Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium

Chronic cutaneous and mucosal mucormycosis: Rhizopus arrhizus as a major pathogenic fungus

Chronic cutaneous mucormycosis is a rare condition distinct from the acute form, characterized by a prolonged, indolent course and varied clinical presentations. This study presents a 5-year experience from a tertiary dermato-mycology clinic, identifying six cases, the majority of whom were immunocompetent, with trauma history reported in four patients. The median duration from symptom onset to diagnosis was 60 months. The primary pathogens identified were Rhizopus arrhizus, Mucor variabilis, and Lichtheimia ramosa. Histopathological analysis demonstrated the absence of fungal angioinvasion, a hallmark of acute mucormycosis, which likely accounts for the slower progression observed in chronic cases. Systemic Amphotericin B treatment achieved favourable outcomes in most patients though significant morbidity persisted in some cases. This case series underscores the clinical and pathological distinctions of chronic cutaneous mucormycosis, highlighting the potential influence of host factors and environmental conditions on chronicity. The predominance of Rhizopus arrhizus suggests that chronicity is driven more by hostpathogen interactions than fungal species-specific factors. Increased recognition of the atypical clinical features, such as diverse cutaneous manifestation and slower progression course, as well as the utilization of diagnostic tools including histopathology, fungal culture, and advanced molecular techniques, is essential for the timely diagnosis of this rare presentation.

Posaconazole effectiveness in rare invasive fungal infections: A systematic literature review

INTRODUCTION

Mucormycosis, hyalohyphomycosis, chromoblastomycosis, and fungal mycetoma are rare invasive fungal infections (IFIs) that cause significant morbidity and mortality in immunocompromised patients. Few effective treatment options are available for these IFIs.

METHODS

We performed a systematic literature review of MEDLINE and Embase to identify studies published from 2005 (year of posaconazole approval) to 22 October 2022, reporting the efficacy/effectiveness of posaconazole monotherapy or combination therapy for treating mucormycosis, hyalohyphomycosis, chromoblastomycosis, and mycetoma. Positive outcomes or positive clinical outcomes were defined as reporting of a positive efficacy/effectiveness measure (i.e. no relapse, response, cure, radiological improvement, clinical/symptom improvement, or survived therapy).

RESULTS

Of 3207 articles identified (after removing duplicates), 533 articles (mostly case reports) were included. Positive clinical outcomes with posaconazole therapy were observed in most patients with mucormycosis (74.8%, 1197/1601), hyalohyphomycosis (58.5%, 62/106), chromoblastomycosis (90.5%, 19/21), and mycetoma (100%, 5/5). Overall survival was around 70% or greater across the IFIs examined. Positive response was higher in second-line monotherapy than first-line monotherapy in mucormycosis and chromoblastomycosis. Higher mortality was observed with combination therapy than monotherapy in mucormycosis and hyalohyphomycosis infections (except for first-line use in mucormycosis). Positive clinical outcome was 78.6% and overall survival was 78.6% in 323 coronavirus disease-associated mucormycosis infection cases.

CONCLUSIONS

Despite the rarity of these IFIs, substantial data have been published since posaconazole was initially approved in 2005, and the real-world case reports demonstrate that posaconazole is an effective therapeutic option alone or in combination for the treatment of these rare IFIs.

A Global Analysis of Cases of Mucormycosis Recorded in the European Confederation of Medical Mycology / International Society for Human and Animal Mycology (ECMM / ISHAM) Zygomyco.net Registry from 2009 to 2022

We analyzed mucormycosis data from the Zygomyco.net registry (2009-2022), encompassing cases from 16 countries. India, Russia and the Czech Republic provided the largest contributions. India reported the highest case number, consistent with its substantially higher incidence compared to that of high-income countries. Among the 382 patients with mucormycosis, 236 (61.8%) were male (male-to-female ratio 1.6). The median age was 48 years [interquartile range (IQR) 32-60]. There were 59 pediatric patients (median age ranging from < 1 month to 19 years). Diabetes mellitus type 2 was the most common underlying condition (39%), with significant geographic variation (> 70% of cases in India and Iran but only 6.9% in Europe). Hematologic malignancies (HM, 31.4%), the second most common underlying condition, were absent in India and Iran. The primary clinical presentations were rhino-orbito-cerebral mucormycosis (ROCM, 36.6%), pulmonary (33.2%) and cutaneous mucormycosis (17.5%). Patients with diabetes mellitus typically developed ROCM (55.9%), while pulmonary infections were more common in those with HM or hematopoietic cell transplantation (HCT) (47.5%, p < 0.001). Rhizopus was the leading fungal genus (58%), followed by Lichtheimia (13.7%) and Mucor (7%), with regional variations. Pulmonary infections in HM patients were linked to L. corymbifera and R. microsporus, while Apophysomyces spp. and Saksenaea spp. were more frequent in Indian healthcare-associated cutaneous cases. Concomitant infections were observed in 8.7% of patients with HM, complicating diagnosis and treatment. In most of them (57.1%), Aspergillus spp. was involved. Improved diagnostic practices, including direct microscopy and cultures, showed higher positivity rates, although PCR remained underutilized. Antifungal therapy, primarily with an amphotericin B formulation, combined with surgery, was the most common therapeutic approach. Overall mortality was high (47.8%), particularly in disseminated or advanced ROCM cases. Multivariable analysis identified older age, advanced ROCM, and HM/HCT as independent mortality risk factors (p < 0.05); whereas localized sinusitis and combined medical and surgical therapy were independently associated with improved outcomes (p < 0.006). This study underscores regional disparities in the mucormycosis epidemiology and species distribution. Improved early detection is needed, particularly in immunocompromised populations with HM. Enhanced surveillance and tailored public health strategies are crucial to address this ongoing global health threat.

Duration of systemic antifungal therapy for patients with invasive fungal diseases: A reassessment

Invasive fungal diseases are associated with significant morbidity and mortality, especially among immunocompromised patients, and often prompt for rapid and aggressive treatment aiming cure. Due to the expanding magnitude of patients burdened by chronic immunosuppression and affected by fungal diseases, the diversity of clinical settings has risen. This often results in prolonged therapy (induction, consolidation and maintenance) associated with potentially severe side effects, and clinicians face the challenging decisions of when and how to stop anti-fungal therapy. Adequate duration of therapy is poorly defined, hampered by the lack of dedicated trials to the question, the heterogeneity of cases (type of fungal pathogen, localization of infection, underlying host conditions) and various confounding factors that may influence the clinical response (e.g. persistence vs recovery of immunosuppression, impact of surgery). In this review, we aim to evaluate the existing data underlying the guidelines and recommendations of treatment duration for the most frequent invasive fungal diseases (cryptococcal meningitis, Pneumocystis pneumonia, invasive aspergillosis, invasive candidiasis and mucormycosis), as well as specific localizations of deep-seated diseases (osteo-articular or central nervous system diseases and endocarditis) and emerging considerations and strategies.

Invasive tracheal mucormycosis complicated by myiasis following tracheostomy in a diabetic patient: A case report

Invasive tracheal mucormycosis is a rare but fatal opportunistic infection, particularly common in immunocompromised patients. This case report describes a 23-year-old female diabetic patient who developed invasive tracheal mucormycosis following a tracheostomy. The mucormycosis infection was brought under control after antifungal therapy and surgical debridement; however, due to multiple contributing factors, the patient subsequently developed myiasis. This case highlights the importance of early diagnosis, aggressive treatment, and proper tracheostomy management in preventing severe complications.

Surgical outcomes of minimally invasive thoracoscopic surgery for pulmonary mycosis complicated with hematopoietic malignancy

OBJECTIVE

Patients with hematopoietic malignancies (HM) are often immunocompromised and, therefore, susceptible to developing invasive fungal infections, including pulmonary mycosis. Surgical resection is indicated for localized pulmonary mycosis refractory to antifungal agents. This study investigated the feasibility and outcomes of minimally invasive surgery for pulmonary mycosis patients complicated with HM.

METHODS

We retrospectively reviewed 56 cases of surgically treated pulmonary mycosis among the 3994 lung resections performed in our department between 2011 and 2020, focusing on the 19 cases under treatment for HM.

