Epidemiology of Mucormycosis in India

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.

The WHO fungal priority pathogens list: a crucial reappraisal to review the prioritisation

In October, 2022, WHO published the first fungal priority pathogen list, which categorised 19 fungal entities into three priority groups (critical, high, and medium), for prioritisation of research efforts. The final ranking was determined via multiple criteria decision analysis, considering both research and development needs and perceived public health importance. In this Personal View, we discuss the positioning of the fungal pathogens, namely, Mucorales, Candida spp, Histoplasma spp, Coccidioides and Paracoccidioides spp, Fusarium spp, eumycetoma causative agents, Talaromyces marneffei, and Pneumocystis jirovecii, while expressing concerns about potential disparities between the WHO fungal priority pathogen list ranking and the actual disease burden associated with these pathogens. Finally, we propose a revised prioritisation list that also considers the regional disparities in the burden of fungal diseases.

Virulence traits and novel drug delivery strategies for mucormycosis post-COVID-19: a comprehensive review

The outbreak of a fatal black fungus infection after the resurgence of the cadaverous COVID-19 has exhorted scientists worldwide to develop a nutshell by repurposing or designing new formulations to address the crisis. Patients expressing COVID-19 are more susceptible to Mucormycosis (MCR) and thus fall easy prey to decease accounting for this global threat. Their mortality rates range around 32-70% depending on the organs affected and grow even higher despite the treatment. The many contemporary recommendations strongly advise using liposomal amphotericin B and surgery as first-line therapy whenever practicable. MCR is a dangerous infection that requires an antifungal drug administration on appropriate prescription, typically one of the following: Amphotericin B, Posaconazole, or Isavuconazole since the fungi that cause MCR are resistant to other medications like fluconazole, voriconazole, and echinocandins. Amphotericin B and Posaconazole are administered through veins (intravenously), and isavuconazole by mouth (orally). From last several years so many compounds are developed against invasive fungal disease but only few of them are able to induce effective treatment against the micorals. Adjuvant medicines, more particularly, are difficult to assess without prospective randomized controlled investigations, which are challenging to conduct given the lower incidence and higher mortality from Mucormycosis. The present analysis provides insight into pathogenesis, epidemiology, clinical manifestations, underlying fungal virulence, and growth mechanisms. In addition, current therapy for MCR in Post Covid-19 individuals includes conventional and novel nano-based advanced management systems for procuring against deadly fungal infection. The study urges involving nanomedicine to prevent fungal growth at the commencement of infection, delay the progression, and mitigate fatality risk.

COVID-19-associated mucormycosis in India: Why such an outbreak?

An unprecedented mucormycosis outbreak occurred in India during the second COVID-19 wave in spring 2021. COVID-19-associated mucormycosis (CAM) was observed, mainly rhino-orbito-cerebral mucormycosis (ROCM), in patients with poorly controlled diabetes and treated with inappropriate doses of glucocorticoids. The aim of this mini-review was to compare the characteristics of the CAM epidemic in India with (i) mucormycosis cases before the COVID-19 pandemic and (ii) CAM in the rest of the world (particularly in France) in order to identify the reasons for this outbreak. In India, the major mucormycosis epidemiologic change during the COVID-19 pandemic was an increase in the percentage of patients treated with corticosteroids who developed CAM. Compared with the rest of the world, India reported a higher mucormycosis incidence even before the COVID-19 pandemic. Moreover, in India, patients with CAM were more likely to have diabetes mellitus and ROCM; conversely, mortality rates were lower. The reasons for such a localized epidemic in India have remained unclear, but some hypotheses can be put forward, particularly the combination of high prevalence of uncontrolled diabetes mellitus and frequent indiscriminate corticosteroid utilization in a country that already had a high mucormycosis burden before the COVID-19 pandemic.

Mucormycosis, past and present: a comprehensive review

Mucormycosis is an emerging opportunistic angioinvasive fungal infection. Predisposing factors such as diabetes, neutropenia, long-term corticosteroid therapy, solid organ transplantation and immunosuppression contribute to its occurrence. This disease was not of significant concern prior to the COVID-19 pandemic, but gained prominence due to infections in COVID-19 patients. Mucormycosis needs special attention and coordinated efforts of the scientific community and medical professionals to reduce morbidity and mortality. Here we present an overview of the epidemiology and prevalence of mucormycosis in the pre- and post-COVID-19 eras, the factors that contributed to the abrupt increase in COVID-19-associated mucormycosis (CAM), the actions taken by the regulatory agencies (including Code Mucor and CAM registry), the existing diagnostic tools and CAM management strategies.

A fungal epidemic amidst a viral pandemic: Risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis in India

PURPOSE

To study the risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis (ROCM) during the COVID-19 pandemic in India.

METHODS

Multi-centric retrospective case-control study conducted from October 2020 to May 2021. Cases comprised of consecutive patients of COVID-19-associated ROCM (CA-ROCM) presenting at the participating ophthalmic institutes. Controls comprised of COVID-19-positive or COVID-19-recovered patients who did not develop ROCM. Comparative analysis of demographic, COVID-19 infection, treatment parameters and vaccination status between cases and controls performed. Clinical and imaging features of CA-ROCM analyzed.

