Mucormycosis: risk factors, diagnosis, treatments, and challenges during COVID-19 pandemic

Rhino-Orbital Mucormycosis in a Postpartum Diabetic Patient: An Atypical Presentation of Oral Ulcers and Facial Swelling

Mucormycosis is a rare, life-threatening fungal infection primarily affecting immunocompromised individuals, particularly those with poorly controlled diabetes mellitus. This case report presents a 40-year-old female with a decade-long history of uncontrolled type 2 diabetes who developed progressively worsening oral ulcers, facial swelling, and vomiting, following a recent stillbirth. The patient exhibited extensive necrotic lesions involving the nose, oropharynx, and soft palate, leading to a high suspicion of invasive fungal infection. Diagnostic imaging with magnetic resonance imaging (MRI) revealed extensive sinus and orbital involvement, while histopathological examination confirmed rhino-orbital mucormycosis. The patient was managed with liposomal amphotericin B, strict glycemic control, and surgical debridement to remove necrotic tissue. This case underscores the importance of early recognition and multidisciplinary management of mucormycosis, particularly in atypical presentations involving postpartum immunosuppression. Given the rising incidence of invasive fungal infections, clinicians must maintain a high index of suspicion in high-risk patients, especially those with uncontrolled diabetes. Awareness of mucormycosis and its varied clinical presentations can aid in timely diagnosis and improve patient outcomes. The report highlights a unique presentation in a postpartum female, suggesting a potential link between obstetric complications and invasive fungal infections, warranting further research into postpartum-related immunosuppression as a risk factor.

Synthesis and characterization of allomelanin model from 1,8-dihydroxynaphthalene autooxidation

In this work a novel method for synthesis of 1,8-dihydroxynaphthalene melanin was presented, as well as the physicochemical properties, molecular structure, and characteristics of the pigment. The proposed synthesis protocol is simple and cost-effective with no enzymes or catalysts needed. The final product is not adsorbed on any surface, since the pigment is the result of autooxidation of 1,8-dihydroxynaphthalene. Performed analyses revealed that the solubility, optical and paramagnetic properties are typical for melanins, and in the EPR spectra an unusual hyperfine structure was observed. The molecular structure of the pigment consists of three different layers forming polar and non-polar surfaces. Additionally, the presence of ether bonds presence was revealed. The developed method creates new opportunities for melanin research and eliminates the need to extract melanins from biological samples, which often lead to structural changes in isolated melanins, which undermines the reliability of analyses of the properties and structure of these polymers. On the other hand, the ubiquity of melanins in living organisms and the diversity of their biological functions have let to the growing interest of researchers in this group of pigments. The analyses carried out show that the obtained synthetic DHN polymer can be considered as a model DHN-melanin in mycological studies and material research.

Rhino-orbital-cerebral mucormycosis in acute myeloid leukemia patients: a case series from Sri Lanka

BACKGROUND

Mucormycosis, is a rare yet potentially life-threatening fungal infection common in immunocompromised patients. Despite optimal care, mucormycosis in haemato-oncological patients often results in poor outcomes. This case series details the presentations and unique challenges faced during the management of patients with acute myeloid leukemia who developed rhino-cerebral mucormycosis.

CASE PRESENTATION

We present three cases of rhino-cerebral mucormycosis in patients with acute myeloid leukemia: two females aged 35 and 29, and one male aged 42. Symptoms manifested during chemotherapy induction, with all patients experiencing symptoms suggestive of rhino, orbital, or cerebral infection in a background of severe neutropenia (ANC < 0.5). Nasal endoscopy revealed necrotic tissue in all cases, with contrast-enhanced computer tomography (CECT) confirming invasive fungal infection. Rhizopus species were isolated in cultures from the two female patients, and histopathological evidence of fungal invasion was noted in one. Prompt treatment with liposomal Amphotericin B combined with surgical debridement with functional endoscopic sinus surgery (FESS) and treatment of neutropenic sepsis resulted in the survival of two patients, though one succumbed during treatment.

CONCLUSIONS

This case series highlights the importance of early clinical suspicion and treatment of mucormycosis in hematological malignancies. Due to mild and atypical presentations and lack of confirmation by microbiological and histological methods, a multifaceted diagnostic approach combining clinical, laboratory, and imaging modalities is essential. A multidisciplinary treatment approach with the management of concomitant complications like neutropenic sepsis is crucial for better outcomes.

