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.

Probiotics and their postbiotics for the control of opportunistic fungal pathogens: A review

During past twenty years the opportunistic fungal infections have been emerging, causing morbidity and mortality. The fungi belonging to Aspergillus, Mucor, Rhizopus, Candida, Fusarium, Penicillium, Dermatophytes and others cause severe opportunistic fungal infections. Among these Aspergillus and Candida spp cause majority of the diseases. The continuum of fungal infections will prolong to progress in the surroundings of the growing inhabitants of immunocompromised individuals. Presently many chemical-based drugs were used as prophylactic and therapeutic agents. Prolonged usage of antibiotics may lead to some severe effect on the human health. Also, one of the major threats is that the fungal pathogens are becoming the drug resistant. There are many physical, chemical, and mechanical methods to prevent the contamination or to control the disease. Owing to the limitations that are observed in such methods, biological methods are gaining more interest because of the use of natural products which have comparatively less side effects and environment friendly. In recent years, research on the possible use of natural products such as probiotics for clinical use is gaining importance. Probiotics, one of the well studied biological products, are safe upon consumption and are explored to treat various fungal infections. The antifungal potency of major groups of probiotic cultures such as Lactobacillus spp, Leuconostoc spp, Saccharomyces etc. and their metabolic byproducts which act as postbiotics like organic acids, short chain fatty acids, bacteriocin like metabolites, Hydrogen peroxide, cyclic dipeptides etc. to inhibit these opportunistic fungal pathogens have been discussed here.

A pictorial review of imaging manifestations of rhino-orbito-cerebral mucormycosis–emerging threat in COVID pandemic

Mucormycosis is an aggressive invasive fungal infection caused by mycocetes fungi. It is an opportunistic infection, associated with high morbidity and mortality. In the current era of COVID-19 pandemic, the entire world has witnessed a dramatic upsurge in cases of Mucormycosis. Paranasal sinuses are the commonest site to be affected with the tendency for rapid spread to orbit, face, and brain. Early diagnosis and prompt medical or surgical intervention are the only ways for preventing morbidity and saving precious lives. Imaging plays a crucial role not only in diagnosis but also in defining the extent of the disease for presurgical mapping. Black turbinate sign in the nasal cavity, mucosal thickening in paranasal sinuses with periantral invasion, and bony erosion are the early diagnostic signs. This pictorial review shall provide a comprehensive review of the various imaging manifestations of rhino-orbito-cerebral mucormycosis with a final proposed reporting checklist.

Indications that the Antimycotic Drug Amphotericin B Enhances the Impact of Platelets on Aspergillus

Platelets are currently thought to harbor antimicrobial functions and might therefore play a crucial role in infections, e.g., those caused by Aspergillus or mucormycetes. The incidence of invasive fungal infections is increasing, particularly during the coronavirus disease 2019 (COVID-19) pandemic, and such infections continue to be life-threatening in immunocompromised patients. For this reason, the interaction of antimycotics with platelets is a key issue to evaluate modern therapeutic regimens. Amphotericin B (AmB) is widely used for the therapy of invasive fungal infections either as deoxycholate (AmB-D) or as a liposomal formulation (L-AmB). We showed that AmB strongly activates platelets within a few minutes. AmB concentrations commonly measured in the blood of patients were sufficient to stimulate platelets, indicating that this effect is highly relevant in vivo. The stimulating effect was corroborated by a broad spectrum of platelet activation parameters, including degranulation, aggregation, budding of microparticles, morphological changes, and enhanced adherence to fungal hyphae. Comparison between the deoxycholate and the liposomal formulation excluded the possibility that the liposomal part of L-Amb is responsible for these effects, as no difference was visible. The induction of platelet activation and alteration by L-AmB resulted in the activation of other parts of innate immunity, such as stimulation of the complement cascade and interaction with granulocytes. These mechanisms might substantially fuel the antifungal immune reaction in invasive mycoses. On the other hand, thrombosis and excessive inflammatory processes might occur via these mechanisms. Furthermore, the viability of L-AmB-activated platelets was consequently decreased, a process that might contribute to thrombocytopenia in patients.

Pediatric intussusception due to basidiobolomycosis: a case report and literature review

Background

Pediatric gastrointestinal basidiobolomycosis is an unusual fungal infection caused by Basidiobolus ranarum, an environmental saprophyte found worldwide. Typically, basidiobolomycosis presents as a subcutaneous infection or soft tissue tumor-like lesion, and rarely involves the gastrointestinal tract. Gastrointestinal basidiobolomycosis is most common in young infants. It has no definitive clinical presentation, and almost all cases are misdiagnosed during the initial presentation.

