A prospective multicenter study on mucormycosis in India: Epidemiology, diagnosis, and treatment

Mucormycosis

Mucormycosis is an aggressive and frequently lethal disease. Most patients with mucormycosis have poorly controlled diabetes mellitus and rhino-orbito-cerebral disease. Patients with hematologic malignancy and transplant recipients mostly present with rhino-orbito-cerebral or pulmonary disease. Prompt recognition of clinical symptoms and radiographic features of mucormycosis is required to establish timely diagnosis and initiate targeted therapy. Diagnosis is, historically, made by direct microscopy, culture, and pathology of biopsy tissue, but molecular methods are increasingly playing a role in establishing an earlier diagnosis. Treatment is multidisciplinary, involving early surgical intervention, antifungal therapy, and correction of underlying immune compromising risk factors when possible.

Characterization of the Spatiotemporal Localization of a Pan-Mucorales-Specific Antigen During Germination and Immunohistochemistry

BACKGROUND

Mucormycosis is an aggressive invasive fungal infection caused by molds in the order Mucorales. Early diagnosis is key to improving patient prognosis, yet it relies on insensitive culture or nonspecific histopathology. A pan-Mucorales-specific monoclonal antibody (mAb), TG11, was recently developed. Here, we investigate the spatiotemporal localization of the antigen and specificity of the mAb for immunohistochemistry.

METHODS

We used immunofluorescence microscopy to assess antigen localization in 11 Mucorales species of clinical importance and live imaging of Rhizopus arrhizus germination. Immunogold transmission electron microscopy revealed the subcellular location of mAb TG11 binding. Finally, we performed immunohistochemistry of R arrhizus in an ex vivo murine lung infection model alongside lung infection by Aspergillus fumigatus.

RESULTS

Immunofluorescence revealed TG11 antigen production at the emerging hyphal tip and along the length of growing hyphae in all Mucorales except Saksenaea. Time-lapse imaging revealed early antigen exposure during spore germination and along the growing hypha. Immunogold transmission electron microscopy confirmed mAb TG11 binding to the hyphal cell wall only. The TG11 mAb stained Mucorales but not Aspergillus hyphae in infected murine lung tissue.

CONCLUSIONS

TG11 detects early hyphal growth and has valuable potential for diagnosing mucormycosis by enhancing discriminatory detection of Mucorales in tissue.

Estimation of the pattern of ocular manifestations, risk factors, and imaging of rhino-orbital-cerebral mucormycosis in COVID-19 patients

Purpose

To estimate the pattern of ocular manifestations, as observed clinically and radiologically, and associated risk factors in cases of coronavirus disease 2019 (COVID-19)-related rhino-orbital cerebral mucormycosis (ROCM) during the second wave at presentation to the hospital in northern India.

Materials and Methods

A total of 35 patients of ROCM associated with active cases of COVID-19 or recovered cases of COVID-19 presenting to the Ophthalmology outpatient department or admitted in the COVID ward of the hospital with clinical features suggestive of ROCM. They were confirmed as mucormycosis on KOH and fungal cultures of nasal scrapings and histopathology of debrided tissue. This is an ambispective study with retrospective medical records review for COVID-19 analysis and prospective assessment of ROCM-associated COVID-19 during the second outbreak of the COVID-19 pandemic.

Results

The total patients included were 35, which ranged in the age group of 52.91+/- 11.93 years, and the male-to-female ratio was 24:11. The duration between the first positive COVID report and onset of COVID-19-associated ROCM was 9.46+/-11.63 days. The majority (82.9%; n-29) either were diabetics or had high blood glucose levels during the recent COVID-19 infection. 45.7% of patients gave a history of steroid therapy. The most common ocular clinical features were ptosis (80%) and loss of vision 48.7%, respectively. There was diffuse involvement of sinuses in 18 cases (51.4%). Staging based on magnetic resonance imaging scans showed that 7 (20%) had stage II, 20 (57.1%) had stage III, and 28.7% had stage IV disease. Ten patients had varied intracranial extension ranging from meningitis and cavernous sinus thrombophlebitis/thrombosis to brain abscess.

Conclusions

COVID-associated ROCM was very rapidly spreading and more destructive. Ptosis and loss of vision related to third nerve involvement and CRAO, respectively, were alarming signs and bad prognostic indicators to the patient. Intracranial involvement and CRAO were poor prognostic features in this type of mucormycosis.

Application of Metagenomics Next-Generation Sequencing on Diagnosis of Disseminated Infection Caused by Rhizomucor pusillus in an Acute Lymphoblastic Leukemia Patient

Background

Rhizomucor pusillus is one of the major pathogens in mucormycosis. Infection due to R. pusillus is rare and has a high mortality rate, especially disseminated mucormycosis infections. Rapid and accurate pathogen identification is important for the development of targeted antifungal therapies.

Case Presentation

We presented a case of disseminated R. pusillus infection, identified through metagenomics next-generation sequencing (mNGS), in a 4-year-old patient with acute lymphoblastic leukemia. On days 22, 23, and 28, R. pusillus was detected in bronchoalveolar lavage fluid, blood, and hydrothorax, respectively, through mNGS. The patient developed lung, pleural, and blood disseminated lesions caused by R. pusillus infection. Subsequently, the patient was treated with antifungal therapy, including posaconazole, amphotericin B, and isacconazole, with supportive treatment. However, with the continuous deterioration of symptoms, the patient's family decided to give up treatment. The patient eventually died of multiple-organ failure on day 34.

Conclusion

mNGS facilitates prompt diagnosis of disseminated R. pusillus infections. The successful application of mNGS provided a new perspective for the clinician, underscoring the technique's potential for rapid diagnostic etiology. mNGS has the capability to identify pathogens at the species level, which is a significant asset in guiding clinical medication decisions.

Laboratory practices for the diagnosis and management of mucormycosis in France, 2024

This study investigates the diagnostic practices for mucormycosis among 30 French University Hospital mycology laboratories, in 2024. All laboratories perform both direct examination and culture, with fluorescent brighteners being the most commonly used method for direct examination. While 77 % of the participating laboratories routinely identify Mucorales to the species level, with 70 % having adopted Mucorales-specific quantitative PCR, primarily for the diagnosis of invasive fungal infections. Antifungal susceptibility testing practices varied between centers, with 36.7 % of laboratories consistently performing these tests, primarily using gradient concentration strips. Amphotericin B, posaconazole, and isavuconazole were the most frequently tested antifungals. These findings highlight variations in laboratory practices and emphasize the importance of establishing uniform diagnostic and susceptibility testing methods to optimize mucormycosis management.

Epidemiological Trends of Mucormycosis in Europe, Comparison with Other Continents

Mucormycosis is an invasive fungal infection, caused by fungi of the order Mucorales, and it is associated with high morbidity and mortality. The epidemiology of mucormycosis is evolving. The incidence, underlying risk factors, clinical presentation, as well as the responsible mucoralean agents, vary by geographic region. The estimated incidence in developed countries ranges from less than 0.06 to 0.3 cases per 100,000 population per year, while in India, it reaches approximately 14 cases per 100,000 population per year, which is about 80 times higher. In European countries the estimated incidence ranges from less than 0.04 to 0.12 per 100,000 population per year. Diabetes mellitus (DM) is the leading underlying disease globally. In Europe, hematological malignancies are the most common risk factor for mucormycosis, while in Asia diabetes predominates. The rhino-cerebral form of mucormycosis is most commonly seen in patients with DM, whereas pulmonary mucormycosis in patients with hematological malignancies and transplants. The most common species globally is Rhizopus arrhizus, whereas new emerging species only occasionally cause infection in Europe. However, vigilance is required, as they may raise concerns-especially in light of climate change- due to their potential to cause serious infections in both immunocompetent and immunosuppressed individuals.

The first report of rhinosinusitis by Rhizopus delemar in a patient with severe COVID-19 in Iran: a case report

BACKGROUND

Mucormycosis is a severe and fatal fungal infection in patients with coronavirus disease 2019 caused by Mucorales. Here we present a case of a 63-year-old man with coronavirus disease 2019 infection, along with rhinosinusitis mucormycosis caused by Rhizopus delemar.

