Epidemiology and clinical manifestations of mucormycosis

Fatal necrotising cutaneous mucormycosis due to novel Saksenaea species: a case study

This case report describes the progressive wound infection in the left thigh of a 34-year-old man due to an old landmine explosion. The infection developed into rapidly spreading skin and soft tissue necrotising Saksenaea infection, despite antifungal therapy and surgical debridement. The report provides evidence that Saksenaea spp. should be added to the list of mucoralean fungi that can cause severe necrotising infection. It also highlights the need for improved early diagnostic procedures and enhanced understanding of Saksenaea virulence factors that contribute to necrotising infection.

Critical peritonitis secondary to gastrointestinal mucormycosis in a peritoneal dialysis patient: a case report

Immunodeficient patients are susceptible to systemic fungal infections; however, these rarely cause secondary peritonitis. A 66-year-old man with multiple myeloma and diabetes mellitus on continuous ambulatory peritoneal dialysis (CAPD) presented with cloudy ascitic fluid. He had been treated with corticosteroids for 1 month for Tolosa-Hunt syndrome. We diagnosed peritoneal dialysis-related peritonitis caused by Enterococcus avium, removed the CAPD catheter, and initiated intravenous ampicillin. Computed tomography (CT) revealed an intramural gastric mass and a thinning ascending colon wall. Four days later, follow-up contrast-enhanced CT showed penetration of the ascending colon and rupture of the ileocolic artery. Emergency open surgery revealed hemorrhagic infarction with mucormycosis. We initiated intravenous liposomal amphotericin B 20 days after admission; however, he died 55 days later. Anatomical abnormalities, such as gastrointestinal perforation, should be considered for peritonitis in immunodeficient patients. Gastrointestinal mucormycosis is rare but fatal, resulting from a delay in diagnosis and consequent gastrointestinal perforation. For an early diagnosis and a favorable clinical outcome, it is important to consider the risk factors for mucormycosis, including corticosteroid use, diabetes, end-stage kidney diseases.

Increased incidence of rhino-orbital mucormycosis in an educational therapeutic hospital during the COVID-19 pandemic in western Iran: An observational study

Background

COVID‐19 patients, especially the patients requiring hospitalisation, have a high risk of several complications such as opportunistic bacterial and fungal infections. Mucormycosis is a rare and opportunistic fungal infection that mainly affects diabetic and immunocompromised patients. An increase has been observed in the number of rhino‐orbital mucormycosis in patients with COVID‐19 admitted to Imam Khomeini Hospital, Kermanshah, Iran, since October 2020. This is a report of the frequency, risk factors, clinical manifestations, treatment and prognosis of COVID‐19 associated with mucormycosis infection.

Methods

The medical records of COVID‐19 patients with rhino‐orbital mucormycosis who were diagnosed in an educational therapeutic hospital in Kermanshah, west of Iran were surveyed. Several parameters were analysed including demographic, clinical, therapeutic and laboratory characteristics.

Results

Twelve patients with COVID‐19–associated rhino‐orbital mucormycosis were identified from 12 October to 18 November 2020. All cases reported as proven mucormycosis had a history of hospitalisation due to COVID‐19. Comorbidities mainly included diabetes mellitus (83.33%) and hypertension (58.33%). Seventy‐five per cent of patients received corticosteroids for COVID‐ 19 treatment. The sites of involvement were rhino‐sino‐orbital (83%) and rhino‐sino (17%). Amphotericin B/liposomal amphotericin B alone or in combination with surgical debridement or orbital exenteration was used as the first‐line therapy. The overall mortality rate was 66.7% (8/12).

Conclusions

We found a high incidence of mucormycosis among COVID‐19 patients. Diabetes mellitus and corticosteroid use were the dominant predisposing factor of mucormycosis. Mucormycosis is a life‐threatening and opportunistic infection; therefore, physicians should know the signs and symptoms of the disease so that a timely diagnosis and therapy can be performed.

Post-Covid alliance-mucormycosis, a fatal sequel to the pandemic in India

As the battle against the deadly Covid-19 pandemic is still continuing worldwide, several complications are being reported in patients who have recovered post-covid. One such lethal complication being reported in patients in India in recent times, who have tested positive for Covid-19 and are gradually recovering, is a fungal disease called Mucormycosis or the black fungus. With several hundreds of cases being reported all over the country, it has triggered an additional wave of panic among the general public. Post-Covid-19 patients who are more vulnerable to Mucormycosis are those with a history of poorly controlled diabetes mellitus and also those who are immuno-compromised and have been treated with steroids and other drugs for Covid-19. The aim of this short review is to briefly cover the epidemiology of mucormycosis, its possible pathophysiology in Post Covid scenario, the clinical presentation and its diagnosis and management.

