Epidemiology and Diagnosis of Mucormycosis: An Update

Mucormycosis: A Rare disease to Notifiable Disease

Mucormycosis is the third most frequent invasive mycosis, following candidiasis and aspergillosis. It is frequently neglected due to its rare occurrence; but recently attend the status of notifiable disease due to its higher incidence in both developed and developing nations. India has received global notice since its estimated instances were greater than the global estimated figures. Mucormycosis has several clinical manifestations, including rhino-orbital-cerebral (ROCM), pulmonary, gastrointestinal, cutaneous, renal, and diffuse Mucormycosis. ROCM is the most frequent clinical manifestation in India, although pulmonary mucormycosis is prevalent worldwide. This review also discusses host defenses, pre disposing risk factors and fungal virulence factors that impair host's ability to prevent fungus invasion and disease establishment. The diagnosis of the disease depends on clinical interventions, histological or microbiological procedures along with molecular methods to obtain timely results. But there are still unmet challenges for rapid diagnosis of the disease. Treatment of the disease is achieved by multimodal approaches such as reversal of underlying predisposing factors, rapid administration of antifungals in optimal doses and surgical procedures to remove infected tissues. Liposomal Amphotericin B, Posaconazole and Isavuconazoles are preferred as the first line of treatment procedures. clinical trials. Different studies have improved the existing drug and under clinical trials while several studies predicted the new potential targets as CotH and Ftr1 as shown in infection and in vitro models. Therefore, current scenario demands a multidisciplinary approach is needed to investigate the prevalence, pathogenesis which is highly important for the advancement of rapid diagnosis and effective treatment.

A Seminested PCR Method for the Diagnosis of Invasive Fungal Infections in Combat Injured

Background

Among combat injured, invasive fungal infections (IFIs) result in significant morbidity. Cultures and histopathology are the primary diagnostic methods for IFIs, but they have limitations. We previously evaluated a panfungal polymerase chain reaction assay, which was 83% sensitive and 99% specific for angioinvasive IFIs. Here, we evaluated 3 less resource-intensive seminested assays targeting clinically relevant fungi in the order Mucorales and genera Aspergillus and Fusarium.

Methods

Formalin-fixed paraffin-embedded tissue specimens from a multicenter trauma IFI cohort (2009-2014) were used. Cases were US military personnel injured in Afghanistan with histopathologic IFI evidence. Controls were patients with similar injury patterns and no laboratory IFI evidence (negative culture and histopathology). Seminested assays specific to Mucorales (V4/V5 regions of 18S rDNA), Aspergillus (mitochondrial tRNA), and Fusarium (internal transcribed spacer [ITS]/28A regions of DNA) were compared with a panfungal assay amplifying the internal transcribed spacer 2 region of rDNA and to histopathology.

Results

Specimens from 92 injury sites (62 subjects) were compared with control specimens from 117 injuries (101 subjects). We observed substantial agreement between the seminested and panfungal assays overall, especially for the order Mucorales. Moderate agreement was observed at the genus level for Aspergillus and Fusarium. When compared with histopathology, sensitivity and specificity of seminested assays were 67.4% and 96.6%, respectively (sensitivity increased to 91.7% when restricted to sites with angioinvasion).

Conclusions

Prior studies of seminested molecular diagnostics have focused on culture-negative samples from immunocompromised patients. Our findings underscore the utility of the seminested approach in diagnosing soft-tissue IFIs using formalin-fixed paraffin-embedded tissue samples, especially with angioinvasion.

Unveiling the menace: a thorough review of potential pandemic fungal disease

Fungal diseases have emerged as a significant global health threat, with the potential to cause widespread outbreaks and significant morbidity and mortality. Anticipating future pandemic fungal diseases is essential for effective preparedness and response strategies. This comprehensive literature review aims to provide a comprehensive analysis of the existing research on this topic. Through an extensive examination of scholarly articles, this review identifies potential fungal pathogens that have the potential to become pandemics in the future. It explores the factors contributing to the emergence and spread of these fungal diseases, including climate change, globalization, and antimicrobial resistance. The review also discusses the challenges in diagnosing and treating these diseases, including limited access to diagnostic tools and antifungal therapies. Furthermore, it examines the strategies and interventions that can be employed to mitigate the impact of future pandemic fungal diseases, such as improved surveillance systems, public health education, and research advancements. The findings of this literature review contribute to our understanding of the potential risks posed by fungal diseases and provide valuable insights for public health professionals and policymakers in effectively preparing for and responding to future pandemic outbreaks. Overall, this review emphasizes the importance of proactive measures and collaborative efforts to anticipate and mitigate the impact of future pandemic fungal diseases.

Human Vγ9Vδ2 T cells exhibit antifungal activity against Aspergillus fumigatus and other filamentous fungi

Invasive aspergillosis (IA) and mucormycosis are life-threatening diseases, especially among immunocompromised patients. Drug-resistant Aspergillus fumigatus strains have been isolated worldwide, which can pose a serious clinical problem. As IA mainly occurs in patients with compromised immune systems, the ideal therapeutic approach should aim to bolster the immune system. In this study, we focused on Vγ9Vδ2 T cells that exhibit immune effector functions and examined the possibility of harnessing this unconventional T cell subset as a novel therapeutic modality for IA. A potent antifungal effect was observed when A. fumigatus (Af293) hyphae were challenged by Vγ9Vδ2 T cells derived from peripheral blood. In addition, Vγ9Vδ2 T cells exhibited antifungal activity against hyphae of all Aspergillus spp., Cunninghamella bertholletiae, and Rhizopus microsporus but not against their conidia. Furthermore, Vγ9Vδ2 T cells also exhibited antifungal activity against azole-resistant A. fumigatus, indicating that Vγ9Vδ2 T cells could be used for treating drug-resistant A. fumigatus. The antifungal activity of Vγ9Vδ2 T cells depended on cell-to-cell contact with A. fumigatus hyphae, and degranulation characterized by CD107a mobilization seems essential for this activity against A. fumigatus. Vγ9Vδ2 T cells could be developed as a novel modality for treating IA or mucormycosis.

IMPORTANCE

Invasive aspergillosis (IA) and mucormycosis are often resistant to treatment with conventional antifungal agents and have a high mortality rate. Additionally, effective antifungal treatment is hindered by drug toxicity, given that both fungal and human cells are eukaryotic, and antifungal agents are also likely to act on human cells, resulting in adverse effects. Therefore, the development of novel therapeutic agents specifically targeting fungi is challenging. This study demonstrated the antifungal activity of Vγ9Vδ2 T cells against various Aspergillus spp. and several Mucorales in vitro and discussed the mechanism underlying their antifungal activity. We indicate that adoptive immunotherapy using Vγ9Vδ2 T cells may offer a new therapeutic approach to IA.

Molecular mechanisms that govern infection and antifungal resistance in Mucorales

SUMMARYThe World Health Organization has established a fungal priority pathogens list that includes species critical or highly important to human health. Among them is the order Mucorales, a fungal group comprising at least 39 species responsible for the life-threatening infection known as mucormycosis. Despite the continuous rise in cases and the poor prognosis due to innate resistance to most antifungal drugs used in the clinic, Mucorales has received limited attention, partly because of the difficulties in performing genetic manipulations. The COVID-19 pandemic has further escalated cases, with some patients experiencing the COVID-19-associated mucormycosis, highlighting the urgent need to increase knowledge about these fungi. This review addresses significant challenges in treating the disease, including delayed and poor diagnosis, the lack of accurate global incidence estimation, and the limited treatment options. Furthermore, it focuses on the most recent discoveries regarding the mechanisms and genes involved in the development of the disease, antifungal resistance, and the host defense response. Substantial advancements have been made in identifying key fungal genes responsible for invasion and tissue damage, host receptors exploited by the fungus to invade tissues, and mechanisms of antifungal resistance. This knowledge is expected to pave the way for the development of new antifungals to combat mucormycosis. In addition, we anticipate significant progress in characterizing Mucorales biology, particularly the mechanisms involved in pathogenesis and antifungal resistance, with the possibilities offered by CRISPR-Cas9 technology for genetic manipulation of the previously intractable Mucorales species.