Case presentation

We report the case of a 4-year-old Saudi boy who presented to the emergency department with abdominal pain, nausea, vomiting, and weight loss. Ultrasonography revealed a target sign. Based on the ultrasonography findings, surgery was performed, which revealed the presence of intussusception. Eventually, the patient was diagnosed with intussusception secondary to intra-abdominal basidiobolomycosis based on the histological findings. The patient was readmitted and intravenous voriconazole therapy was initiated. One week after the second admission, the patient developed abdominal pain, nausea, vomiting, inability to hold down food, and constipation. Computed tomography of the abdomen was suggestive of small bowel obstruction, which was managed conservatively. The patient responded well and was subsequently discharged with a prescription of oral voriconazole.

Conclusions

This case reveals that gastrointestinal basidiobolomycosis can cause intussusception. This report will inform clinicians of the importance of considering gastrointestinal basidiobolomycosis in the differential diagnosis of chronic abdominal pain in children, even in the absence of fever or a clinically obvious abdominal mass, especially in countries such as Saudi Arabia, where cases have been reported.

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.

Zoonotic diseases of fish and their prevention and control

Fish and aquatic-derived zoonotic diseases have caused considerable problems in the aquaculture industry and fishery worldwide. In particular, zoonotic diseases can pose widespread threats to humans. With the world’s growing population and potential global trade of aquaculture and fish, the risk of environmental contamination and development of fish and aquatic-derived zoonoses in humans are increasing. The important causes of zoonoses include bacteria, parasites, viruses, and fungi. The zoonotic bacterial agents are divided into two main groups: Gram-positive (Mycobacteriaceae, Streptococcaceae, Erysipelothricaceae families) and Gram-negative (Aeromonadaceae, Vibrionaceae, Pseudomondaceae, Enterobacteriaceae, and Hafniaceae families). The premier parasitic agents include cestodes (tapeworm; e.g. Diphyllobothrium spp.), trematodes (fluke; e.g. Opisthorchis spp.), and nematodes (round worm; e.g. Anisakis spp.). In addition, protozoan organisms such as Cryptosporidium spp. are also considered fish-derived zoonotic pathogens. Two groups of fish-associated fungi causing basidiobolomycosis and sporotrichosis also pose a zoonotic risk for humans. The majority of the fish-derived zoonotic diseases are transmitted to humans mainly via the consumption of improperly cooked or raw fish or fish products. Therefore, the incidence of zoonotic diseases can be reduced by properly processing fish and fish products, e.g. by thermal (heat/freezing) treatment. The prevalence of zoonotic agents in fishes varies seasonally and should be regularly monitored to evaluate the prevalence of pathogens in both wild and cultured fish populations. This review focuses on the fish zoonotic agents/diseases and their control and prevention.

Antibody responses and CNS pathophysiology of Mucormycosis in Chronic SARS CoV-2 infection: Current Therapies against Mucormycosis

The incidence rate of opportunistic secondary infections through invasive fungi has been observed to be 14.5% to 27% in the SARS CoV pandemic during the year 2003. But, the incidence of SARS CoV-2 is accompanied by the substantial rise in secondary opportunistic infections like mucormycosis (black fungus) mainly in the immunocompromised individuals, and diabetic patients taking steroids. Substantial rates of COVID-19 cases with mucormycosis were reported in India and other parts of the world. Previous research reports delineated the ability of Mucorales in invading the various tissues like lungs, brain, sinus through the GRP78 and subsequently this infection could invoke crusting, edema, and necrosis of brain parenchyma, ptosis, proptosis, and vision loss due to intraorbital & intracranial complications. Similarities of these pathophysiological complications with already existing diseases are causing clinicians to face several challenges in order to diagnose and treat this disease effectively at the early stage. This minireview depicts the mucormycosis-induced immune, and pathophysiological alterations in COVID-19 patients comorbid with diabetes, immunosuppression, and also reported the various clinical manifestations, and the therapeutic modalities and the failures of anti-fungal vaccines. Therefore, the emerging mucormycosis in COVID-19 patients need a rapid investigation and selective optimization of the effective therapeutic modalities including antifungal vaccines to minimize mortality rate.

Clinical Characteristics, Healthcare Utilization, and Outcomes among Patients in a Pilot Surveillance System for Invasive Mold Disease—Georgia, United States, 2017–2019

Background

Invasive mold diseases (IMD) cause severe illness, but public health surveillance data are lacking. We describe data collected from a laboratory-based, pilot IMD surveillance system.

