Mucormycosis in systemic lupus erythematosus

The impact of mucormycosis (black fungus) on SARS-CoV-2-infected patients: at a glance

The emergence of various diseases during the COVID-19 pandemic made health workers more attentive, and one of the new pathogens is the black fungus (mucormycosis). As a result, millions of lives have already been lost. As a result of the mutation, the virus is constantly changing its traits, including the rate of disease transmission, virulence, pathogenesis, and clinical signs. A recent analysis revealed that some COVID-19 patients were also coinfected with a fungal disease called mucormycosis (black fungus). India has already categorized the COVID-19 patient black fungus outbreak as an epidemic. Only a few reports are observed in other countries. The immune system is weakened by COVID-19 medication, rendering it more prone to illnesses like black fungus (mucormycosis). COVID-19, which is caused by a B.1.617 strain of the SARS-CoV-2 virus, has been circulating in India since April 2021. Mucormycosis is a rare fungal infection induced by exposure to a fungus called mucormycete. The most typically implicated genera are Mucor rhyzuprhizopusdia and Cunninghamella. Mucormycosis is also known as zygomycosis. The main causes of infection are soil, dumping sites, ancient building walls, and other sources of infection (reservoir words "mucormycosis" and "zygomycosis" are occasionally interchanged). Zygomycota, on the other hand, has been identified as polyphyletic and is not currently included in fungal classification systems; also, zygomycosis includes Entomophthorales, but mucormycosis does not. This current review will be focused on the etiology and virulence factors of COVID-19/mucormycosis coinfections in COVID-19-associated mucormycosis patients, as well as their prevalence, diagnosis, and treatment.

Risks of developing ulcerative colitis and Crohn's disease in relation to silica dust exposure in Sweden: a case-control study

OBJECTIVE

To determine whether occupational exposure to silica dust causes an increased risk of developing Crohn's disease (CD) and ulcerative colitis (UC).

DESIGN

Case-control study of CD (K50) and UC (K51) from 2007 through 2016. Controls were matched to cases (2:1) based on age, sex and county at the time of diagnosis. A job exposure matrix was used to estimate the occupational silica exposure of all cases and controls.

SETTING

Medical and occupational data from the National Outpatient Register were used to implement a case-control analysis, while the two controls used for each case were selected from the National Register of the Total Population.

PARTICIPANTS

All men and women aged 20-65 years old who were diagnosed with CD (K50) and UC (K51) during the years of study were included and assigned two controls, resulting in 58 136 cases and 116 272 controls.

MAIN OUTCOMES

Silica dust exposure correlates with an increased risk of developing UC in men and CD in women.

RESULTS

The prevalence of UC was significantly higher in the group exposed to silica dust (OR 1.13, 95% CI 1.06 to 1.21) than in controls, particularly in individuals with over 5 years exposure. When stratified by sex, a significantly increased OR was detected for men (OR 1.33, 95% CI 1.05 to 1.22). This trend was also consistent with longer exposure times. The prevalence of UC was not increased in exposed women. The prevalence of CD was significantly increased among exposed women (OR 1.29, 95% CI 1.01 to 1.65), but not for exposed men.

CONCLUSIONS

Silica dust exposure correlates with an increased risk of developing UC, especially in men, and the risk seems to increase with the duration and degree of exposure. Conversely, silica dust exposure correlates positively with the risk of developing CD in women.

Ruptured Mycotic Aneurysm of the Distal Circulation in a Patient with Mucormycosis Without Direct Skull Base Extension: Case Report

BACKGROUND AND IMPORTANCE

Infectious intracranial aneurysms are a rare subset of intracranial aneurysms caused by bacterial, fungal, or viral sources. Intracranial aneurysms of fungal etiology carry a high mortality risk and typically occur in immunocompromised patients via direct extension of skull base infections, or more rarely, after intracranial surgery.

CLINICAL PRESENTATION

We present the case of a 27-yr-old female with systemic lupus erythematous and primary pulmonary mucormycosis, who suffered a subarachnoid hemorrhage from a ruptured fusiform distal middle cerebral artery aneurysm. Despite undergoing a successful extracranial-to-intracranial bypass and aneurysm excision, the patient ultimately died following progressive disseminated infection and a secondary intracranial hemorrhage of unknown etiology. Pathological examination of the excised artery confirmed Mucor infection.