CASE PRESENTATION

A 63-year-old Iranian man suffering from a coronavirus disease 2019 infection with symptoms of cough, shortness of breath, and generalized body pain. On the basis of the clinical manifestations, such as headache, a history of black nasal discharge, nasal hypoesthesia, facial swelling, numbness, nasal obstruction, presence of necrotic lesions on the nasal passages on physical examination, and abnormal computed tomography scans of paranasal sinuses, the patient underwent surgical debridement. Direct microscopy of specimens obtained from the paranasal sinuses, and subsequent isolation and identification, revealed a rhinosinusitis mucormycosis caused by R. delemar. Despite therapeutic measures, such as sinus debridement surgery and antifungal therapy with amphotericin B injection (50 mg/day), the patient died after 35 days of hospitalization.

CONCLUSION

In this report, we present the first documented case of human infection with R. delemar in a patient with coronavirus disease 2019 infection, who also exhibited rhinosinusitis mucormycosis. R. delemar appears to be an emerging agent of rhinosinusitis mucormycosis in this region. Furthermore, prompt diagnosis and the exploration of alternative antifungal treatments, beyond amphotericin B, may be crucial for effectively managing patients with R. delemar infections.

Continuous debridement combined with short-term posaconazole therapy for cutaneous mucormycosis caused by Rhizopus oryzae infection secondary to acute myeloid leukemia: a case report

Cutaneous mucormycosis is a rare fungal infection marked by skin abscesses, swelling, necrosis, dry ulcers, and eschars. Though less fatal compared to other mucormycosis forms, delayed diagnosis and treatment in immunocompromised patients can cause the infection to spread to vital organs, becoming life-threatening. We report a case of lower extremity cutaneous mucormycosis secondary to acute myeloid leukemia, successfully managed with sustained surgical debridement and short-term oral posaconazole. This case highlights the effectiveness of surgical debridement and the potential for short-course antifungal therapy in managing cutaneous mucormycosis.

Post-COVID-19 Rhino-Orbito-Maxillary Mucormycosis Defect: Our Surgical Experience with Single Stage Delayed Reconstruction Using Free Flap

Introduction  The effect of the second wave of COVID-19 was immense in India, specifically in the form of vicious COVID-19-associated mucormycosis. A higher number of radical debridements are required for disease control in combination with antifungal drugs in cases of COVID-19-associated mucormycosis, which results in complex maxillofacial defects. We aimed to evaluate the clinical outcomes in patients with rhino-orbito-maxillary defects due to COVID-19-associated mucormycosis undergoing a single stage delayed free flap reconstruction. Methodology  This prospective, single-center, multisurgeon study was performed on eight patients with COVID-19-associated rhino-orbito-maxillary mucormycosis in the department of burns and plastic surgery. The postoperative clinical outcome was evaluated using the University of Washington Quality of Life Questionnaire for patient's quality of life (QOL), aesthetic numeric analog (ANA) scale for patient's satisfaction for aesthetics, and the functional intraoral Glasgow scale for speech and deglutition at 1 and 3 months. Results  The median age of the study patients was 40 years, with 75% of the patients being males. Diabetes mellitus (DM) was present in all the patients. Mucormycosis was diagnosed within the first 3 months of COVID-19 infection. Maxillary defect was present in 62.5% of patients, out of which 50% had bilateral maxillary defects. There was significant improvement in the QOL and the aesthetics of patients from 1 to 3 months ( p  < 0.001). Speech and deglutition were also improved at 3 months, but the difference was not statistically significant. Conclusion  Single stage delayed free flap reconstruction can be advocated in patients with COVID-19-associated rhino-orbito-maxillary mucormycosis defect as there is considerable improvement in patients' QOL, aesthetics, speech, and deglutition over a period of time.

Epidemiology and prognostic factors of mucormycosis in France (2012-2022): a cross-sectional study nested in a prospective surveillance programme

Background

Mucormycosis is a deadly invasive fungal infection recently included in the WHO priority pathogen list. Here we sought to describe epidemiological trends of mucormycosis in France, and to evaluate factors associated with mortality.

Methods

From 2012 to 2022, we implemented a nationwide prospective surveillance programme for mucormycosis in France, focusing on epidemiology, species, seasonal variations. Factors associated with 3-month mortality were studied by univariable and multivariable logistic regression.

Findings

Among 550 cases of mucormycosis, the main underlying conditions were haematological malignancy (HM, 65.1%, 358/550), trauma (8%, 44/550), diabetes (7.5%, 41/550) and solid-organ transplants (6.5%, 36/550). Site of infection was pulmonary in 52.4% (288/550), rhinocerebral in 14.5% (80/550), and cutaneo-articular in 17.1% (94/550). Main species identified were Rhizopus arrhizus (21%, 67/316), Rhizopus microsporus (13.6%, 43/316), Lichtheimia corymbifera and Mucor circinelloides (13.3%, 42/316 each), Rhizomucor pusillus (12%, 38/316), and Lichtheimia ramosa (10.8%, 34/316). We found associations between underlying condition, site of infection, and infecting species, including a previously undescribed triad of trauma, cutaneo-articular localisations, and L. ramosa/M. circinelloides. Diagnostic contribution of Polymerase Chain Reaction (PCR) increased from 16% (4/25) in 2012 to 91% (61/67) in 2022, with more than 50% of diagnoses relying solely on PCR in 2022. We also found seasonal variations with relatively more cases in autumn. Ninety-day mortality was 55.8% (276/495). Independent prognostic factors were age, diagnosis in Intensive Care Unit (ICU), and HM while diagnosis after 2015 (i.e. large implementation of PCR) and surgery were associated with reduced mortality.

Interpretation

This study reveals major mucormycosis epidemiological changes in France, with a large predominance of HM patients, and a parallel between PCR multicentre implementation and improved prognosis. We also evidence new associations between species, localisations and risk factors, as well as seasonal variations.

Funding

Recurrent financial support from Santé Publique France and Institut Pasteur.

Post debridement - Mental health and body image satisfaction among mucormycosis patients: Concern beyond surgical debridement

A sudden surge in the cases of mucormycosis forced India's coronavirus disease 2019 task force to issue evidence-based advisory on the disease. Severity was seen as comparatively high among diabetic and immuno-compromised individuals. Surgical procedures leading to scars of incision and disfigurement of the face might trigger dissatisfaction with body image and poor mental health. The study was conducted to assess mental health and level of satisfaction with body image among patients diagnosed with mucormycosis during the post-operative period. A descriptive cross-sectional study was conducted among patients diagnosed with mucormycosis who underwent surgical debridement in a tertiary care hospital among 56 patients selected by the total enumeration sampling technique. Data were collected using DASS-21 and a modified version of the body image scale. Among 56 patients, most participants (n = 43) were highly satisfied with their body image. In terms of mental health, patients reported mild levels of depression (12.5%), anxiety (7.1%), and stress (1.8%) after surgery. Body image scores were positively correlated with stress scores (r = 0.323) at P < 0.05. Among the sub-scales of mental health, scores of anxiety and stress were found to be correlated (r = 0.457) at P < 0.01. A statistical association was found between occupational status and level of depression (χ2 = 13.501, P = 0.007), body image and number of post-operative days (χ2 = 13.654, P = 0.033), and body mass index and level of depression (χ2 = 12.396, P = 0.005). Early identification of predictors of mental health disorders due to dissatisfaction with body image among post-debridement mucormycosis patients could help in planning psycho-social interventions.

Preventability and manageability of adverse drug reactions in COVID-19 with mucormycosis: An observational study

Background

In the intricate landscape of healthcare amid the COVID-19 pandemic, the emergence of mucormycosis as a severe complication posed a significant challenge to primary healthcare. This study delved into the complexities of adverse drug reactions (ADRs) in COVID-19 patients with mucormycosis undergoing treatment with conventional amphotericin B.

Methods

Ethically approved and meticulously conducted, the study scrutinized 154 ADRs in depth, shedding light on their classification, outcomes, and interventions in COVID patients with mucormycosis. A descriptive analysis was carried out to report the findings of this study.

Results

The findings revealed that a substantial proportion (85.6%) of these ADRs were manageable, emphasizing the need for vigilant monitoring and timely interventions. Notably, gender disparities surfaced, indicating potential gender-specific responses to amphotericin B. Causality assessments based on the WHO-UMC scale classified the majority of ADRs as certain, providing a robust foundation for understanding the intricate relationships between amphotericin B and the observed adverse events.

