Epidemiology and clinical manifestations of mucormycosis

Mucormycosis and COVID-19-Associated Mucormycosis: Insights of a Deadly but Neglected Mycosis

The ongoing COVID-19 pandemic has quickly become a health threat worldwide, with high mortality and morbidity among patients with comorbidities. This viral infection promotes the perfect setting in patients for the development of opportunistic infections, such as those caused by fungi. Mucormycosis, a rare but deadly fungal infection, has recently increased its incidence, especially in endemic areas, since the onset of the pandemic. COVID-19-associated mucormycosis is an important complication of the pandemic because it is a mycosis hard to diagnose and treat, causing concern among COVID-19-infected patients and even in the already recovered population. The risk factors for the development of mucormycosis in these patients are related to the damage caused by the SARS-CoV-2 itself, the patient's overstimulated immune response, and the therapy used to treat COVID-19, causing alterations such as hyperglycemia, acidosis, endothelial and lung damage, and immunosuppression. In this review, the molecular aspects of mucormycosis and the main risk factors for the development of COVID-19-associated mucormycosis are explained to understand this virus-fungi-host interaction and highlight the importance of this neglected mycosis.

Paraplegia secondary to disseminated mucormycosis: case report and literature review

BACKGROUND

We report a case of spine infection with mucormycosis that manifested signs of paraplegia in a patient suffering from disseminated mucormycosis. Timely and effective surgery was performed. A review of the literature is included.

CASE PRESENTATION

A patient with diabetic ketoacidosis complained of back pain and fatigue for one month, and his right lower extremity activity had been limited for 10 days. T4-T6 vertebral and paravertebral soft tissue-involved infections were identified by MRI, which were derived from right lung pneumonia. He underwent abscess debridement, spinal canal decompression, pedicle screw fixation and amphotericin B liposome injection. Histopathological examination revealed broad aseptate hyphae suggestive of invasive mucormycosis. There was improvement in neurological function after surgical and medical treatment. Three months after the surgery, the patient died of uncontrollable massive bleeding of the urinary system. Mucormycosis is characterized by rapid development and a high mortality rate. This case shows the significance of a multidisciplinary team in the diagnosis and treatment of patients with mucormycosis. In addition, orthopedic surgeons should design appropriate surgery plans for spine-involved mucormycosis patients.

CONCLUSION

This case present a patient with paraplegia caused by the spread of pulmonary mucormycosis to the vertebral and paravertebral soft tissue of levels T4-T6. After medical treatment, surgical debridement and internal fixation, the patient recovered well but later patient died of possible disease dissemination to the renal or urinary tract which resulted in massive haemorrhage.

Mucormycosis in Different Clinical Settings: A Case Series

Mucormycosis is a fungal infection that can be very destructive and often fatal. People most prone to this infection include those who are immunocompromised. Early diagnosis and treatment, along with addressing the risk factors, play a pivotal role in the management. Here, the authors are reporting three cases of immunocompromised patients. Among them, two had uncontrolled diabetes, and the third had a history of renal transplant and COVID-19 infection. All three cases are distinct anatomically; one is pulmonary, one is rhino-orbital-cerebral, and the last one is rhino-maxillary.

Sensitivity of liquid-based cytology in the diagnosis of mucormycosis in COVID-19 treated patients

BACKGROUND

The coronavirus disease 2019 (COVID-19) infection caused by the novel severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is associated with a wide range of disease patterns, ranging from mild to life-threatening pneumonia. COVID-19 can be associated with a suppressed immune response and/or hyperinflammatory state due to cytokine storm. Reduced immunity, combined with steroid usage to prevent cytokine storm along with various pre-existing co morbidities can prove to be a fertile ground for various secondary bacterial and fungal infection, including mucormycosis. Diagnosis of mucor is a challenging task given high negativity rate of various detection methods. While histopathology is considered the gold standard, the acquisition of necessary tissue biopsy specimens requires invasive procedures and is time consuming.

METHOD

In this study various methods of mucor detection, like conventional cytopathology (CCP), liquid-based cytology (LBC, BD SurepathTM ), potassium hydroxide mount (KOH) preparation, culture and histopathology were analysed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for various methods.

RESULTS

This study showed that LBC has sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 72.4%,100%,100% and 38.4% respectively.

CONCLUSION

This study showed that, liquid-based cytology (LBC) can be a rapid and effective alternative to histopathology in mucor diagnosis.

The fecal mycobiome in non-alcoholic fatty liver disease

BACKGROUND & AIMS

Studies investigating the gut-liver axis have largely focused on bacteria, whereas little is known about commensal fungi. We characterized fecal fungi in patients with non-alcoholic fatty liver disease (NAFLD) and investigated their role in a fecal microbiome-humanized mouse model of Western diet-induced steatohepatitis.

METHODS

We performed fungal internal transcribed spacer 2 sequencing using fecal samples from 78 patients with NAFLD, 16 controls and 73 patients with alcohol use disorder. Anti-Candida albicans (C. albicans) IgG was measured in blood samples from 17 controls and 79 patients with NAFLD. Songbird, a novel multinominal regression tool, was used to investigate mycobiome changes. Germ-free mice were colonized with feces from patients with non-alcoholic steatohepatitis (NASH), fed a Western diet for 20 weeks and treated with the antifungal amphotericin B.

RESULTS

The presence of non-obese NASH or F2-F4 fibrosis was associated with a distinct fecal mycobiome signature. Changes were characterized by an increased log-ratio for Mucor sp./Saccharomyces cerevisiae (S. cerevisiae) in patients with NASH and F2-F4 fibrosis. The C. albicans/S. cerevisiae log-ratio was significantly higher in non-obese patients with NASH when compared with non-obese patients with NAFL or controls. We observed a different fecal mycobiome composition in patients with NAFLD and advanced fibrosis compared to those with alcohol use disorder and advanced fibrosis. Plasma anti-C. albicans IgG was increased in patients with NAFLD and advanced fibrosis. Gnotobiotic mice, colonized with human NASH feces and treated with amphotericin B were protected from Western diet-induced steatohepatitis.