Complete central airway obstruction from aggressive mucormycosis in a patient with acute myeloid leukaemia

A woman in her 30s with type 2 diabetes and morbid obesity presented with flu-like symptoms, persistent cough and mild dyspnoea, unresponsive to pneumonia treatment. Diagnosed with acute myeloid leukaemia, she was started on induction chemotherapy. Despite prophylactic antifungal and antibacterial therapy, she developed a fever, a right upper lobe opacity and a complete airway obstruction by a large endobronchial mass in the right main stem. Bronchoscopy with biopsy and PCR confirmed mucormycosis. Although a combined antifungal regimen was started promptly, her condition worsened, leading to acute respiratory distress syndrome, tracheo-pleural fistulas and extensive necrotic mucosa in the airways. Surgical intervention was not feasible, and she was transitioned to hospice. Complete central airway obstruction and trachea-pleural fistula are rare manifestations of pulmonary mucormycosis. We conduct a literature review of endobronchial mucormycosis to highlight the importance of early recognition and a multimodal treatment approach to improve 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.

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.

Post-COVID-19 Related Rhinocerebral Mucormycosis in Bulgaria: A Report of Three Cases

Rhinocerebral mucormycosis is a rare and rapidly progressive fungal infection caused by opportunist fungi from the Mucoraceae family, which are omnipresent in nature. Fungal sporangiospores discharged into the atmosphere could be inhaled or directly penetrate damaged skin and mucosa, and they strongly prefer angioinvasive spread. These relatively rare and opportunistic infections have spiked in recent years, particularly during the coronavirus disease identified in 2019 (COVID-19). Herein, we describe a series of three cases of rhino-orbital-cerebral mucormycosis (ROCM) during the second and third waves of COVID-19 in Bulgaria. The average age of the patients was 60.3 years (range 40-73, standard deviation ± 17.8). All of them contracted COVID-19 prior to developing ROCM and have a common comorbidity: type II diabetes mellitus. One of the cases was further complicated with a cerebral abscess as a result of ROCM. All patients underwent surgical treatments, and full recovery was achieved in two of the cases. In the third case, despite the extent of surgical and pharmaceutical treatment, ROCM progressed to a stable chronic disease.

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.

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.

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.

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.

Mucormycosis: A Rare disease to Notifiable Disease

Mucormycosis is the third most frequent invasive mycosis, following candidiasis and aspergillosis. It is frequently neglected due to its rare occurrence; but recently attend the status of notifiable disease due to its higher incidence in both developed and developing nations. India has received global notice since its estimated instances were greater than the global estimated figures. Mucormycosis has several clinical manifestations, including rhino-orbital-cerebral (ROCM), pulmonary, gastrointestinal, cutaneous, renal, and diffuse Mucormycosis. ROCM is the most frequent clinical manifestation in India, although pulmonary mucormycosis is prevalent worldwide. This review also discusses host defenses, pre disposing risk factors and fungal virulence factors that impair host's ability to prevent fungus invasion and disease establishment. The diagnosis of the disease depends on clinical interventions, histological or microbiological procedures along with molecular methods to obtain timely results. But there are still unmet challenges for rapid diagnosis of the disease. Treatment of the disease is achieved by multimodal approaches such as reversal of underlying predisposing factors, rapid administration of antifungals in optimal doses and surgical procedures to remove infected tissues. Liposomal Amphotericin B, Posaconazole and Isavuconazoles are preferred as the first line of treatment procedures. clinical trials. Different studies have improved the existing drug and under clinical trials while several studies predicted the new potential targets as CotH and Ftr1 as shown in infection and in vitro models. Therefore, current scenario demands a multidisciplinary approach is needed to investigate the prevalence, pathogenesis which is highly important for the advancement of rapid diagnosis and effective treatment.

Mucormycosis during COVID-19 era: A retrospective assessment

In a retrospective view, this review examines the impact of mucormycosis on health workers and researchers during the COVID era. The diagnostic and treatment challenges arising from unestablished underlying pathology and limited case studies add strain to healthcare systems. Mucormycosis, caused by environmental molds, poses a significant threat to COVID-19 patients, particularly those with comorbidities and compromised immune systems. Due to a variety of infectious Mucorales causes and regionally related risk factors, the disease's incidence is rising globally. Data on mucormycosis remains scarce in many countries, highlighting the urgent need for more extensive research on its epidemiology and prevalence. This review explores the associations between COVID-19 disease and mucormycosis pathology, shedding light on potential future diagnostic techniques based on the fungal agent's biochemical components. Medications used in ICUs and for life support in ventilated patients have been reported, revealing the challenge of managing this dual onslaught. To develop more effective treatment strategies, it is crucial to identify novel pharmacological targets through "pragmatic" multicenter trials and registries. In the absence of positive mycology culture data, early clinical detection, prompt treatment, and tissue biopsy are essential to confirm the specific morphologic features of the fungal agent. This review delves into the history, pathogens, and pathogenesis of mucormycosis, its opportunistic nature in COVID or immunocompromised individuals, and the latest advancements in therapeutics. Additionally, it offers a forward-looking perspective on potential pharmacological targets for future drug development.

