201
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Nair AG, Dave TV. Transcutaneous retrobulbar injection of amphotericin B in rhino-orbital-cerebral mucormycosis: a review. Orbit 2021; 41:275-286. [PMID: 34720026 DOI: 10.1080/01676830.2021.1990351] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Mucormycosis is an aggressive and potentially fatal invasive fungal infection. The most common form of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). While it is commonly seen in immunocompromised patients, it is also known to affect healthy individuals. The global disease burden of ROCM has increased significantly following the surge in cases during the COVID-19 pandemic. Endoscopic sinus debridement, systemic antifungal therapy, and control of the underlying immunosuppressive condition are essential for the management of ROCM. Orbital involvement, however, presents a challenge to clinicians. Intervention strategies that have been described to treat orbital disease include orbital exenteration, conservative orbital debridement with or without irrigation with amphotericin B and transcutaneous retrobulbar injection of amphotericin B (TRAMB). Currently, there is a lack of clarity regarding the indications and outcomes of TRAMB as a treatment modality. In this review, the drug formulations used, the complications, and outcomes of previously described cases that have used TRAMB in cases of ROCM are discussed. Favorable outcomes following TRAMB depend on appropriate patient selection and radiological evidence of the orbital burden of the disease. This review aims to familiarize clinicians with objective parameters for patient selection for TRAMB, namely the extent of the disease, the clinical features, and radiological findings; viz. the clinical interpretation of areas of contrast uptake and those of necrosis. TRAMB can be considered as a viable option in select cases of orbital mucormycosis where exenteration or debridement are not indicated, or when there is limited orbital disease.
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Affiliation(s)
- Akshay Gopinathan Nair
- Ophthalmic Plastic Surgery and Ocular Oncology Services, Aditya Jyot Eye Hospital, Mumbai, India.,Advanced Eye Hospital & Institute, Navi Mumbai, India.,Department of Ophthalmology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.,Ophthalmic Plastic Surgery and Ocular Oncology Services, R. Jhunjhunwala Sankara Eye Hospital, Panvel, India
| | - Tarjani Vivek Dave
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, India
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202
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Bretagne S, Sitbon K, Botterel F, Dellière S, Letscher-Bru V, Chouaki T, Bellanger AP, Bonnal C, Fekkar A, Persat F, Costa D, Bourgeois N, Dalle F, Lussac-Sorton F, Paugam A, Cassaing S, Hasseine L, Huguenin A, Guennouni N, Mazars E, Le Gal S, Sasso M, Brun S, Cadot L, Cassagne C, Cateau E, Gangneux JP, Moniot M, Roux AL, Tournus C, Desbois-Nogard N, Le Coustumier A, Moquet O, Alanio A, Dromer F. COVID-19-Associated Pulmonary Aspergillosis, Fungemia, and Pneumocystosis in the Intensive Care Unit: a Retrospective Multicenter Observational Cohort during the First French Pandemic Wave. Microbiol Spectr 2021; 9:e0113821. [PMID: 34668768 PMCID: PMC8528108 DOI: 10.1128/spectrum.01138-21] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/17/2021] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to evaluate diagnostic means, host factors, delay of occurrence, and outcome of patients with COVID-19 pneumonia and fungal coinfections in the intensive care unit (ICU). From 1 February to 31 May 2020, we anonymously recorded COVID-19-associated pulmonary aspergillosis (CAPA), fungemia (CA-fungemia), and pneumocystosis (CA-PCP) from 36 centers, including results on fungal biomarkers in respiratory specimens and serum. We collected data from 154 episodes of CAPA, 81 of CA-fungemia, 17 of CA-PCP, and 5 of other mold infections from 244 patients (male/female [M/F] ratio = 3.5; mean age, 64.7 ± 10.8 years). CA-PCP occurred first after ICU admission (median, 1 day; interquartile range [IQR], 0 to 3 days), followed by CAPA (9 days; IQR, 5 to 13 days), and then CA-fungemia (16 days; IQR, 12 to 23 days) (P < 10-4). For CAPA, the presence of several mycological criteria was associated with death (P < 10-4). Serum galactomannan was rarely positive (<20%). The mortality rates were 76.7% (23/30) in patients with host factors for invasive fungal disease, 45.2% (14/31) in those with a preexisting pulmonary condition, and 36.6% (34/93) in the remaining patients (P = 0.001). Antimold treatment did not alter prognosis (P = 0.370). Candida albicans was responsible for 59.3% of CA-fungemias, with a global mortality of 45.7%. For CA-PCP, 58.8% of the episodes occurred in patients with known host factors of PCP, and the mortality rate was 29.5%. CAPA may be in part hospital acquired and could benefit from antifungal prescription at the first positive biomarker result. CA-fungemia appeared linked to ICU stay without COVID-19 specificity, while CA-PCP may not really be a concern in the ICU. Improved diagnostic strategy for fungal markers in ICU patients with COVID-19 should support these hypotheses. IMPORTANCE To diagnose fungal coinfections in patients with COVID-19 in the intensive care unit, it is necessary to implement the correct treatment and to prevent them if possible. For COVID-19-associated pulmonary aspergillosis (CAPA), respiratory specimens remain the best approach since serum biomarkers are rarely positive. Timing of occurrence suggests that CAPA could be hospital acquired. The associated mortality varies from 36.6% to 76.7% when no host factors or host factors of invasive fungal diseases are present, respectively. Fungemias occurred after 2 weeks in ICUs and are associated with a mortality rate of 45.7%. Candida albicans is the first yeast species recovered, with no specificity linked to COVID-19. Pneumocystosis was mainly found in patients with known immunodepression. The diagnosis occurred at the entry in ICUs and not afterwards, suggesting that if Pneumocystis jirovecii plays a role, it is upstream of the hospitalization in the ICU.