CONCLUSIONS

Non-obese patients with NAFLD and more advanced disease have a different fecal mycobiome composition to those with mild disease. Antifungal treatment ameliorates diet-induced steatohepatitis in mice. Intestinal fungi could be an attractive target to attenuate NASH.

LAY SUMMARY

Non-alcoholic fatty liver disease is one of the most common chronic liver diseases and is associated with changes in the fecal bacterial microbiome. We show that patients with non-alcoholic fatty liver disease and more severe disease stages have a specific composition of fecal fungi and an increased systemic immune response to Candida albicans. In a fecal microbiome-humanized mouse model of Western diet-induced steatohepatitis, we show that treatment with antifungals reduces liver damage.

Mucormycosis and COVID-19 pandemic: Clinical and diagnostic approach

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is yet to be controlled worldwide, especially in India. The second wave of coronavirus disease 2019 (COVID-19) led to panic and confusion in India, owing to the overwhelming number of the population that fell prey to this highly infectious virus of recent times. In the second wave of COVID-19, the patients had to fight both the virus and opportunistic infections triggered by fungi and bacteria. Repeated use of steroids, antibiotics, and oxygen masks during the management of severely and critically ill COVID-19 patients nurtured opportunistic infections such as mucormycosis. Despite mucormycosis being a decades-old disease, it has gained notice of its widespread occurrence in COVID-19 patients throughout India. Instances of mucormycosis are usually unearthed in immunocompromised individuals and are caused by the inhalation of filamentous fungi, either from the natural environment or through supportive care units. In the recent outbreak during the second wave of COVID-19 in India, it has been seen to cause secondary infection as it grows along with the treatment of COVID-19. Furthermore, COVID-19 patients with comorbidities such as diabetes were more likely to have the mucormycosis co-infection because of their challenged immune systems' inability to fight it. Despite the hype, mucormycosis still remains neglected and least studied, which is predominantly due to all focus on diagnostics, vaccine, and therapeutic research. In this review, we emphasize mainly on the association of mucormycosis in COVID-19 patients. We also present the molecular mechanism of mucormycosis for a better understanding of the fungal infections in patients who have recently been infected with SARS-CoV-2. Better understanding of fungal pathogens, immediate diagnosis, and management of the infections are crucial in COVID-19 patients, as high mortalities have been recorded in co-infected patients despite recovery from COVID-19.

Rhinocerebral Mucormycosis Associated With Anterior Skull Base Actinomyces Osteomyelitis in a Pediatric Patient With Type 1 Diabetes

Rhino-orbital-cerebral mucormycosis (ROCM) is a fulminant, often fatal, angioinvasive fungal infection commonly transmitted through inhalation of fungal spores and traumatic inoculation. While the literature has documented rare cases of infection in immunocompetent patients, the vast majority of case fatalities are noted in immunosuppressed populations. Common predisposing factors to infection include immunosuppressive therapies, hematologic malignancies, and most notably, uncontrolled diabetes. Actinomycosis is a subacute to chronic bacterial infection stemming from non-spore-forming anaerobic/microaerophilic bacteria of the genus Actinomyces. Infection with Actinomyces species has been documented across numerous anatomical sites; however, literature on concurrent infection with ROCM in pediatric patients is sparse. We document a case of a 17-year-old male with uncontrolled type 1 diabetes who presented to the emergency department with combined ROCM and actinomycotic infection of his anterior skull base.

The cross-talk between mucormycosis, steroids and diabetes mellitus amidst the global contagion of COVID-19

Mucormycosis is an opportunistic fungal disease that targets individuals having an impaired immune system due to a wide array of risk factors including HIV-AIDS, immunosuppressive therapy, diabetes mellitus, etc. The current explosive outbreak of coronavirus disease 2019 (COVID-19) has become the latest threat to such patients who are already susceptible to secondary infections. Physiological outcomes of COVID-19 end up in a cascade of grave alterations to the immunological profile and irreparable harm to their respiratory passage, heart and kidneys. Corticosteroidal treatment facilitates faster recovery and alleviates the adverse pathological effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). But clinical reports lend this approach a darker perspective especially if these patients have pre-existing diabetes mellitus. The mucormycotic fungal genera belonging to the order Mucorales not only survive but thrive under the comorbidity of COVID-19 and diabetes, often staying undetected until they have inflicted irreversible damage. Steroidal usage has been noted to be a common thread in the sudden spurt in secondary fungal infections among COVID-19 cases. Once considered a rare occurrence, mucormycosis has now acquired a notoriously lethal status in mainstream medical hierarchy. We set out to investigate whether corticosteroidal therapy against COVID-19 emboldens the development of mucormycosis. We also assess the conditions brought forth by steroidal usage and uncontrolled progression of diabetes in COVID-19 cases and their effect on the susceptibility towards mucormycosis.

Genetic Manipulation in Mucorales and New Developments to Study Mucormycosis

The study of the Mucoralean fungi physiology is a neglected field that the lack of effective genetic tools has hampered in the past. However, the emerging fungal infection caused by these fungi, known as mucormycosis, has prompted many researchers to study the pathogenic potential of Mucorales. The main reasons for this current attraction to study mucormycosis are its high lethality, the lack of effective antifungal drugs, and its recent increased incidence. The most contemporary example of the emergence character of mucormycosis is the epidemics declared in several Asian countries as a direct consequence of the COVID-19 pandemic. Fortunately, this pressure to understand mucormycosis and develop new treatment strategies has encouraged the blossoming of new genetic techniques and methodologies. This review describes the history of genetic manipulation in Mucorales, highlighting the development of methods and how they allowed the main genetic studies in these fungi. Moreover, we have emphasized the recent development of new genetic models to study mucormycosis, a landmark in the field that will configure future research related to this disease.