Diagnosis of Pneumonia Due to Invasive Molds

Pneumonia is the most common presentation of invasive mold infections (IMIs), and is pathogenetically characterized as angioinvasion by hyphae, resulting in tissue infarction and necrosis. Aspergillus species are the typical etiologic cause of mold pneumonia, with A. fumigatus in most cases, followed by the Mucorales species. Typical populations at risk include hematologic cancer patients on chemotherapy, bone marrow and solid organ transplant patients, and patients on immunosuppressive medications. Invasive lung disease due to molds is challenging to definitively diagnose based on clinical features and imaging findings alone, as these methods are nonspecific. Etiologic laboratory testing is limited to insensitive culture techniques, non-specific and not readily available PCR, and tissue biopsies, which are often difficult to obtain and impact on the clinical fragility of patients. Microbiologic/mycologic analysis has limited sensitivity and may not be sufficiently timely to be actionable. Due to the inadequacy of current diagnostics, clinicians should consider a combination of diagnostic modalities to prevent morbidity in patients with mold pneumonia. Diagnosis of IMIs requires improvement, and the availability of noninvasive methods such as fungal biomarkers, microbial cell-free DNA sequencing, and metabolomics-breath testing could represent a new era of timely diagnosis and early treatment of mold pneumonia.

Survival of an immuno-competent patient from splenic and gastric mucormycosis-case report and review of the literature

Mucormycosis is a life-threatening disease responsible for a high mortality rate. The disease usually affects immuno-compromised patients. While all sites might be involved, gastrointestinal disease is rare, occurring for 5% to 13% of all mucormycosis cases. We report herein the fifth case of splenic and gastric mucormycosis revealed after gastric perforation and the first case occurring among an immuno-competent patient, and we review all reported cases of splenic mucormycosis by searching PubMed publications till October 2020. The literature search yielded 27 cases of splenic mucormycosis including our case. The majority of the cases had underlying immuno-compromised conditions, except for 6 cases, including ours. A male predominance was noted (22 cases). Involvement of the spleen and the stomach was rare, occurring among four immuno-compromised patients. The outcome was death in more than half of the cases. Splenic and gastric mucormycosis is a rare disease. The diagnosis of splenic mucormycosis should be considered in front of splenic lesions suggesting abscess or infarction, especially among immuno-compromised patients.

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

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

Rare case of gastrointestinal mucormycosis with colonic perforation in an immunocompetent patient with COVID-19

Primary gastrointestinal mucormycosis is a rare disease associated with an increased mortality and is rarely reported in an immunocompetent host. We report the first case of mucormycosis-associated colonic perforation in a COVID-19 patient with a favourable outcome. A 48-year-old healthy male doctor in home isolation due to COVID-19 was admitted to COVID-19 intensive care unit when his symptoms deteriorated. The patient was put on non-invasive ventilation (NIV) using Bilevel Positive Airway Pressure (BiPAP) and treatment given as per existing hospital protocol. The patient improved clinically, and was discharged on day 10 of admission. Two days later, he presented with acute gastrointestinal symptoms to the emergency department. A diagnosis of perforation peritonitis was made, the patient was stabilised and sigmoid colectomy with descending colon colostomy was done. A diagnosis of gastrointestinal mucormycosis was made and injectable antifungal was started. The patient was discharged after his general conditions improved.

Mass spore production of Mucor circinelloides on rice

Mucor circinelloides is a fungus that produces diverse spores throughout its life cycle. The sporangiospores, which are the most well-studied spores in this fungus, are asexual spores produced during aerial mycelial development. M. circinelloides has the potential to be used in diverse biotechnological applications. In this study, we propose rice (Oryza sativa) grains as an alternative substrate for inexpensive and large-scale sporangiospore production. The sporangiospores produced from rice and a yeast extract-peptone-glucose (YPG) medium exhibited similar protein and nucleic acid contents and phenotypes in terms of germination under different conditions and culture media, including similar virulence rates against the nematode Caenorhabditis elegans. Transgenic strains carrying self-replicative plasmids were sporulated on rice and showed plasmid stability similar to that of spores produced on the YPG medium. Approximately 20% of the spore population lost plasmids after the first passage on rice. These results reveal that rice is a suitable substrate for the mass production of sporangiospores in M. circinelloides.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13205-021-02853-1.