H3K4 methylation regulates development, DNA repair, and virulence in Mucorales

Mucorales are basal fungi that opportunistically cause a potentially fatal infection known as mucormycosis (black fungus disease), which poses a significant threat to human health due to its high mortality rate and its recent association with SARS-CoV-2 infections. On the other hand, histone methylation is a regulatory mechanism with pleiotropic effects, including the virulence of several pathogenic fungi. However, the role of epigenetic changes at the histone level never has been studied in Mucorales. Here, we dissected the functional role of Set1, a histone methyltransferase that catalyzes the methylation of H3K4, which is associated with the activation of gene transcription and virulence. A comparative analysis of the Mucor lusitanicus genome (previously known as Mucor circinelloides f. lusitanicus) identified only one homolog of Set1 from Candida albicans and Saccharomyces cerevisiae that contains the typical SET domain. Knockout strains in the gene set1 lacked H3K4 monomethylation, dimethylation, and trimethylation enzymatic activities. These strains also showed a significant reduction in vegetative growth and sporulation. Additionally, set1 null strains were more sensitive to SDS, EMS, and UV light, indicating severe impairment in the repair process of the cell wall and DNA lesions and a correlation between Set1 and these processes. During pathogen-host interactions, strains lacking the set1 gene exhibited shortened polar growth within the phagosome and attenuated virulence both in vitro and in vivo. Our findings suggest that the histone methyltransferase Set1 coordinates several cell processes related to the pathogenesis of M. lusitanicus and may be an important target for future therapeutic strategies against mucormycosis.

Ophthalmic presentation and outcomes of rhino-orbito-cerebral mucormycosis during the COVID-19 pandemic: An 18-month follow-up report

PURPOSE

To investigate the long-term outcomes of COVID-19-associated rhino-orbito-cerebral mucormycosis (ROCM) patients.

METHODS

Retrospective, observational study including all COVID-19 patients who developed ROCM and were referred to our oculoplastic clinic.

RESULTS

Twenty-one patients with COVID-19-associated ROCM were included in this study. Twelve (57.1%) individuals were female with a mean age of 50.7±7.6 years (range 33-59), and nine (38.1%) were male with a mean age of 58.7±14.4 years (range 37-82). Corticosteroids were used in 85.7% of patients, and three patients received no systemic corticosteroids; 76.2% were diabetic and two of these developed new-onset diabetes mellitus (DM) after receiving corticosteroids during their treatment course. The average interval between COVID-19 and the development of ROCM in our subjects was 18.6 days (range 8-46 days). In our series of patients, decreasing vision, proptosis, and periorbital edema constituted the most prevalent presentation, seen in 52.4% of subjects. Endoscopic paranasal sinus debridement was performed a mean of 3.4 times in 95.2%, abscess drainage in one, and orbital exenteration in three (14.2%) patients. Orbital apex and bilateral paranasal sinus involvement were significantly associated with higher mortality, and the overall 18-month survival rate was 52.3%.

CONCLUSION

Based upon common factors among the COVID-19-associated ROCM patients, we presume that DM and drug-induced immunosuppression are two main factors, which may lead to a higher rate of ROCM infection in areas where fungal spores are more likely to be present, such as hospitals.

Airway necrosis and granulation tissue formation caused by Rhizopus oryzae leading to severe upper airway obstruction: a case report

Pulmonary Mucormycosis is a fatal infectious disease with high mortality rate. The occurrence of Mucormycosis is commonly related to the fungal virulence and the host's immunological defenses against pathogens. Mucormycosis infection and granulation tissue formation occurred in the upper airway was rarely reported. This patient was a 60-year-old male with diabetes mellitus, who was admitted to hospital due to progressive cough, sputum and dyspnea. High-resolution computed tomography (HRCT) and bronchoscopy revealed extensive tracheal mucosal necrosis, granulation tissue proliferation, and severe airway stenosis. The mucosal necrotic tissue was induced by the infection of Rhizopus Oryzae, confirmed by metagenomic next-generation sequencing (mNGS) in tissue biopsy. This patient was treated with the placement of a covered stent and local instillation of amphotericin B via bronchoscope. The tracheal mucosal necrosis was markedly alleviated, the symptoms of cough, shortness of breath, as well as exercise tolerance were significantly improved. The placement of airway stent and transbronchial microtube drip of amphotericin B could conduce to rapidly relieve the severe airway obstruction due to Mucormycosis infection.

Diagnosis of Mucormycosis Using Frozen Section, Histopathology, Culture, and Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) Techniques: A Comparative Study

Mucormycosis usually occurs in immunocompromised patients or those with uncontrolled diabetes. Along the third wave of SARS-CoV-2, an associated angioinvasive opportunistic infection with Mucor, a life-threatening fungal infection, was rampant and emerging. With an increase in the usage of steroids in the COVID scenario, the rate of mucormycosis did take a rapid and alarming increase in King Edward Memorial Hospital, Pune, India. Any delay in the diagnosis and management of the disease was life-threatening. The most conventional methods to diagnose mucormycosis are microbiological culture and histopathology of the tissue. The microbiological culture method plays an important role in the diagnosis of mucormycosis. However, the technique is labour-intensive, taking seven to eight days. Histopathology leads to false-negative reports if the tissue is not biopsied from representative sites. On the other hand, molecular methods are rapid, reliable, and applicable to different body samples, such as tissue, paraffin-embedded tissue blocks, plasma, and urine. We aimed to use a reverse transcriptase polymerase chain reaction (RT-PCR) method to detect Mucor in plasma samples. Due to a lack of availability of fresh samples, nucleic acid was extracted from the tissue sections of 69 cases diagnosed as Mucor by histopathology. These samples were subjected to RT-PCR using the MucorGenius kit (Pathonostics, Maastricht, Netherlands). A total of 57 tissue samples were sent for culture, and 49% of our cases were positive by culture and equally by RT-PCR. There was 80% sensitivity and 76% specificity between culture and PCR techniques. However, the use of blood/plasma for RT-PCR for early diagnosis of mucormycosis will be the method of choice.

The potential for rapid antigen testing for mucormycosis in the context of COVID-19

INTRODUCTION

Mucormycosis is a highly aggressive angio-invasive disease of humans caused by Mucorales fungi. Prior to the COVID-19 pandemic, mucormycosis was a rare mycosis typically seen in immunocompromised patients with hematological malignancies or in transplant recipients. During the second wave of the pandemic, there was a dramatic increase in the disease, especially in India where a unique set of circumstances led to large numbers of life-threatening and disfiguring rhino-orbital-cerebral mucormycosis (ROCM) infections.

AREAS COVERED

The review examines mucormycosis as a super-infection of COVID-19 patients, and the risk factors for COVID-19-associated mucormycosis (CAM) that drove the ROCM epidemic in India. The limitations of current diagnostic procedures are identified, and the measures needed to improve the speed and accuracy of detection discussed.

EXPERT OPINION

Despite increased awareness, global healthcare systems remain unprepared for further outbreaks of ROCM. Current diagnosis of the disease is slow and inaccurate, negatively impacting on patient survival. This is most evident in low- to middle-income countries which lack suitably equipped diagnostic facilities for rapid identification of the infecting pathogens. Rapid antigen testing using point-of-care lateral-flow assays could potentially have aided in the quick and accurate diagnosis of the disease, allowing earlier intervention with surgery and Mucorales-active antifungal drugs.

Trans-kingdom fungal pathogens infecting both plants and humans, and the problem of azole fungicide resistance

Azole antifungals are abundantly used in the environment and play an important role in managing fungal diseases in clinics. Due to the widespread use, azole resistance is an emerging global problem for all applications in several fungal species, including trans-kingdom pathogens, capable of infecting plants and humans. Azoles used in agriculture and clinics share the mode of action and facilitating cross-resistance development. The extensive use of azoles in the environment, e.g., for plant protection and wood preservation, contributes to the spread of resistant populations and challenges using these antifungals in medical treatments. The target of azoles is the cytochrome p450 lanosterol 14-α demethylase encoded by the CYP51 (called also as ERG11 in the case of yeasts) gene. Resistance mechanisms involve mainly the mutations in the coding region in the CYP51 gene, resulting in the inadequate binding of azoles to the encoded Cyp51 protein, or mutations in the promoter region causing overexpression of the protein. The World Health Organization (WHO) has issued the first fungal priority pathogens list (FPPL) to raise awareness of the risk of fungal infections and the increasingly rapid spread of antifungal resistance. Here, we review the main issues about the azole antifungal resistance of trans-kingdom pathogenic fungi with the ability to cause serious human infections and included in the WHO FPPL. Methods for the identification of these species and detection of resistance are summarized, highlighting the importance of these issues to apply the proper treatment.

Alternative in-vivo models of mucormycosis

Mucormycosis is still regarded a rare fungal infection, but the high incidences of COVID-associated cases in India and other countries have shown its potential threat to large patient cohorts. In addition, infections by these fast-growing fungi are often fatal and cause disfigurement, badly affecting patients' lives. In advancing our understanding of pathogenicity factors involved in this disease, to enhance the diagnostic toolset and to evaluate novel treatment regimes, animal models are indispensable. As ethical and practical considerations typically favor the use of alternative model systems, this review provides an overview of alternative animal models employed for mucormycosis and discusses advantages and limitations of the respective model.

