ESCMID† and ECMM‡ joint clinical guidelines for the diagnosis and management of mucormycosis 2013

Antibody Responses and CNS Pathophysiology of Mucormycosis in Chronic SARS Cov-2 Infection: Current Therapies Against Mucormycosis

The incidence rate of opportunistic secondary infections through invasive fungi has been observed to be 14.5% to 27% in the SARS CoV pandemic during the year 2003. However, the incidence of SARS CoV-2 is accompanied by a substantial rise in secondary opportunistic infections like mucormycosis (black fungus), mainly in the immunocompromised individuals and diabetic patients taking steroids. Substantial rates of COVID-19 cases with mucormycosis were reported in India and other parts of the world. Previous research reports delineated the ability of Mucorales to invade the various tissues like lungs, brain, and sinus through the GRP78, and subsequently, this infection could invoke crusting, edema, and necrosis of the brain parenchyma, ptosis, proptosis, and vision loss due to intraorbital and intracranial complications. Similarities of these pathophysiological complications with already existing diseases are causing clinicians to face several challenges in order to diagnose and treat this disease effectively at the early stage. This minireview depicts the mucormycosis-induced immune and pathophysiological alterations in COVID-19 patients comorbid with diabetes and immunosuppression and also reported the various clinical manifestations, the therapeutic modalities, and the failures of anti-fungal vaccines. Therefore, the emerging mucormycosis in COVID-19 patients needs rapid investigation and selective optimization of the effective therapeutic modalities, including antifungal vaccines, to minimize the mortality rate.

Case Report: Is Surgical Treatment Beneficial for Intracranial Basal Ganglia Cunninghamellamycosis Following Haematopoietic Stem Cell Transplantation?

Cunninghamellamycosis is an unusual but often highly fatal mucormycosis caused by Cunninghamella bertholletiae, which belongs to the basal lineage order Mucorales. It is especially fatal when the central nervous system is involved. So far, there are few reported cases of surgical treatment for intracranial mucormycosis in children after allogeneic haematopoietic stem cell transplantation (HSCT). The surgical management of deep-seated basal ganglia fungal lesions remains controversial, and its clinical benefits are not yet well established. Herein, we present a rare case of disseminated mucormycosis caused by C. bertholletiae involving the lung and intracranial basal ganglia after homologous leucocytic antigen-matched sibling donor HSCT. The patient was successfully treated for intracranial cunninghamellamycosis with neuroendoscopic surgery and systemic wide-spectrum antifungal treatment and achieved pulmonary recovery without recurrent C. bertholletiae infection or neurologic sequelae. Over the follow-up period of 13 months, there were no adverse events associated with the intracranial surgical debridement, and the patient remained in good health.

The Past, Present and Future of COVID-19 Associated Mucormycosis: A Rapid Review

Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2, which is known for the multiple mutations and forms that have rapidly spread across the world. With the imminent challenges faced by low- and middle-income countries in curbing the public health fallbacks due to limited resources, mucormycosis emerged as a fungal infection associated with high mortality. In this rapid review, we explored MEDLINE, Cochrane, Web of Science, WHO Global Database, and the search engine—Google Scholar for articles listed until July 2021 and presented a narrative synthesis of findings from 39 articles. The epidemiology, causative factors, incidence parameters, pharmacological treatment, and recommendations for low- and middle-income countries are enlisted. This study concludes that a majority of the globally reported COVID-19 associated mucormycosis cases stemmed from India. Individuals receiving systemic corticosteroids or who have a history of diabetes mellitus are more prone to contracting the disease. Public health authorities in LMIC are recommended to strengthen antifungal therapies for COVID-19 associated mucormycosis and to strategize reduction in diabetes mellitus prevalence.

COVID-19 associated mucormycosis: evolving technologies for early and rapid diagnosis

The post-coronavirus disease (COVID-19) mucormycosis is a deadly addition to the pandemic spectrum. Although it’s a rare, aggressive, and opportunistic disease, the associated morbidity and mortality are significant. The complex interplay of factors aggravating CAM is uncontrolled diabetes, irrational and excessive use of antibiotics, steroids, and an impaired immune system. Recently, India has been witnessing a rapid surge in the cases of coronavirus disease-associated mucormycosis (CAM), since the second wave of COVID-19. The devastating and lethal implications of CAM had now become a matter of global attention. A delayed diagnosis is often associated with a poor prognosis. Therefore, the rapid and early diagnosis of infection would be life-saving. Prevention and effective management of mucormycosis depend upon its early and accurate diagnosis followed by a multimodal therapeutic approach. The current review summarizes an array of detection methods and highlights certain evolving technologies for early and rapid diagnosis of CAM. Furthermore, several potential management strategies have also been discussed, which would aid in tackling the neglected yet fatal crisis of mucormycosis associated with COVID-19.

Case reports of invasive mucormycosis associated neutropenic enterocolitis in leukemic children: diagnostic and treatment challenges and review of literature

Background

Bacterial enterocolitis is one of the most common neutropenic fever complications during intensive chemotherapy. Despite aggressive antibacterial treatments, this complication usually imposes high morbidity and mortality in cancer patients. Management of bacterial neutropenic enterocolitis are well known; however, management of fungal neutropenic enterocolitis may be more challenging and needs to be investigated. Prompt diagnosis and treatment may be life-saving, especially in patients at risk of mucormycosis-associated neutropenic enterocolitis.

Case presentation

We report two mucormycosis-associated neutropenic enterocolitis cases in pediatric leukemic patients receiving salvage chemotherapy for disease relapse. Both patients' clinical signs and symptoms differ from classical bacterial neutropenic enterocolitis. They were empirically treated as bacterial neutropenic enterocolitis with anti-gram-negative combination therapy. Despite broad-spectrum antimicrobial treatment, no clinical improvement was achieved, and both of them were complicated with severe abdominal pain necessitating surgical intervention. Mucormycosis is diagnosed by immunohistopathologic examination in multiple intraoperative intestinal tissue biopsies. Both patients died despite antifungal treatment with liposomal amphotericin-B and surgical intervention.

