When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis

Cerebritis, optic ischemia, and cavernous sinus thrombosis arising from sinonasal mucormycosis

Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients. We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis.

Demographic characteristics and risk factors for invasive fungal sinusitis in the context of COVID-19: A systematic review and meta-analysis

OBJECTIVES

To identify the demographic characteristics and potential risk factors of invasive fungal sinusitis (IFS) patients with Coronavirus Disease in 2019 (COVID-19).

METHODS

Web of Science, Embase, the Cochrane Library, and PubMed were searched from database inception to August 2023 using the combination of medical searching heading terms "invasive fungal sinusitis" and "COVID-19" and their free words. The research protocol was registered on PROSPERO (CRD42023467175).

RESULTS

A total of 53 studies were included. The mean age of IFS patients with COVID-19 was 53.72 (95% credible interval [CI]: 51.08, 56.36), with 66% males (95% CI: 0.62, 0.70), and 81% diabetes (95% CI: 0.77, 0.86). The mean time from COVID-19 diagnosis to IFS onset was 19.09 days (95% CI: 16.96, 21.22). The percentage of patients with COVID-19 PCR positivity was 33% (95% CI: 0.21, 0.45). Overall, 71% of patients receiving steroid therapy during COVID-19 infection (95% CI: 0.63, 0.78). The odds ratio of diabetes mellitus, steroid administration, and COVID-19 PCR positivity were 6.09, 2.21, and 1.82, respectively. COVID-19 infection did not affect the IFS stage.

CONCLUSION

IFS patients with COVID-19 had an average age of 53.72 years and were predominantly males, with a mean interval of 19.09 days from COVID-19 diagnosis to IFS onset. Diabetes, steroid administration, and COVID-19 PCR positivity were risk factors.

Multiple roles for hypoxia inducible factor 1-alpha in airway epithelial cells during mucormycosis

During pulmonary mucormycosis, inhaled sporangiospores adhere to, germinate, and invade airway epithelial cells to establish infection. We provide evidence that HIF1α plays dual roles in airway epithelial cells during Mucorales infection. We observed an increase in HIF1α protein accumulation and increased expression of many known HIF1α-responsive genes during in vitro infection, indicating that HIF1α signaling is activated by Mucorales infection. Inhibition of HIF1α signaling led to a substantial decrease in the ability of R. delemar to invade cultured airway epithelial cells. Transcriptome analysis revealed that R. delemar infection induces the expression of many pro-inflammatory genes whose expression was significantly reduced by HIF1α inhibition. Importantly, pharmacological inhibition of HIF1α increased survival in a mouse model of pulmonary mucormycosis without reducing fungal burden. These results suggest that HIF1α plays two opposing roles during mucormycosis: one that facilitates the ability of Mucorales to invade the host cells and one that facilitates the ability of the host to mount an innate immune response.

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.

COVID-19 associated rhino-orbital-cerebral mucormycosis-an institutional series

Mucormycosis is almost always confined to the patients with altered host defenses amongst which diabetes is considered as the strongest risk factor. COVID-19 only been seen in severe cases but also in mild and moderate cases of SARS-CoV-2 infections. After preliminary clinical and radiological diagnosis, surgical management in the form of endoscopic sinus surgery, debridement, and orbital exenteration (8) was performed. Medical management in the form of antifungal therapy (amphotericin-B, posaconazole, and isavuconazole) was initiated. In this case series, 79 proven cases of COVID-19 associated rhino-orbital-cerebral mucormycosis were analyzed retrospectively from mid-April 2021 to mid-September 2021. 67 patients were known diabetics, whereas rest 12 had new onset diabetes mellitus. Of these 79 cases, 27 cases had the disease limited to sinuses (rhino-mucormycosis), 43 had orbital involvement also (rhino-orbital mucormycosis), and 9 had cerebral involvement as well (rhino-orbital-cerebral mucormycosis). During this time-period, a total of 14 mortalities occurred. Most of the patients were discharged after completion of amphotericin-B therapy and rest stayed little longer till their general condition improved. COVID-19 causes dysregulation and alteration of immune response in the body which predispose to invasive fungal infections. In addition, uncontrolled diabetes mellitus and corticosteroid treatment increase the risk of mucormycosis by many folds.

Displacement of Zygomatic Implant in Infratemporal Region in a Case of COVID-19-Associated Mucormycosis

Reconstruction of maxillary defects can be carried out using a variety of treatment modalities. The choice of modality depends on numerous factors, including the size and extent of the defect, patient characteristics, and existing comorbidities. One of the various options is reconstruction and rehabilitation using a fixed prosthesis supported over a zygomatic implant. In maxillectomy cases, a zygomatic implant can be used to improve the retention of the obturator prosthesis, as the loss of alveolar bone makes it impossible to use conventional endosseous implants. Although zygomatic implants are reported to have high success rates, they are not free of complication. We hereby present a rare complication associated with the placement of a zygomatic implant in a patient with COVID-19-associated mucormycosis who underwent operation. This rare complication has never been reported before. This case report also highlights on the management of complications involving displacement of a zygomatic implant in the infratemporal region.

The Impact of Dimitrios P. Kontoyiannis on Mucormycosis Research

Dimitrios P [...].

Resurgence of orbital mucormycosis during COVID-19 pandemic: Study from a tertiary care center in Eastern India

PURPOSE

A sudden surge of Mucormycosis cases during the second wave of Covid 19 was observed in certain parts of India. The reasons for this upsurge remain unknown. However its impact on the overall healthcare system was quite overwhelming. In this context this study was decided to estimate and assess the spectrum of orbital involvement in patients with Mucormycosis, to find its association with coexisting disease entities if any, and at the same time evaluate the therapeutic response to established treatment regimens.

MATERIALS AND METHODS

This descriptive longitudinal study was conducted over a period of six months. Patients presenting with symptoms of Mucormycosis were jointly evaluated by a multi speciality team. After confirmation of diagnosis, patients were treated with intravenous Amphotericin B, surgical debridement of affected sinuses and orbital exenteration when indicated. They were followed up for three months after discharge.

RESULTS

Forty-three patients were enrolled in this study. Thirty-seven (86.04%) were COVID positive. All of them had history of steroid exposure during COVID treatment. Ninety five percent of study participants had diabetes mellitus. Twenty-seven (62.79%) patients had orbital involvement. Most common clinical presentation was peri-orbital or facial pain and edema. Besides medical treatment, thirty-nine patients (90.69%) required sinus debridement and nine patients (20.9%) required orbital exenteration. Thirteen patients (30.23%) expired during the follow up period. With treatment disease regressed in twenty patients (46.51%).

CONCLUSION

Diabetes and use of steroids to prevent anticipated cytokine storm may be the inciting factors for Orbital Mucormycosis in COVID patients. Early diagnosis, treatment and control of risk factors are keys for recovery and survival..

Risk factors and clinical presentation of rhino-orbital mucormycosis: Lesson learnt during Covid pandemic

Aim

To analyze the potential predisposing factors and clinical presentation of mucormycosis in patients with COVID-19.

Material and Methods

Medical records of 141 patients with COVID-19-associated mucormycosis (CAM) treated at a tertiary care center in Bihar were reviewed. The predisposing factors, clinical features, and imaging findings of mucormycosis were analyzed.

Results

The median age was 48 years (IQR, 43-60). A total of 58 patients developed concurrent CAM and 83 post-CAM. The median interval between COVID-19 and onset of CAM symptoms was 15 days (IQR, 9-16). A total of 80 patients received at-home treatment for COVID-19, and 73 had mild-to-moderate disease. While 61 patients received in-hospital treatment, 57 had severe disease. At presentation, 131 patients had hyperglycemia: 64 type 2 diabetes mellitus (DM) and 67 new-onset DM. The history of glucocorticoid use for COVID-19 was present in 125 patients; 47% were administered at home without monitoring plasma glucose. The common presenting features were toothache, periocular or facial pain, and edema. Rhino-orbital mucormycosis was the most common. Imaging revealed rhinosinusitis in all patients, including pansinusitis (68%), pterygopalatine fossa involvement (21%), cavernous sinus thrombosis (38%), brain abscess (8%), and infarct (4%). All patients received intravenous liposomal amphotericin B, and surgical debridement was performed in 113.

