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

Severe Fatal Mucormycosis in a Patient with Chronic Lymphocytic Leukaemia Treated with Zanubrutinib: A Case Report and Review of the Literature

Severe mucormycosis is a fatal disease rarely complicating chronic lymphoproliferative disorders. We present a fulminant and fatal case of a 74-year-old Caucasian woman suffering from CLL treated with second-generation BTK inhibitor zanubrutinib. After a first septic episode a month prior, originating from the lung with later systemic involvement by an unidentified agent and treated with large-spectrum antibiotics and fluconazonle, a slow-onset enlarging tender warm and erythematous nodular swollen cutaneous lesion appeared in her lower limbs and spread subsequently to her upper limbs, progressing towards central ulceration with a necrotic core. Suspecting a mycotic dissemination from an unknown agent, a skin punch biopsy was performed, and intraconazole was started. Due to spread of the skin lesions, the patient was hospitalized and intravenous liposomal ampthotericin B was started. Histopathology showed an atypical sporangium-rich mycotic angioinvasion of the small vessels. Only the increase of BDG and GM could corroborate the hypothesis of mycotic infection. However, long-term CLL, immunosuppressive therapies, neutropenia, and prior use of azoles and other antimycotic agents were risk factors for mucormycosis; BTK inhibitor could also be added as another novel risk factor. Despite all therapeutic efforts, the patient died. Post-mortem molecular exams confirmed the diagnosis of disseminated mucormycosis.

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.

COVID-19-associated mucormycosis: A systematic review and meta-analysis of 958 cases

BACKGROUND

Mucormycosis, a rare fungal infection, has shown an increase in the number of reported cases during the COVID-19 pandemic.

OBJECTIVES

To provide a comprehensive insight into the characteristics of COVID-19-associated mucormycosis (CAM), through a systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus, Web of Science, Cochrane, CINAHL, Ovid MEDLINE, and FungiSCOPE.

STUDY ELIGIBILITY CRITERIA

Studies reporting individual-level information in adult CAM patients between January 1, 2020 and December 28, 2022.

PARTICIPANTS

Adults who developed mucormycosis during or after COVID-19.

ASSESSMENT OF RISK OF BIAS

Quality assessment was performed based on the National Institutes of Health Quality Assessment Tool for Case Series Studies.

METHODS OF DATA SYNTHESIS

Demographic information and clinical features were documented for each patient. Logistic regression analysis was used to predict the risk of mortality.

RESULTS

958 individual cases reported from forty-five countries were eligible. 88.1% (844/958) were reported from low- or middle-income countries (LMIC). Corticosteroid use for COVID-19 (78.5%, 619/789) and diabetes (77.9%, 738/948) were common. Diabetic ketoacidosis (p<0.001), history of malignancy (p<0.001), underlying pulmonary (p=0.017) or renal disease (p<0.001), obesity (p<0.001), hypertension (p=0.040), age (>65 years) (p=0.001), Aspergillus co-infection (p=0.037), and tocilizumab use during COVID-19 (p=0.018) increased the mortality. CAM occurred on average 22 days after COVID-19 and 8 days after hospitalization. Diagnosis of mucormycosis in patients with Aspergillus co-infection and pulmonary mucormycosis was made on average 15.4 days (range 0-35) and 14.0 days (range 0-53) after hospitalization, respectively. Cutaneous mucormycosis accounted for <1% of cases. The overall mortality rate was 38.9% (303/780).

CONCLUSION

Mortality of CAM was high, and most reports were from LMIC countries. We detected novel risk factors for CAM such as older age, specific comorbidities, Aspergillus co-infection and tocilizumab use, in addition to previously identified factors.

Comparison of MRI Findings in Diabetic and Nondiabetic Patients with Rhino-Orbito-Cerebral Mucormycosis

Objective Rhino-orbito-cerebral mucormycosis (ROCM) has emerged as a key concern during the period of coronavirus disease 2019 (COVID-19) pandemic. Diabetes mellitus is a known risk factor for invasive fungal infection. The aim of this article was to study and compare the radiological features of COVID-19-associated ROCM between diabetic and nondiabetic patients using magnetic resonance imaging.

Materials and Methods A retrospective observational study comprising 78 diabetics and 40 nondiabetics who developed ROCM after COVID-19 was conducted. The imaging data of both groups were analyzed, findings tabulated and compared using statistical methods.

Results Maxillary and ethmoid sinuses were commonly involved in both groups. Periantral fat and orbits were the most common sites of disease extension. The spread of infection to periantral soft tissue was significantly higher in diabetics (p = 0.049). Diabetics were more likely to have bone, orbit, and brain involvement than nondiabetics, although the difference was not statistically significant. Diabetic patients were the only ones to experience complications such as fungal abscess and cavernous sinus and internal carotid artery involvement. However, a considerable number of nondiabetic patients (22.5%) also had an intracranial extension of disease.

Conclusion The radiological appearances and common sites of invasion in ROCM are similar in diabetic and nondiabetic patients. The extensive spread of infection to extra-sinus regions can occur in nondiabetic patients with COVID-19 but is less frequent compared with diabetics.

In vitro Activity of Isavuconazole and Comparators Against Clinical Isolates of Molds from a Multicenter Study in China

Purpose

Methods

Results

Conclusion

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: A new threat to Coronavirus disease 2019 with special emphasis on India

The main reason for the growth of mucormycosis in people with Coronavirus disease-2019 (COVID-19) is mainly produced by Rhizopus spp. The infective mechanisms and issues recognized in Rhizopus spp. are the cell wall, germination proteins, and enzymes assisted to iron sequestration, CotH protein, and positive regulation of the GRP78 cell receptor. Mucormycosis is mainly caused by the Rhizopus spp. such as R. oryzae, R. microsporus, R. arrhizus, R. homothallicus, etc. that are gifted to numerous host defense mechanisms and attribute to the endothelium via specific receptors, GRP78 simplifying their endocytosis and angio-invasion. Factors such as hyperglycemia, elevated iron concentrations, and ketoacidosis have been shown to contribute to the pathogenesis in the tentative situation. The analytical data of 'black fungus disease' or 'mucormycosis', specify India reported for about 42.3% of published cases, followed by the USA about 16.9%, Iraq, Bangladesh, Iran, Paraguay, and 1 case each from Brazil, Mexico, Italy, UK, China, France, Uruguay, Turkey, and Austria. The COVID-19 infection is maybe a predisposing factor for mucormycosis and is related to a high mortality rate. Early recognition and restriction of hyperglycemia, liposomal amphotericin B, and surgical debridement are the bases in the successful managing of mucormycosis.

