Nosocomial cutaneous zygomycosis in a patient with diabetic ketoacidosis

Management of Invasive Infections in Diabetes Mellitus: A Comprehensive Review

Patients with diabetes often have more invasive infections, which may lead to an increase in morbidity. The hyperglycaemic environment promotes immune dysfunction (such as the deterioration of neutrophil activity, antioxidant system suppression, and compromised innate immunity), micro- and microangiopathies, and neuropathy. A greater number of medical interventions leads to a higher frequency of infections in diabetic patients. Diabetic individuals are susceptible to certain conditions, such as rhino-cerebral mucormycosis or aspergillosis infection. Infections may either be the primary symptom of diabetes mellitus or act as triggers in the intrinsic effects of the disease, such as diabetic ketoacidosis and hypoglycaemia, in addition to increasing morbidity. A thorough diagnosis of the severity and origin of the infection is necessary for effective treatment, which often entails surgery and extensive antibiotic use. Examining the significant issue of infection in individuals with diabetes is crucial. Comprehensive research should examine why infections are more common amongst diabetics and what the preventive treatment strategies could be.

Infection prevention practices and the use of medical tapes

BACKGROUND

Medical tapes are ubiquitous in healthcare and there are currently no guidelines for their storage and use. Tapes cannot be cleaned or disinfected; yet, several clinicians may use a given roll for any number of patients. Reports of tape contamination associated with clinical infection have been published.

PURPOSE

We reviewed the literature reporting microbiological studies, case reports of infections, and nosocomial outbreaks associated with the use of medical tapes and other adhesive devices to assess the prevalence of this problem.

METHODS

We conducted a literature search for cross-contamination due to medical tape use in 6 databases in June 2020 using indexing terms for surgical tape, adhesive agent, adhesives or the keyword for tape. We compiled available evidence on tape contamination as a cause for healthcare-associated infections (HAIs).

MAIN FINDINGS

Forty-two publications reported relevant microbiological studies, case reports of infections, and/or nosocomial outbreaks. Results demonstrated that tape rolls handled with questionable practices can harbor pathogens. Some studies showed the association between contaminated tape and HAIs, which in some cases even led to death.

CONCLUSIONS

The time has come to establish national guidelines to help reduce the risk of cross-contamination from medical tapes. We offer suggested elements for these guidelines. The COVID-19 pandemic brings greater scrutiny to eliminate any avoidable cause of infection transmission.

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.

Mucormycosis in Cairo, Egypt: review of 10 reported cases

We report on 10 cases of mucormycosis, as defined by The European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG) standards of invasive fungal diseases, among patients with a recent history of neutropenia, prolonged use of corticosteroids and treatment with immunosuppressants. They were all observed at the Ain Shams University Specialized Hospital in Cairo, Egypt, during the year 2010. These cases were categorized as 50% proven and 50% probable, with none considered to be possible mucormycosis. The median age of the patients discussed in this report was 50 years (range 22-68 years), of which 80% were male and 20% were female. Uncontrolled diabetes with ketoacidosis was noted in 60% of cases, while 40% of the patients had undergone liver transplantations. Pulmonary mucormycosis was the predominant presentation as it was noted in 80% of cases, but there was only 20% sinus involvement. Members of the genus Lichtheimia were the most common etiologic agents (40% of all cases), whereas Rhizopus ssp. were recovered from 30% of cases, Syncephalastrum spp. in 20%, and 10% of patients were infected with Rhizomucor. Liposomal formulation of amphotericin B (LAMB) was successfully used to treat all the cases described in this report. We concluded that the incidence of mucormycosis was relatively high during the study period in this one-center study and that additional studies looking into the diagnosis and the control of mucormycosis in Egypt are required.

First case report of bloodstream infection by Rhizomucor pusillus in a child with hemophagocytic lymphohistiocytosis

We describe an unusual presentation of fatal infection due to Rhizomucor pusillus bloodstream infection in a 12-year old pediatric patient recently diagnosed with hemophagocytic lymphohistiocytosis. R. pusillus was isolated from one blood culture drawn on Day 11 of hospitalization.

Global epidemiology of cutaneous zygomycosis. Clin Dermatol. 2012;30:628-632. [PMID: 23068150 DOI: 10.1016/j.clindermatol.2012.01.010]

The large majority of cases reported worldwide as zygomycosis are infections caused by fungi belonging to the order Mucorales. These infections are invasive, often lethal, and they primarily affect immunocompromised patients. Cutaneous zygomycosis is the third most common clinical presentation, after sinusitis and pulmonary disease. Most patients with cutaneous zygomycosis have underlying diseases, such as hematological malignancies and diabetes mellitus, or have received solid organ transplantation, but a large proportion of these patients are immunocompetent. Trauma is an important mode of acquiring the disease. The disease can be very invasive locally and penetrate from the cutaneous and subcutaneous tissues into the adjacent fat, muscle, fascia, and bone. The diagnosis of cutaneous zygomycosis is often difficult because of the nonspecific findings of the infection. The clinician must have a high degree of suspicion and use all available diagnostic tools, because early diagnosis leads to an improved outcome. The treatment of zygomycosis is multimodal and consists of surgical debridement, use of antifungal drugs, and reversal of underlying risk factors, when possible. The main antifungal drug used in the treatment of zygomycosis is amphotericin B. Posaconazole is sometimes used for salvage treatment, as continuation of treatment after initial administration of amphotericin B, or in combination. The mortality of cutaneous zygomycosis is lower in comparison with other forms of the disease, but it is still significant. When the disease is localized, mortality still ranges from 4% to 10%.

Primary cutaneous zygomycosis in India

Cutaneous zygomycosis remains underdiagnosed despite being frequently encountered. Delay in the diagnosis contributes to delay in treatment, and a resultant high morbidity and mortality. A retrospective analysis of the reported cases of cutaneous zygomycosis from India was made using various search engines and cross-referencing from available manuscripts. A total of 42 publications from India on the topic were identified, since the first reported case of primary cutaneous zygomycosis by Veliath et al. (1976). There are 130 described cases of cutaneous zygomycosis with an overall mortality of 35 %. The commonest zygomycete identified was Apophysomyces elegans, and the commonest predisposing factor was breach of the skin. Surprisingly, diabetes was reported only in 36 cases (27.69 %). It is important to be aware of this unusual but fatal infection in order to manage it properly and have a good outcome.