A prospective study of mucormycosis in north India: experience from a tertiary care hospital

Resurgence of orbital mucormycosis during COVID-19 pandemic: Study from a tertiary care center in Eastern India

PURPOSE

A sudden surge of Mucormycosis cases during the second wave of Covid 19 was observed in certain parts of India. The reasons for this upsurge remain unknown. However its impact on the overall healthcare system was quite overwhelming. In this context this study was decided to estimate and assess the spectrum of orbital involvement in patients with Mucormycosis, to find its association with coexisting disease entities if any, and at the same time evaluate the therapeutic response to established treatment regimens.

MATERIALS AND METHODS

This descriptive longitudinal study was conducted over a period of six months. Patients presenting with symptoms of Mucormycosis were jointly evaluated by a multi speciality team. After confirmation of diagnosis, patients were treated with intravenous Amphotericin B, surgical debridement of affected sinuses and orbital exenteration when indicated. They were followed up for three months after discharge.

RESULTS

Forty-three patients were enrolled in this study. Thirty-seven (86.04%) were COVID positive. All of them had history of steroid exposure during COVID treatment. Ninety five percent of study participants had diabetes mellitus. Twenty-seven (62.79%) patients had orbital involvement. Most common clinical presentation was peri-orbital or facial pain and edema. Besides medical treatment, thirty-nine patients (90.69%) required sinus debridement and nine patients (20.9%) required orbital exenteration. Thirteen patients (30.23%) expired during the follow up period. With treatment disease regressed in twenty patients (46.51%).

CONCLUSION

Diabetes and use of steroids to prevent anticipated cytokine storm may be the inciting factors for Orbital Mucormycosis in COVID patients. Early diagnosis, treatment and control of risk factors are keys for recovery and survival..

Novel Grading System Based on Nasal Endoscopy: Our Experience with 650 Mucormycosis Cases

Rhinocerebralmucormycosis, is a progressive fungal invasion of a hard palate, paranasal sinuses, orbit, and brain. Post covid the huge number of mucor cases reported in our institute. To combat them a uniform assessment scale was needed as multiple healthcare workers were involved. Thus, a novel linear grading system on nasal endoscopy was developed for the early management of patients to prevent morbidity and mortality. A Prospective study of 650 patients in Epidemic duration from April to June 2021 in a tertiary health center, Central India. Patients subjected to Nasal Endoscopy with 0degree 4 mm Telescope and classified into 5 categories according to the severity of the disease. In a novel grading system, minimum patients were of grade 0, maximum was in Grade I. Maxillary sinus was most commonly involved. This novel grading system on nasal endoscopy makes the management of patients much easier in an epidemic, reducing human errors, morbidity, and mortality of the fulminant disease.

An Observational Study of Fungal Infections in COVID-19: Highlighting the Role of Mucormycosis in Tertiary Healthcare Settings

Background Fungal infections, especially mucormycosis, have remarkably surged during the coronavirus disease 2019 (COVID-19) era, especially during the second wave peak of the pandemic raising the concern of the clinicians for the admitted patients. Steroid therapy, diabetes, and other immunocompromised states are more commonly associated with COVID-19-associated mucormycosis (CAM). Aim and objective The aim of this study is to ascertain the prevalence of fungal infections amidst the second wave of the COVID-19 pandemic and discern the associated risk factors. Materials and methods During the second peak of COVID-19, samples were received in the microbiology laboratory from all clinically suspected mucormycosis patients. These samples underwent processing for potassium hydroxide (KOH) wet mount, fungal culture on Sabouraud's dextrose agar (SDA) medium, and COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) testing. All relevant clinical and associated risk factors were tabulated and analyzed. Results Among the 107 suspected cases of mucormycosis, 39 (36.4%) were confirmed positive for COVID-19 via RT-PCR, while 68 (63.6%) tested negative. Males exhibited a predominant infection rate, with the rhinocerebral system being the most commonly affected site. Significantly higher mortality rates were observed in COVID-19-associated mucormycosis (CAM) patients (33.4%) compared to those without COVID-19 (5.9%), with a notable p-value of 0.0005. CAM patients also demonstrated a higher frequency of ICU admissions (77%) compared to non-COVID-19-associated mucormycosis patients (21.4%), a statistically significant finding (p-value of 0.007). Additionally, immunocompromised states, diabetes, and the administration of oxygen therapy were identified as significant risk factors in CAM (p < 0.05). Notably, mucormycosis accounted for the majority of fungal isolates (48.27%) among COVID-19 patients. Conclusion Mucormycosis infection is more commonly seen in COVID-19-infected patients as compared to non-COVID-19 patients, especially with comorbidities such as diabetes mellitus, steroid usage, and other immunocompromised states.

Acute invasive fungal rhinosinusitis in post-COVID-19 patients in Vietnam

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is a potentially lethal infection commonly found in immunocompromised patients. It is considered the most aggressive subtype of fungal sinusitis and can lead to severe morbidity and mortality. There was a significant increase in the incidence of AIFR in post-COVID-19 patients compared to AIFR cases before the COVID-19 pandemic. This study aimed to describe the clinical presentation of AIFR associated with COVID-19 illness.

METHODS

A retrospective study included 22 patients diagnosed with AIFR with a recent COVID-19 infection.

RESULTS

The most frequent disease associated with AIFR was diabetes mellitus (95.5%). The mycological analysis identified infection caused by Aspergillus species in 72.7% of patients. Along with stabilizing hemodynamic parameters and controlling any comorbidities, all patients in the present study underwent combined surgical debridement followed by antifungal medications. The overall survival rate was 72.7%. The chance of developing a fatal outcome was significantly higher if meningitis presented initially (odds ratio 35.63, p < 0.05).

CONCLUSION

The presence of meningitis upon initial diagnosis is related to a significantly higher chance of developing a fatal outcome and should be considered, especially in AIFR patients previously treated for COVID-19 infections. Early diagnosis, early use of antifungal agents, aggressive surgical debridement, and control of comorbid conditions remain crucial in managing AIFR.

LEVEL OF EVIDENCE: 4

COVID-19 associated mucormycosis (CAM) in Kashan, Iran: clinical presentations, risk factors, management, and outcomes

BACKGROUND

This study aimed to estimate the disease burden and describe the clinical presentation, risk factors, and outcome of CAM in a single centre in Iran.

METHODS

A case of mucormycosis was defined as one that had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological and molecular examination.

RESULTS

We report 30 cases of COVID-19 associated mucormycosis (CAM). The results of this study showed the affected age group in the range of 40-79 years (median = 65.5; IQR = 5) with women (16/30, 53%) affected more than men (14/30, 47%). Among the fungi recovered, Rhizopus oryzae had the highest frequency (79%). Out of the 30 patients, 28 (93%) patients were diabetic with 24 (80%) patients having other co-morbidities. Headache followed by retro-orbital pain, proptosis/ptosis and rapid diminution of vision was a common sequence of symptoms reported by the majority of cases. Use of mechanical ventilation (58% vs. 6%, p = 0.003), O2 required (92% vs. 50%, p = 0.024), and development of renal dysfunction during hospital stay (17% vs. 0%, p = 0.041) was significantly higher in non-survivors than survivors. Temperature (C°), PR (pulse rate), mean levels of serum creatinine, BUN, troponin, and neutrophils were significantly higher in non-survivors (p < 0.05). Besides, Albumin and PO2 were also significantly higher in survivors than non-survivors.

CONCLUSION

Despite medical and surgical treatment, the mortality rate among CAM patients is still high. Thus, concerted efforts of revamping surveillance, diagnosis and management, along with public awareness and patient education, are the requisites for managing COVID-19 and mucormycosis.

Rhino-orbito-cerebral mucormycosis during Covid-19 pandemic- a prospective observational study

OBJECTIVE

An unprecedented rise in mucormycosis cases; apparently called 'an epidemic within a pandemic' was seen worldwide. Therefore, the following study was conducted to know the epidemiology, underlying risk factors, diagnostic approach, and possible outcome of mucormycosis during the Covid-19 pandemic.

METHODS

A prospective observational study was conducted on patients with a high index of clinical suspicion of mucormycosis Data about demographics, co-morbidities, laboratory investigations, radiology, management, and outcomes were collected.