RESULTS

All patients underwent 3-port video-assisted thoracoscopic surgery, including one patient converted to open surgery. The 30 day mortality rate was zero. The overall survival rate 1 year after surgery was 63.2%. No relapse of mycosis was observed, and the majority of the cause of death was the progression of HM. The rate of major postoperative complications was comparable between the patients with HM (3/19) and without HM (5/37), despite the patients with HM having a higher frequency of immunocompromised status than those without HM. Most patients who underwent surgery before hematopoietic stem cell transplantation (HSCT) had leukocytopenia, while all patients who underwent surgery after HSCT received immunosuppressants. Mucormycosis was observed in 13 out of 19 patients (68%) with HM, and it was significantly associated with preoperative pancytopenia and usage of immunosuppressants.

CONCLUSION

Minimally invasive surgery was feasible for pulmonary mycosis complicated with HM despite the high frequency of immunosuppression. These findings will deepen our understanding of pulmonary mycosis associated with HM and may improve perioperative patient care.

Disseminated Cunninghamella bertholletiae Infection From Latent Lower Limb Mass After Kidney Transplant: A Case Report

BACKGROUND

Cunninghamella bertholletiae (C. bertholletiae), a rare yet highly virulent species within the Mucorales order, predominantly affects individuals with compromised immune systems. Disseminated infections caused by this pathogen frequently lead to severe complications, underscoring the necessity for prompt diagnosis and aggressive therapeutic interventions. Invasive fungal diseases (IFDs) continue to be a major cause of morbidity and mortality among kidney transplant recipients, characterized by elevated incidence and mortality rates. The early and precise identification of fungal pathogens is crucial for optimizing patient outcomes.

CASE PRESENTATION

This report presents a case study of a 37-year-old male kidney transplant recipient who developed a disseminated C. bertholletiae infection from a latent lower limb lesion. Initially, he showed symptoms of high fever and dyspnea, leading to diagnoses of sepsis, severe pneumonia, acute respiratory distress syndrome, and allograft dysfunction. After surgery, he had recurrent pleural effusion and worsening pulmonary nodules. Metagenomic next-generation sequencing (mNGS) confirmed C. bertholletiae infection, and histopathology revealed mucormycosis with vascular invasion, thrombosis, and tissue necrosis. The patient underwent a 13-month antifungal treatment with amphotericin B lipid complex, posaconazole, and isavuconazole.

CONCLUSION

This case highlights the essential role of histopathology and mNGS in early detection of rare IFDs and stresses the need for a multidisciplinary approach combining surgery with antifungal therapy. The effective management of disseminated C. bertholletiae infection using a triple antifungal regimen offers important insights for future cases, underscoring the importance of early diagnosis and personalized treatment in immunocompromised patients.

Diagnosis, clinical features, and mortality risk factors in a Chinese cohort with pulmonary mucormycosis

BACKGROUND

Pulmonary mucormycosis is a rare and often fatal fungal infection. Identifying high-risk factors for pulmonary mucormycosis holds the potential to improve patient outcomes. This study aimed to identify the clinical characteristics and risk factors associated with pulmonary mucormycosis outcomes in a Chinese cohort.

MATERIALS AND METHODS

A retrospective analysis was conducted on 37 patients diagnosed with pulmonary mucormycosis, focusing on clinical records, laboratory findings, and computed tomography (CT) imaging. Diagnosis was primarily based on histopathology or next-generation sequencing.

RESULTS

The median age of the patients was 55 years, and the most common underlying conditions were hematological malignancies, diabetes, and organ transplantation. Imaging frequently revealed bilateral lung involvement with ground-glass opacities and nodular lesions. The overall mortality rate was 29.7%, with significant risk factors for 90-day mortality including hypertension (Hazard Ratio [HR] = 3.36, 95% Confidence Interval [CI] = 1.01-11.12, P = 0.048), organ transplantation (HR = 4.93, 95% CI = 1.48-16.4, P = 0.009), and immunosuppression (HR = 8.83, 95% CI = 1.13-69.14, P = 0.038).

CONCLUSIONS

Early suspicion and timely diagnostic measures, such as biopsy or metagenomic sequencing, are crucial for improving patient outcomes. These findings underscore the importance of recognizing and managing pulmonary mucormycosis in high-risk populations.

Case Report: Co-infection of mucormycosis with mycoplasma pneumoniae in children with diabetes mellitus: report of two rare cases

Background

Mucormycosis is a rare disease characterized by its highly vascular invasiveness, rapid progression, and high mortality rate. Historically, reports on mucormycosis have been concentrated in the adult population, with few cases documented in pediatrics. Notably, there have been no reports of mucormycosis in either adults or children during the prevalence of mycoplasma pneumoniae.

Case presentation

This paper presents two cases of newly diagnosed diabetic children who developed concurrent mucormycosis during mycoplasma pneumoniae infection. Both patients received aggressive antifungal therapy, with one surviving and the other succumbing to the disease.

Conclusions

The paper discusses the diagnostic and therapeutic challenges of mucormycosis in patients with diabetes and concurrent mycoplasma pneumoniae, emphasizing the need for more proactive identification of infecting pathogens in the diabetic population during mycoplasma pneumoniae outbreaks. When routine anti-mycoplasma treatments are ineffective and chest enhanced CT scans reveal pulmonary vascular destruction, the possibility of mucormycosis should be considered. Particularly in patients with a history of corticosteroid use, clinical suspicion should be heightened. Concurrent mucormycosis infection may worsen patient outcomes, and further clinical exploration of the pathogenesis and treatment recommendations for mucormycosis associated with mycoplasma pneumoniae is warranted.

Mucormycosis Caused by Apophysomyces elegans-A Case Report and Systematic Review of the Literature of Rhino-Orbito-Cerebral Cases of the Genus Apophysomyces

INTRODUCTION

Orbitocerebral mucormycosis, caused by Apophysomyces, is a rare infection, usually occurring in tropical and subtropical climates, with a high mortality rate. We report a case of orbitocerebral mucormycosis caused by A. elegans in a person living with HIV (PLWHIV) from Africa alongside a systematic literature review updating current diagnostic and treatment strategies for orbitocerebral mucormycosis caused by Apophysomyces.

METHODS

The presented case was treated in our hospital for polytrauma following a motor vehicle accident (MVA) with aggressive surgical debridement and therapy with liposomal Amphotericin B (AMB). We evaluated clinical presentation, imaging, surgery, and postoperative outcomes. A systematic review of English or German language articles (published between 1985 and 2025) was performed according to PRISMA guidelines. Articles describing patients with mucormycosis due to Apophysomyces were summarized. Quantitative values for relevant parameters that indicated a reduction in mortality and morbidity were obtained.

RESULTS

The systematic search initially identified 452 publications, from which 79 studies were retrieved. Seventeen publications comprising 21 cases were included, along with one additional case from our institution, for a total of 22 rhino-orbito-cerebral infections caused by the genus Apophysomyces. Apophysomyces elegans (A. elegans) was the most frequently isolated species (n = 17), followed by A. variabilis (n = 4) and A. ossiformis (n = 1); A. trapeziformis was not reported. The majority of patients were male (72.7%), with a mean age of 40.7 ± 15.9 years. Trauma (27.3%) and diabetes mellitus (18.2%) were the most common underlying risk factors, with SARS-CoV-2 infection identified in 13.6% of cases.

CONCLUSION

Mucormycosis due to Apophysomyces is a rare but potentially devastating condition. Based on our experience and the literature, we suggest that the early diagnosis of Apophysomyces treated with liposomal AMB and aggressive surgical debridement is essential to reduce morbidity and mortality.

Management of a pediatric patient with rapidly progressive glomerulonephritis and cutaneous mucormycosis: a case report

Mucormycosis is a highly invasive and rare opportunistic infection caused by mucor fungi, characterized by challenging diagnosis and rapid disease progression. It predominantly affects patients with compromised immune systems due to various reasons, such as kidney failure, long-term use of antibiotics or corticosteroids. We recently successfully treated a pediatric patient with rapidly progressive glomerulonephritis accompanied by severe cutaneous mucormycosis. To our knowledge, this is the first reported case of rapidly progressive glomerulonephritis nephritis accompanied by dermatophytosis in a pediatric patient. In this case, we share our management experience, including special nursing experience. Cutaneous mucormycosis progresses quickly and is difficult to diagnose and treat, especially in children with compromised immune function, warranting high vigilance from clinicians and nursing staff. Early diagnosis and targeted treatment are crucial for improving the prognosis of patients. Therefore, once there is a suspicion of a mucormycosis infection, we recommend the early application of various testing methods such as fungal culture, skin biopsy and genetic testing in order to to promptly confirm the diagnosis.

