Epidemiology and clinical manifestations of mucormycosis

Dental and Oral Manifestations of COVID-19 Related Mucormycosis: Diagnoses, Management Strategies and Outcomes

It has been nearly two years since the pandemic caused by the novel coronavirus disease (COVID-19) has affected the world. Several innovations and discoveries related to COVID-19 are surfacing every day and new problems associated with the COVID-19 virus are also coming to light. A similar situation is with the emergence of deep invasive fungal infections associated with severe acute respiratory syndrome 2 (SARS-CoV-2). Recent literature reported the cases of pulmonary and rhino-cerebral fungal infections appearing in patients previously infected by COVID-19. Histopathological analysis of these cases has shown that most of such infections are diagnosed as mucormycosis or aspergillosis. Rhino-orbital-cerebral mucormycosis usually affects the maxillary sinus with involvement of maxillary teeth, orbits, and ethmoidal sinuses. Diabetes mellitus is an independent risk factor for both COVID-19 as well as mucormycosis. At this point, there is scanty data on the subject and most of the published literature comprises of either case reports or case series with no long-term data available. The aim of this review paper is to present the characteristics of COVID-19 related mucormycosis and associated clinical features, outcome, diagnostic and management strategies. A prompt diagnosis and aggressive treatment planning can surely benefit these patients.

A rare case report of post-Covid Mucormycosis-Aspergillosis co-infection

Background and Purpose: Mucormycosis and Aspergillosis square measure the foremost frequent fungal infections caused by these filiform fungi. Coinfection is scarce and incorporates a poor prognosis. The commonest presentation of invasive fungal infection (IFI) is rhinocerebral involvement. It ordinarily affects immunocompromised patients. Case report: A 55-year-old post-COVID male patient with uncontrolled Diabetes Mellitus developed swelling and chemosis in the left eye. In plain CT orbit, mucosal thickenings were seen in the ethmoid, sphenoid, left frontal, and left maxillary sinuses without any erosions or extensions. Nasal endoscopy showed black-brown overgrowth on the left middle turbinate. Biopsy revealed growth of both Mucor and Aspergillus. The patient was treated for Diabetic Ketoacidosis along with Amphotericin-B for anti-fungal management and showed significant improvement and is stable. Conclusion: It is probably the first rare case of coinfection with Mucormycosis (Rhizopus spp.) and Aspergillosis (Aspergillus flavus). Early diagnosis is a major advantage in management. The multidisciplinary approach of such cases is invaluable. The implementation of higher diagnostic methods including PCR in the diagnosis at all tertiary care facilities. A refined selection of post-COVID cases in higher numbers and cautious collection and processing of patient specimens will certainly attribute to higher chances of a definitive diagnosis and an early initiation of specific and efficient treatment.

Characteristics of Mucormycosis in Hematological Patients and a Death Prediction Model

Mucormycosis is an angioinvasive fungal infection, associated with high mortality. The aim of our study was to explore the high-risk factors and predict the death of hematological disease complicated with mucormycosis. We retrospectively analyzed clinical data of 31 patients with hematological disease complicated with mucormycosis, adopted random forest to establish the death prediction model, and validated the model in another 15 patients. The median age of the 31 cases was 46 (28–51) years, male to female ratio 1.38:1, and 90-day mortality rate 54.8%. The most common underlying disease was acute myeloid leukemia (58.1%). The main clinical symptoms were fever (100%), cough (87.1%), sputum (80.6%), chest pain (61.3%), and hemoptysis (19.4%). Reversed halo sign (83.9%) was the most common computed tomography sign. A total of 48.4% of patients also had aspergillus or bacterial infections. Discriminative models were constructed by random forest with 17 non-survivors and 14 survivors. Procalcitonin, the duration of intravenous administration of amphotericin B or amphotericin B liposomes, and neutropenia at death or 90 days of survival were the leading risk factors for poor prognosis, with area under the curve of 0.975 (95% CI 0.934–1). We chose 0.6775 as death prediction threshold (with 82.3% sensitivity and 100% specificity) and validated the model successfully in another 15 patients. Chest pain and reversed halo sign are specific clinical and image signs of hematological disease complicated with mucormycosis. Neutropenia, elevated procalcitonin, and insufficient use time of amphotericin B or amphotericin B liposomes are risk factors for death.

"MuCovid-21" study: Mucormycosis at an Indian tertiary care centre during the COVID-19 pandemic

BACKGROUND

Mucormycosis has been reported in several Indian states with the second wave of COVID-19 from January 2021 onwards. This prospective study was conducted with the objective of defining the contribution or association of various known and many suspected factors in the incidence of this disease during the ongoing pandemic.

METHOD

The study included 464 adults with mucormycosis. Basic demographic data were collected. Patient history of COVID infection, its severity, duration of treatment, and oxygen use was taken to assess the association. History of use of antibiotics, steroids, antivirals, biologicals, and other complementary treatments was sought. History of diabetes and other comorbidities was noted. Patients were investigated for mucor confirmation using a nasal swab KOH mount, nasal endoscopy with biopsy, and radiological investigations were done to assess the extent.