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Affiliation(s)
- Stéphane Bretagne
- Institut Pasteur, Université de Paris, CNRS UMR2000, unité de Mycologie Moléculaire, Centre national de Référence Mycoses Invasives et Antifongiques, Paris, France
- Laboratoire de Parasitologie-Mycologie, Hôpital Saint Louis, Assistance Publique-Hôpitaux De Paris (AP-HP), Paris, France
- Université de Paris, Paris, France
| | - Karine Sitbon
- Institut Pasteur, Université de Paris, CNRS UMR2000, unité de Mycologie Moléculaire, Centre national de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Françoise Botterel
- Assistance Publique-Hôpitaux De Paris (AP-HP), Hôpital Henri Mondor, Université Paris-Est Créteil Val-de-Marne, Créteil, France
| | - Sarah Dellière
- Institut Pasteur, Université de Paris, CNRS UMR2000, unité de Mycologie Moléculaire, Centre national de Référence Mycoses Invasives et Antifongiques, Paris, France
- Laboratoire de Parasitologie-Mycologie, Hôpital Saint Louis, Assistance Publique-Hôpitaux De Paris (AP-HP), Paris, France
- Université de Paris, Paris, France
| | - Valérie Letscher-Bru
- Service de Parasitologie et de Mycologie Médicale, CHU de Strasbourg, Strasbourg, France
| | - Taieb Chouaki
- Laboratoire de Parasitologie-Mycologie, CHU Amiens-Picardie, Amiens, France
| | | | - Christine Bonnal
- Assistance Publique-Hôpitaux De Paris (AP-HP), Laboratoire de Parasitologie-Mycologie, Hôpital Universitaire Bichat, Paris, France
| | - Arnault Fekkar
- Assistance Publique-Hôpitaux De Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Service de Parasitologie Mycologie, Sorbonne Université, Inserm, CNRS, Centre d’Immunologie et des Maladies Infectieuses (CIMI), Paris, France
| | - Florence Persat
- Hospices Civils de Lyon, Service de Parasitologie et Mycologie Médicale, Hôpital de la Croix-Rousse, Lyon–Université Claude Bernard Lyon 1, Lyon, France
| | - Damien Costa
- Laboratoire de Parasitologie-Mycologie, CHU Charles-Nicolle, Rouen, France
| | - Nathalie Bourgeois
- Laboratoire de Parasitologie-Mycologie, CHU de Montpellier, Montpellier, France
| | - Frédéric Dalle
- Laboratoire de Parasitologie Mycologie, Centre Hospitalier Universitaire de Dijon—Hôpital François Mitterrand, Dijon, France
| | | | - André Paugam
- Université de Paris, Paris, France
- Assistance Publique-Hôpitaux De Paris (AP-HP), Hôpital Cochin, Paris, France
| | - Sophie Cassaing
- Service de Parasitologie-Mycologie, Hôpital Purpan Toulouse, CHU Toulouse, Toulouse, France
| | - Lilia Hasseine
- Laboratoire de Parasitologie Mycologie CHU de Nice, Nice, France
| | - Antoine Huguenin
- Parasitologie Mycologie-Laboratoire de Parasitologie-Mycologie, Pôle de Biopathologie, CHU de Reims, Université de Reims Champagne Ardenne, Reims, France
| | - Nadia Guennouni
- Assistance Publique-Hôpitaux De Paris (AP-HP), Service de Bactériologie, Virologie, Parasitologie et Hygiène, Hôpital Necker-Enfants Malades, IHU Imagine, Paris, France
| | - Edith Mazars
- CH de Valenciennes, Laboratoire de Microbiologie, Valenciennes, France
| | - Solène Le Gal
- Laboratoire de Parasitologie et Mycologie, Hôpital de La Cavale Blanche, CHU de Brest, Brest, France
| | - Milène Sasso
- Laboratoire de Parasitologie Mycologie CHU Nîmes, Nîmes, France
| | - Sophie Brun
- Assistance Publique-Hôpitaux De Paris (AP-HP), Laboratoire de Parasitologie Mycologie Hôpital Avicenne, Bobigny, France
| | - Lucile Cadot
- Département d'Hygiène Hospitalière, CHU Montpellier, Montpellier, France
| | - Carole Cassagne
- IHU Marseille—Institut Hospitalier Universitaire Méditerranée Infection, Marseille, France
| | - Estelle Cateau
- Laboratoire de Parasitologie-Mycologie, CHU de Poitiers, Poitiers, France
| | - Jean-Pierre Gangneux
- CHU de Rennes, Université de Rennes, Institut de Recherche en Santé, Environnement et Travail (IRSET), Rennes, France
| | - Maxime Moniot
- Laboratoire de Parasitologie-Mycologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne-Laure Roux
- Assistance Publique-Hôpitaux De Paris (AP-HP), Hôpital Raymond Poincaré Garches, Hôpital Ambroise Paré, Boulogne Billancourt, France
| | - Céline Tournus
- Laboratoire de Microbiologie, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Nicole Desbois-Nogard
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Martinique, Fort-de-France, La Martinique, France
| | | | - Olivier Moquet
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier de Beauvais, Beauvais, France
| | - Alexandre Alanio
- Institut Pasteur, Université de Paris, CNRS UMR2000, unité de Mycologie Moléculaire, Centre national de Référence Mycoses Invasives et Antifongiques, Paris, France
- Laboratoire de Parasitologie-Mycologie, Hôpital Saint Louis, Assistance Publique-Hôpitaux De Paris (AP-HP), Paris, France
- Université de Paris, Paris, France
| | - Françoise Dromer
- Institut Pasteur, Université de Paris, CNRS UMR2000, unité de Mycologie Moléculaire, Centre national de Référence Mycoses Invasives et Antifongiques, Paris, France
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203
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Casalini G, Giacomelli A, Ridolfo A, Gervasoni C, Antinori S. Invasive Fungal Infections Complicating COVID-19: A Narrative Review. J Fungi (Basel) 2021; 7:921. [PMID: 34829210 PMCID: PMC8620819 DOI: 10.3390/jof7110921] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022] Open
Abstract
Invasive fungal infections (IFIs) can complicate the clinical course of COVID-19 and are associated with a significant increase in mortality, especially in critically ill patients admitted to an intensive care unit (ICU). This narrative review concerns 4099 cases of IFIs in 58,784 COVID-19 patients involved in 168 studies. COVID-19-associated invasive pulmonary aspergillosis (CAPA) is a diagnostic challenge because its non-specific clinical/imaging features and the fact that the proposed clinically diagnostic algorithms do not really apply to COVID-19 patients. Forty-seven observational studies and 41 case reports have described a total of 478 CAPA cases that were mainly diagnosed on the basis of cultured respiratory specimens and/or biomarkers/molecular biology, usually without histopathological confirmation. Candidemia is a widely described secondary infection in critically ill patients undergoing prolonged hospitalisation, and the case reports and observational studies of 401 cases indicate high crude mortality rates of 56.1% and 74.8%, respectively. COVID-19 patients are often characterised by the presence of known risk factors for candidemia such as in-dwelling vascular catheters, mechanical ventilation, and broad-spectrum antibiotics. We also describe 3185 cases of mucormycosis (including 1549 cases of rhino-orbital mucormycosis (48.6%)), for which the main risk factor is a history of poorly controlled diabetes mellitus (>76%). Its diagnosis involves a histopathological examination of tissue biopsies, and its treatment requires anti-fungal therapy combined with aggressive surgical resection/debridement, but crude mortality rates are again high: 50.8% in case reports and 16% in observational studies. The presence of other secondary IFIs usually diagnosed in severely immunocompromised patients show that SARS-CoV-2 is capable of stunning the host immune system: 20 cases of Pneumocystis jirovecii pneumonia, 5 cases of cryptococcosis, 4 cases of histoplasmosis, 1 case of coccidioides infection, 1 case of pulmonary infection due to Fusarium spp., and 1 case of pulmonary infection due to Scedosporium.