RESULTS

There were 179 cases and 361 controls. Mean age of presentation in cases was 52.06 years (p = .001) with male predominance (69.83%, p = .000011). Active COVID-19 infection at the time of presentation of ROCM (57.54%, p < .0001), moderate to severe COVID-19 (p < .0001), steroid administration (OR 3.63, p < .00001), uncontrolled diabetes (OR 32.83, p < .00001), random blood sugar >178 mg/dl were associated with development of CA-ROCM. Vaccination showed a protective effect (p = .0049). In cases with intracranial or cavernous sinus extension there was history of steroid administration (OR 2.89, p = .024) and orbital apex involvement on imaging (OR 6.202, p = .000037) compared to those with only rhino-orbital disease.

CONCLUSION

Male gender, active COVID-19 infection, moderate or severe COVID-19, uncontrolled diabetes, steroid administration during COVID-19 treatment are risk factors for developing rhino-orbital-cerebral mucormycosis. Vaccination is protective. Random blood sugar of >178 mg/dl in COVID-19 positive or recovered patients should warrant close observation and early detection of ROCM. Presence of ophthalmoplegia, blepharoptosis at first clinical presentation and orbital apex involvement on imaging are associated with intracranial extension in ROCM.

The Psychological Impact of Rhino-Orbital Mucormycosis During the Second Wave of COVID-19 Pandemic From South East Asian Country

AIM

The present study addressed overcoming the lacunae in the literature of psychiatric manifestations associated with rhino-orbital mucormycosis. The current study aimed to assess the symptoms of depression, anxiety, stress, coping measures, suicidal intent, and visual disability in patients of rhino-orbital mucormycosis (ROM) during the epidemic of the disease at the nodal tertiary care center in North India.

METHODS

Fifty-four inpatients of laboratory-proven rhino-orbital mucor-mycosis (ROM) were included for an observational, cross-sectional study at nodal, designated COVID-19, and mucormycosis treating tertiary care hospital. Patients with Hindi Mini-Mental State Examination score <24, prior psychiatric illness, and severely ill requiring ventilator support were excluded. The psychological variables were assessed using Depression, Anxiety, and Stress Scale 21 (DASS 21), Beck's Suicide intent Scale, Coping Scale Questionnaire, and Visual disability scale (IND-VFQ33). Their socioeconomic status was assessed using the Modified Kuppuswamy Scale.

RESULTS

Ninety percent of patients with ROM had diabetes mellitus. The majority (44%) of patients belonged to lower socioeconomic strata. Higher frequencies of severe depression (28%), extremely severe anxiety (26%), and mild stress (17%) were noted in the study participants. On the Tukey test, depression score was higher in patients of ROM compared to COVID (with ROM) (p-value= 0.016). On Tukey analysis, anxiety score was significantly higher in ROM patients compared to COVID (with ROM) patients (p-value = 0.018). Coping scores were significantly higher in COVID (with ROM) patients compared to ROM patients (p value = 0.035). Mild to moderate visual disability was noted in the study participants.  Conclusion: The current study reflects the association of higher depression and anxiety scores in cases with ROM that indicated higher mental health needs. Early assessment, early detection, and early intervention for psychological help, along with the multidisciplinary team, helped to improve the overall psychological outcome of the affected patients.

Mucormycosis in Post Novel Corona Virus Patients: An Institutional Experience

Mucormycosis is an emerging angioinvasive fungal infection caused by ubiquitous saprophytic filamentous fungus that belongs to the class Zygomycosis. Mucormycosis or black fungus infections in patients with recent COVID-19 infections has given rise to a new epidemic during the second wave of this current COVID-19 pandemic in India. Steroid misuse, poor glycemic control, use of industrial grade oxygen, improper humidification and specific variants strains have resulted in profound immunosuppression and are attributed for the high incidence of COVID associated Mucormycosis (CAM) in India. The aims of the present study were to assess the age and gender specific incidence of CAM, the utility of special stains (PAS and GMS) for diagnosing mucormycosis (false negatives and sensitivity). In the present study emphasis was laid on identifying if there exists a correlation between host response, angioinvasion and bone invasion with mortality. The Present study is a retrospective, cross sectional analytical study taken up in the Department of Pathology, Guntur Medical College for a period of 2 months between 1st of May 2021 to 30th of June 2021. Results were tabulated in Microsoft excel 2016 and SPSS software version 14 was used for calculation of odds ratio and for performing multivariate analysis. All samples were routinely fixed using 10% buffered formalin, processed and sectioned. All the sections were stained with Haematoxylin and Eosin and also special stains for fungus like periodic acid Schiff (PAS) and Gomori Methenamine silver (GMS) were used wherever required. CAM is a serious complication after recovery from COVID-19 infection due to its high morbidity and mortality (13.7% in this series). CAM epidemiology and presentation is mostly similar to non-COVID mucormycosis seen in pre-COVID era.

Burden of Serious Fungal Infections in India

Background

Fungal disease is frequent in India, but its incidence and prevalence are unclear. This review aims at defining the frequency or burden of various fungal infections in India.

Methods

A systematic review of the literature on the PubMed, Embase, and Web of Science (WOS) databases was conducted using appropriate search strings. Deterministic modeling determined annual incidence and prevalence estimates for multiple life- and sight-threatening infections with significant morbidity.