RESULTS

Out of 464 patients, 175 were known diabetics, and 157 were treated with steroids during COVID infection. Out of 287 post-COVID patients, 125 (44%) had rhino-mucormycosis (RM), 102 (35%) had rhino-oculo-mucormycosis (ROM) and 60 (21%) had rhino-oculo-cerebral-mucormycosis (ROCM). 162 did not have a history of COVID, of which 93 (57%) had RM, 48 (30%) had ROM and 21 (13%) had ROCM.

CONCLUSION

This study has showed that COVID was not the only factor contributing to mucor, rather other factors such as diabetes, steroid use etc. were also contributory. Many patients who were suffering from mucormycosis did not have a history of COVID. Advanced age, ROCM, and ICU admission were associated with increased mortality.

Invasive Fungal Infections and Targeted Therapies in Hematological Malignancies

The use of targeted biologic therapies for hematological malignancies has greatly expanded in recent years. These agents act upon specific molecular pathways in order to target malignant cells but frequently have broader effects involving both innate and adaptive immunity. Patients with hematological malignancies have unique risk factors for infection, including immune dysregulation related to their underlying disease and sequelae of prior treatment regimens. Determining the individual risk of infection related to any novel agent is challenging in this setting. Invasive fungal infections (IFIs) represent one of the most morbid infectious complications observed in hematological malignancy. In recent years, growing evidence suggests that certain small molecule inhibitors, such as BTK inhibitors and PI3K inhibitors, may cause an increased risk of IFI in certain patients. It is imperative to better understand the impact that novel targeted therapies might have on the development of IFIs in this high-risk patient population.

Gastric mucormycosis with splenic invasion a rare abdominal complication of COVID-19 pneumonia

Mucormycosis (previously called zygomycosis or phycomycosis) is an uncommon opportunistic infection with the gastrointestinal form being the rarest occurrence and one of the most lethal infections known to humanity. The most common risk factors predisposing to develop gastric mucormycosis are uncontrolled diabetes mellitus, stem cell transplantation, or underlying any hematologic malignancy and major trauma. Pain abdomen, hematemesis, and melena are common symptoms which the patient presents. The exact diagnosis of gastric mucormycosis can be missed due rarity of the disease. A high level of suspicion is required in the early diagnosis and management of disease, particularly in immunocompromised patients. The radiological imaging modalities such as CT scan or MRI of the abdomen initially usually reveal non-specific findings such as mucosal wall thickening, mass, and reactive lymphadenopathy and prompt additional investigation with endoscopic or surgical biopsy of the lesions. The disease outcome and mortality are very high with gastrointestinal mucormycosis.

Aspergillosis: Emerging risk groups in critically ill patients

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

LAY SUMMARY

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

Awareness Toward Mucormycosis Attack for COVID Patients

Risk groups for mucormycosis include persons with immunosuppressed immune system and uncontrolled diabetes. The patients suffering from corona virus or post covid patients have been found to be entrapped with this fungal infection due to suppression in the immune system. Also the major attack was reported in those patients who were in Intensive Care units. It arises due to the fungal infection of various species and can occur simultaneously with covid. The development of black fungus mostly affects lungs, eyes, brain, and skin and is not at all contagious. Proper diagnostic can only predict that the patient is in invasive attack of which mucor species. It is better to take prevention by wearing medicated masks, hand gloves, wearing glasses, avoid dusty and damp places.

Liquid Biopsy for Invasive Mold Infections in Hematopoietic Cell Transplant Recipients With Pneumonia Through Next-Generation Sequencing of Microbial Cell-Free DNA in Plasma

BACKGROUND

Noninvasive diagnostic options are limited for invasive mold infections (IMIs). We evaluated the performance of a plasma microbial cell-free DNA sequencing (mcfDNA-Seq) test for diagnosing pulmonary IMI after hematopoietic cell transplant (HCT).

METHODS

We retrospectively assessed the diagnostic performance of plasma mcfDNA-Seq next-generation sequencing in 114 HCT recipients with pneumonia after HCT who had stored plasma obtained within 14 days of diagnosis of proven/probable Aspergillus IMI (n = 51), proven/probable non-Aspergillus IMI (n = 24), possible IMI (n = 20), and non-IMI controls (n = 19). Sequences were aligned to a database including >400 fungi. Organisms above a fixed significance threshold were reported.

RESULTS

Among 75 patients with proven/probable pulmonary IMI, mcfDNA-Seq detected ≥1 pathogenic mold in 38 patients (sensitivity, 51% [95% confidence interval {CI}, 39%-62%]). When restricted to samples obtained within 3 days of diagnosis, sensitivity increased to 61%. McfDNA-Seq had higher sensitivity for proven/probable non-Aspergillus IMI (sensitivity, 79% [95% CI, 56%-93%]) compared with Aspergillus IMI (sensitivity, 31% [95% CI, 19%-46%]). McfDNA-Seq also identified non-Aspergillus molds in an additional 7 patients in the Aspergillus subgroup and Aspergillus in 1 patient with possible IMI. Among 19 non-IMI pneumonia controls, mcfDNA-Seq was negative in all samples, suggesting a high specificity (95% CI, 82%-100%) and up to 100% positive predictive value (PPV) with estimated negative predictive values (NPVs) of 81%-99%. The mcfDNA-Seq assay was complementary to serum galactomannan index testing; in combination, they were positive in 84% of individuals with proven/probable pulmonary IMI.

