Epidemiology and Diagnosis of Mucormycosis: An Update

Mucormycosis coinfection in patients with proven aspergillosis

Data on the coinfection of molds are limited. Therefore, we systematically investigated mucormycosis coinfection in patients with morphologically proven aspergillosis. The medical records of adult patients with proven aspergillosis and available formalin-fixed paraffin-embedded (FFPE) tissue sections were retrospectively reviewed at a tertiary hospital between January 2019 and July 2024. The fungal culture results were reviewed and polymerase chain reaction (PCR) was performed to detect Aspergillus- and Mucorales-specific DNA using FFPE tissues. A positive Mucorales PCR test was confirmed when positive results were obtained for both the 18S and 28S targets. A total of 49 patients with proven aspergillosis were analyzed. The sterile specimen was not found to contain Mucorales. However, fungal cultures from a non-sterile site (endotracheal aspirate) revealed the presence of Aspergillus niger and Cunninghamella spp. in 1 (2%) of 49 patients (Patient A). A positive Mucorales-specific PCR result was obtained for one patient (2%) while positive Aspergillus- and Mucorales-specific PCR results were obtained for five patients, including Patient A (10%). Overall, 6 (12%) of the 49 patients with proven aspergillosis were found to be coinfected with mucormycosis. Coinfection with mucormycosis was significantly more associated with rhino-paranasal sinuses (33% vs. 2%, P = .03). In-hospital mortality was not found to significantly differ between patients with mucormycosis coinfection and those with aspergillosis alone (33% [2/6] vs. 14% [6/43], P = .24). Approximately one-tenth of patients with proven aspergillosis had molecular or microbiologic evidence of mucormycosis coinfection. Further studies are needed to highlight the clinical implications of the molecular evidence of mucormycosis coinfection in patients with proven aspergillosis.

Direct Targeted Degradation of Transposon RNAs by the Non-Canonical RNAi Pathway of the Fungus Mucor lusitanicus

Mucor lusitanicus has emerged as a model organism for studying RNAi in early-diverging fungi. This fungus exhibits intricate RNAi pathways that play crucial roles in regulating gene expression, destroying invasive exogenous genetic material, and controlling the movement of transposable elements (TEs) to ensure genome stability. One of the most fascinating RNAi pathways of this fungus is the non-canonical RNAi pathway (NCRIP), which is independent of Dicer and Argonaute proteins and uses the atypical RNase III R3B2 to degrade specific target messenger RNAs (mRNAs), playing an essential role in genome stability and virulence. Despite accumulating data suggesting that this pathway is a degradation mechanism, there has been no conclusive evidence. Here, we conducted a comparative transcriptomic analysis of mRNA and small RNAs regulated by r3b2, identifying 35 direct NCRIP targets. Most of these direct NCRIP targets correspond to TEs, highlighting the significant role of this RNAi pathway in TE control. Detailed functional analysis of the NCRIP targets confirmed the crucial role of r3b2 in regulating gene expression of protein-coding genes and controlling TEs other than centromeric GremLINE1 transposons, emphasizing the important role of r3b2 in genome stability. Interestingly, the RNAs of the NCRIP targets harbor a unique motif consisting of CAG repeats which are known to form hairpin structures which are targeted by RNA interference. Additionally, the generation of transformants expressing mRNAs containing the luciferase reporter gene along direct NCRIP targets reveals that this RNAi pathway is a true degradation mechanism for specific mRNAs. These results are expected to contribute to the understanding of the regulation of the NCRIP pathway through the analysis of its direct targets identified here.

A humanized antibody against mucormycosis targets angioinvasion and augments the host immune response

Mucormycosis is a fungal infection caused by Mucorales fungi that cause severe disease and fatality, especially in immunocompromised individuals. Although vaccines and immunotherapeutics have been successful in combating viral and bacterial infections, approved antifungal immunotherapies are yet to be realized. To address this gap, monoclonal antibodies targeting invasive fungal infections have emerged as a promising approach, particularly for immunocompromised patients who are unlikely to maximally benefit from vaccines. The Mucorales spore coat (CotH) proteins have been identified as crucial fungal invasins that bind to glucose-regulated protein 78 (GRP78) and integrins of host barrier cells. Previously, we described a murine monoclonal antibody, anti-CotH C2, which protected diabetic ketoacidosis (DKA) and neutropenic mice from mucormycosis. Here, we advanced the development of the C2 immunoglobulin G1 (IgG1) by humanizing it, establishing a stable Chinese hamster ovary cell line producing the antibody at commercial yields, and carried out optimization of the upstream and downstream manufacturing processes. The resultant humanized IgG1 (VX-01) exhibited a 10-fold increase in binding affinity to CotH proteins and conferred comparable in vitro and in vivo efficacy when compared to C2 antibody. The mechanism of protection was reliant on prevention of angioinvasion and enhancing opsonophagocytic killing. VX-01 demonstrated acceptable safety profiles with no detectable damage to host cells in vitro and weak or moderate binding to only cytoplasmic proteins in ex vivo good laboratory practice-human tissue cross-reactivity studies. Our studies warrant continued development of VX-01 as a promising adjunctive immunotherapy.

Molecular Assays Versus Mycological Methods for Diagnosis of Rhino Orbital Mucormycosis: Analysis of 120 Clinical Specimens from COVID-19 Patients

BACKGROUND

Mucormycosis, a fungal emergency, poses a serious threat to both COVID-19 and non-COVID-19 individuals due to its invasive nature, rapid progression, and high rates of morbidity and mortality. This underscores the crucial need for timely detection and management. In this study, we investigated the utility of real-time PCR (RT-qPCR) assays for detecting Mucorales in clinical specimens, and assessed the performance of both SYBR Green and TaqMan probe RT-qPCR in amplifying Mucorales-specific 18S rDNA genes. We conducted accuracy analyses using direct examination with KOH as a standard for the laboratory diagnosis of mucormycosis. Additionally, we compared the results with culture and duplex PCR.

PATIENTS/METHODS

Both SYBR Green and TaqMan RT-qPCR were optimized using Mucorales-specific oligonucleotides to amplify the conserved 18S rDNA targets. DNAs extracted from 120 rhino sinus specimens, which all were collected from COVID-19 patients upon suspicion of invasive fungal infections, were used for molecular diagnosis. The results of both RT-qPCR assays were compared with the result of direct microscopy, culture, and duplex Mucorales-specific PCR assay.

RESULTS

SYBR Green real-time PCR produced a distinct melting temperature (Tm) pattern (80.24 ± 0.70 °C) and detected Mucorales in 51 out of 120 clinical samples. When compared to direct examination with KOH, the standard method for diagnosing mucormycosis, SYBR Green PCR demonstrated a sensitivity of 91.67% (95% confidence interval (CI): 86.7-96.5%) and a specificity of 90.28% (95% CI: 84.9-95.5%). In contrast, TaqMan-probe PCR identified Mucorales in 34 out of 120 samples, with a sensitivity of 64.58% (95% CI: 56-73.1%) and a specificity of 95.83% (95% CI: 92.26-99.39%).

CONCLUSION

SYBR Green-based PCR can be used as a reliable confirmatory test for diagnosing mucormycosis, particularly in cases with atypical hyphae, mixed infections (featuring both septate and non-septate hyphae), or when the direct examination is positive but culture results are negative. The lower sensitivity of the TaqMan-probe PCR may be attributed to factors such as using a degenerate probe, which can lead to false-negative results.

Imaging Characteristics and Radiological Analysis of Rhinoorbital - Cerebral Mucormycosis

OBJECTIVE

To demonstrate the usefulness of magnetic resonance imaging (MRI) in diagnosing important imaging findings in rhino-orbito-cerebral mucormycosis.

MATERIALS AND METHODS

This is a retrospective cross-sectional study conducted at three medical colleges over 1 month in the patients diagnosed with coronavirus disease 2019 (COVID-19) and who developed mucormycosis of the paranasal sinuses during the treatment and in the post-recovery phase.

RESULTS

A total of 95 patients with male preponderance presented with mucormycosis. All had an association with COVID-19 virus disease. All the patients had a history of steroid use during their COVID-19 virus disease treatment. Painful proptosis was present in 42% of patients. The maxillary sinuses (97.22%) were the most commonly affected. Intraorbital extension was observed in 63% of cases, while intracranial extension was demonstrated in 10% of cases. Three patients had perineural spread, and one patient developed a mycotic aneurysm.

CONCLUSIONS

MRI plays a very crucial role in the prompt and early diagnosis of rhino-orbito-cerebral mucormycosis, as it is used to evaluate the invasion of the disease into the surrounding structures, as well as in preoperative planning for surgical debridement and to ascertain the prognosis. Diffusion-weighted imaging (DWI) adds specificity to localize the path of disease extension by showing restricted diffusion.

Rhinocerebral Mucormycosis in a Patient With Diabetes: A Rare but Critical Infection in the United Arab Emirates

A middle-aged man with no chronic medical conditions presented to the emergency department with flu-like symptoms, breathlessness, and vomiting. Arterial blood gas analysis revealed high blood glucose and an elevated anion-gap metabolic acidosis, suggestive of diabetic ketoacidosis, prompting the initiation of treatment. Neurological examination revealed multiple cranial nerve palsies with cranial mononeuritis multiplex, raising suspicion of rhino-orbito-cerebral mucormycosis. Liposomal amphotericin B was started empirically. Nasal endoscopy and biopsy, along with microbiological evidence, confirmed mucormycosis. Treatment required a multidisciplinary approach involving both medical and surgical specialties. In this case, we utilized treatments beyond current guidelines, including retrobulbar and intrathecal amphotericin in addition to intravenous dual antifungal therapy. Multiple surgical interventions were also performed. Over time, this approach led to clinical and biochemical improvement, allowing the patient to be discharged safely.