Clinical Features and Mortality of COVID-19-Associated Mucormycosis: A Systematic Review and Meta-Analysis

The recent increase of COVID-19-associated mucormycosis (CAM) has been commanding global attention. However, basic epidemiologic characteristics have not firmly been established. In this systematic review and meta-analysis, we sought to determine the clinical manifestations, potential risk factors, and outcomes of CAM. Observational studies reporting CAM were searched with PubMed and EMBASE databases in January 2022. We collected data on comorbidities and treatment for COVID-19, and performed a one-group meta-analysis on the frequency of orbital exenteration procedure and mortality of CAM using a random-effect model. Fifty-one observational studies, including a total of 2,312 patients with proven CAM, were identified. Among the 51 studies, 37 were conducted in India, 8 in Egypt, and 6 in other countries. The most common comorbidity was diabetes mellitus (82%). While 57% required oxygenation, 77% received systemic corticosteroids. Among CAM, 97% were rhino-orbital-cerebral (ROCM), and 2.7% were pulmonary mucormycosis. Usual presentations were headache (54%), periorbital swelling/pain (53%), facial swelling/pain (43%), ophthalmoplegia (42%), proptosis (41%), and nasal discharge/congestion (36%). Regarding the outcomes, orbital exenteration was performed in 17% (95% CI: 12–21%, I² = 83%) of the COVID-19-associated ROCM patients. The mortality of CAM was 29% (95% CI; 22–36%, I² = 92%). In conclusion, this systematic review and meta-analysis indicated that the most prevalent type of CAM was ROCM, and most CAM patients had diabetes mellitus and received systemic glucocorticoids. Clinicians in the endemic areas should have a high index of suspicion for this invasive fungal complication of COVID-19 when a diabetic patient who received high-dose systemic glucocorticoids developed rhino-orbital symptoms.

In Silico Evaluation of Antifungal Compounds from Marine Sponges against COVID-19-Associated Mucormycosis

The world is already facing the devastating effects of the SARS-CoV-2 pandemic. A disseminated mucormycosis epidemic emerged to worsen this situation, causing havoc, especially in India. This research aimed to perform a multitargeted docking study of marine-sponge-origin bioactive compounds against mucormycosis. Information on proven drug targets and marine sponge compounds was obtained via a literature search. A total of seven different targets were selected. Thirty-five compounds were chosen using the PASS online program. For homology modeling and molecular docking, FASTA sequences and 3D structures for protein targets were retrieved from NCBI and PDB databases. Autodock Vina in PyRx 0.8 was used for docking studies. Further, molecular dynamics simulations were performed using the IMODS server for top-ranked docked complexes. Moreover, the drug-like properties and toxicity analyses were performed using Lipinski parameters in Swiss-ADME, OSIRIS, ProTox-II, pkCSM, and StopTox servers. The results indicated that naamine D, latrunculin A and S, (+)-curcudiol, (+)-curcuphenol, aurantoside I, and hyrtimomine A had the highest binding affinity values of -8.8, -8.6, -9.8, -11.4, -8.0, -11.4, and -9.0 kcal/mol, respectively. In sum, all MNPs included in this study are good candidates against mucormycosis. (+)-curcudiol and (+)-curcuphenol are promising compounds due to their broad-spectrum target inhibition potential.

Exclusion of Mucorales Co-Infection in a Patient with Aspergillus flavus Sinusitis by Fluorescence In Situ Hybridization (FISH)

Invasive fungal infections are associated with increased mortality in hematological patients. Despite considerable advances in antifungal therapy, the evaluation of suspected treatment failure is a common clinical challenge requiring extensive diagnostic testing to rule out potential causes, such as mixed infections. We present a 64-year-old patient with secondary AML, diabetes mellitus, febrile neutropenia, and sinusitis. While cultures from nasal tissue grew Aspergillus flavus, a microscopic examination of the tissue was suggestive of concomitant mucormycosis. However, fluorescence in situ hybridization (FISH) using specific probes targeting Aspergillus and Mucorales species ruled out mixed infection. This was confirmed by specific qPCR assays amplifying the DNA of Aspergillus, but not of Mucorales. These results provided a rational basis for step-down targeted therapy, i.e., the patient received posaconazole after seven days of calculated dual therapy with liposomal amphotericin B and posaconazole. Despite clinical response to the antifungal therapy, he died due to the progression of the underlying disease within two weeks after diagnosis of fungal infection. Molecular diagnostics applied to tissue blocks may reveal useful information on the etiology of invasive fungal infections, including challenging situations, such as with mixed infections. A thorough understanding of fungal etiology facilitates targeted therapy that may improve therapeutic success while limiting side effects.

COVID-19-Related Rhino-Orbito-Cerebral Mucormycosis Complicated by the Optic Nerve and Optic Tract Ischemia With Ischemic Neuropathy

Mucormycosis is a life-threatening invasive fungal infection usually seen in immunocompromised patients and patients with poorly controlled diabetes mellitus with or without diabetic ketoacidosis. We present a rhino-orbito-cerebral mucormycosis (ROCM) case in a coronavirus disease 2019 (COVID-19) patient complicated by the optic nerve and optic tract ischemia with ischemic neuropathy. Both CT and MRI played an essential role in diagnosing ROCM and the accompanying complications in our patient.

CT showed sinonasal sinusitis and MRI showed the sinusitis and its progression to ROCM. MRI also showed necrosis involving the bilateral orbits, basal ganglia, thalamus, internal capsule, hypothalamus, optic chiasm, optic nerves, olfactory bulbs, and skull base. ROCM associated with optic nerve ischemia is a rare but life-threatening complication of COVID-19, especially in patients with underlying diabetes and/or those treated with corticosteroids. Physicians should be aware of this complication as early diagnosis may improve the chances of survival in such patients.

