Successful Treatment of Mucormycosis Endocarditis Complicated by Pulmonary Involvement

Colonic Mucormycosis in Fistulizing Crohn's Disease

Gastrointestinal mucormycosis, a rare fatal fungal infection in an immunocompromised host, affects mainly the stomach. Colonic mucormycosis is infrequent and is associated with high mortality. Perianal involvement is seen in almost one-third of patients with Crohn's disease. Perianal Crohn's disease is a particularly debilitating form of the disease, which requires multidisciplinary care. It may also require profound immunosuppression with biological agents to control disease activity. Opportunistic infections can complicate the disease course in these patients. We present a case of a middle-aged female with perianal Crohn's disease on adalimumab who developed colonic mucormycosis causing a flare in her disease activity. This patient highlights the need to increase awareness about fungal infections as a cause of disease flare in inflammatory bowel disease.

Disseminated Cunninghamella spp. Endocarditis in a Beta-Thalassemia Patient after Asymptomatic COVID-19 Infection

Cunninghamella spp. is a group of fungi belonging to the Mucorales order. Cases of fungal endocarditis are sporadic, but more frequent in immunocompromised patients. COVID-19 (SARS-CoV-2 Infection Disease 2019) infections, prematurity, deferoxamine treatment, iron overload, neutropenia, diabetes, and malignant hemopathies proved to be risk factors for mucormycosis. We present the case of a 7-year-old boy who was treated every three weeks with blood transfusion for major beta-thalassemia, receiving deferoxamine for secondary hemochromatosis. After two weeks with nonspecific respiratory and digestive symptoms, he was admitted for fever, followed by lower limb ischemia and neurological signs. Echocardiography revealed massive endocarditis affecting the mitral and tricuspid valves with embolization phenomena in the brain, lungs, kidney, spleen, and lower limbs. As a particular finding, IgG antibodies for COVID-19 were positive. Emergency cardiac surgery was performed. The mitral valve necessitated replacement with CarboMedics prosthesis. Unfortunately, the patient did not survive. Cunninghamella spp. was confirmed via the PCR analysis of vegetations. Cunninghamella endocarditis in the context of a systemic infection presented as an opportunistic infection affecting a child who had several risk factors. Mucormycosis is challenging to treat, with high mortality. Prophylactic treatment in beta-thalassemia patients with iron-chelator deprivation drugs, such as deferiprone, may help in preventing these particular fungal infections.

Disseminated Mucormycosis with Extensive Cardiac Involvement

Mucormycosis is an opportunistic fungal infection. Cardiac involvement is a rare, yet fatal, complication that can occur in disseminated disease. A strong index of suspicion is necessary for prompt treatment, especially in high-risk patients. We present a 62-year-old male patient with a history of diabetes and acute myeloid leukemia; he had pulmonary mucormycosis that was complicated by cardiac involvement as part of disseminated mucormycosis syndrome.

Disseminated mucormycosis: A sinister cause of neutropenic fever syndrome

A 15 year old girl presented with complaints of prolonged fever and recurrent episodes of hemoptysis. Initial investigation showed pancytopenia and radiological imaging was suggestive of necrotizing pneumonia. Subsequently, mucor was isolated from bronchoalveolar lavage fluid, but even on appropriate medications her condition kept deteriorating. She had multiple bouts of hemoptysis and a repeat imaging of chest showed dissemination of mucormycosis to pulmonary vein and heart. Bone marrow biopsy identified acute lymphoblastic leukemia (ALL) as the cause of pancytopenia. She was planned for bronchial artery embolization and chemotherapy for ALL, but consent was not given and she left our institute against medical advice. Our case highlights the importance of keeping a high index of suspicion for disseminated mucormycosis in neutropenic patients, as any delay in diagnosis and treatment could have grave consequences.

