An increasing trend of cutaneous zygomycosis caused byMycocladus corymbifer(formerlyAbsidia corymbifera): report of two cases and review of primary cutaneousMycocladusinfections

Rare Presentation of Nasal Mucormycosis

Nasal mucormycosis is a rare opportunistic infection of the nasal cavity and paranasal sinuses caused by saprophytic fungi which can rapidly lead to death. It usually affects individuals with poorly controlled diabetes mellitus (especially those with ketoacidosis), solid malignancies, iron overload, extensive burns, in patients undergoing treatment with glucocorticosteroid agents and in patients with neutropenia related to haematologic malignancies. Presentation of nasal mucormycosis is always very extensive, but in some patients, it can present in chronic indolent form also. Here, we present a case of 65-year old male with a history of exposed nasal bone after nasal trauma 8 months back. His diabetes was in control with oral hypoglycaemics. Debridement and local flap closure was done. Culture showed the growth of Lichtheimia corymbifera and in HPE, the fungus was seen branching at right angles. So, we conclude that the possibility of nasal mucormycosis should always be borne in mind so that early and effective treatment can be initiated on time to decrease the morbidity and mortality.

Characterization of mitogenomes from four Mucorales species and insights into pathogenicity

BACKGROUND

Mucorales, as one major order of Zygomycetes fungi, can infect human beings and cause serious consequence. We have noticed the pathogenicity of Mucorales is closely related to energy metabolism, while mitochondria play the role of energy factories in almost all biological activities.

METHODS

Virulence of M irregularis, M hiemalis, L corymbifera and R arrhizus were verified in Galleria mellonella larvae, as well as mitochondrial gene copies analysed with RT-qPCR. Mitogenomes of the four Mucorales species were sequenced based on illumina NovaSeq technology to study their characteristic features and functional regions.

RESULTS

Variant virulence of M irregularis, M hiemalis, L corymbifera and R arrhizu were verified by clinical retrospective data and our G mellonella infection models, also copies of mitochondrial genes indicated the significant associations with pathogenicity. A total of 274.18 clean reads were generated to be assembled; the complete mitogenomes of the four Mucorales species were obtained with totally different length. After the genomes annotated and compared, M irregularis was found more similar with M hiemalis than those of L corymbifera and R arrhizus, especially the small (rrns) and large (rrnl) subunits of mitochondrial ribosomal RNA (rRNA) genes. The GC content, ncRNAs and the distribution of the SNPs and InDels were also compared, and the GC content rate of fungi seems to be related to the fungal thermal adaptability. In addition, linear mitogenomes of these four Mucorales showed diverse arrangements of orf genes and directionality of some conserved gene elements.

CONCLUSION

This study uncovered the pathogenicity variances among the four Mucorales species and the relationship between their mitogenomic features and clinical pathogenicity. Further studies like spatial structure of mitochondrial genomes and the comprehensive analysis of transcription regulation are needed.

Invasive Fungal Infections Secondary to Traumatic Injury

Invasive fungal infection (IFI) is a rare but serious complication of traumatic injury. The purpose of this article is to review the epidemiology, natural history, mycology, risk factors, diagnosis, treatment, and outcomes associated with post-traumatic IFI in military and civilian populations. The epidemiology of post-traumatic IFI is poorly characterized, but incidence appears to be rising. Patients often suffer from severe injuries and require extensive medical interventions. Fungi belonging to the order Mucorales are responsible for most post-traumatic IFI in both civilian and military populations. Risk factors differ between these cohorts but include specific injury patterns and comorbidities. Diagnosis of post-traumatic IFI typically follows positive laboratory results in the appropriate clinical context. The gold standard of treatment is surgical debridement in addition to systemic antifungal therapy. Patients with post-traumatic IFI may be at greater risk of amputation, delays in wound healing, hospital complications, and death as compared to trauma patients who do not develop IFI. More research is needed to understand the factors surrounding the development and management of post-traumatic IFI to reduce the significant morbidity and mortality associated with this disease.