Disseminated Cunninghamella spp. Endocarditis in a Beta-Thalassemia Patient after Asymptomatic COVID-19 Infection

Cunninghamella spp. is a group of fungi belonging to the Mucorales order. Cases of fungal endocarditis are sporadic, but more frequent in immunocompromised patients. COVID-19 (SARS-CoV-2 Infection Disease 2019) infections, prematurity, deferoxamine treatment, iron overload, neutropenia, diabetes, and malignant hemopathies proved to be risk factors for mucormycosis. We present the case of a 7-year-old boy who was treated every three weeks with blood transfusion for major beta-thalassemia, receiving deferoxamine for secondary hemochromatosis. After two weeks with nonspecific respiratory and digestive symptoms, he was admitted for fever, followed by lower limb ischemia and neurological signs. Echocardiography revealed massive endocarditis affecting the mitral and tricuspid valves with embolization phenomena in the brain, lungs, kidney, spleen, and lower limbs. As a particular finding, IgG antibodies for COVID-19 were positive. Emergency cardiac surgery was performed. The mitral valve necessitated replacement with CarboMedics prosthesis. Unfortunately, the patient did not survive. Cunninghamella spp. was confirmed via the PCR analysis of vegetations. Cunninghamella endocarditis in the context of a systemic infection presented as an opportunistic infection affecting a child who had several risk factors. Mucormycosis is challenging to treat, with high mortality. Prophylactic treatment in beta-thalassemia patients with iron-chelator deprivation drugs, such as deferiprone, may help in preventing these particular fungal infections.

Hematogenous dissemination of pulmonary mucormycosis manifested as multiple subcutaneous nodules: a case report and review of the literature

BACKGROUND

Disseminated mucormycosis presenting with multiple subcutaneous nodules is a rare condition with a poor prognosis, and delayed diagnosis and treatment is common.

CASE PRESENTATION

We report a case of 64-year-old Thai woman with colorectal cancer who initially presented with Acinetobacter baumannii pneumonia and respiratory failure. Following 10 days after her admission to the intensive care unit, she developed hospital-acquired pneumonia. Five days later, multiple subcutaneous nodules appeared on both arms and both legs. Bronchoalveolar lavage and skin biopsy cultures both grew Mucor spp. She was diagnosed with disseminated mucormycosis and was treated with liposomal amphotericin B at a dose of 5 mg/kg/day. Despite treatment, our patient succumbed to septic shock and multiorgan failure on the third day after definitive diagnosis.

CONCLUSIONS

This case demonstrates that the subcutaneous nodules caused by hematogenously disseminated mucormycosis are unusual in a patient with a solid tumor. Clinicians should be aware of this atypical presentation of mucormycosis in patients with solid tumors.

Risk factors for palatal and orbital involvement in mucormycosis epidemic-Report of a center in India

BACKGROUND

Mucormycosis of the nose and paranasal sinuses has emerged as an epidemic following COVID-19 pandemic. The management involves surgical debridement, the extent of which depends on the bulk of the disease. Extension to the orbit and palate depends on the involvement of specific sites in the nose and paranasal sinuses. This study intended to identify those sites.

MATERIALS AND METHODS

This was a single-center case-control study. There were 3 groups according to the region involved (Palate, orbit and both). The fourth group with neither involvement was the control. Scoring system was used to estimate the bulk of disease according to the site involved in MRI scan. Odds ratio and chi-square tests were used to study risk and association respectively. ROC curve was obtained for the MRI scores of the cases and controls.

RESULTS

214 patients were studied in all; 44.39% and 61.68% had palate and orbit involvement, respectively. Maxillary sinus roof had significant association and the highest risk for spread of disease into the palate. The risk for the orbit to be involved was increased when there was disease in the cavernous and sphenoid sinus. For the orbit, the site with the significant association was the ethmoid sinus, infratemporal fossa and roof of the maxillary sinus.

CONCLUSION

Due attention should be given for clearance during surgical debridement to the high-risk sites to prevent recurrences and reduce morbidity and mortality. MRI scores were most helpful to identify the bulk of disease when both palate and orbit were involved.

Mucor circinelloides: a model organism for oleaginous fungi and its potential applications in bioactive lipid production

Microbial oils have gained massive attention because of their significant role in industrial applications. Currently plants and animals are the chief sources of medically and nutritionally important fatty acids. However, the ever-increasing global demand for polyunsaturated fatty acids (PUFAs) cannot be met by the existing sources. Therefore microbes, especially fungi, represent an important alternative source of microbial oils being investigated. Mucor circinelloides—an oleaginous filamentous fungus, came to the forefront because of its high efficiency in synthesizing and accumulating lipids, like γ-linolenic acid (GLA) in high quantity. Recently, mycelium of M. circinelloides has acquired substantial attraction towards it as it has been suggested as a convenient raw material source for the generation of biodiesel via lipid transformation. Although M. circinelloides accumulates lipids naturally, metabolic engineering is found to be important for substantial increase in their yields. Both modifications of existing pathways and re-formation of biosynthetic pathways in M. circinelloides have shown the potential to improve lipid levels. In this review, recent advances in various important metabolic aspects of M. circinelloides have been discussed. Furthermore, the potential applications of M. circinelloides in the fields of antioxidants, nutraceuticals, bioremediation, ethanol production, and carotenoids like beta carotene and astaxanthin having significant nutritional value are also deliberated.

How to Treat a Child With a Concurrent Diagnosis of Leukemia and Generalized Mucormycosis? Case Report

Mucormycosis is a rare but a devastating and lifethreatening fungal infection caused by fungi of the order Mucorales usually in immunocompromised patients. Depending on the organs and tissues involved, there are sinus, pulmonary, gastrointestinal, orbital, cerebral, cutaneous and disseminated mucormycosis. Only sporadic cases of hepatic mucormycosis have been described. Hence, we present a complicated treatment management in a 16-month-old child with leukemia and generalized mucormycosis localized in the liver and in the gastrointestinal tract. The collaboration of a multidisciplinary team and appropriate therapy gave a chance not only to save the patient's life, but to carry out anticancer treatment, which resulted in leukemia remission. A 6-month course of isavuconazole and amphotericin B liposomal as well as surgical treatment led to the cure of the fungal infection.