Methods

During 2017–2019, the Emerging Infections Program conducted active IMD surveillance at three Atlanta-area hospitals. We ascertained potential cases by reviewing histopathology, culture, and Aspergillus galactomannan results and classified patients as having an IMD case (based on European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group [MSG] criteria) or a non-MSG IMD case (based on the treating clinician’s diagnosis and use of mold-active antifungal therapy). We described patient features and compared patients with MSG versus non-MSG IMD cases.

Results

Among 304 patients with potential IMD, 104 (34.2%) met an IMD case definition (41 MSG, 63 non-MSG). The most common IMD types were invasive aspergillosis (n = 66, 63.5%), mucormycosis (n = 8, 7.7%), and fusariosis (n = 4, 3.8%); the most frequently affected body sites were pulmonary (n = 66, 63.5%), otorhinolaryngologic (n = 17, 16.3%), and cutaneous/deep tissue (n = 9, 8.7%). Forty-five (43.3%) IMD patients received intensive care unit-level care, and 90-day all-cause mortality was 32.7%; these outcomes did not differ significantly between MSG and non-MSG IMD patients.

Conclusions

IMD patients had high mortality rates and a variety of clinical presentations. Comprehensive IMD surveillance is needed to assess emerging trends, and strict application of MSG criteria for surveillance might exclude > one-half of clinically significant IMD cases.

Mucormycosis in COVID-19 patients: predisposing factors, prevention and management

India is considered the diabetes capital of the world and has the highest burden of mucormycosis. Bacterial, viral and fungal co-infections are increasingly being reported in severe acute respiratory syndrome virus 2 (SARSCoV-2) infected patients. India is one of the worst affected countries during the second wave of the COVID-19 pandemic. This combination of diabetes mellitus, COVID-19 and mucormycosis has led to the drastic upsurge of COVID-19-associated mucormycosis (CAM) in India. Immunosuppression, iron disequilibrium, endothelial injury, ketoacidosis and hypoxia are some of the other COVID-19-related risk factors for CAM. There has been an increase in the proportion of mucormycosis affecting paranasal sinuses and central nervous system (CNS) in CAM compared to pre-COVID-19 literature due to the SARSCoV-2-related pathophysiological mechanisms, complications and treatment strategies. CAM is a medical and surgical emergency, and it can present with non-specific symptoms and signs initially resulting in diagnostic delay. High index of suspicion and regular screening for features of CAM are of paramount importance to prevent lethal consequences. Rapid action with a tripod approach consisting of withdrawal of immunomodulators, early antifungal therapy and extensive surgical debridement is considered the best possible treatment model. We review the published data to give a detailed account of the predisposing factors and their mechanisms, diagnostic work-up, treatment modalities and prevention strategies of CAM with special emphasis on CNS mucormycosis.

Isolated Cerebral Mucormycosis Caused by Lichtheimia Species in a Polytrauma Patient

Isolated post-traumatic cerebral mucormycosis represents an extremely rare and severe disease. A case of isolated cerebral mucormycosis infection caused by Lichtheimia spp. in a 21-year-old multi-trauma patient is presented. The patient was hospitalized in the intensive care unit and underwent craniotomy due to brain injuries. Two weeks following the initial procedure, pus drained from the surgical wound was microscopically examined and cultured, yielding Lichtheimia spp. Imaging showed parietal, temporal and frontal abscesses at the right side. The patient was commenced on amphotericin B and underwent surgical debridement, while histopathological examination of the affected tissue demonstrated broad, aseptate hyphae, findings typical for mucormycetes. The patient passed away due to heavy traumatic injuries after 2 months. It is speculated that direct inoculation was the portal of entry for infection, and that high steroid use for 2 weeks following inoculation contributed to the severity of infection that developed. Isolated cerebral mucormycosis in immunocompetent hosts is an extremely rare, but severe disease. Diagnosis is established through direct microscopy, histopathology and/or cultures. PCR-based techniques are useful either to detect mucormycetes in tissues, especially when cultures are negative, or to accurately identify the fungi grown in cultures at the species level. A high suspicion index, especially in the necrotic lesions of traumas, is of the utmost importance for early diagnosis. Appropriate surgical debridement, as well as antifungal therapy, including amphotericin B, represents the treatment of choice.

Subcutaneous basidiobolomycosis treated successfully with oral itraconazole: A case report

Basidiobolomycosis is an opportunistic fungal infection with a high morbidity and mortality rate. It is known to cause invasive disease in immunocompromised persons but it may produce only cutaneous or subcutaneous infections in an immunocompetent patient. Treatment is difficult due to its fulminant course and lack of effective anti-fungal drugs. But here, we report a rare case of Basidiobolomycosis detected in an immunocompetent patient—without any debilitating illness, which showed a complete response to itraconazole 200 mg daily without any surgical intervention.