RESULTS

We got 45 cases of proven Rhino-orbital-cerebral-mucormycosis (ROCM) from clinically suspected cases. Covid-19 was the most common underlying risk factor (n ​= ​41, 91.11%) followed by Diabetes mellitus (DM) (n ​= ​39; 86.67%). Steroids and oxygen usage were noted in 53.66% (n ​= ​22) and 41.46% (n ​= ​17) respectively. Among the 51 suspected cases of mucormycosis, 47 were supported by radiodiagnosis. Histopathology diagnosed the highest number of mucormycosis cases (n ​= ​44; 97.78%), followed by KOH examination (n ​= ​36; 80%) and Culture (n ​= ​28; 62.22%). The most common species isolated from the tissue samples was Rhizopus species (n ​= ​17; 60.71%), followed by Mucor species (n ​= ​7; 25%). The mortality rate was 17.14%.

CONCLUSION

DM, Covid-19, and corticosteroids are the chief underlying risk factor for ROCM. Rhizopus spp. was the most dominant etiological agent. Early diagnosis and management with combined medical & surgical intervention have a better survival rate.

A Retrospective Observational Study on the Comparison of Different Diagnostic Modalities of Post-COVID Mucormycosis

Background Mucormycosis, attributed to a group of molds known as mucormycosis, is a rare yet life-threatening fungal infection often colloquially referred to as black fungus. While its incidence notably surged during the second wave of COVID-19 infections in India, it's essential to recognize that mucormycosis was a significant concern even before the advent of the pandemic. Understanding the prevalence and characteristics of this infection in the pre-COVID era provides a crucial context for evaluating its impact and dynamics during the pandemic. Multiple diagnostic methods, such as potassium hydroxide (KOH) mount, culture, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and histopathological examination (HPE), are available for identifying this lethal infection. The primary objective of this study is to ascertain the sensitivity of various diagnostic methods for mucormycosis and to analyze the comparative effectiveness of microbiological versus histopathological diagnoses. Methods We conducted a retrospective observational study spanning six months, from May 2021 to October 2021, encompassing all mucormycosis cases meeting the inclusion criteria and diagnosed via histopathological examination (HPE) in the departments of pathology and microbiology. Microbiological tests were performed prior to the histopathological examinations. Sensitivity was assessed through statistical analysis, and the relationship between microbiological and histopathological diagnoses was evaluated using the chi-square test. Results Biopsy samples of 77 patients were collected, comprising 56 male and 21 female patients. Regarding age distribution, most patients fell within the 41-60 age bracket, while the smallest proportion was over 60 years old. The sensitivity and specificity of histopathological diagnosis, confirmed with periodic acid-Schiff (PAS) and Grocott-Gomori's methenamine silver (GMS) staining, both recorded a flawless 100%. KOH mount sensitivity stood at 88.3%, while fungal culture and MALDI-TOF exhibited sensitivities of 75.3%. Histopathological analysis revealed that 17% of cases displayed minimal fungal hyphae alongside necrotic tissue, whereas 58% exhibited abundant fungal hyphae accompanied by inflammatory cells. Additionally, absolute neutrophilia was observed in 55% of cases. Conclusions In our study, histopathology and KOH mount emerged as not only compassionate but also cost-effective diagnostic tools for identifying mucormycosis. The economic aspect of these diagnostic methods is highlighted in the results section to provide a comprehensive understanding of their cost-effectiveness. Additionally, we utilized MALDI-TOF MS as a straightforward, economically viable, and expeditious method specifically for confirming the fungal subtype in mucormycosis cases. The rationale behind choosing either MALDI-TOF MS or KOH for the diagnosis is elucidated, contributing to a clearer interpretation of our diagnostic approach. Furthermore, our findings indicate that absolute neutrophilia consistently manifests in 55% of mucormycosis cases.

Mucormycosis and Its Upsurge During COVID-19 Epidemic: An Updated Review

Although mucormycosis may have reached an epidemic situation during the COVID-19 pandemic, the term was much more familiar even before the COVID-19 period. The year 2020 showed an outbreak of novel coronavirus (SARS-CoV-2) which affected millions of people all over the world. One of the noticeable complications observed to be associated with this disease is mucormycosis. It is an opportunistic infection caused by members of the Order Mucorales existing worldwide and has been commonly reported as a laboratory contaminant for a long time. However, nowadays due to the changes in the host environment, they have been emerging as potent opportunistic pathogens responsible for causing primary infections or coinfections with other diseases eventually resulting in morbidity and even mortality in severe cases. Although immunocompromised patients are more susceptible to this infection, few cases have been reported in immunocompetent individuals. Various risk factors which are responsible for the acquisition of mucormycosis include diabetes mellitus type 2, ketoacidosis, hematological malignancies, organ transplants, and chemotherapy recipients. Among the various etiological agents, Rhizopus is found to be the most common, and rhino-cerebral to be the most frequent clinical presentation. As far as pathogenesis is concerned, host cell invasion, thrombosis, and necrosis are the main events in the progression of this disease. The aim of the present review is to address a complete spectrum of mucormycosis and COVID-19-associated mucormycosis (CAM) in a single article. Both global and Indian scenarios of mucormycosis are taken into account while framing this review.

Relevance of Conventional Microscopy in the Diagnosis of Mucormycosis during COVID-19 Pandemic

Introduction

Mucormycosis is a lethal disease which bewildered the health-care community of India during the ongoing second wave of the COVID-19 pandemic. The diagnosis is challenging considering the poor isolation in culture.

Aims

The aim of the study was to emphasize the utility of potassium hydroxide (KOH) mount examination using conventional light microscopy for early diagnosis of mucormycosis in resource-limited settings.

Materials and Methods

A retrospective analysis of results for all the samples including tissue biopsies, swabs, and pus received in the laboratory for KOH microscopy was done, and results were recorded. The clinical and demographic details of the patients were collected from the hospital information system.

Results

A total of 75 samples from 50 patients were received in the laboratory. Out of these, 43 samples from 35 patients showed fungal hyphae (38 patients with only nonseptate hyaline hyphae, 2 with septate hyaline hyphae, and 3 samples with mixed infections). All patients except one were positive for severe acute respiratory syndrome coronavirus 2 infection. The most common age group was 45-59 years (40%), followed by 30-44 years (34.28%) with a male predominance. There was a significant difference in hemoglobin A1C (P = 0.005) and ferritin (P = 0.017) levels between laboratory-confirmed mucormycosis patients and clinically suspected mucormycosis patients without confirmation.

Conclusion

Early diagnosis and initiation of targeted therapy is the cornerstone for treating mucormycosis patients. Hence, a rapid and reliable mode of diagnosis is the need of the hour. Conventional microscopy is such a tool that may be used, especially in resource-limited settings.

Case report: The clinical utility of metagenomic next-generation sequencing in mucormycosis diagnosis caused by fatal Lichtheimia ramosa infection in pediatric neuroblastoma

Lichtheimia ramosa (L. ramosa) is an opportunistic fungal pathogen of the order Mucorales that may result in a rare but serious mucormycosis infection. Mucormycosis could be angioinvasive, causing thrombosis and necrosis in the nose, brain, digestive tract, and respiratory tract. The infection is highly lethal, especially in immunocompromised hosts, and the incidence has been on the rise. However, due to its relatively low incidence in pediatric population and the challenges with diagnosis, the awareness and management experience for pediatric mucormycosis are extremely limited, which might lead to poor outcomes. In this study, we comprehensively reviewed the course of a fatal rhinocerebral mucormycosis case in a pediatric neuroblastoma patient receiving chemotherapy. Due to a lack of awareness of the infection, the standard care of amphotericin B treatment was delayed and not administered until the identification of L. ramosa by metagenomic next-generation sequencing (mNGS)-based pan-pathogen detection of the patient's peripheral blood sample. We also reviewed the literature on L. ramosa infection cases reported worldwide between 2010 and 2022, with an analysis of clinical manifestation, prognosis, and epidemiological data. Our study not only highlighted the clinical value of comprehensive mNGS in rapid pathogen detection but also raised awareness of recognizing lethal fungal infection early in immunocompromised hosts including pediatric cancer patients.