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

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

Blockade of the PD-1/PD-L1 Immune Checkpoint Pathway Improves Infection Outcomes and Enhances Fungicidal Host Defense in a Murine Model of Invasive Pulmonary Mucormycosis

Anecdotal clinical reports suggested a benefit of adjunct immune checkpoint inhibitors (ICIs) to treat invasive mucormycosis. However, proof-of-concept data in animal models and mechanistic insights into the effects of ICIs on host defense against Mucorales are lacking. Therefore, we studied the effects of PD-1 and PD-L1 inhibitors (4 doses of 250 µg/kg) on outcomes and immunopathology of invasive pulmonary mucormycosis (IPM) in cyclophosphamide- and cortisone acetate-immunosuppressed mice. Rhizopus arrhizus-infected mice receiving either of the ICI treatments had significantly improved survival, less morbidity, and lower fungal burden compared to isotype-treated infected mice. While early improvement of morbidity/mortality was comparable between the ICI treatments, anti-PD-L1 provided more consistent sustained protection through day 7 post-infection than anti-PD-1. Both ICIs enhanced the fungicidal activity of ex-vivo splenocytes and effectively counteracted T-cell exhaustion; however, macrophages of ICI-treated mice showed compensatory upregulation of other checkpoint markers. Anti-PD-1 elicited stronger pulmonary release of proinflammatory cytokines and chemokines than anti-PD-L1, but also induced cytokines associated with potentially unfavorable type 2 T-helper-cell and regulatory T-cell responses. Although no signs of hyperinflammatory toxicity were observed, mice with IPM receiving ICIs, particularly anti-PD-1, had elevated serum levels of IL-6, a cytokine linked to ICI toxicities. Altogether, inhibition of the PD-1/PD-L1 pathway improved clinical outcomes of IPM in immunosuppressed mice, even without concomitant antifungals. PD-L1 inhibition yielded more favorable immune responses and more consistent protection from IPM-associated morbidity and mortality than PD-1 blockade. Future dose-effect studies are needed to define the “sweet spot” between ICI-induced augmentation of antifungal immunity and potential immunotoxicities.

Global Cutaneous Mucormycosis: A Systematic Review

Cutaneous mucormycosis is the third most common clinical type of mucormycosis. The signs and symptoms vary widely, and it is important to make the diagnosis as early as possible in order to achieve a better outcome. We present a systematic review of its epidemiology, clinical presentation, diagnosis, and treatment, analyzing cases published from 1958 until 2021. The review was conducted according to the PRISMA guidelines and included 693 cases from 485 articles from 46 countries. Most publications were from North America (256 cases, 36.9%) and Asia (216 cases, 31.2%). The most common risk factors were diabetes mellitus (20%) and hematological malignancies (15.7%). However, a large proportion of published cases (275, 39.6%) had no identified underlying disease. The most common mode of transmission was trauma (54%), and 108 (15.6%) cases were healthcare-associated. In this review, 291 (42.5%) patients had localized infection, and 90 (13%) had disseminated mucormycosis. In Europe, N. America and S. America, the most common genus was Rhizopus spp., while in Asia it was Apophysomyces spp. (34.7%). Treatment was performed with antifungals, mainly amphotericin B, and/or surgery. Mortality was significantly lower when both antifungals and surgery were applied (29.6%).

Cutaneous mucormycosis: an unusual cause of decompensation in a patient with ethanol-related cirrhosis with COVID-19 exposure

We describe a case of cutaneous mucormycosis in a middle-aged man with ethanol-related chronic liver disease. He presented with symptoms of fever, breathlessness for 10 days and altered mental status for 2 days. On admission, he was in septic shock and had acute respiratory distress syndrome (ARDS). He was noted to have ruptured blisters in his left axilla. Although he repeatedly had negative COVID-19 Reverse Transcription-PCR results, he had positive IgG antibodies for COVID-19. He was managed with broad-spectrum antibiotics, steroids, vasopressors and ventilation for ARDS. Over the course of his hospitalisation, the axillary lesion progressed to a necrotising ulcer with deep tissue invasion. Debridement and culture of the axillary ulcer revealed mucor species, and he was started on amphotericin and posaconazole for mucormycosis. Unfortunately, he continued to deteriorate despite aggressive management and died after a prolonged hospital stay of 40 days.

Coronavirus Disease 2019-Associated Mucormycosis Diagnosed by Fine-Needle Aspiration Cytology

The temporal association of mucormycosis with coronavirus disease 2019 (COVID-19) has been termed COVID-19-associated mucormycosis (CAM). Because of its poor prognosis, early diagnosis and treatment are crucial. Although tissue samples for culture and histological evaluation are the cornerstones of diagnosis, the role of fine-needle aspiration cytology (FNAC) and cytologic findings are also significant. Here, we report a case of mucormycosis in a COVID-19-positive 34-year-old male diagnosed by FNAC and confirmed by fungal culture. To our knowledge, this is possibly the first and only case report of CAM diagnosed by FNAC.

Risks of mucormycosis in the current Covid-19 pandemic: a clinical challenge in both immunocompromised and immunocompetent patients

Mucormycosis, also called "Black Fungus", is a new cause for worry in the current Coronavirus disease 2019 (covid-19) pandemic. Mucormycosis is devasting due to its high rate of morbidity and mortality which is a great cause of concern. Mucormycosis, in general, affects immunocompromised patients including diabetic, people with malignancies, organ and stem cell transplants and people affected with pandemic diseases like covid-19. Diagnosis of Mucormycosis is often delayed either due to clinical complications or misdiagnosed as symptoms of other diseases, especially covid-19. This could delay the treatment protocol which results in the failure of treatment. Mortality rate due to secondary infections in covid-19 patients with uncontrolled diabetics and who are on steroid therapy can soon reach 100% if diagnosis and treatment doesn't happen on timely basis. Risk of Mucormycosis is not just in immunosuppressed patients, but immunocompetent people with late diagnosis are also prone to infection. In view of this, we present a comprehensive review on risks of Mucormycosis in immunocompromised and immunocompetent patients highlighting the epidemiology, forms of Mucormycosis, immune response against Mucorales, difficulties in diagnosis and challenges in treatment of Mucormycosis, with emphasis on covid-19 associated Mucormycosis. Importantly, we have discussed the precautions and care to effectively manage Mucormycosis in immunocompromised and immunocompetent patients. Thus, current review helps clinicians in understanding various risk factors in both immunocompromised (especially covid-19 patients) and immunocompetent patients which is critical in managing Mucormycosis in current covid-19 pandemic.

