphotericin B. Simultaneous correction of the underlying immunosuppressive condition was carried out. The primary outcome assessed was disease-free survival, and the patients were followed up for up to 6 months after discharge.

Results:

In this series, the cause of immunosuppression was uncontrolled diabetes mellitus in all patients. All the patients responded to the treatment protocol and were free of the disease up to 6 months of follow-up.

Conclusion:

Mucormycosis is an invasive and potentially fatal disease. Prognosis can be improved by early recognition and prompt treatment with aggressive resection, intravenous amphotericin B, and control of the patient's underlying systemic condition.