Rhinocerebral mucormycosis in COVID-19 patient with diabetes a deadly trio: Case series from the north-western part of India

Coronavirus disease 2019 (COVID-19), may present with a myriad of clinical manifestations and complications. Patients with COVID-19 are at increased risk of pulmonary thromboembolism, acute cardiac injury, arrhythmias, acute stroke, and secondary infections. Mucormycosis is a catastrophic fungal infection characterized by vascular invasion, thrombosis, and necrosis of tissues. We report five cases of COVID-19 infection, who developed rhino-orbital mucormycosis, during the course of treatment. Early recognition of this life-threatening infection is the key to allow for optimal treatment and improved outcomes.

Invasive Mucormycosis in Children With Malignancies: Report From the Infection Working Group of the Hellenic Society of Pediatric Hematology-Oncology

Mucormycosis is an invasive, life-threatening fungal infection that mainly affects immunocompromised hosts. We collected data of pediatric mucormycosis cases from all 7 Greek Hematology-Oncology Departments for the years 2008-2017. Six cases of invasive mucormycosis diagnosed during treatment for malignancies were included in the study. In 4 children (66%) mucormycosis occurred within the first 20 days after diagnosis of the underlying disease. Two cases were classified as proven mucormycosis and 4 as probable. The most frequently recorded species was Rhizopus arrhizus (2 patients), followed by Mucor spp (1), and Lichtheimia spp (1). All patients received liposomal amphotericin B. Combined antifungal treatment was used in 5 cases. Surgical excision was performed in 4 cases (66%). Two patients died at 6 and 12 months after the diagnosis, respectively, 1 (17%) because of mucormycosis. Our data suggest that mucormycosis may occur early after the initiation of intensive chemotherapy in children with malignancies.

Pulmonary Mucormycosis: An Interesting Case of Rhizopus Mucormycosis

We report a case of a 57-year-old Vietnamese gentleman who presented with chest pain and shortness of breath for four weeks. The patient had a history of diabetes mellitus and kidney transplant in the past year and was currently on immunosuppressive agents. The patient's condition worsened despite broad-spectrum antibiotics, so amphotericin was added. Further evaluation with bronchoscopy and transbronchial biopsy was suggestive of Rhizopus mucormycosis. Despite antifungal therapy, his condition worsened, resulting in multi-organ failure and eventual mortality.

Rhizopus microsporus Infections Associated with Surgical Procedures, Argentina, 2006-2014

Rhizopus spp. fungi are ubiquitous in the environment and a rare but substantial cause of infection in immunosuppressed persons and surgery patients. During 2005–2017, an abnormally high number of Rhizopus infections in surgery patients, with no apparent epidemiologic links, were reported in Argentina. To determine the likelihood of a common source of the cluster, we performed whole-genome sequencing on samples collected during 2006–2014. Most isolates were separated by >60 single-nucleotide polymorphisms, and we found no evidence for recombination or nonneutral mutation accumulation; these findings do not support common source or patient-to-patient transmission. Assembled genomes of most isolates were ≈25 Mbp, and multiple isolates had substantially larger assembled genomes (43–51 Mbp), indicative of infections with strain types that underwent genome expansion. Whole-genome sequencing has become an essential tool for studying epidemiology of fungal infections. Less discriminatory techniques may miss true relationships, possibly resulting in inappropriate attribution of point source.

[Mucormycosis: Current and future management perspective]

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

Central nervous system infection: imaging findings suggestive of a fungus as the cause

Fungal infections of the central nervous system (CNS) are rare. However, because of the increase in the number of immunocompromised individuals, they have been gaining prominence in the differential diagnosis of CNS infections. Imaging techniques are sensitive for detecting and localizing an abnormality, in many cases allowing the origin of a lesion to be categorized as infectious, inflammatory, neoplastic, or vascular. This essay illustrates the magnetic resonance imaging and computed tomography findings of the most common fungal infections of the CNS, based on the experience of the Radiology Department of the Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, RS, Brazil.

Immunology of Fungal Infections

Complex processes mediate immunity to fungal infections. Responses vary depending on the organism, morphogenic state, and infection site. Innate immune effectors such as epithelia, phagocytes, and soluble molecules detect pathogens, kill fungi, release cytokines, and prime the adaptive response. Adaptive responses to mucocutaneous or invasive disease are markedly different but intersect at certain pathways (molecules required for IL-23 and IL-12 signaling). Many of these pathways have been elucidated from the study of inborn errors of immunity. This review explores the general aspects of antifungal immunity and delves into the mechanisms that mediate protection from frequently encountered fungi.