CONCLUSIONS

Noninvasive mcfDNA-Seq had moderate sensitivity and high specificity, NPV, and PPV for pulmonary IMI after HCT, particularly for non-Aspergillus species.

Mucormycosis: A triple burden in patients with diabetes during COVID-19 Pandemic

With the upsurge in the cases of COVID-19 around the world, plenty of potential COVID-19 complications are becoming more prevalent, including a higher risk of secondary bacterial and fungal infections. Mucormycosis is one such condition which has high prevalence among individuals with diabetes who were infected with COVID-19.The usage of steroids in the treatment further inflates the risk of infection and exacerbation of disease in pre-existent mucormycosis patients. Generally, Corticosteroid-induced diabetes can arise on long-term steroid medication, increasing the likelihood of mucormycosis. In patients with COVID-19, the indications and dose of corticosteroids should be properly regulated, and persons with diabetes who take insulin or oral anti-diabetic medicines should be cautious. To avoid poor outcomes, strategies to improve glycemic management should be emphasized. This narrative review elucidates different disciplines on rampant use of steroids, iron and zinc supplements as well as the methods utilized as primary or adjunctive treatment of this fatal condition. This article may help to pave the way for robust research that needs to be done to tackle the deadly triple burden of the disease.

Emphysematous gastritis associated with mucormycosis in a patient with fulminant myocarditis requiring veno-arterial extracorporeal membrane oxygenation

We present the case of a 37-year-old male who admitted to our hospital with fever, weakness, limb pain for 6 days and dyspnea for 14 hours .The patient had no immune related diseases.He was rapidly diagnosed with fulminant myocarditis and progressed to severe cardiogenic shock during the early stage.Then he was treated with V-A extracorporeal membrane oxygenation (ECMO). It is worth mentioning that the patient's peripheral blood was taken for metagenomic Next-Generation Sequencing(mNGS) upon admission and the results did not find any pathogenic bacteria.But there is no further examination(such as coronary angiography and myocardial biopsy) to determine the etiology of myocarditis.

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

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

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

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

A Rare Presentation of Ileocecal Mucormycosis in a Heart Transplant Recipient

Mucorales is an order of angioinvasive fungi that classically infects immunocompromised patients. As an aerogenous pathogen, it most frequently causes disease of the lungs and paranasal sinuses. Gastrointestinal mucormycosis represents a particularly rare site of infection. This case report describes the complicated presentation of ileocecal mucormycosis in an immunocompromised orthotopic heart transplant recipient. The diagnosis was made status-post ileocolonic resection, and the patient was promptly started on liposomal amphotericin B and micafungin. Unfortunately, the patient ultimately succumbed to disseminated infection. In this study, we review the epidemiology, the presenting features of gastrointestinal mucormycosis, and emphasize the prompt initiation of therapy on suspected disease.

Novel Pathogenic Mucorales Identified Using the Silkworm Infection Model

Mucormycosis, a rare but highly fatal infection, is caused by fungi of the order Mucorales. Due to their ubiquitous nature, reduced susceptibility to antifungals, acid tolerance, and ability to infect immunocompromised patients through rapid dissemination, these fungi have been frequently reported to infect the COVID-19 patients. In order to develop strategies to overcome mucormycosis, it is essential to understand and identify novel Mucorales present in the environment. In this study, we report the identification of four novel pathogenic Mucorales using the silkworm (Bombyx mori) model. The strains’ phylogeny was analyzed using the genome sequence of the large subunit ribosomal ribonucleic acid (LSU rRNA) and the internal transcribed spacer (ITS) region, where strains 1-3, 5-3, and S286-1101 claded with Mucor orantomantidis, and strain 827-14 claded with Backusella lamprospora. All the strains had a cold-sensitive phenotype with their inability to grow prominently at 4 °C. Mucor sp. 1-3 and 5-3 were characterized by their filamentous and yeast-like growth under aerobic and anaerobic conditions, respectively. The yeast colonies of Mucor sp. 5-3 had multipolar budding cells often observed with cleaved cell surfaces under a scanning electron microscope. We further found that these strains were able to kill immunocompromised mice suggesting their pathogenicity to mammals. Our study established an invertebrate model-based screening system to identify novel pathogenic Mucorales from the natural environment and provided a clue towards the rapid increase in COVID-19 related mucormycosis.

Incidence and risk factors for mucormycosis in renal transplant patients

BACKGROUND

Renal transplant patients are at increased risk for mucormycosis. Diabetes, neutropenia, deferoxamine therapy, and immunosuppressive medications have been associated with increased risk of mucormycosis in studies of solid organ transplant recipients. To focus on renal transplant patients, the US Renal Data System (USRDS) was queried to determine the incidence and risk factors for mucormycosis.

METHODS

All renal transplant patients in the USRDS from 1988 to 2015 were queried for a diagnosis of mucormycosis after the first transplant date using ICD-9 and ICD-10 codes. The International Classification of Diseases (ICD) codes, which currently exist in the ninth and tenth revisions, are a global system of classification used to code diagnoses, procedures, and symptoms. We defined proven mucormycosis by a histopathologic or fungal stain procedure code within 7 days of the diagnosis code. Logistic regression controlling for person-years at risk was used to examine demographic and clinical diagnosis risk factors for mucormycosis.