Conclusion

COVID-19 patients with hyperglycemia are at risk of developing CAM, irrespective of the severity. Timely recognition of symptoms and prompt initiation of therapy by primary healthcare physicians are imperative for enhancing outcomes. Additionally, glucocorticoid overuse should be avoided, and close monitoring for hyperglycemia development is warranted.

Oral mucormycosis associated with COVID-19 and diabetes mellitus: Case report and literature review

Mucormycosis is an invasive opportunistic fungal infection with high mortality, mainly detected in people with COVID-19, especially those with underlying diseases such as diabetes mellitus. Mucormycosis prevalence is 0.005 to 1.7 cases per million inhabitants, and it has been increasing in countries like India and Pakistan. This mycosis can affect different organs, and clinical manifestations reflect the transmission mechanism. Frequent forms are rhino-orbital-cerebral and pulmonary. This disease should be suspected in patients with necrotic injuries on mucous membranes or skin. We present a case of a patient with diabetes mellitus and diagnosed with oral mucormycosis associated with COVID-19.

Investigations of an increased incidence of non-Aspergillus invasive mould infections in an onco-haematology unit

AIMS OF THE STUDY

Invasive mould infections are life-threatening complications in patients with haematologic cancer and chemotherapy-induced neutropenia. While invasive aspergillosis represents the main cause of invasive mould infections, non-Aspergillus mould infections, such as mucormycosis, are increasingly reported. Consequently, their local epidemiology should be closely monitored. The aim of this study was to investigate the causes of an increased incidence of non-Aspergillus mould infections in the onco-haematology unit of a Swiss tertiary care hospital.

METHODS

All cases of proven and probable invasive mould infections were retrospectively identified via a local registry for the period 2007-2021 and their incidence was calculated per 10,000 patient-days per year. The relative proportion of invasive aspergillosis and non-Aspergillus mould infections was assessed. Factors that may affect invasive mould infections' incidence, such as antifungal drug consumption, environmental contamination and changes in diagnostic approaches, were investigated.

RESULTS

A significant increase of the incidence of non-Aspergillus mould infections (mainly mucormycosis) was observed from 2017 onwards (Mann and Kendall test p = 0.0053), peaking in 2020 (8.62 episodes per 10,000 patient-days). The incidence of invasive aspergillosis remained stable across the period of observation. The proportion of non-Aspergillus mould infections increased significantly from 2017 (33% vs 16.8% for the periods 2017-2021 and 2007-2016, respectively, p = 0.02). Building projects on the hospital site were identified as possible contributors of this increase in non-Aspergillus mould infections. However, novel diagnostic procedures may have improved their detection.

CONCLUSIONS

We report a significant increase in non-Aspergillus mould infections, and mainly in mucormycosis infections, since 2017. There seems to be a multifactorial origin to this increase. Epidemiological trends of invasive mould infections should be carefully monitored in onco-haematology units in order to implement potential corrective measures.

The potential for rapid antigen testing for mucormycosis in the context of COVID-19

INTRODUCTION

Mucormycosis is a highly aggressive angio-invasive disease of humans caused by Mucorales fungi. Prior to the COVID-19 pandemic, mucormycosis was a rare mycosis typically seen in immunocompromised patients with hematological malignancies or in transplant recipients. During the second wave of the pandemic, there was a dramatic increase in the disease, especially in India where a unique set of circumstances led to large numbers of life-threatening and disfiguring rhino-orbital-cerebral mucormycosis (ROCM) infections.

AREAS COVERED

The review examines mucormycosis as a super-infection of COVID-19 patients, and the risk factors for COVID-19-associated mucormycosis (CAM) that drove the ROCM epidemic in India. The limitations of current diagnostic procedures are identified, and the measures needed to improve the speed and accuracy of detection discussed.

EXPERT OPINION

Despite increased awareness, global healthcare systems remain unprepared for further outbreaks of ROCM. Current diagnosis of the disease is slow and inaccurate, negatively impacting on patient survival. This is most evident in low- to middle-income countries which lack suitably equipped diagnostic facilities for rapid identification of the infecting pathogens. Rapid antigen testing using point-of-care lateral-flow assays could potentially have aided in the quick and accurate diagnosis of the disease, allowing earlier intervention with surgery and Mucorales-active antifungal drugs.

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

Introduction

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

Objectives

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

Materials and Methods

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

Results

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

Discussion

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

Summary and Conclusion

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

Invasive Sinusitis Presenting with Orbital Complications in COVID Patients: Is Mucor the Only Cause?

The second wave of COVID pandemic was associated with an outbreak of Mucormycosis. The mortality rate of Mucormycosis reaches 50-80% in cases with orbital and intracranial extension (Fadda in Acta Otorhinolaryngol Ital 41:43-50, 2021). In this outbreak we found that few of these patients had bacterial invasive sinusitis mimicking fungal sinusitis. Amphotericin the only effective drug against Mucormycosis is highly toxic and expensive and not indicated in bacterial sinusitis. Our aim was to  determine the exact etiologic agent, predisposing factors and outcome of treatment of COVID associated invasive sinusitis presenting with orbital complications. It is a retrospective observational study done in 33 patients with orbital complications in COVID associated invasive sinusitis. Demographic details of the patients and clinical presentation were documented. Rhinological examination was done and a nasal swab was taken for KOH mount along with Gram`s stain and Culture and Sensitivity. All Patients underwent radiological evaluation by contrast enhanced computed tomography (CECT) or MRI. Liposomal Amphotericin B was started. Surgical debridement done. Amphotericin-B was stopped in cases reported negative for fungal elements and antibiotics administered for two weeks. Outcome of treatment was documented. A total of 33 patients were included in the study. 48.5% patients were found to have bacterial infection and 27.3% patient's fungal infections and 24.2% mixed infections.Eschar formation, necrotic tissue, erosion of the lamina papyracea was seen in both Klebsiella (33.3%) and Staphylococcal infections (16.6%) similar to Mucor and mixed infections. Persistent opthalmoplegia and deterioration of vision was associated with Mucor and mixed infections. However improvement in proptosis, ptosis, ophthalmoplegia, and vision was observed in cases associated with bacterial invasive sinusitis. Invasive bacterial sinusitis was under diagnosed during second wave of COVID. Identification of invasive bacterial sinusitis can help in de-escalation of treatment.

COVID-19 associated mucormycosis surge: A review on multi-pathway mechanisms

Mucormycosis is a fungal infection caused by moulds from the Mucorales order. Concerns have been mounting due to the alarming increase in severe morbidity and mortality associated with mucormycosis during the COVID-19 pandemic. This condition, known as COVID-19-associated mucormycosis (CAM), has been linked to various environmental, host-related, and medical factors on a global scale. We have categorized the most significant potential risk factors for developing mucormycosis in individuals with a previous history of coronavirus infection into 10 major categories. These categories include acute hyperglycemia, the impact of cytokine release, immune response deficiencies in COVID-19 patients, microvasculopathy and dysfunction of endothelial cells, imbalances in iron metabolism, metabolic acidosis, organ damage resulting from COVID-19, underlying health conditions (such as diabetes), environmental factors, and medical treatments that can be iatrogenic in nature (such as inappropriate glucocorticoid use). Many of these factors can lead to potentially life-threatening infections that can complicate the treatment of COVID-19. Physicians should be vigilant about these factors because early detection of mucormycosis is crucial for effective management of this condition.