The rise in cases of mucormycosis, candidiasis and aspergillosis amidst COVID19

The Coronavirus outbreak globally has changed the medical system and also led to a shortage of medical facilities in both developing and underdeveloped countries. The COVID19 disease, being novel in nature along with high infectivity and frequent mutational rate, has been termed to be fatal across the globe. The advent of infection by SARS-CoV-2 has brought a myriad of secondary complications and comorbidities resulting in additional challenges to the health care system induced by novel therapeutic procedures. The emerging variant with respect to the Indian subcontinent and the associated genetic mutations have worsened the situation at hand. Proper clinical management along with epidemiological studies and clinical presentations in scientific studies and trials is necessary in order to combat the simultaneous waves of emerging strains. This article summarizes three of the major fungal outbreaks in India namely mucormycosis, candidiasis and aspergillosis, and elaborates their subtypes, pathogenesis, symptoms and treatment and detection techniques. A detail of future therapeutics under consideration are also elaborated along with a general hypothesis on how COVID19 is related to immunological advances leading to major widespread fungal infection in the country. The factors that contribute in promoting virus proliferation and invasive fungal infections include cell-mediated immunity, associated immunocompromised conditions and treatment protocols that slows down immune mechanisms. To better comprehend a fungal or bacterial outbreak, it is very important to conduct audits mediated through multicenter national and state research teams for recognizing patterns and studying current cases of fungal infection in both healthy and comorbid groups of COVID19 patients.

Detection of mucormycosis caused by Apophysomyces elegans in a Lesser Long-nosed Bat (Leptonycteris yerbabuenae) in Central Mexico

We describe a case of mucormycosis in a Lesser Long-nosed Bat (Leptonycteris yerbabuenae) caused by Apophysomyces elegans in Puebla, Central Mexico. The diagnosis was supported by laboratory analysis and necropsy. We present the first report of the fungus in a wild host; therefore, we indicate that further studies are necessary to understand its infection cycle since this pathogen may indicate a risk of zoonotic, and anthropozoonotic diseases.

The disease burden of mucormycosis in Japan: results from a systematic literature review and retrospective database study

OBJECTIVE

To evaluate outcomes, healthcare resource utilization, and costs associated with mucormycosis in inpatient settings in Japan.

METHODS

We performed a systematic literature review, followed by a retrospective database study using hospital health claims for patients in Japan hospitalized with a diagnosis of mucormycosis between January 2010 and January 2019. Outcomes assessed included duration of index hospitalization; index stay mortality; hospital readmission within 30, 60, and 90 days after index hospitalization discharge; drug/treatment utilization and patterns; number of patients examined for mucormycosis during the index hospitalization; and index stay inpatient costs.

RESULTS

From our systematic literature review of articles describing 133 patients with mucormycosis, mortality in the index hospitalization was 55.6%. From our database study of 126 patients hospitalized for mucormycosis, mortality during the index hospitalization was 35.7% and mean index stay duration was 94 days. Hematologic malignancies were the most common risk factor in the literature review and the most common comorbidity in the database study. During the index stay, 39 patients (31.0%) received liposomal amphotericin B (L-AMB) treatment and 74 patients (58.7%) received other antifungal treatments. Median total inpatient costs for the index hospitalization were equivalent to approximately US$60,945, including US$29,283 in drug costs.

CONCLUSIONS

This study investigated the healthcare resource utilization and cost of medical resources caused by mucormycosis in Japan. The drug costs for antifungal treatments comprised about half of total inpatient costs. Mucormycosis leads to high mortality, high healthcare resource utilization, and high costs.

Comparative host transcriptome in response to pathogenic fungi identifies common and species-specific transcriptional antifungal host response pathways

Candidiasis, aspergillosis, and mucormycosis cause the majority of nosocomial fungal infections in immunocompromised patients. Using an unbiased transcriptional profiling in PBMCs exposed to the fungal species causing these infections, we found a core host response in healthy individuals that may govern effective fungal clearance: it consists of 156 transcripts, involving canonical and non-canonical immune pathways. Systematic investigation of key steps in antifungal host defense revealed fungal-specific signatures. As previously demonstrated, Candida albicans induced type I and Type II interferon-related pathways. In contrast, central pattern recognition receptor, reactive oxygen species production, and host glycolytic pathways were down-regulated in response to Rhizopus oryzae, which was associated with an ER-stress response. TLR5 was identified to be uniquely regulated by Aspergillus fumigatus and to control cytokine release in response to this fungus. In conclusion, our data reveals the transcriptional profiles induced by C. albicans, A. fumigatus, and R. oryzae, and describes both the common and specific antifungal host responses that could be exploited for novel therapeutic strategies.

Mucormycosis at a tertiary-care center in Mexico. A 35-year retrospective study of 214 cases

BACKGROUND

Mucormycosis is a rare, invasive disease associated with high mortality rates, produced by opportunistic pathogens related to the Mucorales order and characterised by a diverse range of clinical forms; acute rhino-orbital-cerebral and pulmonary symptoms are the most reported ones.

OBJECTIVES

To report the experience of mucormycosis observed in a tertiary-care hospital in Mexico for 35 years.

METHODS

This was a retrospective, descriptive and observational study on mucormycosis at a tertiary-care hospital in Mexico from January 1985 to December 2019. Demographic and clinical data and mycological and histopathological records were selected.