Conclusion

This research not only categorizes ADRs as preventable and manageable but also offers practical insights into their nature and the diverse strategies employed for their management. The study's outcomes underline the importance of personalized healthcare approaches that can be adopted by primary care physicians for effective patient care.

Clinical characteristics and mortality of mucormycosis in hematological malignancies: a retrospective study in Eastern China

BACKGROUND

Mucormycosis is a significant cause of morbidity and mortality in patients with hematological malignancies, but its characteristics are not fully understood. This study aimed to gain a better understanding of the clinical features of mucormycosis in patients with hematological malignancies in eastern China.

METHODS

A single-center retrospective analysis was conducted on the demographic profile, microbiology, management, and 90-day mortality of mucormycosis patients with hematological malignancies between 2018 and 2023.

RESULTS

A total of 50 cases were included in the study, consisting of 11 proven and 39 probable cases of mucormycosis. The median age of the patients was 39.98 ± 18.52 years, with 52% being male. Among the cases, 46% had acute myeloid leukemia (AML), 16% had acute lymphoblastic leukemia (ALL), and 16% had myelodysplastic syndrome. The most common manifestations of mucormycosis were pulmonary (80%), disseminated (16%), and rhinocerebral (4%). The diagnosis was confirmed through histology, culture, microscopy, and molecular diagnostic techniques. The most commonly identified fungal species were Cunninghamella (40%), Rhizopus (26%), and Rhizomucor (22%). Treatment involved antifungals in 84% of cases and surgery in 10% of cases. The 90-day mortality rate was 76%. Logistic regression analysis revealed that treatment with amphotericin B and surgery was associated with improved survival, while neutropenia and administration of voriconazole prior to diagnosis was associated with higher mortality.

CONCLUSIONS

Mucormycosis continues to have a high mortality rate in patients with hematological malignancies. Early diagnosis using various techniques, including molecular biology, along with the appropriate use of amphotericin B and surgery when possible, is vital for the successful treatment of mucormycosis.

ISCCM Position Statement on the Management of Invasive Fungal Infections in the Intensive Care Unit

Rationale

Invasive fungal infections (IFI) in the intensive care unit (ICU) are an emerging problem owing to the use of broad-spectrum antibiotics, immunosuppressive agents, and frequency of indwelling catheters. Timely diagnosis which is imperative to improve outcomes can be challenging. This position statement is aimed at understanding risk factors, providing a rational diagnostic approach, and guiding clinicians to optimize antifungal therapy.

Objectives

To update evidence on epidemiology, risk factors, diagnostic approach, antifungal initiation strategy, therapeutic interventions including site-specific infections and role of therapeutic drug monitoring in IFI in ICU and focus on some practice points relevant to these domains.

Methodology

A committee comprising critical care specialists across the country was formed and specific aspects of fungal infections and antifungal treatment were assigned to each member. They extensively reviewed the literature including the electronic databases and the international guidelines and cross-references. The information was shared and discussed over several meetings and position statements were framed to ensure their reliability and relevance in critical practice. The draft document was prepared after obtaining inputs and consensus from all the members and was reviewed by an expert in this field.

Results

The existing evidence on the management of IFI was updated and practice points were prepared under each subheading to enable critical care practitioners to streamline diagnosis and treatment strategies for patients in the ICU with additional detail on site-specific infections therapeutic drug monitoring.

Conclusion

This position statement attempts to address the management of IFI in immunocompetent and non-neutropenic ICU patients. The practice points should guide in optimization of the management of critically ill patients with suspected or proven fungal infections.

How to cite this article

Bhattacharya PK, Chakrabarti A, Sinha S, Pande R, Gupta S, Kumar AAK, et al. ISCCM Position Statement on the Management of Invasive Fungal Infections in the Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S20-S41.

Mucorales: A systematic review to inform the World Health Organization priority list of fungal pathogens

The World Health Organization, in response to the growing burden of fungal disease, established a process to develop a fungal priority pathogens list (FPPL). This systematic review aimed to evaluate the epidemiology and impact of invasive fungal disease due to Mucorales. PubMed and Web of Science were searched to identify studies published between January 1, 2011 and February 23, 2021. Studies reporting on mortality, inpatient care, complications and sequelae, antifungal susceptibility, risk factors, preventability, annual incidence, global distribution, and emergence during the study time frames were selected. Overall, 24 studies were included. Mortality rates of up to 80% were reported. Antifungal susceptibility varied across agents and species, with the minimum inhibitory concentrations lowest for amphotericin B and posaconazole. Diabetes mellitus was a common risk factor, detected in 65%-85% of patients with mucormycosis, particularly in those with rhino-orbital disease (86.9%). Break-through infection was detected in 13.6%-100% on azole or echinocandin antifungal prophylaxis. The reported prevalence rates were variable, with some studies reporting stable rates in the USA of 0.094-0.117/10 000 discharges between 2011 and 2014, whereas others reported an increase in Iran from 16.8% to 24% between 2011 and 2015. Carefully designed global surveillance studies, linking laboratory and clinical data, are required to develop clinical breakpoints to guide antifungal therapy and determine accurate estimates of complications and sequelae, annual incidence, trends, and global distribution. These data will provide robust estimates of disease burden to refine interventions and better inform future FPPL.

Causal relationship between type 1 diabetes mellitus and mycoses: a Mendelian randomization study

Background

Type 1 diabetes mellitus (T1DM) is frequently associated with various infections, including mycoses; however, the direct link between T1DM and fungal infections remains under-researched. This study utilizes a Mendelian randomization (MR) approach to investigate the potential causal relationship between T1DM and mycoses.

Methods

Genetic variants associated with T1DM were sourced from the European Bioinformatics Institute database, while those related to fungal infections such as candidiasis, pneumocystosis, and aspergillosis were obtained from the Finngen database, focusing on European populations. The primary analysis was conducted using the inverse variance weighted (IVW) method, with additional insight from Mendelian randomization Egger regression (MR-Egger). Extensive sensitivity analyses assessed the robustness, diversity, and potential horizontal pleiotropy of our findings. Multivariable Mendelian randomization (MVMR) was employed to adjust for confounders, using both MVMR-IVW and MVMR-Egger to evaluate heterogeneity and pleiotropy.

Results

Genetically, the odds of developing candidiasis increased by 5% in individuals with T1DM, as determined by the IVW method (OR = 1.05; 95% CI 1.02-1.07, p = 0.0001), with a Bonferroni-adjusted p-value of 0.008. Sensitivity analyses indicated no significant issues with heterogeneity or pleiotropy. Adjustments for confounders such as body mass index, glycated hemoglobin levels, and white blood cell counts further supported these findings (OR = 1.08; 95% CI:1.03-1.13, p = 0.0006). Additional adjustments for immune cell counts, including CD4 and CD8 T cells and natural killer cells, also demonstrated significant results (OR = 1.04; 95% CI: 1.02-1.06, p = 0.0002). No causal associations were found between T1DM and other fungal infections like aspergillosis or pneumocystosis.

Conclusion

This MR study suggests a genetic predisposition for increased susceptibility to candidiasis in individuals with T1DM. However, no causal links were established between T1DM and other mycoses, including aspergillosis and pneumocystosis.

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.

Successful Treatment of Sternal Osteomyelitis and Mediastinitis Caused by Rhizopus Following Cardiac Surgery

Sternal osteomyelitis and mediastinitis are rare yet severe complications post-cardiac surgery, often associated with significant morbidity and mortality. Fungal etiologies, particularly those caused by Rhizopus spp., are infrequent but can lead to aggressive infections. Here, we present the case of a 68-year-old male who developed sternal osteomyelitis and mediastinitis caused by Rhizopus spp. two weeks following coronary artery bypass grafting surgery. Debridement and pectoralis flap reconstruction were performed following clinical identification and confirmation with microbiological examinations and a CT scan. Prompt recognition, aggressive surgical intervention, and targeted antifungal therapy were crucial for successful management. This case underscores the importance of considering fungal pathogens, such as Rhizopus, in the differential diagnosis of post-cardiac surgery infections, as well as aggressive treatment to improve outcomes for affected patients.