Value of Imprint Cytology for the Rapid Diagnosis of Mucormycosis in the COVID-19 Pandemic Setting - A Pilot Study

Background

The second wave of the coronavirus disease 2019 (COVID-19) pandemic recorded a surge in rhino-orbital-cerebral mucormycosis (ROCM) infection in COVID-19-positive patients with diabetes and on concomitant steroid therapy. The rapidly progressive and devastating nature of the disease necessitated prompt diagnosis and early intervention to improve patient outcomes. Histopathology and fungal culture remain essential tools; however, these investigations have long and variable turn-around times (TATs) and may delay the initiation of treatment. Frozen section is not widely available and should be avoided in COVID-19-positive cases due to the risk of aerosol production and droplet exposure. In cases with high clinicoradiologic suspicion for mucormycosis, imprint cytologic evaluation provides a rapid diagnosis. Familiarity with fungal cytomorphology, awareness of morphologic pitfalls, and implementation of a standardized reporting format aid in diagnostic accuracy.

Method

Eighteen COVID-19-positive patients, who were admitted to our hospital with clinical suspicion of mucormycosis during June and July 2021, were included in the study. We used nasal or oral imprint cytology for the initial, rapid detection of Mucor. Cytology findings were correlated with histopathology and fungal culture results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

Results

The sensitivity, specificity, PPV, and NPV were 100%, 100%, 100% and 100%, respectively.

Conclusion

This study showed that imprint cytology can be a rapid, cost-effective, first-line diagnostic modality in Mucor diagnosis.

Magnetic Resonance Imaging in COVID-19 Associated Rhino-Sinusal Mucormycosis

Rhino-sinusal mucormycosis is an acute invasive fungal infection rarely encountered in the clinical setting, occurring in severe immunosuppressed patients. However, in patients suffering from COVID-19 disease a dramatic increase in the incidence of mucormycosis has been recorded. The aim of the study is to discuss the MRI findings of patients with COVID-19 associated mucormycosis. This is a retrospective review of 10 hospitalized and operated patients in three Otolaryngologic Departments between the 1st of February 2021 and the 30th of October 2021. All patients presented nasal mucormycosis, histologically verified along with documented SARS-CoV-2 positive RT-PCR test. The sinus involvement, extra sinus spread and peri-sinus invasion were documented in all patients. The correlation between MRI and intra-operative findings was also assessed. The black turbinate sign and peri-antral soft tissue infiltration are early MRI signs characteristic of mucormycosis. Moreoever, MRI has a significantly high positive predictive value for intra-operative findings in COVID-19 associated mucormycosis.

Fungal infections in patients after recovering from COVID-19: a systematic review

Background and aims

The presence of fungal infections has been described in patients after recovering from COVID-19. This study aims to conduct a systematic review of studies that reported fungal infections (Mucor spp., Pneumocystis jirovecii, or Aspergillus spp.) in adults after recovering from COVID-19.

Methods

We performed a systematic review through PubMed, Web of Science, OVID-Medline, Embase, and Scopus. The study selection process was performed independently and by at least two authors. We performed a risk of bias assessment using the Newcastle-Ottawa Scale for cohort and case-control studies, and the Joanna Briggs Institute's Checklists for Case Series and Case Reports.

Results

The systematic search found 33 studies meeting all inclusion criteria. There was a total population of 774 participants, ranging from 21 to 87 years. From them, 746 developed a fungal infection. In 19 studies, Mucor spp. was reported as the main mycosis. In 10 studies, P. jirovecii was reported as the main mycosis. In seven studies, Aspergillus spp. was reported as the main mycosis. Regarding the quality assessment, 12 studies were classified as low risk of bias and the remaining studies as high risk of bias.

Conclusion

Patients' clinical presentation and prognosis after recovering from COVID-19 with fungal infection differ from those reported patients with acute COVID-19 infection and those without COVID-19 infection.

Development of a monoclonal antibody and a lateral-flow device for the rapid detection of a Mucorales-specific biomarker

Mucoromycosis is a highly aggressive angio-invasive disease of humans caused by fungi in the zygomycete order, Mucorales. While Rhizopus arrhizus is the principal agent of mucoromycosis, other Mucorales fungi including Apophysomyces, Cunninghamella, Lichtheimia, Mucor, Rhizomucor and Syncephalastrum are able to cause life-threatening rhino-orbital-cerebral, pulmonary, gastro-intestinal and necrotising cutaneous infections in humans. Diagnosis of the disease currently relies on non-specific CT, lengthy and insensitive culture from invasive biopsy, and time-consuming histopathology of tissue samples. At present, there are no rapid antigen tests that detect Mucorales-specific biomarkers of infection, and which allow point-of-care diagnosis of mucoromycosis. Here, we report the development of an IgG2b monoclonal antibody (mAb), TG11, which binds to extracellular polysaccharide (EPS) antigens of between 20 kDa and 250 kDa secreted during hyphal growth of Mucorales fungi. The mAb is Mucorales-specific and does not cross-react with other yeasts and molds of clinical importance including Aspergillus, Candida, Cryptococcus, Fusarium, Lomentospora and Scedosporium species. Using the mAb, we have developed a Competitive lateral-flow device that allows rapid (30 min) detection of the EPS biomarker in human serum and bronchoalveolar lavage (BAL), with a limit of detection (LOD) in human serum of ~100 ng/mL serum (~224.7 pmol/L serum). The LFD therefore provides a potential novel opportunity for detection of mucoromycosis caused by different Mucorales species.

A pediatric case and literature review of mucormycosis: Diagnostic and treatment challenges in a resource poor setting

Mucormycosis is an emerging disease that primarily affects immunocompromised patients; however, it has also been reported in immunocompetent individuals. Studies in the pediatric population are limited and reported mostly in case studies or series. The aim of this case report is to present a pediatric mucormycosis originated from Sumatra Island, Indonesia. A 13-year-old boy was referred to a tertiary hospital with facial necrosis involving the nasal, oral, and left maxillary areas, as well as left periorbital edema. No known underlying conditions were documented. The diagnosis was confirmed by histopathological findings of broad, pauci-septate, ribbon-like hyphae branching at 90°. The patient was managed by a multidisciplinary team consisting of the ear, nose, and throat, infectious diseases, dermatology, surgery, microbiology, and pathology departments. Management of the patient included debridement of the necrotic lesion and antibiotics and anti-fungal (fluconazole). Due to unavailability, the patient was not treated with amphotericin B. The patient died after 30 days of admission. This case highlights the importance of maintaining a high suspicion of invasive mucormycosis, even in immunocompetent children, when symptoms and signs are present, especially in resource-limited settings.

Clinical, Demographic, and Oral Presentations of COVID-19 Associated Mucormycosis from a Tertiary Care Hospital in India: A Cross-Sectional Study

Background

The black fungus, mucormycosis, is on the list of lethal complications reported in recent times in COVID patients.

Methodology

This cross-sectional study included all cases of post-COVID-19 mucormycosis. Patients' demographics, clinical presentations, and general health information were collected using a pre-designed form.

Results

The study included 171 participants with the mean (SD) age as 49 (10) years with the sex distribution as 71% (122/171) male and 29% (49/122) females. About half of the admitted patients (47%) were known cases of Diabetes Mellitus type II with a median (IQR) Glycosylated Haemoglobin (HbA1c) of 9.1% (7-11.1%). Only 28% (48/171) had received the first COVID vaccination, and 2.9% (5/171) were fully vaccinated with two doses. During COVID-19, 76% (130/171) required hospitalisation for a mean (SD) stay of 11 (6.4) days. Eighty percent of the patients (136/171) received steroids during therapy, while 87% (150/171) and 51% (88/171) received antibiotics and antivirals, respectively. Oxygen was administered to 71% of hospitalised patients (120/171), with 39.1% (47/120) receiving it for more than 7 days. About the development of the first symptoms of mucormycosis (headache, nasal congestion, black crusts in the nose, facial pain, swelling in cheeks and eyes, and loss of vision) after being diagnosed with COVID-19, 16% (28/171) reported it within 7 days, 75% (127/171) between 8 and 30th days and 9% (16/171) after a month. On examination, 20% of mucor patients had hard palate findings, eschars, fistulas, and perforations, 38% had periodontal abscesses, and 5% reported tenderness to percussion.