Mucormycoses caused by Lichtheimia species

Mucormycoses are life-threatening infections with fungi from the order Mucorales (Mucoromycotina). Although mucormycoses are uncommon compared to other fungal infections, e.g. aspergillosis and candidiasis, the number of cases is increasing especially in immunocompromised patients. Lichtheimia (formerly Absidia) species represent the second to third most common cause of mucormycoses in Europe. This mini review presents current knowledge about taxonomy and clinical relevance of Lichtheimia species. In addition, clinical presentation and risk factors will be discussed. Proper animal infection models are essential for the understanding of the pathogenesis and the identification of virulence factors of fungal pathogens. To date, several animal models have been used to study Lichtheimia infection. A brief overview of the different models and the main conclusions from the infection experiments is summarised in this review.

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%.

Wound infection caused by Lichtheimia ramosa due to a car accident

A 32-year-old immunocompetent man sustained severe traumas contaminated with organic material due to a car accident. An infection caused by Lichtheimia ramosa at the site of contamination was early diagnosed and cured by multiple surgical debridement and daily cleansing with antiseptic solution only.

Diagnosis and treatment of mucormycosis in patients with hematological malignancies: guidelines from the 3rd European Conference on Infections in Leukemia (ECIL 3)

Mucormycosis is an emerging cause of infectious morbidity and mortality in patients with hematologic malignancies. However, there are no recommendations to guide diagnosis and management. The European Conference on Infections in Leukemia assigned experts in hematology and infectious diseases to develop evidence-based recommendations for the diagnosis and treatment of mucormycosis. The guidelines were developed using the evidence criteria set forth by the American Infectious Diseases Society and the key recommendations are summarized here. In the absence of validated biomarkers, the diagnosis of mucormycosis relies on histology and/or detection of the organism by culture from involved sites with identification of the isolate at the species level (no grading). Antifungal chemotherapy, control of the underlying predisposing condition, and surgery are the cornerstones of management (level A II). Options for first-line chemotherapy of mucormycosis include liposomal amphotericin B and amphotericin B lipid complex (level B II). Posaconazole and combination therapy of liposomal amphotericin B or amphotericin B lipid complex with caspofungin are the options for second line-treatment (level B II). Surgery is recommended for rhinocerebral and skin and soft tissue disease (level A II). Reversal of underlying risk factors (diabetes control, reversal of neutropenia, discontinuation/taper of glucocorticosteroids, reduction of immunosuppressants, discontinuation of deferroxamine) is important in the treatment of mucormycosis (level A II). The duration of antifungal chemotherapy is not defined but guided by the resolution of all associated symptoms and findings (no grading). Maintenance therapy/secondary prophylaxis must be considered in persistently immunocompromised patients (no grading).

Mucormycosis treated with posaconazole: review of 96 case reports

Mucormycosis is an emerging invasive fungal infection, primarily affecting immunocompromised patients. The disease is difficult to diagnose and mortality reaches 40% even if treated adequately. Depending on site of infection and risk factors, surgical debridement in combination with systemically active antifungal drugs are the mainstay treatment strategies. Lipid-based amphotericin B is the treatment of choice for first-line therapy while posaconazole may be a promising alternative. We performed a PubMed search on reports of patients with mucormycosis treated with posaconazole. From 2003 to 2011, 96 cases have been published. Diagnosis was based on histology alone in 2 (2.1%) and microbiological evidence in 67 (69.8%), while no data on the diagnostic approach was reported in 27 (28.1%) patients. The most frequent pathogens were Rhizopus spp. (31.2%), followed by Mucor spp. (14.6%). The site of infection was predominantly rhino-orbital (38.5%, of which 43% also had central nervous system [CNS] involvement), followed by disseminated disease (22.1%). A complete response was achieved in 62 (64.6%), partial response in 7 (7.3%) patients, and stable disease in 1 (1%). Overall mortality was 24% (lacking data for three patients). In published case reports on posaconazole treatment for mucormycosis, the drug was frequently and successfully used in combination or as second line therapy.