RESULTS

Of the 306,482 renal transplant patients, 222 (0.07%) had codes consistent with proven mucormycosis. The incidence of mucormycosis increased from 1990 to 2000 (peak 17.6 per 100,000 person-years) and subsequently demonstrated more variability. Hispanic ethnicity (OR=1.45), age 65 years or greater (OR=1.64), other or black race compared with white race (OR=1.96 and 1.74), cadaver or other donor type (OR=2.41), and receiving tacrolimus (OR=2.09) were associated with increased risk. Comorbidities associated with decreased risk of mucormycosis included female sex (OR=0.68), iron overload (OR=0.56), and receiving mycophenolate mofetil (OR=0.67) or azathioprine (OR=0.53).

CONCLUSIONS

In renal transplant patients, age, deceased donor graft transplant, tacrolimus administration, race other than white, and Hispanic ethnicity were associated with increased risk of mucormycosis. Unexpectedly, iron overload was protective. Mucormycosis is a rare infection in renal transplant patients which should be considered in patients with the above risk factors after more common infections have been ruled out.

Global Prevalence of COVID-19-Associated Mucormycosis (CAM): Living Systematic Review and Meta-Analysis

Mucormycosis, a secondary fungal infection, gained much attention in the ongoing COVID-19 pandemic. This deadly infection has a high all-cause mortality rate and imposes a significant economic, epidemiological, and humanistic burden on the patients and healthcare system. Evidence from the published epidemiological studies showed the varying prevalence of COVID-19-associated mucormycosis (CAM). This study aims to compute the pooled prevalence of CAM and other associated clinical outcomes. MEDLINE, Embase, Cochrane COVID-19 Study Register, and WHO COVID-19 databases were scanned to retrieve the relevant articles until August 2021. All studies reporting the prevalence of mucormycosis among COVID-19 patients were eligible for inclusion. Two investigators independently screened the articles against the selection criteria, extracted the data, and performed the quality assessment using the JBI tool. The pooled prevalence of CAM was the primary outcome, and the pooled prevalence of diabetes, steroid exposure, and the mortality rate were the secondary outcomes of interest. Comprehensive Meta-Analysis software version 2 was used for performing the meta-analysis. This meta-analysis comprised six studies with a pooled sample size of 52,916 COVID-19 patients with a mean age of 62.12 ± 9.69 years. The mean duration of mucormycosis onset was 14.59 ± 6.88 days after the COVID-19 diagnosis. The pooled prevalence of CAM (seven cases per 1000 patients) was 50 times higher than the highest recorded background of mucormycosis (0.14 cases per 1000 patients). A high mortality rate was found among CAM patients with a pooled prevalence rate of 29.6% (95% CI: 17.2-45.9%). Optimal glycemic control and the judicious use of steroids should be the approach for tackling rising CAM cases.

Risk Assessment for Molds in the Vicinity of a Child Requiring Peritoneal Dialysis Living in a Rural Northern German Area

As well as severe immunosuppression, other predisposing factors may facilitate invasive mycosis caused by molds. Chronic kidney disease and the resulting peritoneal dialysis have been reported as factors putting patients at risk of fungal infections from environmental sources. We describe an environmental investigation undertaken to guide exposure prevention for a peritoneal dialysis patient with transient colonization of her nostrils by Lichtheimia corymbifera in a rural area of northern Germany. Systematic screening for airborne and surface-deposited molds enabled targeted recommendations to be made, although Lichtheimia corymbifera itself was not grown from the collected environmental samples. This communication is intended to illustrate how such an investigation can be performed on the basis of the environmental distribution of the molds and how preventive recommendations can be derived from the results.

Transcutaneous retrobulbar injection of amphotericin B in rhino-orbital-cerebral mucormycosis: a review

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.

IFN-γ Mediated Signaling Improves Fungal Clearance in Experimental Pulmonary Mucormycosis

We established three immunocompetent murine models of pulmonary mucormycosis to determine the involvement of the adaptive immune response in host resistance in pulmonary mucormycosis, a rapidly fatal disease caused mainly by Rhizopus spp. Immunocompetent inbred (C57BL/6, BALB/c) and outbred (Swiss) strains of mice were inoculated with R. oryzae via the intratracheal route. The inoculation resulted in a disseminated infection that spread to the brain, spleen, kidney, and liver. After 7 and 30 days of R. oryzae infection, BALB/c mice showed the lowest fungal load and highest production of IFN-γ and IL-2 by splenocytes. Swiss mice showed a higher fungal load 30 days p.i. and was associated with a weak development of the Th-1 profile. To confirm our findings, R. oryzae-infected IFN-γ⁻/⁻ mice were evaluated after 60 days, where the mice still showed viable fungi in the lungs. This study showed, for the first time, that pulmonary mucormycosis in three widely used mouse strains resulted in an acute fungal dissemination without immunosuppression whose outcome varies according to the genetic background of the mice. We also identified the partial role of IFN-γ in the efficient elimination of R. oryzae during pulmonary infection.