RESULTS

Two hundred fourteen proven cases of mucormycosis for 35 years at a tertiary-care hospital in Mexico were included. Most of the cases were male patients with a median age of 45 years. The two most associated underlying diseases were diabetes mellitus (76.6%) and haematologic malignancy (15.4%). The three primary clinical forms were as follows: rhino-orbito-cerebral (75.9%), cutaneous (8.41%) and pulmonary (7.47%) mucormycosis. The most isolated agents were Rhizopus arrhizus (58.4%) and Lichtheimia corymbifera (12.3%). The overall therapeutic response was 58.5%, and the best response was observed with amphotericin B deoxycholate and surgical debridement.

CONCLUSION

Mucormycosis is an emerging disease, and its incidence has increased at our hospital over the years. In this study, the rhino-cerebral clinical type was the most frequent in patients with uncontrolled diabetes; the main aetiological agent was R. arrhizus. Early diagnosis, control of the underlying disease and prompt management may increase the survival rate.

Mucormycosis with cutaneous involvement. A retrospective study of 115 cases at a tertiary care hospital in Mexico

BACKGROUND/OBJECTIVES

Cutaneous mucormycosis is an emerging opportunistic mycosis caused by Mucorales. It can be divided into primary caused by trauma and secondary by extension of rhino-cerebral and disseminated cases. The objective is to present a retrospective study of cases of mucormycosis with cutaneous involvement.

METHODS

A retrospective and descriptive study was carried out. Mucormycosis patients were included and divided into two groups: a) Primary Cutaneous and b) Secondary Cutaneous. Mycological tests were performed; the agents were identified by morphology and molecular studies (PCR and sequencing); some cases underwent histopathology. Clinical data and response to treatment were collected.

RESULTS

115 cases were included, 18 of primary, and 97 of secondary cutaneous mucormycosis. Primary cutaneous mucormycosis was most associated with adhesive bands (44.4%) and trauma from traffic accidents (33.3%). The principal clinical form was extensive and deep necrotic ulcers. Secondary cutaneous mucormycosis cases were rhino-cerebral with uncontrolled diabetes (81.4%) The most frequent clinical presentation was necrosis of the eyelid and the nose (65.9%). In both groups, the principal agent was Rhizopus arrhizus, 38.8% and 74.2% respectively. The most effective treatment was the combination of amphotericin B with surgical debridement. The clinical and mycological cure was achieved in 31.0% of primary cases, and 44.4% for secondary cases.

CONCLUSION

Primary cutaneous mucormycosis is caused by implantation of the Mucorales due to trauma or rupture of the cutaneous barrier-breach, and secondary cutaneous mucormycosis develops as part of the rhino-cerebral process. The response to treatment depends on the extension and depth, as well as the predisposing factors.

Gastrointestinal involvement of unusual Mucormycete Syncephalastrum racemosum in a diabetic patient with adenocarcinoma: rare case presentation with review of literature

BACKGROUND

Mucormycosis is a serious and often fatal mycotic infection caused by members of class Mucormycetes in populations with immunologic or metabolic disorders. Though several clinical manifestations are associated with mucormycetes, gastrointestinal involvement is quite rare.

CASE DESCRIPTION

We described a rare case of invasive fungal infection due to Syncephalastrum racemosum associated with gastric adenocarcinoma in a 48-year-old male patient with type II Diabetes mellitus. He presented with complaints of abdominal pain, nausea, vomiting, dyspepsia, dysphagia, loss of appetite, and weight. Histopathological examination showed broad and aseptate hyphae and culture of endoscopic biopsy tissue from pylorus and antrum yielded the fungal pathogen S. racemosum. The species was confirmed by molecular sequencing of D1/D2 region of the ribosomal DNA. The in vitro susceptibility of S. racemosum was tested by broth microdilution assay as per CLSI guidelines. The MICs suggest that the isolate was susceptible to Amphotericin B (0.25 µg/ml), Itraconazole (0.25 µg/ml) and Posaconazole (0.06 µg/ml) and showed resistance to Micafungin (>16 µg/ml). The patient was successfully treated with radical subtotal gastrectomy with lymphadenectomy and Amphotericin B antifungal therapy. There was a dilemma in concluding the pathogenicity of the isolate since; the symptoms noted were common for both gastric adenocarcinoma and mucormycosis. A review of previously reported cases on Syncephalastrum was presented in the paper with their clinical manifestations, treatment, and outcome.

CONCLUSION

To the best of our knowledge, this is the first report from India on the gastrointestinal involvement of S. racemosum. Patients with immunocompromised status are more prone to mucormycotic infections, and any typical presentations should be carefully examined for their etiological agent, and appropriate species directed therapy would help in a better outcome.

Biotic Environments Supporting the Persistence of Clinically Relevant Mucormycetes

Clinically relevant members of the Mucorales group can grow and are found in diverse ecological spaces such as soil, dust, water, decomposing vegetation, on and in food, and in hospital environments but are poorly represented in mycobiome studies of outdoor and indoor air. Occasionally, Mucorales are found in water-damaged buildings. This mini review examines a number of specialised biotic environments, including those revealed by natural disasters and theatres of war, that support the growth and persistence of these fungi. However, we are no further forward in understanding exposure pathways or the chronicity of exposure that results in the spectrum of clinical presentations of mucormycosis.

A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India

OBJECTIVES

To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality.

METHODS

We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed.

RESULTS

We included 465 patients. Rhino-orbital mucormycosis was the most common (315/465, 67.7%) presentation followed by pulmonary (62/465, 13.3%), cutaneous (49/465, 10.5%), and others. The predisposing factors included diabetes mellitus (342/465, 73.5%), malignancy (42/465, 9.0%), transplant (36/465, 7.7%), and others. Rhizopus species (231/290, 79.7%) were the most common followed by Apophysomyces variabilis (23/290, 7.9%), and several rare Mucorales. Surgical treatment was performed in 62.2% (289/465) of the participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. The 90-day mortality rate was 52% (242/465). On multivariate analysis, disseminated and rhino-orbital (with cerebral extension) mucormycosis, shorter duration of symptoms, shorter duration of antifungal therapy, and treatment with amphotericin B deoxycholate (versus liposomal) were independent risk factors of mortality. A combined medical and surgical management was associated with a better survival.