Conclusion

Mucormycosis-associated neutropenic enterocolitis is one of the most unfavorable and untreatable side effects of salvage chemotherapy in leukemic children with disease relapse. This report could be of considerable insight to the clinicians and scientists who counter the enigma of fungal infections during febrile neutropenia and help to understand better diagnosis and management.

Systemic antifungal therapy with isavuconazonium sulfate or other agents in adults with invasive mucormycosis or invasive aspergillosis (non-fumigatus): A multicentre, non-interventional registry study

BACKGROUND

Isavuconazole, administered as isavuconazonium sulfate (ISAVUSULF), is a broad-spectrum triazole agent for the treatment of invasive fungal disease. In phase 3 studies, ISAVUSULF showed comparable efficacy to voriconazole and amphotericin B for the treatment of invasive aspergillosis (IA) and invasive mucormycosis (IM), respectively.

OBJECTIVES

The objective of this study is to determine all-cause mortality and safety outcomes among adults with IM and/or IA non-fumigatus (nf) treated with ISAVUSULF or other antifungal therapies (AFT).

PATIENTS AND METHODS

This multicentre, non-interventional registry enrolled patients aged ≥18 years with IM or IA-nf who received systemic AFT from January 2016 to November 2018. Patients received primary ISAVUSULF, non-primary ISAVUSULF, or other AFT, as monotherapy or combination therapy. The primary end point was all-cause mortality at Days 42 and 84; safety outcomes were adverse drug reactions (ADRs) to ISAVUSULF.

RESULTS

Of 204 patients enrolled, 74 received primary ISAVUSULF, 30 non-primary ISAVUSULF, and 100 other AFT. All-cause mortality through Day 42 was numerically lower in the non-primary ISAVUSULF group than in the primary ISAVUSULF and other AFT groups, for patients with IM (20.0% vs. 33.3% and 41.3%, respectively) or IA-nf (0% vs. 14.8% and 17.8%, respectively). All-cause mortality tended to be lower with combination therapy than with monotherapy, except for patients with IM receiving primary ISAVUSULF. Of 111 patients receiving ISAVUSULF, 14 (12.6%) reported ADRs, of whom three (2.7%) developed serious ADRs. There were no drug-related deaths.

CONCLUSIONS

This study supports the effectiveness and tolerability of ISAVUSULF in clinical practice. Further research is required to confirm the value of ISAVUSULF combination therapy over monotherapy.

Aspergillosis: Emerging risk groups in critically ill patients

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

LAY SUMMARY

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

Mucormycosis in burns: a review

Mucormycosis is a rare fungal infection with a high mortality rate. It presents with scattered black/necrotic ulcers, white fungal elements, and progression of wounds despite seemingly adequate debridement. Diagnosis is confirmed on wound histology, however this is often delayed. There is currently no comprehensive review of burn related mucormycosis within the literature, making this the first paper to provide evidence-based treatment guidance. We performed a review of publications from 1946 - present. There were 151 cases of mucormycosis complicating burns. The mortality rate was 54.5%, and there was a significant increase in mortality with axial body site involvement compared with isolated peripheral involvement. The standard treatment was prompt and radical debridement. Utilisation of frozen section to guide debridement aided in clinical decision making. No systemic treatment reached statistical significance, however amphotericin B trended towards significance. Although there is no strong evidence for topical amphotericin B or hyperbaric oxygen, there may be benefit in some cases. This study recommends early radical debridement in conjunction with the European Confederation of Medical Mycology guidelines of IV liposomal/lipid complex amphotericin B >5mg/kg/day, with posaconazole 800mg daily in divided doses as a salvage or oral step-down 1.

First reported case of late recurrence of pulmonary mucormycosis in a renal transplant recipient with poorly controlled diabetes mellitus

Pulmonary mucormycosis (PM) is a rare, life-threatening fungal infection usually affecting immunocompromised patients. Its incidence is rising, with a recent outbreak associated with COVID-19 co-infection. Amphotericin B along with early surgery are considered the standard treatment. Recurrence has been reported in patients without adequate treatment and without permanent reversal of predisposing factors. We report a case of late recurrence of PM in a renal transplant recipient. In 2012, he was diagnosed with PM. Imaging at the time showed a lingular mass. He was treated with antifungal for 1 year until complete radiological resolution. Surgical intervention was considered but no further follow-up action was taken. In 2020, he presented with fever and haemoptysis. Imaging again showed a lingular mass, which was confirmed to be PM by bronchoscopic lung biopsy. This case highlights the importance of secondary antifungal prophylaxis for PM if permanent reversal of immunosuppression is not possible.

A Fatal Case of Disseminated Intestinal Mucormycosis in a Patient with Vibrio Sepsis

Mucormycosis is a fungal infection that primarily causes opportunistic infections. Gastrointestinal mucormycosis is a rare infection that can occur in immunocompromised patients, nevertheless, prompt diagnosis and treatment is essential because it can be fatal. Gastrointestinal mucormycosis can only be diagnosed based on the findings of a pathological examination. Mucormycosis should be included in the differential diagnosis if the condition of patients with underlying immunocompromised conditions or diseases does not improve with general intensive care.

Diagnosis, treatment and maxillofacial rehabilitation in rhinocerebral mucormycosis patient: A case report and review of the literature

Mucormycosis is an aggressive, rare and opportunistic infectious disease, with a high mortality rate. Etiologic agents are filamentous fungi, and infection among humans normally occurs through spore inhalation. A 61-year-old male individual, presenting left eye amaurosis, dark epistaxis, hyperalgesia and malodor underwent clinical examination, which detected ulcerative lesion and wide bone exposure in the hard palate and alveolar ridge. Direct microbiological examination, microbiological culture and lesion biopsy were performed. Non-septate smooth fungal hyphae forming right angles with each other were observed through the direct microbiological examination. Microbiological culture revealed fast-growing fungal colonies with cottony texture, identified as Rhizopus sp. Histopathological examination exhibited necrosis areas, intense mononuclear inflammatory infiltrate and bulky hyphae, thus concluding the mucormycosis diagnosis. Amphotericin B antifungal therapy and surgical intervention were adopted as treatment. The patient was then rehabilitated with maxillofacial prosthesis, subsequently to the healing of the surgical wound.