Results

Literature searches yielded >2900 papers; 434 papers with incidence/prevalence/proportion data were analyzed. An estimated 57 251 328 of the 1 393 400 000 people in India (4.1%) suffer from a serious fungal disease. The prevalence (in millions) of recurrent vulvovaginal candidiasis is 24.3, allergic bronchopulmonary aspergillosis is 2.0, tinea capitis in school-age children is 25, severe asthma with fungal sensitization is 1.36, chronic pulmonary aspergillosis is 1.74, and chronic fungal rhinosinusitis is 1.52. The annual incidence rates of Pneumocystis pneumonia (58 400), invasive aspergillosis (250 900), mucormycosis (195 000), esophageal candidiasis in HIV (266 600), candidemia (188 000), fungal keratitis (1 017 100), and cryptococcal meningitis (11 500) were also determined. Histoplasmosis, talaromycosis, mycetoma, and chromoblastomycosis were less frequent.

Conclusions

India's fungal burden is high and underappreciated in clinical practice.

The impact of mucormycosis (black fungus) on SARS-CoV-2-infected patients: at a glance

The emergence of various diseases during the COVID-19 pandemic made health workers more attentive, and one of the new pathogens is the black fungus (mucormycosis). As a result, millions of lives have already been lost. As a result of the mutation, the virus is constantly changing its traits, including the rate of disease transmission, virulence, pathogenesis, and clinical signs. A recent analysis revealed that some COVID-19 patients were also coinfected with a fungal disease called mucormycosis (black fungus). India has already categorized the COVID-19 patient black fungus outbreak as an epidemic. Only a few reports are observed in other countries. The immune system is weakened by COVID-19 medication, rendering it more prone to illnesses like black fungus (mucormycosis). COVID-19, which is caused by a B.1.617 strain of the SARS-CoV-2 virus, has been circulating in India since April 2021. Mucormycosis is a rare fungal infection induced by exposure to a fungus called mucormycete. The most typically implicated genera are Mucor rhyzuprhizopusdia and Cunninghamella. Mucormycosis is also known as zygomycosis. The main causes of infection are soil, dumping sites, ancient building walls, and other sources of infection (reservoir words "mucormycosis" and "zygomycosis" are occasionally interchanged). Zygomycota, on the other hand, has been identified as polyphyletic and is not currently included in fungal classification systems; also, zygomycosis includes Entomophthorales, but mucormycosis does not. This current review will be focused on the etiology and virulence factors of COVID-19/mucormycosis coinfections in COVID-19-associated mucormycosis patients, as well as their prevalence, diagnosis, and treatment.

COVID-19-Associated Mucormycosis in a Tertiary Care Hospital in India: A Case Series

Mucormycosis is a disease that usually occurs in immunocompromised patients or those with uncontrolled diabetes mellitus. The second wave of the coronavirus disease 2019 (COVID-19) pandemic in India was accompanied by an unexpected rise in mucormycosis cases, ranging from the most commonly occurring Rhino-orbital-cerebral mucormycosis (ROCM) to rare cases of pulmonary and gastrointestinal mucormycosis. The majority of cases that presented to our hospital were individuals with underlying diabetes mellitus who received steroids for COVID-19 before being diagnosed with mucormycosis.

In this case series, we present five rhino-orbital-cerebral mucormycosis cases that were histopathologically positive and treated at a tertiary-care hospital in India. Magnetic resonance imaging (MRI) of all of the patients demonstrated orbital apex syndrome and diffuse or focal infiltration of the cavernous sinus. Cases were treated with anti-fungal drugs, transcutaneous retrobulbar injection of amphotericin B (TRAM B), along with appropriate surgical excision and debridement of the involved tissue.

The essential elements for successfully managing this fatal infection are control of the predisposing factors, early detection, anti-fungal drugs, and surgical debridement of the involved tissues.

Spectrum of Mucormycosis Before and During COVID-19: Epidemiology, Diagnosis, and Current Therapeutic Interventions

Purpose of Review

More than half a billion people have been infected and 6.2 million killed by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) since the start of the pandemic in 2019. Systemic glucocorticoids are a double-edged sword, on the one hand, life-saving in treating COVID-19 complications while on the other hand, potentially leading to life-and-limb-threatening opportunistic fungal infections. Mucormycosis (MM) is caused by the mucormycetes family. Although rare, it is characterized by high mortality and significant morbidity. The gross similarities observed with other fungal infections which respond to different treatment regimens have made it all the more imperative to quickly and sensitively diagnose and treat MM. This review discusses the epidemiology of MM before and during the COVID-19 pandemic, associated risk factors, COVID-19-associated MM, diagnosis, and current therapeutic interventions.

Recent Findings

There has been a widespread and worrisome trend of rising in cases of MM, worldwide, but more so in the Indian subcontinent, where it is nicknamed the “black fungus.” This upsurge has picked up the pace ever since the start of the COVID-19 pandemic. Necrosis is secondary to the angio-invasive and pro-thrombotic nature of the mold resulting in extensive lesions presenting mostly as rhino-orbital MM (ROM) and rhino-orbito-cerebral MM (ROCM). Infection is mostly observed in subjects with underlying risk factors such as uncontrolled diabetes, those receiving hematopoietic stem cell transplant, and/or on corticosteroid or immunosuppressive therapy, although it is widely suspected that other factors such as iron and zinc may play a role in the pathogenesis of MM. The “One world one guideline” strategy advocates both prophylactic anti-fungal therapy along with aggressive, prompt, and individualized treatment with anti-fungal drugs such as amphotericin B in addition to vigorous surgical intervention. High-risk groups need particularly rapid diagnosis although empirical anti-fungal therapy may not be delayed. Speeding diagnostic turnaround times are essential to institute early therapy, and there is much scope for newer modalities such as PCR, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and whole-genome sequencing in such endeavors. The results of strict monitoring of blood glucose levels along with rational and limited use of steroids and immunomodulatory drugs have proven to be a significant preventive measure.