Secondary bacterial infections in post-COVID-19 mucormycosis cases: a retrospective study at Imam Khomeini Hospital Complex, March 2020-April 2021

Background and Objectives

To explore the prevalence and characteristics of secondary bacterial infections among patients suffering from mucormycosis following COVID-19 infection.

Materials and Methods

We conducted a cross-sectional, retrospective analysis from March 2020 to April 2022 at Imam Khomeini Hospital Complex in Tehran. The study included patients with histopathologically confirmed mucormycosis and documented secondary bacterial infections. We extracted and analyzed data from hospital records using SPSS software, version 26.

Results

The study comprised 27 patients, with a predominance of females (70.4%) and an average age of 56 years. The majority of these patients (63%) had pre-existing diabetes mellitus. The severity of their COVID-19 infections varied. Treatment regimens included immunosuppressive drugs and antibiotics. Rhinocerebral mucormycosis was the most common form observed. The predominant secondary infections involved the urinary tract, respiratory system, bloodstream (bacteremia), and soft tissues, with resistant strains of Acinetobacter baumannii, Escherichia coli, and Klebsiella pneumoniae being the most frequently identified microorganisms. Notably, cases of bacteremia and pneumonia exhibited a higher mortality rate. Ultimately, 55.6% of patients were discharged, while 44.4% succumbed to their infections.

Conclusion

Patients recovering from COVID-19 with mucormycosis are significantly susceptible to secondary bacterial infections, particularly those with diabetes mellitus or those undergoing immunosuppressive therapy. Such infections compound the morbidity and mortality risks in this vulnerable patient cohort.

Comprehensive Review on the Virulence Factors and Therapeutic Strategies with the Aid of Artificial Intelligence against Mucormycosis

Mucormycosis, a rare but deadly fungal infection, was an epidemic during the COVID-19 pandemic. The rise in cases (COVID-19-associated mucormycosis, CAM) is attributed to excessive steroid and antibiotic use, poor hospital hygiene, and crowded settings. Major contributing factors include diabetes and weakened immune systems. The main manifesting forms of CAM─cutaneous, pulmonary, and the deadliest, rhinocerebral─and disseminated infections elevated mortality rates to 85%. Recent focus lies on small-molecule inhibitors due to their advantages over standard treatments like surgery and liposomal amphotericin B (which carry several long-term adverse effects), offering potential central nervous system penetration, diverse targets, and simpler dosing owing to their small size, rendering the ability to traverse the blood-brain barrier via passive diffusion facilitated by the phospholipid membrane. Adaptation and versatility in mucormycosis are facilitated by a multitude of virulence factors, enabling the pathogen to dynamically respond to various environmental stressors. A comprehensive understanding of these virulence mechanisms is imperative for devising effective therapeutic interventions against this highly opportunistic pathogen that thrives in immunocompromised individuals through its angio-invasive nature. Hence, this Review delineates the principal virulence factors of mucormycosis, the mechanisms it employs to persist in challenging host environments, and the current progress in developing small-molecule inhibitors against them.

Corona-Associated Mucormycosis: Case Series Reports and Review of the Literature

During the COVID-19 pandemic, a significant increase in cases of mucormycosis was observed in COVID-19 patients, especially in India, but not exclusively. The presented cases highlight the heterogeneous nature of mucormycosis, emphasizing the importance of recognizing predisposing factors, such as immunosuppression, due to comorbidities or medication. Diagnosing mucormycosis poses a challenge due to nonspecific clinical manifestations, requiring a multidisciplinary approach for accurate diagnosis. Treatment involves a multi-pronged approach centered around the early initiation of antifungal therapy alongside surgical intervention and the management of underlying conditions, with an emphasis on controlling immunosuppression. Understanding the relationship between COVID-19 and predisposing factors for mucormycosis is fundamental for developing prevention and treatment strategies.

