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Panda S, Sahu MC, Turuk J, Pati S. Mucormycosis: A Rare disease to Notifiable Disease. Braz J Microbiol 2024; 55:1065-1081. [PMID: 38561499 PMCID: PMC11153412 DOI: 10.1007/s42770-024-01315-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024] Open
Abstract
Mucormycosis is the third most frequent invasive mycosis, following candidiasis and aspergillosis. It is frequently neglected due to its rare occurrence; but recently attend the status of notifiable disease due to its higher incidence in both developed and developing nations. India has received global notice since its estimated instances were greater than the global estimated figures. Mucormycosis has several clinical manifestations, including rhino-orbital-cerebral (ROCM), pulmonary, gastrointestinal, cutaneous, renal, and diffuse Mucormycosis. ROCM is the most frequent clinical manifestation in India, although pulmonary mucormycosis is prevalent worldwide. This review also discusses host defenses, pre disposing risk factors and fungal virulence factors that impair host's ability to prevent fungus invasion and disease establishment. The diagnosis of the disease depends on clinical interventions, histological or microbiological procedures along with molecular methods to obtain timely results. But there are still unmet challenges for rapid diagnosis of the disease. Treatment of the disease is achieved by multimodal approaches such as reversal of underlying predisposing factors, rapid administration of antifungals in optimal doses and surgical procedures to remove infected tissues. Liposomal Amphotericin B, Posaconazole and Isavuconazoles are preferred as the first line of treatment procedures. clinical trials. Different studies have improved the existing drug and under clinical trials while several studies predicted the new potential targets as CotH and Ftr1 as shown in infection and in vitro models. Therefore, current scenario demands a multidisciplinary approach is needed to investigate the prevalence, pathogenesis which is highly important for the advancement of rapid diagnosis and effective treatment.
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Affiliation(s)
- Sunita Panda
- Regional Medical Research Center, Bhubaneswar, Odisha, 751023, India
| | | | - Jyotirmayee Turuk
- Regional Medical Research Center, Bhubaneswar, Odisha, 751023, India.
| | - Sanghamitra Pati
- Regional Medical Research Center, Bhubaneswar, Odisha, 751023, India.
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Thornton CR. The potential for rapid antigen testing for mucormycosis in the context of COVID-19. Expert Rev Mol Diagn 2024; 24:161-167. [PMID: 37405409 DOI: 10.1080/14737159.2023.2233906] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/04/2023] [Indexed: 07/06/2023]
Abstract
INTRODUCTION Mucormycosis is a highly aggressive angio-invasive disease of humans caused by Mucorales fungi. Prior to the COVID-19 pandemic, mucormycosis was a rare mycosis typically seen in immunocompromised patients with hematological malignancies or in transplant recipients. During the second wave of the pandemic, there was a dramatic increase in the disease, especially in India where a unique set of circumstances led to large numbers of life-threatening and disfiguring rhino-orbital-cerebral mucormycosis (ROCM) infections. AREAS COVERED The review examines mucormycosis as a super-infection of COVID-19 patients, and the risk factors for COVID-19-associated mucormycosis (CAM) that drove the ROCM epidemic in India. The limitations of current diagnostic procedures are identified, and the measures needed to improve the speed and accuracy of detection discussed. EXPERT OPINION Despite increased awareness, global healthcare systems remain unprepared for further outbreaks of ROCM. Current diagnosis of the disease is slow and inaccurate, negatively impacting on patient survival. This is most evident in low- to middle-income countries which lack suitably equipped diagnostic facilities for rapid identification of the infecting pathogens. Rapid antigen testing using point-of-care lateral-flow assays could potentially have aided in the quick and accurate diagnosis of the disease, allowing earlier intervention with surgery and Mucorales-active antifungal drugs.
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Nidhin Das K, Sharma V, Gupta D, Tiwari S, Elhence P, Jain V, Soni K, Goyal A. Predicting intracranial involvement: Unveiling perineural spread in COVID-19-associated mucormycosis, a novel phenomenon. Med Mycol 2024; 62:myad135. [PMID: 38130212 DOI: 10.1093/mmy/myad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023] Open
Abstract
This study aimed to investigate the risk factors associated with intracranial involvement in COVID-19-associated mucormycosis (CAM) and to develop a nomogram model for predicting the risk of intracranial involvement, with a specific focus on perineural spread. An ambispective analysis was conducted on 275 CAM patients who received comprehensive treatment. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors, and a nomogram was created based on the results of the multivariable analysis. The performance of the nomogram was evaluated using a receiver operating characteristic (ROC) curve, and the discriminatory capacity was assessed using the area under the curve (AUC). The model's calibration was assessed through a calibration curve and the Hosmer Lemeshow test. In the results, the multivariable logistic regression analysis revealed that age (OR: 1.23, 95% CI 1.06-3.79), HbA1c (OR: 7.168, 95% CI 1.724-25.788), perineural spread (OR: 6.3, 95% CI 1.281-19.874), and the disease stage were independent risk factors for intracranial involvement in CAM. The developed nomogram demonstrated good discriminative capacity with an AUC of 0.821 (95% CI 0.713-0.909) as indicated by the ROC curve. The calibration curve showed that the nomogram was well-calibrated, and the Hosmer Lemeshow test yielded a P-value of 0.992, indicating a good fit for the model. In conclusion, this study found that CAM particularly exhibits perineural spread, which is a predictive factor for intracranial involvement. A nomogram model incorporating age, HbA1c, disease stage, and perineural spread was successfully developed for predicting intracranial involvement in CAM patients in both in-patient and out-patient settings.