Case Report: Diagnostic Value of Metagenomics Next Generation Sequencing in Intracranial Infection Caused by Mucor

mNGS(metagenomics Next Generation Sequencing), as a novel culture-independent approach, demonstrated the capability of rapid, sensitive, and accurate pathogen identification. At present, there have been many case reports about the use of mNGS to assist in the diagnosis of bacterial, fungal, viral and parasitic infections and to guide clinicians to determine appropriate treatment. However, the clinical understanding of this technique is not comprehensive, and the experience of using it is relatively limited. We reported a 53-year-old man who was admitted to hospital with a high fever and headache. His inflammatory biomarkers were markedly elevated. Based on the clinical presentation, He was initially diagnosed as having an intracranial infection of unknown etiology and received empirical antibiotics and systemic supportive treatment. But these did not relieve his symptoms. Both the blood and CSF specimens were examined using traditional culture, serological testing, and mNGS. Traditional culture and serological testing produced negative results, while the mNGS revealed the presence of a potential pathogen, mucor, in the CSF specimen. Then targeted antifungal treatment was selected quickly and his temperature gradually returned to normal. Thus, we report the case in which mNGS was an auxiliary method to diagnose mucormycosis, and discuss this case in combination with relevant literature, in order to improve the clinical cognition of this technology.

Nanomaterial-Based Antifungal Therapies to Combat Fungal Diseases Aspergillosis, Coccidioidomycosis, Mucormycosis, and Candidiasis

Over the last years, invasive infections caused by filamentous fungi have constituted a serious threat to public health worldwide. Aspergillus, Coccidioides, Mucorales (the most common filamentous fungi), and Candida auris (non-filamentous fungus) can cause infections in humans. They are able to cause critical life-threatening illnesses in immunosuppressed individuals, patients with HIV/AIDS, uncontrolled diabetes, hematological diseases, transplantation, and chemotherapy. In this review, we describe the available nanoformulations (both metallic and polymers-based nanoparticles) developed to increase efficacy and reduce the number of adverse effects after the administration of conventional antifungals. To treat aspergillosis and infections caused by Candida, multiple strategies have been used to develop new therapeutic alternatives, such as incorporating coating materials, complexes synthesized by green chemistry, or coupled with polymers. However, the therapeutic options for coccidioidomycosis and mucormycosis are limited; most of them are in the early stages of development. Therefore, more research needs to be performed to develop new therapeutic alternatives that contribute to the progress of this field.

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.

Fungal Genomics in Respiratory Medicine: What, How and When?

Respiratory infections caused by fungal pathogens present a growing global health concern and are a major cause of death in immunocompromised patients. Worryingly, coronavirus disease-19 (COVID-19) resulting in acute respiratory distress syndrome has been shown to predispose some patients to airborne fungal co-infections. These include secondary pulmonary aspergillosis and mucormycosis. Aspergillosis is most commonly caused by the fungal pathogen Aspergillus fumigatus and primarily treated using the triazole drug group, however in recent years, this fungus has been rapidly gaining resistance against these antifungals. This is of serious clinical concern as multi-azole resistant forms of aspergillosis have a higher risk of mortality when compared against azole-susceptible infections. With the increasing numbers of COVID-19 and other classes of immunocompromised patients, early diagnosis of fungal infections is critical to ensuring patient survival. However, time-limited diagnosis is difficult to achieve with current culture-based methods. Advances within fungal genomics have enabled molecular diagnostic methods to become a fast, reproducible, and cost-effective alternative for diagnosis of respiratory fungal pathogens and detection of antifungal resistance. Here, we describe what techniques are currently available within molecular diagnostics, how they work and when they have been used.

Invasive Mucormycosis Involving the Laryngopharynx After Bone Marrow Transplantation

ABSTRACT

Invasive larynx or pharyngeal fungal infections are rare. We report an invasive fungal laryngopharyngitis patient who complained of a persistent sore throat after an allogenic bone marrow transplant and a haploidentical stem cell transplant. An antifungal gargle was used after finding necrotic changes extending from the right soft palate to the aryepiglottic fold. Biopsy and culture suggested a fungal infection with suspicious mucormycosis. Imaging showed the right oropharynx, supraglottis, and the parapharnygeal space were involved. After initiating liposomal amphotericin B for 4 days, wide excisional debridement, and a partial pharyngectomy with an anterolateral thigh free flap including the deep fascia were performed. Amphotericin B and posaconazole were used subsequently. Pathology assessment indicated invasive mucormycosis. There was no recurrence for 9 months. Mucormycosis is a fatal opportunistic infection often seen in immunocompromised patients. Rapid detection, radical resection, and reconstruction can save the patient from a life-threatening fungal infection of the laryngopharynx.

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

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

How urgent is the need for new antifungals?

Introduction: Invasive fungal infection carries a high morbidity, mortality and economic cost. In recent times, a rising incidence of fungal infection and antifungal resistance is occurring which has prompted the development of novel antifungal agents.Areas covered:In this perspective, the authors describe the current status of registered antifungals and their limitations in the treatment of invasive fungal infection. They also go on to describe the new antifungal agents that are in the clinical stage of development and how they might be best utilized in patient care in the future.Expert opinion: The antifungal drug development pipeline has responded to a growing need for new agents to effectively treat fungal disease without concomitant toxicity or issues with drug tolerance. Olorofim (F901318), ibrexafungerp (SCY-078), fosmanogepix (APX001), rezafungin (CD101), oteseconazole (VT-1161), encochleated amphotericin B (MAT2203), nikkomycin Z (NikZ) and ATI-2307 are all in the clinical stage of development and offer great promise in offering clinicians better agents to treat these difficult infections.