Diagnostic Challenges in Fungal Coinfections Associated With Global COVID-19

The early diagnosis of opportunistic infections is a critical concern for patient care worldwide, particularly in the context of the COVID-19 pandemic. This review examines the challenges and advancements in the management and early diagnosis of opportunistic fungal infections, which have become increasingly prominent during the pandemic. Using multiple sources, including curated databases such as PubMed and Scopus, as well as Google Scholar for broader literature searches, we systematically reviewed studies on COVID-19-associated fungal infections, with a focus on candidiasis, mucormycosis, and aspergillosis. The inclusion criteria encompassed peer-reviewed articles, clinical case reports, and cohort studies that discussed diagnostic methods, clinical outcomes, and treatment responses. Data were systematically extracted and analyzed to identify key trends and gaps in current diagnostic practices. Given the significance of opportunistic fungal infections-particularly the selected species-this review provides a comprehensive analysis of diagnostic challenges and advancements in the context of COVID-19 and beyond. Currently, there is no definitive strategy for effectively addressing these opportunistic pathogens, highlighting the need for continued research and innovation. Despite advancements in medical technology, opportunistic fungal infections continue to pose significant challenges to early and accurate diagnosis. The COVID-19 pandemic has exacerbated these challenges, with secondary fungal infections contributing to increased morbidity and mortality rates. This review highlights the complexities of diagnosing fungal coinfections and emphasizes the urgent need for improved diagnostic strategies. Enhancing the early and accurate detection of these infections is critical for effective patient management, particularly during viral pandemics. Addressing the challenges outlined in this review requires innovative diagnostic approaches to improve patient outcomes and reduce the burden of opportunistic infections on global healthcare systems.

Predictive nomogram for early detection of invasive fungal disease deterioration --- a 10-year retrospective cohort study

BACKGROUND

Invasive fungal disease (IFD) is characterized by its capacity to rapidly escalate to life-threatening conditions, even when patients are hospitalized. However, the precise prognostic significance of baseline clinical characteristics related to the progression outcome of IFD remains elusive.

METHODS

A retrospective cohort study spanning a duration of 10 years was conducted at two prominent tertiary teaching hospitals in Southern China. Patients with proven IFD were queried and divided into serious and non-serious groups based on the disease deterioration. To establish robust predictive models, patients from the first hospital were randomly assigned to either a training set or an internal validation set, while patients from the second hospital constituted an external test set. To analyze the potential predictors of IFD deterioration and identify independent predictors, the study employed the least absolute shrinkage and selection operator (LASSO) method in conjunction with binary logistic regressions. Based on the outcomes of this analysis, a predictive nomogram was constructed. The performance of the developed model was thoroughly evaluated using the training set, internal validation set, and external test set.

RESULTS

A total of 480 cases from the first hospital and 256 cases from the second hospital were included in the study. Among the 480 patients, 81 cases (16.9%) experienced deterioration, and out of those, 45 (55.6%) cases resulted in mortality. Seven independent predictors were identified and utilized to construct a predictive nomogram. The nomogram exhibited excellent predictive performance in all three sets: the training set, internal validation set, and external test set. The area under the receiver operating characteristic curve (AUC) for the training set was 0.88, for the internal validation set was 0.91, and for the external test set was 0.90. The Hosmer-Lemeshow test and Brier score indicated a high goodness of fit for the model. Furthermore, the calibration curve demonstrated a strong agreement between the predicted outcomes from the nomogram and the actual observations. Additionally, the decision curve analysis exhibited that the nomogram provided significant clinical net benefits in predicting IFD deterioration.

CONCLUSIONS

The study successfully identified seven independent predictors and developed a predictive nomogram for early assessment of the likelihood of IFD deterioration.

A Predictive Model for Diagnosis of Acute Invasive Fungal Rhinosinusitis Among High-Risk Patients

BackgroundAcute invasive fungal rhinosinusitis (AIFR) is a life-threatening disease mainly affecting immunocompromised patients. Early detection is therefore key to improving patient survival. To date, there are still no standard clinical criteria for AIFR diagnosis.ObjectiveThis study develops a predictive model that utilizes clinical presentation and computed tomography (CT) findings to diagnose AIFR.MethodsA retrospective cohort study was conducted on patients with high risk for AIFR at King Chulalongkorn Memorial Hospital over the past 15 years (2008-2022). We constructed several multivariate logistic regression models for AIFR diagnosis based on different subsets of variables from 3 categories: signs/symptoms, endoscopy, and CT imaging.ResultsThere were 67 AIFR-positive patients and 68 AIFR-negative patients. Combining variables from 3 categories, a 6-variable model (fever, visual loss, mucosal discoloration, crusting, mucosal loss of contrast, retroantral fat stranding) achieved the highest area under the receiver operating characteristic curve of 0.8900 (74.63% sensitivity, 89.71% specificity).ConclusionsWe proposed predictive models for AIFR diagnosis in high-risk patients using clinical variables. The models can be used to guide the decision for further management such as biopsy or surgical intervention.

Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM

Candida species are the predominant cause of fungal infections in patients treated in hospital, contributing substantially to morbidity and mortality. Candidaemia and other forms of invasive candidiasis primarily affect patients who are immunocompromised or critically ill. In contrast, mucocutaneous forms of candidiasis, such as oral thrush and vulvovaginal candidiasis, can occur in otherwise healthy individuals. Although mucocutaneous candidiasis is generally not life-threatening, it can cause considerable discomfort, recurrent infections, and complications, particularly in patients with underlying conditions such as diabetes or in those taking immunosuppressive therapies. The rise of difficult-to-treat Candida infections is driven by new host factors and antifungal resistance. Pathogens, such as Candida auris (Candidozyma auris) and fluconazole-resistant Candida parapsilosis, pose serious global health risks. Recent taxonomic revisions have reclassified several Candida spp, potentially causing confusion in clinical practice. Current management guidelines are limited in scope, with poor coverage of emerging pathogens and new treatment options. In this Review, we provide updated recommendations for managing Candida infections, with detailed evidence summaries available in the appendix.

Mixed fungal infection of Actinomucor elegans and Aspergillus fumigatus in a person with severe fever with thrombocytopenia syndrome

In this report, a 69-year-old man with fever, thrombocytopenia, and hepatic and renal dysfunction presented to our hospital. His disease progression was rapid, and he became unconscious. The patient was diagnosed with severe fever with thrombocytopenia syndrome (SFTS). However, his inflammation markers continued to rise until a mixed fungal infection was detected. Metagenomic next-generation sequencing of blood detected elevated sequence numbers for Actinomucor elegans and Aspergillus fumigatus. The culture of the bronchoalveolar lavage fluid were positive for Aspergillus fumigatus and Escherichia coli. Infection was controlled after adjusting the antifungal regimens against Actinomucor elegans. The patient's condition gradually improved. This patient was diagnosed with possible mucormycosis. Reports of Mucorales infection associated with SFTS are rare. We hope that this case report will draw the attention of physicians in the area where SFTS occurs to figure out if patients with SFTS are susceptible to mucormycosis.

Development and evaluation of a Pan-Mucorales Real-time PCR and a multiplex Real-time PCR for detection and identification of Rhizopus arrhizus, Rhizopus microsporus, and Mucor spp. in clinical specimens

Mucormycosis is a life-threatening infection associated with high morbidity and mortality. Rapid and accurate diagnosis is essential for improving patient outcomes. Conventional diagnostic methods, such as histopathology and culture, are limited by low sensitivity and prolonged turnaround times, while commercial polymerase chain reaction (PCR) assays are costly and may lack specific genus or species targets. Here, we present a novel molecular diagnostic workflow to facilitate the rapid detection of Mucorales directly from clinical specimens. This workflow integrates two in-house in vitro diagnostic PCR assays: a real-time, qualitative Pan-Mucorales PCR, followed by a real-time multiplex genus/species-specific PCR targeting Rhizopus arrhizus, Rhizopus microsporus, and Mucor spp. Specificity of the assays was validated using cultured isolates of Mucorales, as well as non-Mucorales fungi and bacteria. The diagnostic performance was assessed across 166 clinical specimens (70 Mucorales-positive and 96 negative), confirmed by an in-house panfungal PCR and DNA sequencing protocol. Specimens studied included fresh and formalin-fixed paraffin-embedded tissues, fluid, bronchoalveolar lavage/washing fluid, fine needle aspirate, cerebrospinal fluid, and bone. The Pan-Mucorales PCR demonstrated 98.6% sensitivity and 100% specificity, while the multiplex genus/species-specific PCR assay yielded sensitivities of 93.8% for R. arrhizus, 70.8% for R. microsporus, and 75% for Mucor spp., each with 100% specificity. Concordance with the panfungal PCR (>99% for Pan-Mucorales PCR and >89% for multiplex PCR) was high, supporting the robustness of the workflow. This diagnostic approach has the potential to significantly reduce turnaround times, labor and costs, while streamlining the diagnostic process through timely, precise diagnostics.

