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Andreescu M, Moldovan C, Lespezeanu DA, Mocanu AI, Schipor MA, Mocanu H. COVID-19-Associated Rhinocerebral Mucormycosis, an Incidental Finding or a Matter of Concern - Mixed-Method Systematic Review. Infect Drug Resist 2024; 17:387-402. [PMID: 38312523 PMCID: PMC10838509 DOI: 10.2147/idr.s445458] [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: 10/18/2023] [Accepted: 01/09/2024] [Indexed: 02/06/2024] Open
Abstract
With the advent of COVID-19, the number of patients diagnosed with mucormycosis has increased, especially in developing countries. The reason behind this increase is that COVID-19 causes hypoxia that promotes the growth of fungus. To identify the association between mucormycosis and COVID-19, in critically ill or immunocompromised COVID-19 patients. The literature included in the review was researched from October 1, 2021, to November 1, 2022, by using the Google Scholar database as the search engine. Of the 20 articles included, there were 4 case reports, 2 case series, 10 narrative reviews, and 4 quantitative studies. Mucormycetes growth is caused by several factors, including hyperglycemia owing to previously existing diabetes or excessive use of steroids, increased ferritin levels owing to the inflammatory cascade initiated by COVID-19, and immunosuppression caused by the use of steroids or other immunosuppressive therapy. Reduced white-cell count and activity in COVID-19 leads to increased germination of fungal spores hence developing a catastrophic picture of rhinocerebral mucormycosis. Considering that the hematological patient is frequently treated with cortisone, immunosuppressed due to the underlying condition, but also through the administered therapy, the association with a possible diabetes makes this patient susceptible to developing rhinocerebral mucormycosis during COVID-19 infection. Despite being severe, the association between mucormycosis and COVID-19 is specific and treatable. Development of mucormycosis in hematological patients suffering from severe COVID-19 disease is dangerous, yet not compulsory and can be prevented. Using a common steroid-dose protocol with hyperbaric oxygen and necessary preventive measure reveals the disease as a superadded infection. Hypoxia, poor glycemic control and overuse of steroids or immunosuppressive drugs cause it.
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Affiliation(s)
- Mihaela Andreescu
- Department of Hematology, Faculty of Medicine, "Titu Maiorescu" University, Bucharest, 031593, Romania
- Department of Hematology, Colentina Clinical Hospital, Bucharest, 01171, Romania
| | - Cosmin Moldovan
- Department of Medical Surgical Disciplines, Faculty of Medicine, "Titu Maiorescu" University, Bucharest, 031593, Romania
- Department of General Surgery, Witting Clinical Hospital, Bucharest, 010243, Romania
| | - Delia-Andreea Lespezeanu
- Doctoral School, Faculty of Medicine, "Titu Maiorescu" University, Bucharest, 031593, Romania
- "Ion Pavel" Diabetes Center, National Institute of Diabetes, Nutrition and Metabolic Diseases "Prof.Dr.N.C. Paulescu", Bucharest, 030167, Romania
| | - Adela-Ioana Mocanu
- Doctoral School, Faculty of Medicine, "Titu Maiorescu" University, Bucharest, 031593, Romania
- Department of ENT&HNS, Polimed Medical Center, Bucharest, 040067, Romania
| | - Mihai-Adrian Schipor
- Institute of Space Technology and Space Applications, University of the Bundeswehr, München, 85579, Germany
| | - Horia Mocanu
- Department of ENT&HNS, Faculty of Medicine, "Titu Maiorescu" University, Bucharest, 031593, Romania
- Department of ENT&HNS, Găești City Hospital, Găești, Dâmbovița, 135200, Romania
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Irfan A, Kamran AH, Ammar M, Rahman SU. Frequency and survival of Covid associated mucormycosis patients at tertiary care hospitals in Pakistan: A retrospective observational study. Health Sci Rep 2023; 6:e1083. [PMID: 36761033 PMCID: PMC9896361 DOI: 10.1002/hsr2.1083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023] Open
Abstract
Background Mucormycosis is a serious fungal infection associated with uncontrolled diabetes and immunocompromised patients. This angioinvasive infection emerged as a post-covid complication worldwide especially in developing countries. Due to the common socio-demographic status of South Asian countries, we expected a surge in mucormycosis cases in Pakistan. This study aims to observe the frequency and survival of Covid associated mucormycosis patients at tertiary care hospitals in Pakistan during the third wave of Covid-19 in 2021. Materials and Methods In this retrospective study, we collected the data of clinically and histopathologically confirmed cases of rhino-occipito-cerebral mucormycosis from three tertiary care hospitals of Lahore. These cases were analysed for history of Covid-19 and other associated comorbidities using SPSS28. History of steroid medication was also taken. Data were retrieved from May to July 2021 after the approval from the ethical review board. Results Out of the total 43 reported patients of mucormycosis in the set time frame only 22 cases had a history of Covid-19. The mean age was 50 ± 13.27 years with slight male predilection (60%). Diabetes mellitus was the most common comorbidity (88.4%) and all the patients with covid associated mucormycosis (CAM) had taken corticosteroid regimen for covid management (p < 0.0001). The survival of the patient was not significantly different between CAM and non-CAM patients of Mucormycosis (p = 0.747). Conclusion Covid-19 and mucormycosis make a lethal duo against the weakened health system of Pakistan. This problem can be prevented by avoiding nonjudicial use of corticosteroids and proper diabetes control program following Covid-19 infection. Furthermore, large-scale epidemiological studies should be carried out to evaluate the true burden of Mucormycosis in the population.