CONCLUSIONS

Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis. Combined surgical and medical management was associated with better outcomes. Several gaps surfaced in the management of mucormycosis. The rarer Mucorales identified in the study warrant further evaluation.

A prospective multicenter study on mucormycosis in India: Epidemiology, diagnosis, and treatment

Mucormycosis due to Mucorales is reported at large numbers in uncontrolled diabetics across India, but systematic multicenter epidemiological study has not been published yet. The present prospective study was conducted at four major tertiary care centers of India (two in north and two in south India) during 2013-2015 to compare the epidemiology, treatment strategies and outcome of mucormycosis between the two regions. Molecular techniques were employed to confirm the identity of the isolates or to identify the agent in biopsy samples. A total of 388 proven/probable mucormycosis cases were reported during the study period with overall mortality at 46.7%. Uncontrolled diabetes (n = 172, 56.8%) and trauma (n = 31, 10.2%) were the common risk factors. Overall, Rhizopus arrhizus (n = 124, 51.9%) was the predominant agent identified, followed by Rhizopus microsporus (n = 30, 12.6%), Apophysomyces variabilis (n = 22, 9.2%) and Rhizopus homothallicus (n = 6, 2.5%). On multivariate analysis, the mortality was significantly associated with gastrointestinal (OR: 18.70, P = .005) and pulmonary infections (OR: 3.03, P = .015). While comparing the two regions, majority (82.7%) cases were recorded from north India; uncontrolled diabetes (n = 157, P = .0001) and post-tubercular mucormycosis (n = 21, P = .006) were significantly associated with north Indian cases. No significant difference was noted among the species of Mucorales identified and treatment strategies between the two regions. The mortality rate was significantly higher in north Indian patients (50.5%) compared to 32.1% in south India (P = .016). The study highlights higher number of mucormycosis cases in uncontrolled diabetics of north India and emergence of R. microsporus and R. homothallicus across India causing the disease.

Global Epidemiology of Mucormycosis

Mucormycosis is an angio-invasive fungal infection, associated with high morbidity and mortality. A change in the epidemiology of mucormycosis has been observed in recent years with the rise in incidence, new causative agents and susceptible population. The rise has been perceived globally, but it is very high in the Asian continent. Though diabetes mellitus overshadow all other risk factors in Asia, post-tuberculosis and chronic renal failure have emerged as new risk groups. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas, pulmonary mucormycosis in patients with haematological malignancy and transplant recipients. In immunocompetent hosts, cutaneous mucormycosis is commonly seen following trauma. The intriguing clinical entity, isolated renal mucormycosis in immunocompetent patients is only reported from China and India. A new clinical entity, indolent mucormycosis in nasal sinuses, is recently recognized. The causative agents of mucormycosis vary across different geographic locations. Though Rhizopusarrhizus is the most common agent isolated worldwide, Apophysomycesvariabilis is predominant in Asia and Lichtheimia species in Europe. The new causative agents, Rhizopus homothallicus, Mucor irregularis, and Thamnostylum lucknowense are reported from Asia. In conclusion, with the change in epidemiology of mucormycosis country-wise studies are warranted to estimate disease burden in different risk groups, analyse the clinical disease pattern and identify the new etiological agents.

Disseminated mycosis in a patient with yellow fever

Disseminated mycosis (DM)—with cardiac involvement and shock—is an unexpected and severe opportunistic infection in patients with yellow fever. DM can mimic bacterial sepsis and should be considered in the differential diagnosis of causes of systemic inflammatory response syndrome in this group of patients, especially in areas where an outbreak of yellow fever is ongoing. We report the case of a 53-year-old male patient who presented to the emergency department with fever, myalgia, headache, and low back pain. The laboratory investigation revealed a positive molecular test for yellow fever, hepatic injury, and renal failure. During hospitalization, the patient developed hepatic encephalopathy, ascending leukocytosis, and ascites, with signs consistent with peritonitis. On the 11th day of hospitalization, the patient developed atrioventricular block, shock and died. At autopsy, angioinvasive mycosis was evidenced mainly in the heart, lungs, kidneys, and adrenals.

Mucormycosis in Iran: A six-year retrospective experience

Mucormycosis is a devastating infection caused by Mucoralean fungi (Mucormycotina, Mucorales). Data concerning the global epidemiology of mucormycosis are scarce and little is known about the characteristics of mucormycosis in Iran. In this study, we aimed to understand the distribution of this infection in Iran retrospectively and to ascertain whether the patterns of infection are associated with specific host factors or not. A total of 208 cases were included in this study occurring during 2008-2014 and were validated according to (EORTC/MSG) criteria. A rising trend as significant increase from 9.7% in 2008 to 23.7% in 2014 was observed. The majority of patients were female (51.4%) with median age of 50 and the infections were seen mostly in autumn season (39.4%). Diabetes mellitus (75.4%) was the most common underlying condition and sinus involvement (86%) was the mostly affected site of infection. Amphotericin B (AmB) was the drug of choice for the majority of cases. Sixty four isolates did not show any growth in the lab and only 21 cases were evaluated by ITS sequencing, among them; Rhizopus arrhizus var. arrhizus was the dominant species. Considering the high mortality rate of mucormycosis, early and accurate diagnosis, with the aid of molecular methods may provide accurate treatments and improve the survival rate. Therefore, increased monitoring and awareness of this life-threatening disease is critical.

