Mucormycosis: what emergency physicians need to know?

High risk and low prevalence diseases: Cavernous sinus thrombosis

INTRODUCTION

Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation.

CONCLUSION

An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Mucormycosis, the Black Fungus in the Post-COVID-19 Pandemic: A Case Report with Review of Literature

Mucormycosis, a concerning and often fatal fungal infection, has shown a significant rise in cases following the COVID-19 pandemic in India, particularly affecting patients with uncontrolled comorbidities such as diabetes mellitus and other immunocompromised individuals. Our case series examines five instances of mucormycosis, supported by appropriate radiographic and histopathological evidence correlating with clinical observations. Our review indicated that patients were experiencing ailments or undergoing treatments that compromised their immune systems. We analyzed additional epidemiological data, including common infection sites, gender predispositions, and mortality rates. Treatments were tailored based on symptom severity, encompassing both surgical and medical approaches. The primary reason for the rise in cases was linked to elevated glycaemic levels and weakened immunity among post-COVID-19 patients. The report provides a detailed explanation of the factors contributing to this correlation. Our findings underscore the critical importance of timely surgical intervention and advocate for further investigation into treatment efficacy and symptom monitoring specific to mucormycosis in post-COVID-19 patients in India.

Physicians' knowledge of invasive fungal disease in China

BACKGROUND

Invasive fungal disease (IFD) is associated with high morbidity and mortality. Data are lacking regarding physicians' perspectives on the diagnosis and management of IFD in China.

OBJECTIVES

To evaluate physicians' perspectives on the diagnosis and management of IFD.

METHODS

Based on current guidelines, a questionnaire was designed and administered to 294 physicians working in haematology departments, intensive care units, respiratory departments and infectious diseases departments in 18 hospitals in China.

RESULTS

The total score and subsection scores for invasive candidiasis, invasive aspergillosis (IA), cryptococcosis and invasive mucormycosis (IM) were 72.0 ± 12.2 (maximum = 100), 11.1 ± 2.7 (maximum = 19), 43.0 ± 7.8 (maximum = 57), 8.1 ± 2.0 (maximum = 11) and 9.8 ± 2.3 (maximum = 13), respectively. Although the perspectives of the Chinese physicians were in good overall agreement with guideline recommendations, some knowledge gaps were identified. Specific areas in which the physicians' perspectives and guideline recommendations differed included use of the β-D-glucan test to facilitate the diagnosis of IFD, relative utility of the serum galactomannan test and bronchoalveolar lavage fluid galactomannan test in patients with agranulocytosis, use of imaging in the diagnosis of mucormycosis, risk factors for mucormycosis, indications for initiating antifungal therapy in patients with haematological malignancies, when to start empirical therapy in mechanically ventilated patients, first-line drugs for mucormycosis and treatment courses for IA and IM.

CONCLUSION

This study highlights the main areas that could be targeted by training programs to improve the knowledge of physicians treating patients with IFD in China.

Neuromucormycosis of Posterior Tibial Nerve: A Rare Presentation of Mucormycosis

Opportunistic fungal infections are known to occur in immunocompromised patients. Mucormycosis is one of the most common opportunistic fungal infections with significant mortality rates. In this article, we present a case of an adult female, a known diabetic who presented with fever and pus discharge from the amputation site of toes in the left foot with blackening of the foot. Examination revealed gangrenous changes of the left foot with no distal pulses palpable. Computed tomography angiogram revealed no flow of blood in distal vessels of the left lower limb. Left below knee guillotine amputation was done. Intraoperative biopsy of the neurovascular bundle revealed invasive neuromucormycosis. She was started on liposomal amphotericin B. The wound started granulating after a few days with serial dressings and the patient was planned for split skin grafting.

Mucormycosis in the COVID-19 Environment: A Multifaceted Complication

The second wave of coronavirus disease 2019 (COVID-19) caused severe infections with high mortality. An increase in the cases of COVID-19-associated mucormycosis (CAM) was reported predominantly in India. Commonly present in immunocompromised individuals, mucormycosis is often a life-threatening condition. Confounding factors and molecular mechanisms associated with CAM are still not well understood, and there is a need for careful research in this direction. In this review, a brief account of the diagnosis, management, and advancement in drug discovery for mucormycosis has been provided. Here, we summarize major factors that dictate the occurrence of mucormycosis in COVID-19 patients through the analysis of published literature and case reports. Major predisposing factors to mucormycosis appear to be uncontrolled diabetes, steroid therapy, and certain cancers. At the molecular level, increased levels of iron in COVID-19 might contribute to mucormycosis. We have also discussed the potential role and regulation of iron metabolism in COVID-19 patients in establishing fungal growth. Other factors including diabetes prevalence and fungal spore burden in India as contributing factors have also been discussed.

COVID ‐19‐associated facial cutaneous mucormycosis superinfection: A potentially life‐threatening disease

A 49‐year‐old male was involved in an accident and an abdominal computer tomographic examination revealed papillary renal cell carcinoma of the right kidney. During hospitalization, the patient was infected with COVID‐19. In the following COVID‐19 treatment, a black dot developed on the right side of the head and face. Antifungal therapy and surgical debridement were initiated and gradual improvement was observed.