COVID-19-associated-mucormycosis: possible role of free iron uptake and immunosuppression

COVID-19-associated-mucormycosis, commonly referred to as the "Black Fungus," is a rare secondary fungal infection in COVID-19 patients prompted by a group of mucor molds. Association of this rare fungal infection with SARS-CoV-2 infection has been declared as an endemic in India, with minor cases in several other countries around the globe. Although the fungal infection is not contagious like the viral infection, the causative fungal agent is omnipresent. Infection displays an overall mortality rate of around 50%, with many other secondary side effects posing a potential threat in exacerbating COVID-19 mortality rates. In this review, we have accessed the role of free iron availability in COVID-19 patients that might correlate to the pathogenesis of the causative fungal agent. Besides, we have analyzed the negative consequences of using immunosuppressive drugs in encouraging this opportunistic fungal infection.

A Unique Triad of Invasive Sinusitis, Brain Abscess with Focal Cerebritis, and COVID-19

Patient: Male, 49-year-old

Final Diagnosis: Rhinosinusitis

Symptoms: Cough • fatigue • headache • seizure

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

Favourable outcome in a child with acute lymphoblastic leukaemia and pulmonary mucormycosis managed with combination antifungal therapy of liposomal amphotericin B and caspofungin

Pulmonary mucormycosis (PM) accounts for more than half the cases of mucormycosis in paediatric haematological malignancies, with mortality reaching as high as 90%. Surgical debridement of lesion along with liposomal amphotericin B (L-AMB) constitutes the mainstay of management of mucormycosis and offers best chances of survival. There are no reliable data available in the literature justifying the use of combination antifungal therapy (CAfT). We describe a child with acute lymphoblastic leukaemia (ALL) who developed multiple localised PM during induction chemotherapy. He was managed with CAfT with L-AMB and caspofungin in view of progressive PM on high-dose L-AMB monotherapy. There was complete resolution of PM after 6 months of CAfT at the end of intensive chemotherapy of ALL. There were no significant side effects of CAfT. CAfT may be of value in cases of mucormycosis refractory to high doses of L-AMB, where surgical debridement is not feasible.

A Rare Case of Gastrointestinal Mucormycosis

Gastrointestinal Mucormycosis (GIM) is a rare life-threatening angio-invasive infection. The classic risk factors include immunosuppression and metabolic derangement. Usually, there are classical risk factors in patients affected by Ileocecal mucormycosis. Few case reports have shown the absence of salient clinical presentation of mucormycosis in prolonged hospitalisation. The presence of association of mucormycosis in patients of typhoid infection is rare. Here, we present a case of invasive ileal mucormycosis occurring as a sequel to typhoid infection which lacked the typical risk factors for mucormycosis.

The Statewide Epidemiology of Mucormycosis Among Trauma Patients in Florida

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Changing Epidemiology of Invasive Fungal Disease in Allogeneic Hematopoietic Stem Cell Transplantation

Invasive fungal disease (IFD) is a common cause of morbidity and mortality in patients with hematologic malignancies, especially among those undergoing allogeneic hematopoietic stem cell transplantation (HSCT). The epidemiology of IFD in HSCT patients has been evolving over the last decades, mainly in relation to changes in HSCT therapies such as antifungal prophylaxis. A progressive decrease in Candida albicans infection has been documented, alongside a progressive increase in infections caused by non-albicans Candida species, filamentous fungi, and/or multidrug-resistant fungi. Currently, the most frequent IFD is invasive aspergillosis. In some parts of the world, especially in north Central Europe, a high percentage of Aspergillus fumigatus isolates are azole-resistant. New diagnostic techniques have documented the existence of cryptic Aspergillus species with specific characteristics. An increase in mucormycosis and fusariosis diagnoses, as well as diagnoses of other rare fungi, have also been described. IFD epidemiology is likely to continue changing further due to both an increased use of mold-active antifungals and a lengthened survival of patients with HSCT that may result in hosts with weaker immune systems. Improvements in microbiology laboratories and the widespread use of molecular diagnostic tools will facilitate more precise descriptions of current IFD epidemiology. Additionally, rising resistance to antifungal drugs poses a major threat. In this scenario, knowledge of current epidemiology and accurate IFD diagnoses are mandatory in order to establish correct prophylaxis guidelines and appropriate early treatments.

How Does Mucorales Benefit from the Dysregulated Iron Homeostasis During SARS-CoV-2 Infection?

Mucorales is the cause of mucormycosis, an emerging opportunistic infection in the era of coronavirus disease 2019 (COVID-19) pandemic. Condition of hyperglycemia, diabetes mellitus, and acidosis; dysregulated iron homeostasis in the form of hyperferritinemic syndrome, and high concentration of iron in circulation; and endothelial injury related to abundance glucose regulated protein 78 (GRP78), which are present in severe COVID-19, could favor Mucorales infection. In this short communication, we summarized how the dysregulated iron homeostasis in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection benefits Mucorales.

Intestinal Perforation Secondary to Mucormycosis Associated With Puerperal Sepsis

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.