Comparison Between Pre-COVID and Post-COVID Mucormycosis: A Systematic Review and Meta-analysis

Introduction

Mucormycosis has emerged as one of the most fatal complications arising due to COVID-19, though it has to be mentioned that the disease is capable of causing serious illness even on its own.

Objectives

Through this investigation, we would review the threat that mucormycosis poses, in terms of its prevalence and degree of severity both in the pre- and post-COVID world.

Materials and Methods

A comprehensive examination of the studies published in online databases turned up 207 papers, 103 of which had undergone in-depth analysis, using both inclusion and exclusion criteria, shortlisting 15 studies that were appropriate for reviewing.

Results

The incidence of mucormycosis was linked to coronavirus in 7 of the 15 studies that were chosen. The remaining eight studies had sufferers of various systemic diseases, like HIV/AIDS and diabetes.

Discussion

All the cases suffered diabetes mellitus. Regardless of the time period of the chosen article, corticosteroids and antifungal medications were administered to all patients. There were noticeable differences in terms of mortality, predisposing factors, and virulence between pre-COVID and post-COVID mucormycosis.

Summary and Conclusion

The prevalence of systemic conditions such as diabetes in cases of mucormycosis has remained the same even after the incidence of this pandemic, showing that the basic treatment modalities continue to remain the same irrespective of the damage that corona virus has caused to the sufferer, although mucormycosis arising due to COVID-19 differs from mucormycosis that was incident before the advent of the pandemic.

Outcome of Total Surgical Debridement of Covid Associated Rhino-Orbito-Cerebral Mucormycosis Based on a New Surgical Staging System: A Cohort Study

To propose a surgical staging system with management protocol for post-covid Rhino-orbito-cerebral mucormycosis (ROCM) with central skull base osteomyelitis. A prospective cohort study of a total of 193 post-covid ROCM patients was conducted between May 2021 and January 2022 at a tertiary care centre. Patients were assessed radiologically and staged from I to V. Follow up period was 16 months and the surgical outcome in terms of recurrent disease was assessed. A total of 193 patients (129 primary and 64 revision) were studied. Maxilla was found to be the epicenter of anterior disease (69.3%) and pterygoid wedge was noted to be the epicenter of posterior disease (85.6%). More than 65% of our patients, at the time of presentation, presented with involvement of the central skull base. Intracranial disease was noted in 13.9% of patients and the mortality rate was 6.2%. This staging system provides a systematic step-by-step protocol for the management of ROCM, with emphasis on meticulous disease clearance at the central skull base.

Rapid detection of Mucorales in human blood and urine samples by functionalized Heusler magnetic nanoparticle assisted customized loop-mediated isothermal amplification

Mucormycosis is a rare disease with scarce diagnostic methods for early intervention. Available strategies employing direct microscopy using calcofluor white-KOH, culture, radiologic, and histopathologic testing often are time-intensive and demand intricate protocols. Nucleic Acid Amplification Test holds promise due to its high sensitivity combined with rapid detection. Loop-mediated isothermal amplification (LAMP) based detection offers an ultrasensitive technique that does not require complicated thermocyclers like in polymerase chain reaction, offering a straightforward means for improving diagnoses as a near-point-of-care test. The study introduces a novel magnetic nanoparticle-based LAMP assay for carryover contaminant capture to reduce false positives. Solving the main drawback of LAMP-based diagnosis techniques. The assay targets the cotH gene, which is invariably specific to Mucorales. The assay was tested with various species of Mucorales, and the limit of detections for Rhizopus microsporus, Lichtheimia corymbifera, Rhizopus arrhizus, Rhizopus homothallicus, and Cunninghamella bertholletiae were 1 fg, 1 fg, 0.1 pg, 0.1 pg, and 0.01 ng, respectively. This was followed by a clinical blindfolded study using whole blood and urine samples from 30 patients diagnosed with Mucormycosis. The assay has a high degree of repeatability and had an overall sensitivity of > 83%. Early Mucormycosis detection is crucial, as current lab tests from blood and urine lack sensitivity and take days for confirmation despite rapid progression and severe complications. Our developed technique enables the confirmation of Mucormycosis infection in < 45 min, focusing specifically on the RT-LAMP process. Consequently, this research offers a viable technique for quickly identifying Mucormycosis from isolated DNA of blood and urine samples instead of invasive tissue samples.

Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Identification of lncRNA and weighted gene coexpression network analysis of germinating Rhizopus delemar causing mucormycosis

Rhizopus delemar, an opportunistic fungal pathogen, causes a highly fatal disease, mucormycosis. Spore germination is a crucial mechanism for disease pathogenesis. Thus, exploring the molecular mechanisms of fungal germination would underpin our knowledge of such transformation and, in turn, help control mucormycosis. To gain insight into the developmental process particularly associated with cell wall modification and synthesis, weighted gene co-expression network analysis (WGCNA) was performed including both coding and non-coding transcripts identified in the current study, to find out the module of interest in the germination stages. The module-trait relationship identified a particular module to have a high correlation only at the resting phase and further analysis revealed the module to be enriched for protein phosphorylation, carbohydrate metabolic process, and cellular response to stimulus. Moreover, co-expression network analysis of highly connected nodes revealed cell wall modifying enzymes, especially those involved in mannosylation, chitin-glucan crosslinking, and polygalacturonase activities co-expressing and interacting with the novel lncRNAs among which some of them predicted to be endogenous target mimic (eTM) lncRNAs. Hence, the present study provides an insight into the onset of spore germination and the information on the novel non-coding transcripts with key cell wall-related enzymes as potential targets against mucormycosis.

A Systematic Review of the Therapeutic Outcome of Mucormycosis

Background

Mucormycosis is a potentially lethal mycosis. We reviewed peer-reviewed publications on mucormycosis to assess therapeutic outcomes.

Methods

A systematic literature search using the Ovid MEDLINE and EMBASE databases identified manuscripts describing human mucormycosis diagnosed according to European Organization for Research and Treatment of Cancer and the Mycoses Study Group criteria with therapeutic outcomes published from 2000 to 2022.

Results

In 126 articles, 10 335 patients were described, most from Asia (n = 6632, 66%). Diabetes was the most frequent underlying disease (n = 6188, 60%); 222 (2.1%) patients had no underlying diseases. The dominant clinical form was rhino-orbitocerebral (n = 7159, 69.3%), followed by pulmonary (n = 1062, 10.3%). Of 5364 patients with outcome data, amphotericin B monotherapy (n = 3749, mortality 31.5%) was most frequent, followed by amphotericin B + azole (n = 843, mortality 6.6%; P < .0001), amphotericin B followed by azole (n = 357, mortality 13.7%; P < .0001), posaconazole only (n = 250, mortality 17.2%; P < .0001), and isavuconazole only (n = 65, mortality 24.6%; P = .24). Duration and dose of antifungals varied widely. Documented outcomes from surgical resections in 149 patients found that 47 of 125 died (37.6%), compared with 16 of 24 (66.7%) patients who did not undergo surgery (P = .008).

Conclusions

Mucormycosis is more frequently reported in Asia than in Europe and is often linked to diabetes. Antifungal therapy, usually with surgery, is frequently effective for mucormycosis.

Value of Imprint Cytology for the Rapid Diagnosis of Mucormycosis in the COVID-19 Pandemic Setting - A Pilot Study

Background

The second wave of the coronavirus disease 2019 (COVID-19) pandemic recorded a surge in rhino-orbital-cerebral mucormycosis (ROCM) infection in COVID-19-positive patients with diabetes and on concomitant steroid therapy. The rapidly progressive and devastating nature of the disease necessitated prompt diagnosis and early intervention to improve patient outcomes. Histopathology and fungal culture remain essential tools; however, these investigations have long and variable turn-around times (TATs) and may delay the initiation of treatment. Frozen section is not widely available and should be avoided in COVID-19-positive cases due to the risk of aerosol production and droplet exposure. In cases with high clinicoradiologic suspicion for mucormycosis, imprint cytologic evaluation provides a rapid diagnosis. Familiarity with fungal cytomorphology, awareness of morphologic pitfalls, and implementation of a standardized reporting format aid in diagnostic accuracy.

Method

Eighteen COVID-19-positive patients, who were admitted to our hospital with clinical suspicion of mucormycosis during June and July 2021, were included in the study. We used nasal or oral imprint cytology for the initial, rapid detection of Mucor. Cytology findings were correlated with histopathology and fungal culture results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

Results

The sensitivity, specificity, PPV, and NPV were 100%, 100%, 100% and 100%, respectively.

Conclusion

This study showed that imprint cytology can be a rapid, cost-effective, first-line diagnostic modality in Mucor diagnosis.