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Affiliation(s)
- Giacomo Casalini
- Luigi Sacco Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy; (G.C.); (A.G.)
| | - Andrea Giacomelli
- Luigi Sacco Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy; (G.C.); (A.G.)
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (A.R.); (C.G.)
| | - Annalisa Ridolfo
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (A.R.); (C.G.)
| | - Cristina Gervasoni
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (A.R.); (C.G.)
| | - Spinello Antinori
- Luigi Sacco Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20157 Milan, Italy; (G.C.); (A.G.)
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (A.R.); (C.G.)
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204
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Guzmán-Castro S, Chora-Hernandez LD, Trujillo-Alonso G, Calvo-Villalobos I, Sanchez-Rangel A, Ferrer-Alpuin E, Ruiz-Jimenez M, Corzo-Leon DE. COVID-19-associated mucormycosis, diabetes and steroid therapy: Experience in a single centre in Western Mexico. Mycoses 2021; 65:65-70. [PMID: 34674319 PMCID: PMC8662123 DOI: 10.1111/myc.13383] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 01/08/2023]
Abstract
Background COVID‐19–associated mucormycosis (CAM) has emerged as a challenging complication as the current pandemic has increased the population requiring treatment with corticosteroids. CAM has caused a massive outbreak in India, reported to be causing cases in Iran, Egypt and The Netherlands. Objectives To describe CAM cases occurring in a single centre in Western Mexico. Methods Our group carried out a retrospective study from May 2020 to May 2021 to identify CAM cases in patients with previous COVID‐19 diagnosis. Results Six CAM cases occurred in a single centre in Western Mexico during the study period, most of them with diabetes (n = 5/6) and all received corticosteroid therapy even when only three had severe COVID‐19. After analysing local COVID‐19 burden, it was estimated that in this region, CAM was 300 times more frequent among COVID individuals than the estimates for general population. Conclusion Similar to large reports in India and other countries, CAM cases reported in this study were diagnosed in individuals with diabetes, hyperglycaemic status and with history of previous use of corticosteroids. Identifying these individuals at risk can help the early identification of CAM. In addition, strict glycaemic control and avoidance of unnecessary corticosteroid in non‐severe COVID‐19 cases could help in preventing this complicated fungal infection.
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Affiliation(s)
| | | | | | | | | | | | | | - Dora E Corzo-Leon
- The Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
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205
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Seidel D, Simon M, Sprute R, Lubnow M, Evert K, Speer C, Seeßle J, Khatamzas E, Merle U, Behrens C, Blau IW, Enghard P, Haas CS, Steinmann J, Kurzai O, Cornely OA. Results from a national survey on COVID-19-associated mucormycosis in Germany: 13 patients from six tertiary hospitals. Mycoses 2021; 65:103-109. [PMID: 34655486 PMCID: PMC8662289 DOI: 10.1111/myc.13379] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Most COVID-19-associated mucormycosis (CAM) cases are reported from India and neighbouring countries. Anecdotally cases from Europe have been presented. OBJECTIVE To estimate the disease burden and describe the clinical presentation of CAM in Germany. METHODS We identified cases through German mycology networks and scientific societies, and collected anonymised clinical information via FungiScope®. RESULTS We identified 13 CAM cases from six tertiary referral hospitals diagnosed between March 2020 and June 2021. Twelve patients had severe or critical COVID-19, eleven were mechanically ventilated for a median of 8 days (range 1-27 days) before diagnosis of CAM. Eleven patients received systemic corticosteroids. Additional underlying medical conditions were reported for all but one patient, five were immunocompromised because of malignancy or organ transplantation, three were diabetic. Eleven patients developed pneumonia. Mortality was 53.8% with a median time from diagnosis of mucormycosis to death of 9 days (range 0-214 days) despite treatment with liposomal amphotericin B and/or isavuconazole in 10 of 13 cases. CAM prevalence amongst hospitalised COVID-19 patients overall (0.67% and 0.58% in two centres) and those admitted to the intensive care unit (ICU) (1.47%, 1.78% and 0.15% in three centres) was significantly higher compared to non-COVID-19 patients (P < .001 for respective comparisons). CONCLUSION COVID-19-associated mucormycosis is rare in Germany, mostly reported in patients with comorbidities and impaired immune system and severe COVID-19 treated in the ICU with high mortality compared to mainly rhino-orbito-cerebral CAM in patients with mild COVID-19 in India. Risk for CAM is higher in hospitalised COVID-19 patients than in other patients.