Unveiling the menace: a thorough review of potential pandemic fungal disease

Fungal diseases have emerged as a significant global health threat, with the potential to cause widespread outbreaks and significant morbidity and mortality. Anticipating future pandemic fungal diseases is essential for effective preparedness and response strategies. This comprehensive literature review aims to provide a comprehensive analysis of the existing research on this topic. Through an extensive examination of scholarly articles, this review identifies potential fungal pathogens that have the potential to become pandemics in the future. It explores the factors contributing to the emergence and spread of these fungal diseases, including climate change, globalization, and antimicrobial resistance. The review also discusses the challenges in diagnosing and treating these diseases, including limited access to diagnostic tools and antifungal therapies. Furthermore, it examines the strategies and interventions that can be employed to mitigate the impact of future pandemic fungal diseases, such as improved surveillance systems, public health education, and research advancements. The findings of this literature review contribute to our understanding of the potential risks posed by fungal diseases and provide valuable insights for public health professionals and policymakers in effectively preparing for and responding to future pandemic outbreaks. Overall, this review emphasizes the importance of proactive measures and collaborative efforts to anticipate and mitigate the impact of future pandemic fungal diseases.

Palatal mucormycosis in a 2-month-old child: A very rare case report and a literature review

A 2-month-old Syrian male child presented with a large blackish ulcerating lesion on his hard palate, along with fever, diarrhea, vomiting, and milk regurgitation from the nose. The child was diagnosed with palatal mucormycosis by histopathology and underwent treatment with liposomal amphotericin B and surgical debridement. However, despite treatment, the child's condition deteriorated, and he died from respiratory failure. An underlying immunodeficiency was not diagnosed, but the family history revealed several deaths of the child's siblings at very early ages due to poorly documented complicated metabolic syndromes. An autopsy was refused by the parents due to cultural reasons.

Rhizopus microsporus and Mucor racemosus coinfection following COVID-19 detected by metagenomics next-generation sequencing: A case of disseminated mucormycosis

Mucormycosis is an invasive opportunistic fungal infection, which may be lethal and mostly affects patients with immunodeficiency or diabetes mellitus. Among Mucorales fungi, Rhizopus spp. is the most common cause of mucormycosis, followed by genera such as Mucor and Lichtheimia. Here we report a patient with severe COVID-19 infection who developed nasal pain, facial swelling, prominent black eschar on the nasal root. CT scan revealed pansinusitis along the maxillary, ethmoidal, and sphenoid sinuses. Mixed mold infection with Rhizopus microsporus and Mucor racemosus was detected by blood metagenomics next-generation sequencing (mNGS) and later nasal mucosa histological investigation confirmed mucormycosis. Severe COVID-19 infection led to the patient's thrombocytopenia and leukopenia. Later disseminated mucormycosis aggravated the infection and sepsis eventually resulted in death. It is the first case report of mucormycosis in which R. microsporus and M. racemosus as the etiologic agents were found simultaneously in one patient. COVID-19 infection combined with disseminated mucormycosisis can be fatal and mNGS is a fast, sensitive and accurate diagnostic method for fungi detection.

Assessment of UV radiation effects on airborne mucormycetes and bacterial populations in a hospital environment

Infections, such as mucormycosis, often result from inhaling sporangiospore present in the environment. Surprisingly, the extent of airborne Mucormycetes sporangiospore concentrations remains inadequately explored. This study aimed to assess the influence of UV radiation on microbial populations and Mucormycetes spore levels within a hospital environment in northern Iran. A comprehensive dataset comprising 298 air samples collected from both indoor and outdoor settings was compiled. The culture was conducted using Blood Agar and Dichloran Rose Bengal Chloramphenicol (DRBC) culture media, with Chloramphenicol included for fungal agents and Blood Agar for bacterial. Before UV treatment, the average count of Mucormycetes ranged from 0 to 26.4 ± 25.28 CFU m-3, fungal agents from 2.24 ± 3.22 to 117.24 ± 27.6 CFU m-3, and bacterial agents from 29.03 ± 9.9 to 359.37 ± 68.50 CFU m-3. Following UV irradiation, the averages were as follows: Mucormycetes ranged from 0 to 7.85 ± 6.8 CFU m-3, fungal agents from 16.58 ± 4.79 to 154.98 ± 28.35 CFU m-3, and bacterial agents from 0.38 ± 0.65 to 43.92 ± 6.50 CFU m-3. This study, notably marks the pioneering use of UV light to mitigate Mucormycetes spore counts and bacterial agents in northeastern Iran, contributing to the advancement of environmental health and safety practices in hospital settings.

COVID-19 associated mucormycosis (CAM) in Kashan, Iran: clinical presentations, risk factors, management, and outcomes

BACKGROUND

This study aimed to estimate the disease burden and describe the clinical presentation, risk factors, and outcome of CAM in a single centre in Iran.