Conclusion

Generally, oral manifestations involved the palate and included varying degrees of mucosal discolouration, swelling, ulcers, superficial necrotic areas, and bone exposure and necrosis with dark eschars.

Mucormycosis: update on clinical presentation, diagnosis, and treatment

PURPOSE OF REVIEW

Mucormycosis (MCR) is a common opportunistic mold infection, and Mucorales were recently designated by WHO as priority pathogens. The interest in this infection has risen significantly since the major outbreak of MCR in the context of the COVID-19 pandemic, particularly in India. Herein, we summarize recently (last 24 months) published information regarding clinical aspects of MCR.

RECENT FINDINGS

The disease remains protean in its clinical presentation, difficult to diagnose, and challenging to treat. In 2021, cases of COVID-19-associated mucormycosis (CAM) exploded in India during COVID-19 and manifested primarily as sino-orbital or sino-cerebral disease. Its classic risk factors included the triad of COVID-19, uncontrolled diabetes mellitus and use of corticosteroids. Despite difficulties in the timely diagnosis of MCR, significant progress has been made with the use of molecular techniques in blood to assist with earlier diagnosis, which can facilitate earlier appropriate therapy and improve outcomes. In addition, advances have been made in the use of imaging to stage the disease, determining what types of multimodal therapy are required depending on staging, and tissue-based identification of Mucorales.

SUMMARY

Although the outlook for MCR has improved, effective new antifungals, risk stratification, and the optimal multimodality approaches remain an unmet need.

Epidemiology, Clinical Profile, and Analysis of Risk Factors in COVID Associated Rhino-orbito-cerebral Mucormycosis Patients - An Observational Study

Aim of Study

To study the clinico-epidemiological profile and identify risk factors for the development of COVID-19-associated mucormycosis (CAM) among the patients treated at our regional mucormycosis center.

Materials and Methods

This was a cross-sectional single-centre observational study. All CAM patients admitted to Government Rajaji Hospital, Madurai from April 2021- August 2021 were included in the study. Information regarding clinical features, potential risk factors, diagnostic workup, and comorbid illness was collected.

Results

A total of 164 patients of CAM were admitted to our hospital with a mean age of 51.7 years. Out of 164 patients, 12 patients were not covid positive, based on imaging and RT-PCR, however subclinical infection could not be ruled out. Out of the 164 patients studied, 160 patients had diabetes, out of which 66% (n = 105) patients had a previous history of diabetes, and 34% (n = 55) had newly detected diabetes. Most of the patients admitted with mucormycosis had uncontrolled diabetes (94%) and were not on insulin therapy, but were on oral antidiabetic drugs alone. The majority of the patients (68%) have received steroids (IV/oral) during the COVID-19 illness. 74% of these patients were under hospitalization for COVID-19 disease. Only 30% (n = 50) of CAM patients had a history of oxygen therapy and 7% of these patients were treated in ICU during active COVID-19 illness. 59% of patients used cloth masks without adequate hygiene, rest 41% (n = 67) patients reused disposable masks. We also found that 87% of the patients developing mucormycosis had exposure to organic material in the convalescence period of COVID-19 illness.

Conclusions

From our study, we found steroid use, poorly controlled diabetes mellitus, reuse of masks, daily steam inhalation, and exposure to organic matter to be more associated with CAM, but oxygen therapy was less associated with CAM. Hence, we could suggest screening for hyperglycemia and daily use of disposable surgical masks to be continued for at least 4 weeks post-COVID-19. It is preferable to continue insulin in titrated doses along with OHA for at least 4 weeks following steroid cessation in the post-COVID-19 period as there is are considerably increased inflammatory cytokine levels in the convalescence phase. Clean environmental hygiene would also help prevent CAM.

COVID-19 Associated Rhino-Orbital-Cerebral Mucormycosis: Clinical Features, Antifungal Susceptibility, Management and Outcome in a Tertiary Hospital in Iran

BACKGROUND

Despite the unprecedented surge in the incidence of mucormycosis in the COVID-19 era, the antifungal susceptibility patterns (ASPs) of COVID-19 associated mucormycosis (CAM) isolates have not been investigated so far and it is unclear if the high mortality rate associated with CAM is driven by decreased susceptibility of Mucorales to antifungal drugs.

OBJECTIVES

To describe the clinical, mycological, outcome and in vitro ASPs of CAM cases and their etiologies from Iran.

PATIENTS/METHODS

A prospective study from January 2020 to January 2022 at a referral tertiary hospital in Tehran, Iran was conducted for screening mucormycosis through histopathology and mycological methods. The identity of Mucorales isolates was revealed with ITS-panfungal PCR& sequencing and MALDI-TOF. The AS for amphotericin B, itraconazole, isavuconazole and posaconazole was cleared according to the EUCAST antifungal susceptibility testing protocol.

RESULT

A total of 150 individuals were diagnosed with CAM. Males constituted 60.7% of the population. The mean age was 54.9 years. Diabetes was the leading risk factor (74.7%). The median interval between diagnosis of COVID-19 and CAM was 31 days. The recovery rate of culture was as low as 41.3% with Rhizopus arrhizus being identified as the dominant (60; 96.7%) agent. Amphotericin B (MIC50 = 0.5 µg/ml) demonstrated the highest potency against Mucorales.

CONCLUSION

Majority of the cases had either diabetes, history of corticosteroid therapy or simultaneously both conditions. Accordingly, close monitoring of blood glucose should be considered. The indications for corticosteroids therapy are recommended to be optimized. Also, an anti Mucorales prophylaxis may be necessitated to be administrated in high risk individuals. Although amphotericin B was the most active agent, a higher rate of resistance to this antifungal was noted here in comparison with earlier studies on mucormycetes from non-CAM cases.

A Comparative Study on Survivors Versus Non-Survivors Among Diabetic Patients Having Mucormycosis

Introduction Mucormycosis is a rare opportunistic fungal infection caused by fungi belonging to the Mucorales order and Mucoraceae family. It ranks as the third most prevalent angioinvasive fungal infection, following aspergillosis and candidiasis. This severe infection typically affects individuals with compromised immune systems, including those with hematological malignancies like leukemia and lymphoma, individuals who have undergone stem cell transplants, and people with diabetes mellitus. Individuals in good health are rarely affected, making immunocompromised individuals particularly vulnerable to this potentially fatal fungal disease. The aim of this study was to perform a comparative analysis of survivors versus non-survivors among diabetes patients admitted with mucormycosis. Methodology This was a descriptive observational study. A total of 338 patients were enrolled in the study. The study variables included demographics, COVID-19 infection, diabetes mellitus history, steroid use, use of oxygen support, and steam inhalation. Results Of the total 338 patients enrolled in the study, 253 (74.9%) were male and 85 (25.01%) were female. The number of survivors were 305 (90.2%) and non-survivors were 33(9.8%). The mean age of survivors was 52.50 ± 11.31 and non-survivors was 54.06 ± 8.54 years. Patients who underwent steam inhalation had a higher chance of survival compared to those who did not undergo steam inhalation and this association was statistically significant (p=0.01). Males showed a higher chance of survival (93.7%) as compared to females (80.0%). The associations between oxygen support, steroid use, and COVID-19 infection with the survival status were statistically non-significant. Conclusion There was a strong association between the history of steam inhalation and the outcome of mucormycosis among diabetes patients admitted with mucormycosis. Female patients demonstrated a higher fatality rate than males indicating a significant gender disparity observed in cases. Our findings may help to better identify and treat patients who are at higher risk for severe forms of mucormycosis.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study

Background and Aims

A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients.