Fungal Infections of the Gastrointestinal Tract

The thinking about fungi has evolved from unusual agents considered contaminants and colonizers to actual pathogens. Fungi are ubiquitous in nature and are found throughout in association with food, soil, mammals, and insects. Fungi have become important pathogens in animals and humans causing infections extending from superficial disease to disseminated infection. Because the gastrointestinal tract is continually exposed to fungi, it is frequently colonized and infected by numerous yeast and other fungi. It is also the origin of many disseminated fungal infections. The increased incidence of fungal infections has led to the approval and use of novel antifungals.

Mucormycosis after Coronavirus disease 2019 infection in a heart transplant recipient - Case report and review of literature

Mucormycosis is an invasive fungal infection (IFI) due to several species of saprophytic fungi, occurring in patients with underlying co-morbidities (including organ transplantation). During the ongoing Coronavirus disease 2019 (COVID-19) pandemic, there have been increasing reports of bacterial and fungal co-infections occurring in COVID-19 patients, including COVID-19 associated pulmonary aspergillosis (CAPA). We describe a case of mucormycosis occurring after COVID-19, in an individual who received a recent heart transplant for severe heart failure. Two months after heart transplant, our patient developed upper respiratory and systemic symptoms and was diagnosed with COVID-19. He was managed with convalescent plasma therapy and supportive care. Approximately three months after COVID-19 diagnosis, he developed cutaneous mucormycosis at an old intravascular device site. He underwent extensive surgical interventions, combined with broad-spectrum antifungal therapy. Despite the aggressive therapeutic measures, he died after a prolonged hospital stay. In this case report, we also review the prior well-reported cases of mucormycosis occurring in COVID-19 patients and discuss potential mechanisms by which COVID-19 may predispose to IFIs. Similar to CAPA, mucormycosis with COVID-19 may need to be evaluated as an emerging disease association. Clinicians should be vigilant to evaluate for invasive fungal infections such as mucormycosis in patients with COVID-19 infection.

Conventional PCR as a reliable method for diagnosing invasive mucormycosis in resource-limited settings

Introduction. Invasive mucormycosis (IM) is a life-threatening infection caused by fungi belonging to the order Mucorales. Histopathology, culture and radiology are the mainstay of diagnosis but lack sensitivity, leading to a delay in timely diagnosis and intervention. Recently, PCR-based approaches have been shown to be a promising method in diagnosing IM.Hypothesis/Gap Statement. Molecular-based approaches may be a valuable adjunct to standard conventional methods for diagnosing IM, especially among culture negatives and patients on antifungal therapy.Aim. In the present study we aimed to evaluate the clinical utility of panfungal and Mucorales-specific PCR for diagnosing IM from various clinical specimens.Methodology. This was a prospective study in which 239 clinically suspected cases of IM attending our tertiary care hospital from August 2015 to March 2018 were enrolled. All the cases were defined as 'proven', 'probable' or 'possible' based on EORTC/MSGERC guidelines. In addition to conventional diagnostics (KOH-calcofluor stain and culture), panfungal and Mucorales-specific PCR assays were also performed. The amplified products were sequenced for species identification. In vitro antifungal susceptibility was performed on all the culture-positive isolates.Results. Among 239 clinically suspected cases of IM, only 140 cases were diagnosed by the demonstration of aseptate ribbon-like hyphae on direct microscopy. Culture was positive in 35.7 % (54/140) of direct microscopy-positive samples. Among the proven cases (n=11), the sensitivity for both Mucorales-specific nested PCR and panfungal PCR was 100 %, but specificity was 91.9 and 73.7% respectively. In probable cases (n=129), the sensitivity of both the PCRs was 98.5 % and specificity for panfungal PCR was 73.7 and 91.9 % for Mucorales-specific PCR.Conclusion. Pan fungal PCR in combination with Mucorales-specific PCR, followed by sequencing, may play a significant role in IM diagnosis especially among those negative for both direct microscopy and culture.

Mucormycosis

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

Fungal pneumonia in kidney transplant recipients

Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.

Spike in Rhino-Orbital-Cerebral Mucormycosis Cases Presenting to a Tertiary Care Center During the COVID-19 Pandemic

Objective: To determine if there was an increase in the rate of cases presenting with rhino-orbital-cerebral mucormycosis (ROCM) to a tertiary care center during the first wave of the coronavirus disease 2019 (COVID-19) pandemic and the characteristics of the presenting cases.