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Affiliation(s)
- Danila Seidel
- Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Michaela Simon
- Institute of Clinical Microbiology and Hygiene, Regensburg University Hospital, Regensburg, Germany
| | - Rosanne Sprute
- Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Matthias Lubnow
- Department of Anesthesiology and Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Katja Evert
- Institute of Pathology, University of Regensburg, Regensburg, Germany
| | - Claudius Speer
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Jessica Seeßle
- Department of Gastroenterology and Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Elham Khatamzas
- Centre for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Uta Merle
- Department of Gastroenterology and Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Christopher Behrens
- Department Medizinische Mikrobiologie und Technische Hygiene, Medizet, Städtisches Klinikum München GmbH, Munich, Germany
| | - Igor Wolfgang Blau
- Department of Hematology, Oncology and Cancer Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité University Medicine Berlin, Berlin, Germany
| | - Christian S Haas
- Department of Internal Medicine, Nephrology and Intensive Care Medicine, University of Marburg, Marburg, Germany
| | - Joerg Steinmann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany.,Institute of Medical Microbiology, University Hospital Essen, Essen, Germany
| | - Oliver Kurzai
- National Reference Center for Invasive Fungal Infections, Leibniz Institute for Natural Product Research and Infection Biology-Hans Knoell Institute, Jena, Germany.,Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Oliver A Cornely
- Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Cologne, Germany
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Bhat V, S A, Thomas A, Kanavi JV, Thomas A. Intestinal Perforation Secondary to Mucormycosis Associated With Puerperal Sepsis. Cureus 2021; 13:e17428. [PMID: 34589337 PMCID: PMC8460554 DOI: 10.7759/cureus.17428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 12/16/2022] Open
Abstract
Mucormycosis is a rare opportunistic infection, usually seen in diabetics, immunocompromised, or those with coronavirus disease 2019 (COVID-19). Gastrointestinal involvement is uncommon but often deadly. We report a case of gastrointestinal mucormycosis causing intestinal perforation in a non-diabetic, COVID-19 negative, immunocompetent woman, associated with puerperal sepsis. A 22-year-old woman presented to our center on post-natal day five, following delivery with insertion of an intrauterine contraceptive device (IUCD). She had complaints of breathlessness, fatigue, and giddiness. Examination revealed tachycardia, tachypnea, hypotension, and bilateral pedal edema. Following appropriate investigations, she was diagnosed with puerperal sepsis with pre-renal acute kidney injury. Imaging was suggestive of retained products of conception, and she subsequently underwent dilation and evacuation (D&E) on day eight of admission. Following brief symptomatic improvement, on day 10 of admission, she developed vomiting, abdominal distension, and pain, with obstipation. Erect X-ray showed air under the diaphragm, suggestive of perforation. She emergently underwent laparotomy with limited right hemicolectomy, ileostomy with mucous fistula. Intraoperative findings revealed a closed-loop obstruction involving terminal ileum, with two perforations. The biopsy report later revealed colonization of Mucor and hemorrhagic necrosis along the entire length of the resected specimen. She was started on amphotericin B, and after a slow recovery, was discharged. Gastrointestinal mucormycosis is rare and has a mortality rate of 94%. It is usually seen in those with predisposing factors for mucormycosis. This is the first report of mucormycosis associated with puerperal sepsis. It is typically acquired via ingestion and may cause perforation, where mortality is further increased. Diagnosis can only be confirmed by histopathology demonstrating the characteristic morphology of Mucor. Treatment requires resection of necrotic tissues, intensive treatment with amphotericin B, and correction of predisposing factors. Our case highlights the need for a high degree of suspicion for mucormycosis in patients with intestinal perforation, even if immunocompetent, and its potential association with puerperal sepsis.
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Affiliation(s)
- Vivek Bhat
- Obstetrics and Gynecology, St. John's Medical College, Bangalore, IND
| | - Anitha S
- Obstetrics and Gynecology, St. John's Medical College, Bangalore, IND
| | - Anu Thomas
- Obstetrics and Gynecology, St. John's Medical College, Bangalore, IND
| | | | - Annamma Thomas
- Obstetrics and Gynecology, St. John's Medical College, Bangalore, IND
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207
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Muthu V, Kumar M, Paul RA, Zohmangaihi D, Choudhary H, Rudramurthy SM, Panda NK, Pannu AK, Sharma N, Sharma S, Chakrabarti A, Agarwal R. Is there an association between zinc and COVID-19-associated mucormycosis? Results of an experimental and clinical study. Mycoses 2021; 64:1291-1297. [PMID: 34420245 PMCID: PMC8661931 DOI: 10.1111/myc.13365] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The enormous increase in COVID-19-associated mucormycosis (CAM) in India lacks an explanation. Zinc supplementation during COVID-19 management is speculated as a contributor to mucormycosis. We conducted an experimental and clinical study to explore the association of zinc and mucormycosis. METHODS We inoculated pure isolates of Rhizopus arrhizus obtained from subjects with CAM on dichloran rose Bengal chloramphenicol (DRBC) agar enriched with (three different concentrations) and without zinc. At 24 h, we counted the viable colonies and measured the dry weight of colonies at 24, 48 and 72 h. We also compared the clinical features and serum zinc levels in 29 CAM cases and 28 COVID-19 subjects without mucormycosis (controls). RESULTS We tested eight isolates of R arrhizus and noted a visible increase in growth in zinc-enriched media. A viable count percentage showed a significantly increased growth in four of the eight isolates in zinc-augmented DRBC agar. A time- and concentration-dependent increase in the mean fungal biomass with zinc was observed in all three isolates tested. We enrolled 29 cases of CAM and 28 controls. The mean serum zinc concentration was below the reference range in all the subjects and was not significantly different between the cases and controls. CONCLUSIONS Half of the R arrhizus isolates grew better with zinc enrichment in vitro. However, our study does not conclusively support the hypothesis that zinc supplementation contributed to the pathogenesis of mucormycosis. More data, both in vitro and in vivo, may resolve the role of zinc in the pathogenesis of CAM.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Mohan Kumar
- Department of Internal MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Raees A. Paul
- Department of Medical MicrobiologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Deepy Zohmangaihi
- Department of BiochemistryPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Hansraj Choudhary
- Department of Medical MicrobiologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | | | - Naresh K. Panda
- Department of Otolaryngology and Head and Neck SurgeryPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Ashok Kumar Pannu
- Department of Internal MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Navneet Sharma
- Department of Internal MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Sadhna Sharma
- Department of BiochemistryPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Arunaloke Chakrabarti
- Department of Medical MicrobiologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Ritesh Agarwal
- Department of Pulmonary MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
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208
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Arora S, Hemmige VS, Mandke C, Chansoria M, Rawat SK, Dravid A, Sethi Y, Medikeri G, Jariwala SP, Puius YA. Online Registry of COVID-19-Associated Mucormycosis Cases, India, 2021. Emerg Infect Dis 2021; 27:2963-2965. [PMID: 34586056 PMCID: PMC8544967 DOI: 10.3201/eid2711.211322] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
We established an online registry of coronavirus disease-associated mucormycosis cases in India. We analyzed data from 65 cases diagnosed during April-June 2021, when the Delta variant predominated, and found that patients frequently received antibacterial drugs and zinc supplementation. Online registries rapidly provide relevant data for emerging infections.