COVID-19-Associated Mucormycosis (CAM): An Updated Evidence Mapping

Mucormycosis, a serious and rare fungal infection, has recently been reported in COVID-19 patients worldwide. This study aims to map all the emerging evidence on the COVID-19-associated mucormycosis (CAM) with a special focus on clinical presentation, treatment modalities, and patient outcomes. An extensive literature search was performed in MEDLINE (Ovid), Embase (Ovid), Cochrane COVID-19 Study Register, and WHO COVID-19 database till 9 June 2021. The primary outcome was to summarize the clinical presentation, treatment modalities, and patient outcomes of CAM. Data were summarized using descriptive statistics and presented in tabular form. This evidence mapping was based on a total of 167 CAM patients with a mean age of 51 ± 14.62 years, and 56.28% of them were male. Diabetes mellitus (73.65% (n = 123)), hypertension (22.75% (n = 38)), and renal failure (10.77% (n = 18)) were the most common co-morbidities among CAM patients. The most common symptoms observed in CAM patients were facial pain, ptosis, proptosis, visual acuity, and vision loss. Survival was higher in patients who underwent both medical and surgical management (64.96%). Overall mortality among CAM patients was found to be 38.32%. In conclusion, this study found a high incidence of CAM with a high mortality rate. Optimal glycemic control and early identification of mucormycosis should be the priority to reduce the morbidity and mortality related to CAM.

Risk Factors for Mucormycosis in COVID-19 Patients

: Opportunistic infections, such as mucormycosis, in coronavirus disease 2019 (COVID-19) patients has become a new health challenge. Since opportunistic infections can exacerbate COVID-19 patients' status, it is vital to identify the risk factors to prevent, diagnose, and treat them as soon as possible. Viral, fungal, environmental, and host factors may be responsible for this situation. Long hospital stays, impaired host immune system function due to viral infection, and excessive consumption of glucocorticoids in managing COVID-19 patients are the main risk factors for the increased risk of mucormycosis in COVID-19 patients. Educating health care workers and considering the association between mucormycosis of the paranasal sinuses and different strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as the cause of COVID-19 can help prevent invasive fungal sinusitis in COVID-19 patients.

Early Surgical Intervention Followed by Antifungals in Rhino-Orbital Mucormycosis in Patients With COVID-19 Favors Clinical Outcome: A Case Series

Mucormycosis is an invasive fungal infection occurring in patients with or without preexisting medical illnesses. During the ongoing coronavirus disease 2019 (COVID-19) pandemic, there have been increasing reports of bacterial and fungal coinfections among some COVID-19 patients with preexisting comorbid illnesses such as diabetes and hypertension, with mucormycosis being one of them. The management of this dreaded fungal infection demands early and prompt surgical intervention to thoroughly remove the infected tissue and necrotic material to reduce the tissue burden of this invasive organism. This should be accompanied by expeditious initiation of amphotericin B along with supportive therapy. Here we present five cases of rhino-orbital mucormycosis in patients with COVID-19, all of whom presented with orbital and facial swelling (three had symptoms of impending blindness) under the backdrop of COVID-19 symptoms in the form of intermittent fever and slight dyspnea. Our treatment strategy comprised an expeditious use of early surgical intervention and amphotericin B along with the control of cytokine storm and hyperglycemia. This treatment strategy eventually resulted in an improved clinical outcome.

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

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

Invasive Mucormycosis Involving the Laryngopharynx After Bone Marrow Transplantation

ABSTRACT

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

Left hand necrosis as the initial presentation of disseminated mucormycosis: A case report and literature review

Cutaneous mucormycosis typically occurs as a primary infection following traumatic inoculation or as a secondary disseminated disease in immunocompromised patients with hematologic malignancy or organ transplantation. We describe an unusual case of a poorly controlled type 1 diabetic patient presenting with wet gangrene of the hand due to angioinvasive dissemination from a primary pulmonary infection, with additional suspected foci of cardiac and central nervous system involvement. Despite combined medical and surgical treatment, the patient ultimately died due to complications of her infection. This case and the associated literature review of secondary cutaneous mucormycosis highlight that invasive fungal infections can present peripherally, and identifying the primary source is important in order to promptly pursue aggressive combined medical and surgical treatment for this highly fatal disease.

Pulmonary Aspergillus and Mucor Co-Infection: A report of two cases

Co-infections or consecutive infections of mucormycosis and aspergillosis are very rare. Additionally, distinguishing between these two infections is also difficult as both these conditions have similar clinical features. We report two similar cases from Tamilnadu, who presented to a tertiary care centre in Puducherry, India in 2017 (first case) and 2019 (second case). The first case was a 70-year-old, non-diabetic male patient who presented with haemoptysis with a prior history of pulmonary tuberculosis. Computed tomography bronchial angiography revealed an air-crescent sign and the histopathological examination showed a fungal ball (aspergillus and mucor) in the right upper lobe and foci of fungal infection in the middle lobe. The second case was a 65-year-old diabetic male patient who presented with blackish expectoration and haemoptysis. A high-resolution computed tomography scan showed a reverse-halo sign in the right upper lobe. The results of the bronchoscopy-guided biopsy were consistent with a diagnosis of mixed mucormycosis and aspergillosis with angioinvasion. Both patients responded to amphotericin B with surgical excision of the affected lobe in the first case. A high degree of clinical suspicion, early surgical intervention and antifungal therapy are essential in the treatment of this rare co-infection.