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

COVID-19 continues to cause significant fatality worldwide. Glucocorticoids prove to play essential roles in COVID-19 management; however, the extensive use of steroids together with the virus immune dysregulation may increase the danger of secondary infections with mucormycosis, an angioinvasive fungal infection. Unfortunately, a definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. In this review, we discuss the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response, risk factors, clinical presentation, diagnosis and treatment. Special emphasis is given to its association with the current COVID-19 pandemic, including latest updates on COVID-19-associated mucormycosis cases globally, with recommendations for efficacious management.

Rhino-orbito-cerebral mucormycosis during the COVID-19 third wave in 2021: an Egyptian preliminary report from a single tertiary hospital

COVID-19 is a pandemic disease which predominantly affects the respiratory system with high critical care mortality and morbidity; however, it also causes multi-organ dysfunction in a subset of patients. Although causality between COVID-19 and mucormycosis remains unclear, many factors including glucocorticoids, worsening of blood glucose control, and viral-induced lymphopenia have been attributed to cause mucormycosis in patients with COVID-19. In COVID-19 patients, especially those who need oxygen support, inflammatory and cytokine storm or usage of steroids make the immune system weak. This may pave the way for opportunistic infections including mucormycosis. We report fourteen cases of COVID-19 infection, who developed rhino-orbito-cerebral mucormycosis, during treatment. Early recognition of this life-threatening infection is the key to allow for optimal treatment and improved outcomes.

Gastrointestinal mucormycosis: A periodic systematic review of case reports from 2015 to 2021

BACKGROUND

GI mucormycosis (GI) is a rare but highly lethal infection in patients. There is no single comprehensive review of the literature that demonstrates the various clinical aspects of this infection.

METHODS

A structured search of PubMed/Medline was used to collect case reports of GI mucormycosis in patients of all ages published between 2015 and November 2021.

RESULTS

Eighty-seven cases were identified through PubMed bibliographic database searches, and final analyses were conducted on 70 adults and ten neonatal patients with GI mucormycosis. Asia had the highest number of reported cases, with 46 (57.5%). Neonatal cases had a mortality rate of 70%, while other cases had a mortality rate of 44%. Corticosteroid therapy and diabetes were the most significant risk factors in patients, while 11% were immunocompetent with no apparent underlying condition. COVID-19 positivity was detected in four adult patients. Moreover, neonatal cases included premature and low-weight infants, metabolic acidosis, and malnutrition. Abdominal pain, fever, and GI perforation were the most common signs of infection, while vomiting occurred in 40% of neonatal cases. In 97% of patients, a histopathologic examination was used to detect infection, whereas culture and molecular methods were used in only 28% and 17% of patients, respectively. Surgery plus anti-infection therapy, anti-infection therapy alone, and surgery alone were used in 61%, 28%, and 11% of patients, respectively. Nonetheless, all neonatal patients underwent surgery. Although used in a small number of patients, posaconazole (30%) and isavuconazole (11%) demonstrated high efficacy in treating patients.

CONCLUSION

GI mucormycosis is a rare but highly lethal disease. Treatment of underlying conditions, the use of multiple diagnostic techniques, and appropriate antifungals in conjunction with surgery can all contribute to infection control.

Pseudomonas indica-Mediated Silver Nanoparticles: Antifungal and Antioxidant Biogenic Tool for Suppressing Mucormycosis Fungi

Mucormycosis is considered one of the most dangerous invasive fungal diseases. In this study, a facile, green and eco-friendly method was used to biosynthesize silver nanoparticles (AgNPs) using Pseudomonas indica S. Azhar, to combat fungi causing mucormycosis. The biosynthesis of AgNPs was validated by a progressive shift in the color of P. indica filtrate from colorless to brown, as well as the identification of a distinctive absorption peak at 420 nm using UV-vis spectroscopy. Fourier-transform infrared spectroscopy (FTIR) results indicated the existence of bioactive chemicals that are responsible for AgNP production. AgNPs with particle sizes ranging from 2.4 to 53.5 nm were discovered using transmission electron microscopy (TEM). Pattern peaks corresponding to the 111, 200, 220, 311, and 222 planes, which corresponded to face-centered cubic forms of metallic silver, were also discovered using X-ray diffraction (XRD). Moreover, antifungal activity measurements of biosynthesized AgNPs against Rhizopus Microsporus, Mucor racemosus, and Syncephalastrum racemosum were carried out. Results of antifungal activity analysis revealed that the biosynthesized AgNPs exhibited outstanding antifungal activity against all tested fungi at a concentration of 400 µg/mL, where minimum inhibitory concentrations (MIC) were 50, 50, and 100 µg/mL toward R. microsporus, S. racemosum, and M. racemosus respectively. In addition, the biosynthesized AgNPs revealed antioxidant activity, where IC₅₀ was 31 µg/mL when compared to ascorbic acid (0.79 µg/mL). Furthermore, the biosynthesized AgNPs showed no cytotoxicity on the Vero normal cell line. In conclusion, the biosynthesized AgNPs in this study can be used as effective antifungals with safe use, particularly for fungi causing mucormycosis.

Resolving the equation between mucormycosis and COVID-19 disease

The COVID-19 patients, both infected and recovered are rapidly contracting mucormycetes infections due to the 'Mucorales' order, under Zygomycetes class of fungi. The mucorales fungi commonly known to exist in our natural surroundings including soil, but the frequency of incidences was never rampant. This sudden spike in infections, is locally known as 'black fungus,' and is affecting various organs, including- eyes, sinuses, nose, brain, skin, intestine, lungs, etc. The severity of situation is ascertainable from the fact that, in certain cases surgical eye/jaws removal persists as the only viable option to avert mortality, as therapeutic interventions are limited. This epidemic situation intrigued experts to investigate the probable reason behind this unpredicted escalation in reported cases, including in recuperated COVID-19 patients, as person-to-person spread of infection is not common. The comparison of physiological parameters in healthy and COVID-19 afflicted patients highlights that the underlying conditions including diabetes mellitus, steroidal therapy, lymphopenia (decreased CD4+ and CD8+ lymphocytes), deregulated cytokine release storm, elevated free iron levels (hemosiderosis) in blood and insulin insensitivity are playing major roles in deteriorating conditions in rarely pathogenic fungal infections. This review is an attempt to explain the rationalities that makes people vulnerable to mucormycetes infection.

