Mucormycosis and entomophthoramycosis: a review of the clinical manifestations, diagnosis and treatment

Endemic pediatric fungal infections in India: clues to diagnosis

This review is intended to familiarize readers with an emerging group of fungal infections that mostly manifest in immunocompetent individuals. This group was initially considered endemic to the tropics, but increasing worldwide prevalence has been reported. The organisms have been divided into dominant non-invasive forms and dominant invasive forms for ease of understanding. The non-invasive organisms include the group Entomophthoromycota, under which two genera Basidiobolus and Conidiobolus, have been identified as human pathogens. They present with plaques in the extremities and rhinofacial region, respectively. The invasive organisms are dematiaceous fungi (phaeohypomycosis), which includes Cladophialophora and Exophiala among others. They cause invasion of deep tissues, with the central nervous system being the most common target. The mycology, epidemiology, diagnosis, and treatment options have been summarized in brief. The clinical presentation, imaging manifestations, differentiation from other common infections and malignancies that show similar features have been detailed.

Comparison Between Pre-COVID and Post-COVID Mucormycosis: A Systematic Review and Meta-analysis

Introduction

Mucormycosis has emerged as one of the most fatal complications arising due to COVID-19, though it has to be mentioned that the disease is capable of causing serious illness even on its own.

Objectives

Through this investigation, we would review the threat that mucormycosis poses, in terms of its prevalence and degree of severity both in the pre- and post-COVID world.

Materials and Methods

A comprehensive examination of the studies published in online databases turned up 207 papers, 103 of which had undergone in-depth analysis, using both inclusion and exclusion criteria, shortlisting 15 studies that were appropriate for reviewing.

Results

The incidence of mucormycosis was linked to coronavirus in 7 of the 15 studies that were chosen. The remaining eight studies had sufferers of various systemic diseases, like HIV/AIDS and diabetes.

Discussion

All the cases suffered diabetes mellitus. Regardless of the time period of the chosen article, corticosteroids and antifungal medications were administered to all patients. There were noticeable differences in terms of mortality, predisposing factors, and virulence between pre-COVID and post-COVID mucormycosis.

Summary and Conclusion

The prevalence of systemic conditions such as diabetes in cases of mucormycosis has remained the same even after the incidence of this pandemic, showing that the basic treatment modalities continue to remain the same irrespective of the damage that corona virus has caused to the sufferer, although mucormycosis arising due to COVID-19 differs from mucormycosis that was incident before the advent of the pandemic.

Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study

PURPOSE

To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM).

METHODS

In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality.

RESULTS

Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality.

CONCLUSIONS

Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

Outcome of Total Surgical Debridement of Covid Associated Rhino-Orbito-Cerebral Mucormycosis Based on a New Surgical Staging System: A Cohort Study

To propose a surgical staging system with management protocol for post-covid Rhino-orbito-cerebral mucormycosis (ROCM) with central skull base osteomyelitis. A prospective cohort study of a total of 193 post-covid ROCM patients was conducted between May 2021 and January 2022 at a tertiary care centre. Patients were assessed radiologically and staged from I to V. Follow up period was 16 months and the surgical outcome in terms of recurrent disease was assessed. A total of 193 patients (129 primary and 64 revision) were studied. Maxilla was found to be the epicenter of anterior disease (69.3%) and pterygoid wedge was noted to be the epicenter of posterior disease (85.6%). More than 65% of our patients, at the time of presentation, presented with involvement of the central skull base. Intracranial disease was noted in 13.9% of patients and the mortality rate was 6.2%. This staging system provides a systematic step-by-step protocol for the management of ROCM, with emphasis on meticulous disease clearance at the central skull base.

Invasive Fungal Infections and Oomycoses in Cats: 1. Diagnostic approach

CLINICAL RELEVANCE

In contrast to superficial fungal infections, such as dermatophytosis, invasive fungal infections (IFIs) are characterised by penetration of tissues by fungal elements. Disease can spread locally within a region or can disseminate haematogenously or via the lymphatics. The environment is the most common reservoir of infection. Since fungal spores are airborne, indoor cats are also susceptible to IFIs. Some environmental fungi are ubiquitous and present globally, while others are endemic or hyperendemic within specific geographic regions. Zoonotic pathogens include Microsporum canis, Sporothrix schenckii and Sporothrix brasiliensis.

AIM

In the first of a two-part article series, the approach to the investigation of feline IFIs and oomycoses is reviewed. As well as tips for diagnosis, and information on the ecological niche and distribution of fungal pathogens, the review covers clinical presentation of the most common IFIs, including cryptococcosis, histoplasmosis, blastomycosis, coccidioidomycosis, sporotrichosis, phaeohyphomycosis, aspergillosis and dermatophytic pseudomycetoma, as well as the oomycoses pythiosis, lagenidiosis and paralagenidiosis. In Part 2, the spectrum of activity, mechanisms of action, pharmacokinetic and pharmacodynamic properties and adverse effects of antifungal drugs are reviewed, and the treatment and prognosis for specific IFIs and oomycoses are discussed.

EVIDENCE BASE

The review draws on published evidence and the authors' combined expertise in feline medicine, mycology, dermatology, clinical pathology and anatomical pathology.

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.

Successful Treatment of Bilateral Renal Mucormycosis With Isavuconazole: A Case Report

Isolated renal mucormycosis (IRM) is a rare disease with high mortality, more commonly seen in immunocompromised patients. Management has traditionally included antifungal drugs with or without nephrectomy. We present the case of a 34-year-old female with a past medical history of type 1 diabetes mellitus and intravenous heroin use who presented with fever, flank pain, hematuria, and vomiting. She was found to have an oliguric acute kidney injury (AKI) with a serum creatinine (Cr) of 2.5 mg/dL. CT showed bilateral emphysematous pyelonephritis and ureteral cultures grew Rhizopus species. Amphotericin B was started before being switched to isavuconazole due to worsening AKI, and hemodialysis was only required transiently. Rather than the traditional approach to treatment, a conservative approach that preserved kidney function was utilized, and the patient was successfully treated with six months of isavuconazole.