Invasive fungal infections in neonates: a review

Invasive fungal infections remain the leading causes of morbidity and mortality in neonates, especially preterm and very low birth weight infants. Most invasive fungal infections are due to Candida or Aspergillus species, and other fungi are increasingly reported and described. Appropriate identification and treatment are required to augment activity and reduce the toxicity of antifungal drugs. Successful use of antifungals in the vulnerable neonatal population is important for both prevention and treatment of infection. Strategies for prevention, including prophylactic antifungal therapy as well as reducing exposure to modifiable risk factors, like limiting antibiotic exposure, discontinuation of central catheters, and hand hygiene are key techniques to prevent and decrease rates of invasive fungal infections. In conclusion, this is a review of the most common causes, prevention strategies, prophylaxis, and treatment of invasive fungal infections in neonates.

Rhino-orbital-cerebral mucormycosis in times of COVID-19: A neurosurgical experience

Background:

The gravity of “second wave” of COVID-19 has effaced many new challenges in India; mucormycosis being a recent one. Diabetes mellitus (DM) is a known significant risk factor for mucormycosis. Here, we present our experience with rhino-orbital-cerebral mucormycosis (ROCM) during the “second wave of COVID-19” at a tertiary health care centre in North India.

Methods:

This case series includes four cases of ROCM that were managed by our neurosurgical team in view ofcerebral involvement.

Results:

All the cases with an exception of one (Case 1), had a history of treatment for COVID-19 pneumonia. Case 2, 3 had undergone functional endoscopic sinus surgery (FESS) and orbital decompression before the onset of cerebral involvement; Case 4 underwent FESS and cranial surgery in the same sitting. All the patients had a history of DM and all the cases treated for COVID-19 pneumonia had a history of treatment with corticosteroids. Two patients underwent surgery with the exception of one patient, who did not provide consent for the same. One patient expired before surgical excision could be attempted.

Conclusion:

Regular and intensive follow-up is the key in swift detection and management of ROCM in post-COVID patients. While surgical excision is advisable in the fungal lesion, it must be borne in mind that radical excision of cerebral lesions is associated with morbidity, delayed recovery, and prolonged ICU stay. Culture and sensitivity-based antibiotics should be used judiciously as fever is a common postoperative complication. Blood sugar monitoring and control of DM are paramount in this condition. Steroids should be avoided in the management of cerebral edema with judicious use of hypertonic saline or mannitol.

Cutaneous Mucormycosis After Elective Outpatient Gastrocnemius Recession for Plantar Fasciitis in an Immunocompetent Host: A Case Report

CASE

A healthy 21-year-old man underwent an elective gastrocnemius recession for plantar fasciitis. At 10 days postoperatively, he developed a severe limb-threatening cutaneous mucormycotic infection that led to multiple debridements and eventual skin grafting.

CONCLUSION

Cutaneous mucormycosis is a rare but severe fungal infection. Early recognition, deep surgical biopsy for diagnosis, and aggressive treatment with frequent thorough surgical debridements and antifungal pharmacotherapy are necessary. Although mucormycosis is more frequently seen in the immunocompromised host, it can occur in the immunocompetent patient most commonly after trauma. If not aggressively treated, it can be limb and life threatening.

Thoracic mucormycosis in immunocompetent patients

BACKGROUND

Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes.

METHODS

We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm.

RESULTS

The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment.

CONCLUSION

Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

A rare case of colon obstruction due to gastrointestinal basidiobolomycosis in a 36-year-old woman

INTRODUCTION

Gastrointestinal basidiobolomycosis (GIB) is an uncommon fungal infection caused byBasidiobolus ranarum, with less than 80 cases reported in the literature.

PRESENTATION OF CASE

A 36-year-old woman presented with colicky upper abdominal pain for 2 months and inability to pass stool for 2 days. Computed tomography of the abdomen and colonoscopy both showed a mass in the transverse colon. Colonoscopic biopsy suggested a zygomycosis. Laparotomy revealed a perforated mass in the transverse colon; the mass also involved the small bowel and stomach. En bloc resection was performed, and the incision was closed for a second-look procedure. The patient was admitted to the intensive care unit and placed on a ventilator and inotropes; however, her condition deteriorated, and she died on day 24 post admission. The histopathology report (obtained after the patient's death) was consistent with GIB.