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.

Clinical and microbiological features and outcomes of mucormycosis in critically ill patients

INTRODUCTION

Mucormycosis is a rare invasive fungal infection with high mortality in patients with severe underlying predisposing factors causing immunosuppression. The exact incidence of mucormycosis and the optimal therapeutic approach is difficult to determine, especially in severe cases, due to the rarity of the disease. The new second-generation triazole isavuconazole provides an alternative treatment option which may represent a potential benefit in severe cases.

MATERIALS AND METHODS

A retrospective case series was conducted of patients with a positive laboratory culture for Mucorales and consistent clinical findings who required intensive care treatment. Patient characteristics including demographics, comorbidities, microbiological analysis, specific antifungal therapy and clinical outcome were analysed.

RESULTS

Fifteen critically ill patients with Mucorales detected between 2016 and 2019 were included in this study; the crude mortality rate was 100%. At the time of diagnosis of mucormycosis, 80% of subjects had relevant medical immunosuppression and 53.3% of subjects had neutropenia. Manifestation of mucormycosis was pulmonary in 53.3% of subjects, rhino-orbital in 20% of subjects and disseminated in 26.7% of subjects. Notably, 40% of all patients had received antifungal prophylaxis prior to mucormycosis, mainly with posaconazole due to underlying haematological malignancy, thus possibly representing break-through infections. Antifungal therapy for invasive mucormycosis was administered in 80% of subjects for a median duration of 16 days.

CONCLUSION

In this retrospective cohort analysis of intensive care patients, the prognosis of mucormycosis was extremely poor. An aggressive strategy for diagnosis and treatment is essential for intensive care patients with mucormycosis. There is a need for further research to determine if combination therapy in higher dosages or prompt surgery is beneficial in severe critically ill patients.

Coinfection pulmonary mucormycosis and aspergillosis with disseminated mucormycosis involving gastrointestinalin in an acute B-lymphoblastic leukemia patient

Pulmonary mucormycosis and aspergillosis with disseminated mucormycosis involving gastrointestinalin is a very rare but lethal infection leading to extreme mortality. Herein, we present a unique case of pulmonary coinfection with Cunninghamella bertholletiae and Aspergillus flavus, with disseminated mucormycosis involving the jejunum caused by C. bertholletiae in an acute B-lymphocytic leukemia (B-ALL) patient with familial diabetes. Early administration of active antifungal agents at optimal doses and complete resection of all infected tissues led to improved therapeutic outcomes.

[Mucormycosis: Current and future management perspective]

Infections caused by mucorales, with an increasing incidence after candidiasis and aspergillosis, are characterized by the fast angioinvasion of blood vessels and invasion of neighboring organs or structures. Mucorales most commonly cause rhinocerebral, pulmonary, cutaneous, digestive or disseminated infections, and their spread is favored by certain underlying diseases (diabetes, kidney failure) and risk factors (neutropenia, immunosuppression, iron overload). These infections have a high mortality rate, over 40% in many series, and the key to their cure depends on both an early diagnosis and an antifungal treatment, associated in most cases with extensive surgical debridement and other adjunctive therapies. Currently, there are international guidelines, not only local ones, for the management of mucormycosis, in which it is considered by consensus and with a strong recommendation that first-line treatment with high-dose liposomal amphotericin B is the best choice. The combined antifungal treatment of polyene agents with triazoles or candins remains in open debate.

Rhizopus microsporus typhlitis in a patient with acute myelogenous leukemia

While patients undergoing treatment for hematologic malignancies are at risk for a variety of infections, gastrointestinal mucormycosis is a rare and feared complication. Diagnosis requires a high index of suspicion and timely evaluation. Prompt treatment improves patient outcomes.

Mucormycosis

Mucormycosis is a rare but aggressive fungal disease that mainly affects patients with poorly controlled diabetes mellitus and those who are severely immunocompromised, including patients with hematological malignancies and solid organ transplant recipients. Early recognition of infection is critical for treatment success, followed by prompt initiation of antifungal therapy with lipid formulation amphotericin B. Posaconazole and isavuconazole should be used for stepdown and salvage therapy. Surgical debridement is key for tissue diagnosis and treatment and should be pursued urgently whenever possible. In addition to surgery and antifungal therapy, reverting the underlying risk factor for infection is important for treatment response.

Breakthrough Invasive Fungal Infections in Allogeneic Hematopoietic Stem Cell Transplantation

Despite the recent introduction of mold-active antifungal prophylaxis (MAP), breakthrough invasive fungal infections (b-IFI) still represent a possible complication and a cause of morbidity and mortality in hematological patients and allogeneic hematopoietic stem-cell transplantation recipients (HSCT). Data on incidence and type of b-IFI are limited, although they are mainly caused by non-fumigatus Aspergillus and non-Aspergillus molds and seem to depend on specific antifungal prophylaxis and patients’ characteristics. Herein, we described the clinical presentation and management of two cases of rare b-IFI which recently occurred at our institution in patients undergoing HSCT and receiving MAP. The management of b-IFI is challenging due to the lack of data from prospective trials and high mortality rates. A thorough analysis of risk factors, ongoing antifungal prophylaxis, predisposing conditions and local epidemiology should drive the choice of antifungal treatments. Early broad-spectrum preemptive therapy with a lipid formulation of amphotericin-B, in combination with a different mold-active azole plus/minus terbinafine, is advisable. The therapy would cover against rare azole-susceptible and -resistant fungal strains, as well as atypical sites of infections. An aggressive diagnostic work-up is recommended for species identification and subsequent targeted therapy.

