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Spectrum of Mucormycosis Before and During COVID-19: Epidemiology, Diagnosis, and Current Therapeutic Interventions. CURRENT FUNGAL INFECTION REPORTS 2022; 16:131-142. [PMID: 35967987 PMCID: PMC9364274 DOI: 10.1007/s12281-022-00438-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
Purpose of Review More than half a billion people have been infected and 6.2 million killed by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) since the start of the pandemic in 2019. Systemic glucocorticoids are a double-edged sword, on the one hand, life-saving in treating COVID-19 complications while on the other hand, potentially leading to life-and-limb-threatening opportunistic fungal infections. Mucormycosis (MM) is caused by the mucormycetes family. Although rare, it is characterized by high mortality and significant morbidity. The gross similarities observed with other fungal infections which respond to different treatment regimens have made it all the more imperative to quickly and sensitively diagnose and treat MM. This review discusses the epidemiology of MM before and during the COVID-19 pandemic, associated risk factors, COVID-19-associated MM, diagnosis, and current therapeutic interventions. Recent Findings There has been a widespread and worrisome trend of rising in cases of MM, worldwide, but more so in the Indian subcontinent, where it is nicknamed the “black fungus.” This upsurge has picked up the pace ever since the start of the COVID-19 pandemic. Necrosis is secondary to the angio-invasive and pro-thrombotic nature of the mold resulting in extensive lesions presenting mostly as rhino-orbital MM (ROM) and rhino-orbito-cerebral MM (ROCM). Infection is mostly observed in subjects with underlying risk factors such as uncontrolled diabetes, those receiving hematopoietic stem cell transplant, and/or on corticosteroid or immunosuppressive therapy, although it is widely suspected that other factors such as iron and zinc may play a role in the pathogenesis of MM. The “One world one guideline” strategy advocates both prophylactic anti-fungal therapy along with aggressive, prompt, and individualized treatment with anti-fungal drugs such as amphotericin B in addition to vigorous surgical intervention. High-risk groups need particularly rapid diagnosis although empirical anti-fungal therapy may not be delayed. Speeding diagnostic turnaround times are essential to institute early therapy, and there is much scope for newer modalities such as PCR, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and whole-genome sequencing in such endeavors. The results of strict monitoring of blood glucose levels along with rational and limited use of steroids and immunomodulatory drugs have proven to be a significant preventive measure. Summary The significant rise in cases of MM worldwide has necessitated viewing each case with a strong index of suspicion. Adoption of rapid diagnostics, early antifungal therapy, and prompt surgical interventions are essential, while high-risk groups need particular focused care which may include prophylactic anti-fungal therapy, limited steroid use, and meticulous control of the underlying disease. Developing quicker and more sensitive diagnostic modalities has great potential to improve the detection and management of MM.
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Current Treatment Options for COVID-19 Associated Mucormycosis: Present Status and Future Perspectives. J Clin Med 2022; 11:jcm11133620. [PMID: 35806905 PMCID: PMC9267579 DOI: 10.3390/jcm11133620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 12/04/2022] Open
Abstract
Mucormycosis has become increasingly associated with COVID-19, leading to the use of the term “COVID-19 associated mucormycosis (CAM)”. Treatment of CAM is challenging due to factors such as resistance to many antifungals and underlying co-morbidities. India is particularly at risk for this disease due to the large number of patients with COVID-19 carrying comorbidities that predispose them to the development of mucormycosis. Additionally, mucormycosis treatment is complicated due to the atypical symptoms and delayed presentation after the resolution of COVID-19. Since this disease is associated with increased morbidity and mortality, early identification and diagnosis are desirable to initiate a suitable combination of therapies and control the disease. At present, the first-line treatment involves Amphotericin B and surgical debridement. To overcome limitations associated with surgery (invasive, multiple procedures required) and amphotericin B (toxicity, extended duration and limited clinical success), additional therapies can be utilized as adjuncts or alternatives to reduce treatment duration and improve prognosis. This review discusses the challenges associated with treating CAM and the critical aspects for controlling this invasive fungal infection—early diagnosis and initiation of therapy, reversal of risk factors, and adoption of a multipronged treatment strategy. It also details the various therapeutic options (in vitro, in vivo and human case reports) that have been used for the treatment of CAM.