DISCUSSION

Gastrointestinal basidiobolomycosis presents with nonspecific signs and symptoms and so the diagnosis is easily missed or delayed. Timely, accurate diagnosis is crucially important, especially when there is intestinal obstruction and sepsis. Persistent severe abdominal pain in a patient with neutropenia should alert the physician to the possibility of a fungal infection. There are reports from several countries of basidiobolomycosis in immunocompetent hosts. The disease shows no age predilection, but males may be more susceptible. Treatment is with surgical debridement and antifungal drugs-ideally the lipid formulation of amphotericin B.

CONCLUSION

Gastrointestinal basidiobolomycosis is a rare infection that can be fatal if not diagnosed and treated early.

Invasive fungal disease in humans: are we aware of the real impact?

Despite the medical advances and interventions to improve the quality of life of those in intensive care, people with cancer or severely immunocompromised or other susceptible hosts, invasive fungal diseases (IFD) remain severe and underappreciated causes of illness and death worldwide. Therefore, IFD continue to be a public health threat and a major hindrance to the success of otherwise life-saving treatments and procedures. Globally, hundreds of thousands of people are affected every year with Candida albicans, Aspergillus fumigatus, Cryptococcus neoformans, Pneumocystis jirovecii, endemic dimorphic fungi and Mucormycetes, the most common fungal species causing invasive diseases in humans. These infections result in morbidity and mortality rates that are unacceptable and represent a considerable socioeconomic burden. Raising the general awareness of the significance and impact of IFD in human health, in both the hospital and the community, is hence critical to understand the scale of the problem and to raise interest to help fighting these devastating diseases.

Comparative immunopathogenesis in a murine model of inhalative infection with the mucormycetes Lichtheimia corymbifera and Rhizopus arrhizus

Pathogenic mucormycetes induce diseases with considerable morbidity and mortality in immunocompromised patients. Virulence data comparing different Mucorales species and various underlying risk factors are limited. We therefore compared the pathogenesis of inhalative infection by Rhizopus (R.) arrhizus and Lichtheimia (L.) corymbifera in murine models for predominant risk factors for onset of infection. Mice with diabetes or treated with cyclophosphamide or cortisone acetate were challenged via the intranasal route with an isolate of R. arrhizus or L. corymbifera, respectively. Clinical, immunological and inflammation parameters as well as efficacy of posaconazole prophylaxis were monitored over 14 days. Whereas immunocompetent mice showed no clinical symptoms after mucormycete infection, mice treated with either cyclophosphamide (CP) or cortisone acetate (CA) were highly susceptible. Animals infected with the isolate of R. arrhizus showed prolonged survival and lower mortality, compared to those exposed to the L. corymbifera isolate. This lower virulence of R. arrhizus was risk factor-dependent, since diabetic mice died only after infection with Rhizopus, whereas all Lichtheimia-infected diabetic animals survived. Under posaconazole prophylaxis, both mucormycetes were able to establish breakthrough infections in CA- and CP-treated mice, but the course of infection was significantly delayed. Detailed analysis revealed that susceptibility of CA- and CP-treated mice could not be mimicked by exclusive lack or downmodulation of neutrophils, platelets or complement, but can be supposed to be the consequence of a broad immunosuppressive effect induced by the drugs. Both Lichtheimia corymbifera and Rhizopus arrhizus induce invasive mycoses in immunocompromised hosts after inhalative infection. Key parameters such as virulence and immunopathogenesis vary strongly according to fungal species and underlying risk group. Selected neutropenia is no sufficient risk factor for onset of inhalative mucormycosis.

Galactosaminogalactan secreted from Aspergillus fumigatus and Aspergillus flavus induces platelet activation

Platelets are meanwhile recognized as versatile elements within the immune system and appear to play a key role in the innate immune response to pathogens including fungi. Previous experiments revealed platelet activation by direct contact with the hyphal-associated polysaccharide galactosaminogalactan (GAG). Since secreted fungal products may also be relevant and trigger immune reactions or thrombosis, we screened culture supernatants (SN) of human-pathogenic fungi for their capacity to activate platelets. For that purpose, platelets were incubated with SN from various fungal species; platelet activation and GAG deposition on the surface of platelets were detected by flow cytometry and electron and confocal microscopy, Culture supernatants of Aspergillus fumigatus and flavus isolates were potent platelet stimulators in a dose- and time-dependent manner, while SN of other Aspergillus species and all tested mucormycete species did not significantly induce platelet activation. The capacity of culture SN to activate platelets was dependent on fungal production of GAG and deposition of secreted GAG on the platelet surface; supernatants from mucormycetes or mutants of A. fumigatus lacking GAG secretion did not affect platelet activity. These results suggest that invading fungi can stimulate platelets not only locally through direct interactions with fungal hyphae, but can also act over a certain distance through secreted GAG.