Nanotechnology-based fungal detection and treatment: current status and future perspective

Fungal infections impose a significant impact on global health and encompass major expenditures in medical treatments. Human mycoses, a fungal co-infection associated with SARS-CoV-2, is caused by opportunistic fungal pathogens and is often overlooked or misdiagnosed. Recently, there is increasing threat about spread of antimicrobial resistance in fungus, mostly in hospitals and other healthcare facilities. The diagnosis and treatment of fungal infections are associated with several issues, including tedious and non-selective detection methods, the growth of drug-resistant bacteria, severe side effects, and ineffective drug delivery. Thus, a rapid and sensitive diagnostic method and a high-efficacy and low-toxicity therapeutic approach are needed. Nanomedicine has emerged as a viable option for overcoming these limitations. Due to the unique physicochemical and optical properties of nanomaterials and newer biosensing techniques, nanodiagnostics play an important role in the accurate and prompt differentiation and detection of fungal diseases. Additionally, nano-based drug delivery techniques can increase drug permeability, reduce adverse effects, and extend systemic circulation time and drug half-life. This review paper is aimed at highlighting recent, promising, and unique trends in nanotechnology to design and develop diagnostics and treatment methods for fungal diseases.

Magnetic Resonance Imaging in COVID-19 Associated Rhino-Sinusal Mucormycosis

Rhino-sinusal mucormycosis is an acute invasive fungal infection rarely encountered in the clinical setting, occurring in severe immunosuppressed patients. However, in patients suffering from COVID-19 disease a dramatic increase in the incidence of mucormycosis has been recorded. The aim of the study is to discuss the MRI findings of patients with COVID-19 associated mucormycosis. This is a retrospective review of 10 hospitalized and operated patients in three Otolaryngologic Departments between the 1st of February 2021 and the 30th of October 2021. All patients presented nasal mucormycosis, histologically verified along with documented SARS-CoV-2 positive RT-PCR test. The sinus involvement, extra sinus spread and peri-sinus invasion were documented in all patients. The correlation between MRI and intra-operative findings was also assessed. The black turbinate sign and peri-antral soft tissue infiltration are early MRI signs characteristic of mucormycosis. Moreoever, MRI has a significantly high positive predictive value for intra-operative findings in COVID-19 associated mucormycosis.

Lucio Phenomenon: An Unusual Case of Skin Necrosis

Introduction

Lucio leprosy is a non-nodular diffuse type of lepromatous leprosy first described by Lucio and Alvarado. Lucio phenomenon is a rare vasculonecrotic reaction characterized by cutaneous necrosis with minimal constitutional features.

Case Presentation

We describe an unusual case of a 53-year-old man from Central India who had blisters, ulcers, and widespread erosions on his foot, forearms, and arms. The diagnosis of lepromatous leprosy with the Lucio phenomenon was established after thorough evaluation by clinical findings, histopathological findings, and slit-skin smear examination.

Conclusion

Lucio phenomenon is an uncommon cause of cutaneous infarction and necrosis. Primary care physicians should keep a high index of suspicion in patients with cutaneous necrosis and minimal constitution features. Since leprosy is a relatively curable disease, primary care physicians should think of a rare form of lepromatous leprosy presenting with cutaneous necrosis, especially in non-endemic zones.

Amphotericin-B-Induced Chronic Kidney Disease in a Post-COVID-19 Patient with Widespread Rhinocerebral Mucormycosis and Pneumonia: A Case Report

BACKGROUND

The COVID-19 pandemic has posed a unique challenge to the medical community due to potential co-infections with bacteria and fungi. We report a case of Rhino cerebral mucormycosis infection in a 67-year-old patient after recovery from COVID-19.

OBJECTIVE

To report a case of Rhino cerebral mucormycosis in a 67-year-old patient with preexisting health conditions after recovering from COVID-19 and to highlight the importance of early detection and treatment of co-infections in patients with pre-existing health conditions.

CASE PRESENTATION

The patient had pre-existing health conditions, including uncontrolled diabetes, hypertension, and Chronic obstructive pulmonary disease (COPD), which made him more vulnerable to complications after COVID-19. He was admitted to the hospital after experiencing a dark discharge from his left eye, later confirmed to be due to mucormycosis. Histopathological examination revealed invasive mucormycosis, highlighting the importance of early detection and treatment. However, the patient experienced Acute kidney injury (AKI) after only 5 days of treatment with conventional amphotericin B, underscoring the need for careful monitoring and adjustment of treatment regimens.

DISCUSSION

The case underscores the need for early detection and treatment of co-infections in vulnerable patients. The patient's pre-existing conditions and immunocompromised state made him more susceptible to the infection. The case also highlights the importance of careful monitoring and adjustment of treatment regimens to minimize the risk of adverse effects.

CONCLUSION

While COVID-19 has presented challenges and uncertainties, it has also provided valuable insights into the interactions between infectious agents and the human body. Continued research and vigilance are necessary to mitigate the impact of co-infections and improve outcomes for patients.

Development of a monoclonal antibody and a lateral-flow device for the rapid detection of a Mucorales-specific biomarker

Mucoromycosis is a highly aggressive angio-invasive disease of humans caused by fungi in the zygomycete order, Mucorales. While Rhizopus arrhizus is the principal agent of mucoromycosis, other Mucorales fungi including Apophysomyces, Cunninghamella, Lichtheimia, Mucor, Rhizomucor and Syncephalastrum are able to cause life-threatening rhino-orbital-cerebral, pulmonary, gastro-intestinal and necrotising cutaneous infections in humans. Diagnosis of the disease currently relies on non-specific CT, lengthy and insensitive culture from invasive biopsy, and time-consuming histopathology of tissue samples. At present, there are no rapid antigen tests that detect Mucorales-specific biomarkers of infection, and which allow point-of-care diagnosis of mucoromycosis. Here, we report the development of an IgG2b monoclonal antibody (mAb), TG11, which binds to extracellular polysaccharide (EPS) antigens of between 20 kDa and 250 kDa secreted during hyphal growth of Mucorales fungi. The mAb is Mucorales-specific and does not cross-react with other yeasts and molds of clinical importance including Aspergillus, Candida, Cryptococcus, Fusarium, Lomentospora and Scedosporium species. Using the mAb, we have developed a Competitive lateral-flow device that allows rapid (30 min) detection of the EPS biomarker in human serum and bronchoalveolar lavage (BAL), with a limit of detection (LOD) in human serum of ~100 ng/mL serum (~224.7 pmol/L serum). The LFD therefore provides a potential novel opportunity for detection of mucoromycosis caused by different Mucorales species.

Insulin and early debridement keys to survival in-COVID 19 associated mucormycosis patients(CAM)- An experience from tertiary care hospital In India

Introduction

Amid the second wave of COVID 19 India witnessed a surge of mucormycosis cases. This worsened the already existing health emergency. India a diabetic capital had all the favourable factors to support the growth of black fungus. This study was conducted with objectives of ascertaining patient characteristics, clinical type of mucormycosis, predisposing factors, predictors of survival and long term outcome of survivors.

Materials and methods

An ambispective study of COVID 19 associated mucormycosis patients admitted in mucor ward of tertiary care hospital between May 2021- August 2021 was done. Study was approved by Institute Ethical Committee. Demographic characteristics, presence of risk factors, clinical sign and symptoms, mode of diagnosis, treatment given, final outcome and long term follow up for a period of 1 year from discharge was done.

Results

367 CAM patients were included in the study. 72.5%(n = 266) were men and 27.5% (n = 101) were females. Mean age group was 51.3 years (SD 12.4 years). Most important comorbidity was diabetes( n = 320,87.2%), followed by cardiovascular disease (n = 68, 18.5%) and hypertension (n = 58,15.8%). Other predisposing factors were use of oxygen (n = 367,100%), antibiotics( n = 213,58%) and steroids (n = 272, 74.1%). Dexamethasone was the most commonly used steroid (n = 218,59.4%). Rhino orbital cerebral mucormycosis was the most common type. 83.7% patients (n = 307) survived and 16.3% (n = 60) succumbed to illness. Kaplan Meir survival analysis curve showed use of insulin (p = 0.025), early debridement ( p < 0.05) significantly increased survival rate. Similarly patients with lesions involving, face (p < 0.05) and nose (p = 0.014) had much better outcome as compared to disseminated forms. Only 96 patients remained in follow up. Of these patients no significant alteration in metabolic profile was noted and they remained euglycemic on oral hypoglycaemics.

Conclusion

Early debridement and insulin use are keys to improved survival. Oxygen, Steroids and antibiotics are the risk factors for mucormycosis. Diabetes is the most important comorbidity.