COVID-19 Associated Mucormycosis

Mucormycosis is a life-threatening opportunistic fungal infection seen in immunocompromised states. Rising incidence of mucormycosis among Coronavirus Disease-2019 infected individuals is an increasing concern in India. The disease which was endemic has blown out to become an epidemic. The purpose of this research is to study the epidemiology, management and outcome of Coronavirus Disease-2019 Associated Mucormycosis (CAM) cases. Additionally, the role of diabetes and steroids in the causation of CAM was determined. A hospital-based observational study was conducted at a tertiary care centre involving cases with rhino-orbital mucormycosis with recent history of COVID-19 infection. Out of 205,166(81%) cases had Diabetes Mellitus as a comorbid condition. Among them, 75(36.6%) cases were diagnosed with diabetes during COVID-19 treatment. 161/205(78.5%) cases received corticosteroids during COVID-19 treatment. Corticosteroids were notindicated in 43(26.7%) cases. 177/205(85.4%) cases were alive at the end of 12 weeks. 8 out of 10 deaths were seen in cases having diabetes. As the incidence of mucormycosis is increasing, better awareness among general population about the disease, early diagnosis and multidisciplinary approach is required to improve prognosis.

Orbital Mucormycosis: Understanding the Deadly Fungus Sweeping the Globe

Introduction Mucormycosis (black fungus) is a rare opportunistic fungal infection commonly affecting immunocompromised individuals. There has been a surge in the number of these cases during the second wave of the coronavirus disease 2019 (COVID-19) in India. Mucormycosis has been reported to occur within a week or a few weeks post-recovery from COVID-19. The most common clinical manifestation of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). At our tertiary care center, we initiated a prospective study to identify risk factors, study ocular manifestations, and explore medical and surgical management of orbital mucormycosis patients in the post-COVID-19 era. Material and methods This is a detailed description of a prospective observational hospital-based study. The study included 148 patients who presented with ROCM. A detailed history was taken regarding the complaint, duration, and associated risk factors. Systemic, local, and complete ophthalmic examinations were done that included assessment of extraocular movements, visual acuity, slit-lamp examination, and fundus examination. All data were recorded separately for each patient in a pre-decided proforma. Result The study group consisted of 148 patients. In our study, the highest association was with COVID-19-positive status (68.24%), out of which 57 (56.43%) were on oxygen support. Diabetes mellitus contributed next to COVID-19 with 86 (58.10%) patients with a positive history of diabetes. Seventy-one (47.97%) patients were on steroids, out of which 68 (67.32%) were COVID-19-positive and the rest (23%) were on steroids due to various systemic reasons. Rhinomaxillary involvement was present (51%). Out of 63 patients with orbital involvement, 16 (25.39%) presented bilaterally and 47 showed unilateral orbital involvement more on the right side (42.85%). The predominant location of orbital involvement was the orbital apex. The most common symptom seen in our study was nasal discharge (86.5%), and ophthalmoplegia was the most common sign. Conclusion Corticosteroids should be used with caution to prevent negative impact and potential ROCM. Good glycemic and metabolic control is crucial for treatment. Management of mucormycosis involves surgical debridement, antifungal agents, and retrobulbar amphotericin B injections. Early diagnosis and aggressive treatment are essential for success. Orbital exenteration may be necessary for advanced stages, while conservative approaches may work for earlier stages. Patient counseling is needed for cosmetic rehabilitation. A multidisciplinary approach involving various specialists is necessary.

Cross-sectional study to describe the severity, bio-chemical associations, and final outcomes of COVID-19-associated rhino-orbital-cerebral mucormycosis in a tertiary hospital of East India

Purpose

The second wave of coronavirus disease 2019 (COVID-19) pandemic triggered a mucormycosis epidemic in India. Diabetes mellitus and dysregulated immune response were contributors, and rhino-orbital-cerebral mucormycosis (ROCM) was the most common presentation. It is however not known whether bio-chemical parameters at presentation correlate with stage of ROCM or final outcome in terms of vision or mortality.

Methods

This retrospective, hospital-based study included all in-patients of mucormycosis with ophthalmic manifestations at presentation admitted during June 1, 2021 to August 31, 2021. It aimed to evaluate the association between severity of infection, serum levels of HbA1c, ferritin, interleukin-6 (IL-6), C-reactive protein (CRP), and D-dimer levels at presentation and outcome.

Results

There were altogether 47 eligible cases having a mean age of 48.8 ± 10.9 years with a male:female ratio of 2.6:1; forty-two (89.4%) had pre-existing diabetes, and five (10.6%) had steroid-induced hyperglycemia. The mean HbA1c among diabetics was 9.7 ± 2.1. HbA1c and serum CRP showed an increase over subsequent stages, which was not statistically significant (P = 0.31). IL-6 values for all stages were similar (P = 0.97). Only serum ferritin levels showed a statistically significant increase over stages (P = 0.04). IL-6 was significantly lower (P = 0.03) in patients who survived, whereas CRP levels were significantly lower in patients who had final visual acuity (VA) better than only perception of light (P = 0.03).

Conclusion

Uncontrolled diabetes mellitus is a significant association of ROCM. Serum ferritin levels at presentation best correlate with extent of the disease. CRP levels are best to prognosticate cases that will have sufficient VA to carry on activities of daily living, whereas IL-6 levels are best associated with survival.

Pediatric invasive fungal rhinosinusitis

Pediatric invasive fungal rhinosinusitis (PIFR) is a rapidly progressive, potentially fatal disease. Previous medical literature demonstrates that its early diagnosis significantly reduces the risk of mortality in these patients. This study aims to present an updated clinical algorithm for optimized diagnosis and management of PIFR. A comprehensive review was conducted with only original, full-text articles published in English and Spanish from Cochrane Library, Pub-Med/MEDLINE, Embase, Scopus, and Google Scholar between January 2010 and June 2022. Relevant information was extracted and then integrated to develop a clinical algorithm for a proper diagnosis and management of PIFR.

A case report of brainstem hemorrhage due to Rhizopus delemar-induced encephalitis diagnosed by metagenomic next-generation sequencing (mNGS)

BACKGROUND

Rhizopus delemar is an invasive fungal pathogen that can cause fatal mucormycosis in immunodeficient individuals. Encephalitis caused by R. delemar is rare and difficult to diagnose early. Clinical detection methods for R. delemar include blood fungal culture, direct microscopic examination, and histopathological examination, but the detection is often inadequate for clinical diagnosis and can easily lead to missed diagnosis with delayed treatment.

CASE PRESENTATION

We report a case of a 47-year-old male with brainstem hemorrhage caused by encephalitis due to R. delemar. The patient had a history of hypertension, type 2 diabetes, and irregular medication. No pathogens were detected in cerebrospinal fluid (CSF) and nasopharyngeal secretion cultures. R. delemar was identified by metagenomic next-generation sequencing (mNGS) in CSF, and in combination with the patient's clinical characteristics, encephalitis caused by R. delemar was diagnosed. Antibiotic treatment using amphotericin B liposome in combination with posaconazole was given immediately. However, due to progressive aggravation of the patient's symptoms, he later died due to brainstem hemorrhage after giving up treatment.

CONCLUSIONS

mNGS technique is a potential approach for the early diagnosis of infections, which can help clinicians provide appropriate antibiotic treatments, thus reducing the mortality and disability rate of patients.

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.

Health Literacy and Clinic-Epidemiological Profile of Patients with COVID-19-Associated Mucormycosis: A Questionnaire-Based Study

Background The patient partnership is desirable for the optimal management of comorbidities. This became significant more so during the coronavirus disease 2019 (COVID-19) crisis wherein health infrastructure was overburdened.

Objectives The aim of this study was to estimate the clinicoepidemiological profile, health literacy regarding predisposing risk factors, and disease management in patients with COVID-19-associated mucormycosis (CAMCR).

Materials and Methods A structured questionnaire-based study on randomly chosen 100 microbiologically proven patients of CAMCR, consisting of 38 multiple choice questions, was designed with each answer having a patient and assessor response to it.

Results A male predilection was seen (68%) with rhino-orbital (73%) being the commonest anatomic site. Forty-nine percent of the study participants had pre-existing diabetes of which 62% did not carry out regular blood sugar monitoring and in 18%, blood sugars were controlled prior to COVID-19. Thirty-five percent of patients with mild COVID-19 illness were treated with unwarranted steroids and 56% of patients had fluctuating blood sugar levels, during COVID-19 illness.

Seventy-nine percent of patients were not vaccinated against COVID-19, 16% only partially vaccinated. Seventy-one percent of patients were not aware of red flag signs and of mucormycosis with 8% presenting early, on noticing nasal symptoms.