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Sharma A, Goel A. Mucormycosis: risk factors, diagnosis, treatments, and challenges during COVID-19 pandemic. Folia Microbiol (Praha) 2022; 67:363-387. [PMID: 35220559 PMCID: PMC8881997 DOI: 10.1007/s12223-021-00934-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Mucormycosis is a deadly opportunistic disease caused by a group of fungus named mucormycetes. Fungal spores are normally present in the environment and the immune system of the body prevents them from causing disease in a healthy immunocompetent individual. But when the defense mechanism of the body is compromised such as in the patients of diabetes mellites, neustropenia, organ transplantation recipients, and other immune-compromised states, these fungal spores invade our defense mechanism easily causing a severe systemic infection with approximately 45-80% of case fatality. In the present scenario, during the COVID-19 pandemic, patients are on immunosuppressive drugs, glucocorticoids, thus are at high risk of mucormycosis. Patients with diabetes mellitus are further getting a high chance of infection. Usually, the spores gain entry through our respiratory tract affecting the lungs and paranasal sinuses. Besides, they can also enter through damage into the skin or through the gastrointestinal route. This review article presents the current statistics, the causes of this infection in the human body, and its diagnosis with available recent therapies through recent databases collected from several clinics and agencies. The diagnosis and identification of the infection were made possible through various latest medical techniques such as computed tomography scans, direct microscopic observations, MALDI-TOF mass spectrometry, serology, molecular assay, and histopathology. Mucormycosis is so uncommon, no randomized controlled treatment studies have been conducted. The newer triazoles, posaconazole (POSA) and isavuconazole (ISAV) (the active component of the prodrug isavuconazonium sulfate) may be beneficial in patients who are refractory to or intolerant of Liposomal Amphotericin B. but due to lack of early diagnosis and aggressive surgical debridement or excision, the mortality rate remains high. In the course of COVID-19 treatments, there must be more vigilance and alertness are required from clinicians to evaluate these invasive fungal infections.
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Affiliation(s)
- Ayushi Sharma
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India
| | - Anjana Goel
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India.
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Bupha-Intr O, Butters C, Reynolds G, Kennedy K, Meyer W, Patil S, Bryant P, Morrissey CO. Consensus guidelines for the diagnosis and management of invasive fungal disease due to moulds other than Aspergillus in the haematology/oncology setting, 2021. Intern Med J 2021; 51 Suppl 7:177-219. [PMID: 34937139 DOI: 10.1111/imj.15592] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Invasive fungal disease (IFD) due to moulds other than Aspergillus is a significant cause of mortality in patients with malignancies or post haemopoietic stem cell transplantation. The current guidelines focus on the diagnosis and management of the common non-Aspergillus moulds (NAM), such as Mucorales, Scedosporium species (spp.), Lomentospora prolificans and Fusarium spp. Rare but emerging NAM including Paecilomyces variotii, Purpureocillium lilacinum and Scopulariopsis spp. are also reviewed. Culture and histological examination of tissue biopsy specimens remain the mainstay of diagnosis, but molecular methods are increasingly being used. As NAM frequently disseminate, blood cultures and skin examination with biopsy of any suspicious lesions are critically important. Treatment requires a multidisciplinary approach with surgical debridement as a central component. Other management strategies include control of the underlying disease/predisposing factors, augmentation of the host response and the reduction of immunosuppression. Carefully selected antifungal therapy, guided by susceptibility testing, is critical to cure. We also outline novel antifungal agents still in clinical trial which offer substantial potential for improved outcomes in the future. Paediatric recommendations follow those of adults. Ongoing epidemiological research, improvement in diagnostics and the development of new antifungal agents will continue to improve the poor outcomes that have been traditionally associated with IFD due to NAM.