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209
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Sarkar S, Gokhale T, Farnaz Y, Deb AK. Smartphone-assisted retinal evaluation in COVID-19 admitted patients. Indian J Ophthalmol 2021; 69:2884-2885. [PMID: 34571665 PMCID: PMC8597498 DOI: 10.4103/ijo.ijo_2043_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sandip Sarkar
- Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Tanmay Gokhale
- Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Y Farnaz
- Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Amit Kumar Deb
- Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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210
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Chandrakanth P, Ramesh PV, Janakiram TN, Ramesh SV, Aji K, Chandrakanth KS, Ramesh MK, Rajasekaran R. Innovative intra-operative rapid detection test for visualisation of mucor. Indian J Ophthalmol 2021; 69:2844-2845. [PMID: 34571646 PMCID: PMC8597490 DOI: 10.4103/ijo.ijo_1912_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In this manuscript, we report a rapid intra-operative detection test for visualisation of mucor, with the use of the Smartphone-based intraocular lens microscope (IOLSCOPE). IOLSCOPE helps not only in detecting tissue affected by mucor, but also makes sure that the surgeon does not leave any fungus behind; similar to the principles employed by a ‘Frozen section’ in conventional general surgery. In the technique proposed by us, we have used an undigested tissue sample, to quickly diagnose mucor, intra-operatively. Thus, in view of tackling the COVID-19 and mucor duplet, IOLSCOPE can be considered by ophthalmologists and otorhinolaryngologists for its rapid screening property, convenience of ease, good quality images and cost effectiveness.
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Affiliation(s)
- Prithvi Chandrakanth
- Department of Vitreo-retinal Services, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
| | - Prasanna Venkatesh Ramesh
- Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
| | | | - Shruthy Vaishali Ramesh
- Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
| | - K Aji
- Department of Optometry and Visual Science, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
| | | | - Meena K Ramesh
- Department of Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
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211
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Padma Srivastava MV, Vishnu VY, Pandit AK. Mucormycosis Epidemic and Stroke in India During the COVID-19 Pandemic. Stroke 2021; 52:e622-e623. [PMID: 34525840 DOI: 10.1161/strokeaha.121.036626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), New Delhi
| | - Venugopalan Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), New Delhi
| | - Awadh Kishor Pandit
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), New Delhi
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212
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Panta P, Stone N. COVID-associated mucormycosis (CAM) in India is a multidimensional problem. Br J Oral Maxillofac Surg 2021; 59:1332-1333. [PMID: 34728106 DOI: 10.1016/j.bjoms.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Prashanth Panta
- Department of Oral Medicine and Radiology, Malla Reddy Institute of Dental Sciences, Suraram X Roads, Jeedimetla, Quthbullapur, Hyderabad, Telangana 500055, India.
| | - Neil Stone
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London W1T 7NF, UK
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213
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Fernández-García O, Guerrero-Torres L, Roman-Montes CM, Rangel-Cordero A, Martínez-Gamboa A, Ponce-de-Leon A, Gonzalez-Lara MF. Isolation of Rhizopus microsporus and Lichtheimia corymbifera from tracheal aspirates of two immunocompetent critically ill patients with COVID-19. Med Mycol Case Rep 2021; 33:32-37. [PMID: 34307008 PMCID: PMC8268675 DOI: 10.1016/j.mmcr.2021.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
We describe two fatal cases of COVID-19 in which Rhizopus microsporus and Lichtheimia corymbifera were cultured from endotracheal aspirate samples. Both patients had no underlying comorbidities other than obesity. Despite antifungal therapy, both cases developed septic shock and progressive refractory hypoxemia without evidence of other underlying infections. It is unclear whether isolation of these fungal organisms represents invasive disease or corresponds to an epiphenomenon of critical illness. Yet, patients suffering from COVID-19 may be at risk of superinfection from a broader range of fungal organisms than previously thought.
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Affiliation(s)
- Oscar Fernández-García
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI. Tlalpan, Mexico City, CP 4080, Mexico
| | - Lorena Guerrero-Torres
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI. Tlalpan, Mexico City, CP 4080, Mexico
| | - Carla M. Roman-Montes
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI. Tlalpan, Mexico City, CP 4080, Mexico
| | - Andrea Rangel-Cordero
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI. Tlalpan, Mexico City, CP 4080, Mexico
| | - Areli Martínez-Gamboa
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI. Tlalpan, Mexico City, CP 4080, Mexico
| | - Alfredo Ponce-de-Leon
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI. Tlalpan, Mexico City, CP 4080, Mexico
| | - María F. Gonzalez-Lara
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI. Tlalpan, Mexico City, CP 4080, Mexico
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214
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Dubey S, Mukherjee D, Sarkar P, Mukhopadhyay P, Barman D, Bandopadhyay M, Pandit A, Sengupta A, Das S, Ghosh S, Adhikari S, Biswas PS, Pal P, Roy H, Patra N, Das A, Sinha P, Mondal MK, Shrivastava SR, Bhattacharya K, Mukhopadhyay M, Ahmed K, Halder TK, Saha M, Ahmed K, Maity S, Mandal A, Chatterjee D, Saha S, Chunakar A, Saha A, Ray BK. COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum. Diabetes Metab Syndr 2021; 15:102267. [PMID: 34509790 PMCID: PMC8407938 DOI: 10.1016/j.dsx.2021.102267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 07/28/2021] [Accepted: 08/30/2021] [Indexed: 12/30/2022]
Abstract
AIMS 1: Describe the epidemiology and determine risk factors for COVID-19 associated mucormycosis. 2: Elaborate the clinical spectrum of Rhino-Orbital-Cerebral Mucormycosis (ROCM), pattern of neuroaxis involvement and it's radiological correlates. METHODS Observational study. Consecutive, confirmed cases of mucormycosis (N = 55) were included. A case of mucormycosis was defined as one who had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological examination (HPE). Data pertaining to epidemiology, risk factors, clinico-radiological features were analysed using percentage of total cases. RESULTS Middle aged, diabetic males with recent COVID-19 infection were most affected. New onset upper jaw toothache was a striking observation in several cases. Among neurological manifestations headache, proptosis, vision loss, extraocular movement restriction; cavernous sinus, meningeal and parenchymal involvement were common. Stroke in ROCM followed a definitive pattern with watershed infarction. CONCLUSIONS New onset upper jaw toothache and loosening of teeth should prompt an immediate search for mucormycosis in backdrop of diabetic patients with recent COVID-19 disease, aiding earlier diagnosis and treatment initiation. Neuroaxis involvement was characterized by a multitude of features pertaining to involvement of optic nerve, extraocular muscles, meninges, brain parenchyma and internal carotid artery.