Gastrointestinal basidiobolomycosis: Beware of the great masquerade a case report

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We describe a previously healthy young patient with gastrointestinal basidiobolomycosis misdiagnosed as colonic malignancy.

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This is the first reported case in an adult patient from Oman suggesting that the disease is possibly under-recognized.

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Acquaintance with this exceptionally rare infection is critical for successful clinical outcome.

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Azoles are effective anti-fungal therapy for gastrointestinal basidiobolomycosis.

Basidiobolomycosis is rare infection caused by the saprophytic fungus Basidiobolus ranarum. Gastrointestinal basidiobolomycosis is an infrequent, albeit, increasingly reported, emerging form of the disease and typically affects immunocompetent individuals with potentially grave sequelae if unrecognized. Acquaintance with this exceptionally rare fungus and its potential for presenting as gastrointestinal mass masquerading as colonic malignancy is critical for timely diagnosis, appropriate treatment and successful clinical outcome.

We report a case of gastrointestinal basidiobolomycosis masquerading as colonic malignancy in a 29-year-old Omani patient successfully treated with combination of surgery and prolonged azole antifungal therapy.

Mucormycosis of the Central Nervous System

Mucormycosis involves the central nervous system by direct extension from infected paranasal sinuses or hematogenous dissemination from the lungs. Incidence rates of this rare disease seem to be rising, with a shift from the rhino-orbital-cerebral syndrome typical of patients with diabetes mellitus and ketoacidosis, to disseminated disease in patients with hematological malignancies. We present our current understanding of the pathobiology, clinical features, and diagnostic and treatment strategies of cerebral mucormycosis. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability. Emerging molecular diagnostics, advances in experimental systems and the establishment of large patient registries are key components of ongoing efforts to provide a timely diagnosis and effective treatment to patients with cerebral mucormycosis.

An aero mycological analysis of Mucormycetes in indoor and outdoor environments of northern India

Mucormycosis is an angio-invasive infection, predominantly acquired by inhalation of sporangiospores from the environment. However, the burden of Mucormycetes sporangiospores in the air is not well studied. We aimed to estimate the burden of Mucormycetes spores in the outdoor and indoor (hospital) environment across different seasons in north India. A total of 380 air samples from outdoor (n = 180) and indoor (n = 200) environment were included in the study. Air samples were suctioned using air sampler (100 l/min) and cultured on Dichloran Rose Bengal Chloramphenicol (DRBC) with benomyl for selective isolation of Mucormycetes. The isolates were identified by phenotypic and genotypic methods. The mean spore count (±SD) of Mucormycetes (cfu/m3) in outdoor samples varied from 0.73 (±0.96) to 8.60 (±5.70) across different seasons. In hospital, the mean spore count varied from 0.68 (±1.07) to 1.12 (±1.07) and 0.88 (±1.01) to 1.72 (±2.17) for air-conditioned wards and non-air-conditioned wards, respectively. Rhizopus arrhizus was the predominant agent isolated from both indoor and outdoor environment followed by Cunninghamella species. We also report a single isolate of the rare mucormycete agent, Apophysomyces variabilis from outdoor environment. The present study highlights the presence of low spore burden of Mucormycetes in outdoor and hospital settings in north India. This study also reports the first isolation of A. variabilis from air samples in the Indian subcontinent.

Disseminated intestinal basidiobolomycosis with mycotic aneurysm mimicking obstructing colon cancer

Basidiobolomycosis is a rare fungal infection that may affect the gastrointestinal tract. It is caused by Basidiobolus ranarum and less than 80 cases have been reported in the literature. The incidence seems to be higher in the Middle East and in particular Saudi Arabia where most cases are diagnosed in the south-western region. An 18-year-old woman presented to the emergency department with an obstructing caecal mass initially suspected to be malignant. Surgical resection was complicated by bowel perforation, histology and cultures confirmed basidiobolomycosis infection. The postoperative course was complicated by an enterocutaneous fistula, fungal intra-abdominal abscesses, liver and lung abscesses, formation of mycotic hepatic artery aneurysm and meningoencephalitis. The patient eventually expired due to sepsis despite aggressive treatment. Diagnosis and management of such rare cases are very challenging and require a multidisciplinary approach. Complications are common and associated with a high mortality.