Characterization of the Spatiotemporal Localization of a Pan-Mucorales-Specific Antigen During Germination and Immunohistochemistry

BACKGROUND

Mucormycosis is an aggressive invasive fungal infection caused by molds in the order Mucorales. Early diagnosis is key to improving patient prognosis, yet it relies on insensitive culture or nonspecific histopathology. A pan-Mucorales-specific monoclonal antibody (mAb), TG11, was recently developed. Here, we investigate the spatiotemporal localization of the antigen and specificity of the mAb for immunohistochemistry.

METHODS

We used immunofluorescence microscopy to assess antigen localization in 11 Mucorales species of clinical importance and live imaging of Rhizopus arrhizus germination. Immunogold transmission electron microscopy revealed the subcellular location of mAb TG11 binding. Finally, we performed immunohistochemistry of R arrhizus in an ex vivo murine lung infection model alongside lung infection by Aspergillus fumigatus.

RESULTS

Immunofluorescence revealed TG11 antigen production at the emerging hyphal tip and along the length of growing hyphae in all Mucorales except Saksenaea. Time-lapse imaging revealed early antigen exposure during spore germination and along the growing hypha. Immunogold transmission electron microscopy confirmed mAb TG11 binding to the hyphal cell wall only. The TG11 mAb stained Mucorales but not Aspergillus hyphae in infected murine lung tissue.

CONCLUSIONS

TG11 detects early hyphal growth and has valuable potential for diagnosing mucormycosis by enhancing discriminatory detection of Mucorales in tissue.

A Small Cut, a Big Challenge: Pediatric Mucormycosis in an Unexpected Host

Mucormycosis is an infrequent fungal infection commonly seen in immunocompromised individuals. However, it can also occur in immunocompetent patients, especially following trauma. We present a case of a 15-month-old girl with increasing swelling and redness in her left eye after a minor traumatic injury. Imaging showed sinusitis with orbital involvement. Histopathology validated the diagnosis of mucormycosis caused by Rhizopus species. The patient had emergency surgery, followed by antifungal and antibiotic therapy. Despite febrile reactions to the treatment, the infection was managed, and the patient was discharged after 2 months. This case highlights the importance of considering mucormycosis in immunocompetent patients with unexplained ocular symptoms after trauma. Early diagnosis and aggressive treatment are essential for improving outcomes, especially in pediatric patients.

Increased serum ferritin is associated with severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis: A quantitative analysis

CONTEXT

Effect of serum ferritin on severity of coronavirus disease 2019 (COVID-19)-associated rhino-orbito-cerebral mucormycosis.

PURPOSE

To study the association between increased serum ferritin and severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis.

SETTINGS AND DESIGN

A cross-sectional study.

METHODS

Hundred ( n ) out of 155 treatment-naive patients of COVID-19 infection presenting with the signs and symptoms of rhino-orbito-cerebral mucormycosis were enrolled in study. Based on the classification proposed by Honavar, the study patients were classified into four stages: Stage 1: involvement of the nasal mucosa ( n = 11), Stage 2: involvement of paranasal sinuses ( n = 14), Stage 3: involvement of the orbit ( n = 37), Stage 4: involvement of the central nervous system ( n = 38). Stage 3 was further divided into four substages: 3a: nasolacrimal duct, medial orbit, vision unaffected ( n = 4); 3b: diffuse orbital involvement (>1 quadrant or >2 structures), vision unaffected ( n = 15); 3c: central retinal artery occlusion or ophthalmic artery occlusion, superior ophthalmic vein thrombosis, involvement of superior orbital fissure, inferior orbital fissure, orbital apex, diminution or loss of vision ( n = 13); 3d: bilateral orbital involvement ( n = 5). Fasting blood sugar (FBS), postprandial blood sugar (PPBS), and inflammatory markers (serum ferritin, interleukin-6, C-reactive protein, and D-dimer) were assessed. Serum level of ferritin was analyzed by using chemiluminescence immunoassay method.

RESULTS

Mean FBS (mg/dl) was 165.03 ± 70.43 for stage 1, 185.67 ± 64.82 for stage 2, 159.05 ± 68.60 for stage 3, and 158.20 ± 62.05 for stage 4. Mean PPBS (mg/dl) was 238.70 ± 141.29 for stage 1, 252 ± 103.69 for stage 2, 257.09 ± 103.48 for stage 3, and 229.53 ± 76.81 for stage 4. Mean serum ferritin (μg/l) was 302.67 ± 266.95 in stage 1, 444.19 ± 116.36 in stage 2, 504.85 ± 205.99 in stage 3, and 825.95 ± 777.30 in stage 4. A statistically significant increase in serum ferritin levels with severity of disease ( P = 0.005) was noted. Similar trend was observed in substages of stage 3. Pearson correlation analysis showed a positive correlation between serum ferritin and severity of disease ( P = 0.0007).

CONCLUSION

Increased serum ferritin was significantly independently associated with severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis.

Mucormycosis Infection in Lung Transplant Patients: Experience in Andalusia, Spain

INTRODUCTION

Mucorales infections in the airways of lung transplant (LT) patients are rare but have a rising incidence in transplanted lungs.

OBJECTIVE

We present our experience with LT in immediate postoperative infections due to mucormycosis.

METHODS

Review of 767 LT performed in Andalusia between 2000 and 2023 identifying Mucorales through microbiological results and histological findings.

RESULTS

The incidence of Mucorales was less than 1% of all LTs performed at our institution but resulted in 100% mortality. In our series, all cases underwent LT for chronic obstructive pulmonary disease. They presented with pulmonary infection that progressed to disseminated infection. Major associated risk factors included prior corticosteroid treatment, malnutrition, solid organ transplantation, single lung transplantation, immunosuppression, and concomitant Aspergillus infection.

CONCLUSIONS

Mucormycosis infection in grafts after lung transplantation is a lethal complication poorly documented in the literature. Vigilance for Mucorales in these patients is crucial for early diagnosis.

Mucormycosis Causing Splenic Infarction, Gastric Fistula, and Brain Abscess in a Patient With Acute Myeloid Leukemia: A Case Report

Invasive mucormycosis is an aggressive fungal infection characterized by rapid progression, primarily impacting immunocompromised individuals. Herein, we report a case of splenic infarction in association with gastrointestinal fistula and brain abscess as a rare presentation of mucormycosis biopsy, proven in a 56-year-old patient diagnosed with acute myeloid leukemia. The patient initially sought medical attention with a 3-week history of fever, night sweats, and malaise. Considering the chest computed tomography findings compatible with fungal disease and neutropenia, he underwent broad-spectrum antifungal therapy. Following the occurrence of splenic infarctions and a gastric fistula, the patient underwent a partial gastrectomy and splenectomy. Despite the interventions, the patient did not have a successful outcome and died on the second postoperative day. This case highlights the importance of timely suspicion, immediate antifungal therapy, and surgical intervention to improve the survival prospects of patients with multifaceted manifestations of mucormycosis.

Functional Rehabilitation - an Integral Component for Quality of Life in the Holistic Management of COVID-19 Associated Mucormycosis

To evaluate the quality of life in the post maxillectomy patients due to Coronavirus disease 2019 (COVID-19) associated Mucormycosis (CAM) following rehabilitation with obturators. The study also described the management and treatment outcomes of CAM patients. The study included 80 confirmed patients of CAM. The demographic profile, clinical presentations, predisposing and risk factors, and treatment outcomes were studied. Surgical and medical outcomes were expressed as percentages. After surgical debridement, 27 out of 80 patients were rehabilitated with obturators. The quality of life (QOL) of post debridement at 1 month (T1) vs. post 3 months (T2) of obturator use was measured using the oral health impact profile 14 (OHIP-14) scale. Maxillary sinus was involved in 98.75%, Ethmoid sinus in 51.25% and Sphenoid sinus in 26.25%. Surgical management involved Infrastructure maxillectomy in 56.25%, subtotal maxillectomy in 23.75%, and total maxillectomy with zygoma debridement in 20% of cases. Maxillary sinus debridement was done in 100%, Ethmoid sinus in 51.25%, and Sphenoid sinus in 26.25%. Medical management involved administration of intravenous Amphotericin B (total 3-5 g), and Posaconazole 300 mg OD for 3 months. The measured QOL using mean scores of each domain and the total score of OHIP-14 were lower at T2 (25.5 ± 6.809) compared to T1 (49.55 ± 9.822), (indicating better treatment outcomes) and were found to be statistically significant (P < 0.001). Early diagnosis, controlling risk factors, combined aggressive surgical and medical management reduces the morbidity and mortality of the patients. Early rehabilitation of the maxillectomy defects in CAM patients with temporary obturators mitigates deficient mastication and speech, thereby leading to improved function, aesthetics, and social well-being, and improving the overall QOL of these patients.

Effectiveness, Safety, and Patterns of Real-World Isavuconazole Use in Europe (2015-2019)

INTRODUCTION

Real-world data from multinational observational studies are required to better understand the role and performance of isavuconazole in real-world practice in Europe.