COVID‐19 infection is spreading rapidly and mucormycosis is an invasive fungal infection which causes a high rate of mortality. Early diagnosis and prompt treatment can result in better outcome of the patient.

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

BACKGROUND

Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

AIM

Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

DESIGN

This was a retrospective, single-centre, observational study.

METHODS

We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

RESULTS

Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

CONCLUSION

COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Disseminated mucormycosis presenting as a renal mass in an human immunodeficiency virus-infected patient: A case report

Mucormycosis, an opportunistic fungal infection, is on the increase. Individuals at risk are those with diabetes mellitus, haematological malignancy, etc. Infections are uncommon in human immunodeficiency virus (HIV). Clinical presentations include rhinocerebral, pulmonary or disseminated forms. Risk factors should alert clinicians to a high index of suspicion. Prompt diagnosis, facilitated by radiological imaging and tissue sampling, with appropriate medical and surgical intervention can potentially improve patient outcomes. Here we describe a rare case of renal mass in a patient living with HIV presenting to casualty department with abdominal pain and fever. Radiological imaging showed a renal mass whilst histopathological findings were suggestive of mucormycosis. Management included antifungal therapy and subsequent nephrectomy. The patient improved significantly and was discharged home.

Disseminated mucormycosis with cerebellum involvement due to Rhizomucor pusillus in a patient with multiple myeloma and secondary myelodysplastic syndrome: A case report

Mucormycosis is an angioinvasive fungal infection with a high mortality rate. Patients with hematological malignancies following voriconazole therapy are at high risk from mucormycosis. Here, the present study reports on a 68-year-old man diagnosed with multiple myeloma and secondary myelodysplastic syndrome, who was infected with disseminated mucormycosis with cerebellum involvement confirmed by mycological culture and histopathological examination. For patients with hematological malignancies who are receiving antifungal therapy, an opportunistic infection of mucormycosis should be considered if a ‘breakthrough’ infection occurs in the predilection sites (such as the sinuses, lungs, skin, brain and gastrointestinal tract). It is difficult to diagnose mucormycosis because of the limited reliable detection methods, and because mucormycosis often presents with an acute onset and progresses rapidly, particularly in immunocompromised patients. Antifungal therapy with amphotericin B or posaconazole should be started as soon as possible considering the empirical diagnosis.

Oncologic Emergencies: The Fever With Too Few Neutrophils

BACKGROUND

Cancer is associated with a variety of complications, including neutropenic fever, which can result in severe morbidity and mortality. This oncologic emergency requires ED management.

OBJECTIVE

This narrative review provides focused updates for emergency clinicians regarding neutropenic fever.

DISCUSSION

Neutropenic fever is defined by fever with oral temperature >38.3°C or temperature >38.0°C for 1 hour with an absolute neutrophil count (ANC) < 1000 cells/microL. Patients who have received chemotherapy within 6 weeks of presentation are at high risk for neutropenia. While most patients with neutropenic fever do not have an identifiable bacterial source of fever, clinicians should treat patients for bacterial infection. Rapid assessment and management are vital to improving outcomes in patients with suspected or confirmed neutropenic fever. History and examination should focus on the most common sites of infection: the gastrointestinal tract, blood, skin, lung, and urinary tract. However, physical examination and laboratory or imaging assessment may not display classic signs of infection. Blood cultures should be obtained, and broad-spectrum antibiotics are recommended. Oncology consultation is an integral component in the care of these patients. Several risk scores can assist in stratifying patients who may be appropriate for discharge home and follow-up.

CONCLUSIONS

Neutropenic fever is an oncologic emergency. Rapid diagnosis and care of patients with neutropenic fever can improve outcomes, along with oncology consultation.

Fatal rhinocerebral mucormycosis in a patient with ulcerative colitis receiving azathioprine and corticosteroid

Background and Purpose:

Rhinocerebral mucormycosis is a rare fatal fungal infection which is on a growing trend, particularly among immunocompromised patients. Immunosuppressive drugs, including corticosteroids and antimetabolites, increase the risk of this infection. Herein, we reported the case of fulminant rhinocerebral mucormycosis in a patient with ulcerative colitis receiving azathioprine and corticosteroid.

Case report:

A 58-year-old woman was admitted to the hospital in a state of coma with an extensive necrosis in her nose. She was afflicted with intestinal bleeding after 1 month of fasting and was treated with azathioprine and a high dose of prednisolone for ulcerative colitis 2 months prior to hospital admission. The direct microscopic examination of the necrotic tissues of the paranasal sinuses showed several non-septate hyphae consistent with Mucorales. Culture media yielded Rhizopus species, which was identified as Rhizopus oryzae by internal transcribed spacer polymerase chain reaction sequencing. Despite the implementation of surgical and pharmaceutical (liposomal amphotericin B) treatments, the patient expired after 2 weeks of admission.