Mucormycosis (black fungus) ensuing COVID-19 and comorbidity meets - Magnifying global pandemic grieve and catastrophe begins

Post COVID-19, mucormycosis occurred after the SARS-CoV-2 has rampaged the human population and is a scorching problem among the pandemic globally, particularly among Asian countries. Invasive mucormycosis has been extensively reported from mild to severe COVID-19 survivors. The robust predisposing factor seems to be uncontrolled diabetes mellitus, comorbidity and immunosuppression acquired through steroid therapy. The prime susceptive reason for the increase of mucormycosis cases is elevated iron levels in the serum of the COVID survivors. A panoramic understanding of the infection has been elucidated based on clinical manifestation, genetic and non- genetic mechanisms of steroid drug administration, biochemical pathways and immune modulated receptor associations. This review lime-lights and addresses the "What", "Why", "How" and "When" about the COVID-19 associated mucormycosis (CAM) in a comprehensive manner with a pure intention to bring about awareness to the common public as the cases are inevitably and exponentially increasing in India and global countries as well. The article also unearthed the pathogenesis of mucormycosis and its association with the COVID-19 sequela, the plausible routes of entry, diagnosis and counter remedies to keep the infection at bay. Cohorts of case reports were analysed to spotlight the link between the pandemic COVID-19 and the nightmare-mucormycosis.

Radhakrishnan A. Rhino-orbital Mucormycosis in a COVID-19 Patient: The First Case in Malaysia

Mucormycosis is an aggressive and potentially fatal fungal infection caused by fungi of the order Mucorales. There has been an increase in the number of cases of rhino-orbital mucormycosis in people with COVID-19, particularly in India. Rhino-orbital-cerebral mucormycosis is the most common manifestation of mucormycosis associated with COVID-19. We report the first case of rhino-orbital mucormycosis in a diabetic patient with SARS-CoV-2 infection in Malaysia. The diagnosis of mucormycosis was confirmed by histopathological examination, but the fungal culture and PCR results were negative. He was treated with antifungal therapy and had extensive debridement. Treatment of mucormycosis requires a multidisciplinary approach that includes addressing underlying risk factors, effective antifungal therapy, and surgical debridement.

Are Low Serum Vitamin D Levels a Risk Factor for Advent of COVID-19 Associated Rhinocerebral Mucormycosis: A Preliminary Case Control Study

To determine whether low serum vitamin D level is a risk factor for development of Rhinocerebral mucormycosis in COVID-19 afflicted patients. A case control study was conducted in a tertiary care hospital utilizing the archived records of COVID-19 afflicted Rhinocerebral mucormycosis cases and age and gender matched controls. The mean value (± standard deviation) of vitamin D level in patients with Mucormycosis was 19.65 ± 13.07 ng/ml and in control subjects it was 27.88 ± 18.04 ng/ml.There was a significant difference between groups (p = 0.02). Thus, low Vitamin D level may be implicated as a risk factor for the advent of mucormycosis in a COVID-19 afflicted patient and therefore Vitamin D supplements may be provided to such patients to achieve normal serum levels.

Mucormycosis Amid COVID-19 Crisis: Pathogenesis, Diagnosis, and Novel Treatment Strategies to Combat the Spread

The havoc unleashed by COVID-19 pandemic has paved way for secondary ominous fungal infections like Mucormycosis. It is caused by a class of opportunistic pathogens from the order Mucorales. Fatality rates due to this contagious infection are extremely high. Numerous clinical manifestations result in damage to multiple organs subject to the patient's underlying condition. Lack of a proper detection method and reliable treatment has made the management of this infection troublesome. Several reports studying the behavior pattern of Mucorales inside the host by modulation of its defense mechanisms have helped in understanding the pathogenesis of this angio-invasive infection. Many recent advances in diagnosis and treatment of this fungal infection have not been much beneficial. Therefore, there is a need to foster more viable strategies. This article summarizes current and imminent approaches that could aid effective management of these secondary infections in these times of global pandemic. It is foreseen that the development of newer antifungal drugs, antimicrobial peptides, and nanotechnology-based approaches for drug delivery would help combat this infection and curb its spread.

Case Report: Metagenomics Next-Generation Sequencing for Diagnosing Cerebral Infarction and Infection Caused by Hematogenous Disseminated Mucormycosis in a Patient With Acute Lymphoblastic Leukemia

Disseminated mucormycosis, a serious complication, is associated with high mortality in patients with acute leukemia after chemotherapy. Blood cultures are always negative because of recurrent empirical antifungal treatments. The identification of pathogens is important for diagnosis and therapy. In this case report, we diagnosed culture-negative disseminated mucormycosis with Rhizomucor miehei infection leading to cerebral infarction in a patient with leukemia using metagenomics next-generation sequencing (mNGS) form peripheral blood, cerebral spinal fluid, and bronchoalveolar lavage fluid. mNGS technology can be applied to precisely diagnose culture-negative disseminated mucormycosis.

Endobronchial mucormycosis: A rare clinical entity diagnosed by endobronchial cryobiopsy

Mucormycosis is a rare fungal infection caused by fungi of the order Mucorales. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas pulmonary mucormycosis is a rare manifestation in patients with hematological malignancy and transplant recipients. We report a case of a 40-year-old male, with history of poorly controlled diabetes, who presented to the emergency room with a one-week history of hemoptysis. Computed Tomography (CT) of the chest was concerning for a lung mass or abscess. Flexible bronchoscopy revealed an endobronchial lesion that was biopsied with a cryoprobe. Histopathologic examination showed non-septate right-angle branching hyphae, typical of mucormycosis. He underwent surgical resection of the right middle and lower lobes and treatment with antimycotic agents with a complete recovery. This case highlights the importance of early histopathological diagnosis of pulmonary mucormycosis in preventing a fatal outcome.