IMPORTANCE

Mucorales fungi, identified collectively as a high-priority pathogen on the World Health Organization fungal priority pathogens list, are the causative agents of mucormycosis. Mortality is high (up to 80%), and early, accurate diagnosis is critical to enable timely initiation of targeted antifungal therapy and surgical debridement for source control to optimize patient outcomes. In our laboratory, as in many others, the current standard for the diagnosis of mucormycosis is histopathology and culture-based methods supplemented by panfungal PCR assay/DNA sequencing; however, this process may take 7 days, with considerable labor and cost implications. Here, we present two Mucorales-specific real-time PCR assays, which when used sequentially, reduce diagnostic turnaround time and costs to detect three common agents of mucormycosis-Rhizopus microsporus, Rhizopus arrhizus, and Mucor species. This approach not only improves diagnostic efficiency and integration into workflow but can facilitate surveillance through accurate genus- and species-level identification.

Is Pulmonary Mycoses Shadowed by Tuberculosis? Mandate to Hit the Bull's Eye-An Indian Perspective

Tuberculosis (TB) poses serious challenges to healthcare personnel as it continues to be highly prevalent in a developing country like India. Several prominent strategies have been adopted to control this contagious infection, but the incidence rate remains high. Many studies have linked fungal infections to TB, apparently elevating concerns in the TB elimination program. Hence, it is essential to understand the mechanisms underlying TB co-infection and pulmonary mycoses to combat the problems caused by these diseases successfully. In addition, differential diagnosis of TB and fungal infections is equally essential to initiate appropriate treatment. This review attempts to describe misdiagnosis of TB and fungal disease and their relative coexistence in the context of the Indian perspective.

Role of liposomal amphotericin B in intensive care unit: an expert opinion paper

INTRODUCTION

Invasive fungal infections (IFI) are frequent in patients admitted to the intensive care unit (ICU). The use of first-line antifungals like triazoles or echinocandins may be limited by the global spread of multi-drug resistance species, drug-drug interactions, low organ penetration, and some safety concerns in case of multi-organ failure. Liposomal amphotericin B (L-AmB) is a polyene drug with a broad activity against mold and yeast and an acceptable safety profile. To outline the role of L-AmB in the treatment of IFI in critically ill patients, a panel of experts was invited to draw up an expert opinion paper on the appropriate place in therapy of L-AmB in different clinical scenarios of patients admitted to ICU.

METHODS

A multidisciplinary group of 16 specialists in infectious disease, microbiology, pharmacology, and intensive care elaborated an expert opinion document through a multi-step approach: (1) the scientific panel defined the items and wrote the statements on the management of IFI in ICU, (2) a survey was submitted to an external panel to express agreement or disagreement on the statements, and (3) the panel reviewed the survey and implemented the final document.

RESULTS

The final document included 35 statements that focused on epidemiology and microbiological rationale of the use of systemic L-AmB in critically ill patients and its potential role in specific clinical scenarios in the ICU.

CONCLUSION

Systemic L-AmB may represent an appropriate therapeutic choice for IFI in ICU patients with different underlying conditions, especially when the use of first-line agents is undermined. This expert opinion paper may provide a useful guide for clinicians.

Clinical Features of Invasive Fungal Disease in China Tertiary Hospital: A Prospective, Multicenter Study

Invasive fungal disease (IFD) has high morbidity and mortality, the spectrum of pathogenic fungi and high-risk groups have also changed. Fewer literature focus on the overall incidence of IFD in various departments of general hospitals. Among the adult inpatients in four Chinese tertiary hospitals located in Beijing, Shanghai, Nanning and Nanchang, proven or probable cases of IFD were included prospectively in this study between May 1, 2021 and May 1, 2022. The clinical data were collected and analyzed. A total of 330 patients (342 episodes) with 278 of proven and 64 of probable IFDs were included, including invasive candidiasis (IC) (132, 40.0%), cryptococcosis (64, 19.4%), invasive aspergillosis (IA) (54, 16.4%), Talaromyces marneffei (TsM) infection (43, 13.0%), Pneumocystis pneumonia (PCP) (16, 4.8%), mixed fungal infection (10, 3.0%), other mold or yeast infection. 37.9% occurred in elderly patients (age ≥ 65 years). Nosocomial infection accounted for 44.5%, the proportion of nosocomial infection was highest in patients with IC (81.8%). Diabetes (19.7%) was the most common underlying disease. 83.9% of the 342 episodes of IFD had evidence of fungal culture, while the proportion of microscopic examination and histopathology as mycological evidence was 26.9% and 3.5%, respectively. The cumulative all-cause mortality at 180 days after diagnosis of IFD was 38.5%. Age ≥ 65 years old (HR = 1.670, P = 0.009), ICU (HR = 2.002, P = 0.001), nosocomial infection (HR = 1.630, P = 0.016) and diabetes (HR = 1.679, P = 0.013) were associated with increased death in IFD patients. The prognosis of IFD patients was poor. Doctors should pay attention to nosocomial fungal infection especially in old and diabetes.

Development and evaluation of real-time recombinase polymerase amplification assay for fast identification of Rhizopus arrhizus

PURPOSE

Timely diagnosis of mucormycosis is challenging as the disease is rare and confusing to laboratory physicians without experience or expertise. Molecular tools like real-time PCR have been developed to diagnose mucormycosis and can circumvent these issues. However, their use requires an expensive thermocycler. Hence, there is a need for an alternative rapid, sensitive, and specific low-cost molecular test. Here, we developed and evaluated a real-time recombinase polymerase amplification (RPA) based test for detection of R. arrhizus, the principal cause of mucormycosis in patient samples with and without COVID-19 associated mucormycosis.

METHODS

Primers and probes targeting Rhizopus arrhizus for RPA-based assay were designed using PrimedRPA and screened per the manufacturer's guidelines. DNA from 40 clinically relevant bacteria and molds were used to determine the analytical specificity of the assay, and probit regression analysis using plasmid DNA standards were used to determine the analytical sensitivity of the assay. The developed assay was evaluated on 110 tissue samples from patients with suspected mucormycosis.

RESULTS

The developed assay was able to detect 9 mucorales viz. R. arrhizus, R. microsporus, R. stolonifer, R. homothallicus, S. racemosum, M. indicus, M. circinelloides, A. variabilis and Cunninghamella spp. and did not cross-react with the remaining 31 molds or bacteria. Its limit of detection at 95 % probability was 18.58 copies. The test demonstrated a sensitivity of 96 % (95 % CI: 86.3 %-99.5 %) and specificity of 95 % (95 % CI: 86.1 %-98.9 %).

CONCLUSION

The developed RPA assay for R. arrhizus demonstrates high diagnostic sensitivity(96 %), specificity(95 %), and low detection limit(18.58 copies). While initial testing using stored unfixed tissue showed promise, comprehensive clinical validation studies are needed to establish the assay's diagnostic utility across diverse clinical settings and specimen types.

Case Report: Pulmonary mucormycosis caused by Rhizopus microsporus in a patient with chronic obstructive pulmonary disease

Background

We report a rare case of pulmonary mucormycosis caused by Rhizopus microsporus, which is rare in patients with chronic obstructive pulmonary disease. Rhizopus microsporus had been reported as the most common etiological agent associated with human infections, except Rhizopus oryzae in some studies.

Case presentation

We described a case of 81-year-old man with pulmonary mucormycosis caused by Rhizopus microsporus but no other apparent risk factors including diabetes. The diagnosis mainly relied on sputum cultures and clinical manifestations. Despite antifungal therapy, his condition worsened, resulting in mortality.

Conclusion

In this case, the patient had no underlying diseases such as diabetes or solid tumors. Clinicians should be aware of routine pathogenic microbiological tests of pulmonary mucormycosis in patients with chronic obstructive pulmonary disease. Early and aggressive treatment can lead to improved prognosis.