A case report of rhino-facial mucormycosis in a non-diabetic patient with COVID-19: a systematic review of literature and current update

BACKGROUND

COVID-19 disease may be associated with a wide range of bacterial and fungal infections. We report a patient with COVID-19 infection who developed rhino-facial mucormycosis during treatment with corticosteroids.

CASE PRESENTATION

A 59-year-old non-diabetic male patient was admitted with a diagnosis of COVID-19 based on positive RT-PCR and CT of the lungs. Due to sever lung involvement, he was treated with methylprednisolone. The patient was re-admitted to hospital, due to nasal obstruction and left side facial and orbital swelling, several days after discharge. In sinus endoscopic surgery, debridement was performed and the specimens were sent to pathology and mycology laboratories. A nasal biopsy showed wide hyphae without septa. The sequenced PCR product revealed Rhizopus oryzae. Despite all medical and surgical treatment, the patient died. In addition, the characteristics of patients with COVID-19-associated mucormycosis were reviewed in 44 available literatures. In most studies, diabetes mellitus was the most common predisposing factor for mucormycosis.

CONCLUSION

Our report highlights the need for assessing the presence of mucormycosis in patients with COVID-19 and also it shows that physicians should consider the potential for secondary invasive fungal infections in COVID-19 cases.

Cutaneous Mucormycosis After Elective Outpatient Gastrocnemius Recession for Plantar Fasciitis in an Immunocompetent Host: A Case Report

CASE

A healthy 21-year-old man underwent an elective gastrocnemius recession for plantar fasciitis. At 10 days postoperatively, he developed a severe limb-threatening cutaneous mucormycotic infection that led to multiple debridements and eventual skin grafting.

CONCLUSION

Cutaneous mucormycosis is a rare but severe fungal infection. Early recognition, deep surgical biopsy for diagnosis, and aggressive treatment with frequent thorough surgical debridements and antifungal pharmacotherapy are necessary. Although mucormycosis is more frequently seen in the immunocompromised host, it can occur in the immunocompetent patient most commonly after trauma. If not aggressively treated, it can be limb and life threatening.

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

AIM

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

METHODOLOGY

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

CONCLUSION

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

Isolation of Rhizopus microsporus and Lichtheimia corymbifera from tracheal aspirates of two immunocompetent critically ill patients with COVID-19

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.

COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum

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.

Rhino-orbital-cerebral-mucormycosis in COVID-19: A systematic review

Since the onset of COVID-19 pandemic, parallel opportunistic infections have also been emerging as another disease spectrum. Among all these opportunistic infection, mucormycosis has become a matter of concern with its rapid increase of cases with rapid spread as compared to pre-COVID-19 era. Cases have been reported in post-COVID-19-related immune suppression along with the presence of comorbidity which adds on the deadly outcome. There is no systematic review addressing the issue of COVID-19-associated mucormycosis. This is the first systematic review of published studies of mucormycosis associated with COVID-19. The aim was to analyze the real scenario of the disease statement including all the published studies from first November 2019 to 30th June to analyze the contemporary epidemiology, clinical manifestations, risk factor, prognosis, and treatment outcome of COVID-19 associated rhino-orbito-cerebral-mucormycosis. A comprehensive literature search was done in following databases, namely, PubMed, Google Scholar, Scopus, and EMBASE using keywords mucormycosis, rhino orbital cerebral mucormycosis, COVID-19, and SARS-CoV-2 (from November 01, 2019 to June 30, 2021). Our study shows that, while corticosteroids have proved to be lifesaving in severe to critical COVID-19 patients, its indiscriminate use has come with its price of rhino-orbito-cerebral mucormycosis epidemic, especially in India especially in patients with preexisting diabetes mellitus with higher mortality. Corticosteroid use should be monitored and all COVID-19 patients should be closely evaluated/monitored for sequelae of immunosuppression following treatment.

Rhino-Orbito-Cerebral-Mucormycosis During the COVID-19 Second Wave in 2021 - A Preliminary Report from a Single Hospital

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.

Fungal Taxa Responsible for Mucormycosis/"Black Fungus" among COVID-19 Patients in India

Mucormycosis is caused by fungi belonging to the order Mucorales. The term “Black Fungus” has been widely applied to human pathogenic Mucorales in India. They mainly infect the sinuses and brain, lungs, stomach and intestines, and skin. While this has been considered a rare disease, thousands of cases have been reported during the second wave of COVID-19 in India, between the months of April and June 2021. Hitherto, more than 45,374 cases and over 4300 deaths have been reported among COVID-19 patients across India from April 2021 to July 21, 2021. Though the mortality rate is estimated to be 50%, it could be above 90% if left untreated. In India, Rhizopus arrhizus has been related to be the most common species to cause human mucormycosis, followed by Apophysomyces variabilis, Rhizopus microsporus, and R. homothallicus. Accurate sample identification of human pathogenic Mucorales species is challenging especially due to the frequent lack of diagnostic morphological features. Traditionally, the culture-based approach has been extensively used to isolate and characterize human pathogenic Mucorales. However, this may not be an appropriate approach to objectively isolate and characterize all species, as the germination and growth of fungal spores are highly dependent on culture media and environmental conditions. Therefore, a robust approach to the accurate and rapid identification of human pathogenic Mucorales species is a prerequisite. The metagenomic approach comprehensively sequences and analyzes all genetic material in a complex biological sample and, consequently, this could be an appropriate approach to objectively characterize human pathogenic Mucorales taxa without the need for in vitro culture. The precise identification of the species will not only be useful for the correct diagnosis of this disease, but also for the development of antifungal drugs specific for each species. Accurate and rapid species identification is desperately needed to save lives in the mucormycosis outbreak among COVID-19 patients in India and neighboring countries.