Summary

The significant rise in cases of MM worldwide has necessitated viewing each case with a strong index of suspicion. Adoption of rapid diagnostics, early antifungal therapy, and prompt surgical interventions are essential, while high-risk groups need particular focused care which may include prophylactic anti-fungal therapy, limited steroid use, and meticulous control of the underlying disease. Developing quicker and more sensitive diagnostic modalities has great potential to improve the detection and management of MM.

A Review on Medicinally Important Heterocyclic Compounds

Heterocyclic compounds account for the most prominent and diverse class of organic compounds. A significant number of heterocyclic compounds have been synthesized up to this point. Heterocyclic compounds are rapidly increasing in number due to extensive synthetic research and also their synthetic utility. Such compounds have a wide range of uses in the field of medicinal chemistry. Dyestuff, sanitizers, corrosion inhibitors, antioxidants, and copolymer synthesis are additional well-known applications. There are always distinguishing characteristics of an efficient approach for producing newly discovered heterocyclic compounds and their moieties. According to prior research, more than 90% of medicines containing heterocyclic compounds have been developed after the obtainment of a thorough scientific grasp of the biological system. It was discovered in the neoteric developments of heterocyclic compounds that these play a vital role in curative chemistry, and exert anticancer, anti-inflammatory, antifungal, antiallergic, antibacterial, anti-HIV, antiviral, anti-convulsant, and other biological activities. The present article provides detailed information regarding such heterocyclic compounds.

Risk factors for Coronavirus disease-associated mucormycosis

BACKGROUND

The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies.

METHODS

We performed a case-control study comparing cases diagnosed with CAM and taking controls as recovered COVID 19 patients who did not develop mucormycosis. Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Multivariate regression analysis was used to identify independent predictors.

RESULTS

A total of 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean of 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases had conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95% CI 1.1-11), use of systemic steroids (aOR 7.7, 95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs. no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6, 95% CI 1.2-2.2). Zinc therapy was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM.

CONCLUSION

Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.

New insights on mucormycosis and its association with the COVID-19 pandemic

COVID-19 continues to cause significant fatality worldwide. Glucocorticoids prove to play essential roles in COVID-19 management; however, the extensive use of steroids together with the virus immune dysregulation may increase the danger of secondary infections with mucormycosis, an angioinvasive fungal infection. Unfortunately, a definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. In this review, we discuss the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response, risk factors, clinical presentation, diagnosis and treatment. Special emphasis is given to its association with the current COVID-19 pandemic, including latest updates on COVID-19-associated mucormycosis cases globally, with recommendations for efficacious management.

Mucormycosis Amid COVID-19 Crisis: Pathogenesis, Diagnosis, and Novel Treatment Strategies to Combat the Spread

The havoc unleashed by COVID-19 pandemic has paved way for secondary ominous fungal infections like Mucormycosis. It is caused by a class of opportunistic pathogens from the order Mucorales. Fatality rates due to this contagious infection are extremely high. Numerous clinical manifestations result in damage to multiple organs subject to the patient's underlying condition. Lack of a proper detection method and reliable treatment has made the management of this infection troublesome. Several reports studying the behavior pattern of Mucorales inside the host by modulation of its defense mechanisms have helped in understanding the pathogenesis of this angio-invasive infection. Many recent advances in diagnosis and treatment of this fungal infection have not been much beneficial. Therefore, there is a need to foster more viable strategies. This article summarizes current and imminent approaches that could aid effective management of these secondary infections in these times of global pandemic. It is foreseen that the development of newer antifungal drugs, antimicrobial peptides, and nanotechnology-based approaches for drug delivery would help combat this infection and curb its spread.

The Past, Present and Future of COVID-19 Associated Mucormycosis: A Rapid Review

Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2, which is known for the multiple mutations and forms that have rapidly spread across the world. With the imminent challenges faced by low- and middle-income countries in curbing the public health fallbacks due to limited resources, mucormycosis emerged as a fungal infection associated with high mortality. In this rapid review, we explored MEDLINE, Cochrane, Web of Science, WHO Global Database, and the search engine—Google Scholar for articles listed until July 2021 and presented a narrative synthesis of findings from 39 articles. The epidemiology, causative factors, incidence parameters, pharmacological treatment, and recommendations for low- and middle-income countries are enlisted. This study concludes that a majority of the globally reported COVID-19 associated mucormycosis cases stemmed from India. Individuals receiving systemic corticosteroids or who have a history of diabetes mellitus are more prone to contracting the disease. Public health authorities in LMIC are recommended to strengthen antifungal therapies for COVID-19 associated mucormycosis and to strategize reduction in diabetes mellitus prevalence.

Prosthetic Rehabilitation of Nose After Partial Rhinectomy in a Patient Affected with Mucormycosis: A Case Report

Mucormycosis is a fungal infection commonly seen in Indian population, in which aggressive surgical intervention to cut away the infected tissue becomes necessary. This may cause disfigurement and leave open wounds which requires prosthetic replacement for psychological benefit and also protect the inner soft tissues of the patient which are exposed to the foreign bodies. Mucormycosis has shown a sudden surge in recent times associated with patients affected by Covid-19. It is a rare but serious complication which can cause loss of eye, nose and associated structures leaving the patient disfigured. The aim of this case report is to describe an economic but effective nonsurgical treatment option to restore the facial defect using acrylic resin baseplate to enhance retention by using the available undercuts and was packed using silicone material. The prosthesis was retained mechanically and omitted the use of any retentive aids such as the use of spectacles or implants.