Fungal diversity in the soil Mycobiome: Implications for ONE health

Today, over 300 million individuals worldwide are afflicted by severe fungal infections, many of whom will perish. Fungi, as a result of their plastic genomes have the ability to adapt to new environments and extreme conditions as a consequence of globalization, including urbanization, agricultural intensification, and, notably, climate change. Soils and the impact of these anthropogenic environmental factors can be the source of pathogenic and non-pathogenic fungi and subsequent fungal threats to public health. This underscores the growing understanding that not only is fungal diversity in the soil mycobiome a critical component of a functioning ecosystem, but also that soil microbial communities can significantly contribute to plant, animal, and human health, as underscored by the One Health concept. Collectively, this stresses the importance of investigating the soil microbiome in order to gain a deeper understanding of soil fungal ecology and its interplay with the rhizosphere microbiome, which carries significant implications for human health, animal health and environmental health.

Utility of an in-house real-time PCR in whole blood samples as a minimally invasive method for early and accurate diagnosis of invasive mould infections

INTRODUCTION

Invasive mould infections (IMIs) are a leading cause of death in patients with compromised immune systems. Proven invasive mould infection requires detection of a fungus by histopathological analysis of a biopsied specimen, sterile culture, or fungal DNA amplification by PCR in tissue. However, the clinical performance of a PCR assay on blood samples taken from patients suspected of invasive mould disease has not been fully evaluated, particularly for the differential diagnosis of invasive aspergillosis (IA) and invasive Mucormycosis (IM).

OBJECTIVES

To assess the diagnostic utility of our previously validated in-house real-time PCR in blood samples for diagnosis of invasive aspergillosis and mucormycosis in patients with suspected invasive mould infection.

METHODS

All patients with suspected invasive mould infection were prospectively enrolled from May 2021 to July 2021. Conventional fungal diagnosis was performed using tissue and respiratory samples. In-house PCR was performed on blood samples and its diagnostic performance evaluated.

RESULTS

A total of 158 cases of suspected invasive mould infection were enrolled in the study. The sensitivity and specificity of in-house PCR performed on blood samples was found to be 92.5% and 81.4% respectively for diagnosis of probable IA, and 65% and 84.62% respectively for diagnosis of proven and probable IM. It was also able to detect 3 out of 5 cases of possible IM where no other microbiological evidence of IM was obtained.

CONCLUSIONS

This assay could be helpful in minimally invasive diagnosis of IMIs for patients in whom invasive sampling is not feasible, especially as a preliminary or screening test. It can help in early diagnosis, anticipating conventional laboratory confirmation by days or weeks. Possible correlation between fungal load and mortality can help in initiating aggressive treatment for patients with high initial fungal load.

Clinical Manifestation, mNGS Based Diagnosis and Treatment of Pulmonary Mucormycosis with Rhizopus delemar in a Diabetic Patient

Pulmonary mucormycosis is a severe and often fatal disease that commonly affects patients with underlying conditions, such as diabetes. Early diagnosis and appropriate treatment are crucial for improving survival rates. However, clinical diagnosis remains challenging due to difficulty in obtaining etiological evidence. In this particular case, the patient presented with a cough-producing bloody sputum, and a chest CT revealed lesions in the right upper lobe of the lung. The patient was ultimately diagnosed with pulmonary mucormycosis caused by Rhizopus delemar through clinical bronchoscopy biopsy and metagenomic next-generation sequencing (mNGS) analysis of bronchoalveolar lavage fluid sample. Subsequently, antifungal therapy using the less toxic Amphotericin B cholesterol Organosulfate complex was initiated, improving the patient's condition. In conclusion, our findings underscore the potential of mNGS to provide an accurate and rapid etiological diagnosis of pulmonary mucormycosis, offering a foundation for treatment.

Maxillary Mucormycotic Osteonecrosis as a Manifestation of Post-COVID-19 Infection in Non-diabetic Patients: Report of Two Cases

Mucormycosis is a rare, opportunistic fungal infection prevalent in the elderly, especially in patients with uncontrolled diabetes or a compromised immune system. However, the outbreak of the pandemic declared by the World Health Organization in late 2019 increased the incidence of mucormycosis cases in COVID-19 patients due to increased steroid usage that resulted in an immunocompromised state. The current report presents two cases of oral mucormycotic osteomyelitis in patients who developed diabetes post-COVID infection, along with a review and relevant literature.

Colonic Mucormycosis in Fistulizing Crohn's Disease

Gastrointestinal mucormycosis, a rare fatal fungal infection in an immunocompromised host, affects mainly the stomach. Colonic mucormycosis is infrequent and is associated with high mortality. Perianal involvement is seen in almost one-third of patients with Crohn's disease. Perianal Crohn's disease is a particularly debilitating form of the disease, which requires multidisciplinary care. It may also require profound immunosuppression with biological agents to control disease activity. Opportunistic infections can complicate the disease course in these patients. We present a case of a middle-aged female with perianal Crohn's disease on adalimumab who developed colonic mucormycosis causing a flare in her disease activity. This patient highlights the need to increase awareness about fungal infections as a cause of disease flare in inflammatory bowel disease.

Risk factors and clinical presentation of rhino-orbital mucormycosis: Lesson learnt during Covid pandemic

Aim

To analyze the potential predisposing factors and clinical presentation of mucormycosis in patients with COVID-19.

Material and Methods

Medical records of 141 patients with COVID-19-associated mucormycosis (CAM) treated at a tertiary care center in Bihar were reviewed. The predisposing factors, clinical features, and imaging findings of mucormycosis were analyzed.

Results

The median age was 48 years (IQR, 43-60). A total of 58 patients developed concurrent CAM and 83 post-CAM. The median interval between COVID-19 and onset of CAM symptoms was 15 days (IQR, 9-16). A total of 80 patients received at-home treatment for COVID-19, and 73 had mild-to-moderate disease. While 61 patients received in-hospital treatment, 57 had severe disease. At presentation, 131 patients had hyperglycemia: 64 type 2 diabetes mellitus (DM) and 67 new-onset DM. The history of glucocorticoid use for COVID-19 was present in 125 patients; 47% were administered at home without monitoring plasma glucose. The common presenting features were toothache, periocular or facial pain, and edema. Rhino-orbital mucormycosis was the most common. Imaging revealed rhinosinusitis in all patients, including pansinusitis (68%), pterygopalatine fossa involvement (21%), cavernous sinus thrombosis (38%), brain abscess (8%), and infarct (4%). All patients received intravenous liposomal amphotericin B, and surgical debridement was performed in 113.

Conclusion

COVID-19 patients with hyperglycemia are at risk of developing CAM, irrespective of the severity. Timely recognition of symptoms and prompt initiation of therapy by primary healthcare physicians are imperative for enhancing outcomes. Additionally, glucocorticoid overuse should be avoided, and close monitoring for hyperglycemia development is warranted.

Oral mucormycosis associated with COVID-19 and diabetes mellitus: Case report and literature review

Mucormycosis is an invasive opportunistic fungal infection with high mortality, mainly detected in people with COVID-19, especially those with underlying diseases such as diabetes mellitus. Mucormycosis prevalence is 0.005 to 1.7 cases per million inhabitants, and it has been increasing in countries like India and Pakistan. This mycosis can affect different organs, and clinical manifestations reflect the transmission mechanism. Frequent forms are rhino-orbital-cerebral and pulmonary. This disease should be suspected in patients with necrotic injuries on mucous membranes or skin. We present a case of a patient with diabetes mellitus and diagnosed with oral mucormycosis associated with COVID-19.

Ophthalmic presentation and outcomes of rhino-orbito-cerebral mucormycosis during the COVID-19 pandemic: An 18-month follow-up report

PURPOSE

To investigate the long-term outcomes of COVID-19-associated rhino-orbito-cerebral mucormycosis (ROCM) patients.

METHODS

Retrospective, observational study including all COVID-19 patients who developed ROCM and were referred to our oculoplastic clinic.

RESULTS

Twenty-one patients with COVID-19-associated ROCM were included in this study. Twelve (57.1%) individuals were female with a mean age of 50.7±7.6 years (range 33-59), and nine (38.1%) were male with a mean age of 58.7±14.4 years (range 37-82). Corticosteroids were used in 85.7% of patients, and three patients received no systemic corticosteroids; 76.2% were diabetic and two of these developed new-onset diabetes mellitus (DM) after receiving corticosteroids during their treatment course. The average interval between COVID-19 and the development of ROCM in our subjects was 18.6 days (range 8-46 days). In our series of patients, decreasing vision, proptosis, and periorbital edema constituted the most prevalent presentation, seen in 52.4% of subjects. Endoscopic paranasal sinus debridement was performed a mean of 3.4 times in 95.2%, abscess drainage in one, and orbital exenteration in three (14.2%) patients. Orbital apex and bilateral paranasal sinus involvement were significantly associated with higher mortality, and the overall 18-month survival rate was 52.3%.