Frontal osteomyelitis post-COVID-19 associated mucormycosis

Rhino-orbito-cerebral mucormycosis (ROCM) is the most commonly noted form of mucormycosis, which is the most common secondary fungal infection following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Osteomyelitis is one of the rare sequelae of ROCM, frontal osteomyelitis being the rarest. We present four patients of coronavirus disease 2019 (COVID-19)-associated mucormycosis, who presented with frontal bone osteomyelitis after being treated for ROCM surgically and medically. This is the first case series highlighting this complication in post-COVID-19 mucormycosis patients and needs utmost attention as it can be life-threatening and can cause extreme facial disfiguration. All four patients are alive with salvage of the affected globe and vision being preserved in one patient. If identified early, disfiguration of face and intracranial extension can be avoided.

Dermatopathology and the Diagnosis of Fungal Infections

Diagnosis of superficial/cutaneous fungal infections from skin, hair and nail samples is generally achieved using microscopy and culture in a microbiology laboratory, however, any presentation that is unusual or subcutaneous is sampled by taking a biopsy. Using histological techniques a tissue biopsy enables a pathologist to perform a full examination of the skin structure, detect any inflammatory processes or the presence of an infectious agent or foreign body. Histopathological examination can give a presumptive diagnosis while a culture result is pending, and may provide valuable diagnostic information if culture fails. This review demonstrates how histopathology contributes to the diagnosis of fungal infections from the superficial to the life threatening.

Part 1: Mucormycosis: Prevalence, Risk Factors, Clinical Features and Diagnosis

INTRODUCTION

Mucormycosis (MCR) is caused by filamentous molds within the Class Zygomycetes and Order Mucorales. Infections can result from inhalation of spores into the nares, oropharynx or lungs, ingestion of contaminated food or water, or inoculation into disrupted skin or wounds. In developed countries, MCR occurs primarily in severely immunocompromised hosts. In contrast, in developing/low income countries, most cases of MCR occur in persons with poorly controlled diabetes mellitus and some cases in immunocompetent subjects following trauma. Mucormycosis exhibits a propensity to invade blood vessels, leading to thrombosis and infarction of tissue. Mortality rates associated with invasive MCR are high and can exceed 90% with disseminated disease. Mucormycosis can be classified as one of six forms: (1) rhino-orbital-cerebral mucormycosis (ROCM); (2) pulmonary; (3) cutaneous; (4) gastrointestinal or renal (5); disseminated; (6) uncommon (focal) sites.

AREAS COVERED

The authors discuss the prevalence, risk factors and clinical features of mucormycosis.A literature search of mucormycosis was performed via PubMed (up to November 2022), using the key words: invasive fungal infections; mold; mucormycosis; Mucorales; Zyzomyces; Zygomycosis; Rhizopus, diagnosis.

EXPERT OPINION

Mucormycosis occurs primarily in severely immunocompromised hosts. Mucormycosis can progress rapidly, and delay in initiating treatment by even a few days worsens outcomes.

Intratemporal mucormycosis: a rare COVID-19 sequelae

A man in his 50s presented with a 2-month history of left ear discharge associated with hearing loss and weakness of left half of face since 15 days. The patient had no comorbidities, but he gave history of being treated for COVID-19 pneumonia 2 months ago post which he started experiencing left-sided aural symptoms. Clinical examination of ear revealed a subtotal perforation with multiple granulations in middle ear. Facial nerve examination revealed grade 3 lower motor neuron palsy. The biopsy of the granulations was sent to aid in diagnosis which later confirmed left ear mucormycosis. Otological involvement with facial palsy and sudden sensorineural loss in a patient with prior history of COVID-19 has not been reported until in literature. We try to communicate our experience to bridge the gap in understanding and managing this extremely rare occurrence of mucormycosis in the ear of a patient diagnosed with COVID-19 infection.

Rhino-Orbital Cerebral Mucormycosis: A Fatal Evolution

Rhino-orbital cerebral mucormycosis is a rare and serious fungal infection caused by fungi of the Mucorales order, most commonly by the species Rhizopus oryzae. It occurs generally in an immunocompromised host, and the contamination of healthy subjects remains exceptional. The clinical presentation is not specific. The diagnosis of rhino-orbital cerebral mucormycosis is difficult based on a range of clinical, microbiological, and radiological arguments. Imaging studies may include CT/MRI of the orbit, brain, and sinuses and show signs of aggressiveness, intracranial complications, and evolution under treatment. The standard treatment is antifungal therapy and necrosectomy. We report a case of a 30-year-old patient admitted to intensive care for the management of postpartum hemorrhage complicating severe preeclampsia who presented with rhinocerebral mucormycosis with left orbital extension. Adequate therapeutic management in the intensive care unit was provided; however, the patient died within seven days of septic shock with multiorgan failure. The mortality is determined by the correction of risk factors, the timing of initiation of the antifungal therapy, and surgical debridement.

Saksenaea mucormycosis: a rare and dangerous cause of necrotising fasciitis

Necrotising fasciitis is a rapidly progressing soft tissue infection requiring early and adequate surgical debridement and appropriate antibiotic cover. The present case highlights bacterial fasciitis associated with fungal (Mucor) infection with insidious angioinvasive nature (Saksenaea vasiformis) which required amputation, negative-pressure vacuum dressings and amphotericin B for definitive treatment. This demonstrates a relatively rare case of the group IV classification of necrotising fasciitis, which we must consider when there is slowly progressing tissue death despite seemingly adequate treatment.

Surge of mucormycosis during the COVID-19 pandemic

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

Varied presentations of complicated rhinosinusitis in COVID era: a rational approach to management

Aim

To study the various presentations and manifestations of complicated rhinosinusitis in COVID era- ranging from bacterial rhino sinusitis to invasive fungal rhino sinusitis.