CONCLUSION

To the best of our knowledge, this case represents one of the first mycotic cerebral aneurysms from mucormycosis in a patient without an underlying skull base infection or previous intracranial surgery. Despite optimal surgical management, clinical outcomes for mycotic cerebral aneurysms are largely dependent on the success of medical therapies at controlling systemic disease.

Rhinocerebral Mucormycosis Among Diabetic Patients: An Emerging Trend

Mucormycosis is an acute necrotic fungal infection with a fulminant course. Earlier considered a rare entity, mucormycosis is being reported with increasing frequency in recent years, possibly due to the increase in immunocompromised population especially diabetic patients. We report three cases of rhinocerebral mucormycosis among poorly controlled diabetic patients. This article emphasizes the need for further awareness of this disease, early diagnosis, and treatment to counter this opportunistic infection.

Black yeasts and their filamentous relatives: principles of pathogenesis and host defense

Among the melanized fungi, the so-called "black yeasts" and their filamentous relatives are particularly significant as agents of severe phaeohyphomycosis, chromoblastomycosis, and mycetoma in humans and animals. The pathogenicity and virulence of these fungi may differ significantly between closely related species. The factors which probably are of significance for pathogenicity include the presence of melanin and carotene, formation of thick cell walls and meristematic growth, presence of yeast-like phases, thermo- and perhaps also osmotolerance, adhesion, hydrophobicity, assimilation of aromatic hydrocarbons, and production of siderophores. Host defense has been shown to rely mainly on the ingestion and elimination of fungal cells by cells of the innate immune system, especially neutrophils and macrophages. However, there is increasing evidence supporting a role of T-cell-mediated immune responses, with increased interleukin-10 (IL-10) and low levels of gamma interferon (IFN-γ) being deleterious during the infection. There are no standardized therapies for treatment. It is therefore important to obtain in vitro susceptibilities of individual patients' fungal isolates in order to provide useful information for selection of appropriate treatment protocols. This article discusses the pathogenesis and host defense factors for these fungi and their severity, chronicity, and subsequent impact on treatment and prevention of diseases in human or animal hosts.

Dual disseminated infection with Nocardia farcinica and Mucor in a patient with systemic lupus erythematosus: a case report

INTRODUCTION

Infections remain a major cause of morbidity and mortality in immunocompromised patients and require early diagnosis and treatment. However, correct diagnosis and treatment are often delayed by a multitude of factors. We report what we believe to be the first case of a combined disseminated infection with Nocardia and Mucor in a patient with systemic lupus erythematosus.

CASE PRESENTATION

A 74-year-old Caucasian woman with systemic lupus erythematosus presented with recurrent pneumonia. Despite empirical treatment with antibiotics, her condition gradually deteriorated. Microbiological sampling by thoracoscopy revealed the presence of Nocardia. Despite the institution of therapy for disseminated nocardiosis, she died of multi-organ failure. A post-mortem investigation confirmed nocardiosis, but showed concomitant disseminated mucormycosis infection as well.

CONCLUSION

Members of the bacterial genus Nocardia and the fungal genus Mucor are ubiquitous in the environment, have the ability to spread to virtually any organ, and are remarkably resistant to appropriate therapy. Both pathogens can mimic other pathologies both on clinical and radiological investigations. Invasive sampling procedures are often needed to prove their presence. Establishing a timely, correct diagnosis and a specific treatment is essential for patient survival.

Rhino cerebral mucormycosis in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystem connective tissue disease. Patients with SLE develop cutaneous infections due to immune dysregulation and treatment with immunosuppressive agents. Deep fungal infections are rare in SLE but are important cause of morbidity. We report a case of successfully treated rhino cerebral mucormycosis (RCM) in a female patient with SLE.

Mucormycosis and chromoblastomycosis occurring in a patient with leprosy type 2 reaction under prolonged corticosteroid and thalidomide therapy

Mucormycosis is an uncommon fungal infection caused by Mucorales. It frequently occurs in patients with neutropenia, diabetes, malignancy and on corticoid therapy. However, it is rare in patients with AIDS. Clinical disease can be manifested in several forms. The case reported illustrates the rare occurrence of chromoblastomycosis and mucormycosis in an immunosuppressed patient with multibacillary leprosy, under prolonged corticosteroid and thalidomide therapy to control leprosy type 2 reaction. Neutrophil dysfunction, thalidomide therapy and work activities are some of the risk factors in this case. Chromoblastomycosis was treated by surgical excision and mucormycosis with amphotericin B. Although the prognosis of mucormycosis is generally poor, in the reported case the patient recovered successfully. This case should alert dermatologists to possible opportunistic infections in immunosuppressed patients.