CONCLUSION

Based upon common factors among the COVID-19-associated ROCM patients, we presume that DM and drug-induced immunosuppression are two main factors, which may lead to a higher rate of ROCM infection in areas where fungal spores are more likely to be present, such as hospitals.

An Observational Study of Fungal Infections in COVID-19: Highlighting the Role of Mucormycosis in Tertiary Healthcare Settings

Background Fungal infections, especially mucormycosis, have remarkably surged during the coronavirus disease 2019 (COVID-19) era, especially during the second wave peak of the pandemic raising the concern of the clinicians for the admitted patients. Steroid therapy, diabetes, and other immunocompromised states are more commonly associated with COVID-19-associated mucormycosis (CAM). Aim and objective The aim of this study is to ascertain the prevalence of fungal infections amidst the second wave of the COVID-19 pandemic and discern the associated risk factors. Materials and methods During the second peak of COVID-19, samples were received in the microbiology laboratory from all clinically suspected mucormycosis patients. These samples underwent processing for potassium hydroxide (KOH) wet mount, fungal culture on Sabouraud's dextrose agar (SDA) medium, and COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) testing. All relevant clinical and associated risk factors were tabulated and analyzed. Results Among the 107 suspected cases of mucormycosis, 39 (36.4%) were confirmed positive for COVID-19 via RT-PCR, while 68 (63.6%) tested negative. Males exhibited a predominant infection rate, with the rhinocerebral system being the most commonly affected site. Significantly higher mortality rates were observed in COVID-19-associated mucormycosis (CAM) patients (33.4%) compared to those without COVID-19 (5.9%), with a notable p-value of 0.0005. CAM patients also demonstrated a higher frequency of ICU admissions (77%) compared to non-COVID-19-associated mucormycosis patients (21.4%), a statistically significant finding (p-value of 0.007). Additionally, immunocompromised states, diabetes, and the administration of oxygen therapy were identified as significant risk factors in CAM (p < 0.05). Notably, mucormycosis accounted for the majority of fungal isolates (48.27%) among COVID-19 patients. Conclusion Mucormycosis infection is more commonly seen in COVID-19-infected patients as compared to non-COVID-19 patients, especially with comorbidities such as diabetes mellitus, steroid usage, and other immunocompromised states.

Comparison Between Pre-COVID and Post-COVID Mucormycosis: A Systematic Review and Meta-analysis

Introduction

Mucormycosis has emerged as one of the most fatal complications arising due to COVID-19, though it has to be mentioned that the disease is capable of causing serious illness even on its own.

Objectives

Through this investigation, we would review the threat that mucormycosis poses, in terms of its prevalence and degree of severity both in the pre- and post-COVID world.

Materials and Methods

A comprehensive examination of the studies published in online databases turned up 207 papers, 103 of which had undergone in-depth analysis, using both inclusion and exclusion criteria, shortlisting 15 studies that were appropriate for reviewing.

Results

The incidence of mucormycosis was linked to coronavirus in 7 of the 15 studies that were chosen. The remaining eight studies had sufferers of various systemic diseases, like HIV/AIDS and diabetes.

Discussion

All the cases suffered diabetes mellitus. Regardless of the time period of the chosen article, corticosteroids and antifungal medications were administered to all patients. There were noticeable differences in terms of mortality, predisposing factors, and virulence between pre-COVID and post-COVID mucormycosis.

Summary and Conclusion

The prevalence of systemic conditions such as diabetes in cases of mucormycosis has remained the same even after the incidence of this pandemic, showing that the basic treatment modalities continue to remain the same irrespective of the damage that corona virus has caused to the sufferer, although mucormycosis arising due to COVID-19 differs from mucormycosis that was incident before the advent of the pandemic.

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.

Invasive Sinusitis Presenting with Orbital Complications in COVID Patients: Is Mucor the Only Cause?

The second wave of COVID pandemic was associated with an outbreak of Mucormycosis. The mortality rate of Mucormycosis reaches 50-80% in cases with orbital and intracranial extension (Fadda in Acta Otorhinolaryngol Ital 41:43-50, 2021). In this outbreak we found that few of these patients had bacterial invasive sinusitis mimicking fungal sinusitis. Amphotericin the only effective drug against Mucormycosis is highly toxic and expensive and not indicated in bacterial sinusitis. Our aim was to  determine the exact etiologic agent, predisposing factors and outcome of treatment of COVID associated invasive sinusitis presenting with orbital complications. It is a retrospective observational study done in 33 patients with orbital complications in COVID associated invasive sinusitis. Demographic details of the patients and clinical presentation were documented. Rhinological examination was done and a nasal swab was taken for KOH mount along with Gram`s stain and Culture and Sensitivity. All Patients underwent radiological evaluation by contrast enhanced computed tomography (CECT) or MRI. Liposomal Amphotericin B was started. Surgical debridement done. Amphotericin-B was stopped in cases reported negative for fungal elements and antibiotics administered for two weeks. Outcome of treatment was documented. A total of 33 patients were included in the study. 48.5% patients were found to have bacterial infection and 27.3% patient's fungal infections and 24.2% mixed infections.Eschar formation, necrotic tissue, erosion of the lamina papyracea was seen in both Klebsiella (33.3%) and Staphylococcal infections (16.6%) similar to Mucor and mixed infections. Persistent opthalmoplegia and deterioration of vision was associated with Mucor and mixed infections. However improvement in proptosis, ptosis, ophthalmoplegia, and vision was observed in cases associated with bacterial invasive sinusitis. Invasive bacterial sinusitis was under diagnosed during second wave of COVID. Identification of invasive bacterial sinusitis can help in de-escalation of treatment.

Mucormycosis mimicking portal hypertensive haemorrhage as a complication of alcoholic liver cirrhosis: a case report

Mucor is a rare cause of gastrointestinal ulcers. This case describes a case of mucormycosis that occurred in a patient with liver cirrhosis who was hospitalized to accept a splenectomy for traumatic splenic rupture. During the perioperative period, the patient developed upper gastrointestinal bleeding(UGIB), which was diagnosed as mucormycosis-related gastric ulcer according to gastroscopy. Patients with liver cirrhosis often get UGIB for Portal hypertension, but they also can develop UGIB for multiple other reasons, including infectious ulcers for immunosuppression. The case emphasizes the importance of excluding fungal-induced ulcer haemorrhage before diagnosing Portal hypertensive-induced variceal haemorrhage in patients with liver cirrhosis.

Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Clinical impact of metagenomic next-generation sequencing of peripheral blood for the diagnosis of invasive mucormycosis: a single-center retrospective study

IMPORTANCE

Given the high fatality rates, prompt and accurate identification of the fungal culprit is crucial, emphasizing the need for invasive mucormycosis. Unfortunately, mucormycosis lacks definitive biomarkers, depending primarily on smears, cultures, or pathology, all necessitating invasive specimen collection from the infection site. However, obtaining valid specimens early in critically ill patients poses substantial risks and challenges. Whether peripheral blood metagenomic next-generation sequencing (mNGS) can enhance early mucormycosis diagnosis, especially when direct specimen collection from the infection site is challenging, is warranted. This is a large-scale clinical study conducted to evaluate the utility and clinical impact of mNGS of peripheral blood for the diagnosis of invasive mucormycosis. We believe our study provided both novelty in translational medicine and a great value for the medical community to understand the strengths and limitations of mNGS of peripheral blood as a new diagnostic tool for the diagnosis and management of invasive mucormycosis.

Role of Amphotericin B in the Treatment of Mucormycosis

BACKGROUND

Regardless of the most recent inclusion of mold-active agents (isavuconazole and posaconazole) to antifungal agents against mucormycosis, in conjunction with amphotericin B (AMB) items, numerous uncertainties still exist regarding the treatment of this rare infection. The order Mucorales contains a variety of fungi that cause the serious but uncommon fungal illness known as mucormycosis. The moulds are prevalent in nature and typically do not pose significant risks to people. Immunocompromised people are affected by it.

OBJECTIVE

This article's primary goal is to highlight the integral role that AMB plays in this condition.