METHODS

A retrospective medical record review was conducted at 16 sites in Europe (France, Germany, Italy, Spain, and the United Kingdom). Eligible records were from patients aged ≥ 18 years at the time of isavuconazole initiation and received at least one dose of isavuconazole for suspected or confirmed invasive aspergillosis (IA) or invasive mucormycosis (IM) during the eligibility period (October 15, 2015 to June 30, 2019). Data were descriptively analysed. Success rates, overall survival, and times to these events were descriptively analysed.

RESULTS

Data were abstracted from 218 patients (201, IA; 17, IM) who received isavuconazole as monotherapy (initiated as infusion, 52%; oral, 46%). Isavuconazole was initiated as primary therapy in 92 patients (42.2%) and salvage therapy in 121 patients (55.5%) (unknown for five patients). Mean (standard deviation) age was 56.8 (15.6) years, 66% were men and 62% had at least three comorbidities, most frequently haematologic malignancy (62%). Estimated clinical response rate at week 24 was 54.5% (95% confidence interval [CI], 38.2-66.5%) for primary treatment and 73.5% (95% CI, 62.7-81.1%) for salvage therapy. Overall, 45 patients (21%) experienced at least one adverse event (AE). Serious AEs were experienced by 37 patients (17%), with seven related to isavuconazole; five patients (2.3%) discontinued isavuconazole monotherapy due to the serious AE. A total of 137 patients (63%) died, with 17 deaths (12.4%) related to their invasive fungal infection, 11 of whom initiated isavuconazole as salvage therapy.

CONCLUSIONS

This study adds to the growing body of evidence that whether used as first-line therapy or after the failure of other antifungal therapies, isavuconazole appears to have a promising clinical response and a good safety profile as an antifungal agent in patients with varied underlying conditions.

Orbital apex syndrome in a man with rhino-ocular cerebral mucormycosis: a case report

BACKGROUND

Orbital apex syndrome is a symptom complex of visual loss and ophthalmoplegia resulting from a disease involving the orbital apex. It can be caused by inflammation, infection, and malignancies. Mucormycosis is an infection caused by filamentous saprophytes of the order Mucorales. It is ubiquitous, and the infection can occur from ingesting contaminated food, inhaling spores, or injecting the disrupted skin or wounds. It is mainly a disease of the immunocompromised, affecting patients with poorly controlled diabetes, organ transplant recipients, and patients with hematological malignancies. We present the case of a man with orbital apex syndrome resulting from rapidly spreading rhino-ocular cerebral mucormycosis, who had a poor outcome despite an aggressive combined medical and surgical treatment. This is an unusual cause of orbital apex syndrome.

CASE PRESENTATION

A 46-year-old Bangladeshi man presented to the emergency department with a history of toothache and pain in the left eye. On examination, the patient had a left-sided periorbital edema, ptosis, and proptosis. He had complete ophthalmoplegia and absent direct pupillary response in the left eye. Magnetic resonance imaging of the brain and orbit showed bilateral ethmoidal, left frontal, maxillary, and sphenoidal sinusitis with left orbital cellulitis. His left orbit was surgically decompressed and histology confirmed mucormycosis. Despite aggressive treatment, the patient had only a partial improvement in his symptoms.

CONCLUSIONS

Mucormycosis is a rare disease that can easily be misdiagnosed, leading to delayed treatment and disease dissemination. Clinicians must be suspicious of mucormycosis in patients presenting with multiple cranial nerve palsy.

The Rising Threat of Mucormycosis: Oman's Experience Before and During the COVID-19 Pandemic

Mucormycosis is a rare, severe fungal infection mainly affecting immunocompromised individuals. Because of limited data on its epidemiology in Oman, we present this national, multicentric, retrospective review that includes all cases of proven mucormycosis between 2006 and 2022 in Oman. There were 51 cases of mucormycosis reported in Oman. The annual incidence of mucormycosis was 0.38-0.69 cases per million population before COVID-19. During the pandemic, the incidence rose significantly to 1.76 in 2020, 5.31 in 2021, then decreased to 0.87 per million population in 2022. Diabetes was observed in 82.4% (n = 42) of the cases, COVID-19 in 47.1% (n = 24), and other chronic diseases in 72.6%. The use of steroids was reported in 33.3% (n = 17) and many patients (64.7%, n = 33) had multiple risk factors. The overall mortality rate was 41.2% (n = 21) and most deaths occurred within a month of diagnosis. Mortality rate among patients diagnosed with COVID-19 was 58.3% (14/24). Survival analysis showed a statistically significant association between COVID-19 status and patient survival (p = 0.024). Annual incidence of mucormycosis in Oman rose during the pandemic. This study highlights the epidemiological features of mucormycosis and emphasizes the importance of its inclusion in the national notifiable communicable diseases priority list as well as the importance of enhancing diagnostic capacities to detect and improve patient outcomes.

Venous intestinal ischemia of fungal origin as a cause of intestinal obstruction in immunocompromised patients: case report and literature review

BACKGROUND

Mucormycosis is a highly lethal opportunistic fungal disease caused by ubiquitous molds of the order Mucorales, with Rhizopus, Lichtheimia and Mucor being the most common genera. This rare disease primarily affects immunocompromised patients, with presentations ranging from rhino-orbito-cerebral infections to disseminated mucormycosis with angioinvasion, leading to thrombosis and tissue infarction. Gastrointestinal mucormycosis is the least common clinical presentation and is believed to be secondary to spore ingestion. It can involve multiple components of the gastrointestinal tract, such as the stomach, liver, ileum, and colon, with nonspecific manifestations, including pain, nausea, vomiting, and abdominal distension. The initial clinical presentation may even manifest as gastrointestinal bleeding due to gastric ulceration or intestinal perforation.

CASE PRESENTATION

Here we present the case of a 48-year-old male patient with a 9-year history of human immunodeficiency virus (HIV) infection who was hospitalized in the context of febrile neutropenia and whose acute respiratory infection was documented; therefore, antibiotic treatment was initiated. However, due to persistent febrile peaks and peripheral blood showing documentation of multilineage cytopenias, a bone marrow biopsy was performed, compatible with presenting features of marrow myelodysplasia. During hospitalization, the patient presented left flank abdominal pain, and an abdominal computed tomography (CT) scan revealed signs of intussusception of a small bowel loop at the distal jejunum level, leading to intestinal obstruction with ischemic progression, requiring ileectomy (60 cm). Histopathological analysis of the resected intestine revealed severe transmural ischemic changes associated with venous thrombosis due to fungal structures, with histochemical studies demonstrating the presence of zygomycete (Mucor) fungal structures, leading to the initiation of treatment with amphotericin B. However, despite treatment, the patient experienced progressive clinical deterioration with persistent fever and ventilatory failure, with follow-up tests showing absolute neutropenia and blood cultures positive for yeast, leading to death 52 days after admission.

CONCLUSIONS

The diagnosis of intestinal mucormycosis may be delayed due to the lack of specificity of the signs and symptoms. Pathologists as well as histopathological studies are essential for timely treatment.

Recent Advances in Diagnostic Approaches for Mucormycosis

Mucormycosis, an invasive fungal infection caused by members of the order Mucorales, often progresses fulminantly if not recognized in a timely manner. This comprehensive review discusses the latest developments in diagnostic approaches for mucormycosis, from traditional histopathology and culture-based methods to advanced and emerging techniques such as molecular assays, imaging, serology, and metabolomics. We discuss challenges in the diagnosis of mucormycosis and emphasize the importance of rapid and accurate identification of this life-threatening infection.

Invasive Fungal Rhinosinusitis: The First Histopathological Study in Vietnam

BACKGROUND

Invasive fungal rhinosinusitis (IRFS) is a rare but highly fatal disease. The two primary groups of pathogens, Mucorales and Aspergillus, require different treatments and have distinct prognoses.

PURPOSE

This study aimed to analyze the histopathological features of IFRS.

METHODS

We conducted a retrospective study involving 57 IFRS cases. Demographic and comorbid characteristics were obtained from clinical records. Two pathologists independently examined the histopathological features using H&E, PAS, and GMS-stained slides. Fungal groups were identified with PCR under the guidance of histopathology.

RESULTS

The mean age of IFRS was 58.9 ± 13.4. The male-to-female ratio was 1.4:1. 100% of cases had diabetes comorbidity. Mucorales, Aspergillus, and other fungi were found in 61.4%, 33.3%, and 5.3% of cases, respectively. No Aspergillus and Mucorales co-infections were detected. Histopathology and PCR results were strongly concordant in classifying pathogens (Cohen's kappa = 84.2%, 95% CI 60.1% - 100%, p < 0.001). Mucormycosis exhibited higher rates of extensive necrosis and vascular invasion, and lower rates of pigment and spore presence than the non-Mucormycosis group (p < 0.001, p = 0.01, p = 0.02, p = 0.03, respectively). Extensive necrosis and vascular invasion were statistically significantly correlative (OR = 13.03, 95% CI 2.62-64.75, p = 0.002).

CONCLUSIONS

IFRS predominantly affects older adults and males. Histopathology is a reliable method for differentiating between Mucorales and Aspergillus. When extensive necrosis is detected, it is critical to investigate for vascular invasion carefully. The vascular invasion, degree of necrosis, pigments, and spores are valuable factors for distinguishing fungal agents of IFRS.