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Affiliation(s)
- Olivia Bupha-Intr
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
| | - Coen Butters
- Department of General Paediatric and Adolescent Medicine, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - Karina Kennedy
- Department of Infectious Diseases and Microbiology, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, Australia.,ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Wieland Meyer
- Molecular Mycology Research Laboratory, Centre for Infectious Diseases and Microbiology, Westmead Clinical School and Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, New South Wales, Australia
| | - Sushrut Patil
- Malignant Haematology and Stem Cell Transplantation Service, Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Penelope Bryant
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Catherine O Morrissey
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Mitra S, Ray S, Kaur G, Kumar P, Kaur H, Saikia U. Neonatal Acute Liver Failure Associated with Angioinvasive Hepatic Zygomycosis. Fetal Pediatr Pathol 2019; 38:167-174. [PMID: 30595071 DOI: 10.1080/15513815.2018.1556368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Neonatal acute liver failure (NALF) is often a fatal condition. Zygomycosis is a fungal infection that is often fatal in both adults and infants. Only a few cases of hepatic zygomycosis are reported in the literature and they are invariably associated with immunosuppression. MATERIALS AND METHODS Post-mortem liver biopsy from a 14-day old neonate demonstrated confluent panacinar necrosis with angioinvasive zygomycosis. The limited work-up could not rule out an underlying immunodeficiency. CONCLUSION Angioinvasive hepatic zygomycosis can present in the neonatal period as NALF.
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Affiliation(s)
- Suvradeep Mitra
- a Department of Histopathology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Somosri Ray
- b Department of Neonatology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Gurwinder Kaur
- a Department of Histopathology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Praveen Kumar
- b Department of Neonatology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Harsimran Kaur
- c Department of Medical Microbiology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Uma Saikia
- a Department of Histopathology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
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Combined Medical and Surgical Management of Hepatic Mucormycosis in an Adult with Acute Myeloid Leukemia: Case Report and Review of the Literature. Mycopathologia 2018; 184:155-158. [PMID: 30062389 DOI: 10.1007/s11046-018-0289-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Abstract
Hepatic mucormycosis is a disease caused by a ubiquitous fungus which is especially important in patients with hematologic malignancies. We present a case of an adult patient with acute myeloid leukemia who developed the infection after undergoing chemotherapy. His successful management was an integrated approach of a minimally invasive surgical resection with anti-fungal therapy. We describe the management of this patient and a review of the literature.
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Therapy of Mucormycosis. J Fungi (Basel) 2018; 4:jof4030090. [PMID: 30065232 PMCID: PMC6162664 DOI: 10.3390/jof4030090] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 12/18/2022] Open
Abstract
Despite the recent introduction of mold-active agents (posaconazole and isavuconazole), in addition to amphotericin B products, to our armamentarium against mucormycosis, many uncertainties remain for the management of this uncommon opportunistic infection, as there are no data from prospective randomized clinical trials to guide therapy. In this mini-review, we present the current status of treatment options. In view of the heterogeneity of the disease (different types of affected hosts, sites of infection, and infecting Mucorales), mucormycosis management requires an individualized management plan that takes into account the net state of immunosuppression of the host, including comorbidities, certainty of diagnosis, site of infection, and antifungal pharmacological properties.
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Karigane D, Kikuchi T, Sakurai M, Kato J, Yamane Y, Hashida R, Abe R, Hatano M, Hasegawa N, Wakayama M, Shibuya K, Okamoto S, Mori T. Invasive hepatic mucormycosis: A case report and review of the literature. J Infect Chemother 2018; 25:50-53. [PMID: 30057341 DOI: 10.1016/j.jiac.2018.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
Mucormycosis generally develops under immunocompromised conditions, including hematological malignancies and solid organ or hematopoietic stem cell transplantation. Although mucormycosis usually affects the lungs and paranasal sinuses, sporadic cases of invasive mucormycosis of the liver have been reported. We hereby report a patient with myelofibrosis who developed hepatic mucormycosis diagnosed by post-mortem examination. An extensive literature review identified 13 reported cases of hepatic mucormycosis, including ours, without lung involvement. Most of the underlying diseases or conditions were hematological malignancies and solid organ transplantation. Three cases had splenic lesions and four had gastrointestinal lesions, suggesting the possibility of translocation to the liver and/or spleen from the gastrointestinal tracts. Hepatic mucormycosis should be recognized as one of the presentations of invasive mucormycosis, especially when hepatic nodules are found in immunocompromised patients such as those with hematological malignancy or recipients of solid organ transplantation.
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Affiliation(s)
- Daiki Karigane
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Taku Kikuchi
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masatoshi Sakurai
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kato
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yusuke Yamane
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Risa Hashida
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ryohei Abe
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mami Hatano
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hasegawa
- Center for Infectious Diseases and Infection Control, Keio University School of Medicine, Tokyo, Japan
| | - Megumi Wakayama
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Kazutoshi Shibuya
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan; Center for Infectious Diseases and Infection Control, Keio University School of Medicine, Tokyo, Japan.
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