Methods

Design-A retrospective observational study was carried out from March 2020 to May 2021. Setting-Tertiary care hospital subjects—all COVID-positive patients who had paranasal sinus involvement. Methods-Patients were evaluated based on their symptomatology profile. Fungal stains and culture were carried out for all. They underwent Magnetic resonance Imaging and Computed Tomography scan on case-to-case basis, apart from routine nasal endoscopy. All were managed both medically and surgically depending upon their diagnosis. The natural course including outcomes, was studied, documented and analyzed.

Results

Out of 496 patients presenting with sinonasal disease, 126 were COVID-positive, 16 patients had complicated rhino sinusitis, of which 4 patients had complicated rhinosinusitis with intraorbital, intracranial or combined complications. All patients were managed successfully with combined medical and surgical approach. Twelve patients had invasive mucormycosis with overall mortality rate of 37%.

Conclusion

Complicated sinusitis was encountered in COVID-positive patients either when they were being actively treated for COVID-19 or as part of post-COVID sequalae. Though rhino-orbito-cerebral mucormycosis constituted the major disease burden in such patients but the possibility of bacterial rhino sinusitis with or without complications must also be kept in mind while evaluating such patients. We must remember every complicated rhinosinusitis in COVID-positive patient may not be mucor and manage appropriately.

Antifungal Activity of Plant Secondary Metabolites on Candida albicans: An Updated Review

Fungal infections have been increasing continuously worldwide, especially in immunocompromised individuals. Fungi, regarded as eukaryotic pathogens, have many similarities to the host cells, which inhibit anti-fungal drug development progress. Various fungal model systems have been studied, and it was concluded that Candida spp. is the most common disease-causing fungus. Candida species are well known to cause infections not only in our mouth, skin, and vagina, but they are also a frequent cause of life-threatening hospital bloodstream infections. The morphological and developmental pathways of Candida have been studied extensively, providing insight into the fungus development. Candida albicans is known to be the most pathogenic species responsible for a variety of infections in humans. Conventional anti-fungal drugs, mainly azoles drugs available in the market, have been used for years developing resistance in C. albicans. Hence, the production of new anti-fungal drugs, which require detailed molecular knowledge of fungal pathogenesis, needs to be encouraged. Therefore, this review targets the new approach of "Green Medicines" or the phytochemicals and their secondary metabolites as a source of novel anti-fungal agents to overcome the drug resistance of C. albicans, their mechanism of action, and their combined effects with the available anti-fungal drugs.

Post-COVID Mucormycosis Involving Mandible: A Rare Phenomenon

Mucormycosis is a fungal disease involving predominantly the paranasal sinuses and further spreading to the orbit and cerebral regions. It does rarely affect the pulmonary region and gastrointestinal regions. This disease is seen more in a very serious state, where the tissues undergo necrosis and cause huge morbidity and, in some cases, end up being fatal. The disease was common in individuals with an immune-compromised state, thus more commonly presenting in individuals with uncontrolled diabetes. The disease is usually acquired through coming into contact with spores of the fungus Mucormycetes through the nose, and the fungi invade the paranasal regions, colonize, and spread locally with angio-invasion and relying on host ferritin for survival, thereby causing tissue necrosis. The incidence of mucormycosis had increased considerably post-COVID-19 due to host immune factors. This fungus commonly spreads from paranasal regions to the cranial direction through orbit. The spread is rapid, thus needing early medical and surgical intervention. The spread of infection from the paranasal regions to the caudally placed mandible is very rarely seen. In this paper, we present three cases of mucormycosis spreading caudally and involving the mandibular regions.

Focusing COVID-19-associated mucormycosis: a major threat to immunocompromised COVID-19

COVID-19 disease has been identified to cause remarkable increase of mucormycosis infection cases in India, with the majority of cases being observed in individuals recovering from COVID-19. Mucormycosis has emanated as an outcome of the recent COVID-19 pandemic outbreak as rapidly developing fatal illness which was acquired by Mucorales fungus which is a subcategory of molds known as mucormycetes. Mucormycosis is one of the serious, sporadic mycotic illnesses which is a great threat to immunocompromised COVID-19 patients and affects people of all ages, including children with COVID-19 infections. This is associated with tissue damaging property and, therefore, causes serious clinical complications and elevated death rate. The COVID-19-associated mucormycosis or "black fungus" are the terms used interchangeably. The rapid growth of tissue necrosis presenting as "rhino-orbital-cerebral, pulmonary, cutaneous, gastrointestinal, and disseminated disease" are various clinical forms of mucormycosis. The patient's prognosis and survival can be improved with proper surgeries using an endoscopic approach for local tissue protection in conjunction with course of appropriate conventional antifungal drug like Amphotericin-B and novel drugs like Rezafungin, encochleated Amphotericin B, Orolofim, and SCY-078 which have been explored in last few years. This review provides an overview of mucormycosis including its epidemiology, pathophysiology, risk factors, its clinical forms, and therapeutic approaches for disease management like antifungal therapy, surgical debridement, and iron chelators. The published patents and ongoing clinical trials related to mucormycosis have also been mentioned in this review.

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Risk Factors of Rhino Orbital Mucormycosis

PURPOSE

To determine the clinical presentation and risk factors associated with rhino orbital mucormycosis.

INTRODUCTION

Mucormycosis is a rapidly progressive fungal infection caused by filamentous fungi in the Mucoraceae family. In large numbers, they release spores into the air, and humans get exposed through inhalation. The spores inoculate in the paranasal sinuses and nasopharynx and subsequently spread to the orbit and intracranial cavity. The present COVID-19 pandemic has witnessed a resurgence of rhino-orbital mucormycosis cases, mainly seen in patients with immunocompromised status. Hence, our study evaluated the risk factors and clinical features of rhino orbital mucormycosis.