Conclusion:

The gastroenterologists should be aware of the adverse effect of immunosuppressive drugs they prescribe for the treatment of inflammatory bowel disease.

Fungal Rhino-orbital Cerebritis in a Patient with Steroid-induced Ketoacidosis

Fungal rhino-orbital cerebritis is a devastating opportunistic invasive disease. Survival requires urgent diagnosis. Thus, all patients at risk who present with rhinosinusitis-type symptoms and have co-morbid conditions that decrease their immunocompetence should trigger the clinician’s consideration of this disease. Treatment includes antifungals and emergent surgical debridement.

Imaging Patterns of Rhino-Orbital-Cerebral Mucormycosis in Immunocompromised Patients : When to Suspect Complicated Mucormycosis

PURPOSE

The aim of this study was to describe radiological imaging findings of a complicated sinusitis, which should raise the suspicion of rhino-orbital-cerebral mucormycosis as being the underlying cause.

METHODS

In this retrospective analysis, we describe the cases and imaging findings of 8 patients with proven mucormycosis. These patients presented mostly with new facial or orbital swelling and were referred for imaging to our institution. Magnetic resonance imaging and computed tomography images were classified as abnormal or normal with respect to orbital, paranasal and cerebral signal results. Special emphasis was placed on the distribution of the signal abnormalities regarding involvement of the skull base and the cavernous sinus.

RESULTS

Out of a pool of 43 patients with colonization or proven Mucorales infection at different sites of the body, we identified 8 patients with infiltration of the midface and skull base. Unexpectedly seven out of the eight patients with abnormal findings of the paranasal sinuses and the adjacent tissues showed no bony sinus wall destruction. Of the eight patients seven showed inflammatory changes involving the infratemporal fossa and facial/periorbital tissues, three of the eight patients suffered from fungal invasion of the cavernous sinus and the carotid artery and one of the eight patients had a local infection of the hard palate only.

CONCLUSION

Imaging findings of inflammatory tissue infiltration adjacent to the paranasal sinuses with possible extension into the pterygopalatine fossa, infratemporal fossa and orbit or the cavernous sinus should raise the suspicion of a mucormycosis, especially in immunocompromised patients.

Role of microglia in fungal infections of the central nervous system

Most fungi are capable of disseminating into the central nervous system (CNS) commonly being observed in immunocompromised hosts. Microglia play a critical role in responding to these infections regulating inflammatory processes proficient at controlling CNS colonization by these eukaryotic microorganisms. Nonetheless, it is this inflammatory state that paradoxically yields cerebral mycotic meningoencephalitis and abscess formation. As peripheral macrophages and fungi have been investigated aiding our understanding of peripheral disease, ascertaining the key interactions between fungi and microglia may uncover greater abilities to treat invasive fungal infections of the brain. Here, we present the current knowledge of microglial physiology. Due to the existing literature, we have described to greater extent the opportunistic mycotic interactions with these surveillance cells of the CNS, highlighting the need for greater efforts to study other cerebral fungal infections such as those caused by geographically restricted dimorphic and rare fungi.

Cutaneous mucormycosis postcosmetic surgery: A case report and review of the literature

BACKGROUND

Mucormycosis is a rare, aggressive, and life-threatening infection that is caused by organisms belonging to the order Mucorales. It is usually acquired through direct means and virtually always affects immunocompromised patients with the port of entry reflecting the site of infection, in this case, cutaneous. Unlike other mucormycoses, patients affected by Apophysomyces elegans (A elegans) are known to be immunocompetent. This locally aggressive disease penetrates through different tissue plains invading adjacent muscles, fascia, and even bone causing extensive morbidity and may prove fatal if treated inadequately. Cutaneous mucormycosis is associated with disruption of cutaneous barriers such as trauma. However, rarely, it may be iatrogenic. No cases have been previously reported postcosmetic surgery, especially one that is so commonly performed, lipofilling.

CASE REPORT

The patient is a, previously healthy, 41-year-old middle-eastern female who was admitted to the plastic surgery department 17 days after undergoing cosmetic surgery. She suffered from extensive tissue inflammation and necrosis in both gluteal regions. Following admission, she was initially started on empirical antimicrobial therapy which was changed to an antifungal agent, voriconazole, when preliminary microbiological results showed filamentous fungi. This was discontinued and liposomal amphotericin B was commenced when further mycological analysis identified A elegans. Furthermore, she underwent a total of 10 sessions of extensive debridement to the extent that portions of the sacrum and left femoral head became exposed. Her clinical status and wounds improved with the appropriate management and she remained an inpatient for 62 days. Subsequently, she had defects in both gluteal regions which required reconstructive surgery.

CONCLUSION

A elegans is an uncommon cause of iatrogenic cutaneous mucormycosis. A high index of clinical suspicion is required, especially in the absence of clinical improvement despite conventional methods of treatment, so that early diagnosis can be reached and the appropriate management instigated promptly in order to mitigate morbidity and mortality. Reversal of predisposing risk factors, regular extensive surgical debridement, and antifungal therapy remain the cornerstones of therapy for this life-threatening condition.