A first-line antiretroviral therapy-resistant HIV patient with rhinoentomophthoromycosis

The Conidiobolus coronatus-related rhinoentomophthoromycosis in immunocompetent and immunocompromised (HIV negative) individuals has been treated successfully with antifungal drugs. However, C. coronatus infections in first-line antiretroviral therapy (ART)-resistant (HIV infected) individuals particularly with rhinoentomophthoromycosis have not been reported previously. Here, we describe a case of itraconazole non-responding rhinoentomophthoromycosis in an HIV-infected patient with first-line antiretroviral (ART) drug resistance which was successfully managed through systematic diagnostic and therapeutic approaches in dermatologic setting. A 32-year-old HIV-1-infected man presented with painless swelling, nasal redness and respiratory difficulty. The patient was receiving first-line ART and had a history of traumatic injury before the onset of nasopharyngeal manifestations. The patient's previous history included oral candidiasis and pulmonary tuberculosis.

Facial Reconstruction of a Mucormycosis Survivor by Free Rectus Abdominis Muscle Flap, Tissue Expansion, and Ocular Prosthesis

Invasive sinonasal mucormycosis is a rare fungal infection that usually occurs in immunocompromised or diabetic patients, and it is often fatal. The authors present a case of a woman patient suffering from systemic lupus erythematosus and diabetes mellitus treated with prednisone, presenting with a rapidly progressive rhino-orbital-cerebral mucormycosis. She was successfully treated with combined intravenous antifungal therapy and radical debridement followed by complex defect reconstruction with a free vertical rectus abdominis myocutaneous flap, tissue expander, and ophthalmic prosthesis.

Disseminated mucormycosis (DM) after pneumonectomy: a case report

BACKGROUND

Mucormycosis is a kind of rare opportunistic fungal disease and the incidence of which has gradually increased. Disseminated mucormycosis (DM) is a life-threatening infection that mostly occurs in immunocompromised patients. The lung and brain are usually involved in disseminated mucormycosis, and other sites are scare. We report the first case of disseminated mucormycosis whose infection sites included lung, skin, liver, vertebra, and spinal cord that ensued after a right lung pneumonectomy in an immunocompetent patient.

CASE PRESENTATION

A 20-year-old female underwent a right lung pneumonectomy for "lung cancer" presented with an intermittent fever for two years. A computed tomography (CT) scan showed an enclosed outstanding mass in the right chest wall. The patient also suffered from lower limb numbness and weakness, difficulty walking, and dysuria. Medical examination showed superficial feeling of the abdominal wall was decreased from the T7 and T8 level; muscle strength for both lower limbs was decreased; muscle tension of both lower limbs was also diminished. A biopsy through the right chest wall mass and thoracic mass by fistula of chest wall showed broad nonseptate hyphae with right-angle branching, consistent with mucormycosis. With titration of amphotericin B and its lipid complex, the patient recovered.

CONCLUSIONS

Our case showed an unusual clinical presentation of disseminated mucormycosisin an immunocompetent patient.

Ventriculitis due to infection with Rhizopus arrhizus

A 52-year-old heart–lung transplant patient presented to the emergency department with acute onset of neurologic symptoms. MRI showed ballooning of the left ventricle, midline shift and contrast enhancement in the anterior horn of the left ventricle. Ventricle neuroendoscopy revealed whitish, floccose aerial structures within the left ventricle. Brain biopsy cultures grew Rhizopus arrhizus. Therapy with liposomale amphotericin B and posaconazole was performed. Except for hemianopsia and deficits in minute motor activity, the patient completely recovered.

Subcutaneous Zygomycosis: A Report of One Case Responding Excellently to Potassium Iodide

Subcutaneous Zygomycosis is a rare opportunistic fungal infection caused by Basidiobolus ranarum. Though this entity is endemic in South India, limited numbers of cases have been reported from this part of the country. We report a case of subcutaneous zygomycosis in a 25 year old lady who presented with a nontender, firm to hard swelling over the upper-left arm. Finger was easily inserted below the indurated edge. Histopathology revealed suppurative granuloma with aseptate hyphae. Patient responded excellently to saturated solution of potassium iodide in subsequent visits.

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 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.

Granulomatous disorders

Almost all granulomatous skin disorders can cause red lesions on the face. Such disorders may include many bacterial, fungal, or parasitic infections, noninfectious inflammatory disorders, foreign body reactions, and even neoplasms. Clinically, they usually present with papules, plaques, nodules, and/or abscesses, which may ulcerate. It may be helpful in their differential diagnosis to define certain clinical patterns, such as multiple and discrete papules, necrotic or umbilicated papules or nodules, annular plaques, vegetative plaques or tumors, verrucous plaques or tumors, abscesses and/or sinuses, and lymphocutaneous pattern. Some disorders, such as sarcoidosis, can cause a wide variety of lesions. We accept that cutaneous leishmaniasis is also among such great imitators.