Challenges in the Diagnosis of Invasive Fungal Infections in Immunocompromised Hosts

Purpose of review

The expanding population of immunocompromised patients coupled with the recognition of a growing number of different species of fungi responsible for diseases in such hosts makes the diagnosis of invasive fungal infection (IFI) a challenging task. The recent advances and challenges in the diagnosis of IFI in the setting of immunocompromised hosts are reviewed. The advantages and limitations of histopathology and the role of culture-independent methods, such as those based on the use of nucleic acids applied to fresh and formalin-fixed, paraffin-embedded sections, besides culture- and non-culture-based diagnostic methods, to obtain a timely and correct diagnosis of IFI are highlighted.

Recent findings

The therapeutic implications of identifying the genus and species of the fungus present in the specimen with the molecular diagnostics applied to tissue specimens are reviewed. No method alone is efficient in correctly identifying fungi and it is essential to combine the traditional histochemical staining with molecular methods to achieve a rapid and genus-/species-specific diagnosis of IFI.

Summary

We review the recent findings and challenges in the hystopathologic diagnosis of IFI in the setting of immunocompromised hosts. Non method alone is efficient in correctly identify fungi and pathologists should combine classic staining with molecular methods to achieve a rapid and genus/species fungal diagnosis.

Fatal Pulmonary Mucormycosis due to Rhizopus homothallicus

We report here a case of cavitary pneumonia due to Rhizopus homothallicus in a diabetic patient. This is the first proven case of R. homothallicus infection in Western countries and the third case described worldwide. The organism was isolated from lung biopsy and identified after amplification and sequencing of the internal transcribed spacer region.

The global diabetes epidemic: what does it mean for infectious diseases in tropical countries?

Tropical countries are experiencing a substantial rise in type 2 diabetes, which is often undiagnosed or poorly controlled. Since diabetes is a risk factor for many infectious diseases, this increase probably adds to the large infectious disease burden in tropical countries. We reviewed the literature to investigate the interface between diabetes and infections in tropical countries, including the WHO-defined neglected tropical diseases. Although solid data are sparse, patients with diabetes living in tropical countries most likely face increased risks of common and health-care-associated infections, as well as infected foot ulcers, which often lead to amputation. There is strong evidence that diabetes increases the severity of some endemic infections such as tuberculosis, melioidosis, and dengue virus infection. Some HIV and antiparasitic drugs might induce diabetes, whereas helminth infections appear to afford some protection against future diabetes. But there are no or very scarce data for most tropical infections and for possible biological mechanisms underlying associations with diabetes. The rise in diabetes and other non-communicable diseases puts a heavy toll on health systems in tropical countries. On the other hand, complications common to both diabetes and some tropical infections might provide an opportunity for shared services-for example, for eye health (trachoma and onchocerciasis), ulcer care (leprosy), or renal support (schistosomiasis). More research about the interaction of diabetes and infections in tropical countries is needed, and the infectious disease burden in these countries is another reason to step up global efforts to improve prevention and care for diabetes.

Chronic orbital and calvarial fungal infection with Apophysomyces variabilis in an immunocompetent patient

Apophysomyces is a rare fungal organism causing rhino-orbito-cerebral mycotic infections with high morbidity and mortality, typically in immunocompetent individuals. Several cases of Apophysomyces elegans orbital disease have been reported. Herein, we report a case of Apophysomyces variabilis infection involving the orbit, sinuses, and calvarium in an immunocompetent 74-year-old woman, with a review of the literature. Unlike prior cases of A. elegans classic rhino-orbito-cerebral infection, our case included diffuse calvarial lytic lesions and overlying soft tissue nodules, but without parenchymal intracranial involvement. There was radiographic and clinical evidence of infarction of the orbital contents and cavernous sinus thrombosis. Anastomoses between the superior orbital (ophthalmic) vein and diploic veins of the calvarium are believed to be primarily responsible for the unusual mode of spread on the extradural surface of the brain. Although the patient stabilized without definitive surgical intervention, her disease slowly and intermittently progressed for over a year after presentation, requiring multiple courses of antifungal treatment.

Prevalence, clinical and economic burden of mucormycosis-related hospitalizations in the United States: a retrospective study

Background

Mucormycosis is a rare but devastating fungal infection primarily affecting immunocompromised patients such as those with hematological malignancy, bone marrow and solid organ transplantation, and patients with diabetes, and, even more rarely, immunocompetent patients. The objective of this study was to assess the prevalence and burden, both clinical and economic, of mucormycosis among hospitalized patients in the U.S.

Methods

This is a retrospective study using the Premier Perspective^TM Comparative Database, with more than 560 participating hospitals covering 104 million patients (January 2005-June 2014). All hospitalizations in the database were evaluated for the presence of mucormycosis using either an ICD-9 code of 117.7 or a positive laboratory result for Mucorales. Hospitalizations were further required to have prescriptions of amphotericin B or posaconazole to be considered as mucormycosis-related hospitalizations. The prevalence of mucormycosis-related hospitalizations among all hospital discharges was estimated. Mortality rate at discharge, length of hospital stay, and readmission rates at 1 and 3 months were evaluated among mucormycosis-related hospitalizations. Cost per hospital stay and average per diem cost (inflated to 2014 USD) were reported.

Results

The prevalence of mucormycosis-related hospitalizations was estimated as 0.12 per 10,000 discharges during January 2005-June 2014. It increased to 0.16 per 10,000 discharges if the definition of mucormycosis was relaxed to not require the use of amphotericin B or posaconazole. The median length of stay was 17 days, with 23% dead at discharge; readmission rates were high, with 30 and 37% of patients readmitted within one and three months of discharge, respectively. The average cost per hospital stay was $112,419, and the average per diem cost was $4,096.

Conclusions

The study provides a recent estimate of the prevalence and burden of mucormycosis among hospitalized patients. The high clinical and economic burden associated with mucormycosis highlights the importance of establishing active surveillance and optimizing prophylactic and active treatment in susceptible patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-2023-z) contains supplementary material, which is available to authorized users.