Invasive Fungal Infections in Immunocompromised Conditions: Emphasis on COVID-19

The COVID-19 pandemic caused death of 6 million lives globally, primarily from respiratory failure, but also a significant number from invasive fungal co-infections in these patients, owing to the immune dysfunction in hospitalized patients. Such complications occurred more often in critically ill, hospitalized patients particularly those admitted in intensive care units and were reported as the major reason associated with a high mortality rate worldwide. Fungal pathogens most commonly associated with COVID-19 patients comprise members of the Mucorales (such as Rhizopus, Mucor, and Lichtheimia), as well as genera Aspergillus and Candida. In India, the prevalence rate of mucormycosis is relatively high than aspergillosis and candidiasis, and the predisposing risk factors associated with such infections included uncontrolled diabetes, underlying lung disease, leukopenia, neutropenia, malignancies and prolonged steroid therapy. However, co-infection with other fungi, including Alternaria and Scedosporium was also sporadically reported. These devastating invasive fungal infections are associated with differential mortality (high-low) and morbidity rates even after active management. The diagnosis of such infections is often challenging due to lack of sensitivity in contemporary diagnostic methods and poses an enormous challenge to healthcare experts. Thus, the role of early and accurate diagnosis, and management of such fungal infections, is vital in preventing life-threatening situations. Hence, this review focusses primarily on the epidemiology, predisposing risk factors, host environment, diagnosis and treatment of the most common medically important invasive fungal infections in immunocompromised conditions associated with COVID-19.

Impact of prosthodontic rehabilitation on psychological status and quality of life in maxillectomy patients of coronavirus disease 2019-associated mucormycosis at a tertiary care center: A prospective clinical study

AIMS

The study was aimed to evaluate the effect of prosthodontic rehabilitation on psychological status (PS) and quality of life (QoL) in maxillectomy patients of coronavirus disease 2019-associated mucormycosis (CAM).

SETTINGS AND DESIGN

The study was designed as a prospective and clinical study.

MATERIALS AND METHODS

Twenty-four CAM patients undergoing maxillectomy and subsequent prosthetic rehabilitation were included. The treatment involved surgical, intermediate, and definitive obturator delivery at various phases of healing. PS was assessed using the Hospital Anxiety and Depression Scale (HADS), QOL using the European Organization for Research and Treatment of Cancer QoL Questionnaire-Head and Neck Module (EORTC QLQ-HandN35), and the functioning of obturator was assessed utilising the Obturator Functioning Scale (OFS) at various time points: before maxillectomy (T1), 2 weeks after maxillectomy (T2), 2 weeks upon usage of intermediate obturator (T3), just before delivery of definitive obturator (T4), and 12 weeks after the usage of definitive obturator (T5).

STATISTICAL ANALYSIS USED

Data were analyzed using a social science statistical analysis program (Stata 14.0; StataCorp LLC, Texas, USA). The significance level was chosen <0.05. Shapiro-Wilk test was used to assess the normality of quantitative data. Student's t-test was employed (α =0.05) to evaluate if the patient's PS, QOL, and obturator function had changed over time. The Spearman correlation coefficient (α =0.05) was utilized to evaluate the correlation coefficient between PS, QOL, and obturator function seen at T3 and T5.

RESULTS

Out of 24 enrolled patients, nine were dropped out. HADS-anxiety score was the highest at T1 (18.6 ± 1.2) and HADS-depression score was the highest at T2 (18.8 ± 1.6). HADS scores decreased significantly (P = 0.001) after prosthetic rehabilitation. EORTC QLQ-HandN35 score was the highest at T2 (105.8 ± 29.5), with statistical significance (P = 0.001) after rehabilitation. OFS was the highest at T3 (51.9 ± 3.9) and lowest at T5 (25.4 ± 2.8).

CONCLUSION

CAM and maxillectomy deliberately affects the PS and QOL. Prosthetic rehabilitation, psychological motivation, and education create greater improvement in PS and QOL. The progress in parameters showed an upward trend with good obturator quality over a period of time.

Utility of intraoperative scoring system in rhino-orbital mucormycosis as a prognostic tool

Objective

To assess the utility of an intraoperative scoring system for mucormycosis and to predict prognosis by comparing the score with postoperative outcomes.

Methods

This study was conducted among 80 patients with mucormycosis who underwent surgical management with mandatory pterygopalatine fossa and infratemporal fossa exploration. All cases were scored using our intraoperative scoring assessment tool. Postoperative outcomes in terms of favourable prognosis and mortality were evaluated and compared with demographics, clinical history and intraoperative findings.

Results

An intraoperative score of more than 25 was statistically significant in predicting mortality (p < 0.0001). In all, 86.7% of patients with a score above 25 succumbed to the disease. Statistical significance of mortality (p < 0.05) was observed in those with involvement of pterygopalatine fossa (78.9%), orbit (73.7%), infratemporal fossa (57.9%), cribriform plate (36.8%) and those with history of intake of antiviral drugs (47.4%), use of supplemental oxygen (31.6%) and renal failure (26.3%).

Conclusions

This study enabled better prediction of postoperative prognosis in mucormycosis and reiterated the importance of exploration of pterygopalatine fossa and infratemporal fossa in management and prognostication of invasive fungal sinusitis.

Clinical Significance of Mucor in Airway Culture of Immunocompetent Patients With Chronic Lung Disease

OBJECTIVES

Mucor within the airways of immunocompromised patients often signifies an invasive life-threatening infection. However, its significance in immunocompetent patients with chronic lung diseases is less clear. We aimed to assess the clinical implication of mucor in airway-secretion cultures of these patients.

METHODS

A single-center retrospective cohort study was performed. Patients with cystic fibrosis (CF), primary ciliary dyskinesia (PCD) or non-CF/non-PCD bronchiectasis followed in our Pediatric Pulmonary Institute, with sputum or bronchoalveolar lavage cultures growing Mucorales molds in the years 2010-2022, were included. Demographic and clinical parameters such as body mass index and spirometry values (forced expiratory volume at 1 second) were collected and compared with values up to 12 months prior to and following the index (positive culture) visit.

RESULTS

A total of 27 patients of whom 22 (82%) patients were with CF, 3 with PCD (11%) and 2 (7%) with non-CF/non-PCD bronchiectasis were included. Median age was 21.8 (14.9-32.1) years, with forced expiratory volume at 1 second of 62.8% ± 21.9% at the index visit. None of the patients developed disseminated disease, none had clinical or radiological evidence of fungal disease and none required antifungal therapy. Throughout the 12 months prior to and following the positive cultures, no significant changes were noted in body mass index, forced expiratory volume at 1 second, frequency of pulmonary exacerbations, days of hospitalization or days of antibiotic treatment.

CONCLUSIONS

Evidence of mucor in airway cultures of immunocompetent patients with chronic lung disease does not necessarily signify clinical deterioration nor suggests invasive fungal disease. Larger, long-term prospective studies are required to obviate the need for a thorough evaluation in these patients.

Post COVID-19 mucormycosis in critical care settings: A prospective cohort study in a tertiary care center in Egypt

BACKGROUND

The emergence of mucormycosis as a life-threatening fungal infection after the coronavirus disease of 2019 (COVID-19) is a major concern and challenge, but there is limited information on the risk factors for mortality in patients.

METHODS

We conducted a prospective cohort study from May 2021 to April 2022 to determine the in-hospital outcomes of post-COVID-19 mucormycosis during the intensive care unit (ICU) stay. The sample of the study was collected as consecutive sampling using all accessible patients in the study period. The Statistical Package for Social Sciences (SPSS), version 25 (IBM, Chicago, Illinois, USA) was used for statistical analysis.

RESULTS

Among 150 patients with post-COVID-19 mucormycosis, the majority had a primary sinus infection (86.0 %), while 11.3 % had both sinus and ocular infections, and 2.7 % had sinus and cutaneous infections. Around 21 % (n = 31) of patients deceased after staying in the ICU for a median (range) of 45.0 (10.0-145.0) days. The majority of the patients who deceased had pneumonia patches on computed tomography (CT) (90.3 %) while none of the patients who were discharged had pneumonia patches (p < 0.001). The deceased group had higher rates of pulmonary embolism (93.5 %) compared to the surviving groups (21.8 %). In a multivariate Cox regression analysis, the risk of death was higher in older patients above 60 years old (hazard ratio (95 %CI): 6.7 (1.73-15.81)), increase among patient with history of steroid administration (hazard ratio (95 %CI): 5.70 (1.23-10.91)), who had facial cutaneous infection with mucormycosis (hazard ratio (95 %CI): 8.76 (1.78-25.18)), patients with uncontrolled diabetes (hazard ratio (95 %CI): 10.76 (1.78, 65.18)), and total leukocytic count (TLC>10 ×103 mcL) (hazard ratio (95 %CI): 10.03 (3.29-30.61)).

CONCLUSIONS

Identifying high-risk patients especially old diabetic patients with corticosteroid administration and detecting their deterioration quickly is crucial in reducing post-COVID-19 mucormycosis mortality rates, and these factors must be considered when developing treatment and quarantine strategies.