Conclusion This study observed diabetes as the most common comorbidity in patients with CAMCR. A lacuna in the health literacy of diabetics presenting with CAMCR was found. Additionally, knowledge regarding glycemic control during COVID-19 illness with or without the use of steroids and awareness of the “red flag” signs of CAMCR were mostly lacking. Interventions to improve awareness amongst patients with diabetes should help in optimal glycemic control, and avoid potential complications like severe COVID-19 illness, and mucormycosis.

Surge of mucormycosis during the COVID-19 pandemic

Patients with respiratory viral infections are more likely to develop co-infections leading to increased fatality. Mucormycosis is an epidemic amidst the COVID-19 pandemic that conveys a 'double threat' to the global health fraternity. Mucormycosis is caused by the Mucorales group of fungi and exhibits acute angioinvasion generally in immunocompromised patients. The most familiar foci of infections are sinuses (39%), lungs (24%), and skin tissues (19%) where the overall dissemination occurs in 23% of cases. The mortality rate in the case of disseminated mucormycosis is found to be 96%. Symptoms are mostly nonspecific and often resemble other common bacterial or fungal infections. Currently, COVID-19-associated mucormycosis (CAM) is being reported from a number of countries such as the USA, Turkey, France, Mexico, Iran, Austria, UK, Brazil, and Italy, while India is the hotspot for this deadly co-infection, accounting for approximately 28,252 cases up to June 8, 2021. It strikes patients within 12-18 days after COVID-19 recovery, and nearly 80% require surgery. Nevertheless, the mortality rate can reach 94% if the diagnosis is delayed or remains untreated. Sometimes COVID-19 is the sole predisposing factor for CAM. Therefore, this study may provide a comprehensive resource for clinicians and researchers dealing with fungal infections, intending to link the potential translational knowledge and prospective therapeutic challenges to counter this opportunistic pathogen.

Spotlight on the Mucormycosis Outbreak: A Deadly Fungal Infection That Followed the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic along with its treatment has brought myriad potential complications including the heightened risk of secondary fungal infections like mucormycosis. Mucormycosis is a rare angioinvasive fungal infection that has traditionally been highly fatal despite surgical intervention and antifungal medications.

AIM

To re-evaluate the risk factors, epidemiology, and possible COVID-19-associated conditions on a larger sample size than the existing data.

METHODOLOGY

We studied the possible risk factors, clinical presentations, treatment, and outcome of 203 patients with mucormycosis in a single-center retrospective-prospective observational study for three months at a tertiary care hospital after obtaining due permission from the institutional ethics committee.

RESULTS

The mean age of patients was 52 ± 11.5 years, and 92.61% had a history of COVID-19 infection. Around 86.7% of patients were suffering from diabetes mellitus with 50% being already known cases whereas the other 50% developed post-COVID-19 infection; 65.02% of patients were administered corticosteroids during their COVID-19 treatment. About 51.72% of patients required hospital admission and among them, 16.25% of patients required ICU support. The mean oxygen saturation (SpO2) levels on admission were 84.61 ± 12.96%, and 38.92% of patients required mechanical respiratory support. The mean duration between COVID-19 infection and the onset of mucormycosis was 18.80 ± 16.61 days. The most common clinical presentations were facial pain and swelling (26.6%) and ophthalmic symptoms including eye swelling, pain, and ptosis (25.12%). Antifungal treatment was given to all the patients and 89.36% of the patients underwent surgical debridement of fungal mass. At the end of three months, 60.59% of the 188 patients survived with improvement, 13.30% had no improvement and/or deterioration of health, and 18.72% succumbed to mucormycosis. Intracranial involvement and leukocytosis were positively associated with mortality whereas surgical intervention was significant for positive outcomes at the end of three months in patients with mucormycosis (p<0.05).

CONCLUSION

The sudden rise of mucormycosis during the second wave of COVID-19 can be attributed to uncontrolled blood sugar levels along with high corticosteroid usage as well as various nosocomial factors during the COVID-19 treatment. Early and aggressive treatment with surgical intervention and antifungal drugs can improve disease outcomes.

Epidemiological Characteristics, Pathogenesis and Clinical Implications of Sinusitis in the Era of COVID-19: A Narrative Review

Sinusitis is a common condition with various forms and different etiologies. In the era of COVID-19, a large number of studies covered the association between sinusitis and COVID-19, while others reported the impact of COVID-19 on the development of acute invasive fungal rhinosinusitis (AIFR), together with the most commonly associated predisposing factors. Fungal sinusitis, particularly AIFR, can be life-threatening. It is important to dissect this association and improve current evidence and management. Therefore, we conducted this literature review to highlight the association between COVID-19 and sinusitis based on evidence from the available studies in the literature. Evidence shows that chronic sinusitis might have a negative impact on COVID-19 outcomes. However, current results are conflicting, and further studies are needed. On the other hand, COVID-19 can also cause olfactory dysfunction, which is usually temporary. In addition, we found several studies that indicated the association between COVID-19 and AIFR. The condition is usually associated with severe morbidities, as affected patients are usually immunocompromised, including those with uncontrolled diabetes, malignancy, immunosuppression, AIDS, the administration of chemotherapy and other immunosuppressive drugs, and COVID-19.

Diagnostic and therapeutic strategies of acute invasive fungal rhinosinusitis

Acute invasive fungal rhinosinusitis (AIFR) is a rare disease, but the prognosis is by no means ideal. Pathologically, fungal infection is not only located in the sinus cavity, but also invades the sinus mucosa and bone wall, the surrounding structures and tissues such as the orbit and anterior skull base are often compromised and are accompanied with intracranial and extracranial complications. Despite decades of efforts, acute invasive fungal rhinosinusitis remains a devastating disease, the mortality of the disease continues to hover around 50%. The main impediments to improving the prognosis of acute invasive fungal rhinosinusitis are the difficulties of early diagnosis and the rapid reversal of immune insufficiency. Moreover, aggressive surgery combined with systemic antifungal therapy are significant positive prognostic factors as well. Progress and standardization of AIFR treatment protocols have been limited by the scarcity of the disease and the absence of published randomized studies. Therewith, how to improve the therapeutic outcome and reduce the mortality rate has always been a challenging clinical discussion. We have summarized the relevant case series and literature from the recent years, management with optimal diagnostic and curative strategies are reviewed.

Mucormycosis as Post Coronavirus Disease Complication

Mucormycosis is called as black fungus, which is caused by fungus belonged to Mucorales. If this fungus, effects healthy individuals it won't cause any serious complications, but it may cause life-threatening issues when Mucorales affects individuals who have low immunity. The mortality rate of black fungus is more than 50%, and it may also range till 100% if the individual is having any preexisting or chronic disease. This was the case of a 55-year-old male patient complaint of having generalized pain in the maxillary teeth bilaterally and suffering fullness in the maxillary sinus. To check on other possible diseases, doctors have conducted other diagnosis tests, and orthopantomogram revealed in the diagnosis that there was the presence of haziness in the left maxillary sinus, which looked like an incompletely formed soap bubble and additionally he diagnosed with coronavirus disease positive. Then, doctors suggested a chest computerized tomography (CT) along with head CT excluding the brain and further investigation of this case was given below in detail. The report reveals acute necrotizing suppurative sinusitis with dead bony tissue, soft-tissue necrosis with fungal infestation showing broad hyphae with right-angle branching suggestive of mucormycosis.

A case of COVID-19-associated rhino-orbito-cerebral mucormycosis caused by Apophysomyces variabilis with a review of the literature

A fatal case of COVID-19-associated mucormycosis (CAM) affected a 40-year-old woman who was initially admitted to our hospital due to a SARS-CoV-2 infection. Her clinical condition worsened, and she finally died because of respiratory failure, hemodynamic instability, and mucormycosis with invasion into the orbit and probably the brain. According to DNA sequence analysis of the fungus isolated from the patient, Apophysomyces variabilis was involved. This is the first published case of CAM and the third case of mucormycosis due to this mold.

Mucormycosis in pre-COVID-19 and COVID-19 era: A study of prevalence, risk factors and clinical features

Objective

Mucormycosis is a rare yet devastating fungal disease with a frequently fatal outcome. The purpose of this study was to compare the prevalence of mucormycosis, evaluate its risk factors, and assess the patients' outcomes in pre-COVID-19 and COVID-19 era.

