[Incidence of endomycoses in the autopsy material of the Berlin Charité Hospital]

Angioinvasive mucormycosis in burn intensive care units: A case report and review of literature

BACKGROUND

Mucormycosis is a rare, rapidly progressive and often fatal fungal infection. The rarity of the condition lends itself to unfamiliarity, delayed treatment, and poor outcomes. Diagnosis of fungal infections early enough to enable appropriate treatment occurs in less than half of affected patients.

CASE SUMMARY

An 11-year-old girl with a history of 15% total body surface area scald burns involving both lower limbs progressed to develop angioinvasive mucormycosis. This further led to a thrombosis of the right external iliac artery and vein and rapidly progressive necrosis of surrounding soft tissues. She also had dextrocardia and patent foramen ovale. A right hip disarticulation and serial aggressive debridements were performed but she went on to develop systemic sepsis with multisystem involvement and succumbed to the infection. Pathology revealed mucor species with extensive vascular invasion.

CONCLUSION

This case highlights the importance of maintaining vigilance for mycotic infections and acting appropriately when there are signs of fulminant wound infection.

Focusing COVID-19-associated mucormycosis: a major threat to immunocompromised COVID-19

COVID-19 disease has been identified to cause remarkable increase of mucormycosis infection cases in India, with the majority of cases being observed in individuals recovering from COVID-19. Mucormycosis has emanated as an outcome of the recent COVID-19 pandemic outbreak as rapidly developing fatal illness which was acquired by Mucorales fungus which is a subcategory of molds known as mucormycetes. Mucormycosis is one of the serious, sporadic mycotic illnesses which is a great threat to immunocompromised COVID-19 patients and affects people of all ages, including children with COVID-19 infections. This is associated with tissue damaging property and, therefore, causes serious clinical complications and elevated death rate. The COVID-19-associated mucormycosis or "black fungus" are the terms used interchangeably. The rapid growth of tissue necrosis presenting as "rhino-orbital-cerebral, pulmonary, cutaneous, gastrointestinal, and disseminated disease" are various clinical forms of mucormycosis. The patient's prognosis and survival can be improved with proper surgeries using an endoscopic approach for local tissue protection in conjunction with course of appropriate conventional antifungal drug like Amphotericin-B and novel drugs like Rezafungin, encochleated Amphotericin B, Orolofim, and SCY-078 which have been explored in last few years. This review provides an overview of mucormycosis including its epidemiology, pathophysiology, risk factors, its clinical forms, and therapeutic approaches for disease management like antifungal therapy, surgical debridement, and iron chelators. The published patents and ongoing clinical trials related to mucormycosis have also been mentioned in this review.

Cutaneous mucormycosis postcosmetic surgery: A case report and review of the literature

BACKGROUND

Mucormycosis is a rare, aggressive, and life-threatening infection that is caused by organisms belonging to the order Mucorales. It is usually acquired through direct means and virtually always affects immunocompromised patients with the port of entry reflecting the site of infection, in this case, cutaneous. Unlike other mucormycoses, patients affected by Apophysomyces elegans (A elegans) are known to be immunocompetent. This locally aggressive disease penetrates through different tissue plains invading adjacent muscles, fascia, and even bone causing extensive morbidity and may prove fatal if treated inadequately. Cutaneous mucormycosis is associated with disruption of cutaneous barriers such as trauma. However, rarely, it may be iatrogenic. No cases have been previously reported postcosmetic surgery, especially one that is so commonly performed, lipofilling.

CASE REPORT

The patient is a, previously healthy, 41-year-old middle-eastern female who was admitted to the plastic surgery department 17 days after undergoing cosmetic surgery. She suffered from extensive tissue inflammation and necrosis in both gluteal regions. Following admission, she was initially started on empirical antimicrobial therapy which was changed to an antifungal agent, voriconazole, when preliminary microbiological results showed filamentous fungi. This was discontinued and liposomal amphotericin B was commenced when further mycological analysis identified A elegans. Furthermore, she underwent a total of 10 sessions of extensive debridement to the extent that portions of the sacrum and left femoral head became exposed. Her clinical status and wounds improved with the appropriate management and she remained an inpatient for 62 days. Subsequently, she had defects in both gluteal regions which required reconstructive surgery.

CONCLUSION

A elegans is an uncommon cause of iatrogenic cutaneous mucormycosis. A high index of clinical suspicion is required, especially in the absence of clinical improvement despite conventional methods of treatment, so that early diagnosis can be reached and the appropriate management instigated promptly in order to mitigate morbidity and mortality. Reversal of predisposing risk factors, regular extensive surgical debridement, and antifungal therapy remain the cornerstones of therapy for this life-threatening condition.

"An unusual presentation of colonic mucormycosis mimicking carcinoma colon- a surgeon's perspective"

INTRODUCTION

Mucormycosis caused by order mucorales, an ubiquitous saprophytic mold found in soil and organic matter worldwide, is a rare but invasive opportunistic fungal infection. Gastrointestinal mucormycosis is the most uncommon clinical presentation being particularly rare, accounted for 4-7% of all cases.

PRESENTATION OF CASE

We report an unusual presentation of mucormycosis of ascending colon that was simulating carcinoma colon.