METHODS

A case of mucormycosis was defined as one that had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological and molecular examination.

RESULTS

We report 30 cases of COVID-19 associated mucormycosis (CAM). The results of this study showed the affected age group in the range of 40-79 years (median = 65.5; IQR = 5) with women (16/30, 53%) affected more than men (14/30, 47%). Among the fungi recovered, Rhizopus oryzae had the highest frequency (79%). Out of the 30 patients, 28 (93%) patients were diabetic with 24 (80%) patients having other co-morbidities. Headache followed by retro-orbital pain, proptosis/ptosis and rapid diminution of vision was a common sequence of symptoms reported by the majority of cases. Use of mechanical ventilation (58% vs. 6%, p = 0.003), O2 required (92% vs. 50%, p = 0.024), and development of renal dysfunction during hospital stay (17% vs. 0%, p = 0.041) was significantly higher in non-survivors than survivors. Temperature (C°), PR (pulse rate), mean levels of serum creatinine, BUN, troponin, and neutrophils were significantly higher in non-survivors (p < 0.05). Besides, Albumin and PO2 were also significantly higher in survivors than non-survivors.

CONCLUSION

Despite medical and surgical treatment, the mortality rate among CAM patients is still high. Thus, concerted efforts of revamping surveillance, diagnosis and management, along with public awareness and patient education, are the requisites for managing COVID-19 and mucormycosis.

Overcoming the Odds: Successful Treatment of Disseminated Mucormycosis with Gastrointestinal and Jaw Involvement in a Patient with Acute Myeloid Leukemia

Disseminated mucormycosis is a rare life-threatening fungal infection that is uniquely seen in severely immunocompromised patients including those with hematological malignancies. We report a case of disseminated mucormycosis with a biopsy-proven gastrointestinal and oral cavity involvement in a patient with acute myeloid leukemia during induction chemotherapy. The patient had a successful outcome with limited resection of the involvement bowel segment, multiple maxillary dental extractions, debridement of the alveolus and hard palate, and combined antifungal therapy. After clinical improvement, stable infection on serial abdominal imaging, and completion of 6 weeks of combined antifungal therapy, consolidation chemotherapy was given, and molecular remission was achieved. The patient remained clinically well on secondary antifungal prophylaxis.

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.

Factors associated with cutaneous colonization of Mucormycetes in diabetic and non-diabetic individuals

This study was conducted to assess factors associated with cutaneous colonization of Mucormycetes in diabetic and non-diabetic individuals. A total of 800 swab samples from 200 participants including 100 diabetics and 100 non-diabetics were collected from four different body sites: (1) the forehead, (2) nasal cavity, (3) hands and (4) feet. Fungal isolation, fungal identification and antibiotic sensitivity tests were performed on the isolates. Overall, 12.0 % of the participants showed Mucormycetes colonization while the commonest fungal isolates were Mucor Species (Spp.). followed by Rhizopus spp. Diabetics had a 11 times higher odds of colonization compared to non-diabetics. The majority of the isolates were resistant to itraconazole; however, all isolates were sensitive to amphotericin B. A significant association was observed between profession and Mucormycetes (P=0.03) with significantly higher colonization in retired people compared to business people. Higher odds of colonization were demonstrated among older ages, lower class status and individuals with prolonged contact time with soil.

Diagnosis of invasive fungal infections: challenges and recent developments

BACKGROUND

The global burden of invasive fungal infections (IFIs) has shown an upsurge in recent years due to the higher load of immunocompromised patients suffering from various diseases. The role of early and accurate diagnosis in the aggressive containment of the fungal infection at the initial stages becomes crucial thus, preventing the development of a life-threatening situation. With the changing demands of clinical mycology, the field of fungal diagnostics has evolved and come a long way from traditional methods of microscopy and culturing to more advanced non-culture-based tools. With the advent of more powerful approaches such as novel PCR assays, T2 Candida, microfluidic chip technology, next generation sequencing, new generation biosensors, nanotechnology-based tools, artificial intelligence-based models, the face of fungal diagnostics is constantly changing for the better. All these advances have been reviewed here giving the latest update to our readers in the most orderly flow.

MAIN TEXT

A detailed literature survey was conducted by the team followed by data collection, pertinent data extraction, in-depth analysis, and composing the various sub-sections and the final review. The review is unique in its kind as it discusses the advances in molecular methods; advances in serology-based methods; advances in biosensor technology; and advances in machine learning-based models, all under one roof. To the best of our knowledge, there has been no review covering all of these fields (especially biosensor technology and machine learning using artificial intelligence) with relevance to invasive fungal infections.