Gastrointestinal and Intra-Abdominal Mucormycosis in Non-Haematological Patients-A Comprehensive Review

Intra-abdominal and gastrointestinal mucormycosis are less frequent than rhino-orbito-cerebral and pulmonary mucormycosis, but highly lethal. Their diagnosis remains challenging due to the non-specific clinical presentation. We collected English-language cases of intra-abdominal and gastrointestinal mucormycosis in non-haematological and non-neonatal patients published up to October 2024. This review analysed the epidemiological, clinical, and therapeutic charts of 290 cases. A proportion of 53.4% were reported from India and the USA. The main predisposing conditions were diabetes, solid organ transplant, ICU, and corticosteroid treatment. The most common site was the stomach (53.8%). Gastrointestinal perforation, skin breakdown, and abdominal wall infection were sources of intra-abdominal localisation. The most common symptoms were abdominal pain, vomiting, and gastrointestinal bleeding. The diagnosis relied on histology (93.8%), mycology with microscopy and culture (38.8%), and molecular methods (9.9%). Mortality (52.9%) was lower when treatment was intravenous amphotericin B, combined or not with surgery. Prompt treatment, essential for a favourable outcome, relies on early suspicion and diagnosis. Gastrointestinal and intra-abdominal mucormycosis should also be suspected in patients admitted in ICU with ventilation/nasogastric tube and corticosteroids and those with abdominal trauma or surgery, presenting abdominal distension, pain, and GI bleeding. Mycological diagnosis including direct examination, culture and Mucorales qPCR on tissue should assist with rapid diagnosis and thus treatment.

The first report of pseudoaneurysm secondary to Cunninghamella bertholletiae infection in a Haematopoietic stem cell transplantation recipient: a case report and literature review

BACKGROUND

Mucormycosis is a life-threatening complication that occurs in haematopoietic stem cell transplantation (HSCT) recipients. Among mucormycosis patients, those infected with Cunninghamella bertholletiae have the poorest prognosis because of the high virulence and angioinvasive nature of this organism. Despite its high vascular invasiveness, pseudoaneurysm caused by C. bertholletiae in HSCT recipients has rarely been reported.

CASE PRESENTATION

An 8-year-old HSCT recipient experienced recurrent fever, cough and pain after HSCT. Teicoplanin, acyclovir, posaconazole and caspofungin were used for infection prophylaxis. The sputum, stool, urine, peripheral blood and central venous catheter (CVC) blood culture results were negative. Next-generation sequencing (NGS) of the peripheral blood, pleural effusion and bronchoalveolar lavage fluid revealed the presence of C. bertholletiae, and amphotericin B combined with posaconazole was administered; however, the infection progressed. Fibreoptic bronchoscopies revealed that C. bertholletiae had invaded the bronchial wall, and enhanced computerized tomography (CT) revealed a pseudoaneurysm of the descending aorta resulting from C. bertholletiae. Debridement and vessel replacement were considered but not performed because of the severity of the infection and the patient's poor physical condition. Unfortunately, the patient died from pseudoaneurysm rupture with no presymptoms 56 d after HSCT.

CONCLUSION

For the first time, we report pseudoaneurysm secondary to C. bertholletiae infection in a HSCT recipient, highlighting the importance of clinical awareness of vessel lesions resulting from C. bertholletiae and emphasizing the value of enhanced CT for the early detection of vessel lesions in this rare infection.

Siglec-targeted liposomes to identify sialoglycans present on fungal pathogens

The sialic acid Ig-like lectins Siglec-3 and Siglec-15 are pathogen receptors that bind sialic acid-modified glycoproteins, best characterized in metastatic cancers. Because fungi produce sialoglycans and sialo-glycoproteins, we wondered if Siglecs had the potential for targeted delivery of antifungal drugs. We purified the extracellular V-region Ig-like C2 ligand-binding domains and stalk regions of SIG3 and SIG15. We floated the two polypeptides on the surface of liposomes loaded with amphotericin B (AmB) and labeled with rhodamine B to prepare SIG3-Ls and SIG15-Ls. Using these two reagents, we explored the sialoglycans of two evolutionarily distant and deadly human fungal pathogens, the Mucormycete Rhizopus delemar and the Ascomycete Aspergillus fumigatus. We found that SIG3-Ls and SIG15-Ls localized in a continuous layer over the cell wall surface of germ tubes and hyphae of both fungal species and to the conidia of A. fumigatus. Binding was Neu5Ac-specific and appeared confined to N-linked sialoglycans on fungal proteins. SIG3 and SIG15 proteins bound to diverse sialo-glycoproteins extracted from the hyphae of both species. SIG3-Ls and SIG15-Ls delivering sub-micromolar concentrations of AmB were moderately more effective at inhibiting and/or killing both species relative to control liposomes. We discuss the roles that sialo-glycoproteins may play in fungal pathogens.

First reported case of disseminated Cunninghamella phaeospora infection with multidrug resistance in acute myeloid leukemia

Mucormycosis is a severe mold infection primarily affecting immunocompromised patients. Neutropenia, steroid use, hyperglycemia, and diabetes are recognized as significant risk factors. Cunninghamella species are rare pathogenic fungi associated with high mortality rates and multidrug resistance. However, there have been no reports of C. phaeospora being identified as the causative agent of clinical infection. We report a case of a 71-year-old man who developed right middle lobe pneumonia during salvage induction therapy for relapsed acute myeloid leukemia. Based on the clinical course, mucormycosis was suspected, and antifungal therapy was initiated with isavuconazole (200 mg every 8 hours for six doses, followed by 200 mg daily) and later switched to liposomal amphotericin B (5 mg/kg/day). Despite these interventions, the patient's respiratory failure progressed, culminating in a fatal hemorrhagic infarction of the right lung. An autopsy revealed invasive fungal involvement in multiple organs, including the lungs and liver. Genetic identification of the isolated fungi demonstrated C. phaeospora, confirming disseminated C. phaeospora infection. Susceptibility testing showed high Minimum Inhibition Concentrations/Minimum Effective Concentrations to all tested antifungal agents. This is the first reported case of disseminated infection caused by C. phaeospora with multidrug resistance. This case highlights the diagnostic and therapeutic challenges associated with rare pathogenic fungi. It underscores the importance of early identification of Mucorales, including susceptibility testing, to optimize antifungal therapy and consider appropriate surgical interventions. Further research is required to elucidate the mechanisms of antifungal resistance and clinical characteristics of C. phaeospora.

Sensitivity and Specificity of Plasma and Bronchoalveolar Lavage Fluid PCR for Diagnosing Pulmonary Mucormycosis in Subjects With Diabetes Mellitus

BACKGROUND

Mucorales polymerase chain reaction (PCR) is used to diagnose pulmonary mucormycosis (PM) among neutropenic individuals. However, data on the utility of PCR in patients with diabetes mellitus, another major risk factor for PM, are limited.

OBJECTIVE

The primary objective was to assess the diagnostic performance of a commercial real-time PCR assay (MucorGenius) in plasma and bronchoalveolar lavage fluid (BALF) for diagnosing PM (proven and probable cases only) in patients with suspected invasive mould disease (IMD). For the secondary objective, we evaluated the performance of the MucorGenius assay in all PM (proven, probable, and possible) cases.

METHODS

We prospectively enrolled patients with suspected IMD and assessed the performance of MucorGenius PCR (index test) in plasma and BALF samples. A multidisciplinary team assigned the final diagnosis of IMD (reference standard) based on microscopy, histopathology, cytology, and culture. We report the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI).

RESULTS

We enrolled 103 patients, of whom 43 (41.7%) were confirmed to have PM. Plasma PCR showed a sensitivity of 18.6% (95% CI: 8.4-33.4), specificity of 90.7% (95% CI:77.9-97.4), PPV of 66.7%, and NPV of 52.7%. Including possible PM/IMD cases improved the plasma PCR sensitivity to 30.0% (95% CI: 18.9-43.2) and retained specificity at 90.7%. BALF PCR had better sensitivity (47.4%) but poorer specificity (69.6%), with a PPV of 56.3% and NPV of 61.5%.

CONCLUSION

Plasma and BALF MucorGenius PCR have poor diagnostic performance for diagnosing PM among individuals with diabetes mellitus. Further multicenter studies are needed to validate these findings.

Management of Rhinomaxillary Mucormycosis: A Case Report

This case report describes a rare occurrence of palatal mucormycosis in a 45-year-old immunocompetent female patient who developed black discoloration of the palate following a tooth extraction. Initial diagnostic investigations and superficial biopsy revealed aspergillosis; however, further postoperative histopathological examination confirmed mucormycosis. Aggressive surgical intervention, including maxillectomy, alveolectomy, and functional endoscopic sinus surgery, combined with targeted antifungal therapy, facilitated successful treatment. The importance of timely diagnosis and comprehensive management in mucormycosis cases, even among immunocompetent patients, is highlighted.

