Tracheal Mucormycosis Pneumonia: A Rare Clinical Presentation

Isolated laryngeal Mucormycosis requiring laryngectomy

We report a case of isolated laryngeal mucormycosis in a patient who presented in diabetic ketoacidosis (DKA). The patient was managed with antifungal therapy and eventual total laryngectomy. To our knowledge, this is the first case presented of mucormycosis with isolated laryngeal involvement.

Isolated tracheobronchial mucormycosis: report of a case and systematic review of literature

BACKGROUND

Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature.

CASE DESCRIPTION AND SYSTEMATIC REVIEW

A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky hemoptysis, and hoarseness of voice two weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycemic control, posaconazole, and inhaled amphotericin B (eight weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in 2 lung transplant recipients), post-viral illness (post-COVID-19 [n=3], and influenza [n=1]), and post-intubation mucormycosis (n=1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26; 19.2%) or bronchoscopic instillation (1/26; 3.8%) of amphotericin B and surgery (6/26; 23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive hemoptysis.

CONCLUSION

Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible.

Near‐Complete tracheal obstruction due to mucormycosis: A report of two cases

We present two cases with diabetes and mucormycosis of the major airways. Both patients underwent fiberoptic bronchoscopic evaluation, showing near‐complete occlusion of major airways with creamy necrotic mass lesions. Prompt and accurate diagnosis is vital to limit the extent of tissue destruction and prevent death due to asphyxia.

Subglottic mucormycosis in a COVID-19 patient: a rare case report

Mucormycosis is an opportunistic fungal infection caused by fungi of Mucorale order. Uncontrolled diabetes mellitus and other immunosuppressive conditions such as neutropenia and corticosteroid therapy are known risk factors. A new risk factor for this infection is COVID-19 which facilitates mucormycosis by different mechanisms. The rhino-orbito-cerebral involvement is the most common form. Involvement of other anatomical regions may occur in rare situations. As we presented here, a 51-year-old woman presented with respiratory distress and subglottic lesion during COVID-19 (Delta variant) treatment which was diagnosed by histopathological examination as a subglottic mucormycosis postoperatively. The patient underwent tracheostomy and debridement of the necrotic tissues followed by antifungal treatment. New manifestations of COVID-19 are appearing over time. The association between coronavirus and mucormycosis of the laryngeal and airway region must be given serious consideration. Current guidelines recommend a combined medical and surgical approach for achieving the best outcome.

Perioperative Challenges in the Management of Rhino-Orbital Cerebral Mucormycosis: An Observational Study from a Tertiary Care Hospital

Background

Coronavirus disease 2019 (COVID-19) pandemic is the biggest threat of the century. Associated with this disease, are a number of rhino orbital cerebral mucormycosis cases seen as post COVID sequelae. Amphotericin B and surgical debridement are the treatment modalities.

Aims

This study aimed to describe the clinical characteristics and perioperative outcomes of patients with ROCM.

Settings and Design

This was a prospective, observational study.

Materials and Methods

We carried out a study of 238 patients with confirmed ROCM posted for functional endoscopic sinus surgery, craniotomies, maxillofacial surgeries, and orbital exenteration under general anesthesia and the perioperative challenges therein.

Statistical Analysis Used

Data were entered in the excel sheet. Descriptive statistics were used to summarize the data. Analysis was done using the Statistical Package for the Social Sciences (SPSS) version 27:0. Categorical variables were expressed as counts and percentages.

Results

78% had diabetes mellitus, 64% had received steroids, 59% had a preoperative oxygen saturation of less than 90%, 86% had a 4-6 zone involvement on chest radiograph, and more than 50% had an anticipated difficult airway. Postsurgery, 13% of patients required intensive care. The 15-day mortality rate was 3% among the operated cases.

Conclusion

Post-COVID ROCM is challenging in terms of preoperative poor general condition, difficult airway, intraoperative concerns due to pathophysiology of the disease and its effect on organ systems, and the requirement of postoperative vigilant monitoring.

As the virus sowed, the fungus reaped! A Comparative Analysis of the Clinico-epidemiological Characteristics of Rhino-orbital Mucormycosis before and during Covid -19 Pandemic

Background

The sudden surge of mucormycosis cases which happened during the second wave of COVID‐19 pandemic was a significant public health problem in India.

Objectives

The aim of this study was to analyse the clinico‐epidemicological characteristics of the mucormycosis cases to determine the changes that had occurred due to COVID‐19 pandemic.