Methods

In this retrospective observational study, clinical data of 158 patients with confirmed histopathological diagnosis of mucormycosis were collected from the medical records departments of Imam Reza and Ghaem hospitals, Mashhad, Iran during 2018-2021. The collected data were risk factors associated with mucormycosis including age, gender, underlying diseases, details of corticosteroid administration, and complications such as blindness and mortality.

Results

Of 158 studied patients, 48 patients were diagnosed in the pre-pandemic period whereas 110 cases were admitted during the pandemic era. COVID-19 associated mucormycosis (CAM) was observed in 58.1% of the pandemic cases. In the pre-pandemic period, cancer (89.5% vs. 39%, p < .001) was significantly more prevalent while during the pandemic era, the prevalence of diabetes mellitus (16.7% vs. 51%, p < .001) was remarkably higher. Moreover, the mortality rate of mucormycosis was considerably reduced after the pandemic (64.6%-45.4%), especially in CAM patients (35.9%).

Conclusion

The COVID-19 pandemic has led to an increased prevalence of mucormycosis, due to the convergence of interlinked risk factors such as diabetes mellitus, corticosteroid therapy, and COVID-19. Therefore, clinicians must be aware of the probable occurrence of mucormycosis in the first or second week of COVID-19 infection in vulnerable patients and use the steroids cautiously.

Level of evidence

4 Laryngoscope Investigative Otolaryngology, 2022.

Gastrointestinal Mucormycosis-Induced Massive Lower Gastrointestinal Bleeding, Rectal Perforation, and Pulmonary Embolism: A Long Diagnostic Pathway in a Case Report

Introduction

Mucormycosis is a rare systemic fungal infection, mainly observed in immunocompromised patients. It is responsible for surface and deep tissue destruction leading to perforations and hemorrhage. Its pathogenesis represented by an angio-invasion is at the origin of a local infarction and a vascular thrombosis. We report a case of gastrointestinal (GI) mucormycosis-induced multiple gastric ulcers, GI bleeding and rectal perforation.

Case Presentation

A 75-year-old man, with type II diabetes mellitus, was admitted to the intensive care unit for an acute abdominal pain associated with massive hematochezia. Clinical examination was that of an acute peritonitis and a hemorrhagic shock state. Abdominal and pelvic CT scan with intravenous contrast concluded to a perforation of the anterior wall of the rectum. He underwent immediate laparotomy with temporary colostomy. Several upper GI endoscopies had shown multiple gastric ulcer lesions. Lower GI endoscopy showed a fistulous orifice of the rectum on its anterior surface. Histopathology of the gastric biopsy showed acute and subacute inflammatory changes with filamentous elements suggesting mucormycosis. Histopathology of the rectal biopsy showed a subacute non-specific inflammation. Culture of the secretions from the rectal fistula orifice showed the strain Rhizopus sp. Antifungal susceptibility testing reported sensitivity to liposomal amphotericin B. The diagnosis of GI mucormycosis-induced multiple gastric ulcers, rectal perforation and pulmonary embolism in the patient with type II diabetes mellitus was retained. The outcomes were favorable after 6 weeks of treatment with liposomal amphotericin B associated with temporary colostomy and appropriate diabetes management.

Conclusion

GI mucormycosis remains a multidisciplinary diagnostic challenge, less frequent in clinical practice, with a long diagnostic pathway. This opportunistic systemic mycosis can lead to numerous GI complications including perforation, massive GI bleeding and even multiple extra-GI complications. GI mucormycosis has a good prognosis if it is treated early with medical and surgical treatment.

Mortality-Related Risk Factors for Coronavirus Disease (COVID-19)-Associated Mucormycosis: a systematic review and meta-analysis

Purpose of Review

Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) can increase the susceptibility of individuals to contracting mucormycosis through several mechanisms. Nowadays, coronavirus disease (COVID-19)-associated mucormycosis (CAM) is a serious public health concern, particularly in developing countries. This meta-analysis aims to identify the risk factors that affect the mortality rate of patients with CAM.

Recent Findings

We systematically searched PubMed, Google Scholar, Scopus, Cochrane library, and preprint databases using pertinent keywords and the reference lists of the included relevant articles from inception till October 27, 2021. In order to reduce the effects of small-scale studies, we only selected cross-sectional, case–control, and cohort studies and case series with at least four patients. We identified 26 articles that included 821 patients with CAM. The effect size (ES) of mortality rate was 28% (95% confidence interval (CI) 20%–38%; I² =82.28%; p for Cochran Q<0.001). The CAM patients with a history of comorbidities other than diabetes (malignancies, transplant, or renal failure), mechanical ventilation due to COVID-19, pulmonary and cerebral mucormycosis, and those who only received medical treatment for mucormycosis had the highest mortality rate.

Summary

Coronavirus disease (COVID-19)-associated mucormycosis (CAM) is a major public health problem, particularly in developing countries. Severe COVID-19 infection, history of mechanical ventilation, early CAM, comorbidities other than diabetes (malignancies, transplant, or renal failure), pulmonary and rhino-orbito-cerebral mucormycosis, and delivering only medical treatment for mucormycosis were the worst prognostic factors in CAM patients. Identifying the mortality-related risk factors in CAM patients may help reduce the mortality rate by implementing optimized treatment approaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12281-022-00440-2.

Rhino-Orbital-Cerebral Mycosis and Extranodal Natural Killer or/and T-Cell Lymphoma, Nasal Type

Background

Extranodal natural killer/T-cell lymphoma, nasal type is a syndrome of middle face destruction with an association to Epstein-Barr virus. Fungi have been recovered from the diseased tissue now and then but were often seen as a lymphoma-associated secondary infection. However, there are ENKTL-NT cases with the recoveries of fungi and complete recovery with antifungal therapy, which are quite similar to rhino-orbital-cerebral mycosis (ROCM) that often confuses the physicians.

Methods

We searched Medline for English-language manuscripts limited to “human” and “case reports,” “letters,” “reviews,” and “clinical conferences” from 1966 to 2022. We used MeSH terms “lymphoma, extranodal nk-t-cell” [MeSH Terms] or “lethal midline granuloma” [MeSH Terms], in combination with MeSH terms “microbiology” [subheading] or “microbiology” [all fields] or “fungi” [all fields] or “fungi” [MeSH Terms] for ENKTL-NT with infections. We used MeSH terms “Mycoses” in combination with “Nose” [Mesh] OR “Orbital Diseases” [Mesh] for rhino-orbital-cerebral fungal infections.

Results

We appraised 149 included articles and extracted references related to ENKTL-NT and/or ROCM. Themes and subcategories were subsequently derived. Our findings revealed that ROCM and ENKTL-NT are characterized by progressive and destructive ulcers in the midline face or rhino-orbital structures. ROCM is mainly caused by fungi in the order of Mucorales, and ENKTL-NT is usually associated with Epstein-Barr virus and sometimes fungi. Radiologically, both are characterized by non-specific features of sinusitis, soft tissue infection, and necrosis. Pathologically, ROCM and ENKTL-NT share the same characteristics of inflammation, necrosis, and granuloma. ROCM is characterized by the detection of fungi in tissue, while ENKTL-NT is typically positive for NK/T-cell markers and cytotoxic granule-associated proteins, proliferation, and vascular damage of angioinvasion, which could be incited by Mucor irregularis and Rhizopus arrhizus in patients and mice.

Conclusion

ENKTL-NT and ROCM share many similarities in clinical presentations, radiology, and histopathology, and might have the same etiology. This may explain why the two diseases are tangled together in the reported cases, and suggests the role that the fungi may play in the development of these ENKTL-NT/ROCM diseases. The reason why ENKTL-NT and ROCM are sometimes confused is that the main pathogens of ROCM, Mucor irregularis and Rhizopus arrhizus, are the fungal causative agents of ENKTL-NT.

