Fatal renal mucormycosis with Apophysomyces elegans in an apparently healthy male

Mucormycosis caused by Apophysomyces species: An experience from a tertiary care hospital in Western India and systematic review of global cases

Apophysomyces species are an emerging cause of mucormycosis in several regions of the world, primarily affecting immunocompetent individuals. The present study addresses the global epidemiology, clinical presentation, management and outcome of mucormycosis caused by Apophysomyces spp. The study included patients diagnosed with Apophysomyces infection at our hospital between March 2019 and August 2020. In addition, cases published in PubMed and Google Scholar from inception to July 2022 were systematically searched and analysed. Only proven and probable cases that meet the eligibility criteria were included. The Indian cases were compared with those from other countries, and the results were analysed by descriptive statistics. In total, six cases of mucormycosis due to Apophysomyces spp. were diagnosed at our hospital, with additional 250 cases identified through literature search. The main underlying diseases were diabetes mellitus (24%), malignancy (3.2%) and chronic kidney disease (2.8%). The major predisposing factor was trauma (55.6%). Necrotizing fasciitis was the most common (63.2%) clinical presentation. Healthcare-associated mucormycosis accounted for 10.4% of the cases. Globally, A. elegans was the most common species (48.8%), whereas A. variabilis was predominant (86.2%) in India. Surgery was performed in 83.5% of patients. Among those treated with antifungal agents, 98% received amphotericin B and 8.1% received posaconazole. Inappropriate antifungal usage was observed in 12.7%. The overall mortality was 42.3%. A combined medical and surgical management was associated with higher survival. Our study highlights the knowledge gap among physicians regarding this infection. A timely diagnosis and aggressive management can improve the outcomes in such cases.

Clinical presentations, diagnosis, management, and outcomes of renal mucormycosis: An overview of case reports

Background

Renal mucormycosis (RM) is a rare presentation of invasive mucormycosis with a high mortality rate. There is no single systematic review of the literature that indicates the different clinical aspects of RM.

Methods

A systematic search of PubMed/Medline was performed to collect individual case reports of RM in patients of all ages published between 2010 and April 2022.

Results

Seventy-one individual cases were detected through PubMed bibliographic database searches, with a final assessment performed on 60 patients with RM. India and Asia had the largest number of reported cases, with 30 (50%) and 42 (70%) reports, respectively. Also, 74 and 26% of the patients with a mean age of 33 years were male and female, respectively. RM showed 44% mortality rate in the analyzed cases. Immunosuppressive agent therapy followed by tissue transplantation (kidney and liver) and diabetes were the most remarkable risk factors in patients. Nevertheless, 22% of the patients were immunocompetent with no apparent underlying condition. COVID-19 positivity was detected in eight adult patients with an 87% mortality rate. The most common signs of infection were fever, flank pain, and oliguria; additionally, isolated RM was reported in 57% of the cases. In 55% of the patients, histopathologic examination alone was sufficient to diagnose RM, whereas molecular methods and culture were used in only 18 and 35% of patients, respectively. Surgery alone, surgery plus anti-infection therapy, and anti-infection therapy alone were used in 12, 60, and 13% of patients, respectively. Furthermore, 15% of the patients died before any treatment.

Conclusion

The early diagnosis of RM is necessary. In this regard, the use of molecular-based diagnostic assays can help identify the fungus at the genus and species levels and use an appropriate treatment in the shortest possible amount of time. Because of the increase in antibiotic resistance in recent years, determining microbial susceptibility tests can lead to the better infection management. Additionally, withdrawal of immunosuppressant, appropriate surgical intervention, and antifungal therapy are the main factors associated with a successful outcome in RM.

Community-acquired fungal pyelonephritis with renal infarction and gangrene of the colon: an uncommon diagnosis

A 54-year-old male farmer with a history of long-standing uncontrolled type 2 diabetes mellitus (HbA1c 10.8) presented with a 3-week history of fever, intermittent vomiting, malaise and left flank pain for which he was treated with broad-spectrum antibiotics and oral antifungals for Candida isolated from urine culture. CT of the abdomen revealed predominant involvement of the left kidney and retroperitoneal structures. Nephrectomy was performed due to worsening abdominal pain and features of bowel perforation found on imaging. Pus culture from the necrotic kidney grew aseptate fungal hyphae, and the histopathological examination was suggestive of zygomycosis. He received amphotericin B postoperatively, but his condition deteriorated and he succumbed to nosocomial gram-negative septicaemia.

COVID-19 associated mucormycosis: evolving technologies for early and rapid diagnosis

The post-coronavirus disease (COVID-19) mucormycosis is a deadly addition to the pandemic spectrum. Although it’s a rare, aggressive, and opportunistic disease, the associated morbidity and mortality are significant. The complex interplay of factors aggravating CAM is uncontrolled diabetes, irrational and excessive use of antibiotics, steroids, and an impaired immune system. Recently, India has been witnessing a rapid surge in the cases of coronavirus disease-associated mucormycosis (CAM), since the second wave of COVID-19. The devastating and lethal implications of CAM had now become a matter of global attention. A delayed diagnosis is often associated with a poor prognosis. Therefore, the rapid and early diagnosis of infection would be life-saving. Prevention and effective management of mucormycosis depend upon its early and accurate diagnosis followed by a multimodal therapeutic approach. The current review summarizes an array of detection methods and highlights certain evolving technologies for early and rapid diagnosis of CAM. Furthermore, several potential management strategies have also been discussed, which would aid in tackling the neglected yet fatal crisis of mucormycosis associated with COVID-19.

Diagnosis of an intestinal mucormycosis 'fungus ball' located with PET/CT with [18F] FDG-PET/CT

Mucormycosis is a life-threatening infection with most commonly rhino-orbital-cerebral and pulmonary syndromes that mostly occurs in immunocompromised patients. FDG-PET/CT emerged as a sensitive non-invasive tool to identify systemic mucormycosis. We present a 59-year-old woman for whom a PET/CT with ¹⁸F-FDG was performed in search of a primary location of mucormycosis with non-contributive conventional workup. A large left abdominal mass was seen, compatible with a fungus ball, with intense parietal uptake and without any central uptake. The localization of the infection provided a target for surgery and permitted to adapt the therapeutic strategy. After resection, the final diagnosis was consistent with mucormycosis. To our knowledge, this is the first report of a PET/CT image with FDG showing an intestinal fungus ball. PET/CT with ¹⁸F-FDG may contribute to the management of patients with fungal infections of unknown origin.