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.

Mucormycosis: A new threat to Coronavirus disease 2019 with special emphasis on India

The main reason for the growth of mucormycosis in people with Coronavirus disease-2019 (COVID-19) is mainly produced by Rhizopus spp. The infective mechanisms and issues recognized in Rhizopus spp. are the cell wall, germination proteins, and enzymes assisted to iron sequestration, CotH protein, and positive regulation of the GRP78 cell receptor. Mucormycosis is mainly caused by the Rhizopus spp. such as R. oryzae, R. microsporus, R. arrhizus, R. homothallicus, etc. that are gifted to numerous host defense mechanisms and attribute to the endothelium via specific receptors, GRP78 simplifying their endocytosis and angio-invasion. Factors such as hyperglycemia, elevated iron concentrations, and ketoacidosis have been shown to contribute to the pathogenesis in the tentative situation. The analytical data of 'black fungus disease' or 'mucormycosis', specify India reported for about 42.3% of published cases, followed by the USA about 16.9%, Iraq, Bangladesh, Iran, Paraguay, and 1 case each from Brazil, Mexico, Italy, UK, China, France, Uruguay, Turkey, and Austria. The COVID-19 infection is maybe a predisposing factor for mucormycosis and is related to a high mortality rate. Early recognition and restriction of hyperglycemia, liposomal amphotericin B, and surgical debridement are the bases in the successful managing of mucormycosis.

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.

Management of coronavirus disease (Covid-19) associated mucormycosis with palatal ulcer, dental pain and anterior maxillary teeth mobility- A clinical dilemma of Covid 19 pandemic in India

Mucormycosis represents a group of life-threatening infections caused by fungi of the order mucorales of subphylum mucormycotina. Due to high vascularity, the maxilla rarely undergoes necrosis. Mucormycosis is an opportunistic fulminant fungal infection, which mainly infects immune-compromised patients. Due to the inhalation of fungal spores, the infection may begin in the nose and paranasal sinuses. Necrosis of hard and soft tissues is due to thrombosis of arteries, which is caused by the inhalation of fungal spores. We report a case of maxillary necrosis by mucormycosis in a COVID-19-recovered patient to emphasize the early diagnosis of this potentially fatal fungal infection. We reviewed the current concepts in the management of mucormycosis and different diseases that can lead to maxillary necrosis. The mortality and morbidity of this lethal fungal infection can be successfully reduced by early diagnosis and quick treatment by the general primary care provider, family physicians, and dentists.

Let's talk about mucormycosis emergency with COVID-19: Invest in future

Despite recent breakthroughs in the detection and treatment during the COVID-19 pandemic, mucormycosis is a serious infection with a high death rate. It is a filamentous fungal infection from the zygomycetes class of order mucorales. It is a fatal fungal infection with a 50% or higher overall fatality rate. Mucormycosis is a fungal infection caused by mucor, which is a mold that can be found in soil, rotting fruits, and vegetables. It can primarily affect the brain, lungs, and sinuses. It is very much fatal in patients with diabetes or who are highly immunocompromised such as patients with cancer. In addition to more than 50% mortality rate, surgical intervention may require necrotic tissue removal, which leads to severely disfiguring surgery.

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.

Primary mucormycosis infection in the submandibular area after esthetic lipolytic injection in an immunocompetent patient: A case report

As the popularity of injection lipolysis increases, several side effects of injection lipolysis have been reported. In this case, A 53-year-old woman visited our outpatient clinic with a new round-shaped protruding mass (size: 5.0 cm × 3.0 cm) in the submental area. The patient had received the injection lipolysis treatment before the visit. She had received injections in the submental area at 1-week intervals (i.e., 4, 5, and 6 weeks). We performed contrast-enhanced computed tomography of the neck for differential diagnosis and found a 5.0 cm × 3.7 cm × 2.1 cm rim-enhanced fluid-density lesion in the submental. Hence, surgical removal of the lesion was planned based on the diagnosis of unspecified complicated fluid collection. The removed mass was a 3.0 cm × 2.0 cm × 2.0 cm whitish fibrous tissue. Histological examination revealed mucormycosis infection. Although several side effects of lipolysis have been reported to date, mucormycosis infection in the submental area has not been reported before.

An unexpected case of disseminated mucormycosis following pacemaker placement and brief course of oral corticosteroids

Mucormycosis is a rare opportunistic fungal infection with a high degree of morbidity and mortality. It classically presents with rapidly progressing, necrotic rhinocerebral mucocutaneous lesions in the setting of an immunocompromised host, especially with concomitant uncontrolled diabetes. We report the case of a 67-year-old man with well-controlled non-insulin dependent diabetes and brief steroid exposure who presented in sepsis with a tender posterior shoulder skin lesion. The initial lesion enlarged and progressed over several days, developing central areas of ecchymosis and bullae, with several other large lesions appearing at various distant sites. He also experienced an array of systemic symptoms, including fever, malaise, weakness, and acute encephalopathy. A diagnosis of mucor was made by histopathological examination of the initial skin lesion. Despite initiation of amphotericin B and aggressive surgical debridement including transfer to specialist tertiary burn center, the patient passed away less than a week after definitive diagnosis. This is a unique case of disseminated mucormycosis given his lack of chronic immunosuppression or uncontrolled diabetes, and with no risk factors for inoculation except for pacemaker placement 2 months prior to admission. The case highlights the importance of considering mucormycosis in the early differential diagnosis of rapidly progressing skin lesions, as rapid detection and treatment is critical to mitigate the deadly effects of this fast-moving fatal fungus. Moreover, the case serves as a testament to the unpredictable progression of disseminated disease, while also demonstrating an unusual potential mode of introduction and a rare but fatal consequence of prescribing corticosteroids in an infected host.