Mucormycosis in COVID-19 Patients: A Case-Control Study

(1) Background: During the second wave of COVID-19, India faced a rapid and sudden surge of not only COVID19-delta variant cases but also mucormycosis, making the infection even more fatal. We conducted a study to determine factors associated with the occurrence of mucormycosis in patients with COVID-19. (2) Methods: This case–control study comprised 121 patients; 61 cases (mucormycosis with COVID-19) and 60 controls. Patients were included from April 10, 2021 onwards. Follow-up was conducted after about 90 days and health status was recorded based on the modified Rankin Scale (mRS). (3) Results: Mucormycosis with COVID-19 cases had a median (IQR) age of 49 (43–59) years with 65.6% males and were older (95% CI 1.015–1.075; p = 0.002) than in the control group with median (IQR) 38 (29–55.5) years and 66.6% males. Baseline raised serum creatinine (OR = 4.963; 95% CI 1.456–16.911; p = 0.010) and D-dimer (OR = 1.000; 95% CI 1.000–1.001; p = 0.028) were independently associated with the occurrence of mucormycosis in COVID-19 patients. Additionally, diabetes mellitus (OR = 26.919; 95% CI 1.666–434.892; p = 0.020) was associated with poor outcomes and increased mortality in patients with mucormycosis with COVID-19 as per the multivariable analysis. A total of 30/61 mucormycosis patients had intracranial involvement. (4) Conclusions: The study observed elevated levels of baseline raised creatinine and D-dimer in mucormycosis pa-tients with COVID-19 as compared to the control group. However, future studies may be conducted to establish this cause–effect relationship.

Mass spectrometry in research laboratories and clinical diagnostic: a new era in medical mycology

Diagnosis by clinical mycology laboratory plays a critical role in patient care by providing definitive knowledge of the cause of infection and antimicrobial susceptibility data to physicians. Rapid diagnostic methods are likely to improve patient. Aggressive resuscitation bundles, adequate source control, and appropriate antibiotic therapy are cornerstones for success in the treatment of patients. Routine methods for identifying clinical specimen fungal pathogen are based on the cultivation on different media with the subsequent examination of its phenotypic characteristics comprising a combination of microscopic and colony morphologies. As some fungi cannot be readily identified using these methods, molecular diagnostic methods may be required. These methods are fast, but it can cost a lot. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) is suitable for high-throughput and rapid diagnostics at low costs. It can be considered an alternative for conventional biochemical and molecular identification systems in a microbiological laboratory. The reliability and accuracy of this method have been scrutinized in many surveys and have been compared with several methods including sequencing and molecular methods. According to these findings, the reliability and accuracy of this method are very high and can be trusted. With all the benefits of this technique, the libraries of MALDI-TOF MS need to be strengthened to enhance its performance. This review provides an overview of the most recent research literature that has investigated the applications and usage of MT-MS to the identification of microorganisms, mycotoxins, antifungal susceptibility examination, and mycobiome research.

Mucormycosis, a post-COVID infection: possible adjunctive herbal therapeutics for the realigning of impaired immune-metabolism in diabetic subjects

Cytokine storm is believed as a major root cause for multi-organ failure and death in severely infected diabetic patients with COVID-19. This condition is treated with anti-inflammatory drugs, mainly steroids, to recover people from critical conditions. However, steroid therapy causes immune suppression and uncontrolled hyper-glycaemia in post-COVID. This altered immune-metabolism provides a fertile environment for the infection of a black fungus, Rhizopus arrhizus which causes mucormycosis in diabetic patients. It is a life-threatening infection causing death in different countries. It is treated either with anti-fungal drugs, surgical debridement, or adjunctive therapies. The available therapies for mucormycosis have been associated with several drawbacks. Thus, the present review has explored and suggested herbs-spices based adjunctive therapy for possible realignment of the impaired immune system in the post-COVID diabetic subjects. The consumption of herbal therapeutics after COVID-19 could realign the impaired immune-metabolism in the post-COVID and thereby exert prophylactic effects against mucormycosis. Furthermore, the suggested herbal sources could help in the discovery of novel therapeutics against the COVID-19 associated mucormycosis.

Oral Tissue Involvement and Probable Factors in Post-COVID-19 Mucormycosis Patients: A Cross-Sectional Study

The primary goal of this study was to assess the prevalence of oral involvement and, secondarily, the likely variables in patients with confirmed COVID-19 accompanied by mucormycosis infection. The study design was a cross-sectional descriptive sort that was performed at a tertiary centre. The non-probability convenience sampling approach was used to determine the sample size. Between May 2021 and July 2021, all patients who presented to our tertiary care centre with suspected mucormycosis were considered for the investigation. The research only included individuals with proven mucormycosis after COVID-19. The features of the patients, the frequency of intraoral signs/symptoms, and the possible variables were all noted. Of the 333 COVID-19-infected patients, 47 (14%) were diagnosed with confirmed mucormycosis. The mean (SD) age of the patients was 59.7 (11.9) years. Of the 47 patients with confirmed mucormycosis, 34% showed sudden tooth mobility, 34% expressed toothache, 8.5% reported palatal eschar, 34% presented with jaw pain, 8.5% had tongue discoloration, and 17% had temporomandibular pain. About 53% of the patients were known cases of type 2 diabetes mellitus, 89% of patients had a history of hospitalization due to COVID-19 infection, 89.3% underwent oxygen support therapy, and 89.3% were administered intravenous steroids during hospitalization due to COVID-19 infection. About 14% of the suspected cases attending the mucormycosis out-patient department (OPD) had been confirmed with definite mucormycosis. Oral involvement was seen in 45% of cases of CAM (COVID-associated mucormycosis). The most frequent oral symptoms presented in CAM were sudden tooth mobility and toothache. Diabetes and steroids were the likely contributing factors associated with CAM.

Mucormycosis infection in patients with COVID ‐19: A systematic review

Introduction

Several reports previously described mucormycosis co‐infection in patients with COVID‐19. As mucormycosis and COVID‐19 co‐infection might adversely affect patients' outcomes, we aimed to systematically review the related evidence and the subsequent outcomes.

Methods

We conducted a systematic review of relevant articles searching the keywords in the online databases of PubMed, Scopus, Embase, Cochrane, and Web of Science. All the records from the start of the pandemic until June 12th, 2021 underwent title/abstract and then full‐text screening process, and the eligible studies were included. We did not include any language or time restrictions for the included studies.

Results

We found 31 eligible studies reporting 144 total cases of COVID‐19 and mucormycosis co‐infection. The nose, cranial sinuses, and orbital cavity were the most commonly involved organs, although the cerebrum, lungs, and heart were also involved in the studies. Pre‐existing diabetes mellitus (DM), as well as corticosteroid use, were the most commonly identified risk factors, but other underlying conditions and immunomodulatory drug use were also present in several cases. Aspergillus was the most commonly reported micro‐organism that caused further co‐infections in patients with concurrent COVID‐19 and mucormycosis. As most of the studies were case reports, no reliable estimate of the mortality rate could be made, but overall, 33.6% of the studied cases died.

Conclusion

Early diagnosis of mucormycosis co‐infection in COVID‐19 patients and selecting the right treatment plan could be a challenge for physicians. Patients with underlying co‐morbidities, immunocompromised patients, and those receiving corticosteroids are at higher risk of developing mucormycosis co‐infection and it is crucial to have an eye examination for early signs and symptoms suggesting a fungal infection in these patients.

The Spectrum of Invasive Fungal Sinusitis in COVID-19 Patients: Experience from a Tertiary Care Referral Center in Northern India

This study aimed to determine the patient demographics, risk factors, which include comorbidities, medications used to treat COVID-19, and presenting symptoms and signs, and the management outcome of COVID-19-associated invasive fungal sinusitis. A retrospective, propensity score-matched, comparative study was conducted at a tertiary care center, involving 124 patients with invasive fungal sinusitis admitted between April 2021 and September 2021, suffering from or having a history of COVID-19 infection. Among the 124 patients, 87 were male, and 37 were female. A total of 72.6% of patients received steroids, while 73.4% received antibiotics, and 55.6% received oxygen during COVID-19 management. The most common comorbidities were diabetes mellitus (83.9%) and hypertension (30.6%). A total of 92.2% had mucor, 16.9% had aspergillus, 12.9% had both, and one patient had hyalohyphomycosis on fungal smear and culture. The comparative study showed the significant role of serum ferritin, glycemic control, steroid use, and duration in COVID-19-associated invasive fungal disease (p < 0.001). Headache and facial pain (68, 54.8%) were the most common symptoms. The most involved sinonasal site was the maxillary sinus (90, 72.6%). The overall survival rate at the three-month follow-up was 79.9%. COVID-19-related aggressive inflammatory response, uncontrolled glycemic level, and rampant use of steroids are the most important predisposing factors in developing COVID-19-associated invasive fungal sinusitis.

Covid-19-Related Acute Invasive Fungal Sinusitis: Clinical Features and Outcomes

Introduction There is a noticeable increase in the incidence of acute invasive fungal sinusitis which coincides with the ongoing coronavirus pandemic. It is a potentially-lethal fungal infection, with the most common form being the rhino-orbito-cerebral presentation.