Methodology

A retrospective cross‐sectional study was conducted at the Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India. Patients diagnosed with rhino‐orbital mucormycosis were categorised into the following groups: Pre‐pandemic(May 2019 to April 2020), Pandemic Pre‐epidemic (May 2020 to April 2021) and Epidemic (1 May 2021 to 12 July 2021). The epidemiological, clinical and surgical data of all the patients were retrieved from the hospital records and analysed.

Results

The epidemic period had 370 cases, compared with 65 during pandemic period and 42 in the pre‐pandemic period. Diabetes mellitus was seen in 87% of cases during epidemic period, 92.9% in the pre‐pandemic period and 90.8% in the pre‐pandemic pre‐epidemic period. The proportion of patients suffering from vision loss, restricted extra‐ocular movements, palatal ulcer and nasal obstruction was higher in the pre‐epidemic groups, and the difference was significant (p, <.01). There was no history of oxygen use in 85.9% of patients and no steroid use in 76.5%. The death rates were the lowest during epidemic (10%).

Conclusion

COVID‐19 has caused a statistically significant increase in the number of mucormycosis infections. The mortality and morbidity which showed an increase during the first wave of COVID‐19 decreased significantly during the epidemic period.

The double-edged sword of systemic corticosteroid therapy in viral pneumonia: A case report and comparative review of influenza-associated mucormycosis versus COVID-19 associated mucormycosis

Acute respiratory distress syndrome is a common complication of severe viral pneumonia, such as influenza and COVID‐19, that requires critical care including ventilatory support, use of corticosteroids and other adjunctive therapies to arrest the attendant massive airways inflammation. Although recommended for the treatment of viral pneumonia, steroid therapy appears to be a double‐edged sword, predisposing patients to secondary bacterial and invasive fungal infections (IFIs) whereby impacting morbidity and mortality. Mucormycosis is a fungal emergency with a highly aggressive tendency for contiguous spread, associated with a poor prognosis if not promptly diagnosed and managed. Classically, uncontrolled diabetes mellitus (DM) and other immunosuppressive conditions including corticosteroid therapy are known risk factors for mucormycosis. Upon the background lung pathology, immune dysfunction and corticosteroid therapy, patients with severe viral pneumonia are likely to develop IFIs like aspergillosis and mucormycosis. Notably, the combination of steroid therapy and DM can augment immunosuppression and hyperglycaemia, increasing the risk of mucormycosis in a susceptible individual. Here, we report a case of sinonasal mucormycosis in a 44‐year‐old woman with hyperglycaemia secondary to poorly controlled diabetes following dexamethasone therapy on a background of influenza pneumonia and review 15 available literatures on reported cases of influenza and COVID‐19 associated mucormycosis.

A case of invasive pulmonary mucormycosis resulting from short courses of corticosteroids in a well-controlled diabetic patient

A patient with well-controlled type 2 diabetes mellitus developed a severe pulmonary infection secondary to Rhizopus spp. after receiving short courses of corticosteroids for a respiratory tract infection. He recovered after an aggressive surgical intervention and treatment with isavuconazole. Patients on chronic corticosteroid therapy have a higher risk for pulmonary mucormycosis, but there are much fewer reports of mucormycosis occurring in patients after only short courses of steroid therapy.

Tracheal, laryngeal and pulmonary mucormycosis followed by organizing pneumonia in a patient with Adult Onset Still's Disease

We report a case of tracheal, laryngeal and pulmonary mucormycosis in a patient receiving immunosuppressive medication for an autoinflammatory fever syndrome. Mucormycosis was confirmed by histopathology from tracheal specimens and molecular evidence of Lichtheimia. A surgical approach was not possible because of the multifocal disease pattern and the extent of tracheal involvement. The patient was successfully treated with liposomal amphotericin B followed by posaconazole maintenance therapy. After 9 months, recurrent pulmonary mucormycosis was suspected but emerged as organizing pneumonia without evidence of active fungal infection.

Update on childhood and adult infectious tracheitis

The trachea is a pivotal organ of the respiratory tract. Rather than a genuine anatomic border, it acts as a crossroad in all respiratory infectious processes. Even though not strictly limited to the trachea, infections such as laryngotracheitis and tracheobronchitis are frequently diagnosed in children, in particular during the winter season. Infectious tracheitis etiologies are diverse and the distinction between viral and bacterial origins, albeit difficult, remains relevant considering the substantial differences in terms of gravity and therapeutic management. This literature review summarizes the microbiological and clinical aspects of community-acquired and nosocomial tracheitis in adults and children, as well as the adequate diagnostic and therapeutic approaches. It also highlights the emergence of fungal tracheitis in immunocompromised patients, of ventilator-associated tracheitis in intensive care medicine, and beyond all that the potential short and long-term consequences of tracheitis.