A pediatric case and literature review of mucormycosis: Diagnostic and treatment challenges in a resource poor setting

Mucormycosis is an emerging disease that primarily affects immunocompromised patients; however, it has also been reported in immunocompetent individuals. Studies in the pediatric population are limited and reported mostly in case studies or series. The aim of this case report is to present a pediatric mucormycosis originated from Sumatra Island, Indonesia. A 13-year-old boy was referred to a tertiary hospital with facial necrosis involving the nasal, oral, and left maxillary areas, as well as left periorbital edema. No known underlying conditions were documented. The diagnosis was confirmed by histopathological findings of broad, pauci-septate, ribbon-like hyphae branching at 90°. The patient was managed by a multidisciplinary team consisting of the ear, nose, and throat, infectious diseases, dermatology, surgery, microbiology, and pathology departments. Management of the patient included debridement of the necrotic lesion and antibiotics and anti-fungal (fluconazole). Due to unavailability, the patient was not treated with amphotericin B. The patient died after 30 days of admission. This case highlights the importance of maintaining a high suspicion of invasive mucormycosis, even in immunocompetent children, when symptoms and signs are present, especially in resource-limited settings.

The outcome and the risk factors of mucormycosis among patients with hematological diseases: a systematic and meta-analysis

Objectives

Mucorale has come into a significant pathogen over recent decades. Nonetheless, mucormycosis-related mortality rates among patients with hematological disorders remain unascertained. Thus, we conducted a meta-analysis to determine mortality rates of mucormycosis in patients with hematology-related conditions.

Methods

We scoured PubMed, Embase, and Web of Science for original papers exploring the intersection of Mucormycosis and Hematological Diseases (from 2000 to 2022). We scrutinized the overall mortality across three distinct periods, as well as differentiating between high-income and middle-income nations. We further evaluated the pooled mortality and the risk differential (RD) across several subgroups.

Results

The overall mortality rate for hematology patients with mucormycosis was 61%, within a 95% confidence interval (CI) of 0.54-0.68. A significant observation was that mortality rates were somewhat lower in high-income countries compared to middle-income countries (0.60 versus 0.64, p = 0.45). Importantly, we discovered that a combination of surgical and medical treatment significantly improved survival rates compared to medical treatment alone [mortality 0.49 versus 0.67, RD -0.19 (95%CI -0.38-0.00, I2 63.7%)]. As might be expected, disseminated mucormycosis posed a significantly higher risk of death compared to isolated mucormycosis [0.60 versus 0.57, RD death 0.16 (95%CI 0.03-0.28)]. Additionally, our analysis showed no discernible differences in survival rates between genders, between patients with and without breakthrough infection, between those who received mucor-active or mucor-inactive drugs prior to mucor infection, or between those on a multi-drug regimen and those on a single drug treatment.

Conclusion

Despite the high mortality rates associated with mucormycosis in patients with hematological disorders, those receiving both medical and surgical interventions, as well as those with isolated infection sites, exhibited improved survival outcomes. Conversely, factors such as gender, the presence of breakthrough infection, the use of mucor-active drugs before mucor infection, and multi-drug administration did not significantly influence patient outcomes.

Predictors of disease severity in COVID-19 associated mucormycosis: impact of HbA1C levels, time lag to mucormycosis onset, and radiologic patterns of paranasal sinuses and spaces involvement

BACKGROUND

Identifying early predictors of severe Covid-19 associated mucormycosis (CAM) can help improve management and treatment outcomes.

OBJECTIVES

Primary: To identify clinical and radiological predictors of disease severity in CAM. Secondary: To describe patterns of central nervous system (CNS) involvement in CAM.

METHODS

A total of 71 patients with CAM were included in the study. Based on the anatomical extent of involvement on MRI, patients were divided into three groups: Sinus (paranasal sinuses), Orbit (orbital spread), and CNS (CNS spread). Clinical parameters and radiological patterns of involvement of sinuses and extra sinus spaces were studied between the three groups. Patterns of CNS involvement were also described.

RESULTS

A shorter time lag between COVID-19 infection and CAM, as well as high HbA1C levels, were found to be associated with severe disease. Involvement of the sphenoid, ethmoid and frontal sinuses, T1 hyperintense signal in the sphenoid, as well as bony involvement of the sphenoid sinus, were significantly associated with severe disease. Extra-sinus spread into pre/retroantral space, pterygopalatine fossa, and masticator spaces were also significantly associated with a severe disease course. The most common pattern of CNS spread was cavernous sinus involvement, followed by pachymeningeal spread and cranial nerve involvement.

CONCLUSION

Early identification of the above-described predictors in patients presenting with CAM can help detect those at risk for developing severe disease. A longer duration of amphotericin, combined with a more aggressive surgical approach in selected cases, may lead to better long-term outcomes.

Mucormycosis, New Causative Agents, and New Susceptible Populations: Review of Cases in a Tertiary Care Hospital in Iran (2007-2021)

Background

Mucormycosis is an aggressive opportunistic fungal infection that afflicts patients with severe underlying immunosuppression, uncontrolled hyperglycemia and/or ketoacidosis, iron overload, and occasionally healthy patients who are inoculated with fungal spores through traumatic injuries. The epidemiology of mucormycosis has changed after the COVID-19 pandemic, with mucormycosis becoming the most common and the fatal coinfection.

Methods

In a retrospective, cross-sectional study, 82 hospitalized patients with a definite diagnosis of mucormycosis were reported from 2007 to 2021 in a referral, tertiary care center in Tehran, Iran.

Results

The number of post-COVID cases increased 4.6 times per year, with 41.5% of patients admitted during the two years of the pandemic. Mucormycosis was more common in women (57.3%), and the most common underlying diseases were diabetes (43.7%), both COVID-19 and diabetes (23.2%), cancer (11%), rheumatic diseases (7.3%), COVID-19 without other underlying diseases (6.1%), and transplantation (4.9%). Rhino-orbito-cerebral Mucormycosis (54.9%) followed by Sino-orbital infection (23.2%) was the most common presentation. There was a significant relationship between the use of immunosuppressive agents and the development of Mucormycosis (P<0.005) The average mortality was 41.5%, but this ratio decreased to 35% during the pandemic era.

Conclusion

The COVID-19 pandemic caused a 4.6-fold increase in the number of mucormycosis patients, and there was a significant relationship between hyperglycemia, corticosteroid use, and mucormycosis. The death rate during the COVID-19 pandemic has decreased by 6.5%, and during the COVID period, the interval between the arrival of a patient with mucormycosis and the start of the correct treatment was significantly decreased.

Diverse Clinical Manifestations and Challenges of Mucormycosis: Insights From Serial Cases

Mucormycosis is a severe and potentially life-threatening infection caused by a group of fungi classified as mucormycetes within the scientific order Mucorales. These infections are characterized by rapid and invasive fungal growth, presenting significant treatment challenges. Here we present 5 cases encountered from 2018 to 2022 at the University of Texas Medical Branch in Galveston, Texas, including a novel Apophysomyces species. These cases illustrate the diverse clinical manifestations of mucormycosis, including pulmonary, rhino-cerebral, gastrointestinal, and soft tissue involvement. Our investigation incorporates information provided by a multidisciplinary team of clinical collaborators, emphasizing the findings from radiology, histopathology, and microbiology. Given the escalating global incidence of mucormycosis, it is crucial for clinicians to become familiar with associated clinical findings, comorbidities, and risk factors to facilitate prompt recognition, appropriate diagnostic testing, and timely initiation of treatment.

Orbital Onslaught: An Atypical Presentation of Mucormycosis in a Diabetic and Hypertensive Patient

Mucormycosis, primarily known to affect the sinuses and brain, severely threatens immunocompromised individuals. Its occurrence in the orbital region is rare and potentially devastating. We report a unique case of a 50-year-old male with longstanding diabetes and hypertension who exhibited isolated orbital mucormycosis confined to the right eye. The patient presented with fever and acute vision loss without classic sinusitis symptoms; earlier mismanagement led to an aggressive relapse. An orbital computed tomography (CT) scan revealed inflammatory changes indicative of an early-stage invasive fungal infection. Comprehensive management involving surgical debridement and antifungal therapy successfully halted intracranial spread and further complications. This case underscores the necessity for high clinical vigilance in diagnosing atypical presentations of mucormycosis in susceptible populations, advocating for a rapid, multidisciplinary approach to ensure optimal outcomes. It also adds to the existing literature on the myriad manifestations of this formidable fungal infection.

