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Tanwar M, Singh A, Singh TP, Sharma S, Sharma P. Comprehensive Review on the Virulence Factors and Therapeutic Strategies with the Aid of Artificial Intelligence against Mucormycosis. ACS Infect Dis 2024; 10:1431-1457. [PMID: 38682683 DOI: 10.1021/acsinfecdis.4c00082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Mucormycosis, a rare but deadly fungal infection, was an epidemic during the COVID-19 pandemic. The rise in cases (COVID-19-associated mucormycosis, CAM) is attributed to excessive steroid and antibiotic use, poor hospital hygiene, and crowded settings. Major contributing factors include diabetes and weakened immune systems. The main manifesting forms of CAM─cutaneous, pulmonary, and the deadliest, rhinocerebral─and disseminated infections elevated mortality rates to 85%. Recent focus lies on small-molecule inhibitors due to their advantages over standard treatments like surgery and liposomal amphotericin B (which carry several long-term adverse effects), offering potential central nervous system penetration, diverse targets, and simpler dosing owing to their small size, rendering the ability to traverse the blood-brain barrier via passive diffusion facilitated by the phospholipid membrane. Adaptation and versatility in mucormycosis are facilitated by a multitude of virulence factors, enabling the pathogen to dynamically respond to various environmental stressors. A comprehensive understanding of these virulence mechanisms is imperative for devising effective therapeutic interventions against this highly opportunistic pathogen that thrives in immunocompromised individuals through its angio-invasive nature. Hence, this Review delineates the principal virulence factors of mucormycosis, the mechanisms it employs to persist in challenging host environments, and the current progress in developing small-molecule inhibitors against them.
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Affiliation(s)
- Mansi Tanwar
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Anamika Singh
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Tej Pal Singh
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Sujata Sharma
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Pradeep Sharma
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
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Retrobulbar Amphotericin B Injection in Curbing the Progression of COVID Associated Rhino-orbital Cerebral Mucormycosis: A Retrospective Case Series. Indian J Otolaryngol Head Neck Surg 2022; 74:3352-3358. [PMID: 36246726 PMCID: PMC9547996 DOI: 10.1007/s12070-022-03199-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 09/23/2022] [Indexed: 10/30/2022] Open
Abstract
Purpose To assess whether transcutaneous retrobulbar Amphotericin B (TRAMB) injection can halt disease progression and reduce the requirement of exenteration in post-COVID 19 Rhino-orbital cerebral Mucormycosis (ROCM)) with limited orbital disease. Methods Retrospective series from a single center included 22 patients with KOH proved post-COVID 19 ROCM with radiographic evidence of limited orbital involvement were evaluated from May 2021 to October 2021. TRAMB was given along with systemic intravenous Amphotericin B injection and sinus debridement. Demographic profile, clinical data, operative notes, blood and radiological investigations were evaluated. The primary outcome was to assess the halt in the progression of orbital disease. The primary outcome measure was to assess the halt of the disease progression and the secondary outcome was improvement in the clinical signs and symptoms. Results The mean age was 50.36 ± 9.72 years and 77.3% were men. The Stagewise distribution was twelve (54.5%) patients in stage 3a, four (18.2%) patients in stage 3b, four (18.2%) in stage 3c, one (4.5%) patient in stage 3d and one (4.5%) had stage 4 disease. Improvement in lid edema and conjunctival chemosis were noticed and it was statistically significant (p value < 0.01), similarly visual acuity and ocular motility showed significant improvements (p value 0.04 and < 0.01 respectively). 1 patient died and 1 patient required exenteration later. Twenty patients showed halting of orbital disease after TRAMB injection. Conclusion TRAMB can be an alternative adjuvant therapeutic option to preserve the globe in patients with limited orbital disease but not at all replacement for exenteration.
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Randhawa G, Hagaman S, Pourabdollah Tootkaboni M, Kundal SV, Oli S, Alrassi J, Schild SD, Abu-Ghanem S, Brejt S. A Rare Case of Invasive Mucormycosis in a Diabetic Patient Treated with a Short Course of Dexamethasone. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932129. [PMID: 34310559 PMCID: PMC8323743 DOI: 10.12659/ajcr.932129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patient: Female, 74-year-old Final Diagnosis: Mucormycosis Symptoms: Altered mental status Medication:— Clinical Procedure: Central venous catheterization • debridement Specialty: Infectious Diseases • General and Internal Medicine • Otolaryngology
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Affiliation(s)
| | - Sean Hagaman
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | | | - Sanchit V Kundal
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Sharad Oli
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - James Alrassi
- Department of Otolaryngology, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA.,Department of Otolaryngology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Sam D Schild
- Department of Otolaryngology, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA.,Department of Otolaryngology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Sara Abu-Ghanem
- Department of Otolaryngology, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA.,Department of Otolaryngology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Shelly Brejt
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
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Chegini Z, Didehdar M, Khoshbayan A, Rajaeih S, Salehi M, Shariati A. Epidemiology, clinical features, diagnosis and treatment of cerebral mucormycosis in diabetic patients: A systematic review of case reports and case series. Mycoses 2020; 63:1264-1282. [PMID: 32965744 DOI: 10.1111/myc.13187] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with diabetes are known as an important high-risk group for cerebral mucormycosis (CM). METHOD We conducted a structured search using PubMed/MEDLINE to collect both case reports and case series case (ie including at least two patients) onto CM in diabetic patient published between 2000 and March 2020. RESULTS Forty-five reports of individual cases and eighteen case series articles were included. India accounted for the largest share of reports with 37.7% and 38.8% of individual cases and case series, respectively. Mortality ranged from 0% to 100% in the case series. The overall mortality in the individual cases was 46.3%, and 64.2% of deaths were reported in patients with ketoacidosis diabetes. Facial swelling (53.3%), headache (44.4%), loss of vision (35.5%) and ophthalmoplegia (35.5%) were the most frequently reported clinical symptoms. In all patients except 4 (91.1%), CM was treated surgically; however, in many cases (42%), despite the use of surgery, death occurred. Amphotericin B deoxycholate (AMB) and lipid-based AMB (LAMB) were used as the first lines of treatment for all patients; however, posaconazole, echinocandins, hyperbaric oxygen therapy (HBOT) and deferasirox were used in combination for a number of patients. Posaconazole has been shown to have positive therapeutic effect; however, posaconazole, LAMB and HBOT are not commonly used in low-income and health-challenged countries. CONCLUSION Cerebral mucormycosis is a rapidly progressive infection in diabetic patients and carries immense morbidity despite early diagnosis and treatment. Low-income countries have had the highest number of reports of the disease in recent years, indicating the need to control diabetes in these countries.