Material and Methods

This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted.

Results

The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%).

Conclusion

Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

Compositional profiling and molecular docking studies of Eucalyptus polybrachtea essential oil against mucormycosis and aspergillosis

Essential oil (EO) from Eucalyptus polybrachtea is used as complementary and traditional medicine worldwide. The present study aimed at compositional profiling of EO and molecular docking of EO's bioactive compound 1,8 cineole against fungal enzymes involved in the riboflavin synthesis pathway, namely riboflavin synthase (RS), riboflavin biosynthesis protein RibD domain-containing protein (RibD), and 3,4-dihydroxy-2-butanone 4-phosphate synthase (DBPS) as apposite sites for drug designing against aspergillosis and mucormycosis, and in vitro confirmation. The compositional profile of EO was completed by GC-FID analysis. For molecular docking, the Patchdock tool was used. The ligand-enzyme 3-D interactions were examined, and ADMET properties (absorption, distribution, metabolism, excretion, and toxicity) were calculated. GC-FID discovered the occurrence of 1,8 cineole as a major component in EO, which was subsequently used for docking analysis. The docking analysis revealed that 1,8 cineole actively bound to RS, RibD, and DBPS fungal enzymes. The results of the docking studies demonstrated that the ligand 1,8 cineole exhibited H-bond and hydrophobic interactions with RS, RibD, and DBPS fungal enzymes. 1,8 cineole obeyed Lpinsky's rule and exhibited adequate bioactivity. Wet-lab authentication was achieved by using three fungal strains: Aspergillus niger, Aspergillus oryzae, and Mucor sp. Wet lab results indicated that EO was able to inhibit fungal growth.

Mucormycosis in 2023: an update on pathogenesis and management

Mucormycosis (MCR) is an emerging and frequently lethal fungal infection caused by the Mucorales family, with Rhizopus, Mucor, and Lichtheimia, accounting for > 90% of all cases. MCR is seen in patients with severe immunosuppression such as those with hematologic malignancy or transplantation, Diabetes Mellitus (DM) and diabetic ketoacidosis (DKA) and immunocompetent patients with severe wounds. The recent SARS COV2 epidemy in India has resulted in a tremendous increase in MCR cases, typically seen in the setting of uncontrolled DM and corticosteroid use. In addition to the diversity of affected hosts, MCR has pleiotropic clinical presentations, with rhino-orbital/rhino-cerebral, sino-pulmonary and necrotizing cutaneous forms being the predominant manifestations. Major insights in MCR pathogenesis have brought into focus the host receptors (GRP78) and signaling pathways (EGFR activation cascade) as well as the adhesins used by Mucorales for invasion. Furthermore, studies have expanded on the importance of iron availability and the complex regulation of iron homeostasis, as well as the pivotal role of mycotoxins as key factors for tissue invasion. The molecular toolbox to study Mucorales pathogenesis remains underdeveloped, but promise is brought by RNAi and CRISPR/Cas9 approaches. Important recent advancements have been made in early, culture-independent molecular diagnosis of MCR. However, development of new potent antifungals against Mucorales remains an unmet need. Therapy of MCR is multidisciplinary and requires a high index of suspicion for initiation of early Mucorales-active antifungals. Reversal of underlying immunosuppression, if feasible, rapid DKA correction and in selected patients, surgical debulking are crucial for improved outcomes.

Clinicoradiological Profile of COVID-19-Associated Rhino-Orbital Cerebral Mucormycosis with a Focus on Computed Tomography: A Clinical Case Series and Review

COVID-19-associated rhino-orbital cerebral mucormycosis (ROCM) has a rapidly evolving course with high morbidity and mortality. We describe imaging features of COVID-19-associated ROCM based on noncontrast computed tomography (NCCT). This retrospective single-center observational study included 50 patients with COVID-19 from January 1, 2021 to June 30, 2021 who subsequently developed ROCM confirmed by fungal culture studies. All patients underwent NCCT of the paranasal sinuses as the diagnostic workup. The involvement of the nasal cavity, paranasal sinuses, orbits, and intracranial cavity was identified and graded. The ethmoid sinuses were most commonly involved [right (n = 46 of 50) > left (n = 45 of 50)], followed by the maxillary, sphenoid, and frontal sinuses. Thinning and erosions of the hard palate were noted in 18% of patients (n = 9), whereas 34% (n = 17) showed dehiscence of the lamina papyracea. Retromaxillary fat stranding was noted in 68% of patients (n = 34). Severe ethmoid sinusitis was associated significantly with ipsilateral pterygopalatine fossa involvement. The extraocular muscles were involved in 64% of patients (n = 32), with 84% (n = 42) showing orbital fat stranding. Proptosis of the affected eye was seen in 66% of patients, optic nerve involvement in 52%, and irregularity of globe contour in 12% (n = 6). The cavernous sinuses were affected in 10% of patients (n = 5), with three of them having temporal infarcts. COVID-19-associated ROCM is an acute, invasive fungal disease characterized by multisinus involvement, often with orbital and intracranial extension. Bilateral involvement with rapid progression should alert one to underlying COVID-19 disease.

Prosthodontic restoration of a COVID-19 associated mucormycosis defect: A clinical report

INTRODUCTION

Coronavirus Disease 2019 (COVID-19) pandemic brought the clinical practice of dentistry and prosthodontics at the threshold of a new era, due to the increasing prevalence of a relative rare condition normally affecting the immunocompromised patients.

AIM

The aim of this clinical case report is to briefly describe the etiopathogenesis, the surgical and prosthodontic management of this evolving medical condition emphasizing the emerging role of the maxillofacial prosthodontist in restoring the patients' well-being.

METHODS AND RESULTS

The surgical and prosthodontic rehabilitation of a COVID-19 infected patient with a mucormycotic lesion of the maxilla will be presented.

CONCLUSION

The role of the maxillofacial prosthodontist is important in alleviating this severe COVID-19 associated morbidity.

Mucormycosis and Its Upsurge During COVID-19 Epidemic: An Updated Review

Although mucormycosis may have reached an epidemic situation during the COVID-19 pandemic, the term was much more familiar even before the COVID-19 period. The year 2020 showed an outbreak of novel coronavirus (SARS-CoV-2) which affected millions of people all over the world. One of the noticeable complications observed to be associated with this disease is mucormycosis. It is an opportunistic infection caused by members of the Order Mucorales existing worldwide and has been commonly reported as a laboratory contaminant for a long time. However, nowadays due to the changes in the host environment, they have been emerging as potent opportunistic pathogens responsible for causing primary infections or coinfections with other diseases eventually resulting in morbidity and even mortality in severe cases. Although immunocompromised patients are more susceptible to this infection, few cases have been reported in immunocompetent individuals. Various risk factors which are responsible for the acquisition of mucormycosis include diabetes mellitus type 2, ketoacidosis, hematological malignancies, organ transplants, and chemotherapy recipients. Among the various etiological agents, Rhizopus is found to be the most common, and rhino-cerebral to be the most frequent clinical presentation. As far as pathogenesis is concerned, host cell invasion, thrombosis, and necrosis are the main events in the progression of this disease. The aim of the present review is to address a complete spectrum of mucormycosis and COVID-19-associated mucormycosis (CAM) in a single article. Both global and Indian scenarios of mucormycosis are taken into account while framing this review.