The environmental source of emerging Apophysomyces variabilis infection in India

The rare mucoraceous fungus, Apophysomyces species complex ranks second after Rhizopus arrhizus causing mucormycosis in India. The source of this agent in the environment is not clearly known. We conducted an environmental study to find its presence in Indian soil. The soil samples from different geographical locations were analyzed for isolation of Mucorales. Rhizopus arrhizus (24.6%) was most commonly isolated from soil, followed by Lichtheimia spp. (23.2%), Cunninghamella spp. (21.7%), Rhizopus microsporus (14%) and Apophysomyces spp. (4.5%). The isolation of Apophysomyces species complex was significantly associated with low nitrogen content of the soil. Based on sequencing of internal transcribed spacer (ITS) and 28S (D1/D2) regions of ribosomal DNA, the Apophysomyces isolates were identified as Apophysomyces variabilis with 98 to 100% similarity to type strain A. variabilis (CBS658.93). The analysis of amplified fragment length polymorphism (AFLP) fingerprinting data demonstrated genomic diversity of A. variabilis isolates with multiple clades (similarity 40-90%). The minimum inhibitory concentrations (MIC), MIC50 and MIC90 for A. variabilis isolates were 1 and 4 μg/ml for amphotericin B, 0.25 and 0.5 μg/ml for itraconazole, 0.125 and 0.25 μg/ml for posaconazole, 0.06 and 0.12 μg/ml for terbinafine, respectively. The present study revealed abundant presence of A. variabilis in Indian soil with low nitrogen content, its genetic heterogeneity and relatively high MICs for amphotericin B.

Early Complications and Outcomes in Combat Injury-Related Invasive Fungal Wound Infections: A Case-Control Analysis

OBJECTIVE

Clinicians have anecdotally noted that combat-related invasive fungal wound infections (IFIs) lead to residual limb shortening, additional days and operative procedures before initial wound closure, and high early complication rates. We evaluated the validity of these observations and identified risk factors that may impact time to initial wound closure.

DESIGN

Retrospective review and case-control analysis.

SETTING

Military hospitals.

PATIENTS/PARTICIPANTS

US military personnel injured during combat operations (2009-2011). The IFI cases were identified based on the presence of recurrent, necrotic extremity wounds with mold growth in culture, and/or histopathologic fungal evidence. Non-IFI controls were matched on injury pattern and severity. In a supplemental matching analysis, non-IFI controls were also matched by blood volume transfused within 24 hours of injury.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Amputation revision rate and loss of functional levels.

RESULTS

Seventy-one IFI cases (112 fungal-infected extremity wounds) were identified and matched to 160 control patients (315 non-IFI extremity wounds). The IFI wounds resulted in significantly more changes in amputation level (P < 0.001). Additionally, significantly (P < 0.001) higher number of operative procedures and longer duration to initial wound closure were associated with IFI. A shorter duration to initial wound closure was significantly associated with wounds lacking IFIs (Hazard ratio: 1.53; 95% confidence interval, 1.17-2.01). The supplemental matching analysis found similar results.

CONCLUSIONS

Our analysis indicates that IFIs adversely impact wound healing and patient recovery, requiring more frequent proximal amputation revisions and leading to higher early complication rates.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mucormycosis in Iran: a systematic review

Fungi in the order Mucorales cause acute, invasive and frequently fatal infections in susceptible patients. This study aimed to perform a systematic review of all reported mucormycosis cases during the last 25 years in Iran. After a comprehensive literature search, we identified 98 cases in Iran from 1990-2015. The mean patient age was 39.8 ± 19.2 years. Diabetes was the most common underlying condition (47.9%), and 22.4% of the patients underwent solid organ or bone marrow transplantation. The most common clinical forms of mucormycosis were rhinocerebral (48.9%), pulmonary (9.2%) and cutaneous (9.2%). Eight cases of disseminated disease were identified. Overall mortality in the identified cases was 40.8%, with the highest mortality rate in patients diagnosed with disseminated infection (75%). The mortality rate in rhinocerebral infection patients was significantly lower (45.8%). Rhinocerebral infection was the most common clinical manifestation in diabetes patients (72.9%). Patients were diagnosed using various methods including histopathology (85.7%), microscopy (12.3%) and culture (2.0%). Rhizopus species were the most prevalent (51.7%), followed by Mucor species (17.2%). Sixty-nine patients were treated with a combination of surgery and antifungal therapy (resulting survival rate, 66.7%). Owing to the high mortality rate of advanced mucormycosis, early diagnosis and treatment may significantly improve survival rates. Therefore, increased monitoring and awareness of this life-threatening disease is critical.

Mucormycete infection or colonisation: experience of an Australian tertiary referral centre

Mucormycosis is associated with significant morbidity and mortality. We reviewed patients with mucormycete isolated at Alfred Health, Australia. A retrospective review of 66 patients with mucormycete(s) identified, between 1 April 2008 and 30 June 2014. Baseline demographic, microbiological, radiological, treatment/outcome data were recorded. Site of isolation was sinopulmonary in 77% and skin/soft tissue in 21%. A total of 32% of cases were proven-IFD, 12% probable-IFD and 56% were defined as no-IFD (or colonisation). Rhizopus spp. was identified in 48%. Comparing probable/proven-IFD with no-IFD/colonisation, more patients were postallogeneic stem cell transplantation (28% vs. 0%, P < 0.01) and were receiving immunosuppressive therapy (59% vs. 24%, P < 0.01) including prednisolone >20 mg daily (24% vs. 5%, P = 0.04). A total of 93% of patients with proven/probable IFD received treatment while 30% of no-IFD/colonisation were treated. A total of 72% of patients with proven/probable IFD and 92% of those with colonisation had no further mucormycete isolated. Thirty day mortality was higher in the proven/probable-IFD cohort (24%) compared with no-IFD/colonisation (3%) (P = 0.02). Mucormycosis remains uncommon, with 56% of cases not associated with clinical infection. Immunosuppressive therapy remains strongly associated with mucormycosis. Mortality remains high in those with proven/probable IFD.