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Affiliation(s)
- Zahra Chegini
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Didehdar
- Department of Medical Parasitology and Mycology, Arak University of Medical Sciences, Arak, Iran
| | - Amin Khoshbayan
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Shahin Rajaeih
- ENT and Head and Neck Research Center and Department, The Five Senses Health Institute, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Salehi
- Department of Infectious Disease, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Aref Shariati
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Vaughan C, Bartolo A, Vallabh N, Leong SC. A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis-has anything changed in the past 20 years? Clin Otolaryngol 2018; 43:1454-1464. [PMID: 29947167 DOI: 10.1111/coa.13175] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 06/22/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Rhino-orbital-cerebral mucormycosis (ROCM) is an uncommon yet potentially lethal fungal infection. Although most cases originate from developing countries, an ageing population and increased prevalence of chronic illness may mean some clinicians practicing in developed countries will encounter ROCM cases in their careers. Yohai et al published a systematic review of 145 case reports from 1970 to 1993 assessing prognostic factors for patients presenting with ROCM. We present an updated review of the literature and assess whether survival outcomes have changed in the two decades since that seminal paper. SEARCH STRATEGY An extensive Medline literature search was performed for case reports published between 1994 and 2015. RESULTS In total, 210 published cases were identified from the literature review, of which 175 patients from 140 papers were included in this review. Fifty-five were female, with an overall mean age of 43 years. Overall survival rate was 59.5%, which was not significantly better than the previous series reported (60%) reported by Yohai et al. Survival rates in patients with chronic renal disease had improved, from 19% to 52%, and in patients with leukaemia (from 13% to 50%). Facial necrosis and hemiplegia remained poor prognostic indicators (33% and 39% survival rates, respectively). Early commencement of medical treatment related to better survival outcomes (61% if commenced within first 12 days of presentation, compared to 33% if after 13 days). Timing of surgery had less of an effect on overall survival. However, in 28 cases that did not receive any surgical treatment, survival was only 21%. CONCLUSIONS Although overall survival rates have not improved, survival in patients with renal disease were better, potentially due to the introduction of liposomal amphotericin B which is less nephrotoxic. Prompt recognition of ROCM, reversal of predisposing co-morbidities and aggressive medical treatment remain the cornerstone of managing this highly aggressive disease.
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Affiliation(s)
- Casey Vaughan
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Amanda Bartolo
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Nimisha Vallabh
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Samuel C Leong
- Department of Otorhinolaryngology - Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Jacob NB, Chaney S. Rhino Orbito Cerebral Mucormycosis: A Fatal Acute Invasive Fungal Infection in Uncontrolled Diabetes. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2016.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cutaneous Mucormycosis: Mycological, Clinical, and Therapeutic Aspects. CURRENT FUNGAL INFECTION REPORTS 2015. [DOI: 10.1007/s12281-015-0236-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Anders UM, Taylor EJ, Martel JR, Martel JB. Acute orbital apex syndrome and rhino-orbito-cerebral mucormycosis. Int Med Case Rep J 2015; 8:93-6. [PMID: 25945068 PMCID: PMC4407820 DOI: 10.2147/imcrj.s83036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To demonstrate the successful clinical identification and management of rhino-orbital mucormycosis, a fungal infection with a high mortality rate. Patients and methods A diabetic male patient with a headache and orbital apex syndrome in the right eye was examined using computed tomography (CT) and magnetic resonance imaging (MRI) for a possible fungal infection. Endoscopic surgical resection was performed and a pathology sample was taken. Specimens were prepared with Gömöri methenamine silver and hematoxylin and eosin staining. The patient was treated with liposomal amphotericin B 400 mg daily, followed by posaconazole 400 mg twice daily. Results CT and MRI revealed a mass of the right sphenoid spreading into the orbit, indicative of a fungal infection. The biopsy confirmed the diagnosis of mucormycosis. Complete recovery of eyelid and oculomotor function was achieved after 10 months of treatment, although the patient continues to suffer from irreversible blindness in the right eye due to optic nerve atrophy. He has been without signs or symptoms of recurrence. Conclusion Patients with rhino-orbito-cerebral mucormycosis need extensive surgical and medical treatment to maximize outcomes. Success requires multidisciplinary management.
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Affiliation(s)
- Ursula M Anders
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA
| | - Elise J Taylor
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA
| | - Joseph R Martel
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA ; Graduate Medical Education, California Northstate University College of Medicine, Elk Grove, CA, USA ; Department of Ophthalmology, Dignity Health, Carmichael, CA, USA
| | - James B Martel
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA ; Graduate Medical Education, California Northstate University College of Medicine, Elk Grove, CA, USA ; Department of Ophthalmology, Dignity Health, Carmichael, CA, USA
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