CONCLUSION

The review will undoubtedly assist in updating the scientific community's understanding of the most recent advancements that are on the horizon and that may be implemented as adjuncts to the traditional diagnostic algorithms.

Biosynthesis, Characterization, and Antifungal Activity of Novel Trimetallic Copper Oxide-Selenium-Zinc Oxide Nanoparticles against Some Mucorales Fungi

Metal nanoparticles are assumed to be a new generation of biologically active materials. The integrations between more than one metal are synergetic multifunctional features. In the current study, trimetallic copper-selenium-zinc oxide nanoparticles (Tri-CSZ NPs) were successfully mycosynthesized using Aspergillus niger through an ecofriendly method for the first time. The biosynthesis of the particles was characterized using physiochemical and topographical analysis. The physiochemical analysis included Fourier transform infrared spectroscopy (FTIR), which affirmed that the biosynthesis of Tri-CSZ NPs relies on the functional groups of fungal filtrates. Additionally, the UV-visible and X-ray diffraction patterns were proposed for the formation of Tri-CSZ NPs; moreover, topography analysis confirmed that the micromorphology of the nanoparticles were similar to a stick, with ends having a tetragonal pyramid shape, and with an average nanosize of about 26.3 ± 5.4 nm. Cytotoxicity results reveled that the Tri-CSZ NPs have no cytotoxicity on the human normal cell line Wi 38 at low concentrations, where the IC50 was 521 µg/mL. Furthermore, the antifungal activity of the Tri-CSZ NPs was evaluated. The antifungal results revealed that the Tri-CSZ NPs have promising antifungal activity against Mucor racemosus, Rhizopus microsporus, Lichtheimia corymbifera, and Syncephalastrum racemosum, where the minimum inhibitory concentrations (MICs) were 1.95, 7.81, 62.5, and 3.9 µg/mL, and the minimum fungicidal concentrations (MFCs) were 250, 62.5, 125, and 1000 µg/mL, respectively. In conclusion, Tri-CSZ NPs were successfully mycosynthesized using A. niger, which have a promising antifungal activity against fungi causing mucormycosis.

Accidental finding of COVID-associated mucormycosis (CAM) in a patient presenting as toothache: A case report and review of literature

Mucormycosis is an angio-invasive rapidly progressing fungal infection, usually reported in immunocompromised individuals. We present a case of COVID-associated mucormycosis in a patient with a presenting symptom of toothache in the maxilla with a possible mild case of COVID-19.

Abstract

Coronavirus-associated mucormycosis (CAM) had reached epidemic status, especially during the second wave of COVID-19. It was especially prevalent in India with a large mortality rate. Mucormycosis, particularly the rhinocerebral type is seen to be greatly associated with COVID-19, especially in patients with altered immunity. Uncontrolled diabetes, chronic kidney disease, immunocompromised patients, malignant hematological diseases, etc. are the major risk factors of CAM, precipitated by the injudicious use of corticosteroids for the treatment of COVID-19. CAM may often present in the maxillofacial region which warrants that dental clinicians be aware of the clinical presentation, diagnostic guidelines, and appropriate management measures for the disease. This report is one such case of CAM involving the posterior maxilla in a middle-aged individual with mild COVID-19 symptoms.

Burden of fungal infections in Kenya

The burden of fungal infections has been on the rise globally and remains a significant public health concern in Kenya. We estimated the incidence and prevalence of fungal infections using all mycology publications in Kenya up to January 2023, and from neighbouring countries where data lacked. We used deterministic modelling using populations at risk to calculate the disease burden. The total burden of serious fungal infections is estimated to affect 6,328,294 persons which translates to 11.57% of the Kenyan population. Those suffering from chronic infections such as chronic pulmonary aspergillosis are estimated to be 100,570 people (0.2% of the population) and probably nearly 200,000 with fungal asthma, all treatable with oral antifungal therapy. Serious acute fungal infections secondary to HIV (cryptococcal meningitis, disseminated histoplasmosis, pneumocystis pneumonia, and mucosal candidiasis) affect 196,543 adults and children (0.4% of the total population), while cancer-related invasive fungal infection cases probably exceed 2,299 and those in intensive care about 1,230 incident cases, including Candida auris bloodstream infection. The burden of fungal infections in Kenya is high; however, limited diagnostic test availability, low clinician awareness and inadequate laboratory capacity constrain the country's health system in responding to the syndemic of fungal disease in Kenya.