Mold infections of the central nervous system

The recent outbreak of exserohilum rostratum meningitis linked to epidural injections of methylprednisolone acetate has brought renewed attention to mold infections of the central nervous system (CNS). Although uncommon, these infections are often devastating and difficult to treat. This focused review of the epidemiologic aspects, clinical characteristics, and treatment of mold infections of the CNS covers a group of common pathogens: aspergillus, fusarium, and scedosporium species, molds in the order Mucorales, and dematiaceous molds. Infections caused by these pathogen groups have distinctive epidemiologic profiles, clinical manifestations, microbiologic characteristics, and therapeutic implications, all of which clinicians should understand.

Primary cutaneous mucormycosis presenting as a giant plaque: uncommon presentation of a rare mycosis

Mucormycosis is an uncommon systemic mycosis affecting the immunocompromised individuals. It is usually caused by organisms of the genera Rhizopus and Mucor, although rarely other organisms have also been implicated. Mycoses due to these angioinvasive fungi have an acute onset, rapidly progressive course with high mortality rate. A rare and less well known is the chronic subtype of primary cutaneous mucormycosis (PCM). Herein, we report a case of PCM clinically presenting as a chronic, giant destructive plaque in a young immunocompetent male and coin the term chronic granulomatous mucormycosis. A clinicopathological classification for cutaneous mucormycosis is also proposed.

Mixed fungal infection (Aspergillus, mucor, and Candida) of severe hand injury

Severe hand injuries are almost always heavily contaminated and hence wound infections in those patients are frequent. Fungal wound infections are rare in immunocompetent patients. A case of mixed fungal infection (Aspergillus, Mucor, and Candida) was documented in a young male patient, with a severe hand injury caused by a corn picker. The diagnosis of fungal infection was confirmed microbiologically and histopathologically. The treatment was conducted with repeated surgical necrectomy and administration of antifungal drugs according to the antimycogram. After ten weeks the patient was successfully cured. The aggressive nature of Mucor and Aspergillus skin infection was described. A high degree of suspicion and a multidisciplinary approach are necessary for an early diagnosis and the initiation of the adequate treatment. Early detection, surgical intervention, and appropriate antifungal therapy are essential in the treatment of this rare infection that could potentially lead to loss of limbs or even death.

Importance of immediate surgical intervention and antifungal treatment for rhinocerebral mucormycosis: a case report

Rhinocerebral mucormycosis (RCM) is an opportunistic, potentially life-threatening fungal disease. This infective disease invades not only the facial sinuses, but also the maxilla, zygoma, and rhino-cerebral structures with a massive destruction of the facial skeletons and soft tissue. This disease progresses within various underlying diseases, such as diabetes mellitus, hematologic malignancy, renal failure, and systemic immunodepression. The relationship between mucormycosis and these underlying conditions have been discussed extensively in the literature. The authors studied 6 cases of RCM diagnosed by a tissue biopsy and treated at the department of oral and maxillofacial surgery, from 1997 to 2012. Patients were treated with several kinds of surgical interventions and antifungal agents, and their clinical & radiological signs, underlying conditions, surgical methods, and outcomes were analyzed.

Invasive mucormycosis in a patient with liver cirrhosis: case report and review of the literature

INTRODUCTION

Cutaneous Mucormycosis is a rare opportunistic infection caused by Zygomycetes class of fungi that is often fatal, requiring aggressive local control as well as systemic therapy. Few cases of mucormycosis were described in patients with liver cirrhosis, mostly rhino-orbital. To our knowledge, only two cases of upper extremity involvement was reported in cirrhosis while a few cases were reported in the post-transplant setting. We report herein the third case of upper extremity mucor infection in the setting of liver cirrhosis.

CASE PRESENTATION

We described a rare case of forearm infection originating in a traumatic intravenous access portal in a 25 year-old woman with liver cirrhosis secondary to autoimmune hepatitis.

DISCUSSION

She developed acute on chronic liver failure during the last trimester of pregnancy, which was terminated. Painful, erythematous lesion was noted on her right forearm in the area of intravenous access, which later became necrotic. Extensive debridement was done and histopathological examination confirmed the diagnosis of mucormycosis. The patient started on Amphotericin B. Her condition continued to deteriorate and ended up with above elbow amputation followed by right shoulder disarticulation. She died two days later due to multi-organ failure. In conclusion, forearm mucromycosis in liver cirrhosis can be fatal.