Clinical Profile and Factors Associated with Adverse Outcomes in Coronavirus Disease 2019-associated Mucormycosis: A Single-centre Study

Background: The coronavirus disease 2019 (COVID-19) pandemic was associated with an increased incidence of mucormycosis globally. However, the clinical pattern, epidemiologic features and risk factors for adverse outcomes are not well established. Methods: We performed a retrospective analysis of the data from patients hospitalized with proven mucormycosis between April 2021 and August 2021. Patients were managed with a multi-disciplinary approach involving medical, surgical, and comorbidity treatment. The clinical presentation, management details, complications and outcomes, including mortality, were reviewed from clinical records. Results: The mean age of presentation was 53.7 (± 11.8) years, and 88 (84.6%) were men. Of the 104 cases with COVID-19-associated mucormycosis, 97 (93.27%) patients had diabetes, and 80.8% had a haemoglobin A1C (HbA1c) of ≥6.4% at diagnosis. Seventy percent of diabetes cases experienced steroid-induced hyperglycaemia during treatment. Even with appropriate treatment, 17 (16.35%) patients died. High HbA1c and creatinine levels, presence of chronic kidney disease (CKD), need for intensive care unit admission, and orbital evisceration were the risk factors associated with high mortality on multivariate logistic regression analysis. Cox regression analysis revealed that the overall mortality increased by a factor of 12% with each 1 percentage point increase in HbA1c ≥6.4% (hazard ratio 1.12; 95% confidence interval 0.95- 1.31). The mortality risk was even higher when diabetes was associated with CKD (hazard ratio 1.82; 95% confidence interval 0.24-14.00). Conclusion: High HbA1c and creatinine levels, intensive care unit admission, CKD, and aggressive disease requiring orbital evisceration are the predictors of mortality in patients with COVID-19-associated mucormycosis. Patients with these risk factors should be managed more actively to reduce morbidity and mortality.

Epidemiology, Clinical Profile, and Analysis of Risk Factors in COVID Associated Rhino-orbito-cerebral Mucormycosis Patients - An Observational Study

Aim of Study

To study the clinico-epidemiological profile and identify risk factors for the development of COVID-19-associated mucormycosis (CAM) among the patients treated at our regional mucormycosis center.

Materials and Methods

This was a cross-sectional single-centre observational study. All CAM patients admitted to Government Rajaji Hospital, Madurai from April 2021- August 2021 were included in the study. Information regarding clinical features, potential risk factors, diagnostic workup, and comorbid illness was collected.

Results

A total of 164 patients of CAM were admitted to our hospital with a mean age of 51.7 years. Out of 164 patients, 12 patients were not covid positive, based on imaging and RT-PCR, however subclinical infection could not be ruled out. Out of the 164 patients studied, 160 patients had diabetes, out of which 66% (n = 105) patients had a previous history of diabetes, and 34% (n = 55) had newly detected diabetes. Most of the patients admitted with mucormycosis had uncontrolled diabetes (94%) and were not on insulin therapy, but were on oral antidiabetic drugs alone. The majority of the patients (68%) have received steroids (IV/oral) during the COVID-19 illness. 74% of these patients were under hospitalization for COVID-19 disease. Only 30% (n = 50) of CAM patients had a history of oxygen therapy and 7% of these patients were treated in ICU during active COVID-19 illness. 59% of patients used cloth masks without adequate hygiene, rest 41% (n = 67) patients reused disposable masks. We also found that 87% of the patients developing mucormycosis had exposure to organic material in the convalescence period of COVID-19 illness.

Conclusions

From our study, we found steroid use, poorly controlled diabetes mellitus, reuse of masks, daily steam inhalation, and exposure to organic matter to be more associated with CAM, but oxygen therapy was less associated with CAM. Hence, we could suggest screening for hyperglycemia and daily use of disposable surgical masks to be continued for at least 4 weeks post-COVID-19. It is preferable to continue insulin in titrated doses along with OHA for at least 4 weeks following steroid cessation in the post-COVID-19 period as there is are considerably increased inflammatory cytokine levels in the convalescence phase. Clean environmental hygiene would also help prevent CAM.

Rapid detection of Mucorales based on recombinase polymerase amplification and real-time PCR

Mucormycosis, an invasive fungal disease with severe consequences, poses a significant threat to immunocompromised individuals. However, the timely and accurate identification of Mucorales infection continues to present difficulties. In this study, novel detection techniques utilizing recombinase polymerase amplification (RPA) and quantitative real-time polymerase chain reaction (qPCR) were developed, specifically targeting the mitochondrial rnl gene, in order to address this challenge. The specificity of the RPA and qPCR assay was assessed by adding genomic DNAs extracted from 14 non-targeted strains, as well as human and mouse blood. No false-positive results were observed. Additionally, genomic DNAs from 13 species in five genera of order Mucorales were tested and yielded positive results in both methods. To further evaluate the sensitivity of the assays, DNAs from Rhizopus oryzae, Mucor racemosus, Absidia glauca, Rhizomucor miehei, and Cunninghamella bertholletiae were utilized, with concentrations ranging from 1 ng/μL to 1 fg/μL. The limit of detection (LoD) for the RPA assay was determined to be 1 pg., with the exception of Rhizomucor miehei which had a LoD of 1 ng. The LoD for the qPCR assay varied between 10 fg and 1 pg., depending on the specific species being tested. Sensitivity analysis conducted on simulated clinical samples revealed that the LoD for RPA and qPCR assays were capable of detecting DNA extracted from 103 and 101 colony forming units (CFU) conidia in 200 μL of blood and serum, respectively. Consequently, the real-time RPA and qPCR assays developed in this study exhibited favorable sensitivity and specificity for the diagnosis of mucormycosis.

Prognostic Association of Liposomal Amphotericin B Doses Above 5 mg/kg/d in Mucormycosis: A Nationwide Epidemiologic and Treatment Analysis in Japan

Background

Mucormycosis is a potentially fatal fungal infection, and there is limited information on its precise epidemiology and treatment practices, including the optimal dosage of liposomal amphotericin B.

Methods

A retrospective, multicenter, nationwide analysis of 82 proven and probable cases of mucormycosis was performed. Cases between 2015 and 2022 were collected from 51 hospitals in Japan by hematologists and infectious disease specialists. The study included the epidemiology, treatment details, and association between the dose of liposomal amphotericin B and the outcome.

Results

The lungs were the most commonly involved organ (70.7% of cases), and 35.4% of patients had disseminated disease. Rhizopus spp., Cunninghamella spp., and Mucor spp. were the most common organisms. Mortality at 4 weeks was 41.5%. The survivors had a shorter duration of neutropenia (P = .006) and less persistent hyperglycemia (P = .023). The site of infection and species of Mucorales had no detectable effect on survival. Survival did not differ between patients receiving liposomal amphotericin B at 5 mg/kg/d relative to those receiving >5 mg/kg/d (P = .625). Using Cox proportional hazards models and adjusting for confounders, the hazard ratio for the influence of >5 mg/kg/d liposomal amphotericin B on 4-week survival was 0.86 (95% CI, 0.28-2.68; P = .796) compared with 5 mg/kg/d.

Conclusions

This study provides important insights into the precise epidemiology and treatment practices of mucormycosis. Treatment with liposomal amphotericin B at doses higher than 5 mg/kg/d did not improve outcomes relative to 5 mg/kg/d.

Fungal pathogens and COVID-19

COVID-19 pandemic highlighted the complications of secondary fungal infections that occurred globally in severe cases of coronavirus disease managed in the intensive care units. Furthermore, varied underlying host factors, such as preexisting immunosuppression, the use of immunomodulatory agents, and invasive procedures predisposing lung tissues to fungal colonization and proliferation, caused increased susceptibility to fungal infections in COVID-19 patient populations. These invasive fungal infections directly impact the overall length of hospitalization and mortality. The most commonly reported fungal infections in patients with COVID-19 include aspergillosis, invasive candidiasis, and mucormycosis. An overall worldwide increase in the prevalence of candidiasis and aspergillosis was observed in COVID-19 patients , whereas outbreaks of mucormycosis were mainly recorded from India. Diagnostic challenges and limited antifungal treatment options make secondary fungal infections among COVID-19 patients more burdensome, which results in improper management and increased mortality.

Satellite Epidemic of Covid-19 Associated Mucormycosis in India: A Multi-Site Observational Study

BACKGROUND

Sudden upsurge in cases of COVID-19 Associated Mucormycosis (CAM) following the second wave of the COVID-19 pandemic was recorded in India. This study describes the clinical characteristics, management and outcomes of CAM cases, and factors associated with mortality.

METHODS

Microbiologically confirmed CAM cases were enrolled from April 2021 to September 2021 from ten diverse geographical locations in India. Data were collected using a structured questionnaire and entered into a web portal designed specifically for this investigation. Bivariate analyses and logistic regression were conducted using R version 4.0.2.

RESULTS

A total of 336 CAM patients were enrolled; the majority were male (n = 232, 69.1%), literate (n = 261, 77.7%), and employed (n = 224, 66.7%). The commonest presenting symptoms in our cohort of patients were oro-facial and ophthalmological in nature. The median (Interquartile Range; IQR) interval between COVID diagnosis and admission due to mucormycosis was 31 (18, 47) days, whereas the median duration of symptoms of CAM before hospitalization was 10 (5, 20) days. All CAM cases received antifungal treatment, and debridement (either surgical or endoscopic or both) was carried out in the majority of them (326, 97.02%). Twenty-three (6.9%) of the enrolled CAM cases expired. The odds of death in CAM patients increased with an increase in HbA1c level (aOR: 1.34, 95%CI: 1.05, 1.72) following adjustment for age, gender, education and employment status.