Epidemiology and clinical manifestations of mucormycosis

Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the Mucorales order of the class of Zygomycetes. Mucormycosis has emerged as the third most common invasive mycosis in order of importance after candidiasis and aspergillosis in patients with hematological and allogeneic stem cell transplantation. Mucormycosis also remains a threat in patients with diabetes mellitus in the Western world. Furthermore, this disease is increasingly recognized in recently developed countries, such as India, mainly in patients with uncontrolled diabetes or trauma. Epidemiological data on this type of mycosis are scant. Therefore, our ability to determine the burden of disease is limited. Based on anatomic localization, mucormycosis can be classified as one of 6 forms: (1) rhinocerebral, (2) pulmonary, (3) cutaneous, (4) gastrointestinal, (5) disseminated, and (6) uncommon presentations. The underlying conditions can influence clinical presentation and outcome. This review describes the emerging epidemiology and the clinical manifestations of mucormycosis.

Zygomycosis in Immunocompromised non-Haematological Patients

Zygomycoses caused by fungi of the mucorales order (mucormycoses) are emerging fungal diseases with a high fatality rate. The most important risk factors include neutropenia or functional neutropenia, diabetic ketoacidosis, iron overload, major trauma, prolonged use of corticosteroids, illicit intravenous drug (ID) use, neonatal prematurity, malnourishment, and maybe a previous exposure to antifungal agents with no activity against zygomycetes, such as voriconazole and echinocandins.A high index of suspicion is crucial for the diagnosis, as prompt and appropriate management can considerably reduce morbidity and mortality. Suspicion index can be increased through recognition of the differential patterns of clinical presentation. In the non- haematological immunocompromised patients, mucormycosis can manifest in various clinical forms, depending on the underlying condition: mostly as rhino-orbital or rhino-cerebral in diabetes patients, pulmonary infection in patients with malignancy or solid organ transplantation, disseminated infection in iron overloaded or deferoxamine treated patients, cerebral - with no sinus involvement - in ID users, gastrointestinal in premature infants or malnourishment, and cutaneous after direct inoculation in immunocompetent individuals with trauma or burns.Treating a patient's underlying medical condition and reducing immunosuppression are essential to therapy. Rapid correction of metabolic abnormalities is mandatory in cases such as uncontrolled diabetes, and corticosteroids or other immunosuppressive drugs should be discontinued where feasible. AmphotericinB or its newer and less toxic lipid formulations are the drugs of choice regarding antifungal chemotherapy, while extensive surgical debridement is essential to reduce infected and necrotic tissue. A high number of cases could be prevented through measures including diabetes control programmes and proper pre- and post-surgical hygiene.

Mucormycosis complications in systemic lupus erythematosus

This case involved a 75-year-old woman with systemic lupus erythematosus. Two months previously, she had a flare that was treated successfully by increasing the dosages of prednisone and azathioprine. A sudden onset of ocular pain, diplopia, and loss of vision suggestive of optical neuritis or vascular involvement confused the issue, and rhinocerebral zygomycosis was demonstrated later. We review the presentations of this fungal infection in patients with systemic lupus erythematosus with emphasis on its initial features.

Successful treatment of invasive gastric mucormycosis in a child with systemic lupus erythematosus

We describe a child with systemic lupus erythematosus and invasive gastric mucormycosis, who was successfully treated with aggressive antifungal therapy and a unique interventional radiology procedure. Lupus (2010) 19, 646—649.

Infections as triggers and complications of systemic lupus erythematosus

A growing body of experimental and clinical evidence supports the pivotal role of infections in the induction or exacerbation of systemic lupus erythematosus (SLE). Infections can be responsible for aberrant immune response leading to a loss of tolerance towards native proteins. Molecular mimicry, especially between Sm or Ro autoantigens and EBV Nuclear Antigen-1 response, as well as the over-expression of type 1 INF genes are among the major contributors to SLE development. On the other hand infections are very common in SLE patients, where they are responsible for 30-50% of morbidity and mortality. Several factors, either genetic, including complement deficiencies or mannose-binding lectin deficiency or acquired such as severe disease manifestations or immunosuppressant use, predispose SLE patients to infections. All types of infections, including bacterial, viral and opportunistic infections, have been reported and the most frequently involved sites of infections are the same as those observed in the general population, including respiratory, skin, and urinary tract infections. Some preventive measures could be adopted in order to reduce the rate of infections in SLE patients: i.e. screening for Mycobacterium tuberculosis and for some chronic viral infections before immunosuppressive treatment; adequate prophylaxes or drug adjustments when indicated, and pneumococcal and influenza vaccinations in patients with stable disease.