Methods: Retrospective observational study reviewing ROCM cases presenting from March 25 until September 25, 2020. Cases fulfilling the clinical, radiological, and pathological/microbiological criteria for diagnosis with ROCM were included. The number of cases presenting during the designated interval, their COVID-19 status, comorbidities, and clinical presentation were analyzed. The number of cases during the corresponding interval in the previous 3 years was used as reference to detect if there was a recent spike.

Results: Of the 12 ROCM cases identified, 5 had a concurrent positive reverse transcription PCR (RT-PCR) test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 1 had a prior positive result, and 6 did not have concurrent nor prior positive test results. Nine of the 12 cases had poorly controlled diabetes mellitus, and 2 cases had a hematological malignancy. All cases had orbital invasion, and eight cases had cerebral invasion. The number of cases identified during the interval is much higher than the numbers presenting in the prior 3 years during equivalent intervals (range, one to two cases) than those reported in the literature in different settings in the pre-pandemic era.

Conclusions: There is an increased rate of ROCM cases presenting to our center during the first wave of the COVID-19 pandemic. This is a preliminary report, and further studies are needed to corroborate the findings and explain possible underlying links.

Autoptic identification of disseminated mucormycosis in a young male presenting with cerebrovascular event, multi-organ dysfunction and COVID-19 infection

Among the secondary fungal infections in Coronavirus-19 (COVID-19) infection, Aspergillosis has been reported more often than Mucormycosis. Disseminated mucormycosis is almost always a disease of severely immunosuppressed hosts. We report a young obese Asian male who was admitted with an acute anterior cerebral artery (ACA) territory infarct and severe COVID-19 pneumonitis to the intensive care unit (ICU). He had a complicated stay with recurrent episodes of vasoplegic shock and multi-organ dysfunction. At autopsy, he was confirmed to have disseminated mucormycosis. We believe this to be the first documented case of disseminated mucormycosis in an immunocompetent host with COVID-19 infection. The lack of sensitive non-invasive modalities and biomarkers to diagnose mucormycosis, along with the extremely high mortality in untreated cases, present a unique challenge to clinicians dealing with critically ill patients with COVID-19.

Comparison of invasive fungal diseases between patients with acute myeloid leukemia receiving posaconazole prophylaxis and those not receiving prophylaxis: A single-center, observational, case-control study in South Korea

Posaconazole prophylaxis is effective in decreasing the incidence of invasive fungal diseases (IFDs) in patients with acute myeloid leukemia (AML). However, the use of antifungal prophylaxis varies in real-life practice, and only a small number of studies have compared the incidence of IFDs between those receiving posaconazole prophylaxis and those without prophylaxis. We compared the clinical characteristics and outcomes of IFDs between patients with AML who received posaconazole prophylaxis and those without antifungal prophylaxis.We reviewed the medical records of adult AML patients who underwent induction chemotherapy between June 2016 and October 2019 at Asan Medical Center (Seoul, South Korea), where posaconazole prophylaxis is not administered in patients with gastrointestinal symptoms that may hinder sufficient absorption of oral prophylactic agents, and in patients with abnormal liver functions considering the possible exacerbation of adverse events. Patients who received posaconazole prophylaxis for ≥7 days were included in the prophylaxis group. Clinical characteristics and outcomes including the incidence of IFDs were compared between the 2 groups.Of the 247 patients with AML who underwent induction chemotherapy, 162 (66%) received posaconazole prophylaxis and 85 (34%) did not receive any prophylaxis. The incidence of proven/probable IFD was significantly higher in the no prophylaxis group than in the prophylaxis group (9.4% [8/85] vs 2.5% [4/162], P = .03). Of the 8 cases of IFDs in the no prophylaxis group, 7 were mold infections and 1 was invasive candidiasis. Of the 4 cases of IFDs in the prophylaxis group, 3 were mold infections and 1 was invasive candidiasis. Patients with posaconazole prophylaxis less frequently received therapeutic antifungal therapy (2.5% vs 9.4%, P = .03) and had a longer median, duration from chemotherapy to antifungal therapy compared with the no prophylaxis group (18 vs 11 days, P < .01). The rate of IFD-related mortality was similar between the 2 groups (0.6% vs 0%, P > .99).Patients with AML who received posaconazole prophylaxis had a lower incidence of breakthrough IFDs compared with those who did not receive any prophylaxis. Invasive mold infection was the most common IFD regardless of antifungal prophylaxis.