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Affiliation(s)
- K Nidhin Das
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur 342005, India
| | - Vidhu Sharma
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur 342005, India
| | - Diksha Gupta
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur 342005, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur 342005, India
| | - Poonam Elhence
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Jodhpur 342005, India
| | - Vidhi Jain
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur 342005, India
| | - Kapil Soni
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur 342005, India
| | - Amit Goyal
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur 342005, India
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Thornton CR, Davies GE, Dougherty L. Development of a monoclonal antibody and a lateral-flow device for the rapid detection of a Mucorales-specific biomarker. Front Cell Infect Microbiol 2023; 13:1305662. [PMID: 38145040 PMCID: PMC10739493 DOI: 10.3389/fcimb.2023.1305662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Mucoromycosis is a highly aggressive angio-invasive disease of humans caused by fungi in the zygomycete order, Mucorales. While Rhizopus arrhizus is the principal agent of mucoromycosis, other Mucorales fungi including Apophysomyces, Cunninghamella, Lichtheimia, Mucor, Rhizomucor and Syncephalastrum are able to cause life-threatening rhino-orbital-cerebral, pulmonary, gastro-intestinal and necrotising cutaneous infections in humans. Diagnosis of the disease currently relies on non-specific CT, lengthy and insensitive culture from invasive biopsy, and time-consuming histopathology of tissue samples. At present, there are no rapid antigen tests that detect Mucorales-specific biomarkers of infection, and which allow point-of-care diagnosis of mucoromycosis. Here, we report the development of an IgG2b monoclonal antibody (mAb), TG11, which binds to extracellular polysaccharide (EPS) antigens of between 20 kDa and 250 kDa secreted during hyphal growth of Mucorales fungi. The mAb is Mucorales-specific and does not cross-react with other yeasts and molds of clinical importance including Aspergillus, Candida, Cryptococcus, Fusarium, Lomentospora and Scedosporium species. Using the mAb, we have developed a Competitive lateral-flow device that allows rapid (30 min) detection of the EPS biomarker in human serum and bronchoalveolar lavage (BAL), with a limit of detection (LOD) in human serum of ~100 ng/mL serum (~224.7 pmol/L serum). The LFD therefore provides a potential novel opportunity for detection of mucoromycosis caused by different Mucorales species.
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Affiliation(s)
- Christopher R. Thornton
- Biosciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
- ISCA Diagnostics Ltd., Hatherly Laboratories, Exeter, United Kingdom
| | - Genna E. Davies
- ISCA Diagnostics Ltd., Hatherly Laboratories, Exeter, United Kingdom
| | - Laura Dougherty
- Biosciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
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Chaudhari HS, Palkar OS, Abha Mishra KM, Sethi KK. An extensive review on antifungal approaches in the treatment of mucormycosis. J Biochem Mol Toxicol 2023; 37:e23417. [PMID: 37345721 DOI: 10.1002/jbt.23417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 03/14/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
During the period of COVID-19, the occurrences of mucormycosis in immunocompromised patients have increased significantly. Mucormycosis (black fungus) is a rare and rapidly progressing fungal infection associated with high mortality and morbidity in India as well as globally. The causative agents for this infection are collectively called mucoromycetes which are the members of the order Mucorales. The diagnosis of the infection needs to be performed as soon as the occurrence of clinical symptoms which differs with types of Mucorales infection. Imaging techniques magnetic resonance imaging or computed tomography scan, culture testing, and microscopy are the approaches for the diagnosis. After the diagnosis of the infection is confirmed, rapid action is needed for the treatment in the form of antifungal therapy or surgery depending upon the severity of the infection. Delaying in treatment declines the chances of survival. In antifungal therapy, there are two approaches first-line therapy (monotherapy) and combination therapy. Amphotericin B (1) and isavuconazole (2) are the drugs of choice for first-line therapy in the treatment of mucormycosis. Salvage therapy with posaconazole (3) and deferasirox (4) is another approach for patients who are not responsible for any other therapy. Adjunctive therapy is also used in the treatment of mucormycosis along with first-line therapy, which involves hyperbaric oxygen and cytokine therapy. There are some drugs like VT-1161 (5) and APX001A (6), Colistin, SCH 42427, and PC1244 that are under clinical trials. Despite all these approaches, none can be 100% successful in giving results. Therefore, new medications with favorable or little side effects are required for the treatment of mucormycosis.