CONCLUSION

A longer vigil of around 4-6 weeks post-COVID-19 diagnosis is suggested for earlier diagnosis of CAM. Better glycemic control may avert mortality in admitted CAM cases.

Mucor osteomyelitis after traumatic forearm amputation in a 38-year-old patient

We report the case of a forest ranger who developed a polymicrobial infection with Mucor circinelloides after traumatic forearm amputation. Based on our case report we discuss epidemiology and management of this rare and potentially fatal infection.

Reconstructive cranial surgery for invasive and non-responsive mucormycosis

The incidence of mucormycosis showed a sharp rise during the COVID-19 pandemic in vulnerable populations like people with diabetes. Here, we report a case of mucormycosis of the frontal and ethmoid sinuses in a man in his mid-50s with a background of diabetes mellitus and COVID-19 infection requiring steroids and oxygen support. The infection had remained persistent despite initial debridement by functional endoscopic sinus surgery of the anterior frontal sinus wall and re-exploration, followed by debridement using the brow incision. The patient had received an entire course of systemic antifungal therapy during the postoperative period. A bifrontal craniotomy, excision of the supraorbital ridge and complete removal of bilateral frontal sinuses managed the persistent fungal infection. The defect was reconstructed with a custom-made three-dimensional-printed MRI-compatible titanium cranioplasty mesh. The patient had no signs of infection on the 9-month follow-up.

The SSS revolution in fungal diagnostics: speed, simplicity and sensitivity

INTRODUCTION

Fungal disease has historically presented a diagnostic challenge due to its often non-specific clinical presentations, relative infrequency and reliance on insensitive and time-intensive fungal culture.

SOURCES OF DATA

We present the recent developments in fungal diagnostics in the fields of serological and molecular diagnosis for the most clinically relevant pathogens; developments that have the potential to revolutionize fungal diagnosis through improvements in speed, simplicity and sensitivity. We have drawn on a body of evidence including recent studies and reviews demonstrating the effectiveness of antigen and antibody detection and polymerase chain reaction (PCR) in patients with and without concurrent human immunodeficiency virus infection.

AREAS OF AGREEMENT

This includes recently developed fungal lateral flow assays, which have a low cost and operator skill requirement that give them great applicability to low-resource settings. Antigen detection for Cryptococcus, Histoplasma and Aspergillus spp. are much more sensitive than culture. PCR for Candida spp., Aspergillus spp., Mucorales and Pneumocystis jirovecii is more sensitive than culture and usually faster.

AREAS OF CONTROVERSY

Effort must be made to utilize recent developments in fungal diagnostics in clinical settings outside of specialist centres and integrate their use into standard medical practice. Given the clinical similarities of the conditions and frequent co-infection, further study is required into the use of serological and molecular fungal tests, particularly in patients being treated for tuberculosis.

GROWING POINTS

Further study is needed to clarify the utility of these tests in low-resource settings confounded by a high prevalence of tuberculosis.

AREAS TIMELY FOR DEVELOPING RESEARCH

The diagnostic utility of these tests may require revision of laboratory work flows, care pathways and clinical and lab coordination, especially for any facility caring for the immunosuppressed, critically ill or those with chronic chest conditions, in whom fungal disease is common and underappreciated.

Severe Fatal Mucormycosis in a Patient with Chronic Lymphocytic Leukaemia Treated with Zanubrutinib: A Case Report and Review of the Literature

Severe mucormycosis is a fatal disease rarely complicating chronic lymphoproliferative disorders. We present a fulminant and fatal case of a 74-year-old Caucasian woman suffering from CLL treated with second-generation BTK inhibitor zanubrutinib. After a first septic episode a month prior, originating from the lung with later systemic involvement by an unidentified agent and treated with large-spectrum antibiotics and fluconazonle, a slow-onset enlarging tender warm and erythematous nodular swollen cutaneous lesion appeared in her lower limbs and spread subsequently to her upper limbs, progressing towards central ulceration with a necrotic core. Suspecting a mycotic dissemination from an unknown agent, a skin punch biopsy was performed, and intraconazole was started. Due to spread of the skin lesions, the patient was hospitalized and intravenous liposomal ampthotericin B was started. Histopathology showed an atypical sporangium-rich mycotic angioinvasion of the small vessels. Only the increase of BDG and GM could corroborate the hypothesis of mycotic infection. However, long-term CLL, immunosuppressive therapies, neutropenia, and prior use of azoles and other antimycotic agents were risk factors for mucormycosis; BTK inhibitor could also be added as another novel risk factor. Despite all therapeutic efforts, the patient died. Post-mortem molecular exams confirmed the diagnosis of disseminated mucormycosis.

Prosthodontic restoration of a COVID-19 associated mucormycosis defect: A clinical report

INTRODUCTION

Coronavirus Disease 2019 (COVID-19) pandemic brought the clinical practice of dentistry and prosthodontics at the threshold of a new era, due to the increasing prevalence of a relative rare condition normally affecting the immunocompromised patients.

AIM

The aim of this clinical case report is to briefly describe the etiopathogenesis, the surgical and prosthodontic management of this evolving medical condition emphasizing the emerging role of the maxillofacial prosthodontist in restoring the patients' well-being.

METHODS AND RESULTS

The surgical and prosthodontic rehabilitation of a COVID-19 infected patient with a mucormycotic lesion of the maxilla will be presented.

CONCLUSION

The role of the maxillofacial prosthodontist is important in alleviating this severe COVID-19 associated morbidity.

Emergence of Rhino-Orbito-Cerebral Mucormycosis in Peru: Impact of the COVID-19 Pandemic

Introduction Mucormycosis is an invasive fungal infection caused by Mucorales that has been increasingly recognized over the years, particularly during the COVID-19 pandemic. Nevertheless, in Peru, there has been limited research on this disease. This study seeks to provide insights into the demographics, clinical presentations, treatment, and outcomes of patients with mucormycosis, before and during the COVID-19 pandemic. Materials and methods We conducted a retrospective case series by reviewing the medical records of Peruvian patients hospitalized at a referral medical center between 2017 and 2021. The selection criteria included patients aged 18 years or older with clinical features of rhino-orbito-cerebral mucormycosis supported by radiological imaging. We extracted data related to risk factors for mucormycosis infection, clinical presentation, management, and hospitalization. Data analysis was performed using Stata software (StataCorp LLC, College Station, Texas, USA) to compare patient groups before and during the COVID-19 pandemic. Results Nineteen cases met our selection criteria: 11 men and eight women with an average age of 57.6 ± 10.6 years. All 19 patients had type 2 diabetes mellitus as comorbidity, with 13 cases exhibiting uncontrolled diabetes. Six patients presented before the COVID-19 pandemic, while 13 during its course. Within the group of patients diagnosed during the pandemic, nine were diagnosed with SARS-CoV-2 infection. Regarding the site of mucormycosis infection, the paranasal sinuses were predominantly involved. Survival analysis indicated that patients who developed mucormycosis during the COVID-19 pandemic, those with uncontrolled diabetes, or those who did not undergo surgery had lower probabilities of survival. Conclusion Mucormycosis is a rare infection associated with high mortality and morbidity with increased frequency during the COVID-19 pandemic. Early diagnosis, timely administration of antifungal treatment, surgery, and effective management of comorbidities can have life-saving implications. Unfortunately, despite the availability of various diagnostic tests and less toxic antifungal options such as liposomal amphotericin-B, such resources are not accessible in Peru's national hospitals.

Mucormycosis: A 14-Year Retrospective Study from a Tertiary Care Center in Lebanon

Mucormycosis (MCM) is a serious invasive fungal disease (IFD) that is associated with high mortality, particularly in immunocompromised patients. A global surge in MCM cases was reported with the COVID-19 pandemic. We analyzed all recorded cases of MCM at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon, over 14 years. We aimed to identify the incidence, seasonal variation, clinical characteristics of the patients, and predictors of mortality. We conducted a retrospective chart review between 1 January 2008 and 1 January 2023. All patients with proven or probable MCM were included in the study. Proven or probable MCM was defined by positive histopathology and/or positive cultures. A total of 43 patients were identified as having MCM. Their median age was 53 years, and the majority were males (58.1%). Most of the cases were diagnosed in the autumn season. In total, 67.4% of the patients had hematological malignancies (HMs), and 34.9% had uncontrolled diabetes mellitus (DM). The most common site of involvement was rhino-orbital-cerebral MCM (ROCM) (74%). The annual cases of MCM per 100,000 patient days increased markedly during the years of the COVID-19 pandemic (from 0 to 4.4 cases/100,000 patient days to 7.5 cases/100,000 during 2020 and 2021). Liposomal amphotericin (Ampho) B was used as a first-line agent in most of the patients (86%). The median duration of total in-hospital antifungal therapy was 21 days and 51.2% of the patients received step-down therapy with azoles. Surgical debridement and isolated ROCM were significantly associated with survival (p-value: 0.02 and <0.001, respectively). All-cause mortality was 46.7%, with chronic renal disease being significantly associated with mortality (p-value < 0.05). The incidence of MCM has been increasing at our institution, particularly since the COVID-19 pandemic. Early diagnosis, treatment, and surgical debridement improve patient outcomes and overall survival.