METHODS

Like sinusitis (including pansinusitis, rhino-orbital, or rhino-cerebral sinusitis) is one of the many signs and symptoms of mucormycosis. The National Center for Biotechnology Information (NCBI) produces a variety of online information resources for review articles on the topic-based mucormycosis, AMB, diagnosis of mucormycosis and the PubMed® database of citations and abstracts published in life science journals. These resources can be accessed through the NCBI home page at https://www.ncbi.nlm.nih.gov.

RESULTS

The article provides a summary of the pharmacological attributes of the various AMB compositions accessible for systemic use.

CONCLUSION

The article demonstrates the traits of the drug associated with its chemical, pharmacokinetics, stability, and other features, and illustrates their most useful characteristics for clinical application.

Fungal infections in patients after recovering from COVID-19: a systematic review

Background and aims

The presence of fungal infections has been described in patients after recovering from COVID-19. This study aims to conduct a systematic review of studies that reported fungal infections (Mucor spp., Pneumocystis jirovecii, or Aspergillus spp.) in adults after recovering from COVID-19.

Methods

We performed a systematic review through PubMed, Web of Science, OVID-Medline, Embase, and Scopus. The study selection process was performed independently and by at least two authors. We performed a risk of bias assessment using the Newcastle-Ottawa Scale for cohort and case-control studies, and the Joanna Briggs Institute's Checklists for Case Series and Case Reports.

Results

The systematic search found 33 studies meeting all inclusion criteria. There was a total population of 774 participants, ranging from 21 to 87 years. From them, 746 developed a fungal infection. In 19 studies, Mucor spp. was reported as the main mycosis. In 10 studies, P. jirovecii was reported as the main mycosis. In seven studies, Aspergillus spp. was reported as the main mycosis. Regarding the quality assessment, 12 studies were classified as low risk of bias and the remaining studies as high risk of bias.

Conclusion

Patients' clinical presentation and prognosis after recovering from COVID-19 with fungal infection differ from those reported patients with acute COVID-19 infection and those without COVID-19 infection.

Insulin and early debridement keys to survival in-COVID 19 associated mucormycosis patients(CAM)- An experience from tertiary care hospital In India

Introduction

Amid the second wave of COVID 19 India witnessed a surge of mucormycosis cases. This worsened the already existing health emergency. India a diabetic capital had all the favourable factors to support the growth of black fungus. This study was conducted with objectives of ascertaining patient characteristics, clinical type of mucormycosis, predisposing factors, predictors of survival and long term outcome of survivors.

Materials and methods

An ambispective study of COVID 19 associated mucormycosis patients admitted in mucor ward of tertiary care hospital between May 2021- August 2021 was done. Study was approved by Institute Ethical Committee. Demographic characteristics, presence of risk factors, clinical sign and symptoms, mode of diagnosis, treatment given, final outcome and long term follow up for a period of 1 year from discharge was done.

Results

367 CAM patients were included in the study. 72.5%(n = 266) were men and 27.5% (n = 101) were females. Mean age group was 51.3 years (SD 12.4 years). Most important comorbidity was diabetes( n = 320,87.2%), followed by cardiovascular disease (n = 68, 18.5%) and hypertension (n = 58,15.8%). Other predisposing factors were use of oxygen (n = 367,100%), antibiotics( n = 213,58%) and steroids (n = 272, 74.1%). Dexamethasone was the most commonly used steroid (n = 218,59.4%). Rhino orbital cerebral mucormycosis was the most common type. 83.7% patients (n = 307) survived and 16.3% (n = 60) succumbed to illness. Kaplan Meir survival analysis curve showed use of insulin (p = 0.025), early debridement ( p < 0.05) significantly increased survival rate. Similarly patients with lesions involving, face (p < 0.05) and nose (p = 0.014) had much better outcome as compared to disseminated forms. Only 96 patients remained in follow up. Of these patients no significant alteration in metabolic profile was noted and they remained euglycemic on oral hypoglycaemics.

Conclusion

Early debridement and insulin use are keys to improved survival. Oxygen, Steroids and antibiotics are the risk factors for mucormycosis. Diabetes is the most important comorbidity.

Study of rhino-orbital-cerebral mucormycosis and its correlates during COVID-19 pandemic in a tertiary eye care institute of central India

PURPOSE

To evaluate factors associated with the occurrence of ROCM in COVID-19 patients and to compare its related parameters and outcomes between active and recovered COVID-19 groups.

METHODS

A total of 35 patients of ROCM associated with COVID-19 (active and post-COVID-19) were included. This is an ambispective study with retrospective medical records review for COVID-19 analysis and prospective assessments of ROCM-associated COVID-19 during the second wave of the COVID-19 pandemic. The demographic data, clinical parameters, and outcome were recorded on MS excel sheet, and various parameters were compared between active and recovered COVID-19 groups.

RESULTS

ROCM in recovered COVID-19 group was higher (57.1%) as compared to active COVID-19 (42.9%) (P = 1.00). High occurrence of ROCM was seen in those who had a history of hospitalization due to severity of COVID-19 (n 33, 94.28%), oxygen support (77.14), and received systemic steroids (82.9%). The most common comorbidity was diabetes mellitus (82.9%), and new-onset hyperglycemia was noticed in 17.1% of patients. Exenteration (28.6%) was performed in severe cases who had stage IV ROCM, bilateral, and CNS involvement (RR = 7.2, 95% CI: 2.91 to 18.00). The risk of globe exenteration was 1.35 (0.7-2.29) times higher in recovered COVID-19 group, and mortality was 1.76 (0.72-3.36) times higher in active COVID-19 group.

CONCLUSION

Monitored use of systemic steroids and the prompt management of hyperglycemia in COVID-19 patients are important factors for favorable outcomes with reference to globe salvage and life-saving in ROCM associated with COVID-19. Even recovered COVID-19 patients should be observed for persistent hyperglycemia and occurrence of ROCM.

Clinical, Demographic, and Oral Presentations of COVID-19 Associated Mucormycosis from a Tertiary Care Hospital in India: A Cross-Sectional Study

Background

The black fungus, mucormycosis, is on the list of lethal complications reported in recent times in COVID patients.

Methodology

This cross-sectional study included all cases of post-COVID-19 mucormycosis. Patients' demographics, clinical presentations, and general health information were collected using a pre-designed form.

Results

The study included 171 participants with the mean (SD) age as 49 (10) years with the sex distribution as 71% (122/171) male and 29% (49/122) females. About half of the admitted patients (47%) were known cases of Diabetes Mellitus type II with a median (IQR) Glycosylated Haemoglobin (HbA1c) of 9.1% (7-11.1%). Only 28% (48/171) had received the first COVID vaccination, and 2.9% (5/171) were fully vaccinated with two doses. During COVID-19, 76% (130/171) required hospitalisation for a mean (SD) stay of 11 (6.4) days. Eighty percent of the patients (136/171) received steroids during therapy, while 87% (150/171) and 51% (88/171) received antibiotics and antivirals, respectively. Oxygen was administered to 71% of hospitalised patients (120/171), with 39.1% (47/120) receiving it for more than 7 days. About the development of the first symptoms of mucormycosis (headache, nasal congestion, black crusts in the nose, facial pain, swelling in cheeks and eyes, and loss of vision) after being diagnosed with COVID-19, 16% (28/171) reported it within 7 days, 75% (127/171) between 8 and 30th days and 9% (16/171) after a month. On examination, 20% of mucor patients had hard palate findings, eschars, fistulas, and perforations, 38% had periodontal abscesses, and 5% reported tenderness to percussion.

Conclusion

Generally, oral manifestations involved the palate and included varying degrees of mucosal discolouration, swelling, ulcers, superficial necrotic areas, and bone exposure and necrosis with dark eschars.