The use of posaconazole delayed-release tablets in the successful treatment of suspected mucormycosis in a bottlenose dolphin (Tursiops truncatus) calf

Mucorales infections in cetaceans have a high mortality rate. This case report refers to a bottlenose dolphin calf with suspected mucormycosis treated with posaconazole. This antifungal agent was discontinued after 96 days of therapy, however, the infection relapsed. Posaconazole was then resumed for a total of 255 days, with no signs of disease reactivation. The retrospective analysis of posaconazole serum levels in this successful case showed concentrations varying between 5.18 and 11.63 mg/L.

Clinical utility of antifungal susceptibility testing in patients with fungal rhinosinusitis

PURPOSE

To determine the association between antifungal susceptibility test (AFST) results and in vivo therapeutic response in Indian patients with fungal rhinosinusitis.

METHODS

The clinicoradiological, fungal culture, AFST, histopathology results and outcomes of 48 patients with fungal rhinosinusitis seen between 20132015 were analysed. Minimum inhibitory concentration (MIC) determination was performed for amphotericin B, itraconazole, voriconazole and posaconazole.

RESULTS

Forty patients had invasive and 8 had non-invasive fungal sinusitis. Rhizopus and Aspergillus species which comprised 46.9% each of isolates were mostly associated with acute invasive fungal rhinosinusitis and chronic granulomatous fungal rhinosinusitis respectively. All patients with non-invasive fungal rhinosinusitis had Aspergillus isolates. The Geometric Mean (GM) MIC for R. arrhizus of amphotericin B and posaconazole was 0.51 mcg/mL and 3.08 mcg/mL respectively and for A. flavus species for amphotericin B and voriconazole values were 1.41mcg/mL and 0.35 mcg/mL respectively. In patients with Aspergillus infections, while there was no association of MICs for azoles and outcome (p = 1), a strong association was noted between azole therapy and a good outcome (p = 0.003). In patients with Rhizopus infections, no association was found between MICs for amphotericin B and outcome (p = 1) and because of therapeutic complications, no association was found between amphotericin B therapy and outcome (p = 1).

CONCLUSION

No significant association exists between in vitro (AFST) and in vivo responses despite low GM MICs for the drugs used in Aspergillus and Rhizopus infections. Therapeutic complications following conventional amphotericin B therapy confounds analysis. Clinical responses suggest that azoles are the drug of choice for Aspergillus infections.

Emerging Invasive Fungal Infections in Critically Ill Patients: Incidence, Outcomes and Prognosis Factors, a Case-Control Study

Comprehensive data on emerging invasive fungal infections (EIFIs) in the critically ill are scarce. We conducted a case-control study to characterize EIFIs in patients admitted to a French medical ICU teaching hospital from 2006 to 2019. Among 6900 patients, 26 (4 per 1000) had an EIFI: Mucorales accounted for half, and other isolates were mainly Saprochaete, Fusarium and Scedosporium. EIFIs occurred mostly in patients with immunosuppression and severe critical illness. Antifungal treatments (mainly amphotericin B) were administered to almost all patients, whereas only 19% had surgery. In-ICU, mortality was high (77%) and associated with previous conditions such as hematological malignancy or cancer, malnutrition, chronic kidney disease and occurrence of acute respiratory distress syndrome and/or hepatic dysfunction. Day-90 survival rates, calculated by the Kaplan-Meier method, were similar between patients with EIFIs and a control group of patients with aspergillosis: 20%, 95% CI (9- 45) versus 18%, 95% CI (8- 45) (log-rank: p > 0.99). ICU management of such patients should be assessed on the basis of underlying conditions, reversibility and acute event severity rather than the mold species.

Characterization of Three Pleiotropic Drug Resistance Transporter Genes and Their Participation in the Azole Resistance of Mucor circinelloides

Mucormycosis is a life-threatening opportunistic infection caused by certain members of the fungal order Mucorales. This infection is associated with high mortality rate, which can reach nearly 100% depending on the underlying condition of the patient. Treatment of mucormycosis is challenging because these fungi are intrinsically resistant to most of the routinely used antifungal agents, such as most of the azoles. One possible mechanism of azole resistance is the drug efflux catalyzed by members of the ATP binding cassette (ABC) transporter superfamily. The pleiotropic drug resistance (PDR) transporter subfamily of ABC transporters is the most closely associated to drug resistance. The genome of Mucor circinelloides encodes eight putative PDR-type transporters. In this study, transcription of the eight pdr genes has been analyzed after azole treatment. Only the pdr1 showed increased transcript level in response to all tested azoles. Deletion of this gene caused increased susceptibility to posaconazole, ravuconazole and isavuconazole and altered growth ability of the mutant. In the pdr1 deletion mutant, transcript level of pdr2 and pdr6 significantly increased. Deletion of pdr2 and pdr6 was also done to create single and double knock out mutants for the three genes. After deletion of pdr2 and pdr6, growth ability of the mutant strains decreased, while deletion of pdr2 resulted in increased sensitivity against posaconazole, ravuconazole and isavuconazole. Our result suggests that the regulation of the eight pdr genes is interconnected and pdr1 and pdr2 participates in the resistance of the fungus to posaconazole, ravuconazole and isavuconazole.