Risk Based Decision Algorithms for Management of COVID-19 Associated Rhino-orbital Mucormycosis

Introduction

COVID associated mucormycosis is a challenging problem with significant morbidity and mortality implications. COVID affliction, pre-existing medical conditions especially diabetes and steroid prescription are supposed contributors for development of this opportunistic fungal infection. Surgery remains the mainstay of treatment with adequate post-op anti-fungal therapy.

Materials and methods

This is a retrospective analysis of prospectively maintained database of all surgical patients between March-May 2021 at a single centre. Prognosticators such as severity of COVID affliction, use of steroids, extent of rhino-orbital mucormycosis, extent of surgery and outcomes were studied. Descriptive statistics was used to analyse frequency of different variables and chi square test was used to analyse prognostic factors. P value < 0.05 were deemed significant.

Results

74 patients with an average 30 day follow-up were included. All patients had preceding COVID infection and 71.6% were diabetic and 25.7% were diagnosed during the course of their COVID treatment. Multiple sinus involvement being most common (52.61%), 10.81% underwent orbital exenteration and 24.32% palatectomies were performed. Revision surgeries were warranted in 16.21% patients. 9 patients succumbed to disease/ underlying medical and treatment related complications.

Conclusion

We propose a risk assessment based on general condition of patient and severity of mucormycosis infection to decide appropriate strategy for surgical intervention. Early detection and timely and adequate surgery are essential pre-requisites to good outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02692-9.

Conventional PCR as a reliable method for diagnosing invasive mucormycosis in resource-limited settings

Introduction. Invasive mucormycosis (IM) is a life-threatening infection caused by fungi belonging to the order Mucorales. Histopathology, culture and radiology are the mainstay of diagnosis but lack sensitivity, leading to a delay in timely diagnosis and intervention. Recently, PCR-based approaches have been shown to be a promising method in diagnosing IM.Hypothesis/Gap Statement. Molecular-based approaches may be a valuable adjunct to standard conventional methods for diagnosing IM, especially among culture negatives and patients on antifungal therapy.Aim. In the present study we aimed to evaluate the clinical utility of panfungal and Mucorales-specific PCR for diagnosing IM from various clinical specimens.Methodology. This was a prospective study in which 239 clinically suspected cases of IM attending our tertiary care hospital from August 2015 to March 2018 were enrolled. All the cases were defined as 'proven', 'probable' or 'possible' based on EORTC/MSGERC guidelines. In addition to conventional diagnostics (KOH-calcofluor stain and culture), panfungal and Mucorales-specific PCR assays were also performed. The amplified products were sequenced for species identification. In vitro antifungal susceptibility was performed on all the culture-positive isolates.Results. Among 239 clinically suspected cases of IM, only 140 cases were diagnosed by the demonstration of aseptate ribbon-like hyphae on direct microscopy. Culture was positive in 35.7 % (54/140) of direct microscopy-positive samples. Among the proven cases (n=11), the sensitivity for both Mucorales-specific nested PCR and panfungal PCR was 100 %, but specificity was 91.9 and 73.7% respectively. In probable cases (n=129), the sensitivity of both the PCRs was 98.5 % and specificity for panfungal PCR was 73.7 and 91.9 % for Mucorales-specific PCR.Conclusion. Pan fungal PCR in combination with Mucorales-specific PCR, followed by sequencing, may play a significant role in IM diagnosis especially among those negative for both direct microscopy and culture.

Expression Patterns in Reductive Iron Assimilation and Functional Consequences during Phagocytosis of Lichtheimia corymbifera, an Emerging Cause of Mucormycosis

Iron is an essential micronutrient for most organisms and fungi are no exception. Iron uptake by fungi is facilitated by receptor-mediated internalization of siderophores, heme and reductive iron assimilation (RIA). The RIA employs three protein groups: (i) the ferric reductases (Fre5 proteins), (ii) the multicopper ferroxidases (Fet3) and (iii) the high-affinity iron permeases (Ftr1). Phenotyping under different iron concentrations revealed detrimental effects on spore swelling and hyphal formation under iron depletion, but yeast-like morphology under iron excess. Since access to iron is limited during pathogenesis, pathogens are placed under stress due to nutrient limitations. To combat this, gene duplication and differential gene expression of key iron uptake genes are utilized to acquire iron against the deleterious effects of iron depletion. In the genome of the human pathogenic fungus L. corymbifera, three, four and three copies were identified for FRE5, FTR1 and FET3 genes, respectively. As in other fungi, FET3 and FTR1 are syntenic and co-expressed in L. corymbifera. Expression of FRE5, FTR1 and FET3 genes is highly up-regulated during iron limitation (Fe-), but lower during iron excess (Fe+). Fe- dependent upregulation of gene expression takes place in LcFRE5 II and III, LcFTR1 I and II, as well as LcFET3 I and II suggesting a functional role in pathogenesis. The syntenic LcFTR1 I–LcFET3 I gene pair is co-expressed during germination, whereas LcFTR1 II- LcFET3 II is co-expressed during hyphal proliferation. LcFTR1 I, II and IV were overexpressed in Saccharomyces cerevisiae to represent high and moderate expression of intracellular transport of Fe3+, respectively. Challenge of macrophages with the yeast mutants revealed no obvious role for LcFTR1 I, but possible functions of LcFTR1 II and IVs in recognition by macrophages. RIA expression pattern was used for a new model of interaction between L. corymbifera and macrophages.