The Impact of COVID-19 Infection on Miscellaneous Inflammatory Disorders of the Gastrointestinal Tract

The novel coronavirus pandemic of COVID-19 has emerged as a highly significant recent threat to global health with about 600,000,000 known infections and more than 6,450,000 deaths worldwide since its emergence in late 2019. COVID-19 symptoms are predominantly respiratory, with mortality largely related to pulmonary manifestations, but the virus also potentially infects all parts of the gastrointestinal tract with related symptoms and manifestations that affect patient treatment and outcome. COVID-19 can directly infect the gastrointestinal tract because of the presence of widespread angiotensin-converting enzyme 2 receptors in the stomach and small intestine that can cause local COVID-19 infection and associated inflammation. This work reviews the pathopysiology, clinical manifestations, workup, and treatment of miscellaneous inflammatory disorders of the gastrointestinal tract other than inflammatory bowel disease.

Evaluation of Clinical Manifestations, Pattern of Involvement, and Surgical Outcomes in Patients with Post Covid-19 Head and Neck Mucormycosis Infection among Patients Admitted To Namazi Hospital, Shiraz, Iran (2021-2022)

Background

COVID-19, caused by SARS-CoV-2, is a global pandemic that particularly affects immunocompromised individuals, leading to secondary bacterial and fungal infections. Mucormycosis, caused by Mucorales fungi, is a severe infection primarily affecting immunocompromised individuals. The COVID-19 pandemic has seen a surge in mucormycosis cases worldwide, with India experiencing a significant increase. Various factors, including diabetes mellitus, contribute to the risk of mucormycosis. This study investigated head and neck mucormycosis in patients with prior COVID-19 infection.

Methods

Data from 45 patients were analyzed, with diabetes being the most common risk factor. Visual symptoms, ethmoid bone involvement, and orbital bone involvement were also identified as significant factors.

Results

The COVID-19 pandemic has led to an increase in mucormycosis cases, particularly in the head and neck region, with high mortality. Successful management involves addressing underlying factors, surgical debridement, and antifungal therapy.

Conclusion

Timely debridement reduces morbidity and mortality.

Mucormycosis diagnosis revisited: Current and emerging diagnostic methodologies for the invasive fungal infection (Review)

Mucormycosis, which is a life threatening condition, is one of the side effects experienced by post-COVID-19 patients. Early identification and timely treatment are essential to stop the dissemination of the disease, since invasive mucormycosis has a very high fatality rate and significant disease dispersion. Conventional diagnostic techniques, including clinical diagnosis, serology, histopathology and radiology, have limitations in diagnosing the disease at an early stage. This warrants the need for advanced diagnostic tools such as nucleic acid diagnostics, advanced serological tests (ELISpot), PCR (pan-Mucorale test) and multiplex PCR. These techniques have been introduced to identify this invasive fungal infection at an incipient stage, thereby helping clinicians to prevent adverse outcomes. The use of biosensors and micro-needle based diagnostic methodologies will pave the way for devising more point-of-care tests that can be employed for the detection of mucormycosis at an incipient stage. The present review discusses the current techniques available and their drawbacks, and the usefulness of advanced diagnostic tools. Furthermore, the possibility of using future diagnostic methods for the diagnosis of mucormycosis is highlighted.

Diagnostic and Treatment Challenges of Emergent COVID-Associated-Mucormycosis: A Case Report and Review of the Literature

Mucormycosis is a rare fungal infection, with high mortality, commonly associated with diabetes, malignancies, immunosuppressive therapy, and other immunodeficiency conditions. The emergence of mucormycosis cases has been advanced by the COVID-19 pandemic. Clinical presentation is variable, from asymptomatic to persistent fever or localized infections. We present a case of a Romanian old man, without diabetes or other immunodepression, with COVID-19 who developed severe rhino-orbital mucormycosis and bacterial superinfections, with Pseudomonas aeruginosa and Klebsiella pneumoniae. The late diagnostic and antifungal treatment was related to extensive lesions, bone and tissue loss, and required complex reconstruction procedures. We review the relationships between mucormycosis, COVID-19, and bacterial associated infections. The suspicion index of mucormycosis should be increased in medical practice. The diagnostic and treatment of COVID-19-Associated-Mucormycosis is currently challenging, calling for multidisciplinary collaboration.