Mucormycosis: A 14-Year Retrospective Study from a Tertiary Care Center in Lebanon

Mucormycosis (MCM) is a serious invasive fungal disease (IFD) that is associated with high mortality, particularly in immunocompromised patients. A global surge in MCM cases was reported with the COVID-19 pandemic. We analyzed all recorded cases of MCM at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon, over 14 years. We aimed to identify the incidence, seasonal variation, clinical characteristics of the patients, and predictors of mortality. We conducted a retrospective chart review between 1 January 2008 and 1 January 2023. All patients with proven or probable MCM were included in the study. Proven or probable MCM was defined by positive histopathology and/or positive cultures. A total of 43 patients were identified as having MCM. Their median age was 53 years, and the majority were males (58.1%). Most of the cases were diagnosed in the autumn season. In total, 67.4% of the patients had hematological malignancies (HMs), and 34.9% had uncontrolled diabetes mellitus (DM). The most common site of involvement was rhino-orbital-cerebral MCM (ROCM) (74%). The annual cases of MCM per 100,000 patient days increased markedly during the years of the COVID-19 pandemic (from 0 to 4.4 cases/100,000 patient days to 7.5 cases/100,000 during 2020 and 2021). Liposomal amphotericin (Ampho) B was used as a first-line agent in most of the patients (86%). The median duration of total in-hospital antifungal therapy was 21 days and 51.2% of the patients received step-down therapy with azoles. Surgical debridement and isolated ROCM were significantly associated with survival (p-value: 0.02 and <0.001, respectively). All-cause mortality was 46.7%, with chronic renal disease being significantly associated with mortality (p-value < 0.05). The incidence of MCM has been increasing at our institution, particularly since the COVID-19 pandemic. Early diagnosis, treatment, and surgical debridement improve patient outcomes and overall survival.

Clinical and radiographic assessment of periodontal status among patients with post-COVID mucormycosis: A cross-sectional study

Background

An escalation in cases of rhinomaxillary mucormycosis among post-COVID patients is being reported. However, there is limited information about periodontal features in mucormycosis cases. This study explored the periodontal signs and symptoms among post-COVID mucormycosis individuals.

Materials and Methods

This cross-sectional study was carried out with a total of 25 post-COVID mucormycosis patients attending tertiary care public teaching hospital. Clinical and radiographic assessments were done.

Results

An elevation in mean probing pocket depth (PPD) up to 6.21 ± 2.7 mm was noted. Nearly 16%-40% of patients had Miller's Grade III mobility in the affected site. Forty-four per cent had localized single or multiple abscess, 40% had palatal swelling, 32% had necrosis of soft tissue and bone exposure, and 52% had maxillary dentoalveolar segmental mobility in the affected site. Radiographic examination revealed varying stages of interdental bone loss.

Conclusion

The present study observed an increase in mobility and mean PPD which did not commiserate with interdental bone loss in the affected maxillary region.

A Retrospective Study to Evaluate the Perioperative Clinical Characteristics and Outcomes of Rhino-Orbital Cerebral Mucormycosis in COVID-19 Patients at a Tertiary Care Hospital in India

Background and aims A descriptive analysis of patients who underwent surgical debridement for coronavirus disease 2019 (COVID-19) related mucormycosis was described, which aimed at the evaluation of perioperative clinical characteristics, perioperative complications, and outcomes. Methods We conducted a retrospective study on patients who underwent surgical intervention for mucormycosis during the COVID-19 pandemic at a tertiary care institute in India from March 1, 2021, to June 30, 2021. The medical records of 92 patients were reviewed and analyzed. Results There was a male predominance with a mean age of 50.86 years. The most common comorbidity was diabetes mellitus (DM) (98.9%). Intra-operative complications included hypotension, hyperglycemia, and hypokalemia. Most of the patients (88%) were extubated inside the operation theater, and 48% of patients had mortality. Serum ferritin levels, computed tomography severity score (CTSS), and D-dimers were significantly high in the patient who had mortality. Conclusion The perioperative mortality in patients with COVID-19 associated mucormycosis was very high. DM was the most common comorbidity followed by hypertension. Pre-operative elevated serum ferritin, D-dimer, and high CTSS were associated with higher mortality; hypokalemia, followed by hypocalcemia, was the most common perioperative and post-operative electrolyte imbalance. Thorough pre-operative optimization, multidisciplinary involvement, and perioperative care are of the utmost importance to decrease mortality and improve outcomes.

Mucormycosis in COVID-19 patients - A case series from a dental college in South India

Introduction

Incidence of mucormycosis has increased recently due to rapid spread of coronavirus disease 2019 (COVID-19), which is a hyper-ferritemic state paving a way for easy growth of mucor species. COVID-19 infection results in an immunocompromised state due to the steroid therapy administered to patients and the infection itself. The presence of co-morbidities makes patients more susceptible to acquire mucor infection. Mucormycosis spreads rapidly, associated with aggressive angioinvasion, leading to ischemic necrosis of surrounding tissues. Due to its rapid spread and angioinvasion, mucormycosis is associated with increased mortality and morbidity.

Treatment Planning

Early diagnosis and proper treatment planning are crucial to prevent further spread of infection, where dentists play an important role.

Discussion

This case series is mainly focused on patients reported to the oral medicine department with complaints of discomfort or mobility of teeth in the maxillary region while explaining the role of dentists in diagnosing and treating the disease.

Relevance of Conventional Microscopy in the Diagnosis of Mucormycosis during COVID-19 Pandemic

Introduction

Mucormycosis is a lethal disease which bewildered the health-care community of India during the ongoing second wave of the COVID-19 pandemic. The diagnosis is challenging considering the poor isolation in culture.

Aims

The aim of the study was to emphasize the utility of potassium hydroxide (KOH) mount examination using conventional light microscopy for early diagnosis of mucormycosis in resource-limited settings.

Materials and Methods

A retrospective analysis of results for all the samples including tissue biopsies, swabs, and pus received in the laboratory for KOH microscopy was done, and results were recorded. The clinical and demographic details of the patients were collected from the hospital information system.

Results

A total of 75 samples from 50 patients were received in the laboratory. Out of these, 43 samples from 35 patients showed fungal hyphae (38 patients with only nonseptate hyaline hyphae, 2 with septate hyaline hyphae, and 3 samples with mixed infections). All patients except one were positive for severe acute respiratory syndrome coronavirus 2 infection. The most common age group was 45-59 years (40%), followed by 30-44 years (34.28%) with a male predominance. There was a significant difference in hemoglobin A1C (P = 0.005) and ferritin (P = 0.017) levels between laboratory-confirmed mucormycosis patients and clinically suspected mucormycosis patients without confirmation.

Conclusion

Early diagnosis and initiation of targeted therapy is the cornerstone for treating mucormycosis patients. Hence, a rapid and reliable mode of diagnosis is the need of the hour. Conventional microscopy is such a tool that may be used, especially in resource-limited settings.

Secondary fungal infections in SARS-CoV-2 patients: pathological whereabouts, cautionary measures, and steadfast treatments

The earliest documented COVID-19 case caused by the SARS-CoV-2 coronavirus occurred in Wuhan, China, in December 2019. Since then, several SARS-CoV-2 mutants have rapidly disseminated as exemplified by the community spread of the recent omicron variant. The disease already attained a pandemic status with ever-dwindling mortality even after two and half years of identification and considerable vaccination. Aspergillosis, candidiasis, cryptococcosis and mucormycosis are the prominent fungal infections experienced by the majority of SARS-CoV-2 high-risk patients. In its entirety, COVID-19's nexus with these fungal infections may worsen the intricacies in the already beleaguered high-risk patients, making this a topic of substantial clinical concern. Thus, thorough knowledge of the subject is necessary. This article focuses on the concomitant fungal infection(s) in COVID-19 patients, taking into account their underlying causes, the screening methods, manifested drug resistance, and long-term effects. The information and knowledge shared herein could be crucial for the management of critically ill, aged, and immunocompromised SARS-CoV-2 patients who have had secondary fungal infections (SFIs).