Mucormycosis Epidemic in Covid Era: A Sinister Superinfection

In this study, we attempt to look at the various presentations, comorbidities and association of the recent epidemic of rhino-orbital cerebral mucormycosis with Covid-19 in central India. A prospective study of 612 patients diagnosed with mucormycosis from April to July 2021. Detailed history was taken and thorough clinical examination was done. The relation of mucormycosis with Covid-19 and other morbidities was studied. Nasal endoscopy, imaging and management findings were tabulated and analyzed. Male predominance of the disease was noted. The most common age group affected was found to be 41-50 years group having 33.1% of all patients. 83.2% patients had history of Covid-19 infection. Majority of the patients (41.6%) had mucormycosis symptoms within 1 month of Covid-19 symptom onset. Nasal symptoms predominated with 61.1% patients having one or more of the several nasal symptoms. Most common comorbidity was diabetes mellitus (75.8% cases). Nasal and sinus debridement was performed in 584 patients (95.4%). Mucormycosis turned into a widespread epidemic during the second wave of Covid-19 in India. Diabetes mellitus was the most common associated comorbidity that increased the risk of mucormycosis in patients with history of Covid-19 infection. A high index of suspicion in patients presenting with early symptoms in the context of Covid-19, along with prompt diagnosis using radiological, endoscopic and microbiological tools will help reduce mortality to a great extent. Mainstay of treatment is aggressive surgical and medical management, controlling comorbidities and adequate post-operative care.

The outcome and the risk factors of mucormycosis among patients with hematological diseases: a systematic and meta-analysis

Objectives

Mucorale has come into a significant pathogen over recent decades. Nonetheless, mucormycosis-related mortality rates among patients with hematological disorders remain unascertained. Thus, we conducted a meta-analysis to determine mortality rates of mucormycosis in patients with hematology-related conditions.

Methods

We scoured PubMed, Embase, and Web of Science for original papers exploring the intersection of Mucormycosis and Hematological Diseases (from 2000 to 2022). We scrutinized the overall mortality across three distinct periods, as well as differentiating between high-income and middle-income nations. We further evaluated the pooled mortality and the risk differential (RD) across several subgroups.

Results

The overall mortality rate for hematology patients with mucormycosis was 61%, within a 95% confidence interval (CI) of 0.54-0.68. A significant observation was that mortality rates were somewhat lower in high-income countries compared to middle-income countries (0.60 versus 0.64, p = 0.45). Importantly, we discovered that a combination of surgical and medical treatment significantly improved survival rates compared to medical treatment alone [mortality 0.49 versus 0.67, RD -0.19 (95%CI -0.38-0.00, I2 63.7%)]. As might be expected, disseminated mucormycosis posed a significantly higher risk of death compared to isolated mucormycosis [0.60 versus 0.57, RD death 0.16 (95%CI 0.03-0.28)]. Additionally, our analysis showed no discernible differences in survival rates between genders, between patients with and without breakthrough infection, between those who received mucor-active or mucor-inactive drugs prior to mucor infection, or between those on a multi-drug regimen and those on a single drug treatment.

Conclusion

Despite the high mortality rates associated with mucormycosis in patients with hematological disorders, those receiving both medical and surgical interventions, as well as those with isolated infection sites, exhibited improved survival outcomes. Conversely, factors such as gender, the presence of breakthrough infection, the use of mucor-active drugs before mucor infection, and multi-drug administration did not significantly influence patient outcomes.

Rhino-orbito-cerebral mucormycosis during Covid-19 pandemic- a prospective observational study

OBJECTIVE

An unprecedented rise in mucormycosis cases; apparently called 'an epidemic within a pandemic' was seen worldwide. Therefore, the following study was conducted to know the epidemiology, underlying risk factors, diagnostic approach, and possible outcome of mucormycosis during the Covid-19 pandemic.

METHODS

A prospective observational study was conducted on patients with a high index of clinical suspicion of mucormycosis Data about demographics, co-morbidities, laboratory investigations, radiology, management, and outcomes were collected.

RESULTS

We got 45 cases of proven Rhino-orbital-cerebral-mucormycosis (ROCM) from clinically suspected cases. Covid-19 was the most common underlying risk factor (n ​= ​41, 91.11%) followed by Diabetes mellitus (DM) (n ​= ​39; 86.67%). Steroids and oxygen usage were noted in 53.66% (n ​= ​22) and 41.46% (n ​= ​17) respectively. Among the 51 suspected cases of mucormycosis, 47 were supported by radiodiagnosis. Histopathology diagnosed the highest number of mucormycosis cases (n ​= ​44; 97.78%), followed by KOH examination (n ​= ​36; 80%) and Culture (n ​= ​28; 62.22%). The most common species isolated from the tissue samples was Rhizopus species (n ​= ​17; 60.71%), followed by Mucor species (n ​= ​7; 25%). The mortality rate was 17.14%.

CONCLUSION

DM, Covid-19, and corticosteroids are the chief underlying risk factor for ROCM. Rhizopus spp. was the most dominant etiological agent. Early diagnosis and management with combined medical & surgical intervention have a better survival rate.

Improving Diagnosis of Pulmonary Mucormycosis: Leads From a Contemporary National Study of 114 Cases

BACKGROUND

Pulmonary mucormycosis (PM) is a life-threatening invasive mold infection. Diagnosis of mucormycosis is challenging and often delayed, resulting in higher mortality.

RESEARCH QUESTION

Are the disease presentation of PM and contribution of diagnosis tools influenced by the patient's underlying condition?

STUDY DESIGN AND METHODS

All PM cases from six French teaching hospitals between 2008 and 2019 were retrospectively reviewed. Cases were defined according to updated European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria with the addition of diabetes and trauma as host factors and positive serum or tissue PCR as mycologic evidence. Thoracic CT scans were reviewed centrally.

RESULTS

A total of 114 cases of PM were recorded, including 40% with disseminated forms. Main underlying conditions were hematologic malignancy (49%), allogeneic hematopoietic stem cell transplantation (21%), and solid organ transplantation (17%). When disseminated, main dissemination sites were the liver (48%), spleen (48%), brain (44%), and kidneys (37%). Radiologic presentation included consolidation (58%), pleural effusion (52%), reversed halo sign (26%), halo sign (24%), vascular abnormalities (26%), and cavity (23%). Serum quantitative polymerase chain reaction (qPCR) was positive in 42 (79%) of 53 patients and BAL in 46 (50%) of 96 patients. Results of transthoracic lung biopsy were diagnostic in 8 (73%) of 11 patients with noncontributive BAL. Overall 90-day mortality was 59%. Patients with neutropenia more frequently displayed an angioinvasive presentation, including reversed halo sign and disseminated disease (P < .05). Serum qPCR was more contributive in patients with neutropenia (91% vs 62%; P = .02), and BAL was more contributive in patients without neutropenia (69% vs 41%; P = .02). Serum qPCR was more frequently positive in patients with a > 3 cm main lesion (91% vs 62%; P = .02). Overall, positive qPCR was associated with an early diagnosis (P = .03) and treatment onset (P = .01).

INTERPRETATION

Neutropenia and radiologic findings influence disease presentation and contribution of diagnostic tools during PM. Serum qPCR is more contributive in patients with neutropenia and BAL examination in patients without neutropenia. Results of lung biopsies are highly contributive in cases of noncontributive BAL.

A Retrospective Observational Study on the Comparison of Different Diagnostic Modalities of Post-COVID Mucormycosis

Background Mucormycosis, attributed to a group of molds known as mucormycosis, is a rare yet life-threatening fungal infection often colloquially referred to as black fungus. While its incidence notably surged during the second wave of COVID-19 infections in India, it's essential to recognize that mucormycosis was a significant concern even before the advent of the pandemic. Understanding the prevalence and characteristics of this infection in the pre-COVID era provides a crucial context for evaluating its impact and dynamics during the pandemic. Multiple diagnostic methods, such as potassium hydroxide (KOH) mount, culture, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and histopathological examination (HPE), are available for identifying this lethal infection. The primary objective of this study is to ascertain the sensitivity of various diagnostic methods for mucormycosis and to analyze the comparative effectiveness of microbiological versus histopathological diagnoses. Methods We conducted a retrospective observational study spanning six months, from May 2021 to October 2021, encompassing all mucormycosis cases meeting the inclusion criteria and diagnosed via histopathological examination (HPE) in the departments of pathology and microbiology. Microbiological tests were performed prior to the histopathological examinations. Sensitivity was assessed through statistical analysis, and the relationship between microbiological and histopathological diagnoses was evaluated using the chi-square test. Results Biopsy samples of 77 patients were collected, comprising 56 male and 21 female patients. Regarding age distribution, most patients fell within the 41-60 age bracket, while the smallest proportion was over 60 years old. The sensitivity and specificity of histopathological diagnosis, confirmed with periodic acid-Schiff (PAS) and Grocott-Gomori's methenamine silver (GMS) staining, both recorded a flawless 100%. KOH mount sensitivity stood at 88.3%, while fungal culture and MALDI-TOF exhibited sensitivities of 75.3%. Histopathological analysis revealed that 17% of cases displayed minimal fungal hyphae alongside necrotic tissue, whereas 58% exhibited abundant fungal hyphae accompanied by inflammatory cells. Additionally, absolute neutrophilia was observed in 55% of cases. Conclusions In our study, histopathology and KOH mount emerged as not only compassionate but also cost-effective diagnostic tools for identifying mucormycosis. The economic aspect of these diagnostic methods is highlighted in the results section to provide a comprehensive understanding of their cost-effectiveness. Additionally, we utilized MALDI-TOF MS as a straightforward, economically viable, and expeditious method specifically for confirming the fungal subtype in mucormycosis cases. The rationale behind choosing either MALDI-TOF MS or KOH for the diagnosis is elucidated, contributing to a clearer interpretation of our diagnostic approach. Furthermore, our findings indicate that absolute neutrophilia consistently manifests in 55% of mucormycosis cases.