COVID-19-associated mucormycosis in India: Why such an outbreak?

An unprecedented mucormycosis outbreak occurred in India during the second COVID-19 wave in spring 2021. COVID-19-associated mucormycosis (CAM) was observed, mainly rhino-orbito-cerebral mucormycosis (ROCM), in patients with poorly controlled diabetes and treated with inappropriate doses of glucocorticoids. The aim of this mini-review was to compare the characteristics of the CAM epidemic in India with (i) mucormycosis cases before the COVID-19 pandemic and (ii) CAM in the rest of the world (particularly in France) in order to identify the reasons for this outbreak. In India, the major mucormycosis epidemiologic change during the COVID-19 pandemic was an increase in the percentage of patients treated with corticosteroids who developed CAM. Compared with the rest of the world, India reported a higher mucormycosis incidence even before the COVID-19 pandemic. Moreover, in India, patients with CAM were more likely to have diabetes mellitus and ROCM; conversely, mortality rates were lower. The reasons for such a localized epidemic in India have remained unclear, but some hypotheses can be put forward, particularly the combination of high prevalence of uncontrolled diabetes mellitus and frequent indiscriminate corticosteroid utilization in a country that already had a high mucormycosis burden before the COVID-19 pandemic.

COVID-19-Associated Rhino-Orbital Mucormycosis in a Tertiary Health Care Center in Odisha, India

Background Mucormycosis is an opportunistic infection that mainly affects immunocompromised individuals, including those with uncontrolled diabetes, malignancies, or those who have exposure to high-dose corticosteroids for a long time. Western Odisha, India, witnessed a significant rise in post-COVID-19 rhino-orbital mucormycosis (ROM), which created a need for comprehensive research on post-COVID-19 ROM. Objective This study aimed to investigate the prevalence, clinical characteristics, and outcomes of post-COVID-19 ROM in a tertiary care hospital in Western Odisha, India, with the objective of understanding ROM as a nationally notifiable disease. Subjects and methods A prospective hospital-based study was conducted. Mucormycosis cases were reported within the period, from May 17, 2021, to July 31, 2021, including all post-COVID-19 patients who exhibited clinical manifestations of mucormycosis. Patients with histopathologically negative reports of mucormycosis were excluded. Results Of the 35 included, 25 were diagnosed with ROM. The age group of 46-50 years showed a predominance (n=6), with a mean age of 50.53 years. The male-to-female ratio was 2:1. Specifically, 88% of the patients included had diabetes mellitus, 8% had chronic kidney diseases, 8% had sepsis, and 4% had hypertension. ROM was the predominant manifestation (60%, n=15), with the majority presenting with orbital cellulitis (80%), followed by unilateral orbital apex syndrome (12%), bilateral orbital apex syndrome (4%), ophthalmic vein involvement (4%), and osteomyelitis of the maxillary sinus (4%). Irrigation of the wound was performed, and all 25 ROM patients received IV liposomal amphotericin B (L-AMB). Conclusion Post-COVID-19 status with elevated blood sugar levels was a major risk factor for ROM. Early diagnosis, debridement, L-AMB, retrobulbar AMB deoxycholate, and exenteration are the possible solutions.

Orbital Apex Syndrome Due to Aspergillus flavus Infection in Immunocompetent Patients: A Report of Two Cases

Aspergillus species are fungi that are commonly found in soil and decaying vegetation and have the potential to cause an orbital apex syndrome that is marked by ophthalmoplegia or vision loss. We report the clinical and investigational findings and outcomes of two patients with orbital apex syndrome. The first patient was a 26-year-old female, premorbidly healthy, who presented with a gradually increasing proptosis of the left eye with a reduction in vision. An MRI revealed findings consistent with proptosis, pansinusitis with a soft tissue opacity involving the left orbital apex with optic nerve compression, extending to the cavernous sinus with an associated temporal meningeal enhancement. Following functional endoscopic sinus surgery (FESS), Aspergillus flavus was grown in culture, and oral voriconazole was initiated. The second patient was a 53-year-old male who presented with bilateral reduction of vision and ptosis, proptosis with total ophthalmoplegia (third, fourth, and sixth nerve palsies) of the right eye. An MRI study revealed extensive involvement of the apex of the right orbit, the right cavernous sinus, the medial aspect of the left cavernous sinus, and the pituitary gland. A FESS was done, and the histopathology specimen was suggestive of aspergillosis, and the tissue fungal polymerase chain reaction (PCR) test was positive for Aspergillus flavus. He was treated with amphotericin B and oral voriconazole with significant improvement. Physicians need to have a high index of suspicion for invasive fungal sino-orbital infections, even in immunocompetent patients. The presence of nasal congestion, recurrent sinusitis, facial pain, headache, orbital cellulitis, proptosis, or ophthalmoplegia should prompt early investigations.

Influence of Prosthodontic Rehabilitation Using Zygomatic Implants in Covid 19 Related Mucormycosis (Rhino-Orbital-Cerebral) Maxillectomy Patients Upon Post-Operative Stress, Anxiety and Functional Impairment: A Prospective Cohort Study

Purpose

To determine the influence of prosthodontic rehabilitation using zygomatic implants in partial maxillectomy upon post-operative stress, anxiety and functional impairment, due to covid 19 associated rhino-orbital-cerebral mucormycosis (ROCM).

Patients and Methods

Twenty maxillectomy patients fulfilling study criterion, received zygomatic implants (ZI) (quad zygoma) (ZDI Simpladent, Switzerland) retained/supported complete maxillary denture. Assessment of stress, anxiety, masticatory performance and speech were determined using diurnal salivary cortisol level, Appearance Anxiety Inventory, multiple sieve technique and auditory perception analysis, respectively. Data were recorded at 6 different stages of rehabilitation (after maxillectomy, implant placement, and after prosthesis delivery (1 week, 1 month, 6 months and 1 year)). Demographic data were expressed as frequency distribution, while mean values were used to find differences between various rehabilitation stages using Friedman and chi-square test with statistical significance value at p < 0.05.

Results

Average daily salivary cortisol levels declined from post maxillectomy (22.80 ± 0.902) to 1 year after prosthesis wearing (8.65 ± 0.985), indicating stress reduction after ZI rehabilitation. Mean scores for appearance anxiety reduced from pre-prosthetic rehabilitation (27.350 ± 3.030) to 1 year (8.950 ± 0.887) following prosthesis wearing. Functional parameters for mastication and speech also improved significantly during the course of rehabilitation. All differences between pre-prosthetic to 1-year stage after prosthesis wearing were found to be statistically significant at p < 0.05.

Conclusion

Post ROCM maxillectomy cases after prosthetic rehabilitation using zygomatic implants showed significant improvement in the psychological (stress and anxiety) as well as function (mastication and speech) characteristics. Rehabilitation post ROCM maxillectomy with the present approach of fixed prosthesis using zygomatic implants mitigates deficient mastication and speech. It also impacts positively on patient psychology by decreasing stress and anxiety.

Opportunistic Fungal Invasion in COVID-19 Pandemic: A Critical Review in Diagnosis and Management

Severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) is the culprit behind the pandemic across the globe in recent decades. Variants of SARS-CoV especially coronavirus disease 2019 (COVID-19)-related fungus might not be identified or might be misdiagnosed on a worldwide scale. Patients of COVID-19 acquired invasive mycoses, especially if they are very ill or immunosuppressed. Clinical intervention based on various standard guidelines would be necessary to guarantee that Aspergillus and Candida -infected COVID-19 patients are adequately treated. To facilitate clinical professionals, doctors, paramedics, and laboratory staff in the treatment of various variants of COVID-19 patients with concurrent aspergillosis, candidiasis, mucormycosis, or cryptococcosis, a tabulation format is drafted in this study. We believe it is prudent to take into account the general nature, and variety of the mycosis that is arriving, the strength and limits of the diagnostic tools, clinical conditions, and the need for standardized or customized therapy in various coronavirus-infected patients.