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Affiliation(s)
- Ayesha Irfan
- Department of Oral PathologyFatima Memorial College of Medicine and DentistryLahorePakistan
| | - Afshan Hussain Kamran
- Department of Oral PathologyFatima Memorial College of Medicine and DentistryLahorePakistan
| | - Muhammad Ammar
- Department of Oral Pathology, Lahore General HospitalPostgraduate Medical InstituteLahorePakistan
| | - Saeed ur Rahman
- Department of Community MedicineMinistry of National Guard‐Health AffairsRiyadhSaudi Arabia
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Bonifaz A, Tirado-Sánchez A, Araiza J, Hernández-Medel ML. Mucormycosis in the COVID-19 scenario beyond hospitalized patients. Future Microbiol 2023; 18:5-8. [PMID: 36648217 DOI: 10.2217/fmb-2022-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Alexandro Bonifaz
- Hospital General de México, Dr Eduardo Liceaga, 06720, Mexico City, Mexico
| | - Andrés Tirado-Sánchez
- Hospital General de México, Dr Eduardo Liceaga, 06720, Mexico City, Mexico.,Hospital General de Zona 30, IMSS, 08300, Mexico City, Mexico
| | - Javier Araiza
- Hospital General de México, Dr Eduardo Liceaga, 06720, Mexico City, Mexico
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Morton CO, Griffiths JS, Loeffler J, Orr S, White PL. Defective antifungal immunity in patients with COVID-19. Front Immunol 2022; 13:1080822. [PMID: 36531987 PMCID: PMC9750792 DOI: 10.3389/fimmu.2022.1080822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022] Open
Abstract
The COVID-19 pandemic has placed a huge strain on global healthcare and been a significant cause of increased morbidity and mortality, particularly in at-risk populations. This disease attacks the respiratory systems and causes significant immune dysregulation in affected patients creating a perfect opportunity for the development of invasive fungal disease (IFD). COVID-19 infection can instill a significant, poorly regulated pro-inflammatory response. Clinically induced immunosuppression or pro-inflammatory damage to mucosa facilitate the development of IFD and Aspergillus, Mucorales, and Candida infections have been regularly reported throughout the COVID-19 pandemic. Corticosteroids and immune modulators are used in the treatment of COVID-19. Corticosteroid use is also a risk factor for IFD, but not the only reason for IFD in COVID -19 patients. Specific dysregulation of the immune system through functional exhaustion of Natural killer (NK) cells and T cells has been observed in COVID-19 through the expression of the exhaustion markers NK-G2A and PD-1. Reduced fungicidal activity of neutrophils from COVID-19 patients indicates that immune dysfunction/imbalance are important risk factors for IFD. The COVID-19 pandemic has significantly increased the at-risk population for IFD. Even if the incidence of IFD is relatively low, the size of this new at-risk population will result in a substantial increase in the overall, annual number of IFD cases. It is important to understand how and why certain patients with COVID-19 developed increased susceptibility to IFD, as this will improve our understanding of risk of IFD in the face of future pandemics but also in a clinical era of increased clinical immuno-suppression/modulation.
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Affiliation(s)
| | - James S. Griffiths
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial Sciences, London, United Kingdom
| | - Juergen Loeffler
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Selinda Orr
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
| | - P. Lewis White
- Public Health Wales, Microbiology Cardiff, Wales, United Kingdom,*Correspondence: P. Lewis White,
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Pathogenesis and Pathology of COVID-Associated Mucormycosis: What Is New and Why. CURRENT FUNGAL INFECTION REPORTS 2022; 16:206-220. [PMID: 36193101 PMCID: PMC9520103 DOI: 10.1007/s12281-022-00443-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 12/02/2022]
Abstract
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.