Mucormycosis-induced upper gastrointestinal ulcer perforation in immunocompetent patients: a report of two cases

Background

Gastrointestinal mucormycosis (GIM) is a rare, opportunistic fungal infection with poor prognosis. Clinically, it is difficult to diagnose GIM owing to its nonspecific clinical symptoms and poor suspicion. The estimated incidence of GIM is inaccurate, and most cases are diagnosed accidentally during surgery or upon postmortem examination. GIM usually occurs in patients with immune deficiencies or diabetes. Here, we report two cases of immunocompetent young patients with GIM who had good prognosis after treatment. Compared to other case reports on GIM, our cases had unusual infection sites and no obvious predisposing factors, which make it important to highlight these cases.

Case presentation

The first case was that of a 16-year-old immunocompetent boy who was admitted with gastrointestinal bleeding and perforation due to a gastric ulcer. Strategies used to arrest bleeding during emergency gastroscopy were unsuccessful. An adhesive mass was then discovered through laparoscopy. The patient underwent type II gastric resection. Pathological examination of the mass revealed bacterial infection and GIM. The second case was of a 33-year-old immunocompetent woman with a recent history of a lower leg sprain. The patient subsequently became critically ill and required ventilatory support. After hemodynamic stabilization and extubation, she presented with hematemesis due to exfoliation and necrosis of the stomach wall. The patient underwent total gastrectomy plus jejunostomy. The pathology results revealed severe bacterial infection and fungal infection that was confirmed as GIM. The patient fully recovered after receiving anti-infective and antifungal treatments.

Conclusions

Neither patient was immunosuppressed, and both patients presented with gastrointestinal bleeding. GIM was confirmed via pathological examination. GIM is not limited to immunocompromised patients, and its diagnosis mainly relies on pathological examination. Early diagnosis, timely surgical treatment, and early administration of systemic drug treatment are fundamental to improving its prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01881-8.

COVID-19 Associated Rhino-Orbital Mucormycosis Complicated by Gangrenous and Bone Necrosis-A Case Report from Honduras

BACKGROUND

Mucormycosis is a life-threatening invasive fungal infection most commonly observed in immunocompromised patients. Throughout the COVID-19 pandemic, a growing number of Mucorales associated infections, now termed COVID-19 associated mucormycosis (CAM), have been reported. Despite an increase in fatality reports, no cases of rhino-orbital CAM complicated with gangrenous bone necrosis have been described in the literature to date.

CASE

A 56-year-old male with a recent COVID-19 diagnosis developed rhino-orbital mucormycosis after 22 days of treatment with dexamethasone. Cultures and histopathological assessment of tissue biopsy confirmed the diagnosis. The patient survived after treatment with amphotericin B.

CONCLUSIONS

Mucormycosis is an invasive fungal infection affecting mostly immunocompromised patients. Along with the COVID-19 pandemic, the inappropriate use of steroids, in addition to concurrent risk factors, such as diabetes, has led to an increase in the occurrence of these devastating mycoses, leading to the development of severe presentations and complications, as observed in many cases. Early diagnosis and prompt treatment are crucial in order to avoid dissemination and fatal outcomes.

Management outcomes of mucormycosis in COVID-19 patients: A preliminary report from a tertiary care hospital

Background

Coronavirus disease 2019 (COVID-19) continues to be a significant health problem worldwide. The unprecedented surge of mucormycosis in patients with COVID-19 is a new emerging challenge. Although a few studies documenting high incidence of mucormycosis in COVID -19 patients have recently emerged in literature, data pertaining to treatment outcomes in such cohorts is lacking. Here, we report our experience in management of mucormycosis in COVID-19 patients at our tertiary care centre.

Method

The clinical, imaging, histopathological and treatment data of 20 patients with mucormycosis (in setting of COVID-19) was analysed.

Results

35% and 65 % of cases developed mucormycosis in setting of active and recovered COVID-19 infections respectively. Diabetes mellitus was documented in 80% cases, with 55% demonstrating HbA1c >10%. Steroid was administered in 80% during COVID-19 illness. Imaging demonstrated paranasal sinus (PNS), orbital and intracranial extension in 100%, 55% and 20% patients respectively. All received amphotericin and underwent endoscopic debridement, 20% underwent orbital decompression and 5% maxillectomy with orbital exenteration. 6/20(30%) patients died (4 with rhino-orbito-cerebral disease, 1 with extensive orbito-maxillary involvement and 1 sino-nasal disease). All 6 patients received steroids and documented poor glycaemic control.

Conclusion

The strong association of hyperglycemia and steroid intake with mucormycosis in COVID-19 cases warrants judicious use of corticosteroids and optimal glycaemic control. Our study highlights that good clinical outcome can be achieved in invasive mucormycosis provided prompt treatment is instituted with aggressive surgical debridement and antifungal medication.