METHODS

This was a prospective, single-center, cross-sectional study. Patients attending tertiary care centers fulfilling the inclusion criteria were evaluated with a detailed history including sociodemographic profile, occupation, history of fever, COVID-19 infection, steroid or immunosuppressant use, organ transplants, diabetes mellitus and use of oxygen (O2). A complete ophthalmic evaluation was performed, including best-corrected visual acuity, anterior segment evaluation with slit lamp biomicroscopy, and posterior segment evaluation using indirect ophthalmoscopy. Computed Tomography (CT) scan of paranasal sinuses was done for all the patients, and Magnetic Resonance Imaging (MRI) for a few patients if indicated. Intraoperatively, samples were sent for Potassium Hydroxide (KOH) stain while debridement and patients with positive results were included in the study.

RESULTS

Forty participants were included, out of which 34 (85%) were males and six (15%) were females. The mean age of the patients was 51.75 years. Out of 40 patients, 29 (72.5%) had h/o COVID-19 infection, 30 (75%) were known type 2 diabetes mellitus, 25 (62.5%) had a h/o steroid intake and 25 (62.5%) had a history of O2 use. 17 (42.5%) patients presented with low vision, out of which 15 had no light perception. 30 (75%) patients had ptosis, 22 (55%) patients presented with proptosis, 15 (37.5%) patients had limited ocular motility, 11 (27.5%) had complete ophthalmoplegia, and 11 (27.5%) patients had central retinal artery occlusion.

CONCLUSION

Rhino orbital Mucormycosis is more prevalent in patients with COVID-19 infection, especially those who have used steroids and oxygen and with type 2 diabetes mellitus. Early presentation with treatment can prevent further ocular morbidity.

Epidemiology, clinical features, therapeutic interventions and outcomes of mucormycosis in Shiraz: an 8-year retrospective case study with comparison between children and adults

Mucormycosis is an invasive fungal infection with high morbidity and mortality rate despite the early diagnosis and proper therapeutic interventions. Given the importance of epidemiological data in reviewing the attitude toward infectious diseases in developing countries, the current retrospective case study aimed to compare the epidemiological aspects, risk factors, clinical characteristics, therapeutic interventions, and outcomes of mucormycosis between adults and children during eight years (2013-2021) in the main infectious disease referral centers in the southwest of Iran. The median age of 164 patients included in this study was 47 years (IQR 22-59). The median length of hospitalization was 33 days.The annual incidence of mucormycosis-related hospitalizations was estimated 1.76 per 10,000 admissions during the study period. Moreover, the incidence of infection was 2.4 times higher in males than females in children. Diabetes mellitus was the most frequent predisposing factor in adults (46.0%). The main risk factor in children was hematologic malignancy (52.6%), but a considerable proportion of them (28.9%) were immunocompetent.The most frequent antifungal agent used was liposomal amphotericin B (82.3%) as monotherapy. The combination therapy was used more in adults (15.8%) than children (7.9%). In addition, surgical intervention with antifungal therapy was considered the most effective therapeutic approach. The in-hospital mortality rate was 14.6% for adults, whereas it was zero for children. Our findings provide a recent epidemiologic analysis of mucormycosis among hospitalized patients in both children and adults. Mucormycosis mainly affects individuals with diabetes mellitus or hematological malignancies and presents as rhino-orbito-cerebral form. Proven diagnosis of mucormycosis according to clinical manifestations and histopathology observations accompanied by proper antifungal treatments may improve survival rates.

Case Report: Parapharyngeal Mucormycosis Rare Presentation with Literature Review

Mucormycosis is a rare fungal infection that typically involves the rhino-cerebral area with a high morbidity and mortality. Involvement of the parapharyngeal space and gastrointestinal tract with perforation is rare and may be related to dissemination of the disease. The current antifungal treatment has been shown to be inadequate with variable outcomes and is often instituted late in the disease process with unfortunate outcomes.

Entomophthoromycosis Presenting as a Nasal Mass

Entomophthoromycosis is a rare, invasive fungal infection common in tropics. Potential sources of infection could be contaminated soil, leaf litter, insects and water. High index of suspicion is needed as entomophthoromycosis mimics the common sinonasal disease in its nascent stage. Concurrent medical and surgical management is the most effective treatment.

The impact of mucormycosis (black fungus) on SARS-CoV-2-infected patients: at a glance

The emergence of various diseases during the COVID-19 pandemic made health workers more attentive, and one of the new pathogens is the black fungus (mucormycosis). As a result, millions of lives have already been lost. As a result of the mutation, the virus is constantly changing its traits, including the rate of disease transmission, virulence, pathogenesis, and clinical signs. A recent analysis revealed that some COVID-19 patients were also coinfected with a fungal disease called mucormycosis (black fungus). India has already categorized the COVID-19 patient black fungus outbreak as an epidemic. Only a few reports are observed in other countries. The immune system is weakened by COVID-19 medication, rendering it more prone to illnesses like black fungus (mucormycosis). COVID-19, which is caused by a B.1.617 strain of the SARS-CoV-2 virus, has been circulating in India since April 2021. Mucormycosis is a rare fungal infection induced by exposure to a fungus called mucormycete. The most typically implicated genera are Mucor rhyzuprhizopusdia and Cunninghamella. Mucormycosis is also known as zygomycosis. The main causes of infection are soil, dumping sites, ancient building walls, and other sources of infection (reservoir words "mucormycosis" and "zygomycosis" are occasionally interchanged). Zygomycota, on the other hand, has been identified as polyphyletic and is not currently included in fungal classification systems; also, zygomycosis includes Entomophthorales, but mucormycosis does not. This current review will be focused on the etiology and virulence factors of COVID-19/mucormycosis coinfections in COVID-19-associated mucormycosis patients, as well as their prevalence, diagnosis, and treatment.

Pathogenesis and Pathology of COVID-Associated Mucormycosis: What Is New and Why

Purpose of Review

There is global increase in the incidence of mucormycosis. However, a sudden increase in the COVID-associated mucormycosis (CAM) was noted, particularly in India, during the second wave of the COVID-19 pandemic. The interplay of factors involved in the pathogenesis is complex. In this review, the influence of pre-existing disease, exaggerated risk factors, altered milieu due to COVID-19 itself and the consequences of its treatment on the host pathogen interactions leading to the disease and morphology of the fungus will be highlighted.