Pneumonia and Poorly Controlled Diabetes

CASE PRESENTATION

A 47-year-old man with poorly controlled diabetes mellitus (glycosylated hemoglobin 12%) presented to the ED with a 1-week history of fevers, productive cough, and dyspnea. The patient was febrile and hypoxemic on presentation; laboratory testing was remarkable for hyperglycemia and ketoacidosis. The initial chest CT scan showed right lower lobe consolidation and ground-glass opacities (Fig 1A). He was admitted to the ICU and administered IV antibiotics (cefepime and vancomycin) for the treatment of community-acquired bacterial pneumonia.

CT appearance of gastrointestinal tract mucormycosis

Mucormycosis is a fungal infection caused by fungi of order mucorales. It is most commonly seen in patients with an impaired immune system due to any cause. Gastrointestinal mucormycosis is the least frequent type and may be a primary disease or a feature of generalized mucormycosis. Angioinvasion is the hallmark feature of mucormycosis, leading to bowel infarction which is the responsible for the most common clinical complaint of pain, and is also responsible for most of the imaging findings in this disease. The stomach is most commonly involved organ in the gastrointestinal tract and pneumatosis and lack of gastric wall enhancement are the most common imaging findings. Areas of bowel wall thickening and/ or lack of enhancement are seen in small bowel mucor and perforation can occur due to ischemia. Colonic mucor can present with mural thickening, or complete lack of definition or 'disappearance' of bowel wall with associated air containing collections. Mucormycosis affecting the bowel has a high mortality rate and early recognition and intervention may improve patient outcomes significantly. It should be suspected in immunosuppressed patients with imaging findings of unexplained bowel ischemia, infarction and/or pneumatosis without any obvious visible vascular thrombus.

Isolated pulmonary mucormycosis in an immunocompetent patient: a case report and systematic review of the literature

Background

Pulmonary mucormycosis caused by Mucorales is a highly lethal invasive fungal infection usually found in immunocompromised patients. Isolated pulmonary mucormycosis in immunocompetent patients is very rare. Here, we present a case of a 32-year-old male who developed pulmonary mucormycosis without any known immunodeficiency.

Case presentation

The patient presented to our hospital because of cough and chest pain along with blood in the sputum. He was first treated for community-acquired pneumonia until bronchoalveolar lavage fluid culture confirmed the growth of Absidia. His symptoms were relieved with the use of amphotericin B, and he eventually recovered. We also provide a systematic review of relevant literature to summarize the characteristics of pulmonary mucormycosis in immunocompetent patients.

Conclusions

Pulmonary mucormycosis has variable clinical presentations and is difficult to identify. Due to its high fatality rate, clinicians should make judgements regarding suspected cases correctly and in a timely manner to avoid misdiagnosis and delayed treatment.

In Vivo and In Vitro Impairments in T Helper Cell and Neutrophil Responses against Mucor irregularis in Card9 Knockout Mice

Mucor irregularis is a frequently found fungus in Asia, especially China, and it causes primary cutaneous mucormycosis with a high rate of disfigurement. Caspase recruitment domain-containing protein 9 (Card9) is an essential adaptor molecule downstream of C-type lectin receptors. It mediates the activation of nuclear factor kappa B (NF-κB), regulates T helper 1 (Th1) and Th17 differentiation, and plays an important role in fungal immune surveillance. CARD9 deficiency correlates with the increased susceptibility to many fungal infections, including cutaneous mucormycosis caused by M. irregularis However, the underlying immunological mechanisms were not elucidated. Our study established a murine model of subcutaneous M. irregularis infection, and we isolated immune cells, including bone marrow-derived macrophages, bone marrow-derived dendritic cells, naive T cells, and neutrophils, from wild-type (WT) and Card9 knockout (Card9^-/- ) mice to examine the antifungal effect of Card9 on M. irregularis in vivo and in vitro Card9^-/- mice exhibited increased susceptibility to M. irregularis infection. Impaired local cytokine and chemokine production, NF-κB (p65) activation, and Th1/17 cell differentiation and partially impaired neutrophil-dependent antifungal immunity were observed in Card9^-/- mice. This work enriches our knowledge of the relationship between CARD9 deficiency and mucormycosis.