Objectives The aim of the present study is to discuss the different epidemiological factors, risk factors, clinical presentations and outcomes of acute invasive fungal sinusitis which is noticeably related to the coronavirus disease 2019 (Covid-19) pandemic.

Methods The present cross-sectional cohort study included 22 adult patients who presented with Covid-19-related acute invasive fungal sinusitis. The diagnosis of acute invasive fungal sinusitis was confirmed by histopathological biopsy. All data, including demographics, risk factors, clinical findings, different lines of treatment and their outcomes, were recorded and analyzed.

Results All patients had diabetes mellitus (100%), and 17 (77.3%) had been submitted to systemic steroids. All patients (100%) had unilateral sinonasal disease. Proptosis was found in 15 patients (68.2%), ophthalmoplegia was observed in 12 patients (54.5%), and intracranial affection occurred in 10 patients (45.5%). A total of 20 patients (90.9%) received liposomal amphotericin B. Surgical debridement was performed in 18 patients (45.5%). Non-septated mycelia was present in 19 biopsies (86.4%), while 3 (13.6%)showed septated mycelia. Total improvement was achieved in 10 patients (45.5%), while the mortality rate was of 27.3% (6 out of 22 participants).

Conclusion Diabetes mellitus is the most common preexisting medical condition associated with Covid-19-related acute invasive fungal sinusitis. Systemic corticosteroid therapy is considered a predisposing factor. It is necessary to raise the level of awareness to diagnose this condition, especially in patients with Covid-19 infection or those who have recently recovered from it.

Mucormycosis of jaws – Literature review and current treatment protocols

Mucormycosis is a modern-day lifestyle disease that has burst into the health-care scenario. It is an opportunistic fungal infection that proliferates into the immunocompromised host by invasion of the fungus into the paranasal sinuses, thereby invading the palate, maxilla, and orbit. Left untreated it invades the cranial components such as cavernous sinus, skull base, and brain. Mucormycosis invades blood vessels, making these infections highly angioinvasive. We reviewed 45 cases of mucormycois of the head-and-neck region from 2010 to 2020 on the basis of electronic search peer-reviewed journals in Medline (PubMed) database. Presenting symptoms, risk factors, history of extraction, and treatment were tabulated and the data were analyzed. The mean age of patients was 53.8 years. 73.93% of patients had diabetes mellitus, 13.63% of patients had no immunocompromised state, and 8.74% of patients had other medical disorders. About 34.78% of cases had a history of extraction prior to manifestation of symptoms. Mucormycosis remains difficult to treat disease with a high mortality rate. At present, the triad of clinician's awareness, appropriate antifungal therapy, and aggressive surgical intervention represents treatment protocols against the disease.

Epidemiology and Antifungal Susceptibility Patterns of Invasive Fungal Infections (IFIs) in India: A Prospective Observational Study

The epidemiology of invasive fungal infections (IFI) is ever evolving. The aim of the present study was to analyze the clinical, microbiological, susceptibility, and outcome data of IFI in Indian patients to identify determinants of infection and 30-day mortality. Proven and probable/putative IFI (defined according to modified European Organization for Research and Treatment of Cancer/Mycoses Study Group and AspICU criteria) from April 2017 to December 2018 were evaluated in a prospective observational study. All recruited patients were antifungal naïve (n = 3300). There were 253 episodes of IFI (7.6%) with 134 (52.9%) proven and 119 (47%) probable/putative infections. There were four major clusters of infection: invasive candidiasis (IC) (n = 53, 20.9%), cryptococcosis (n = 34, 13.4%), invasive aspergillosis (IA) (n = 103, 40.7%), and mucormycosis (n = 62, 24.5%). The significant risk factors were high particulate efficiency air (HEPA) room admission, ICU admission, prolonged exposure to corticosteroids, diabetes mellitus, chronic liver disease (CLD), acquired immunodeficiency syndrome (AIDS), coronary arterial disease (CAD), trauma, and multiorgan involvement (p < 0.5; odds ratio: >1). The all-cause 30-day mortality was 43.4% (n = 110). It varied by fungal group: 52.8% (28/53) in IC, 58.8% (20/34) in cryptococcosis, 39.8% (41/103) in IA, and 33.9% (21/62) in mucormycosis. HEPA room, ICU admission for IC; HEPA rooms, diabetes mellitus for cryptococcosis; hematological malignancies, chronic kidney disease (CKD), sepsis, galactomannan antigen index value ≥1 for IA and nodules; and ground glass opacities on radiology for mucormycosis were significant predictors of death (odds ratio >1). High minimum inhibitory concentration (MIC) values for azoles were observed in C. albicans, C. parapsilosis, C. glabrata, A. fumigatus, A. flavus, R. arrhizus, R. microsporus, and M. circinelloides. For echinocandin, high MIC values were seen in C. tropicalis, C. guillermondii, C. glabrata, and A. fumigatus. This study highlights the shift in epidemiology and also raises concern of high MICs to azoles among our isolates. It warrants regular surveillance, which can provide the local clinically correlated microbiological data to clinicians and which might aid in guiding patient treatment.

COVID-19-associated mucormycosis: Preliminary report from a tertiary eye care centre

Purpose:

Mucormycosis is a life-threatening infection that has made sudden comeback in COVID-19 era. We conducted this study to determine demography, site of involvement, management, and outcome in these patients.

Methods:

All cases presenting with signs and symptoms of mucormycosis were thoroughly evaluated and confirmed diagnosis was made on demonstration of fungi in the tissue (or body fluids) either by direct microscopy and/or culture. Patients underwent computerized tomography scan for paranasal sinuses and magnetic resonance imaging scan with contrast orbit and brain to know extent of disease.

Results:

540 proven cases of mucormycosis were included. Most common age group affected was 41–50 years with male preponderance (69%). Sinonasal was the most common site of involvement in mucormycosis (100%), followed by orbital (51.85%), cerebral (9.44%), cutaneous (1.85%), and pulmonary (0.18%). Most common presentation was periocular and facial swelling (28%). 97.96% patients had associated diabetes and 89.44% patients had history of COVID-19 with concurrent steroids use (84.85%), higher antibiotics (82.59%), oxygen therapy (52.40%), remdesivir (28.89%), and biological agents (2.56%). Duration from COVID-19 positivity to presentation of mucormycosis was 22.56 days, while 4.44% patients had coexisting COVID-19 with mucormycosis. The mortality rate was 9.25% (50/540).

Conclusion:

Timely diagnosis and appropriate management can ameliorate the consequences of mucormycosis. With the third wave of COVID-19 coming, epidemiological study to identify risk factors and possible management options can help physicians to develop the treatment strategy.

Rhino-Orbito-Cerebral Mucormycosis During the Second Wave of Covid-19: The Indian Scenario

Mucormycosis is a life threatening, opportunistic infection often seen in individuals with a weak immune system. With an upsurge of cases of Covid-19, a drastic increase in cases of Rhino-Orbito-Cerebral Mucormycosis is being witnessed at present. This article has been written with the purpose of understanding the factors responsible for it and the challenges it brings along for the Indian health-care system at present. Possible solutions for dealing with these problems have also been included in the manuscript. Google, PubMed and ENT Cochrane databases were searched without a time limit using key words like “Mucormycosis”, “Rhino-cerebral-mucormycosis” in conjunction with “COVID-19” and “SARS CoV-2”. We found 34 articles to be relevant and hence included them to write this review. Rhino-Orbito-Cerebral Mucormycosis is being seen due to coming together of the three entities-the agent, host and environment that constitute the epidemiological triad for this disease in India. Responsible factors are uncontrolled diabetes mellitus, overzealous use of steroids and antibiotics and other environment related issues. The solutions for these problems lie in spreading awareness about prevention of these practices along with early diagnosis and treatment of mucormycosis. To deal effectively with this situation, particularly when there is an existing overload on otolaryngologists and the rest of the health-care system, a multipronged and multilevel collaborative approach is the need of the hour. With effective Standard Operating Procedures and guidelines promoting a multidisciplinary approach for early diagnosis and treatment, we can surely overcome this situation.