The importance of mucormycosis infections on example of Rhino Orbital Cerebral Mucormycosis

Mucormycosis is an angioinvasive fungal infection, characterized by high morbidity and mortality and is strongly dependent on the patient’s general health condition, initial site of infection, and the time from diagnosis to treatment commencement. It has been reported that the occurrence of mucormycosis has increased rapidly, also among immunocompetent patients. Moreover, the rise in number is expected to continue. Among all clinical manifestations of mucormycosis, the rhino-orbital-cerebral type (ROCM) is the most common. The aim of this article is to increase the awareness of mucoral infections, especially ROCM, and to describe its first symptoms, as proper treatment requires immediate surgical and medical intervention.

Epidemiology of Mucormycosis in India

Mucormycosis is an angioinvasive disease caused by saprophytic fungi of the order Mucorales. The exact incidence of mucormycosis in India is unknown due to the lack of population-based studies. The estimated prevalence of mucormycosis is around 70 times higher in India than that in global data. Diabetes mellitus is the most common risk factor, followed by haematological malignancy and solid-organ transplant. Patients with postpulmonary tuberculosis and chronic kidney disease are at additional risk of developing mucormycosis in this country. Trauma is a risk factor for cutaneous mucormycosis. Isolated renal mucormycosis in an immunocompetent host is a unique entity in India. Though Rhizopus arrhizus is the most common etiological agent of mucormycosis in this country, infections due to Rhizopus microsporus, Rhizopus homothallicus, and Apophysomyces variabilis are rising. Occasionally, Saksenaea erythrospora, Mucor irregularis, and Thamnostylum lucknowense are isolated. Though awareness of the disease has increased among treating physicians, disease-associated morbidity and mortality are still high, as patients seek medical attention late in the disease process and given the low affordability for therapy. In conclusion, the rise in the number of cases, the emergence of new risk factors and causative agents, and the challenges in managing the disease are important concerns with mucormycosis in India.

An implant-supported prosthetic rehabilitation of a patient with a bilateral subtotal maxillectomy defect secondary to rhino-orbital-cerebral mucormycosis: A clinical report of a graftless approach

This clinical report presents the rehabilitation of extensive hard and soft tissue defects caused by rhino-orbital-cerebral mucormycosis as a result of untreated diabetes mellitus. The patient underwent subtotal maxillectomy and was rehabilitated with an implant-supported maxillofacial prosthesis with zygomatic and pterygoid implants by following an immediate loading protocol.

Thoracic mucormycosis in immunocompetent patients

BACKGROUND

Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes.

METHODS

We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm.

RESULTS

The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment.

CONCLUSION

Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

Comparative immunopathogenesis in a murine model of inhalative infection with the mucormycetes Lichtheimia corymbifera and Rhizopus arrhizus

Pathogenic mucormycetes induce diseases with considerable morbidity and mortality in immunocompromised patients. Virulence data comparing different Mucorales species and various underlying risk factors are limited. We therefore compared the pathogenesis of inhalative infection by Rhizopus (R.) arrhizus and Lichtheimia (L.) corymbifera in murine models for predominant risk factors for onset of infection. Mice with diabetes or treated with cyclophosphamide or cortisone acetate were challenged via the intranasal route with an isolate of R. arrhizus or L. corymbifera, respectively. Clinical, immunological and inflammation parameters as well as efficacy of posaconazole prophylaxis were monitored over 14 days. Whereas immunocompetent mice showed no clinical symptoms after mucormycete infection, mice treated with either cyclophosphamide (CP) or cortisone acetate (CA) were highly susceptible. Animals infected with the isolate of R. arrhizus showed prolonged survival and lower mortality, compared to those exposed to the L. corymbifera isolate. This lower virulence of R. arrhizus was risk factor-dependent, since diabetic mice died only after infection with Rhizopus, whereas all Lichtheimia-infected diabetic animals survived. Under posaconazole prophylaxis, both mucormycetes were able to establish breakthrough infections in CA- and CP-treated mice, but the course of infection was significantly delayed. Detailed analysis revealed that susceptibility of CA- and CP-treated mice could not be mimicked by exclusive lack or downmodulation of neutrophils, platelets or complement, but can be supposed to be the consequence of a broad immunosuppressive effect induced by the drugs. Both Lichtheimia corymbifera and Rhizopus arrhizus induce invasive mycoses in immunocompromised hosts after inhalative infection. Key parameters such as virulence and immunopathogenesis vary strongly according to fungal species and underlying risk group. Selected neutropenia is no sufficient risk factor for onset of inhalative mucormycosis.

Isolated Renal Mucormycosis in Immunocompetent Hosts: Clinical Spectrum and Management Approach

Isolated renal mucormycosis in immunocompetent hosts is a rare entity. We present the largest case series of isolated renal mucormycosis in immunocompetent hosts. Retrospective data of isolated renal mucormycosis from March 2012 to June 2017 was reviewed. Fifteen patients of isolated renal mucormycosis were identified. Contrast-enhanced computed tomography scan showed enlarged globular kidneys with decreased or patchy enhancement, perinephric stranding and thickened Gerota's fascia in all patients. Ten patients with unilateral involvement underwent nephrectomy and two of four patients with bilateral renal mucormycosis underwent bilateral nephrectomy. Two patients were managed with intravenous antifungal therapy alone. Overall, the mortality rate in our series was 40% (6/15). Isolated renal mucormycosis in healthy immunocompetent hosts is an emerging new entity. Prompt diagnosis based on the characteristic clinical and radiological picture and starting high-dose antifungal therapy at least 24 hours before surgical debridement offer the best chance of survival in these patients.