In Vitro Antifungal Drug Resistance Profiles of Clinically Relevant Members of the Mucorales (Mucoromycota) Especially with the Newer Triazoles

Mucoromycoses (infections caused by members of the order Mucorales, phylum Mucoromycota [ex-Zygomycota]) are highly destructive, rapidly progressive infections, with dire prognoses especially when they occur in immunocompromised hosts. Current treatment guidelines recommend liposomal formulations of amphotericin B with adjunctive surgery as first line therapy, with the newer triazoles posaconazole or isavuconazole as alternative treatments, or as salvage therapy. Among the many organisms belonging to this order, a limited number of species in the genera Rhizopus, Mucor, Lichtheimia and Rhizomucor are responsible for most cases of human infection. Here, we present the minimum inhibitory concentration data (MICs) for amphotericin B, posaconazole, isavuconazole, itraconazole and voriconazole with a panel of over 300 isolates of the five most common agents of human infection (Lichtheimia corymbifera, Rhizopus arrhizus, R. microsporus, Rhizomucor pusillus and Mucor spp.) determined using the CLSI broth microdilution method. In agreement with previous studies, the most active antifungal drug for all Mucorales was amphotericin B, with MICs within the range that would predict susceptibility with Aspergillus fumigatus. Conversely, MICs for voriconazole against all species tested were high, and above the range associated with clinical efficacy with A. fumigatus. Interestingly, whilst isavuconazole and posaconazole MIC distributions indicated in vitro activity against some members of the Mucorales, activity was species-dependent for both agents. These data underscore the importance of accurate identification of the causative agents of mucoromycosis, coupled with antifungal susceptibility testing of individual isolates, in determining the optimal treatment of infections caused by these aggressive opportunistic human fungal pathogens.

Fungal Infections of Oral Cavity: Diagnosis, Management, and Association with COVID-19

The frequency of fungal infections is increasing due to immunodeficiency viruses and immunosuppressive drugs. The most common fungal infection of the oral cavity is candidiasis. The existence of Candida can be a part of normal commensal; hence, the isolation of Candida in the absence of clinical symptoms should exclude candidiasis. The pathogenicity of Candida is witnessed as opportunistic when immune status is compromised. Oral fungal infections are uncommon, but when identified, these infections are associated with greater discomfort and are sometimes destruction of tissues. Cytology and tissue biopsy are helpful in confirming the clinical diagnosis. The management of oral fungal infections must strategically focus on signs, symptoms, and culture reports. This article reviews information on diagnosis and therapeutic management of aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, mucormycosis, and geotrichosis.

Hyperbaric oxygen treatment: Results in seven patients with severe bacterial postoperative central nervous system infections and refractory mucormycosis

INTRODUCTION

Resistant bacterial infections following brain and spine surgery and spontaneous mucormycosis with central nervous system (CNS) involvement represent a serious treatment challenge and more efficient therapeutic approaches ought to be considered. Hyperbaric oxygen treatment (HBOT) has shown promise as a complementary therapy. This case series evaluated whether HBOT contributed to infection resolution in seven patients with refractory CNS infectious conditions.

METHODS

Clinical results for seven patients referred for HBOT between 2010 to 2018 to treat refractory postoperative brain and spine infections or spontaneously developing mucormycosis were retrospectively analysed. The patients' clinical files and follow-up consultations were reviewed to assess evolution and outcome.

RESULTS

Seven patients were referred with a median age of 56 years. The median follow-up was 20 months. Four patients had postoperative infections and three had rhino-orbital-cerebral mucormycosis (ROCM). HBOT was used as an adjunctive treatment to antimicrobial therapy in all patients. Prior to HBOT, all patients had undergone an average of four operations due to infection refractoriness and had completed an average of five months of antimicrobial therapy. After HBOT, infection resolution was obtained in six patients without additional operations, while one patient with ROCM stopped HBOT after the third session due to intolerance. Three patients stopped antimicrobial therapy while four were maintained on prophylactic treatment.

CONCLUSIONS

Infection resolution was reached in the six patients that completed HBOT as prescribed. HBOT may serve as an effective complementary treatment in CNS refractory postoperative and spontaneous infections.

Invasive aspergillosis in solid organ transplant patients: diagnosis, prophylaxis, treatment, and assessment of response

BACKGROUND

Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Although IA has significant implications on graft and patient survival, data on diagnosis and management of this infection in SOT recipients are still limited.

METHODS

Discussion of current practices and limitations in the diagnosis, prophylaxis, and treatment of IA and proposal of means of assessing treatment response in SOT recipients.

RESULTS

Liver, lung, heart or kidney transplant recipients have common as well as different risk factors to the development of IA, thus each category needs a separate evaluation. Diagnosis of IA in SOT recipients requires a high degree of awareness, because established diagnostic tools may not provide the same sensitivity and specificity observed in the neutropenic population. IA treatment relies primarily on mold-active triazoles, but potential interactions with immunosuppressants and other concomitant therapies need special attention.

CONCLUSIONS

Criteria to assess response have not been sufficiently evaluated in the SOT population and CT lesion dynamics, and serologic markers may be influenced by the underlying disease and type and severity of immunosuppression. There is a need for well-orchestrated efforts to study IA diagnosis and management in SOT recipients and to develop comprehensive guidelines for this population.

Successful treatment of Rhizopus arrhizus rhino-orbital-cerebral mucormycosis with isavuconazole salvage therapy following extensive debridement

A 61-year old lady with poorly-controlled type 2 diabetes mellitus was diagnosed with rhino-orbital-cerebral mucormycosis following presentation with sinusitis, ophthalmoplegia, proptosis and facial numbness. She was treated successfully with aggressive surgical intervention including orbital exenteration, accompanied by anti-fungal therapy with liposomal amphotericin B and posaconazole, followed by isavuconazole as salvage therapy. We discuss the challenges around optimising antifungal therapy of this lethal infection in the context of hepatic and renal toxicity.

Rhizomucor hepatosplenic abscesses in a patient with renal and pancreatic transplantation

Fungal infections are generally observed in immunosuppressed patients only, with a diagnostic challenge due to non-specific symptoms. For this reason, appropriate management may be delayed. This case report concerns a 36-year-old man with history of pancreas and kidney transplantation. He had chemotherapy for post-transplant B-cell lymphoma and presented with left upper abdominal pain and fever. Multiple investigations led to a final diagnosis of disseminated abdominal mucormycosis with multiple Rhizomucor abscesses in the liver, spleen and kidney transplant. Treatment was antifungal therapy and laparotomy with splenectomy, wedge resection of two fungal abscesses in segments II and IVb, and segmental left colic resection.