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215
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Sahu ES, Sahu A, Ghodgaonkar P, Lahoti K, Bhargava A. COVID-19-associated rhino-orbital- cerebral mixed mycoses with intracranial fungal granuloma - An aggressively managed rare entity. Indian J Ophthalmol 2021; 69:2537-2539. [PMID: 34427263 PMCID: PMC8544050 DOI: 10.4103/ijo.ijo_1598_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Rhino-orbital-cerebral mucormycosis (ROCM) with intracranial extension is a fatal disease. A case of extensive ROCM, with rare intracranial fungal granuloma, seen in a COVID-19 positive young male is described. A successful therapy consisting of a multidisciplinary approach for sinuses debridement, orbital exenteration, and intracranial granuloma excision was done. Nonseptate hyphae of Mucor and septate filamentous Aspergillus grew concurrently from exenterated orbital specimen.
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Affiliation(s)
- Ekta S Sahu
- Consultant Vitreo-Retina and Uvea Services, Retina Speciality Hospital, Indore, Madhya Pradesh, India
| | - Animesh Sahu
- Consultant Cataract and Oculoplasty Services, Retina Speciality Hospital, Indore, Madhya Pradesh, India
| | - Pranav Ghodgaonkar
- Consultant and Chief Neurosurgeon, CHL- Hospital, Indore, Madhya Pradesh, India
| | - Keshav Lahoti
- Consultant Vitreo-Retina and Uvea Services, Retina Speciality Hospital, Indore, Madhya Pradesh, India
| | - Arun Bhargava
- Director and Chief Vitreo-Retina Surgeon, Retina Speciality Hospital, Indore, Madhya Pradesh, India
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216
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Sarkar S, Gokhale T, Kaliaperumal S, Singh R, Begam RB, Deb AK. Exudative retinal detachment in COVID-19 - associated rhino-orbital mucormycosis - A rare clinical finding. Indian J Ophthalmol 2021; 69:2535-2537. [PMID: 34427262 PMCID: PMC8544097 DOI: 10.4103/ijo.ijo_1729_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Rhino-orbital-cerebral mucormycosis is a life-threatening, opportunistic invasive fungal infection. Patients with moderate to severe coronavirus disease 2019 (COVID-19) infection are more vulnerable to it. Varied clinical presentations can be seen in patients with orbital mucormycosis starting from conjunctival chemosis, proptosis, ptosis, restriction of extraocular movements, exposure keratitis, neurotrophic keratitis, and central retinal artery occlusion. Exudative retinal detachment in a patient with orbital mucormycosis is a rare clinical entity. We, hereby, report a case of orbital mucormycosis with exudative retinal detachment in a patient post-COVID-19 infection.
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Affiliation(s)
- Sandip Sarkar
- Department of Ophthalmology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Tanmay Gokhale
- Department of Ophthalmology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Subashini Kaliaperumal
- Department of Ophthalmology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Rakesh Singh
- Department of Microbiology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - R Benazir Begam
- Department of Otorhinolaryngylogy, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Amit Kumar Deb
- Department of Ophthalmology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
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217
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Narayanan S, Chua JV, Baddley JW. COVID-19 associated Mucormycosis (CAM): risk factors and mechanisms of disease. Clin Infect Dis 2021; 74:1279-1283. [PMID: 34420052 PMCID: PMC8499811 DOI: 10.1093/cid/ciab726] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Indexed: 12/14/2022] Open
Abstract
The severe surge of COVID-19 cases in the Indian subcontinent in early 2021 was marked by an unusually high number of cases of COVID-19 associated mucormycosis (CAM) reported during this period. This is significantly higher than predicted based on available data about prevalence or risk factors for this condition. This may be from an unusual alignment of multiple risk factors for this condition. There is high background prevalence of mucormycosis in India probably from high prevalence of risk factors, including undiagnosed or poorly controlled diabetes. COVID-19 induced immune dysregulation, and immune suppression from steroid therapy increase the risk. The role of environmental exposure is unclear. System factors like lack of access to healthcare during a pandemic may result in delayed diagnosis or suboptimal management with potentially poor outcomes. This is a review of currently identified risk factors and pathogenesis of CAM in a pandemic surge.
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218
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Badali H, Cañete-Gibas C, McCarthy D, Patterson H, Sanders C, David MP, Mele J, Fan H, Wiederhold NP. Epidemiology and Antifungal Susceptibilities of Mucoralean Fungi in Clinical Samples from the United States. J Clin Microbiol 2021; 59:e0123021. [PMID: 34232068 PMCID: PMC8373021 DOI: 10.1128/jcm.01230-21] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/01/2021] [Indexed: 01/12/2023] Open
Abstract
The global incidence of mucormycosis has increased in recent years owing to higher numbers of individuals at risk for these infections. The diagnosis and treatment of this aggressive fungal infection are of clinical concern due to differences in species distribution in different geographic areas and susceptibility profiles between different species that are capable of causing highly aggressive infections. The purpose of this study was to evaluate the epidemiology and susceptibility profiles of Mucorales isolates in the United States over a 52-month period. Species identification was performed by combined phenotypic characteristics and DNA sequence analysis, and antifungal susceptibility testing was performed by CLSI M38 broth microdilution for amphotericin B, isavuconazole, itraconazole, and posaconazole. During this time frame, 854 isolates were included, representing 11 different genera and over 26 species, of which Rhizopus (58.6%) was the predominant genus, followed by Mucor (19.6%). The majority of isolates were cultured from the upper and lower respiratory tracts (55%). Amphotericin B demonstrated the most potent in vitro activity, with geometric mean (GM) MICs of ≤0.25 μg/ml against all genera with the exception of Cunninghamella species (GM MIC of 1.30 μg/ml). In head-to-head comparisons, the most active azole was posaconazole, followed by isavuconazole. Differences in azole and amphotericin B susceptibility patterns were observed between the genera with the greatest variability observed with isavuconazole. Awareness of the epidemiology of Mucorales isolates and differences in antifungal susceptibility patterns in the United States may aide clinicians in choosing antifungal treatment regimens. Further studies are warranted to correlate these findings with clinical outcomes.