Evaluation of Direct Examination, Culture, and Histopathology in the Diagnosis of Mucormycosis: Reiterating the Role of KOH Mount for Early Diagnosis

Introduction

Invasive fungal infections have always been a major cause of mortality and morbidity and are especially prevalent in the immunosuppressed groups of patients. Members of the Mucoracea family have an increasing incidence and prevalence. It has always been difficult to diagnose this condition due to various reasons.

Materials and Methods

This was an observational study carried out jointly by the Department of Microbiology and the Department of Pathology for a duration of one year. All patients who presented in various clinical departments with a high index of clinical suspicion for mucormycosis were included in this study. A total of 186 samples were received from suspected cases of mucormycosis and were all subjected to direct microscopy by potassium hydroxide (KOH), fungal culture, and histopathological examination.

Results

Mucormycosis was documented in 33 out of 186 cases on direct microscopy, whereas 21 were positive on fungal culture. Histopathological positivity was reduced with only 11 cases showing aseptate hyphae suggestive of mucormycosis.

Conclusion

As these organisms generally do not grow well on routine culture media and with the histopathological results also being not suggestive clearly of mucormycosis, direct microscopy thus becomes more important and essential in the rapid diagnosis of this deadly condition.

Five probable factors responsible for the COVID-associated mucormycosis outbreak in India

The second wave of COVID-19 due to the delta variant (B.1.617.2) led to a rapid rise in total coronavirus and COVID-associated mucormycosis cases reported from India. Hence, our study explored the possible causes of a rapid upsurge in COVID-associated mucormycosis, which has accounted for over 70% of global cases. Factors associated with the increase in mucormycosis cases in COVID-19 patients include diabetes mellitus, steroid overdose, high iron levels, and immunosuppression, combined with other possible factors, such as unhygienic conditions, prolonged hospitalization, use of ventilators, and leaky humidifiers in oxygen cylinders. These create an ideal environment for contracting mucormycosis. However, these cases could be reduced by disseminating simple preventive measures and creating awareness among the medical society and general public of this rare and deadly contagion of COVID-associated mucormycosis. The identification of early symptoms will also help to restrict the spread of lethal fungal diseases. Furthermore, a collaborative team of surgeons, ophthalmologists, physicians, and otolaryngologists would be required in the hospital wards to accelerate surgeries on severely impacted patients.

COVID-19 associated mucormycosis: Staging and management recommendations (Report of a multi-disciplinary expert committee)

Even before the onslaught of COVID-19 pandemic could settle, the unprecedented rise in cases with COVID-19 associated mucormycosis pushed the medical health to the fringe. Hyperglycaemia and corticosteroids appear to be the most consistent associations leading to the commonest manifestation of mucormycosis, Rhino-Orbito-Cerebral Mucormycosis. To address challenges right from categorisation and staging of the disease to the management of relentless progression, a multi-disciplinary expert committee was formed to handle the task in an evidence-based format to enforce best practices. The report of the committee on one hand attempts to succinctly present the currently available evidence while at the other also attempts to bridge the evidence-deficient gaps with the specialty-specific virtuosity of experts.

Management outcomes of mucormycosis in COVID-19 patients: A preliminary report from a tertiary care hospital

Background

Coronavirus disease 2019 (COVID-19) continues to be a significant health problem worldwide. The unprecedented surge of mucormycosis in patients with COVID-19 is a new emerging challenge. Although a few studies documenting high incidence of mucormycosis in COVID -19 patients have recently emerged in literature, data pertaining to treatment outcomes in such cohorts is lacking. Here, we report our experience in management of mucormycosis in COVID-19 patients at our tertiary care centre.

Method

The clinical, imaging, histopathological and treatment data of 20 patients with mucormycosis (in setting of COVID-19) was analysed.

Results

35% and 65 % of cases developed mucormycosis in setting of active and recovered COVID-19 infections respectively. Diabetes mellitus was documented in 80% cases, with 55% demonstrating HbA1c >10%. Steroid was administered in 80% during COVID-19 illness. Imaging demonstrated paranasal sinus (PNS), orbital and intracranial extension in 100%, 55% and 20% patients respectively. All received amphotericin and underwent endoscopic debridement, 20% underwent orbital decompression and 5% maxillectomy with orbital exenteration. 6/20(30%) patients died (4 with rhino-orbito-cerebral disease, 1 with extensive orbito-maxillary involvement and 1 sino-nasal disease). All 6 patients received steroids and documented poor glycaemic control.

Conclusion

The strong association of hyperglycemia and steroid intake with mucormycosis in COVID-19 cases warrants judicious use of corticosteroids and optimal glycaemic control. Our study highlights that good clinical outcome can be achieved in invasive mucormycosis provided prompt treatment is instituted with aggressive surgical debridement and antifungal medication.

Post Covid-19 Infection Presenting as Rhino-Orbital Mycosis

Rhino-orbital mycosis has been recently recognised as one of the sequelae in COVID-19 recovered patients. In India, detection of mucormycosis is declared as notifiable disease. In this article, the authors aim to describe the characteristics of patients presenting with post covid fungal infection which could be detected on 10% potassium hydroxide (KOH) wet mount and Giemsa stain put on crush biopsy smear. We describe 10 COVID-19 recovered patients admitted to ENT department of the hospital during second wave of COVID-19 infection. They presented with post covid fungal sinusitis and ophthalmic complications and planned for surgery. KOH mount and Giemsa stain were used for possible opinion and confirmed by culture. The observations were described in mean and percentages. All ten (100%) COVID-19 recovered patients were previously diagnosed with type 2 diabetes mellitus (DM) for 2-11 years. All 10 patients (100%) were given oral or intravenous corticosteroids for mean of 21 days (3 weeks-till presentation to ENT department). Simple procedures with 10% KOH mount and Giemsa stain could detect fungal hypae in all the cases and could provide possible opinion in 9 of 10 (90%) cases for timely management of the patients. The authors hypothesize that uncontrolled DM and prolonged use of corticosteroids may act as culprits of rhino-orbital mycosis in COVID-19 recovered patients. Simple and routine 10% KOH mount and Giemsa stain may provide early opinion of fungal hypae to ensure quick management and survival of the patients.

Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India

BACKGROUND AND AIMS

There are increasing case reports of rhino-orbital mucormycosis in people with coronavirus disease 2019 (COVID-19), especially from India. Diabetes mellitus (DM) is an independent risk factor for both severe COVID-19 and mucormycosis. We aim to conduct a systematic review of literature to find out the patient's characteristics having mucormycosis and COVID-19.

METHODS

We searched the electronic database of PubMed and Google Scholar from inception until May 13, 2021 using keywords. We retrieved all the granular details of case reports/series of patients with mucormycosis, and COVID-19 reported world-wide. Subsequently we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, use of steroids and its outcome in people with COVID-19.

RESULTS

Overall, 101 cases of mucormycosis in people with COVID-19 have been reported, of which 82 cases were from India and 19 from the rest of the world. Mucormycosis was predominantly seen in males (78.9%), both in people who were active (59.4%) or recovered (40.6%) from COVID-19. Pre-existing diabetes mellitus (DM) was present in 80% of cases, while concomitant diabetic ketoacidosis (DKA) was present in 14.9%. Corticosteroid intake for the treatment of COVID-19 was recorded in 76.3% of cases. Mucormycosis involving nose and sinuses (88.9%) was most common followed by rhino-orbital (56.7%). Mortality was noted in 30.7% of the cases.

CONCLUSION

An unholy trinity of diabetes, rampant use of corticosteroid in a background of COVID-19 appears to increase mucormycosis. All efforts should be made to maintain optimal glucose and only judicious use of corticosteroids in patients with COVID-19.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1

Purpose

COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.

Methods

This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.

Results

Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).

Conclusion

: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Rhino-orbital mucormycosis in COVID-19 patients—a new threat?

Background

Coronavirus disease 2019 (COVID-19) is known to be associated with a myriad of viral, fungal, and bacterial co-infections. Rhino-orbital mucormycosis is a rare angio-invasive fungal infection which has shown a rising trend in the setting of COVID-19.

Case presentation

We describe the imaging findings in 3 cases of rhino-orbital mucormycosis in patients with history of COVID-19. All cases had varying involvement of paranasal sinuses extending into the orbital compartment while case 3 had intracranial extension of infection.

Conclusions

Rhino-orbital mucormycosis can have aggressive necrosis of the involved paranasal sinuses and orbits with or without cerebral extension. Hence, the correct diagnosis is imperative as prompt antifungal drugs and surgical debridement can significantly reduce mortality and morbidity.