Rising Incidence of Post Covid Rhinocerebral Mucormycosis: An Otolaryngologists Prospective

Mucormycosis or grimmer popular name, "black fungus" has evolved public concern in context of covid-19 pandemic, Covid Associated Mucormycosis (CAM) seen in Covid-19 pandemic and as a post covid sequelae. The present study was conducted to find out the incidence of the Mucormycosis, and to study its association with post-covid status and co-morbidities. A retrospective study conducted at tertiary care centre over a period of four months, involving all patients with mucormycosis of the paranasal sinuses suffering from or having a history of coronavirus disease. 59 patients had CAM, 47 patients had rhino-orbital Mucormycosis, followed by nasal and paranasal Mucormycosis in 8 patients, 3 patients with rhino-orbital-cerebral Mucormycosis, and one patient with pulmonary Mucormycosis. Diabetes mellitus was present in all 59 patients, 60.41% who had HbA1c > 10 (range 7-15), and 39.58% had HbA1c < 10 with range 6-13. Only 8.33% had controlled diabetes status, uncontroled hypertension and diabetes was seen in 34.02%. All patients were started with IV amphotericin B anti-fungal drug, and followed by oral posaconazole. Depending upon the extent of the disease surgical debridement was done in 52 patients. All patients had history of steroid intake. 7 mortality was there. Uncontrolled diabetes, over-zealous use of steroids, uncontrolled underlying primary disease or co-morbidities, prolonged hospitalization in intensive care unit or normal wards, and hyperventilation all these factors together aggravated the CAM. So it's proper management based on, prompt diagnosis, reversal of predisposing condition with proper medical and aggressive surgical debridement remain the corner stone for this deadly CAM.

Correlation of Mucormycosis with Various Clinical Parameters Among COVID-19 Patients: A Cross-Sectional Study

Introduction

Coronavirus disease 2019 (COVID-19), during the second wave in early 2021, caused devastating chaos in India. As daily infection rates continue to rise alarmingly, the number of severe cases also increased dramatically. Mucormycosis is an infection caused by filamentous molds, and there was a rise in mucormycosis cases after COVID-19 infection. The aim of the study is to assess various parameters associated with mucormycosis patients who suffered from COVID-19.

Material and Methodology

This study was a cross-sectional questionnaire study. The target population for the study were 70 mucormycosis-infected patients (51 = males, 19 = females). The questionnaire mainly focused on association of various parameters of COVID-19 with mucormycosis.

Results

Result showed that out of 70 cases of mucormycosis the association was found between history of diabetes mellitus 45 (64.2%), type of hospitalization, number of days of hospitalization, oxygen administered, type and maintenance of face mask, i.e., patient who had reused mask by washing 59 (84.3%), and method of oral hygiene practices.

Conclusion

Mucormycosis is extremely rare in population. The study findings emphasize the need to be aware of invasive mucormycosis developing in COVID-19 patients, especially including patients with diabetes mellitus and outside the ICU, patient who had poor oral hygiene during COVID-19, patients receiving oxygen therapy should ensure that the water in the humidifier is clean and is refilled regularly, knowledge and education about the use of the facemask.

Novel Approaches in the Management of Mucormycosis

Purpose of Review

Invasive mucormycosis (IM), caused by fungi of the order Mucorales, is one of the deadliest fungal infection among hematologic cancer patients. Its incidence is also increasingly reported in immunocompetent individuals, notably with the COVID-19 pandemic. Therefore, there is an urgent need for novel diagnostic and therapeutic approaches of IM. This review discusses the current advances in this field.

Recent Findings

Early diagnosis of IM is crucial and can be improved by Mucorales-specific PCR and development of lateral-flow immunoassays for specific antigen detection. The spore coat proteins (CotH) are essential for virulence of the Mucorales and may represent a target for novel antifungal therapies. Adjuvant therapies boosting the immune response, such as interferon-γ, anti-PDR1 or fungal-specific chimeric antigen receptor (CAR) T-cells, are also considered.

Summary

The most promising perspectives for improved management of IM consist of a multilayered approach targeting both the pathogen and the host immune system.

Epidemiology of COVID-19-Associated Mucormycosis

Purpose of the Review

To describe the epidemiology and risk factors for Coronavirus disease-19 (COVID-19)-associated mucormycosis (CAM) based on current published literature.

Recent Findings

COVID-19 is associated with an increased risk of secondary infections. Mucormycosis is an uncommon invasive fungal infection that typically affects people with immunocompromising conditions and uncontrolled diabetes. Treatment of mucormycosis is challenging and is associated with high mortality even with standard care. During the second wave of the COVID 19 pandemic, an abnormally high number of CAM cases were seen particularly in India. Several case series have attempted to describe the risk factors for CAM.

Summary

A common risk profile identified for CAM includes uncontrolled diabetes and treatment with steroids. COVID-19-induced immune dysregulation as well as some unique pandemic specific risk factors may have played a role.

Evaluation of risk factors, clinico-radiographic presentations of COVID-associated mucormycosis in the maxillofacial region reporting to a tertiary care dental facility

Purpose

To evaluate the prevalence of risk factors associated with COVID-associated mucormycosis (CAM) in the maxillofacial region with emphasis on clinical and radiological characteristics of the disease reporting to the dentists.

Methods

Archival records of the patients diagnosed with rhino-cerebral mucormycosis through histopathology or culture, were screened and 266 records were included. These records were divided into three groups-previously diabetic (PD, n = 122), recently diagnosed diabetic (RD, n = 105) and non-diabetic (ND, n = 39). All the records were evaluated and compared among the three groups for the duration of presentation, history of co-existing medical conditions, the association of treatment given during COVID-19, and the clinical and radiographic presentations of the disease.

Results

The results confirmed uncontrolled diabetes mellitus as the major risk factor for the disease. The prevalence of steroid administration was lower in our study in contrast to previous literature. The risk factors and treatment rendered during COVID-19 did not differ significantly among the three groups (p > 0.05). The findings indicate that the disease was milder and progressed more slowly in the ND group, both clinically and radiographically, and it had close resemblance to odontogenic infection.

Conclusion

Patients with early CAM mimicked the odontogenic infection and were more likely to report in a dental setup. Hence, a multidisciplinary and holistic management approach is necessary.

Higher proinflammatory responses possibly contributing to suppressed cytotoxicity in patients with COVID-19 associated mucormycosis

INTRODUCTION

COVID-19 Associated Mucormycosis (CAM), an opportunistic fungal infection, surged during the second wave of SARS Cov-2 pandemic. Since immune responses play an important role in controlling this infection in immunocompetent hosts, it is required to understand immune perturbations associated with this condition for devising immunotherapeutic strategies for its control. We conducted a study to determine different immune parameters altered in CAM cases as compared to COVID-19 patients without CAM.

METHODOLOGY

Cytokine levels in serum samples of CAM cases (n = 29) and COVID-19 patients without CAM (n = 20) were determined using luminex assay. Flow cytometric assays were carried out in 20 CAM cases and 10 controls for determination of frequency of NK cells, DCs, phagocytes, T cells and their functionalities. The cytokine levels were analyzed for their association with each other as well as with T cell functionality. The immune parameters were also analyzed with respect to the known risk factors such as diabetes mellitus and steroid treatment.

RESULTS

Significant reduction in frequencies of total and CD56 + CD16 + NK cells (cytotoxic subset) was noted in CAM cases. Degranulation responses indicative of cytotoxicity of T cell were significantly hampered in CAM cases as compared to the controls. Conversely, phagocytic functions showed no difference in CAM cases versus their controls except for migratory potential which was found to be enhanced in CAM cases. Levels of proinflammatory cytokines such as IFN-γ, IL-2, TNF-α, IL-17, IL-1β, IL-18 and MCP-1 were significantly elevated in cases as compared to the control with IFN-γ and IL-18 levels correlating negatively with CD4 T cell cytotoxicity. Steroid administration was associated with higher frequency of CD56 + CD16- NK cells (cytokine producing subset) and higher MCP-1 levels. Whereas diabetic participants had higher phagocytic and chemotactic potential and had higher levels of IL-6, IL-17 and MCP-1.