Changing Spectrum of Invasive Fungal Infections of the Anterior Skull Base

Objective  To study the etiological and anatomical factors in pathophysiology of invasive fungal rhinosinusitis affecting the skull base. Design  Retrospective clinical study over 5 years. Setting  Single-center tertiary referral hospital. Materials and Methods  All cases of invasive fungal rhinosinusitis with clinicoradiological and/or operative evidence of anterior and central skull base, orbit, and orbital apex involvement with or without intracranial disease were included in the study. Patients with a sinonasal-palatal disease without the involvement of the skull base or orbit were excluded from the study. In addition, we assessed the risk factors such as coronavirus disease 2019 (COVID-19) infection, diabetes mellitus (DM), and other immunocompromised conditions. Results  There were 79 patients, of which 65.8% had skull base rhino-oribitocerebral mucormycosis (ROCM), and 34.2% had Aspergillus infection. The mean duration from onset of the symptom to presentation of ROCM was 36.75 ± 20.97 days, while for the Aspergillus group was 21 weeks. The majority of patients (66%) with ROCM presented after 30 days of symptom onset. Among ROCM patients, 88.7% had a history of COVID-19 infection, and 96% had DM. In 40.8% of patients with Aspergillus infection, the tissue diagnosis was unavailable, and galactomannan assay and clinicoradiological assessment were used for diagnosis. The most common area of the skull base involved was the pterygopalatine fossa (88.5%), followed by the infratemporal fossa (73.1%). The most common neurovascular structure (75%) involved was the pterygopalatine ganglion and the infraorbital nerve. Conclusion  With the increasing incidence of invasive fungal infections worldwide, particularly after the COVID-19 pandemic, it is crucial to understand the evolving nature of this disease. ROCM, documented in the literature to cause fulminant disease, became a chronic illness, possibly due to the improvement of the patient's immunity during the disease course.

Exploring the feasibility of utilizing universal primers in detecting mucormycosis pathogens: An in-silico analysis

This study aimed to design and evaluate a universal primer for Polymerase Chain Reaction (PCR)- based detection of mucormycosis-causing fungi by targeting their Internal Transcribed Spacer (ITS) sequences. In-silico analysis was conducted to assess primer suitability. Using Clustal Omega and Primer-BLAST, ITS sequences of 32 fungi species causing mucormycosis were aligned and subjected to primer design. Generated primers were sorted and in silico PCR simulations were performed to identify primers capable of amplifying all fungal species. Instead of identifying one pair of universal primer, in silico PCR analysis identified a panel of 14 primer pairs designed from full-length ITS sequences, and a panel of 12 primer pairs designed from conserved regions, that could detect 31 species. The study recommends a panel of 12 primers for multiplex-PCR to detect mucormycosis-causing fungi instead of a long list of PCR analyses for each fungus in diagnosing mucormycosis.

Epidemiology and prognostic factors of mucormycosis in France (2012-2022): a cross-sectional study nested in a prospective surveillance programme

Background

Mucormycosis is a deadly invasive fungal infection recently included in the WHO priority pathogen list. Here we sought to describe epidemiological trends of mucormycosis in France, and to evaluate factors associated with mortality.

Methods

From 2012 to 2022, we implemented a nationwide prospective surveillance programme for mucormycosis in France, focusing on epidemiology, species, seasonal variations. Factors associated with 3-month mortality were studied by univariable and multivariable logistic regression.

Findings

Among 550 cases of mucormycosis, the main underlying conditions were haematological malignancy (HM, 65.1%, 358/550), trauma (8%, 44/550), diabetes (7.5%, 41/550) and solid-organ transplants (6.5%, 36/550). Site of infection was pulmonary in 52.4% (288/550), rhinocerebral in 14.5% (80/550), and cutaneo-articular in 17.1% (94/550). Main species identified were Rhizopus arrhizus (21%, 67/316), Rhizopus microsporus (13.6%, 43/316), Lichtheimia corymbifera and Mucor circinelloides (13.3%, 42/316 each), Rhizomucor pusillus (12%, 38/316), and Lichtheimia ramosa (10.8%, 34/316). We found associations between underlying condition, site of infection, and infecting species, including a previously undescribed triad of trauma, cutaneo-articular localisations, and L. ramosa/M. circinelloides. Diagnostic contribution of Polymerase Chain Reaction (PCR) increased from 16% (4/25) in 2012 to 91% (61/67) in 2022, with more than 50% of diagnoses relying solely on PCR in 2022. We also found seasonal variations with relatively more cases in autumn. Ninety-day mortality was 55.8% (276/495). Independent prognostic factors were age, diagnosis in Intensive Care Unit (ICU), and HM while diagnosis after 2015 (i.e. large implementation of PCR) and surgery were associated with reduced mortality.

Interpretation

This study reveals major mucormycosis epidemiological changes in France, with a large predominance of HM patients, and a parallel between PCR multicentre implementation and improved prognosis. We also evidence new associations between species, localisations and risk factors, as well as seasonal variations.

Funding

Recurrent financial support from Santé Publique France and Institut Pasteur.

A global perspective of the changing epidemiology of invasive fungal disease and real-world experience with the use of isavuconazole

Global epidemiological data show that the incidence of invasive fungal disease (IFD) has increased in recent decades, with the rising frequency of infections caused by Aspergillus and Mucorales order species. The number and variety of patients at risk of IFD has also expanded, owing in part to advances in the treatment of hematologic malignancies and other serious diseases, including hematopoietic stem cell transplantation (HCT) and other therapies causing immune suppression. Isavuconazonium sulfate (active moiety: isavuconazole) is an advanced-generation triazole antifungal approved for the treatment of invasive aspergillosis and mucormycosis that has demonstrated activity against a variety of yeasts, moulds, and dimorphic fungi. While real-world clinical experience with isavuconazole is sparse in some geographic regions, it has been shown to be effective and well tolerated in diverse patient populations, including those with multiple comorbidities who may have failed to respond to prior triazole antifungal therapy. Isavuconazole may be suitable for patients with IFD receiving concurrent QTc-prolonging therapy, as well as those on venetoclax or ruxolitinib. Data from clinical trials are not available to support the use of isavuconazole prophylactically for the prevention of IFD or for the treatment of endemic IFD, such as those caused by Histoplasma spp., but real-world evidence from case studies suggests that it has clinical utility in these settings. Isavuconazole is an option for patients at risk of IFD, particularly when the use of alternative antifungal therapies is not possible because of toxicities, pharmacokinetics, or drug interactions.

Risk Factors and Outcomes of Mucorales Infection in a Modern Cohort of Solid Organ Transplant, Hematopoietic Cell Transplant, and Chimeric Antigen Receptor T-cell Therapy Recipients

BACKGROUND

Mucorales infections continue to cause significant morbidity and mortality in immunocompromised hosts despite the advent of new approaches for diagnosis and treatment of fungal infections. We aimed to evaluate risk factors and outcomes of Mucorales infection in solid organ transplant, hematopoietic cell transplant, and chimeric antigen receptor T-cell therapy recipients.

METHODS

This single-center retrospective study included solid organ transplant, hematopoietic cell transplant, and chimeric antigen receptor T-cell patients with cultures positive for Mucorales.

RESULTS

Forty-three patients were included for analysis; 34 solid organ transplant (79%) and 9 hematopoietic stem cell transplant or chimeric antigen receptor T-cell (21%). Infection with Mucorales occurred a median of 184 days after transplant. At the time of diagnosis, 36 patients were on antifungal prophylaxis with the majority receiving posaconazole (53%). Thirty-three had clinically significant disease; 30 received definitive anti-Mucorales therapy and 3 empiric antifungal therapy. Isavuconazole was the most common azole used for treatment in monotherapy recipients. All-cause mortality was 64% and, of these deaths, 18 (75%) were directly related to Mucormycosis. The highest mortality was seen in disseminated and intra-abdominal disease (100%), followed by pulmonary disease (50%). There was no significant association with mortality and transplant type or number of immunosuppressive agents.

CONCLUSION

Mucormycosis is an important cause of morbidity and mortality in immunocompromised patients. Breakthrough infection was not uncommon in this study. Data regarding the incidence of infection at approximately 6 months after transplantation can inform prophylaxis and treatment regimens. The spectrum of antifungal regimens used reflects the lack of consensus on ideal regimens for these organisms and a need for more studies.

A clinical study of rhino-orbital-cerebral mucormycosis during the COVID-19 pandemic in western Maharashtra

Background

The aim of the study was to describe the epidemiology and study the risk factors, clinical presentation, management, and outcome of rhino-orbital-cerebral mucormycosis (ROCM) in terms of mortality, exenteration, eye salvage, and vision salvage.

Methods

This retrospective, observational study was carried out over a period of two months. A detailed history was noted, and an ophthalmological examination was done. The diagnosis was done by Potassium hydroxide (KOH) mount and fungal culture. Magnetic resonance imaging (MRI) of the orbit, brain, and paranasal sinuses were performed. Medical (intravenous amphotericin B, posaconazole), surgical (retrobulbar amphotericin B injection, exenteration, Functional Endoscopic Sinus Surgery (FESS)), or combined management was evaluated, and clinical outcomes was noted.

Results

The mean age of patients was 54.2 years and the male-to-female ratio was 1.77/1. The most common underlying risk factor for ROCM was uncontrolled diabetes mellitus (70%), followed by the use of corticosteroids for the management of coronavirus disease 2019 (COVID-19) infection in 68% of patients. The most common clinical presentation was diminution of vision followed by eschar, ptosis, and proptosis. Medical and FESS were done in all patients; exenteration was done in 12% of patients. Sixty-six percent of patients were alive with regression of ROCM, 20% of patients were alive with residual, 8% of patients were alive with the progression of ROCM, and 6% of patients had expired. Among the ones who are alive, the ocular outcome was orbital exenteration in 12.76%, the eye was salvaged in 25.53 and vision salvage was achieved in 61.70%.