Recent Findings

Hyperglycemia, acidosis, available free iron, lowered host defenses, and the fungal virulence factors promote the growth of Mucorales. There is a high background prevalence of diabetes mellitus (DM) in India. Uncontrolled or undiagnosed DM, COVID-19 itself, and inappropriate administration of corticosteroids in high doses and for prolonged periods result in hyperglycemia. Diabetic ketoacidosis (DKA) and metabolic acidosis due to hypoxia or renal failure contribute to acidic pH and dissociate bound iron from serum proteins. The host defenses are lowered due to COVID-19-induced immune dysregulation, hyperglycemia itself, and administration of corticosteroids and immune suppressants for the treatment of COVID-19. The altered metabolic milieu in the local microenvironment of nose and paranasal sinuses (PNS) promotes specific interaction of glucose-regulated protein-78 (GRP-78) on host cells with spore coat protein homologue (CotH 3) on Mucorales resulting in rhino-orbito-cerebral mucormycosis (ROCM) as the predominant clinical form in CAM. The pathology is extensive soft tissue involvement with angioinvasion and perineural invasion. Melanized hyphae and sporangia were seen on histopathology, which is unique to CAM. While many factors favor the growth of Mucorales in CAM, hyperglycemia, hyperferritinemia, and administration of hyperbaric oxygen result in reactive oxygen species (ROS) and inadequate humidification results in dehydration. Melanization is possibly the adaptive and protective mechanism of Mucorales to escape the unfavorable conditions due to the treatment of COVID-19.

Summary

High background prevalence of DM, inappropriate administration of corticosteroids and immune dysregulation due to COVID-19 favor the growth of Mucorales in CAM. Melanization of Mucorales hyphae and sporangia on histopathology probably represent adaptive and protective mechanism due to the treatment with hyperbaric oxygen with inadequate humidification as well as the metabolic alterations.

Mucormycosis, Diabetes and COVID-19 Pneumonia: Unleashing the Facts

Background

Mucormycosis (MM) is an angioinvasive locally destructive fungal infection. Before the coronavirus disease 2019 (COVID-19) pandemic, it was associated with diabetes (particularly diabetic ketoacidosis), immunosuppressive drugs and trauma. Among its various forms, cerebral invasion is considered to be highly fatal even if with long-term treatment. Treatment with injection amphotericin B (Amph-B) with early surgical interventions is highly efficacious. Liposomal preparation is considered to be superior in the context of fewer side effects.

Methods

We present a single-centre prospective study of 124 patients with MM in a tertiary care hospital. After the approval from the ethics committee, basic information was taken from all patients including all available past history about the COVID-19 infection and treatment. The studied outcomes were discharge, death and number of days of hospitalisation. Secondary objectives were to estimate the association of MM with known risk factors, to find the association of an outcome with various inflammatory markers, to determine adverse events with the use of injection Amph-B and posaconazole and to find the case fatality rate of MM.

Results

In our study, we observed that the number of patients with MM was double in the less than 60 years age group. However, mortality was 33.3% in the elderly as compared to 15.29% in patients less than 60 years of age. The majority of the patients (69.35%) were males, but no significant difference in mortality was seen between males and females. The case fatality rate was 20.97%. Ocular symptoms such as orbital swelling and pain were the common presenting symptoms. Almost all patients (93.54%) were diabetics. The non-diabetic group consisted of only 8 (6.4%) patients, and therefore, the comparison was not possible. A total of 20 (16%) out of 124 patients who had received high-dose steroids showed higher mortality (55%). Maximum patients (65.32%) had presented with MM following a past COVID-19 infection. However, a significant number of MM patients (20.96%) had a recent COVID infection and had higher mortality (57.69%) compared to their counterparts. The most common site of involvement in our study was the paranasal sinus (50%) and the outcome was the best in those patients whose disease was localised only to the sinuses, although among 14 (11.29%) patients with cerebral involvement, mortality was maximum (42.85%). Renal impairment and dyselectrolytemia were the most common adverse effects of Amph-B, and 46.42% of patients required surgical removal of the local part.

Conclusion

We saw that diabetes was a major contributory factor in the etiopathogenesis of MM. COVID-19 could also be a major causative factor by impairing the immune system; however, further studies at the molecular level are required to establish an association. The use of steroid cannot be the only independent risk factor, and other associated factors must be present. Treatment with antifungal and early surgical intervention had good outcomes. Treatment with conventional lyophilized Amph-B was equally efficacious as lipid-based solutions, but with more side effects. Hypokalemia and hypocalcemia were the most common electrolyte abnormalities associated with the use of injection Amph-B. Uncontrolled diabetes, the severity of the COVID-19 infection at presentation, acidosis, a high C-reactive protein level (above 100) and local brain involvement were associated with a poor outcome.

Functions and applications of glycolipid-hydrolyzing microbial glycosidases

Glycolipids are important components of cell membranes in several organisms. The major glycolipids in mammals are glycosphingolipids (GSLs), which are composed of ceramides. In mammals, GSLs are degraded stepwise from the non-reducing end of the oligosaccharides via exo-type glycosidases. However, endoglycoceramidase (EGCase), an endo-type glycosidase found in actinomycetes, is a unique enzyme that directly acts on the glycosidic linkage between oligosaccharides and ceramides to generate intact oligosaccharides and ceramides. Three molecular species of EGCase, namely EGCase I, EGCase II, and endogalactosylceramidase, have been identified based on their substrate specificity. EGCrP1 and EGCrP2, which are homologs of EGCase in pathogenic fungi, were identified as the first fungal glucosylceramide- and sterylglucoside-hydrolyzing glycosidases, respectively. These enzymes are promising targets for antifungal drugs against pathogenic fungi. This review describes the functions and properties of these microbial glycolipid-degrading enzymes, the molecular basis of their differential substrate specificity, and their applications.