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Tappe B, Lauruschkat CD, Strobel L, Pantaleón García J, Kurzai O, Rebhan S, Kraus S, Pfeuffer-Jovic E, Bussemer L, Possler L, Held M, Hünniger K, Kniemeyer O, Schäuble S, Brakhage AA, Panagiotou G, White PL, Einsele H, Löffler J, Wurster S. COVID-19 patients share common, corticosteroid-independent features of impaired host immunity to pathogenic molds. Front Immunol 2022; 13:954985. [PMID: 36052094 PMCID: PMC9427195 DOI: 10.3389/fimmu.2022.954985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022] Open
Abstract
Patients suffering from coronavirus disease-2019 (COVID-19) are susceptible to deadly secondary fungal infections such as COVID-19-associated pulmonary aspergillosis and COVID-19-associated mucormycosis. Despite this clinical observation, direct experimental evidence for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2)-driven alterations of antifungal immunity is scarce. Using an ex-vivo whole blood stimulation assay, we challenged blood from twelve COVID-19 patients with Aspergillus fumigatus and Rhizopus arrhizus antigens and studied the expression of activation, maturation, and exhaustion markers, as well as cytokine secretion. Compared to healthy controls, T-helper cells from COVID-19 patients displayed increased expression levels of the exhaustion marker PD-1 and weakened A. fumigatus- and R. arrhizus-induced activation. While baseline secretion of proinflammatory cytokines was massively elevated, whole blood from COVID-19 patients elicited diminished release of T-cellular (e.g., IFN-γ, IL-2) and innate immune cell-derived (e.g., CXCL9, CXCL10) cytokines in response to A. fumigatus and R. arrhizus antigens. Additionally, samples from COVID-19 patients showed deficient granulocyte activation by mold antigens and reduced fungal killing capacity of neutrophils. These features of weakened anti-mold immune responses were largely decoupled from COVID-19 severity, the time elapsed since diagnosis of COVID-19, and recent corticosteroid uptake, suggesting that impaired anti-mold defense is a common denominator of the underlying SARS-CoV-2 infection. Taken together, these results expand our understanding of the immune predisposition to post-viral mold infections and could inform future studies of immunotherapeutic strategies to prevent and treat fungal superinfections in COVID-19 patients.
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Affiliation(s)
- Beeke Tappe
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Chris D. Lauruschkat
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Lea Strobel
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Jezreel Pantaleón García
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Oliver Kurzai
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Silke Rebhan
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Elena Pfeuffer-Jovic
- Department of Pulmonary Medicine, Missionsärztliche Klinik Würzburg, Würzburg, Germany
| | - Lydia Bussemer
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Lotte Possler
- Department of Internal Medicine, Main-Klinik Ochsenfurt, Würzburg, Germany
| | - Matthias Held
- Department of Pulmonary Medicine, Missionsärztliche Klinik Würzburg, Würzburg, Germany
| | - Kerstin Hünniger
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Olaf Kniemeyer
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Sascha Schäuble
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - Axel A. Brakhage
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
- Department of Microbiology and Molecular Biology, Institute of Microbiology, Friedrich Schiller University, Jena, Germany
| | - Gianni Panagiotou
- Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology–Hans -Knöll- Institute, Jena, Germany
| | - P. Lewis White
- Public Health Wales, Microbiology Cardiff, Wales, United Kingdom
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Jürgen Löffler
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
- *Correspondence: Jürgen Löffler, ; Sebastian Wurster,
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
- *Correspondence: Jürgen Löffler, ; Sebastian Wurster,
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COVID-19-Associated Mucormycosis: A Matter of Concern Amid the SARS-CoV-2 Pandemic. Vaccines (Basel) 2022; 10:vaccines10081266. [PMID: 36016154 PMCID: PMC9415927 DOI: 10.3390/vaccines10081266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 12/16/2022] Open
Abstract
Mucormycosis is an invasive fungal infection caused by fungi belonging to order Mucorales. Recently, with the increase in COVID-19 infections, mucormycosis infections have become a matter of concern globally, because of the high morbidity and mortality rates associated with them. Due to the association of mucormycosis with COVID-19 disease, it has been termed COVID-19-associated mucormycosis (CAM). In the present review, we focus on mucormycosis incidence, pathophysiology, risk factors, immune dysfunction, interactions of Mucorales with endothelial cells, and the possible role of iron in Mucorales growth. We review the limitations associated with current diagnostic procedures and the requirement for more specific, cost-effective, convenient, and sensitive assays, such as PCR-based assays and monoclonal antibody-based assays for the effective diagnosis of mucormycosis. We discuss the current treatment options involving antifungal drug therapies, adjunctive therapy, surgical treatment, and their limitations. We also review the importance of nutraceuticals-based therapy for the prevention as well as treatment of mucormycosis. Our review also highlights the need to explore the potential of novel immunotherapeutics, which include antibody-based therapy, cytokine-based therapy, and combination/synergistic antifungal therapy, as treatment options for mucormycosis. In summary, this review provides a complete overview of COVID-19-associated mucormycosis, addressing the current research gaps and future developments required in the field.
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