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Affiliation(s)
- Hamid Badali
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Connie Cañete-Gibas
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Dora McCarthy
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Hoja Patterson
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Carmita Sanders
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Marjorie P. David
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - James Mele
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Hongxin Fan
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Nathan P. Wiederhold
- Fungus Testing Laboratory & Molecular Diagnostics Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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219
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Arora R, Goel R, Khanam S, Kumar S, Shah S, Singh S, Chhabra M, Meher R, Khurana N, Sagar T, Kumar S, Garg S, Kumar J, Saxena S, Pant R. Rhino-Orbito-Cerebral-Mucormycosis During the COVID-19 Second Wave in 2021 - A Preliminary Report from a Single Hospital. Clin Ophthalmol 2021; 15:3505-3514. [PMID: 34429582 PMCID: PMC8380130 DOI: 10.2147/opth.s324977] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/05/2021] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To list the clinico-epidemiological profile and possible risk factors of COVID-19 associated rhino-orbital-cerebral mucormycosis (CA-ROCM) patients presenting to a COVID dedicated hospital during the second wave of COVID-19 in India. PATIENTS AND METHODS A cross-sectional, single-center study was done on 60 cases of probable CA-ROCM based on clinical features and supportive diagnostic nasal endoscopic findings and/or radiologic findings. Patients with recent or active COVID-19 were included. The demographic profile, clinical features, possible risk factors and diagnostic workup (microbiological, pathological and radiological) were analysed to identify the triggering factors for CA-ROCM. RESULTS The age of patients ranged from 29 to 75 years and male-female ratio was 3:1. The duration between the first positive COVID report and onset of CA-ROCM was 0 to 47 days. Forty-nine (81.66%) patients had a recent COVID infection and 11 (18.33%) had active COVID infection at presentation. Thirty-five patients (58%) had ocular/orbital involvement at presentation. In the affected eye, 10 had no perception of light and in the rest visual acuity ranged from log MAR 0 to +1.5. Ocular manifestations were ptosis (29), ophthalmoplegia (23), periocular tenderness and edema (33), proptosis (14), black discoloration of eyelids (3), facial palsy (3), endophthalmitis (4), retinal artery occlusion (8), disc edema (4) and disc pallor (5). Twenty-two (25%) patients had neither received steroids nor oxygen. Thirty patients (50%) were managed with oxygen while 38 patients (63.3%) with systemic steroids. The most common risk factor was diabetes in 59 patients. The average glycosylated hemoglobin (HbA1c) was 10.31 ± 2.59%. Systemic Amphotericin B was started in all the patients. Radical surgical debridement was performed in 12 patients and the remaining were planned. CONCLUSION SARS-CoV-2 variant with accompanying glycaemic dysregulation was found to be the triggering factor for the epidemic of CA-ROCM.
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Affiliation(s)
- Ritu Arora
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | - Ruchi Goel
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | - Samreen Khanam
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | - Sumit Kumar
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | - Shalin Shah
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | - Sonam Singh
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | - Mohit Chhabra
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | - Ravi Meher
- Department of Otorhinolaryngology, Maulana Azad Medical College, New Delhi, India
| | - Nita Khurana
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Tanu Sagar
- Department of Microbiology, Maulana Azad Medical College, New Delhi, India
| | - Suresh Kumar
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Sandeep Garg
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Jyoti Kumar
- Department of Radiodiagnosis, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Sonal Saxena
- Department of Microbiology, Maulana Azad Medical College, New Delhi, India
| | - Rashmi Pant
- Society for Health Education and Allied Research, New Delhi, India
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220
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Singh R, Kumari A. Nasal Microbiota Imbalance as a Contributory Link in the Emergence of COVID-19 Associated Mucormycosis. ACS Infect Dis 2021; 7:2211-2213. [PMID: 34328718 DOI: 10.1021/acsinfecdis.1c00371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
COVID-19 associated mucormycosis (CAM) is being reported at an elevated frequency and has been declared an ongoing epidemic in India. A huge diabetic population, inappropriate corticosteroid usage and environmental mucoralean spore count, along with COVID-19 associated glycemic imbalance, hypoxemia, increased iron levels, vascular endothelial injury, as well as the immunosuppressive impact are being considered as important risk factors for CAM. The present viewpoint aims to discuss the plausible role of another important facet, the nasal microbiota imbalance, in the emergence of mucormycosis under the prevailing COVID-19 pandemic conditions.