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Affiliation(s)
- Hrushikesh S Chaudhari
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Guwahati, Assam, India
| | - Omkar S Palkar
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Guwahati, Assam, India
| | - K M Abha Mishra
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Guwahati, Assam, India
| | - Kalyan K Sethi
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Guwahati, Assam, India
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Pham D, Howard-Jones AR, Sparks R, Stefani M, Sivalingam V, Halliday CL, Beardsley J, Chen SCA. Epidemiology, Modern Diagnostics, and the Management of Mucorales Infections. J Fungi (Basel) 2023; 9:659. [PMID: 37367595 DOI: 10.3390/jof9060659] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023] Open
Abstract
Mucormycosis is an uncommon, yet deadly invasive fungal infection caused by the Mucorales moulds. These pathogens are a WHO-assigned high-priority pathogen group, as mucormycosis incidence is increasing, and there is unacceptably high mortality with current antifungal therapies. Current diagnostic methods have inadequate sensitivity and specificity and may have issues with accessibility or turnaround time. Patients with diabetes mellitus and immune compromise are predisposed to infection with these environmental fungi, but COVID-19 has established itself as a new risk factor. Mucorales also cause healthcare-associated outbreaks, and clusters associated with natural disasters have also been identified. Robust epidemiological surveillance into burden of disease, at-risk populations, and emerging pathogens is required. Emerging serological and molecular techniques may offer a faster route to diagnosis, while newly developed antifungal agents show promise in preliminary studies. Equitable access to these emerging diagnostic techniques and antifungal therapies will be key in identifying and treating mucormycosis, as delayed initiation of therapy is associated with higher mortality.
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Affiliation(s)
- David Pham
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Annaleise R Howard-Jones
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
| | - Rebecca Sparks
- Douglass Hanly Moir Pathology, Sydney, NSW 2113, Australia
| | - Maurizio Stefani
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Varsha Sivalingam
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Catriona L Halliday
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Justin Beardsley
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Sydney, NSW 2145, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
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Alam F, Siddiqui B, Hasan N, Arif S, Maheshwari V, Alam K, Hasan M, Khan R, Khan PA, Ahmed A, Gautam S. Rapid Cytological Diagnosis With Evaluation of Pre- and Post-Therapeutic Fungal Morphological Characteristics in Mucormycosis. J Clin Med Res 2023; 15:31-37. [PMID: 36755764 PMCID: PMC9881490 DOI: 10.14740/jocmr4835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/23/2022] [Indexed: 01/26/2023] Open
Abstract
Background Mucormycosis necessitates rapid diagnosis and treatment. Microscopy and culture have been considered the gold standard for diagnosis but both take time of 3 - 5 days. KOH mount is another method for fungal identification that takes 1 - 2 h, but it has its own limitations. This study evaluated crush smear as a means of rapid cytological diagnosis. Methods Biopsy tissue (pre-treatment) from clinically suspicious mucormycosis patients (n = 52) was received in normal saline and crush/imprint smears were prepared; the remaining tissue was processed as routine biopsy specimen. After the rapid initial cytological identification, the patients were managed according to the standard clinical protocol. Random post-therapeutic biopsy samples of some of these patients (n = 19) were also obtained and again evaluated cytologically. Results Crush smears showed sensitivity/specificity of 77.7%/75.0% with histopathology and 72.2%/62.5% with culture, respectively, while KOH mount had values of 71.4%/70.5% with histopathology and 79.3%/69.5% with culture, respectively. Degenerative fungal morphological characteristics and cellular inflammatory infiltrate (predominantly neutrophilic) in the vicinity of fungal hyphae were compared in pre- and post-treatment groups, and we found a statistically significant difference (P < 0.05) between them. Conclusion Our preliminary results suggest that crush smear cytology is a simple, rapid, cost-effective and easily available method for diagnosing mucormycosis. Moreover, crush smears also demonstrated morphological alteration in hyphal structure and accompanying immune cell infiltration which may provide valuable insights into mechanism of therapy/host immune response against fungal pathogen.
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Affiliation(s)
- Feroz Alam
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India,Corresponding Author: Feroz Alam, Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh 202002, India.
| | - Bushra Siddiqui
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Naba Hasan
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - S.H. Arif
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Veena Maheshwari
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Kiran Alam
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Mahboob Hasan
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Roobina Khan
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Parvez Anwer Khan
- Department of Microbiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Aftab Ahmed
- Department of Otorhinolaryngology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | - Surabhi Gautam
- Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
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