Elevating fungal care: bridging Brazil's healthcare practices to global standards

Brazil faces unique challenges in managing invasive fungal infections (IFIs) due to diverse ecosystems, a rural workforce, and prevalent health conditions. In Europe, IFIs are primarily associated with transplantation, intensive care, and chronic diseases. Inspired by initiatives in the Caribbean and Latin America in 2019, efforts to map global diagnostic and treatment resources expanded to Africa, Europe, and Asia/Pacific. This study conducts a comparative analysis, mainly drawing data from Brazil and Europe, to investigate IFI epidemiology and management. Data were collected through online surveys distributed to Brazilian and European institutions, with collaborations from scientific organizations. Surveys covered institutional profiles, IFI diagnoses, accessibility to diagnostic techniques, and antifungal drugs. A comparative survey involving 96 Brazilian and 388 European institutions revealed variations in the perception and practices related to fungal pathogens. Differences in ranking and prevalence were observed, along with variations in diagnostic procedures, fluorescence dye usage, culture practices, antifungal medication availability, and technological approaches. Europe exhibited higher utilization rates for molecular diagnostic approaches, including PCR tests, and therapeutic drug monitoring (TDM) was more widespread in Europe compared with Brazil, indicating substantial differences in understanding and managing fungal infections. Customized IFI management is crucial, considering regional differences and addressing technological gaps like underutilized PCR. The study advocates for increased international collaboration, targeted training, and enhanced resources to foster a unified global approach in preventing, diagnosing, and treating IFI.

IMPORTANCE

This work is significant as it highlights the unique challenges Brazil faces in managing invasive fungal infections (IFIs) due to its diverse ecosystems and public health landscape. By comparing Brazil's situation with Europe-where IFIs are mainly linked to transplantation and intensive care-this study identifies key disparities in diagnostic and treatment practices. The findings reveal substantial differences in the availability and use of molecular diagnostics, antifungal drugs, and therapeutic drug monitoring, with Europe demonstrating more advanced practices. By mapping these variations, the study underscores the importance of tailored approaches to IFI management that consider regional differences and technological gaps. Ultimately, it calls for enhanced international collaboration, targeted training, and resource allocation to improve IFI outcomes globally, particularly in regions with limited access to advanced diagnostic tools and treatments.

American Society of Transplantation and Cellular Therapy Series: #8-Management and Prevention of Non-Aspergillus Molds in Hematopoietic Cell Transplantation Recipients

The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to create a guideline focusing on non-Aspergillus invasive molds, which are uncommon yet lethal invasive fungal diseases in the peri-hematopoietic cell transplant (HCT) period. We used a compendium-style approach by dissecting this broad, heterogeneous, and highly complex topic into a series of standalone frequently asked questions (FAQs) and tables. Adult and pediatric infectious diseases and HCT content experts developed, then answered FAQs, and finalized topics with harmonized recommendations. All the evidence for non-Aspergillus invasive mold infection is non-RCT and mostly level III, therefore there are no recommendation grades, and instead key references are provided. Through this format, this "8th" topic in the series focuses on the relevant risk factors, diagnostic considerations, prophylaxis, and treatment approaches relevant to rare mold infections in the pre- and post-transplant periods.

Periorbital primary cutaneous mucormycosis: a case report and literature review

Mucormycosis is a rare subcutaneous fungal disease caused by mucormycoides, which can affect the skin, nose, brain, lung, gastrointestinal tract and other system. Cutaneous mucormycosis accounts for 10-19% of mucormycosis and is one of the most common types only second to the lung and naso-brain mucormycosis. Here we report a case of periorbital primary cutaneous mucormycosis in a latent immunocompromised male with a suspected history of herpes zoster on the right head and face. He was successfully treated with local injection and oral antifungal drugs combined with debridement, and without recurrence after more than one-year follow-up.

Bronchial stenosis requires vigilance against tracheal mucormycosis: a case report

This report highlights the importance of differentiating the etiology of dyspnea and tracheal stenosis. While acknowledging that tracheal stenosis can significantly cause respiratory distress, we emphasize the need to consider tracheal mucormycosis in the differential diagnosis, particularly in patients with risk factors such as uncontrolled diabetes and trauma. Early recognition and timely antifungal therapy remain crucial in managing this potentially fatal infection. Prioritizing early identification and treatment of mucormycosis before it progresses to the lungs can significantly improve patient outcomes and impact clinical practice.

Impact of current clinical guidelines on the management of invasive fungal disease

Isavuconazole is a new broad-spectrum antifungal triazole with a better safety profile in terms of drug-drug interactions, adverse effects, and tolerance compared to other azoles. Increasing evidence supports the usefulness of isavuconazole in the treatment of invasive fungal diseases. In this review, we aim to analyze the influence of this new evidence on the main clinical guidelines. We reviewed the most recent consensus guidelines issued by the major infectious diseases societies worldwide, focusing on the novelties regarding the recommendations for the use of isavuconazole in different invasive fungal infections and management strategies. Isavuconazole has been included as first-line therapy for invasive aspergillosis, with slight differences in preference for voriconazole or isavuconazole depending on the clinical scenario. In mucormycosis, isavuconazole is considered an alternative first-line therapy to liposomal amphotericin B, especially in those patients with underlying renal impairment. Additionally, the use of isavuconazole is suggested in salvage scenario for both conditions, and the combination with other mold-active drugs is considered. The guidelines report the promising results obtained with the use of this drug for treating mycoses caused by other molds and rare yeasts, as well as endemic mycoses, but since solid evidence is still lacking, the recommendations in this area are generally weak. Isavuconazole is a suitable therapeutic option for invasive fungal infections, offering efficacy against a range of pathogens, including Aspergillus and fungi within the order Mucorales. Its safety profile and its favorable drug interaction profile make it a valuable alternative to traditional agents like voriconazole or liposomal amphotericin B in certain scenarios. However, continued research is essential to better understand its role in combination therapies and to assess its effectiveness against other fungal species.

Diagnosing invasive fungal infections in the laboratory today: It's all good news?

Despite the advances in medical science, invasive fungal infections (IFI) remain a diagnostic challenge. The increasing prevalence of IFI, driven by immunosuppressive therapies, advances in intensive care and emerging pathogens, underscores the need for early and accurate diagnosis. This review evaluates current laboratory methods for the diagnosis of IFI, highlighting their strengths and limitations. Conventional techniques, including fungal culture, direct microscopy, and histopathology, remain the gold standard for the diagnosis of proven IFIs. These methods allow pathogen isolation, species identification and antifungal susceptibility testing. However, these techniques have limitations in terms of sensitivity and turnaround times. Although microscopy is a rapid technique, its sensitivity and species discrimination profile are limited. Modern serological assays, such as β-d-glucan and galactomannan detection, have improved the diagnostic accuracy of probable IFI cases. Integration of these assays with clinical and radiological findings, enables earlier intervention, although this is accompanied by an increased risk of false positives and necessitates careful clinical correlation. Molecular diagnostics, particularly polymerase chain reaction (PCR), allow rapid, species-specific identification directly from clinical samples. The advent of MALDI-TOF mass spectrometry has further improved diagnostic efficiency, particularly for yeast identification, although challenges remain for filamentous fungi. Innovative techniques, such as metagenomic sequencing, lateral-flow assays, and loop-mediated isothermal amplification, offer the potential for rapid and precise detection, even in resource-limited settings. The combination of conventional and innovative methods provides a comprehensive diagnostic framework. The continuous refinement of these tools, in conjunction with multidisciplinary collaboration, is imperative to improve the early diagnostic and targeted treatment of patients with IFI.

Comparison of the Filamentous Fungi Library v4.0 MALDI Biotyper Platform vs MSI-2 performance for identifying filamentous fungi from liquid cultures

Correct, rapid, and reliable filamentous fungi identification is crucial for timely diagnosis and therapy. We compared the performance of the FFLv4.0 MALDI Biotyper and MSI-2 to identify filamentous fungi from clinical isolates. We analyzed 307 clinical isolates of Aspergillus spp., Fusarium spp., and Mucorales and compared them to sequencing as the reference standard. The overall identification rates to genus (Mucorales), section (Aspergillus), and species complex (Fusarium) level were 96% (296/307) for FFLv4.0 and 78.5% (241/307) for MSI-2. By each genus, correct species identification was achieved by FFLv4.0 and MSI-2 as follows: 72.4% (165/228) and 55.3% (126/228) for Aspergillus species, 17.6% (6/34) and 38.2% (13/34) for Fusarium species, and 88.9% (40/45) and 55.5% (25/45) for the Mucorales. The rates of non-identification by FFLv4.0 and MSI-2, respectively, were 4% (9/228) and 18% (41/228) for Aspergillus spp., 0% and 17.6% (6/34) for Fusarium spp. and 4.4% (2/45) and 42.2% (19/45%) for the Mucorales. Misidentification rates by FFLv4.0 and MSI-2, respectively, were 16.2% (37/228) and 6.1% (14/228) for Aspergillus species, 67.6% (23/34) and 14.7% (5/34) for Fusarium spp., and 0% and 2.2% (1/45) for the Mucorales. The FFLv4.0 MALDI Biotyper outperformed MSI-2 in identifying filamentous fungi from liquid culture spectra.