CONCLUSION

CAM cases differed from the controls in terms of higher titers of proinflammatory cytokines, reduced frequency of total and cytotoxic CD56 + CD16 + NK cell. They also had reduced T cell cytotoxicity correlating inversely with IFN-γ and IL-18 levels, possibly indicating induction of negative feedback mechanisms while diabetes mellitus or steroid administration did not affect the responses negatively.

Is Serum Ferritin an Early Marker for COVID-19-Associated Mucormycosis?

Background Coronavirus disease 2019 (COVID-19) is a hyperinflammatory disease caused by severe acute respiratory syndrome coronavirus 2, which makes critically ill patients susceptible to invasive fungal infections. Invasive fungal infections such as mucormycosis are associated with high morbidity and mortality. This study aimed to determine the serum ferritin levels in COVID-19-associated mucormycosis (CAM) patients and isolate and identify the fungi causing secondary fungal infections in patients with suspected CAM. Methodology This cross-sectional study was conducted from June to September 2021 among CAM patients admitted to Bowring and Lady Curzon Hospital. After obtaining approval from the institutional ethics committee and valid consent, data regarding demographic details, past medical history, and serum ferritin levels, along with other blood investigations, were carefully collected from patients presenting with clinical features of mucormycosis and a history of COVID-19. Samples were examined under a bright field microscope using wet mounts of samples in KOH, cultured on Sabouraud's dextrose agar, and examined under a microscope after staining with lactophenol cotton blue for the isolation and correct identification of fungi. Statistical analysis was done using Microsoft Excel (Microsoft Corp., Seattle, WA, USA) and SPSS version 26.0 (IBM Corp., Armonk, NY, USA). A p-value less than <0.05 was considered statistically significant. Results A total of 95 patients with CAM were included in this study, comprising 70 males and 25 females. The mean age of presentation was 49.83 ± 12.41 years, with 73% males and 26% females. Type 2 diabetes mellitus was noted in 69% of patients, hypertension in 29%, and steroid use in 42%. The mean serum ferritin level was 537.38 ± 468.88 ng/mL. We found a significant association between increased serum ferritin and a history of diabetes. Serum ferritin levels had a statistically significant correlation with samples of patients who were positive for Mucorales under KOH microscopy. The fungal culture showed the growth of Aspergillus, Mucor, Rhizopus, and Candida. The mean value of serum ferritin in patients who showed mucor growth was 842.09 ng/mL. Conclusions We found a significant increase in serum ferritin levels in CAM patients. Ferritin can be used as an early marker for screening mucormycosis in COVID-19 patients. Monitoring patients with elevated serum ferritin levels in severe COVID-19, glycemic control, judicious use of corticosteroids, early diagnosis, and appropriate treatment can aid in better management of the disease.

Artificial Intelligence: A Next-Level Approach in Confronting the COVID-19 Pandemic

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which caused coronavirus diseases (COVID-19) in late 2019 in China created a devastating economical loss and loss of human lives. To date, 11 variants have been identified with minimum to maximum severity of infection and surges in cases. Bacterial co-infection/secondary infection is identified during viral respiratory infection, which is a vital reason for morbidity and mortality. The occurrence of secondary infections is an additional burden to the healthcare system; therefore, the quick diagnosis of both COVID-19 and secondary infections will reduce work pressure on healthcare workers. Therefore, well-established support from Artificial Intelligence (AI) could reduce the stress in healthcare and even help in creating novel products to defend against the coronavirus. AI is one of the rapidly growing fields with numerous applications for the healthcare sector. The present review aims to access the recent literature on the role of AI and how its subfamily machine learning (ML) and deep learning (DL) are used to curb the pandemic’s effects. We discuss the role of AI in COVID-19 infections, the detection of secondary infections, technology-assisted protection from COVID-19, global laws and regulations on AI, and the impact of the pandemic on public life.

Radiological Manifestations of Rhino-Orbito-Cranial Mucormycosis in COVID-19 Patients Correlated With Pathological and Clinical Outcomes and Emphasis on Magnetic Resonance Imaging-Based Scoring System

There was tremendous increase in the number of cases of mucormycosis among patients affected by coronavirus disease 2019 (COVID-19) during the second wave of pandemic in South Asian countries. This invasive fungal infection primarily affects paranasal sinuses and can have orbito-facial and intracranial extension. We are presenting the radiological findings of invasive mucormycosis with pathological and clinical outcome correlation. It is important for radiologists to have the knowledge of various presentations of this opportunistic infection for early diagnosis and helping clinicians in planning the appropriate line of management. The study also emphasizes on the correlation between the extent of involvement with clinical outcome and we proposed a magnetic resonance imaging (MRI) based scoring system to standardize and prognosticate the patients affected with mucormycosis.

MATERIALS AND METHODS

We utilized GE 1.5 tesla, 16-channeled MRI machine for scanning the clinically suspected mucormycosis patients and did plain and contrast study of the paranasal sinuses, orbito-facial study and included brain as and when required. Images were acquired in axial, coronal, and sagittal planes using T1, T2, and fat-saturated short tau inversion recovery sequences (STIR), fat-saturated contrast sequences for better evaluation of the extent of the disease. Diffusion-weighted sequence was also acquired to detect ischemic changes in optic nerve or brain parenchyma. Contrast study was used to detect any major vessel occlusion or cavernous sinus thrombosis in the study population.

RESULTS

Total number of cases (n) included in the study were 32. The mean age group was 41-50 years with the median age was 47 years. Out of 32 cases (n=32), in 16 cases (50%) the disease was limited only to the paranasal sinuses and in remaining 16 (50%) cases, disease has spread to other regions such as orbits, facial soft tissues, optic nerve, and brain parenchyma. All the 18 cases with Mild score (MRI ROCM score 1-3) survived and all those with severe score (2 cases) (MRI ROCM score 7-10) did not survive.

CONCLUSION

During the second wave of COVID-19 pandemic, we observed a significant rise in acute invasive mucormycosis infection primarily involving the paranasal sinuses and spread to orbito-facial, cerebral parenchyma causing related complications and hence increased morbidity and death. Radiologically, using MRI, it was effectively possible to detect early extrasinonasal spread and other fatal complications thereby guiding the physicians and surgeons in the proper early aggressive management of the disease. Here, we have described the radiological characteristics of paranasal sinus mucormycosis and its spread to other regions. We also proposed an MRI-based Scoring System for standardized assessment of the disease severity. We observed in our study that the extent of disease on MRI is directly correlating with mortality.

A peek behind the curtain in the diagnosis and management of COVID‑19‑Associated Mucormycosis (CAM)

Coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) is responsible for a high mortality rate due to its unique and severe host-pathogen interactions. Critically ill or immunocompromised COVID-19 patients are more prone to suffer from aggressive mycoses. Probable victims include those with uncontrolled diabetes mellitus (DM), metabolic acidosis, prolonged neutropenia, increased ferritin levels, hypoxia, and prolonged hospitalization with/without mechanical ventilators and corticosteroids administration. The current review aims to outline the journey of patients with CAM as well as the advantages and disadvantages of the currently available diagnostic techniques. It also discussed the current status of treatment options and caveats in the management of mucormycosis. Multidisciplinary team, early diagnosis, controlling the predisposing condition(s), complete surgical debridement, effective antifungal therapies (e.g., amphotericin B, isavuconazole, and posaconazole), and implementing antifungal stewardship programs are imperative in CAM cases.

Renal mucormycosis in post-COVID patients in Australia

Renal mucormycosis is a rare entity that has been described with significant associated morbidity and mortality. It is an opportunistic infection affecting immunocompromised patients. With the pandemic of COVID-19, we report the first case of renal mucormycosis in Australia secondary to COVID-19 and its management.