Conclusion

ROCM affects older males. Immunosuppression due to COVID-19 infection, diabetes mellitus, and corticosteroid use in the management of COVID-19 are the main risk factors for the development of ROCM. Antifungal therapy along with surgical debridement decreases mortality.

MR Imaging in Covid-19-Associated Invasive Fungal Sinusitis

BACKGROUND AND AIM

We witnessed a sharp peak in the incidence of invasive fungal sinusitis, particularly mucormycosis, in patients with history of coronavirus disease 2019 (COVID-19) infection in India. Rhino-orbito-cerebral mucormycosis (ROCM) is a fulminant rapidly progressive disease. Early diagnosis significantly improves patient survival and outcomes. Hence, neuroimaging plays a very important role. We studied the magnetic resonance (MR) imaging manifestations of invasive fungal sinusitis and established an imaging protocol, which helps in early diagnosis of the disease per se as well as its complications. We evaluated the differences between COVID-19-associated and non-COVID-19-associated ROCM.

MATERIALS AND METHODS

We retrospectively analyzed the MR imaging manifestations of 91 histopathologically proven cases of post-COVID-19-invasive fungal sinusitis.

RESULTS

We observed stage I disease limited to sinuses in 25.2%, stage II disease with intraorbital spread in 23%, and stage III disease with intracranial spread in 51.6% of our patients. Dural involvement was the commonest and earliest sign of stage III disease. Direct parenchymal invasion from the adjacent paranasal sinuses was the commonest pattern of cerebral involvement, involving basifrontal lobe (14.2%) followed by anteromedial temporal lobe (5.4%). We observed orbital and intracranial complications including subperiosteal orbital abscess (1%), cavernous sinus involvement (29.6%), angioinvasion (15.3%), perineural spread (9.8%), and osteomyelitis of skull base and craniofacial bones (45%). Contrary to non-COVID-19-associated ROCM, we did not observe any case with superior ophthalmic vein/dural venous sinus thrombosis or basilar artery angioinvasion in our study.

CONCLUSIONS

In our study, stage III disease was most commonly due to direct parenchymal invasion into frontal and temporal lobes from the adjacent frontal and sphenoid sinuses, respectively. The commonest vascular complications in our study were cavernous sinus involvement followed by angioinvasion into the cavernous ICA leading to watershed infarcts.

Precision Detection of Fungal Co-Infections for Enhanced COVID-19 Treatment Strategies Using FESEM Imaging

The treatment of fungal infections presents significant challenges due to the lack of standardized diagnostic procedures, a restricted range of antifungal treatments, and the risk of harmful interactions between antifungal medications and the immunosuppressive drugs used in anti-inflammatory treatment for critically ill patients with COVID-19. Mucormycosis and aspergillosis are the primary invasive fungal infections in patients with severe COVID-19, occurring singly or in combination. Histopathological examination is a vital diagnostic technique that details the presence and invasion of fungi within tissues and blood vessels, and the body's response to the infection. However, the pathology report omits information on the most common fungi associated with the observed morphology, as well as other potential fungi and parasites that ought to be included in the differential diagnosis. This research marks significance in diagnosing fungal infections, such as mucormycosis and aspergillosis associated to COVID-19 by field emission scanning electron microscopy (FESEM) imaging to examine unstained histopathology slides, allowing for a detailed morphological analysis of the fungus. FESEM provides an unprecedented resolution and detail, surpassing traditional Hematoxylin & Eosin (H&E) and Grocott's Methenamine Silver (GMS) staining methods in identifying and differentiating dual fungal infections and diverse fungal species. The findings underscore the critical need for individualized treatment plans for patients severely affected by COVID-19 and compounded by secondary fungal infections. The high-magnification micrographs reveal specific fungal morphology and reproductive patterns. Current treatment protocols largely depend on broad-spectrum antifungal therapies. However this FESEM guided diagnostic approach can help in targeted patient specific anti fungal therapies. Such precision could lead to more effective early interventions, addressing the complex management required for severe COVID-19 cases with coexisting fungal infections. This approach significantly advances disease management and patient recovery, advocating for personalized, precision medicine in tackling this multifaceted clinical challenge.

Graphical Abstract

Clinical characteristics and mortality of mucormycosis in hematological malignancies: a retrospective study in Eastern China

BACKGROUND

Mucormycosis is a significant cause of morbidity and mortality in patients with hematological malignancies, but its characteristics are not fully understood. This study aimed to gain a better understanding of the clinical features of mucormycosis in patients with hematological malignancies in eastern China.

METHODS

A single-center retrospective analysis was conducted on the demographic profile, microbiology, management, and 90-day mortality of mucormycosis patients with hematological malignancies between 2018 and 2023.

RESULTS

A total of 50 cases were included in the study, consisting of 11 proven and 39 probable cases of mucormycosis. The median age of the patients was 39.98 ± 18.52 years, with 52% being male. Among the cases, 46% had acute myeloid leukemia (AML), 16% had acute lymphoblastic leukemia (ALL), and 16% had myelodysplastic syndrome. The most common manifestations of mucormycosis were pulmonary (80%), disseminated (16%), and rhinocerebral (4%). The diagnosis was confirmed through histology, culture, microscopy, and molecular diagnostic techniques. The most commonly identified fungal species were Cunninghamella (40%), Rhizopus (26%), and Rhizomucor (22%). Treatment involved antifungals in 84% of cases and surgery in 10% of cases. The 90-day mortality rate was 76%. Logistic regression analysis revealed that treatment with amphotericin B and surgery was associated with improved survival, while neutropenia and administration of voriconazole prior to diagnosis was associated with higher mortality.

CONCLUSIONS

Mucormycosis continues to have a high mortality rate in patients with hematological malignancies. Early diagnosis using various techniques, including molecular biology, along with the appropriate use of amphotericin B and surgery when possible, is vital for the successful treatment of mucormycosis.

Integrating In-silico and In-vitro approaches to identify plant-derived bioactive molecules against spore coat protein CotH3 and high affinity iron permease FTR1 of Rhizopus oryzae

Rhizopus oryzae is one of the major causative agents of mucormycosis. The disease has a poor prognosis with a high mortality rate, and resistance towards current antifungal drugs poses additional concern. The disease treatment is complicated with antifungals; therefore, surgical approach is preferred in many cases. A comprehensive understanding of the pathogenicity-associated virulence factors of R. oryzae is essential to develop new antifungals against this fungus. Virulence factors in R. oryzae include cell wall proteins, spore germination proteins and enzymes that evade host immunity. The spore coat protein (CotH3) and high-affinity iron permease (FTR1) have been identified as promising therapeutic targets in R. oryzae. In-silico screening is a preferred approach to identify hit molecules for further in-vitro studies. In the present study, twelve bioactive molecules were docked within the active site of CotH3 and FTR1. Further, molecular dynamics simulation analysis of best-docked protein-ligand structures revealed the dynamics information of their stability in the biological system. Eugenol and isoeugenol exhibited significant binding scores with both the protein targets of R. oryzae and followed the Lipinski rule of drug-likeness. To corroborate the in-silico results, in-vitro studies were conducted using bioactive compounds eugenol, isoeugenol, and myristicin against R. oryzae isolated from the soil sample. Eugenol, isoeugenol exhibited antifungal activity at 156 µg/mL whereas myristicin at 312 µg/mL. Hence, the study suggested that eugenol and isoeugenol could be explored further as potential antifungal molecules against R. oryzae.

Rhinocerebral mucormycosis: A clinicopathological analysis of COVID-19-associated mucormycosis

Background

During the coronavirus disease 2019 (COVD-19) pandemic, the incidence of mucormycosis also increased, especially affecting individuals who have had the COVID-19 infection in the past.

Aims

The aim of the study is to assess risk factors and clinical and histopathological features of mucormycosis in post-COVID-19 cases.

Methods

This is a retrospective study conducted in a tertiary care COVID-19-dedicated hospital, Dehradun, Uttarakhand, India, over a period of 2 months during the COVID-19 pandemic. All surgical specimens submitted for histopathology with a suspected diagnosis of mucormycosis were included. Histopathology was considered the gold standard. All histopathologically confirmed cases were studied in detail with respect to histopathology, clinico-radiological features, and microbiological results.

Results

Of 25 cases with clinical diagnosis of mucormycosis, nine were histopathologically confirmed as mucormycosis. Seven patients had diabetes, while two did not have any co-morbidity. The fungal load was heavy in 50% cases, and the proportion of necrosis was higher with diabetes mellitus, as compared to non-diabetic and non-co-morbidity patients. Angioinvasion (33.3% cases), soft-tissue invasion (44.4%), Splendor-Hoeppli phenomenon (44.4%), and neural invasion (11.1%) were also present. Mixed infection (Mucormycosis and Aspergillus species) was present in three of the cases who also had diabetes. The microbiological investigations were positive in only 55.5% cases.

Conclusion

Post-COVID Mucormycosis has fatal outcomes. Early diagnosis and treatment are the key to successful treatment. Early and reliable diagnosis can be offered by histopathological examination.