Molecular Assays Versus Mycological Methods for Diagnosis of Rhino Orbital Mucormycosis: Analysis of 120 Clinical Specimens from COVID-19 Patients

BACKGROUND

Mucormycosis, a fungal emergency, poses a serious threat to both COVID-19 and non-COVID-19 individuals due to its invasive nature, rapid progression, and high rates of morbidity and mortality. This underscores the crucial need for timely detection and management. In this study, we investigated the utility of real-time PCR (RT-qPCR) assays for detecting Mucorales in clinical specimens, and assessed the performance of both SYBR Green and TaqMan probe RT-qPCR in amplifying Mucorales-specific 18S rDNA genes. We conducted accuracy analyses using direct examination with KOH as a standard for the laboratory diagnosis of mucormycosis. Additionally, we compared the results with culture and duplex PCR.

PATIENTS/METHODS

Both SYBR Green and TaqMan RT-qPCR were optimized using Mucorales-specific oligonucleotides to amplify the conserved 18S rDNA targets. DNAs extracted from 120 rhino sinus specimens, which all were collected from COVID-19 patients upon suspicion of invasive fungal infections, were used for molecular diagnosis. The results of both RT-qPCR assays were compared with the result of direct microscopy, culture, and duplex Mucorales-specific PCR assay.

RESULTS

SYBR Green real-time PCR produced a distinct melting temperature (Tm) pattern (80.24 ± 0.70 °C) and detected Mucorales in 51 out of 120 clinical samples. When compared to direct examination with KOH, the standard method for diagnosing mucormycosis, SYBR Green PCR demonstrated a sensitivity of 91.67% (95% confidence interval (CI): 86.7-96.5%) and a specificity of 90.28% (95% CI: 84.9-95.5%). In contrast, TaqMan-probe PCR identified Mucorales in 34 out of 120 samples, with a sensitivity of 64.58% (95% CI: 56-73.1%) and a specificity of 95.83% (95% CI: 92.26-99.39%).

CONCLUSION

SYBR Green-based PCR can be used as a reliable confirmatory test for diagnosing mucormycosis, particularly in cases with atypical hyphae, mixed infections (featuring both septate and non-septate hyphae), or when the direct examination is positive but culture results are negative. The lower sensitivity of the TaqMan-probe PCR may be attributed to factors such as using a degenerate probe, which can lead to false-negative results.

An Update on Fungal Disease Outbreaks of Public Health Concern

For this narrative review, we describe recent high-profile and severe outbreaks of emerging fungal infections, emphasizing lessons learned and opportunities to improve future prevention and response efforts. Several themes and challenges remain consistent across a diverse array of fungal outbreaks, including the multidisciplinary need for improved diagnostic testing to determine species and perform antifungal susceptibility testing, clinical awareness, and optimization of antifungal use. Recent outbreaks exemplify the growing promise of non-culture-based tools in identifying fungal outbreaks and improving responses, although access remains limited. Culture-based tools remain critical for performing antifungal-susceptibility to guide therapy.

A Case Report of Acute Lymphoblastic Leukemia Complicated by Naso-Ophthalmic Mucormycosis

Rhinocerebral mucormycosis, an invasive fungal infection caused by Mucorales species, typically involves the paranasal sinuses, orbits, and central nervous system. Known for its aggressive nature, the infection often leads to severe complications and a high risk of mortality. Common risk factors include uncontrolled diabetes mellitus, immunosuppression, prolonged use of glucocorticoids, and hematologic malignancies. Patients with hematologic malignancies are particularly susceptible to this infection due to compromised immune function. This case report details an instance of acute lymphoblastic leukemia complicated by naso-ocular encephalomycosis, providing a comprehensive overview of its clinical presentation, diagnostic approach, therapeutic management, and prognosis. Additionally, preventive measures and early diagnosis are important in patients with hematologic malignancies.

The diagnosis of mucormycosis by PCR in patients at risk: a systematic review and meta-analysis

Background

This systematic review and meta-analysis aimed to examine the performance of polymerase chain reaction (PCR) assays for diagnosing mucormycosis.

Methods

A standardised search was conducted from conception to December 3rd 2024 using PubMed, Embase, Global Health, and Cochrane library. Original studies that used PCR-based methods on any human specimen to diagnose mucormycosis were analysed for eligibility. Using a bivariate meta-analysis, the diagnostic performance of PCR was examined against the European Organisation for Research and Treatment of Cancer-Mycoses Study Group Education and Research Consortium 2020 (EORTC-MSGERC) definitions of proven and probable invasive mould disease, which was modified to include all patients at risk of mucormycosis. The study protocol was registered on the PROSPERO database (CRD42023478667).

Findings

Of 4855 articles, a total of 30 met inclusion criteria, including 5920 PCR reactions on 5147 non-duplicate specimens from 819 cases of proven/probable mucormycosis and 4266 patients who did not meet the EORTC-MSGERC 2020 criteria. According to specimen type, sensitivity of PCR varied (p < 0.001) whereas specificity was similar (p = 0.662). Bronchoalveolar lavage fluid offered the highest sensitivity of 97.5% (95% CI 83.7-99.7%), specificity of 95.8% (95% CI 89.6-98.4%), positive likelihood ratio (LR+) of 23.5, and negative likelihood ratio (LR-) of 0.03. Tissue provided sensitivity of 86.4% (95% CI 78.9-91.5%), specificity of 90.6% (95% CI 78.1-96.3%), LR+ of 9.2, and LR- of 0.15. Blood provided reduced sensitivity of 81.6% (95% CI 70.1-89.4%), specificity of 95.5% (95% CI 87.4-98.5%), DOR of 95, LR+ of 18.3, and LR- of 0.19. Formalin-fixed paraffin-embedded specimens yielded the lowest sensitivity of 73.0% (95% CI 61.0-82.3%), highest specificity of 96.4% (CI 95% 87.5-99.0%), LR+ of 20.2, and LR- of 0.28. The covariates best explaining heterogeneity of the overall analysis were specimen type, study design (cohort versus case-control) and disease prevalence while patient population (COVID-19 versus other) and PCR (conventional versus quantitative) had less impact on heterogeneity.

Interpretation

This meta-analysis confirms the high performance of PCR for diagnosing mucormycosis and supports the instatement of PCR detection of free-DNA in blood, BALF and tissue into future updated definitions and diagnostic guidelines for mucormycosis.

Funding

None.

Rhinocerebral Mucormycosis in a Patient With Diabetes: A Rare but Critical Infection in the United Arab Emirates

A middle-aged man with no chronic medical conditions presented to the emergency department with flu-like symptoms, breathlessness, and vomiting. Arterial blood gas analysis revealed high blood glucose and an elevated anion-gap metabolic acidosis, suggestive of diabetic ketoacidosis, prompting the initiation of treatment. Neurological examination revealed multiple cranial nerve palsies with cranial mononeuritis multiplex, raising suspicion of rhino-orbito-cerebral mucormycosis. Liposomal amphotericin B was started empirically. Nasal endoscopy and biopsy, along with microbiological evidence, confirmed mucormycosis. Treatment required a multidisciplinary approach involving both medical and surgical specialties. In this case, we utilized treatments beyond current guidelines, including retrobulbar and intrathecal amphotericin in addition to intravenous dual antifungal therapy. Multiple surgical interventions were also performed. Over time, this approach led to clinical and biochemical improvement, allowing the patient to be discharged safely.

Impact of risk factors in craniofacial mucormycosis

BACKGROUND

 Craniofacial mucormycosis is a highly lethal infectious disease. This study aims to assess and analyze multiple variables, including clinical, socioeconomic, and biochemical markers, to identify and examine risk factors for mortality associated with this mycotic infection.