Subcutaneous entomophthoramycosis in a child presenting as panniculitis: a case report from Bihar, India

•

The article reports a rare case of subcutaneous entomophthoramycosis.

•

The patient was misdiagnosed with non-infective panniculitis, which led to extensive involvement.

•

Subsequently, the patient was diagnosed correctly using standard techniques which included KOH wet mount, culture and isolation.

•

Lactophenol cotton blue mount was performed for identification of the organism as Basidiobolus spp.

•

The patient was cured after treatment with itraconazole and potassium iodide.

A 5-year-boy from Bihar, India was admitted to a tertiary care hospital with painful swelling over both lower limbs and buttocks, which had been increasing progressively for the past 1 year. The condition was initially undiagnosed and was later misdiagnosed as non-infective panniculitis, delaying treatment. Subsequently, the patient was diagnosed with subcutaneous entomophthoramycosis caused by Basidiobolus spp. A preliminary diagnosis was made by considering the history, clinical features, radiological findings and histopathological examination of the biopsied tissue. The confirmatory diagnosis was made using conventional techniques on aspirated pus, which included KOH wet mount and fungal culture on Sabouraud dextrose agar tubes incubated at 28°C and 37°C, respectively. Lactophenol cotton blue mount and slide culture were performed for identification of the fungal isolate. The patient responded well to oral itraconazole and oral potassium iodide.

Delayed diagnosis and extensive involvement in a rare case of subcutaneous entomophthoramycosis causing panniculitis emphasizes the importance of correct diagnosis and appropriate, effective treatment.

Mucormycosis Management in COVID-19 Era: Is Immediate Surgical Debridement and Reconstruction the Answer?

Background Excessive use of corticosteroids therapy along with gross immunocompromised conditions in the novel coronavirus disease 2019 (COVID-19) pandemic has raised the risks of contracting opportunistic fungal infections. Here, we describe our experience with the implementation of a surgical protocol to treat and reconstruct rhino-orbital-cerebral mucormycosis.

Methods A retrospective review of our prospectively maintained database was conducted on consecutive patients diagnosed with mucormycosis undergoing immediate reconstruction utilizing our “Mucormycosis Management Protocol.” All patients included in this study underwent reconstruction after recovering from COVID-19. Wide local excision was performed in all cases removing all suspected and edematous tissue. Reconstruction was done primarily after clear margins were achieved on clinical assessment under a cover of injectable liposomal amphotericin B.

Results Fourteen patients were included. The average age was 43.6 years and follow-up was 24.3 days. Thirteen patients had been admitted for inpatient care of COVID-19. Steroid therapy was implemented for 2 weeks in 11 patients and for 3 weeks in 3 patients. Eight patients (57.1%) had a maxillectomy and mucosal lining resection with/without skin excision, and six patients (42.8%) underwent maxillectomy and wide tissue excision (maxillectomy and partial zygomatic resection, orbital exenteration, orbital floor resection, nose debridement, or skull base debridement). Anterolateral thigh (ALT) flaps were used to cover defects in all patients. All flaps survived. No major or minor complications occurred. No recurrence of mucormycosis was noted.

Conclusion The approach presented in this study indicates that immediate reconstruction is safe and reliable in cases when appropriate tissue resection is accomplished. Further studies are required to verify the external validity of these findings.

Sensitivity of liquid-based cytology in the diagnosis of mucormycosis in COVID-19 treated patients

BACKGROUND

The coronavirus disease 2019 (COVID-19) infection caused by the novel severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is associated with a wide range of disease patterns, ranging from mild to life-threatening pneumonia. COVID-19 can be associated with a suppressed immune response and/or hyperinflammatory state due to cytokine storm. Reduced immunity, combined with steroid usage to prevent cytokine storm along with various pre-existing co morbidities can prove to be a fertile ground for various secondary bacterial and fungal infection, including mucormycosis. Diagnosis of mucor is a challenging task given high negativity rate of various detection methods. While histopathology is considered the gold standard, the acquisition of necessary tissue biopsy specimens requires invasive procedures and is time consuming.

METHOD

In this study various methods of mucor detection, like conventional cytopathology (CCP), liquid-based cytology (LBC, BD SurepathTM ), potassium hydroxide mount (KOH) preparation, culture and histopathology were analysed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for various methods.

RESULTS

This study showed that LBC has sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 72.4%,100%,100% and 38.4% respectively.

CONCLUSION

This study showed that, liquid-based cytology (LBC) can be a rapid and effective alternative to histopathology in mucor diagnosis.

Cutaneous Invasive Fungal Infections with Saksenaea Species in Immunocompetent Patients in Europe: A Systematic Review and Case Report

Invasive fungal infections from Saksenaea, a fungus belonging to the Mucorales, have been rarely reported in central European climate zones. This study aims to raise awareness of invasive cutaneous infections with Saksenaea species. The first case of a cutaneous infection was diagnosed in Switzerland in an immunocompetent 79-year-old patient. A minor skin trauma of her left lower leg led to a fulminant infection causing necrosis and extensive loss of tissue. The combination of surgical debridement and administration of antifungal agents averted a prolonged course with a possible worse outcome. A pedicled hemisoleus muscle flap was used to reconstruct the defect and treatment was continued for 63 days.

Radiological spectrum of invasive mucormycosis in COVID-19

Mucormycosis, commonly known as the “black fungus” is recently emerging as a deadly complication in COVID patients in the Indian subcontinent. A growing number of cases are being reported from all over the country, with a majority of the patients either undergoing treatment or having recovered from COVID.

Here, we report three cases of multisystem mucormycosis in COVID positive patients showing, rhino-orbital, cerebral, pulmonary, and genitourinary involvement. The first is a case of a 41-year-old male patient who during his treatment developed left periorbital swelling with ecchymosis and headache. CT and CE-MRI of the paranasal sinuses and brain revealed features of pan fungal sinusitis and subsequent invasion into the left orbit. The second case is of a 52-year-old male patient who after complaining of a severe left-sided hemicranial headache was diagnosed with cavernous sinus thrombosis. The third is of a 57-year-old male patient who presented with left flank pain and dysuria. HRCT (High-resolution CT) chest revealed a thick-walled cavitary lesion, and NCCT KUB (Non-contrast CT of Kidneys, ureters, and bladder) revealed left-sided pyelonephritis. A cystoscopic and microbiological evaluation revealed fungal growth.