Factors affecting clinical outcome in COVID-associated rhino-orbito-cerebral mucormycosis (CAROM) patients-An ambispective, single-arm, observational study

BACKGROUND

COVID-associated Rhino-Orbito-Cerebral Mucormycosis (CAROM) appeared as an epidemic in India during the second wave of the COVID-19 pandemic during the months of March to May 2021. Though many reports have highlighted cross sectional and short-term attributes related to CAROM, long term follow up data is sparse.

OBJECTIVE

This report aims to analyze the follow-up outcomes in consecutive patients presenting to us during the epidemic.

PATIENTS AND METHODS

This was an ambispective observational analytical study, recruiting the consecutive patients admitted to our tertiary care centre during the period of the CAROM epidemic. The mortality rate during the follow-up and various factors affecting survival were studied using univariable and multivariable statistics with the Stata 14.0 software.

RESULTS

Of the 189 patients studied, eight were lost to follow-up. The outcome analysis was performed for the 181 patients. 93.6 % (162/173) of the patients had diabetes. The All-cause mortality was 45 % (81/181), while the ROCM-specific mortality was found to be 24 % (46/181) at a median follow-up of 176 days (IQR: 21-217 days). With univariable analysis, increasing age, higher serum IL-6 levels, presence of additional comorbidities (in addition to Diabetes and hypertension), bilateral disease, skin necrosis, palatal involvement, infratemporal fossa involvement, and impaired vision/ocular movements were found to be associated with increased mortality. However, on multivariable analysis, only 1) increasing age, 2) raised serum IL-6 levels, and 3) bilateral disease were predictive of increased mortality. Surgical debridement (endoscopic, palatal removal, orbital exenteration, neurosurgical intervention) was associated with significantly reduced mortality on both univariable and multivariable analysis.

CONCLUSION

Our intermediate-term follow-up data showed advanced age at presentation, raised IL-6 levels, and bilateral sinonasal involvement to be predictive of increased mortality, while surgical debridement is significantly protective from mortality in CAROM patients.

Post-COVID-19 mucormycosis: A prospective, observational study in patients undergoing surgical treatment

Background and Aims

Post the second wave of COVID-19 in India, our institute became a dedicated center for managing COVID-19-associated mucormycosis (CAM), but there was a paucity of data regarding perioperative considerations in these patients. The objectives of present study was to describe the preoperative clinical profile, the perioperative complications and outcome of CAM patients undergoing urgent surgical debridement.

Material and Methods

This prospective observational study was conducted on CAM patients presenting for surgical debridement from July to September 2021. During preoperative visits, evaluation of extent of disease, any side effects of ongoing medical management and post-COVID-19 systemic sequalae were done. The details of anaesthetic management of these patients including airway management, intraoperative haemodynamic complications and need for perioperative blood transfusion were noted.

Results

One hundred twenty patients underwent surgical debridement; functional endoscopic sinus surgery (FESS) was carried out in 63% of patients, FESS with orbital exenteration in 17.5%, and maxillectomy in 12.5%. Diabetes mellitus was found in 70.8% and post-COVID new onset hyperglycemia in 29.1% of patients. Moderate-to-severe decline in post-COVID functional status (PCFS) scale was observed in 73.2% of patients, but with optimization, only 5.8% required ICU management. The concern during airway management was primarily difficulty in mask ventilation (17.5%). Intraoperatively, hemodynamic adverse events responded to conventional treatment for hypotension, judicious use of fluids and blood transfusion. Perioperatively, 10.8% of patients required blood transfusion and 4.2% of patients did not survive. Non-surviving patients were older, with a more aggressive involvement of CAM, and had comorbidities and a greater decline in functional capacity.

Conclusion

A majority of patients reported a moderate-to-severe decline in PCFS that required a preoperative multisystem optimization and a tailored anesthetic approach for a successful perioperative outcome.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study

Background and Aims

A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients.

Material and Methods

This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted.

Results

The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%).

Conclusion

Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

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.

Emergence of Rhino-Orbito-Cerebral Mucormycosis in Peru: Impact of the COVID-19 Pandemic

Introduction Mucormycosis is an invasive fungal infection caused by Mucorales that has been increasingly recognized over the years, particularly during the COVID-19 pandemic. Nevertheless, in Peru, there has been limited research on this disease. This study seeks to provide insights into the demographics, clinical presentations, treatment, and outcomes of patients with mucormycosis, before and during the COVID-19 pandemic. Materials and methods We conducted a retrospective case series by reviewing the medical records of Peruvian patients hospitalized at a referral medical center between 2017 and 2021. The selection criteria included patients aged 18 years or older with clinical features of rhino-orbito-cerebral mucormycosis supported by radiological imaging. We extracted data related to risk factors for mucormycosis infection, clinical presentation, management, and hospitalization. Data analysis was performed using Stata software (StataCorp LLC, College Station, Texas, USA) to compare patient groups before and during the COVID-19 pandemic. Results Nineteen cases met our selection criteria: 11 men and eight women with an average age of 57.6 ± 10.6 years. All 19 patients had type 2 diabetes mellitus as comorbidity, with 13 cases exhibiting uncontrolled diabetes. Six patients presented before the COVID-19 pandemic, while 13 during its course. Within the group of patients diagnosed during the pandemic, nine were diagnosed with SARS-CoV-2 infection. Regarding the site of mucormycosis infection, the paranasal sinuses were predominantly involved. Survival analysis indicated that patients who developed mucormycosis during the COVID-19 pandemic, those with uncontrolled diabetes, or those who did not undergo surgery had lower probabilities of survival. Conclusion Mucormycosis is a rare infection associated with high mortality and morbidity with increased frequency during the COVID-19 pandemic. Early diagnosis, timely administration of antifungal treatment, surgery, and effective management of comorbidities can have life-saving implications. Unfortunately, despite the availability of various diagnostic tests and less toxic antifungal options such as liposomal amphotericin-B, such resources are not accessible in Peru's national hospitals.

Mucormycosis and Its Upsurge During COVID-19 Epidemic: An Updated Review

Although mucormycosis may have reached an epidemic situation during the COVID-19 pandemic, the term was much more familiar even before the COVID-19 period. The year 2020 showed an outbreak of novel coronavirus (SARS-CoV-2) which affected millions of people all over the world. One of the noticeable complications observed to be associated with this disease is mucormycosis. It is an opportunistic infection caused by members of the Order Mucorales existing worldwide and has been commonly reported as a laboratory contaminant for a long time. However, nowadays due to the changes in the host environment, they have been emerging as potent opportunistic pathogens responsible for causing primary infections or coinfections with other diseases eventually resulting in morbidity and even mortality in severe cases. Although immunocompromised patients are more susceptible to this infection, few cases have been reported in immunocompetent individuals. Various risk factors which are responsible for the acquisition of mucormycosis include diabetes mellitus type 2, ketoacidosis, hematological malignancies, organ transplants, and chemotherapy recipients. Among the various etiological agents, Rhizopus is found to be the most common, and rhino-cerebral to be the most frequent clinical presentation. As far as pathogenesis is concerned, host cell invasion, thrombosis, and necrosis are the main events in the progression of this disease. The aim of the present review is to address a complete spectrum of mucormycosis and COVID-19-associated mucormycosis (CAM) in a single article. Both global and Indian scenarios of mucormycosis are taken into account while framing this review.