A significant number of reported Absidia corymbifera (Lichtheimia corymbifera) infections are caused by Lichtheimia ramosa (syn. Lichtheimia hongkongensis): an emerging cause of mucormycosis

Recently, we and others reported the discovery of Lichtheimia ramosa (syn. Lichtheimia hongkongensis). We also hypothesized that a proportion of ‘Absidia corymbifera (Lichtheimia corymbifera)' reported in the literature could be L. ramosa. In this study, we characterized 13 strains that had been reported as ‘A. corymbifera (L. corymbifera)' in the literature over an 11-year period. Microscopic examination of agar block smear preparations of all 13 strains showed abundant circinate side branches and pleomorphic giant cells with finger-like projections of L. ramosa. ITS1–5.8S–ITS2 rRNA gene cluster (internal transcribed spacer (ITS)) and partial elongation factor-1alpha (EF1α) gene sequencing showed that all 13 strains were clustered with L. ramosa; partial β-actin gene sequencing showed that most of the 13 strains were clustered with L. ramosa; and partial 28S rRNA gene sequencing showed that all 13 strains were clustered with L. ramosa, but one strain of L. corymbifera (HKU25) was also clustered with other strains of L. ramosa. A significant number of reported A. corymbifera (L. corymbifera) infections are L. ramosa infections which are of global distribution. In clinical microbiology laboratories, L. ramosa should be suspected if an Absidia-like mold that possesses abundant circinate side branches on the sporangiophores and pleomorphic giant cells with finger-like projections is observed. ITS and partial EF1α gene sequencing are more reliable than partial β-actin and 28S rRNA gene sequencing for identification of the Lichtheimia species.

Posaconazole for the treatment of mucormycosis

Posaconazole (PCZ) is an orally administered, extended-spectrum triazole antifungal agent with activity against the Mucorales. This article describes the clinical and laboratory data supporting its use against this rare group of pathogens. To date, PCZ has been mostly used for salvage therapy and at present there is no strong published clinical evidence to support its role as a single agent in the treatment of mucormycosis. Further studies are required to explore its role as a single agent and in combination therapy for the management of these infections.

Zygomycosis in Immunocompromised non-Haematological Patients

Zygomycoses caused by fungi of the mucorales order (mucormycoses) are emerging fungal diseases with a high fatality rate. The most important risk factors include neutropenia or functional neutropenia, diabetic ketoacidosis, iron overload, major trauma, prolonged use of corticosteroids, illicit intravenous drug (ID) use, neonatal prematurity, malnourishment, and maybe a previous exposure to antifungal agents with no activity against zygomycetes, such as voriconazole and echinocandins.A high index of suspicion is crucial for the diagnosis, as prompt and appropriate management can considerably reduce morbidity and mortality. Suspicion index can be increased through recognition of the differential patterns of clinical presentation. In the non- haematological immunocompromised patients, mucormycosis can manifest in various clinical forms, depending on the underlying condition: mostly as rhino-orbital or rhino-cerebral in diabetes patients, pulmonary infection in patients with malignancy or solid organ transplantation, disseminated infection in iron overloaded or deferoxamine treated patients, cerebral - with no sinus involvement - in ID users, gastrointestinal in premature infants or malnourishment, and cutaneous after direct inoculation in immunocompetent individuals with trauma or burns.Treating a patient's underlying medical condition and reducing immunosuppression are essential to therapy. Rapid correction of metabolic abnormalities is mandatory in cases such as uncontrolled diabetes, and corticosteroids or other immunosuppressive drugs should be discontinued where feasible. AmphotericinB or its newer and less toxic lipid formulations are the drugs of choice regarding antifungal chemotherapy, while extensive surgical debridement is essential to reduce infected and necrotic tissue. A high number of cases could be prevented through measures including diabetes control programmes and proper pre- and post-surgical hygiene.

Lichtheimia corymbifera subcutaneous infection successfully treated with amphotericin B, early debridement, and vacuum-assisted closure

Lichtheimia corymbifera (syn. Absidia corymbifera, Mycocladus corymbifer) is an ubiquitous cosmopolitan mold that can cause primary cutaneous and deep tissue infection in healthy individuals. We report a subcutaneous L. corymbifera infection in a 13-year-old immune-competent child, with a severe traumatic injury, with a successful outcome after early diagnosis and treatment with lipid amphotericin B, early debridement, and vacuum-assisted closure (VAC).