MATERIAL AND METHODS

 A retrospective analysis was conducted on 38 patients who sought medical attention at the Otolaryngology and Head and Neck Surgery Division of a tertiary-level hospital in Monterrey, Mexico. A broad range of variables was analyzed: clinical features, including the extent of mucormycosis infection; socioeconomic factors such as monthly income, marital status, geographical residence, educational level, and insurance status; as well as biochemical markers, including glucose levels, lactate dehydrogenase (LDH), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and immune cell counts, specifically neutrophils (NEU) and lymphocytes (LYM). Statistical analysis was conducted using SPSS v26. Risk factors for mortality were evaluated using Cox regression. Overall survival (OS) was assessed with the Kaplan-Meier method. The Fisher's exact test and the Chi-square test were used for categorical variables. For median comparisons, the Student's t-test and Mann-Whitney U test were applied; with normality assessed using the Shapiro-Wilk test. A p-value <0.05 was considered statistically significant.

RESULTS

 Mucormycosis was associated with higher mortality in men (p=0.032). The disease primarily affected the paranasal sinuses (p=0.021) and was associated with increased mortality when involving the orbit (p=0.035). Additionally, compromised lymphocyte counts (LYM) (p=0.034) and lower educational levels (p=0.009) were associated with higher mortality. Individuals residing in rural areas also exhibited an elevated risk of mortality (p =0.023).

CONCLUSIONS

 Prevention strategies should focus on high-risk groups to reduce the mortality rate of craniofacial mucormycosis, particularly targeting men and individuals residing in rural areas. Special emphasis should be placed on those without education or health insurance. Early diagnosis and appropriate management are crucial for improving outcomes.

Intra-abdominal Mucormycosis in an Immunocompetent Host: A Rare Presentation and Literature Review

Mucormycosis is a severe, opportunistic infection caused by Mucorales, a taxonomical group of thermotolerant fungi primarily affecting the immunocompromised. Intra-abdominal involvement in mucormycosis is a rare entity, particularly in immunocompetent individuals. We present a fatal case of gallbladder and renal mucormycosis in an immunocompetent female, leading to septic shock and death. The diagnosis was confirmed via histopathology following cholecystectomy for suspected gangrenous cholecystitis and open right nephrectomy due to kidney infarction. Quantitative polymerase chain reaction of the tissue identified the presence of Apophysomyces ossiformis. The clinical picture was confounded by ongoing sepsis due to a Klebsiella pneumoniae-infected retroperitoneal hematoma, non-specific imaging findings, and the absence of traditional risk factors for mucormycosis, leading to a delayed diagnosis. Despite surgical debridement, initiation of liposomal amphotericin B with posaconazole, and aggressive treatment in the intensive care unit, the patient succumbed to complications of mucormycosis. Despite adequate antibiotic coverage, this case underscores the importance of considering Mucorales infection in otherwise immunocompetent patients with a deteriorating clinical condition. Early diagnosis and appropriate intervention are essential in enhancing mucormycosis survivability, though mortality rates remain high in severe cases.

Mucormycosis

Mucormycosis is an aggressive and frequently lethal disease. Most patients with mucormycosis have poorly controlled diabetes mellitus and rhino-orbito-cerebral disease. Patients with hematologic malignancy and transplant recipients mostly present with rhino-orbito-cerebral or pulmonary disease. Prompt recognition of clinical symptoms and radiographic features of mucormycosis is required to establish timely diagnosis and initiate targeted therapy. Diagnosis is, historically, made by direct microscopy, culture, and pathology of biopsy tissue, but molecular methods are increasingly playing a role in establishing an earlier diagnosis. Treatment is multidisciplinary, involving early surgical intervention, antifungal therapy, and correction of underlying immune compromising risk factors when possible.

Septic Cavernous Sinus Thrombosis: Clinical Characteristics, Management, and Outcomes

BACKGROUND

Septic cavernous sinus thrombosis (CST) is a rare condition traditionally associated with high morbidity and mortality. More recent case series report more favorable outcomes, including full functional recovery. A comprehensive assessment of the clinical characteristics and prognostic factors of visual and survival outcomes in septic CST is warranted to contemporize current understanding and help guide management.

METHODS

A multicentered retrospective cohort study was conducted at 2 tertiary care centers using an electronic medical record search of the term, "thrombosis of cavernous venous sinus" between January 1, 2000, and December 31, 2021. Inclusion criteria consisted of active infection and radiographic evidence of associated CST. Demographic and clinical data extracted included age at presentation, sex, infection type and extent, and ophthalmic examination findings at presentation-best-corrected visual acuity (BCVA), presence of relative afferent pupillary defect (RAPD), intraocular pressure (IOP), and extraocular motility (EOM) limitation. Management data collected consisted of type and length of antimicrobial therapy, type and length of anticoagulation administration, and surgical intervention. Primary outcomes assessed were ophthalmic examination findings at final evaluation and same-hospitalization mortality.

RESULTS

A total of 27 patients with imaging-confirmed septic CST were identified at 2 tertiary care centers. At presentation, 2 (8.7%) patients had no light perception (NLP) vision, 8 (29.6%) patients had RAPD, 17 (73.9%) patients had EOM limitation, and 13 (54.2%) had IOP >21 mm Hg. All patients received antimicrobial therapy, with vancomycin being the most common agent. Fifteen patients (55.6%) received anticoagulation, and 21 (81.5%) patients underwent surgical intervention. Same-hospitalization mortality was 3 (11.1%). Among the 21 patients with ophthalmic data at follow-up, 3 (16.7%) had NLP vision, 5 (23.8%) had a persistent RAPD, 7 (31.8%) had persistent EOM limitation, and no patients had IOP elevated above 21 mm Hg. Patients with RAPD at presentation had significantly worse BCVA at final evaluation (logMAR BCVA 1.43 higher on average, P = 0.01) and a significantly higher mortality rate (37.5% vs. 0.0%, P < 0.01) than non-RAPD patients. Demographic features, BCVA at presentation, EOM limitation at presentation, elevated IOP at presentation, and comorbid orbital cellulitis were not associated with worse visual or mortality outcomes.

CONCLUSIONS

Septic CST may result in permanent ophthalmic functional deficit in almost one-third of cases and mortality in approximately 11% of patients under contemporary management. New RAPD at presentation may indicate higher risk of poor visual and survival outcomes.

Subacute onset rhino-orbital mucormycosis caused by Cunninghamella in a Chinese leukemia patient: A case report and literature review

PURPOSE

We herein report a case of subacute-onset rhino-orbital mucormycosis (ROM) in an acute leukemia patent caused by the rare but most lethal pathogenic fungus - Cunninghamella. To the best of our knowledge, this is the first case of ROM caused by Cunninghamella reported in China.

CASE DESCRIPTION

A 50-year-old Chinese female with acute leukemia (M2 type) who, following the completion of two cycles of chemotherapy, began to exhibit naso-ocular symptoms. The patient was initially diagnosed with extramedullary leukemia. As the disease progressed, the patient began to develop specific black crust-like necrosis of the right eyelids. Following multidisciplinary treatment (MDT) consultation and tissue biopsy, the patient was finally diagnosed with a rare type of ROM caused by Cunninghamella infection. Although the mortality associated with Cunninghamella infection was significantly greater than that associated with infections caused by other Mucorales, the infection was eventually controlled through the adjustment of the antifungal drug regimen and timely surgical intervention.

CONCLUSIONS

ROM infection with Cunninghamella is an extremely rare and fatal fungal infection, and early recognition and diagnosis of the disease is critical to the prognosis. The subacute nature of this case may have been a positive factor in the patient's preservation of life.

Gastrointestinal mucormycosis by Mucor indicus: A report of two cases

Mucormycosis is an invasive infection caused by fungi of the order Mucorales, typically affecting immunocompromised individuals, and rarely involving the gastrointestinal tract. We report two cases of gastrointestinal mucormycosis by Mucor indicus: a 77-year-old woman with a gastric ulcer and a 25-year-old man with liver lesions. Both were treated with surgery and liposomal amphotericin B; only one survived. Recognizing gastrointestinal mucormycosis in the correct clinical context is essential and requires timely surgical and antifungal treatment. 2012 Elsevier Ltd. All rights reserved.

Coronavirus Disease 2019 and Emerging Lung Infections in the Immunocompromised Patient

The immunocompromised are at higher risk of COVID-19 and lung infections, and these are associated with more severe presentations and greater risk of complication, increasing the risks of intensive care unit admission and poor outcomes. However, only limited high-quality data are available about the diagnosis and management of lung infections in this population, with many clinical trials and other large studies excluding the immunocompromised. Well-designed studies are needed to better understand the optimal diagnostic and management options to improve outcomes in the increasingly heterogeneous group of immunocompromised patients.