In all three patients, a biopsy from the involved area revealed broad aseptate filamentous fungal hyphae suggestive of mucormycosis, which was confirmed on culture.

These are all unusual cases and physicians should be aware of the possibility of secondary invasive fungal infections in patients with COVID-19 infection.

Necrotizing Fasciitis Caused by Mucormycosis: A Case Report and Literature Review

We present a rare case of Necrotizing fasciitis (NF) caused by mucor. The limb was debrided multiple times and the patient received antifungal treatment. The clinical manifestations and laboratory test results of mucor infections, which were significantly different from those caused by common bacteria, are of great value.

New insights on mucormycosis and its association with the COVID-19 pandemic

COVID-19 continues to cause significant fatality worldwide. Glucocorticoids prove to play essential roles in COVID-19 management; however, the extensive use of steroids together with the virus immune dysregulation may increase the danger of secondary infections with mucormycosis, an angioinvasive fungal infection. Unfortunately, a definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. In this review, we discuss the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response, risk factors, clinical presentation, diagnosis and treatment. Special emphasis is given to its association with the current COVID-19 pandemic, including latest updates on COVID-19-associated mucormycosis cases globally, with recommendations for efficacious management.

A definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. This article can be used as comprehensive tool to help clinicians and the healthcare team in getting a clearer look on the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response. Risk factors, clinical presentation, diagnosis, treatment options and also the latest updates on COVID-19-associated mucormycosis are also discussed, which will help in the understanding of the fatal mucormycosis infection.

Imaging findings in invasive rhino-orbito-cerebral mucormycosis in post-COVID-19 patients

Rhino-orbito-cerebral mucormycosis (ROCM) is a life-threatening addition to the COVID-19 disease spectrum and is caused by an angioinvasive saprophytic opportunistic fungus. Early diagnosis is important to avoid disease spread and mortality. Contrast-enhanced magnetic resonance imaging plays a major role in detection of intraorbital and intracranial extension. We present imaging findings of 15 patients with post-COVID-19 rhino-orbito-cerebral mucormycosis who were diagnosed with invasive sinus mucormycosis at our institution and are currently undergoing treatment. All patients were diabetics, and 80% had a history of steroid intake during the course of COVID-19 treatment. There was a male preponderance (73.3%). The maxillary sinus was most commonly involved (86.7%). Orbital and intracranial invasion was seen in 73.3% and 60% of patients, respectively. The presence of retroantral, facial, infratemporal, and orbital fat stranding was an early sign of extrasinus spread. Other common sites of extrasinus involvement were the orbit and face, followed by the orbital apex, masticator space, pterygopalatine fossa, bone, skull base, cavernous sinus, brain, and internal carotid artery. In conclusion, early detection of extrasinus spread of mucormycosis by imaging is important so that aggressive treatment can be given and mortality can be reduced.

Utility of MGG and Papanicolaou stained smears in the detection of Mucormycosis in nasal swab/scraping/biopsy samples of COVID 19 patients

Background

Methods

Results

Conclusion

COVID-19-Associated Mucormycosis, A New Incident in Recent Time: Is An Emerging Disease in The Near Future Impending?

Mucormycosis (also known as black fungus) is caused by fungi of the Zygomycetes class and is the third most common invasive mycosis after candidiasis and aspergillosis. They colonize a large number of patients without invading them. Systemic glucocorticoids are currently used to treat severe Coronavirus disease 19 (COVID-19). In such patients, opportunistic fungal infections are a problem. Although COVID-19-related pulmonary aspergillosis is becoming more common, mucormycosis is still uncommon. Mucormycosis normally appears 10 to 14 days after being admitted to the hospital. Mucormycosis is a rare but dangerous infection that can make extreme COVID-19 worse. Mucormycosis is more likely to occur in people who have diabetes mellitus and other risk factors. Mucormycosis is most likely exacerbated by concurrent glucocorticoid treatment. To improve outcomes, a high index of suspicion and aggressive management is required. Excessive usage of steroids, monoclonal antibodies, and broad-spectrum antibiotics might cause the formation or worsen of a fungal infection. A high index of suspicion and aggressive management are needed. In patients with COVID-19 infection, physicians should be vigilant of the likelihood of subsequent invasive fungal infections. To enhance results in pulmonary mucormycosis, early diagnosis and treatment are critical. Confirmation of the clinical form necessitates a combination of symptoms that are consistent with tissue invasion histologically. Combining various clinical data and the isolation of the fungus from clinical samples in culture is needed for the probable diagnosis of mucormycosis. The organism that causes mucormycosis is identified using macroscopic and microscopic morphological criteria, carbohydrate assimilation, and the maximum temperature at which they can expand. Mucormycosis must be treated with antifungal medication prescribed by a doctor. It may necessitate surgery in some circumstances, and it can result in the loss of the upper jaw and, in some situations, an eye.

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.

A Fatal Case of Disseminated Intestinal Mucormycosis in a Patient with Vibrio Sepsis

Mucormycosis is a fungal infection that primarily causes opportunistic infections. Gastrointestinal mucormycosis is a rare infection that can occur in immunocompromised patients, nevertheless, prompt diagnosis and treatment is essential because it can be fatal. Gastrointestinal mucormycosis can only be diagnosed based on the findings of a pathological examination. Mucormycosis should be included in the differential diagnosis if the condition of patients with underlying immunocompromised conditions or diseases does not improve with general intensive care.