Global Epidemiology of Mucormycosis

Mucormycosis is an angio-invasive fungal infection, associated with high morbidity and mortality. A change in the epidemiology of mucormycosis has been observed in recent years with the rise in incidence, new causative agents and susceptible population. The rise has been perceived globally, but it is very high in the Asian continent. Though diabetes mellitus overshadow all other risk factors in Asia, post-tuberculosis and chronic renal failure have emerged as new risk groups. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas, pulmonary mucormycosis in patients with haematological malignancy and transplant recipients. In immunocompetent hosts, cutaneous mucormycosis is commonly seen following trauma. The intriguing clinical entity, isolated renal mucormycosis in immunocompetent patients is only reported from China and India. A new clinical entity, indolent mucormycosis in nasal sinuses, is recently recognized. The causative agents of mucormycosis vary across different geographic locations. Though Rhizopusarrhizus is the most common agent isolated worldwide, Apophysomycesvariabilis is predominant in Asia and Lichtheimia species in Europe. The new causative agents, Rhizopus homothallicus, Mucor irregularis, and Thamnostylum lucknowense are reported from Asia. In conclusion, with the change in epidemiology of mucormycosis country-wise studies are warranted to estimate disease burden in different risk groups, analyse the clinical disease pattern and identify the new etiological agents.

Identification of Mucorales in patients with proven invasive mucormycosis by polymerase chain reaction in tissue samples

BACKGROUND

Accurate diagnosis of mucormycosis, a life-threatening fungal infection, remains a challenge for physicians.

OBJECTIVES

To identify the causative Mucorales in fresh clinical samples and formalin-fixed paraffin-embedded (FFPE) samples of patients with proven mucormycosis by molecular method.

PATIENTS/METHODS

Fresh clinical samples of patients with proven mucormycosis according to the EORTC/MSG criteria admitted between 2015 and 2017 and histopathologically proven FFPE archives collected during 2004-2007 and 2015-2017 from Mazandaran University-affiliated hospitals of northern Iran were included. Seminested PCR targeting the 18S rDNA of Mucorales and ITS region was performed, and PCR products were then sequenced.

RESULTS

While culture was positive only in 5 of 9 (56%) of fresh specimen cases, PCR was positive in all 9 (100%) histologically proven mucormycosis. Ten of 18 (56%) FFPE samples were PCR-positive. Overall, Mucorales PCR was positive in 19 of 27 (70%) samples. Mucorales species were Rhizopus arrhizus in 16 (84%) cases, R. arrhizus/Amylomyces rouxii in 2 (10.5%) cases and Rhizopus stolonifer in one case (5.5%). Among 27 mucormycosis cases, 25 (93%) cases were rhinocerebral, and 2 (7%) cases were disseminated. Diabetes mellitus (74%) and neutropaenia (63%) were the main risk factors.

CONCLUSIONS

Seminested PCR targeting 18S rDNA region of Mucorales is useful for identification of the causative agents of mucormycosis.

Issues in antifungal stewardship: an opportunity that should not be lost

Many countries have observed an increase in the incidence of invasive fungal infections (IFIs) over the past two decades with emergence of new risk factors and isolation of new fungal pathogens. Early diagnosis and appropriate antifungal treatment remain the cornerstones of successful outcomes. However, due to non-specific clinical presentations and limited availability of rapid diagnostic tests, in more than half of cases antifungal treatment is inappropriate. As a result, the emergence of antifungal resistance both in yeasts and mycelial fungi is becoming increasingly common. The Delhi Chapter of the Indian Association of Medical Microbiologists (IAMM-DC) organized a 1 day workshop in collaboration with BSAC on 10 December 2015 in New Delhi to design a road map towards the development of a robust antifungal stewardship programme in the context of conditions in India. The workshop aimed at developing a road map for optimizing better outcomes in patients with IFIs while minimizing unintended consequences of antifungal use, ultimately leading to reduced healthcare costs and prevention development of resistance to antifungals. The workshop was a conclave of all stakeholders, eminent experts from India and the UK, including clinical microbiologists, critical care specialists and infectious disease physicians. Various issues in managing IFIs were discussed, including epidemiology, diagnostic and therapeutic algorithms in different healthcare settings. At the end of the deliberations, a consensus opinion and key messages were formulated, outlining a step-by-step approach to tackling the growing incidence of IFIs and antifungal resistance, particularly in the Indian scenario.

Molecular diagnosis of rhino-orbito-cerebral mucormycosis from fresh tissue samples

PURPOSE

We aimed to evaluate a PCR-based technique for the diagnosis of mucormycosis and the identification of fungi from fresh tissue specimens in patients with rhino-orbito-cerebral-mucormycosis (ROCM).

METHODOLOGY

Fifty cases of ROCM were included in the study. Conventional identification was performed using microscopy and culture. Molecular diagnosis was performed by amplifying the ribosomal DNA using pan-fungal ITS primers and semi-nested Mucorales-specific primers of the 18S region. The amplified products were sequenced to identify the agents. The utility of PCR-RFLP of the 18S region of rDNA was evaluated to identify the Mucorales.