The Fatal Course of Pulmonary Mucormycosis: A Case Report

Pulmonary mucormycosis is a rare and lethal fungal infection elicited by fungi of the order Mucorales. The disease predominantly affects immunocompromised hosts, like those with diabetes mellitus, hematologic malignancies, or those undergoing immunosuppressive therapy. We, at this moment, report a case of pulmonary mucormycosis in a 55-year-old gentleman, exemplifying the ferocity of clinical disease, diagnostic dilemmas, and rapidity of progression. A diagnosis of pulmonary mucormycosis was based on diagnostic imaging and flexible bronchoscopy. Despite aggressive antifungal and supportive treatment, the patient's condition deteriorated further, and unfortunately succumbed to cardiorespiratory arrest. This case reinforces the importance of early recognition of pulmonary mucormycosis and aggressive medical management, especially in immunocompromised patients, in salvaging lives with good outcomes and preventing the fulminant progression of the disease process.

Rhino-orbital-cerebral mucormycosis caused by Rhizopus arrhizus diagnosis via metagenomics next-generation sequencing: a case report

Rhino-orbital-cerebral mucormycosis (ROCM) is a rare, invasive, and fatal fungal disease that is often easily misdiagnosed in the early stages due to the lack of specific clinical manifestations and adequate auxiliary examinations. Early diagnosis and timely therapy are essential for successful treatment. In this report, we presented a 46-year-old man with diabetes who experienced gradual vision loss, right ptosis, swelling, and headaches that progressively worsened to death within 4 days after admission. It was finally confirmed as a fungal Rhizopus arrhizus infection by metagenomics next-generation sequencing (mNGS). Our report has proved that mNGS testing should be strongly recommended in highly suspected patients.

Simultaneous endobronchial and mediastinal mucormycosis in a patient with Diabetes Mellitus and SARS-CoV-2: A case report and literature review

Background

Mucormycosis can be lethal in people with immunocompromising conditions, especially Diabetes Mellitus. Correction of the underlying disorders, instant initiation of antifungal therapy, and surgical resection are the main components of treatment. Herin, we present the successful medical management of Mucormycosis in a patient with Diabetic Ketoacidosis and positive SARS-CoV-2 test who presented with a less seen condition: the simultaneity of mediastinal mass on one side and an endobronchial mass on the other.

Case presentation

An 18-year-old male with a history of insulin-dependent DM from 4 years ago presented to our hospital with sudden onset dyspnea, chest pain, sore throat, hoarseness, cough, and sputum. Also, we detected unilateral swelling in the neck and multiple lymph nodes in the neck. Lung auscultation revealed bilateral generalized wheezing. Primary laboratory tests detected high blood sugar, metabolic acidosis, positive urine ketone, high ESR, positive CRP, and leukocytosis; his polymerase chain reaction (PCR) for SARS-CoV-2 was positive. Chest X-ray showed left upper lobe consolidation. Computed tomography scan (CT-scan) of the chest revealed a large collapse consolidation in the left lung, mild left side pleural effusion, mediastinal lymphadenopathy, and distention in the esophagus. With suspicion of malignancy, we performed flexible bronchoscopy and endobronchial Ultrasound (EBUS) which revealed a creamy tumoral lesion in the right main bronchus. The biopsy was consistent with Mucormycosis. We successfully treated Mucormycosis with Amphotericin-B liposomal.

Conclusion

Mucormycosis can mimic the clinical characteristics of malignancy, and emphasize the importance of considering appropriate differential diagnoses because timely diagnosis and treatment is potentially life-saving in Mucormycosis.

Synergistic action of lactoferrin and its derived functional fragments as a promising therapeutic agent in combating mucormycosis

Aim: Currently, we have limited armamentarium of antifungal agents against Mucorales. There is an urgent need to discover novel antifungal agents that are effective, safe and affordable. Materials & methods: In this study, the anti-Mucorale action of native lactoferrin (LF) and its functional fragments CLF, RR6 and LFcin against three common Mucorale species are reported. The synergistic action of LF with antifungal agents like amphotericin B, isavuconazole and posaconazole was analyzed using checkerboard technique. Results: All the three mucor species showed inhibition when treated with fragments. The checkerboard assay confirmed that native LF showed the best synergistic action against Mucorales in combination with Amphotericin B. Conclusion: These results highlight the potential therapeutic value of native LF against Mucorales.

What are the 100 most cited fungal genera?

The global diversity of fungi has been estimated between 2 to 11 million species, of which only about 155 000 have been named. Most fungi are invisible to the unaided eye, but they represent a major component of biodiversity on our planet, and play essential ecological roles, supporting life as we know it. Although approximately 20 000 fungal genera are presently recognised, the ecology of most remains undetermined. Despite all this diversity, the mycological community actively researches some fungal genera more commonly than others. This poses an interesting question: why have some fungal genera impacted mycology and related fields more than others? To address this issue, we conducted a bibliometric analysis to identify the top 100 most cited fungal genera. A thorough database search of the Web of Science, Google Scholar, and PubMed was performed to establish which genera are most cited. The most cited 10 genera are Saccharomyces, Candida, Aspergillus, Fusarium, Penicillium, Trichoderma, Botrytis, Pichia, Cryptococcus and Alternaria. Case studies are presented for the 100 most cited genera with general background, notes on their ecology and economic significance and important research advances. This paper provides a historic overview of scientific research of these genera and the prospect for further research. Citation: Bhunjun CS, Chen YJ, Phukhamsakda C, Boekhout T, Groenewald JZ, McKenzie EHC, Francisco EC, Frisvad JC, Groenewald M, Hurdeal VG, Luangsa-ard J, Perrone G, Visagie CM, Bai FY, Błaszkowski J, Braun U, de Souza FA, de Queiroz MB, Dutta AK, Gonkhom D, Goto BT, Guarnaccia V, Hagen F, Houbraken J, Lachance MA, Li JJ, Luo KY, Magurno F, Mongkolsamrit S, Robert V, Roy N, Tibpromma S, Wanasinghe DN, Wang DQ, Wei DP, Zhao CL, Aiphuk W, Ajayi-Oyetunde O, Arantes TD, Araujo JC, Begerow D, Bakhshi M, Barbosa RN, Behrens FH, Bensch K, Bezerra JDP, Bilański P, Bradley CA, Bubner B, Burgess TI, Buyck B, Čadež N, Cai L, Calaça FJS, Campbell LJ, Chaverri P, Chen YY, Chethana KWT, Coetzee B, Costa MM, Chen Q, Custódio FA, Dai YC, Damm U, de Azevedo Santiago ALCM, De Miccolis Angelini RM, Dijksterhuis J, Dissanayake AJ, Doilom M, Dong W, Alvarez-Duarte E, Fischer M, Gajanayake AJ, Gené J, Gomdola D, Gomes AAM, Hausner G, He MQ, Hou L, Iturrieta-González I, Jami F, Jankowiak R, Jayawardena RS, Kandemir H, Kiss L, Kobmoo N, Kowalski T, Landi L, Lin CG, Liu JK, Liu XB, Loizides M, Luangharn T, Maharachchikumbura SSN, Makhathini Mkhwanazi GJ, Manawasinghe IS, Marin-Felix Y, McTaggart AR, Moreau PA, Morozova OV, Mostert L, Osiewacz HD, Pem D, Phookamsak R, Pollastro S, Pordel A, Poyntner C, Phillips AJL, Phonemany M, Promputtha I, Rathnayaka AR, Rodrigues AM, Romanazzi G, Rothmann L, Salgado-Salazar C, Sandoval-Denis M, Saupe SJ, Scholler M, Scott P, Shivas RG, Silar P, Souza-Motta CM, Silva-Filho AGS, Spies CFJ, Stchigel AM, Sterflinger K, Summerbell RC, Svetasheva TY, Takamatsu S, Theelen B, Theodoro RC, Thines M, Thongklang N, Torres R, Turchetti B, van den Brule T, Wang XW, Wartchow F, Welti S, Wijesinghe SN, Wu F, Xu R, Yang ZL, Yilmaz N, Yurkov A, Zhao L, Zhao RL, Zhou N, Hyde KD, Crous PW (2024). What are the 100 most cited fungal genera? Studies in Mycology 108: 1-411. doi: 10.3114/sim.2024.108.01.

Diagnosis of mucormycosis from nasal swabs using commercial PCR platforms; a feasible alternative?

Rhino-orbital-cerebral mucormycosis (ROCM) is linked to uncontrolled diabetes, diabetic ketoacidosis, iron overload, corticosteroid therapy, and neutropenia. This study evaluated a commercial real-time PCR system's effectiveness in detecting Mucorales from nasal swabs in 50 high-risk patients. Nasal swab PCR showed 30% positivity, compared to 8% with KOH microscopy. Despite its improved sensitivity, nasal swab PCR has limitations, highlighting the importance of established sampling methods in mucormycosis diagnosis. Participants were predominantly male (64%), with diabetes (78%) and amphotericin B use (96%). Prior COVID-19 was 42%, with 30% positive for Mucorales by PCR, compared to 8% with KOH microscopy.