Mucormycosis: A deadly black fungus infection among COVID-19 patients in India

After first phase of Covid-19, the second wave affects a lot to the Indians with mysterious fungal infection known as Mucormycosis. Here, we reviewed clinical pathogenesis, signs, symptoms and treatment against black fungus. The conclusion revealed that use of immunosuppressant to combat Covid-19 also increases the risk to get infected with mucormycosis. Patients with hyperglycemia, ketoacidosis, solid organ or bone marrow transplantion, liver cirrhosis, neutropenia are more susceptible to get attacked by Mucormycosis moulds. Early diagnosis, removal of predisposing factors, timely antifungal therapy with surgical removal of all infected tissues and adjunctive therapies are four major factors to eradicate Mucormycosis.

A Rare Case of Gastrointestinal Mucormycosis

Gastrointestinal Mucormycosis (GIM) is a rare life-threatening angio-invasive infection. The classic risk factors include immunosuppression and metabolic derangement. Usually, there are classical risk factors in patients affected by Ileocecal mucormycosis. Few case reports have shown the absence of salient clinical presentation of mucormycosis in prolonged hospitalisation. The presence of association of mucormycosis in patients of typhoid infection is rare. Here, we present a case of invasive ileal mucormycosis occurring as a sequel to typhoid infection which lacked the typical risk factors for mucormycosis.

Mucormycosis in COVID-19 pandemic and its neurovascular spread

PURPOSE

Rhinocerebral mucormycosis is a rapidly progressive angioinvasive fungal infection commonly seen in diabetics. In the COVID-19 pandemic we have witnessed a sudden surge in these cases. We aimed to evaluate the disease presentation, patterns of spread, and any association with the COVID-19 virus.

METHODS

This prospective study was conducted on mucormycosis patients operated between March and July 2021. The diagnosis was confirmed either on KOH staining, fungal culture or histopathological examination.

RESULTS

Thirty one cases (21 males, 10 females) with a mean age of 53.3 years were included, of which 9 (29.1%) were COVID positive on presentation, 17 (54.8%) were post-COVID, while 5 (16.1%) had radiological evidence of COVID sequelae. Most common symptoms were cheek numbness (87.1%), headache (83.9%), visual disturbances (77.4%), and palate involvement (58.1%). Blackening of turbinates was uncommon (22.6%). Ethmoid sinus was involved in all patients. Pterygopalatine fossa involvement was present in 77.4%, and was accurately diagnosed on contrast enhanced MRI scan. There were 8 (25.8%) deaths, while the remaining are discharged or under treatment.

CONCLUSION

An increase in the incidence of mucormycosis in the COVID-19 pandemic is probably due to a compromise in host immunity along with a synergistic effect in thrombotic microangiopathy. Spread of infection to the soft tissues of the infratemporal fossa, orbit or palate occur via neurovascular structures rather than by bone erosion. The pterygopalatine fossa is involved in most individuals.

Microbial-based cleaning products as a potential risk to human health: A review

Microbial-based cleaning products (MBCPs) have been introduced, on the market, as an alternative to traditional chemical cleaning. In addition to traditional detergents, MBCPs can perform their cleaning function, digesting the smallest particles of dirt and mitigating odours generated by environmental bacterium metabolic processes. Nevertheless, several aspects remain to be clarified and assessed, requiring further studies and new regulations to ensure safety. The particular composition of MBCPs makes it difficult to include these products in a specific class, making the European legal context incomplete and unclear. Moreover, MBCPs effects on human health are poorly documented. Exposure risks can be obtained indirectly by studies conducted in both microorganisms exposure and their metabolic products, such as enzymes, especially in workers. A further limiting factor for the accurate human health risk assessment due to MBCPs use is an incomplete indication about the MBCPs compositions. Moreover, additional factors such as host microorganisms, frequency and space of use, subject health condition, and age can determine different illness scenarios. The findings from the broad range of studies we have reviewed in this paper confirm the necessity of integrative investigation and regulation to address the use of MBCPs.

A rare case of Escherichia coli and Rhizopus sinusitis complicated with pneumocephalus, E. coli psoas abscess and sepsis

Sinusitis is a common ailment a clinician comes across in their day-to-day practice. Simple as it may sound, it may become a very debilitating condition depending on the comorbidities of the patient and the organism involved. Rhizopus and Escherichia coli are less common organisms to affect the sinuses, but they are more common in immunocompromised patients such as patients with uncontrolled diabetes. Rhizopus can be a very debilitating infection as it erodes into the bone and blood vessels resulting in tissue necrosis. However, coinfection of both of these organisms is a very rare occurrence. Psoas abscess is also a less common infection in the immunocompetent patients but it is more common among the immunocompromised patients. It is extremely rare for both of these organisms to cause sinusitis in one patient, and for E. coli to simultaneously infect two different sites in the same patient. We report a case where a diabetic patient who had E. coli and Rhizopus coinfected sinusitis with simultaneous E. coli psoas abscess was successfully managed. The Rhizopus was treated with liposomal amphotericin B for 16 weeks while E. coli was treated with IV Meropenum. Furthermore, pneumocephalus is a condition that usually occurs following head trauma but the patient we are reporting developed pneumocephalus following Rhizopus sinusitis, which was treated with high-flow oxygen.

COVID-19 Associated Mucormycosis: A Systematic Review from Diagnostic Challenges to Management

The coronavirus disease 2019 (COVID-19) outbreak has caused significant destruction, claiming over three million lives worldwide. Post SARS-COV-2 invasion, immunosuppression with hyperglycemia and elevated ferritin levels along with steroidal treatment creates a perfect storm for opportunistic infections. There is increasing evidence of mucormycosis co-infection in COVID-19 patients, during or post-treatment. A worse prognosis, a late diagnosis, and limited guidelines of screening and management of COVID-19 associated mucormycosis have made healthcare professionals fear an epidemic alongside a pandemic. This review geographically reports cases of COVID-19 associated mucormycosis (CAM), evaluates characteristics, clinical manifestations, and outcomes of mucormycosis in COVID-19 active or recovered patients. It further describes preventive strategies and recommendations for optimal management therapy that can be adopted worldwide to curtail an impending threat to the healthcare system.