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Affiliation(s)
- Rachna Singh
- Department of Microbial Biotechnology, Panjab University, Chandigarh-160014, India
| | - Anjna Kumari
- Department of Microbial Biotechnology, Panjab University, Chandigarh-160014, India
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221
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Nair AG, Adulkar NG, D'Cunha L, Rao PR, Bradoo RA, Bapaye MM, Kothari A, Dave TV, Shinde CA. Rhino-orbital mucormycosis following COVID-19 in previously non-diabetic, immunocompetent patients. Orbit 2021; 40:499-504. [PMID: 34338124 DOI: 10.1080/01676830.2021.1960382] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To report a series of 13 immunocompetent patients who developed new-onset uncontrolled diabetes mellitus (DM) following COVID-19 infection and presented as rhino-orbital mucormycosis (ROM). METHOD Retrospective study. RESULTS A total of 127 patients of COVID-19 Associated Mucormycosis (CAM) were evaluated at four centres in India. All patients underwent endoscopic sinus debridement surgery and received systemic amphotericin-B therapy. Five patients (5/13; 38.4%) received retrobulbar amphotericin-B injections. Orbital exenteration was performed in advanced orbital involvement or progression of orbital disease in spite of maximal medical therapy. In his cohort, 13/127 (10.2%) patients presented with new onset DM, where one patient had bilateral disease. The mean age was 35.9 years (range: 20-51 years) and the mean duration from diagnosis of COVID-19 to the diagnosis of mucormycosis was 14.2 days. While 7/13 (53.8%) of the patients received systemic corticosteroids during the course of their treatment for COVID-19, six patients received no steroids or immunomodulators. The mean follow-up period was 9.2 weeks (range: 3-18 weeks) following discharge. Life salvage was possible in 100% of the cases. While overall globe salvage was possible in 42.8% (6/14 eyes), the globe could be preserved in 4/5 patients who received retrobulbar amphotericin-B injections. CONCLUSIONS Those involved in the care of COVID-19 patients should be aware about the possibility of recent-onset DM, even in patients without a history of corticosteroid therapy. Rarely, recent-onset DM following COVID-19 may present as rhino-orbital mucormycosis, which requires aggressive surgical and medical intervention.
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Affiliation(s)
- Akshay Gopinathan Nair
- Department of Ophthalmology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India.,Ophthalmic Plastic Surgery and Ocular Oncology Services, Aditya Jyot Eye Hospital, Wadala, Mumbai, India.,Ophthalmic Plastic Surgery and Ocular Oncology Services, Advanced Eye Hospital & Institute, Navi Mumbai, India.,Oculoplastics and Orbital Surgery, R Jhunjhunwala Sankara Eye Hospital, Panvel, India
| | | | - Lynn D'Cunha
- Department of Ophthalmology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India
| | - Priyanka R Rao
- Department of Ophthalmology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India
| | - Renuka A Bradoo
- Department of Otorhinolaryngology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India
| | | | | | - Tarjani V Dave
- Ophthalmic Plastic Surgery and Ocular Oncology Services, L V Prasad Eye Institute, Hyderabad, India
| | - Chhaya A Shinde
- Department of Ophthalmology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India
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Abstract
BACKGROUND The recent emergence of the Coronavirus Disease (COVID-19) disease had been associated with reports of fungal infections such as aspergillosis and mucormycosis especially among critically ill patients treated with steroids. The recent surge in cases of COVID-19 in India during the second wave of the pandemic had been associated with increased reporting of invasive mucormycosis post COVID-19. There are multiple case reports and case series describing mucormycosis in COVID-19. PURPOSE In this review, we included most recent reported case reports and case-series of mucormycosis among patients with COVID-19 and describe the clinical features and outcome. RESULTS Many of the mucormycosis reports were eported from India, especially in COVID-19 patients who were treated and recovered patients. The most commonly reported infection sites were rhino-orbital/rhino-cerebral mucormycosis. Those patients were diabetic and had corticosteroids therapy for controlling the severity of COVID-19, leading to a higher fatality in such cases and complicating the pandemic scenario. The triad of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), corticosteroid use and uncontrolled diabetes mellitus have been evident for significant increase in the incidence of angioinvasive maxillofacial mucormycosis. In addition, the presence of spores and other factors might play a role as well. CONCLUSION With the ongoing COVID-19 pandemic and increasing number of critically ill patients infected with SARS-CoV-2, it is important to develop a risk-based approach for patients at risk of mucormycosis based on the epidemiological burden of mucormycosis, prevalence of diabetes mellitus, COVID-19 disease severity and use of immune modulating agents including the combined use of corticosteroids and immunosuppressive agents in patients with cancer and transplants.
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223
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Banerjee I, Robinson J, Asim M, Sathian B, Banerjee I. Mucormycosis and COVID-19 an epidemic in a pandemic? Nepal J Epidemiol 2021; 11:1034-1039. [PMID: 34290893 PMCID: PMC8266401 DOI: 10.3126/nje.v11i2.37342] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 12/24/2022] Open
Abstract
Mucormycosis and aspergillosis are rare, invasive and life-threatening infections primarily caused by Rhizopus arrhizus and Aspergillus fumigatus with higher case fatality rates (>50%), respectively. Invasive Aspergillosis and Mucormycosis have been established and recognized as complications of the SARS-CoV-2 infection. Such cases have been intimately linked and related to prior corticosteroid therapy. With the new highly infectious Delta strain (B.1.617.2 and B.1.617.2.1 or AY.1) of the coronavirus which is running rampant throughout India causing unprecedented death tolls, a new crisis is evolving. Invasive "black fungus" (Mucormycosis) is creating an epidemic within a global pandemic. The unique socio-economic, genetic and health status of Indian population culminates into a melting pot which sustains the viable triad for the "black fungus" infection to gain a stronghold. Diabetes mellitus, immunosuppression and the current COVID-19 global pandemic with its massive surges in the country have produced the "perfect storm." Ophthalmologist across India have reported a surge in invasive Mucormycosis cases with a rise in orbital compartment syndrome often calling for radical procedures such as enucleation surgeries. The "black fungus" pandemic and invasive Mucormycosis resulted in the sinister secondary infections and complications are closely linked with the COVID-19 infection in India. It is therefore of the upmost importance that neighbouring countries particularly Nepal and other Asiatic nations take great cognizance of this indolent "black fungus killer" and ensure new screening and testing protocols for early identification to ensure effective management.
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Affiliation(s)
| | - Jared Robinson
- Sir Seewoosagur Ramgoolam Medical College, Belle Rive, Mauritius
| | | | - Brijesh Sathian
- Geriatric and long term care Department, Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Indraneel Banerjee
- Uro oncologist and Robotic Surgeon, Apollo multi speciality Hospitals, Kolkata, West Bengal, India
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224
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Abstract
In India, the peak of SARS-CoV-2 infections in May 2021 was paralleled by an outbreak of rhino-oculo-cerebral mucormycosis (ROCM) — a fungal infection affecting the nose, eyes and brain. This outbreak provided a unique opportunity to study the neurological manifestations of ROCM and to investigate new treatments for the condition.
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