Mucormycosis in patients with inflammatory bowel disease: case series and review of the literature

Mucormycosis is a rare and often fatal invasive fungal infection mostly seen in immune-compromised individuals. A high index of clinical suspicion is necessary, so that effective preemptive therapy can be started, as timely intervention is crucial. In this series we present three cases of invasive mucormycosis in patients with underlying inflammatory bowel disease that had received therapy with immunomodulators prior to the infection. All three had varied clinical manifestations. We also review the literature of invasive mucormycosis in patients with inflammatory bowel disease.

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.

Biofilm formation by zygomycetes: quantification, structure and matrix composition

Most studies on fungal biofilms have focused on Candida in yeasts and Aspergillus in mycelial fungi. To the authors’ knowledge, biofilm formation by zygomycetes has not been reported previously. In this study, the biofilm-forming capacity of Rhizopus oryzae, Lichtheimia corymbifera, Rhizomucor pusillus and Apophysomyces elegans was evaluated. At appropriate seeding spore densities, Rhp . oryzae (105 c.f.u. ml−1), L. corymbifera (104 c.f.u. ml−1) and Rhm. pusillus (104 c.f.u. ml−1) produced highly intertwined, adherent structures on flat-bottomed polystyrene microtitre plates after 24 h at 37 °C. The adhered fungal hyphae were encased in an extracellular matrix, as confirmed by phase-contrast and confocal microscopy. The thickness of Rhp. oryzae, L. corymbifera and Rhm. pusillus biofilms was 109.67±10.02, 242±23.07 and 197±9.0 µm (mean±sd), respectively. Biochemical characterization of the biofilm matrix indicated the presence of glucosamine, constituting 74.54–82.22 % of its dry weight, N-acetylglucosamine, glucose and proteins. Adherence and biofilm formation were not observed in A. elegans. Although A. elegans spores germinated at all three seeding densities tested (1×107, 1×106 and 1×105 c.f.u. ml−1), no significant difference was observed (P>0.05) between the A 490 of wells inoculated with A. elegans and the cut-off A 490 for biofilm detection. This study highlights the potential for biofilm formation by at least three medically important species of zygomycetes.

Lipid formulations of amphotericin B as first-line treatment of zygomycosis

Zygomycosis is a difficult to treat and frequently fatal infection affecting immunocompromised and, rarely, immunocompetent patients. The early diagnosis and immediate initiation of treatment with an antifungal agent in combination with surgical intervention has proved critical for the favourable outcome of the disease. Few antifungal agents are available for treatment. Amphotericin B (AmB) deoxycholate has been the drug of choice for many years and is usually given at high daily doses which can result in renal toxicity. Currently, lipid formulations of AmB (liposomal AmB (L-AmB), AmB lipid complex (ABLC), AmB colloidal dispersion (ABCD)), mainly L-AmB, rather than conventional AmB have become the standard therapy. The rationale behind the use of lipid formulations is that they decrease the nephrotoxicity associated with longterm AmB use. Although there is a developing consensus that high doses of lipid formulations of AmB should be the antifungal therapy of choice for all patients with zygomycosis, until now there have been no data available with which to define the appropriate dose. The duration of therapy remains an unresolved issue, regarding both lipid formulations of AmB as well as sequential or combination treatments consisting of lipid formulations of AmB with posaconazole, a drug which has now emerged as a new therapeutic option.

Zygomycosis presenting as acute myocardial infarction during hematological malignancies

Here we report two patients with hematological malignancies associated with complications of fatal cardiac zygomycosis. The first case, a 72-year-old man with myelodysplastic syndrome being treated with low-dose cytarabine, died of sudden cardiac arrest. An autopsy revealed disseminated zygomycosis accompanied with occlusion of the coronary artery by fungal thrombi. The second case, a 52-year-old woman with acute lymphoblastic leukemia, developed febrile neutropenia and skin eruptions with induration on the face and extremities during the first induction chemotherapy. She experienced sudden bradycardia with unstable hemodynamics and died of acute myocardial infarction. Histological examination of a skin biopsy demonstrated zygomycosis. In light of the above, it should be kept in mind that cardiac zygomycosis might occur in hematologically compromised patients presenting with acute myocardial infarction.