Epidemiology and outcome of zygomycosis: a review of 929 reported cases

BACKGROUND

Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease.

METHODS

We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described.

RESULTS

The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively).

CONCLUSIONS

Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.

[Pulmonary zygomycosis--a rare angioinvasive fungal infection]

Zygomycosis caused by Rhizopus species is an aggressive and rapidly progressive opportunistic fungal infection in immunocompromised patients. It comprises mucocutaneous, rhinocerebral, pulmonary, urological and disseminated infections. Predisposing factors are immunosuppression owing to severe diseases, immunological defects or metabolic disturbances like diabetic ketoacidosis. Rhizopus infections are characterized by angioinvasive growth, necroses of infected tissue and perineural invasion. The histopathologic demonstrable invasion of blood vessels is remarkable for a fungal infection. The mortality of zygomycosis is very high, especially for disseminated disease and when immunosuppression cannot be corrected. We report about two cases of pulmonary zygomycosis, caused by Rhizopus spp.: patient 1, female 73 years old: Delayed clinical course according to hip arthroplasty infection and infection of a femoropopliteal bypass of the right leg, eventually exarticulation of the right hip joint, Pseudomonas pneumonia, severe sepsis caused by staphylococci, acute respiratory distress syndrome (ARDs), acute renal failure and multiple use of antibiotics. Subsequently detection of Rhizopus spp. in the bronchoalveolar lavage and treatment with amphotericin B for this reason. Patient 2, male 68 years old: transplantation of kidney in past medical history, presenting with acute renal failure and with quite a few infections before. In the sequel development of abscessing pneumonia on the right side with a pleural empyema. Rhizopus spp. were detected by microbiological testing in the empyema fluid. These findings required surgical intervention, resection of the lower lobe of the right lung and within the same operation of the renal graft because of rejection. The patient was treated with caspofungin. The further course was delayed by several septic phases. Both patients died later on in spite of all efforts. The very rarely seen pulmonary zygomycosis caused by infection with Rhizopus spp. developed in both patients owing to immunosuppression, in one patient iatrogenically induced by immunosuppressive drugs after organ transplantation, in the other as a result of prolonged severe sepsis. In comparison with other mycoses treatment of Rhizopus infections remains difficult. The affinity to blood vessels, where the fungi multiply, and their feature of vascular invasion with thrombosis and infarction complicate therapeutic efforts.

Genetic identification and detection of human pathogenic Rhizopus species, a major mucormycosis agent, by multiplex PCR based on internal transcribed spacer region of rRNA gene

BACKGROUND

Mucormycosis is an invasive opportunistic infection caused by fungi belonging to the order Mucorales. Due to the lack of laboratory tests, the diagnosis of mucormycosis is notoriously difficult. Added with its rapid progression as well as the debilitated state of the patients who contract the disease, mortality is extremely high.

OBJECTIVE

The goal of this study was to genetically identify human pathogenic Rhizopus species, a major mucormycosis agent, by the internal transcribed spacer (ITS) region of rRNA gene.

METHODS

Primers were designed to identify five Rhizopus species known to cause human disease by multiplex PCR. PCR was done not only with test strains and clinical isolates, but also with clinical samples from cutaneous mucormycosis patients. Sporangiospore morphology was observed by scanning electron microscopy to confirm the correlation of phenotypic and genotypic features.

RESULTS

Multiplex PCR identified five Rhizopus species including Rhizopus oryzae, where R. azygosporus could only be distinguished from R. microsporus by certain polymorphisms that were present in its sequence. When this multiplex PCR was applied to clinical samples from three mucormycosis patients (paraffin sections from all and sera from one patient), Rhizopus DNA corresponding to the isolated pathogens were specifically detected.

CONCLUSION

While fungal DNA detection from clinical samples is a rigorously studied area, this is the first report to genetically identify and detect Rhizopus species from human mucormycosis specimens. This may expand the possibility of this multiplex PCR system not only to identify isolated fungi, but also as a screening method for visceral mucormycosis.