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cutaneous mucormycosis of the lower extremity leading amputation in two diabetic patients

Mucormycosis is an invasive, rapidly progressive, life-threatening fungal infection, with a propensity for diabetic, immunosuppressed, and trauma patients. The classic rhinocerebral variation is most common in diabetic patients. While the cutaneous form is usually caused by direct inoculation in immunocompetent patients. Cutaneous mucormycosis manifests in soft tissue and risks involvement of underlying structures. Tibial osteomyelitis can also occur secondary to cutaneous mucormycosis but is rare. Limb salvage is typically successful after lower extremity cutaneous mucormycosis even when the bone is involved. Herein, we report two cases of lower extremity cutaneous mucormycosis in diabetic patients that presented as acute worsening of chronic pretibial ulcers. Despite aggressive antifungal therapy and surgical debridement, both ultimately required amputation. Such aggressive presentation has not been reported in the absence of major penetrating trauma, recent surgery, or burns.

A 51-Year-Old Woman With a Mediastinal Mass

CASE PRESENTATION

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

Disseminated Mucormycosis in Immunocompromised Children: Are New Antifungal Agents Making a Difference? A Multicenter Retrospective Study

BACKGROUND

Mucormycosis is a life-threatening infection with a tendency for angioinvasion that may lead to progressive dissemination. Disseminated mucormycosis, defined as the involvement of two or more non-contiguous sites, is rare in children, and data concerning its management and outcome are scarce. The aim of this study was to assess the contemporary management strategies and outcomes of disseminated mucormycosis in the pediatric population.

METHODS

We conducted a retrospective search in six large tertiary medical centers for all cases of disseminated mucormycosis that occurred between 2009-2020 in patients aged 1-20 years.

RESULTS

Twelve cases were identified. Underlying conditions included hematological malignancies (n = 10), solid tumor (post-autologous hematopoietic stem cell transplantations; n = 1), and solid organ (liver) transplantation (n = 1). In all cases, amphotericin B formulations were administered as first-line therapy; in eight cases, they were also administered in combination with an echinocandin or triazole. Seven patients underwent surgical debridement procedures. The six-week mortality was 58%. Among the patients diagnosed between 2009-2015, one of the six survived, and of those diagnosed between 2016-2020, four of the six were salvaged.

CONCLUSIONS

Disseminated mucormycosis is a life-threatening and often fatal disease, and improved diagnostic and therapeutic strategies are needed. Nevertheless, in this population-based study, five patients (42%) were salvaged through combined liposomal amphotericin/triazole treatment and extensive surgical interventions.

Simultaneous Infection of the Skin Surface and Dermal Tissue with Two Different Fungus Mimicking Pyoderma Gangrenosum: A Case Report

Mucormycosis is an opportunistic fungal infection driven by subphylum Mucormycotina. Cutaneous mucormycosis is the third most common presentation of mucormycosis, and its characterized presentation is an indurated plaque that rapidly evolves to necrosis. Trichophyton rubrum is one of the most common dermatophytes that mainly cause superficial infections and seldom induce deep infections. The present report presents a case of cutaneous fungal infection, in which two kinds of fungus were isolated, and the skin lesion mimicked pyoderma gangrenosum. Trichophyton rubrum was isolated from the crust and hyphae of subphylum Mucormycotina were found in dermal tissue. The irregular systemic and topical use of steroid therapy is the possible cause of the mixed fungal infection in this patient, suggesting the importance of regular steroid therapy.

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

Background and Purpose:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSES

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

INTERVENTIONS

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

OUTCOMES

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

LESSONS

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

Poor outcome associated with mucormycosis in critically ill hematological patients: results of a multicenter study

Background

Mucormycosis is an emerging fungal infection that may lead to multi-organ failure, especially in patients with hematological malignancies (HM). We performed a retrospective, cohort study, in five intensive care units (ICU) to assess the outcome of critically ill patients with HM and mucormycosis between 2002 and 2018. The secondary objective was to identify prognostic factors in this setting.

Results

Twenty-six patients were included with a median age of 38 years [IQR, 26–57]). Acute leukemia was the most frequent underlying disease (50%). Nine patients (35%) underwent allogeneic stem cell transplantation (SCT). Nineteen patients (73%) had neutropenia and 16 (62%) had received steroids. The main reason for admission was acute respiratory failure (n = 14, 54%) followed by shock (n = 5 19%). The median SOFA score at admission was 7 [5–8].