RESULTS

The ROCM cases were diagnosed by the demonstration of aseptate ribbon-like hyphae in biopsy specimens collected from the patients. Isolation was possible in 24 (48 %) samples. The ITS2 PCR confirmed mucormycosis in 27 cases (54 %; CI 59.4-68.2). By comparison, Mucorales-specific PCR was able to amplify DNA and the sequence enabled the identification of Mucorales speciesin all the patients. PCR-RFLP of the 18S region of rDNA could only identify the agent to genus level.

CONCLUSION

The molecular technique was able to identify Mucorales species in 26 (42 %) cases that were negative by culture. Mucorales-specific semi-nested PCR targeting the 18S region is a better technique than ITS2 PCR for diagnosis. PCR-RFLP of the 18S region helps in identification to genus level.

Evaluation of 30 cases of mucormycosis at a university hospital in Iran

Mucormycosis is a deadly invasive fungal infection and mainly affects immunocompromised patients. To investigate the clinical features of patients who developed mucormycosis and to determine the parameters, which influenced the outcome following mycotic infection. The current investigation retrospectively evaluated the demographic characteristics, clinical features, therapeutic data, as well as the outcomes of treatment in all cases of proven and probable mucormycosis diagnosed from 2002 until 2016 in our hospital. A total of thirty cases were recorded. Rhizopus spp. was the predominant pathogen among the identified Mucorales (26.7%). Diabetes mellitus (46.7%) and haematological malignancy (40%), were the most common underlying diseases. With regard to predisposing factors, neutropenia (43.3%) and chemotherapy (40%) were the leading concomitant parameters. The most frequent sites of infection were lung (30%) and sinus (26.7%), whereas disseminated infection was also found in nine of 30 patients (30%). Neutropenia remained the only independent factor associated with mortality (Relative Risk=3.557, 95% CI=1.365-9.271, P=.009). Diagnostic delay -either due to delayed presentation of patients to our centre or insufficient awareness about invasive fungal infection among our clinicians- is a likely explanation for such a high mortality rate in our series.

Mucormycosis at a tertiary care centre in Gujarat, India

The prevalence of mucormycosis is reportedly high in India, although the studies are mainly from north and south India only. We analysed the mucormycosis cases at tertiary care centres of West India. We retrieved the clinical details of all the patients with probable and proven mucormycosis diagnosed at Sterling Hospital and ID clinic at Ahmedabad, Gujarat over the period from 1 January 2013 through 30 April 2015. The data were analysed to determine demography, risk factors, underlying diseases, site of infection and outcome of these patients. A total of 27 patients with the median age of 50 (16-65) years were diagnosed with mucormycosis during the period. Rhino-orbital-cerebral mucormycosis was the most common (51.9%) presentation. Majority (55.6%) of the patients had uncontrolled diabetes with or without ketoacidosis; 25.9% patients had no underlying disease and most of them (85.7%) had cutaneous mucormycosis. In this group, the mortality was 25.9% and an equal percentage of patients were lost to follow up; 14 (51.9%) patients could complete 6 weeks of amphotericin B therapy. All patients who completed antifungal therapy survived except one. Like other parts of India, uncontrolled diabetes was the predominant risk factor for mucormycosis in our group. Patients completing 6 weeks of amphotericin B treatment were likely to survive.

Mucormycosis in Iran: a systematic review

Fungi in the order Mucorales cause acute, invasive and frequently fatal infections in susceptible patients. This study aimed to perform a systematic review of all reported mucormycosis cases during the last 25 years in Iran. After a comprehensive literature search, we identified 98 cases in Iran from 1990-2015. The mean patient age was 39.8 ± 19.2 years. Diabetes was the most common underlying condition (47.9%), and 22.4% of the patients underwent solid organ or bone marrow transplantation. The most common clinical forms of mucormycosis were rhinocerebral (48.9%), pulmonary (9.2%) and cutaneous (9.2%). Eight cases of disseminated disease were identified. Overall mortality in the identified cases was 40.8%, with the highest mortality rate in patients diagnosed with disseminated infection (75%). The mortality rate in rhinocerebral infection patients was significantly lower (45.8%). Rhinocerebral infection was the most common clinical manifestation in diabetes patients (72.9%). Patients were diagnosed using various methods including histopathology (85.7%), microscopy (12.3%) and culture (2.0%). Rhizopus species were the most prevalent (51.7%), followed by Mucor species (17.2%). Sixty-nine patients were treated with a combination of surgery and antifungal therapy (resulting survival rate, 66.7%). Owing to the high mortality rate of advanced mucormycosis, early diagnosis and treatment may significantly improve survival rates. Therefore, increased monitoring and awareness of this life-threatening disease is critical.

Mucormycosis in India: unique features

Mucormycosis remains a devastating invasive fungal infection, with high mortality rates even after active management. The disease is being reported at an alarming frequency over the past decades from India. Indian mucormycosis has certain unique features. Rhino-orbito-cerebral presentation associated with uncontrolled diabetes is the predominant characteristic. Isolated renal mucormycosis has emerged as a new clinical entity. Apophysomyces elegans and Rhizopus homothallicus are emerging species in this region and uncommon agents such as Mucor irregularis and Thamnostylum lucknowense are also being reported. This review focuses on these distinct features of mucormycosis observed in India.