A 51-Year-Old Woman With a Mediastinal Mass

CASE PRESENTATION

A 51-year-old woman with a medical history of poorly controlled type 1 diabetes mellitus, hyperthyroidism, and tobacco abuse was admitted to the hospital with persistent nausea, vomiting, abdominal discomfort, dry cough, rhinorrhea, and sore throat. She denied fevers, chills, rigors, shortness of breath, hemoptysis, nasal congestion, postnasal drip, and facial pain. She denied any sick contacts, and there was no recent travel outside of Chicago.

The reverse halo sign and spontaneous pneumothorax due to pulmonary mucormycosis

Pulmonary mucormycosis (PM) is a rare opportunistic fungal infection that commonly affects immunocompromised patients. Early diagnosis and initiation of appropriate anti-fungal therapy are crucial, as delay in diagnosis leads to increased mortality. However, the diagnosis is often challenging because of the lack of utility of serum markers and low culture sensitivity. Definitive diagnosis often requires invasive tissue sampling, which may delay treatment. Therefore, chest imaging findings play an important role in the diagnosis of suspected cases. This case highlights the importance of classic reverse halo sign and presence of necrotizing cystic changes resulting in spontaneous pneumothorax in a patient who was later found to have invasive PM.

Mucormycosis: Literature review and retrospective report of 15 cases from Portugal

Background and Purpose:

Prevalence of mucormycosis is growing with the increase of the population at risk. Current recommendations for its management are mostly based on retrospective studies. 3 study aimed to present the cumulative experience of an Infectious Diseases Department from a Portuguese hospital in the management of mucormycosis and discuss the potential gaps in the diagnostic and therapeutic approaches of this infection.

Materials and Methods:

For the purposes of the study, the electronic hospital database was searched for adult patients with mucormycosis from 1996 to 2019 based on the definition provided by the Consensus Definitions of Invasive Fungal Disease. Demographic, clinical, treatment, and outcome data were collected and compared to what had been described in the related literature.

Results:

In total, 15 cases of mucormycosis were found, including 11 cases with sinus involvement (10 with central nervous system involvement), two pulmonary, and two gastrointestinal infections. Diabetes mellitus (n=7) and corticosteroid therapy (n=7) were frequent risk factors. Median duration of symptoms before the suspicion of diagnosis was 26 days (3-158). The diagnosis was confirmed in 12 patients mostly by histopathology (n=9); the culture was positive only once. Systemic antifungals and surgical debridement were the backbones of treatment; however, side effects, the need for therapeutic drug monitoring, and the anatomical location of lesions added complexity to management. Overall, seven patients died, two of them before the consideration of clinical suspicion.

Conclusion:

More medications are becoming available for the treatment of mucormycosis. Nevertheless, we believe that its prognosis will only significantly change through the increase of awareness and reduction of the time to diagnosis. An effective multidisciplinary approach among surgeons, infectious diseases specialists, radiologists, microbiologists, and anatomopathologists is critical to the achievement of this goal.

Oral posaconazole and bronchoscopy as a treatment for pulmonary mucormycosis in pediatric acute lymphoblastic leukemia patient: A case report

RATIONALE

Mucormycosis is a rare fungal infection that typically occurs in immunosuppressed patients following chemotherapy or hematopoietic stem cell transplantation.

PATIENT CONCERNS

An 11-year-old child with newly developed acute lymphoblastic leukemia suffered from the paroxysmal left chest pain, fever, and hemoptysis.

DIAGNOSES

We made a histopathologic diagnosis aided by bronchoscopy techniques, which indicated invasive fungal hyphae that are characteristic of mucormycosis.

INTERVENTIONS

The patient was treated with oral posaconazole and repeated bronchoscopy interventions for 4 months.

OUTCOMES

The patient's clinical signs and symptoms and signs were no longer present. The prior lung lesions were also no longer observable using radiologic methods, and a 3-month follow-up with the patient showed no signs of mucormycosis recurrence. Finally, the patient was cured, when the cancer chemotherapy was stopped. Close follow-up for another 2 years showed no evidence of recurrence.

LESSONS

Mucormycosis diagnosis is difficult as clinical and imaging findings vary. This case demonstrates that posaconazole monotherapy combined with bronchoscopy interventions may be a safe and effective treatment option for pediatric pulmonary mucormycosis.

Transdiaphragmatic Mucormycosis

Mucormycosis is a life-threatening infection. This is the first report of transdiaphragmatic mucormycosis in a series of 3 patients. We observed this phenomenon in 11% of patients. Clinicians should be aware of this possibly underreported entity, and as a consequence we envision more comprehensive imaging studies in patients with mucormycosis.

The role of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) in assessment of complex invasive fungal disease and opportunistic co-infections in patients with acute leukemia prior to allogeneic hematopoietic cell transplant

INTRODUCTION

Individuals diagnosed with acute lymphoid and myeloid malignancies are at significant risk of invasive fungal and bacterial infections secondary to their marked immunocompromised states with a significant high risk of mortality. The role of metabolic imaging with 18F-Fluorodeoxyglucose (FDG) Positron Emission Tomography/Computed Tomography (PET/CT) has been increasingly recognized in optimizing the diagnosis of invasive infection, monitoring the response to therapy and guiding the duration of antimicrobial therapy or need to escalate to surgical intervention.

METHODS

Two distinct cases of pulmonary co-infection of rare fungal and bacterial pathogens are explored in severely immunocompromised individuals where FDG PET/CT aided both patients to make a full recovery and transition to HCT. The first case explores mixed Scedosporium apiospermum and Rhizomucor pulmonary infection on a background of T cell/myeloid mixed phenotype acute leukemia ultimately warranting long-term antifungal therapy and lobectomy prior to HCT. The second case explores Fusarium and Nocardia pulmonary infection on a background of relapsed AML also warranting surgical resection with lobectomy and long-term antimicrobials prior to transition to HCT.