According to EORTC/MSG criteria, mucormycosis was "proven" in 14 patients (54%), "probable" in 5 (19%) and “possible” in 7 (27%) in whom diagnosis was made by qPCR. Rhizopus and Mucor were the most frequent documented species. Seven patients (27%) had concurrent Aspergillus infection. Mucormycosis was diagnosed 1 day [−4 to + 6] after ICU admission. Sixteen patients (62%) had pulmonary involvement and ten (38%) rhino-cerebral involvement. Infection was disseminated in eight patients (31%). Twenty-two patients (85%) were treated with liposomal amphotericin B; 12 (46%) received antifungal combination including posaconazole in 7. Eight patients (31%) underwent curative surgery. Twenty-one patients (81%) required invasive mechanical ventilation (IMV), 18 (69%) vasopressors, and 9 (35%) renal replacement therapy. ICU and hospital mortality rates were 77% and 88%, respectively. The median overall survival was 9 days [3–22]. IMV was strongly associated with ICU mortality (p < 0.001) Three variables were associated with day 90 mortality in a Cox model including allogeneic SCT (HR 4.84 [95% CI 1.64–14.32]), SOFA score (1.19 [1.02–1.39]) and dual therapy (3.02 [1.18–7.72]).

Conclusions

Mucormycosis is associated with a high mortality rate in patients with HM, especially in allogeneic SCT recipients. Benefit of ICU management in these patients should be assessed before admission and strategies aiming to improve these patients’ outcome are urgently needed.

A Rare Indolent Course of Rhinocerebral Mucormycosis

Mucormycosis is a highly invasive and rapidly progressing form of fungal infection that can be fatal. The infection usually begins after oral or nasal inhalation of fungal spores and can enter the host through a disrupted mucosa or an extraction wound. The organism becomes pathogenic when the host is in an immunocompromised state. There are several clinical presentations of mucormycosis including rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated, and miscellaneous forms. The most common clinical presentation of mucormycosis is the rhinocerebral form which has a high predilection for patients with diabetes and metabolic acidosis. An indolent disease course taking weeks to months of this infection is rare making it difficult to diagnose. Therefore, early detection and prompt treatment with surgical and antifungal therapy are very important in achieving good treatment outcomes.

Mucor Osteomyelitis of the Distal Radius Necessitating Ulnocarpal Fusion

This is a case report of a 60-year-old female who developed distal radius osteomyelitis secondary to Mucor infection from likely hematogenous spread that was managed with ulnocarpal wrist fusion. Following serial debridement and systemic antifungal therapy, ulnocarpal wrist fusion offered functional limb salvage rather than amputation in this patient with significant operative risk and comorbidities.

Thoracic mucormycosis in immunocompetent patients

BACKGROUND

Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes.

METHODS

We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm.

RESULTS

The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment.

CONCLUSION

Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

Transdiaphragmatic Mucormycosis

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

Infectious diseases of the upper gastrointestinal tract

A broad spectrum of pathogens produce gastrointestinal disease. The ongoing spread of human immunodeficiency virus/acquired immune deficiency syndrome, the increased use of immunosuppressive therapy and the persistence of overcrowding and suboptimal sanitation in underdeveloped areas facilitate both disease transmission from environmental and foodborne sources and person-to-person transmission. Clinicians increasingly rely on endoscopic biopsy sample interpretation to diagnose gastrointestinal infections. Thus, pathologists must be aware of diagnostic features of a variety of microbial pathogens. Detection with molecular techniques also allows for correlation between infectious agents and their histopathological features, which has expanded our knowledge of the inflammatory changes produced by infectious agents. This review covers infectious disorders of the upper gastrointestinal tract encountered in surgical pathology. Clinical, endoscopic and pathological features are presented. The review emphasises morphological features of viruses, bacteria, fungi and parasites that may be found in tissue samples, and the inflammatory patterns that they produce. Differential diagnoses and useful ancillary techniques are discussed.

Human mucosal-associated invariant T cells respond to Mucorales species in a MR1-dependent manner

Activation of mucosal-associated invariant T cells (MAIT cells) by certain bacteria, viruses, and yeast is well studied, but the activation potential of filamentous moulds from the order Mucorales is not known. Here, we show a rapid response of human MAIT cells against the Mucorales species Mucor circinelloides, Rhizopus arrhizus, and Rhizopus microsporus. This activation included upregulation of CD69 and degranulation marked by increased CD107a expression, while intracellular perforin and granzyme A expression were reduced. Furthermore, blocking of the antigen-presenting molecule major histocompatibility complex class I-related abrogated MAIT cell activation demonstrating a T cell receptor-dependent stimulation by Mucorales.