Myo5B plays a significant role in the hyphal growth and virulence of the human pathogenic fungus Mucor lusitanicus

Mucormycosis is an emerging and deadly invasive fungal infection caused by fungi belonging to the Mucorales order. We investigated the myosin superfamily, which encompasses diverse actin-based motor proteins with various cellular functions. Specifically, the role of the Myo5B (ID 179665) protein from the myosin class V family in Mucor lusitanicus was explored by generating silencing phenotypes and null mutants corresponding to the myo5B gene. Silencing fungal transformants exhibited a markedly reduced growth rate and a nearly complete absence of sporulation compared to the wild-type strain. The myo5BΔ null mutant strain displayed atypical characteristics, including abnormally short septa and inflated hyphae. Notably, there were a majority of small yeast-like cells instead of filamentous hyphae in the mutant. These yeast-like cells cannot germinate normally, resulting in a loss of polarity. In vivo virulence assays conducted in the Galleria mellonella invertebrate model revealed that the myo5BΔ mutant strain was avirulent. These findings shed light on the crucial contributions of the Myo5B protein to the dimorphism and pathogenicity of M. lusitanicus. Therefore, the myosin V family is a potential target for future therapeutic interventions aimed at treating mucormycosis.

MUCORMYCOSIS: Re-emerging opportunistic fungal infections in COVID-19 pandemic times in Indian patients (South Indian) - A series of seven cases

Opportunistic fungal infections are associated with patients having compromised systemic health. In India, a slow rise in cases of mucormycosis has been observed as the country has seen a rising number of diabetes mellitus cases in the recent decades. This apart, an enormous increase in case numbers was seen in association with COVID-19 infections in the Asian subcontinent, Southeast Asia, markedly in India. Many cases of mucormycosis were reported in association with COVID-19 positive history and post-treatment for COVID-19. They were presented in the form of rhino-cerebral-mucormycosis, in patients with and without diabetes. The presentation of the disease differed at different times of the pandemic to some extent. Some of the cases initially came in an acute format, but at the later end of the epidemic, they presented in an indolent form. A compilation of cases is provided to illustrate the variation in presentations and findings of mucormycosis cases diagnosed at different times of infection of the COVID-19 waves.

Combined Effects of Lactic Acid Bacteria and Protease on the Fermentation Quality and Microbial Community during 50 Kg Soybean Meal Fermentation Simulating Actual Production Scale

The improvement in the utilization rate and nutritional value of soybean meal (SBM) represents a significant challenge in the feed industry. This study conducted a 50 kg SBM fermentation based on the 300 g small-scale fermentation of SBM in early laboratory research, to explore the combined effects of lactic acid bacteria (LAB) and acid protease on fermentation quality, chemical composition, microbial population, and macromolecular protein degradation during fermentation and aerobic exposure of SBM in simulated actual production. The results demonstrated that the increase in crude protein content and reduction in crude fiber content were considerably more pronounced after fermentation for 30 days (d) and subsequent aerobic exposure, compared to 3 d. It is also noteworthy that the treated group exhibited a greater degree of macromolecular protein degradation relative to the control and 30 d of fermentation relative to 3 d. Furthermore, after 30 d of fermentation, adding LAB and protease significantly inhibited the growth of undesired microbes including coliform bacteria and aerobic bacteria. In the mixed group, the microbial diversity decreased significantly, and Firmicutes replaced Cyanobacteria for bacteria in both groups' fermentation.

Invasive Fungal Infections of the Head and Neck: A Tertiary Hospital Experience

From the existing millions of fungal species, only a few cause disease. In this study, we investigated invasive fungal infections in the head and neck (H&N) over a 19-year period (2005 to 2024) at a large academic healthcare system. Among the 413 documented fungal H&N infections, 336 were noninvasive, and 77 were invasive. The highest incidence of invasive infections occurred in the sinonasal cavities, with a 15-fold difference compared to other sites. Most infections affected adults over 40 years old. The most common organisms were Mucorales (51%), hyaline molds (29%), and Candida (11%). Risk factors included malignancy, transplant, diabetes, and illicit drug use. Mortality was high in patients with malignancy and/or transplant. Infections affecting the mandible were usually a complication of osteoradionecrosis and were associated with the coinfection of Candida and Actinomyces. At other sites, infections were rare and were usually the result of penetrating injuries or immunosuppression. Treatment typically involved a combination of antifungals and surgical procedures.

Severe mold fungal infections in critically ill patients with COVID-19

The SARS-CoV-2 pandemic put an unprecedented strain on modern societies and healthcare systems. A significantly higher incidence of invasive fungal co-infections was noted compared with the pre-COVID-19 era, adding new diagnostic and therapeutic challenges in the critical care setting. In the current narrative review, we focus on invasive mold infections caused by Aspergillus and Mucor species in critically ill COVID-19 patients. We discuss up-to-date information on the incidence, pathogenesis, diagnosis and treatment of these mold-COVID-19 co-infections, as well as recommendations on preventive and prophylactic interventions. Traditional risk factors were often not recognized in COVID-19-associated aspergillosis and mucormycosis, highlighting the role of other determinant risk factors. The associated patient outcomes were worse compared with COVID-19 patients without mold co-infection.

Clinical features of pediatric mucormycosis: role of metagenomic next generation sequencing in diagnosis

Background

Mucormycosis is an uncommon invasive fungal infection that has a high mortality rate in patients with severe underlying diseases, which leads to immunosuppression. Due to its rarity, determining the incidence and optimal treatment methods for mucormycosis in children is challenging. Metagenomic next-generation sequencing (mNGS) is a rapid, precise and sensitive method for pathogen detection, which helps in the early diagnosis and intervention of mucormycosis in children. In order to increase pediatricians' understanding of this disease, we conducted a study on the clinical features of mucormycosis in children and assessed the role of mNGS in its diagnosis.

Methods

We retrospectively summarized the clinical data of 14 children with mucormycosis treated at the First Affiliated Hospital of Zhengzhou University from January 2020 to September 2023.

Results

Of the 14 cases, 11 case of mucormycosis were classified as probable, and 3 cases were proven as mucormycosis. Most children (85.71%) had high-risk factors for mucormycosis. All 14 children had lung involvement, with 5 cases of extrapulmonary dissemination. Among the 14 cases, 4 cases underwent histopathological examination of mediastinum, lung tissue or kidney tissue, in which fungal pathogens were identified in 3 patients. Fungal hyphae was identified in 3 cases of mucormycosis, but only 1 case yielded a positive culture result. All patients underwent mNGS testing with samples from blood (8/14), bronchoalveolar lavage fluid (6/14), and tissue (1/14). mNGS detected fungi in all cases: 7 cases had Rhizomucor pusillus, 4 cases had Rhizopus oryzae, 3 cases had Rhizopus microsporus, 1 case had Lichtheimia ramosa, and 1 case had Rhizomucor miehei. Coinfections were found with Aspergillus in 3 cases, bacteria in 3 cases, and viruses in 5 cases.

Conclusion

Children with mucormycosis commonly exhibit non-specific symptoms like fever and cough during the initial stages. Early diagnosis based on clinical symptoms and imaging is crucial in children suspected of having mucormycosis. mNGS, as a supplementary diagnostic method, offers greater sensitivity and shorter detection time compared to traditional mucormycosis culture or histopathological testing. Additionally, mNGS enables simultaneous detection of bacteria and viruses, facilitating timely and appropriate administration of antibiotics and thereby enhancing patient outcomes.

Manifestations of Mucormycosis and Its Complications in COVID-19 Patients: A Case Series Study

OBJECTIVE

Mucormycosis is an opportunistic fungal disease that affects immunocompromised patients. With the advent of SARS-CoV-2, this opportunistic disease has increased.

METHODS

A case series of 47 patients with COVID-19 associated mucormycosis have been analyzed. Demographic information, signs, symptoms, laboratory investigations, imaging studies, and their association with ICU admission and 30-day mortality were assessed.

RESULTS

Total number of 47 consecutive rhino-orbital cerebral mucormycosis (ROCM) cases were analyzed. Periorbital swelling was the most common sign among patients. Majority of cases had diabetes. All patients received liposomal Amphotericin B. Debridement was performed for all cases.

CONCLUSIONS

SARS-CoV-2 increases the susceptibility to mucormycosis infection in various ways. Uncontrolled level of HbA1c in all patients, even non-diabetic individuals, indicates hyperglycemia over the past three months. Diabetes, orbital exenteration, ptosis, periorbital swelling, DKA, LOC, brain involvement, and mechanical ventilation all correlated with a higher rate of ICU admission and 30-day mortality. In addition, a higher white blood cell count is related to the higher probability of ICU admission. While considering all of the inflammatory laboratory data and HbA1c could help predict 30-day mortality.

Pediatric mucormycosis associated with COVID-19: A systematic review of clinical cases

The occurrence of mucormycosis has been observed in individuals with COVID-19. However, there is limited information on the epidemiological factors, presentation, diagnostic certainty, and outcome of this infection in children. PubMed, MEDLINE, Scopus, Embase, Web of Science, LitCovid, and back-references of the identified manuscripts were systematically searched from December 2019 to March 2023. We have identified 14 cases of pediatric mucormycosis in patients with COVID-19. The median age of patients was 10.7 years. Among these cases, 10 were associated with active COVID-19. In 7 cases, the patients had pre-existing diabetes mellitus and concomitant diabetic ketoacidosis. Corticosteroids were administered to treat COVID-19 in 7 of the patients. The most common clinical presentation of the disease was rhino-orbital cerebral mucormycosis. Seven patients died (50%). Given the high mortality rate, clinicians should maintain a high level of clinical suspicion of mucormycosis in pediatric patients with COVID-19.