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

Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the Order Mucorales and class of Mucormycetes. We conducted a prospective study of 38 patients who were diagnosed as having mucormycosis in a tertiary care hospital during January 2010 to June 2011. The cases were analyzed regarding the site of involvement, underlying disease and species of fungi isolated, antifungal susceptibility pattern of the isolates, and outcome of therapy. The mean age of the patients was 40.43 years, with 72% male. Rhino-orbital mucormycosis (61.5%) was the most common presentation followed by cutaneous manifestations (31%), gastrointestinal symptoms (5%), and pulmonary (2.5%). Diabetes mellitus (56%) was the significant risk factor in rhino-orbito-cerebral presentation (OR = 7.55, P = 0.001). Among 23 culture isolates, Rhizopus arrhizus (37.5%) was the most common, followed by Apophysomyces variabilis (29.2%), Lichtheimia ramosa (16.7%), Rhizopus microsporus (4.2%), Rhizomucor pusillus (4.2%), and Apophysomyces elegans (4.2%). Rhizopus arrhizus was most commonly isolated from rhino-orbito-cerebral mucormycosis and Apophysomyces species were generally obtained from cutaneous mucormycosis. In vitro antifungal susceptibility showed that 16 isolates were sensitive to amphotericin B (MIC less than 1 μg/ml), while in contrast, all isolates were found to be resistant to voriconazole (MIC- 0.25 to >8), fluconazole (MIC > 32), flucytosine (MIC > 32). Treatment regimens included antifungal therapy, reversal of underlying predisposing risk factors, and surgical debridement. Combination of surgery and medical treatment with amphotericin B was significantly better (OR = 0.2, P < 0.04) than amphotericin B alone (61.5% vs. 10.3% patient survival). The awareness of fungal diseases amongst clinicians is required to decrease the fatal outcome of disease.

Mucormycosis in Cairo, Egypt: review of 10 reported cases

We report on 10 cases of mucormycosis, as defined by The European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG) standards of invasive fungal diseases, among patients with a recent history of neutropenia, prolonged use of corticosteroids and treatment with immunosuppressants. They were all observed at the Ain Shams University Specialized Hospital in Cairo, Egypt, during the year 2010. These cases were categorized as 50% proven and 50% probable, with none considered to be possible mucormycosis. The median age of the patients discussed in this report was 50 years (range 22-68 years), of which 80% were male and 20% were female. Uncontrolled diabetes with ketoacidosis was noted in 60% of cases, while 40% of the patients had undergone liver transplantations. Pulmonary mucormycosis was the predominant presentation as it was noted in 80% of cases, but there was only 20% sinus involvement. Members of the genus Lichtheimia were the most common etiologic agents (40% of all cases), whereas Rhizopus ssp. were recovered from 30% of cases, Syncephalastrum spp. in 20%, and 10% of patients were infected with Rhizomucor. Liposomal formulation of amphotericin B (LAMB) was successfully used to treat all the cases described in this report. We concluded that the incidence of mucormycosis was relatively high during the study period in this one-center study and that additional studies looking into the diagnosis and the control of mucormycosis in Egypt are required.

Primary cutaneous mucormycosis produced by the new species Apophysomyces mexicanus

A case of fungal necrotizing fasciitis that appeared in an immunocompetent Mexican woman after a car accident is described. The patient did not respond to antifungal treatment and died 4 days later. The fungus was molecularly identified as a new species of Apophysomyces, namely, Apophysomyces mexicanus.

Cutaneous mucormycosis and motor vehicle accidents: Findings from an Australian case series

Cutaneous disease is the third most frequent manifestation of mucormycosis. The clinical manifestations of and subsequent mortality due to cutaneous mucormycosis are dependent on the mode of acquisition and the host immune status. Here, we describe the epidemiology, clinical presentation, microbiology, and outcomes of 16 cutaneous mucormycosis infections managed in an Australian tertiary hospital over a 15-year period. The proportion with localized (56%), deep (38%), and disseminated (6%) cutaneous disease as well as the overall mortality (25%) were consistent with findings reported in the published literature. Two novel forms of hospital-acquired infection were reported following a sacral pressure sore and insertion of a foreign body during a bone graft procedure. The majority of patients were immunocompetent (75%) and/or suffered trauma (56%) with associated environmental contamination. A novel finding was that motor vehicle accidents (MVAs) accounted for 78% of all trauma-related cases, suggesting MVAs should receive greater recognition as a potential precipitant of cutaneous mucormycosis. Aggressive decontamination and debridement of devitalized tissue following trauma is therefore likely to play an important role in the prevention of this rare but potentially devastating infection.

Mucormycosis in India: unique features

Mucormycosis remains a devastating invasive fungal infection, with high mortality rates even after active management. The disease is being reported at an alarming frequency over the past decades from India. Indian mucormycosis has certain unique features. Rhino-orbito-cerebral presentation associated with uncontrolled diabetes is the predominant characteristic. Isolated renal mucormycosis has emerged as a new clinical entity. Apophysomyces elegans and Rhizopus homothallicus are emerging species in this region and uncommon agents such as Mucor irregularis and Thamnostylum lucknowense are also being reported. This review focuses on these distinct features of mucormycosis observed in India.

Pathogenesis and host defence against Mucorales: the role of cytokines and interaction with antifungal drugs

Innate immune response, including macrophages, neutrophils and dendritic cells and their respective receptors, plays an important role in host defences against Mucorales with differential activity against specific fungal species, while adaptive immunity is not the first line of defence. A number of endogenous and exogenous factors, such as cytokines and growth factors as well as certain antifungal agents have been found that they influence innate immune response to these organisms. Used alone or especially in combination have been shown to exert antifungal effects against Mucorales species. These findings suggest novel ways of adjunctive therapy for patients with invasive mucormycosis.

Maxillary Osteomyelitis Caused by Apophysomyces Variabilis - Emerging Trends

In the maxillofacial skeleton, chronic osteomyelitis is more often observed in the mandible than maxilla. Maxillary osteomyelitis is rare because of its rich blood supply. It is usually seen in individuals with impaired immune response, uncontrolled diabetes and hospitalized patients. It can be caused by bacterial, fungal or viral infections. We report a rare case of maxillary osteomyelitis caused by an emerging mucormycete, Apophysomyces variabilis.

Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries

BACKGROUND

An outbreak of invasive fungal infections (IFI) began in 2009 among United States servicemen who sustained blast injuries in Afghanistan. In response, the military trauma community sought a uniform approach to early diagnosis and treatment. Toward this goal, a local clinical practice guideline (CPG) was implemented at Landstuhl Regional Medical Center (LRMC) in early 2011 to screen for IFI in high-risk patients using tissue histopathology and fungal cultures.

METHODS

We compared IFI cases identified after initiation of the CPG (February through August 2011) to cases from a pre-CPG period (June 2009 through January 2011).

RESULTS

Sixty-one patients were screened in the CPG period, among whom 30 IFI cases were identified and compared with 44 pre-CPG IFI cases. Demographics between the two study periods were similar, although significantly higher transfusion requirements (p<0.05) and non-significant trends in injury severity scores and early lower extremity amputation rates suggested more severe injuries in CPG-period cases. Pre-CPG IFI cases were more likely to be associated with angioinvasion on histopathology than CPG IFI cases (48% versus 17%; p<0.001). Time to IFI diagnosis (three versus nine days) and to initiation of antifungal therapy (seven versus 14 days) were significantly decreased in the CPG period (p<0.001). Additionally, more IFI patients received antifungal agent at LRMC during the CPG period (30%) versus pre-CPG period (5%; p=0.005). The CPG IFI cases were also prescribed more commonly dual antifungal therapy (73% versus 36%; p=0.002). There was no statistical difference in length of stay or mortality between pre-CPG and CPG IFI cases; although a non-significant reduction in crude mortality from 11.4% to 6.7% was observed.

CONCLUSIONS

Angioinvasive IFI as a percentage of total IFI cases decreased during the CPG period. Earlier diagnosis and commencement of more timely treatment was achieved. Despite these improvements, no difference in clinical outcomes was observed compared with the pre-CPG period.

Risk factors associated with invasive fungal infections in combat trauma

BACKGROUND

In recent years, invasive fungal infections (IFI) have complicated the clinical course of patients with combat-related injuries. Commonalities in injury patterns and characteristics among patients with IFI led to the development of a Joint Trauma System (JTS) clinical practice guideline (CPG) for IFI management. We performed a case-control study to confirm and further delineate risk factors associated with IFI development in combat casualties with the objective of generating data to refine the CPG and promote timelier initiation of treatment.

METHODS

Data were collected retrospectively for United States (U.S.) military personnel injured during deployment in Afghanistan from June 2009 through August 2011. Cases were identified as IFI based upon wound cultures with fungal growth and/or fungal elements seen on histology, in addition to the presence of recurrent wound necrosis. Controls were matched using date of injury (±3 mo) and injury severity score (±10). Risk factor parameters analyzed included injury circumstances, blood transfusion requirements, amputations after first operative intervention, and associated injuries. Data are expressed as multivariate odds ratios (OR; 95% confidence interval [CI]).

RESULTS

Seventy-six IFI cases were identified from 1,133 U.S. military personnel wounded in Afghanistan and matched to 150 controls. Parameters associated significantly with the development of IFI multivariate analysis were blast injuries (OR: 5.7; CI: 1.1-29.6), dismounted at time of injury (OR: 8.5; CI: 1.2-59.8); above the knee amputations (OR: 4.1; CI: 1.3-12.7), and large-volume packed red blood cell (PRBC; >20 U) transfusions within first 24 h (OR: 7.0; CI: 2.5-19.7).

CONCLUSIONS

Our analysis indicates that dismounted blast injuries, resulting in above the knee amputations, and requirement of large volume PRBC transfusions are independent predictors of IFI development. These data confirm all the preliminary risk factors, except for genitalia/perineal injuries, utilized by JTS in their IFI CPG. Model validation is necessary for further risk factor specification.

MALDI-TOF mass spectrometry in the clinical mycology laboratory: identification of fungi and beyond

MALDI-TOF mass spectrometry (MS) is becoming essential in most clinical microbiology laboratories throughout the world. Its successful use is mainly attributable to the low operational costs, the universality and flexibility of detection, as well as the specificity and speed of analysis. Based on characteristic protein spectra obtained from intact cells - by means of simple, rapid and reproducible preanalytical and analytical protocols - MALDI-TOF MS allows a highly discriminatory identification of yeasts and filamentous fungi starting from colonies. Whenever used early, direct identification of yeasts from positive blood cultures has the potential to greatly shorten turnaround times and to improve laboratory diagnosis of fungemia. More recently, but still at an infancy stage, MALDI-TOF MS is used to perform strain typing and to determine antifungal drug susceptibility. In this article, the authors discuss how the MALDI-TOF MS technology is destined to become a powerful tool for routine mycological diagnostics.

A mucormycosis case treated with a combination of caspofungin and amphotericin B

Mucormycosis is a rare, invasive and fatal disease that occurs mainly in diabetes mellitus patients with uncontrolled blood glucose levels or in immunocompromised patients. The mortality rate of this disease is as high as 25 to 80%, despite aggressive surgical treatment and antifungal therapy. This high mortality requires alternative treatment approaches. The accepted treatment modality of invasive mucormycosis are amphotericin B lipid formulations. Although echinocandins generally show no activity against Mucorales, it was shown that Rhizopus oryzae expressed the target enzyme for echinocandins, 1,3-beta-glucan synthase. Additionally, there are some experimental studies in a diabetic mouse model and case reports regarding the effects of caspofungin. In this report, we present a rhinocerebral mucormycosis case treated with liposomal amphotericin B and caspofungin. There was regression of the patient's clinical and radiological condition with the addition of caspofungin, but she died due to discontinuation of her treatment and reasons other than mucormycosis.

Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011

BACKGROUND

Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri.

METHODS

We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case-control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively.

RESULTS

A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1-D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains.

CONCLUSIONS

We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.