Scedosporium apiospermum and Lichtheimia corymbifera Co-Infection Due to Inhalation of Biogas in Immunocompetent Patients: A Case Series

This is the first report describing co-infection of Scedosporium apiospermum and Lichtheimia corymbifera caused by biogas inhalation in two people without underlying medical conditions. Two patients fell into the same pig manure pit at the same time while rescuing another patient (this person died in a few hours) and inhaled biogas. Both patients were diagnosed with pulmonary fungal disease and developed acute liver failure around Day 52. Their results were negative for the 1,3-β-d-glucan test and weakly positive for the galactomannan test. They were treated with amphotericin B and/or posaconazole without surgery. The patient in case 2 required amphotericin B deoxycholate aerosol inhalation to complete the treatment. Both patients recovered completely. For patients with mucormycosis confined to the lungs who cannot tolerate intravenous drip amphotericin B, increasing the dose of nebulised administration maybe a salvage regimen.

Surgical management of post-COVID invasive rhino-orbito-cerebral mucormycosis and its outcomes: Role of neurosurgeons in a tertiary care center

Background:

Mucormycosis, which was previously considered to be rare, has emerged with a new challenge in patients infected with or recovering from COVID-19. Immunocompromised patients are particularly prone to developing this disease. The most common form of presentation is rhino-orbito-cerebral mucormycosis (ROCM). We present various neurosurgical approaches to an entire spectrum of its clinical manifestations.

Methods:

This is a retrospective study of patients who were admitted to the neurosurgery department with ROCM and a history of COVID-19 infection between November 1, 2020, and September 1, 2021. All cases of ROCM underwent contrast-enhanced computed tomography/magnetic resonance imaging of the brain, paranasal sinuses, and orbit. A tissue biopsy was sent for histopathological analysis. All confirmed cases received liposomal amphotericin B and surgical treatment was immediately undertaken.

Results:

Out of 200 patients with ROCM, 40 patients presented with neurological manifestations. Seven out of 40 patients had focal lesions in the brain and skull bone that needed neurosurgical intervention along with sinus debridement and antifungal treatment. These seven patients presented with different clinical manifestations: large-vessel stroke (one), medium-vessel stroke (one), frontal lobe abscess (one), frontal bone osteomyelitis (two), isolated central nervous system involvement (one), and mucor mimicking trigeminal schwannoma (one). The surgical intervention included decompressive craniectomy, frontal craniotomy, subtemporal craniotomy, and a minimally invasive supraorbital keyhole approach.

Conclusion:

In high-risk patients, a high level of clinical suspicion combined with appropriate investigations should be performed as soon as possible. Symptoms and early warning signs should not be overlooked, as treatment delays can be fatal. A minimally invasive surgical approach is possible in view of decreasing the morbidity of large craniotomy.

Histological Spectrum of Post Covid Debridement Tissues: Salient Histomorphological Features With Respect to Identification Fungal Elements

BACKGROUND

Secondary bacterial and fungal infections in COVID patients have been documented during current pandemic. The present study provides detailed account of histomorphology of debridement tissue received for suspected fungal infections. The primary objective was to determine the morphological characteristics that must be recognized for the identification of fungal hyphae.

METHODS

The detailed histological examination of debridement tissue was performed. Demographic and clinical findings with treatment provided was recorded. Presence or absence of necrosis and lecocytoclasis was noted.

RESULTS

A total of 110 cases of debrided tissues were included in the study. Eosinophilic granular necrosis with lecocytoclasis was observed in 103cases; fungal elements were identified in 89.3% (92/103) of these. Eleven cases where necrosis was observed, strong suspicion of fungus was reported, 6 of them displayed fungus on KOH preparation, 3 on repeat biopsy. However, in 2 of these cases, neither KOH nor repeat biopsies identified the fungus. Mucor with aspergillus was observed in 7 cases and actinomyces in 3. In all these 10 cases dense fungal colonies were evident. In 7 cases careful observation revealed fruiting bodies of aspergillus. Cotton ball appearance of actinomyces was evident. Mucor infection in current disease was so rampant that aseptate ribbon like branching mucor hyphae were evident on H&E sections. Diabetes was significantly associated with fungal infection (97.2%; 70/72; P < .005). 90% [19/21] of the patients who were on room air and diagnosed with fungal infection were diabetic.

CONCLUSIONS

Eosinophilic granular necrosis with the presence of neutrophilic debris in a case of suspected fungal disease suggests the presence of fungal elements. This warrants processing of the entire tissue deposited for examination, careful observation, application of fungal stains, and repeat biopsy if clinical suspicion is strong. Moreover, uncontrolled diabetes is more frequently associated with secondary fungal infection in COVID patients as compared to oxygen therapy.