DISCUSSION

The cases highlight the utility of FDG PET/CT to support the diagnosis of infections, including the presence or absence of disseminated infection, and to provide highly sensitive monitoring of the infection over time. FDG PET/CT played a key role in directing therapy duration decisions and prompted the necessity for surgical intervention. Ultimately, the use of FDG PET/CT allowed for a successful transition to HCT highlighting its value in this clinical setting.

CONCLUSION

FDG PET/CT has an emerging role in the diagnostic and monitoring pathway for complex infections in high-risk immunocompromised patients.

Johnson E, Littlechild J, Winlove CP, Vollmer F, Gow NAR. Biosensors and Diagnostics for Fungal Detection

Early detection is critical to the successful treatment of life-threatening infections caused by fungal pathogens, as late diagnosis of systemic infection almost always equates with a poor prognosis. The field of fungal diagnostics has some tests that are relatively simple, rapid to perform and are potentially suitable at the point of care. However, there are also more complex high-technology methodologies that offer new opportunities regarding the scale and precision of fungal diagnosis, but may be more limited in their portability and affordability. Future developments in this field are increasingly incorporating new technologies provided by the use of new format biosensors. This overview provides a critical review of current fungal diagnostics and the development of new biophysical technologies that are being applied for selective new sensitive fungal biosensors to augment traditional diagnostic methodologies.

Topical Treatment for Cutaneous Mucormycosis of the Upper Extremity

Mucormycosis is a relatively rare but extremely aggressive fungal infection that commonly affects patients who are compromised hosts. These infections typically come in various patterns: pulmonary, sinus, rhinocerebral, cerebral, cutaneous, or disseminated forms. Treatment usually consists of a combination of antifungal agents and surgical debridement, although morbidity and mortality are high. In this case report, we describe the course of a patient with a disseminated Mucor infection, primarily involving the upper extremities, who was successfully treated with topical and systemic antifungal agents without the need for surgical intervention.

Introduction of a Comprehensive Diagnostic and Interdisciplinary Management Approach in Haematological Patients with Mucormycosis: A Pre and Post-Intervention Analysis

Mucormycosis is a life threatening infection in patients with haematological disease. We introduced a Mucorales-PCR and an aggressive, multidisciplinary management approach for mucormycosis during 2016-2017 and evaluated patient outcomes in 13 patients diagnosed and treated in 2012-2019. Management principle: repeated surgical debridement until biopsies from the resection margins were clean as defined by negative Blankophor microscopy, Mucorales-PCR (both reported within 24 h), and cultures. Cultured isolates underwent EUCAST E.Def 9.3.1 susceptibility testing. Antifungal therapy (AFT) (mono/combination) combined with topical AFT (when possible) was given according to the minimal inhibitory concentration (MIC), severity of the infection, and for azoles, specifically, it was guided by therapeutic drug monitoring. The outcome was evaluated by case record review. All patients underwent surgery guided by diagnostic biopsies from tissue and resection margins (195 samples in total). Comparing 2012-2015 and 2016-2019, the median number of patients of surgical debridements was 3 and 2.5 and of diagnostic samples: microscopy/culture/PCR was 3/3/6 and 10.5/10/10.5, respectively. The sensitivity of microscopy (76%) and Mucorales-PCR (70%) were similar and microscopy was superior to that of culture (53%; p = 0.039). Initial systemic AFT was liposomal amphotericin B (n = 12) or posaconazole (n = 1) given as monotherapy (n = 4) or in combination with isavuconazole/posaconazole (n = 3/6) and terbinafine (n = 3). Nine patients received topical amphotericin B. All received isavuconazole or posaconazole consolidation therapy (n = 13). Mucormycosis related six month mortality was 3/5 in 2012-2015 and 0/7 patients in 2016-2019 (one patient was lost for follow-up). Implementation of combination therapy (systemic+topical AFT/combination systemic AFT) and aggressive surgical debridement guided by optimised diagnostic tests may improve the outcome of mucormycosis in haematologic patients.

The Diagnostic Pitfalls of Mucormycosis

BACKGROUND

Invasive mucormycosis is a very aggressive fungal disease among immunocompromised pediatric patients caused by saprophytic fungi that belong to the order of the Mucorales.

CASE REPORT

We describe a case of of Lichtheimia corymbifera infection in a 15-year-old child with B-cell-Non-Hodgkin Lymphoma (B-NHL) involving lung, kidney and thyroid that initially was diagnosed as probable aspergillosis delaying the effective therapy for mucormycosis.

CONCLUSIONS

This case showed that also the intensive chemotherapy for B-NHL may represent a risk factor for mucormycosis infection. Liposomal amphotericin B and surgery remain the key tools for the successful treatment of this aggressive disease.

Iron Assimilation during Emerging Infections Caused by Opportunistic Fungi with emphasis on Mucorales and the Development of Antifungal Resistance

Iron is a key transition metal required by most microorganisms and is prominently utilised in the transfer of electrons during metabolic reactions. The acquisition of iron is essential and becomes a crucial pathogenic event for opportunistic fungi. Iron is not readily available in the natural environment as it exists in its insoluble ferric form, i.e., in oxides and hydroxides. During infection, the host iron is bound to proteins such as transferrin, ferritin, and haemoglobin. As such, access to iron is one of the major hurdles that fungal pathogens must overcome in an immunocompromised host. Thus, these opportunistic fungi utilise three major iron acquisition systems to overcome this limiting factor for growth and proliferation. To date, numerous iron acquisition pathways have been fully characterised, with key components of these systems having major roles in virulence. Most recently, proteins involved in these pathways have been linked to the development of antifungal resistance. Here, we provide a detailed review of our current knowledge of iron acquisition in opportunistic fungi, and the role iron may have on the development of resistance to antifungals with emphasis on species of the fungal basal lineage order Mucorales, the causative agents of mucormycosis.