DISCUSSION

GI mucormycosis most commonly involves the stomach (57.5%), followed by the colon (32.3%) and the ileum (6.9%). Initial presentations may be abdominal pain and distension, fever, and diarrhoea. Colonic mucormycosis presenting as a mass with altered bowel habit, melena and abdominal pain in our case is extremely difficult to differentiate it from carcinoma colon. A definitive diagnosis of mucormycosis is almost always ascertained by histopathological evidence of fungal invasion of tissue.

CONCLUSION

Knowing these unusual presentations of this disease, surgeon need to maintain a high index of suspicion and perform timely and appropriate diagnostic evaluation to improve patient outcome. Prompt diagnosis, reversal of predisposing conditions, and aggressive surgical debridement remain cornerstones of therapy for this deadly disease.

Laboratory diagnosis of mucormycosis: current status and future perspectives

ABSTRACT: 

Fungal infections caused by members of the Mucorales order are rapidly progressing and fatal. The importance of mucormycosis has grown in recent years as the number of patients with predisposing factors has increased dramatically. Clinical symptoms are elusive and conventional techniques are often insensitive and unspecific; in particular, cultures are often negative even though direct microscopy is positive. For early diagnosis of the causative agent of disease and subsequently guiding therapy to improving patients’ outcome, molecular assays are promising add-ons. This article provides an overview on current laboratory methods for diagnosing mucormycosis with a special focus on new molecular-based tools. We aim to highlight the pros and cons of various techniques at hand. Given the increase in number and the severity of these infections, molecular approaches for improved diagnosis are highly warranted.

Biology, systematics, and clinical manifestations of Zygomycota infections

Fungi cause opportunistic, nosocomial, and community-acquired infections. Among fungal infections (mycoses) zygomycoses are exceptionally severe, with a mortality rate exceeding 50%. Immunocompromised hosts, transplant recipients, and diabetic patients with uncontrolled keto-acidosis and high iron serum levels are at risk. Zygomycota are capable of infecting hosts immune to other filamentous fungi. The infection often follows a progressive pattern, with angioinvasion and metastases. Moreover, current antifungal therapy frequently has an unfavorable outcome. Zygomycota are resistant to some of the routinely used antifungals, among them azoles (except posaconazole) and echinocandins. The typical treatment consists of surgical debridement of the infected tissues accompanied by amphotericin B administration. The latter has strong nephrotoxic side effects, which make it unsuitable for prophylaxis. Delayed administration of amphotericin and excision of mycelium-containing tissues worsens survival prognoses. More than 30 species of Zygomycota are involved in human infections, among them Mucorales is the most abundant. Prognosis and treatment suggestions differ for each species, which makes fast and reliable diagnosis essential. Serum sample PCR-based identification often gives false-negative results; culture-based identification is time-consuming and not always feasible. With the dawn of Zygomycota sequencing projects significant advancement is expected, as in the case of treatment of Ascomycota infections.

Invasive mold infections in solid organ transplant recipients

Invasive mold infections represent an increasing source of morbidity and mortality in solid organ transplant recipients. Whereas there is a large literature regarding invasive molds infections in hematopoietic stem cell transplants, data in solid organ transplants are scarcer. In this comprehensive review, we focused on invasive mold infection in the specific population of solid organ transplant. We highlighted epidemiology and specific risk factors for these infections and we assessed the main clinical and imaging findings by fungi and by type of solid organ transplant. Finally, we attempted to summarize the diagnostic strategy for detection of these fungi and tried to give an overview of the current prophylaxis treatments and outcomes of these infections in solid organ transplant recipients.

Epidemiology and clinical manifestations of mucormycosis

Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the Mucorales order of the class of Zygomycetes. Mucormycosis has emerged as the third most common invasive mycosis in order of importance after candidiasis and aspergillosis in patients with hematological and allogeneic stem cell transplantation. Mucormycosis also remains a threat in patients with diabetes mellitus in the Western world. Furthermore, this disease is increasingly recognized in recently developed countries, such as India, mainly in patients with uncontrolled diabetes or trauma. Epidemiological data on this type of mycosis are scant. Therefore, our ability to determine the burden of disease is limited. Based on anatomic localization, mucormycosis can be classified as one of 6 forms: (1) rhinocerebral, (2) pulmonary, (3) cutaneous, (4) gastrointestinal, (5) disseminated, and (6) uncommon presentations. The underlying conditions can influence clinical presentation and outcome. This review describes the emerging epidemiology and the clinical manifestations of mucormycosis.

The rise of an opportunistic infection called "Invasive Zygomycosis"

Invasive zygomycosis is a devastating fungal infection seen mostly in immune-compromised patients. We present a case of a 48-year old diabetic man, with aplastic anemia, who developed severe pulmonary mucormycosis that led to his rapid demise despite early diagnosis and treatment with liposomal amphotericin B. We also conducted an extensive review of the pathogenesis of invasive zygomycosis, its history, predisposing factors, clinical aspects, diagnostic modalities, treatment options, morbidity and mortality.

Impact of zygomycosis on microbiology workload: a survey study in Spain

This multicenter, population-based study evaluated the laboratory workload produced by zygomycetes and the number of cases of zygomycosis in Spain during 2005. Less than 8% of the patients who harbored zygomycete isolates had zygomycosis. The incidence of zygomycosis (6 cases) was 0.43 cases/1,000,000 inhabitants and 0.62 cases/100,000 hospital admissions.

Nosocomial fungal infections: epidemiology, diagnosis, and treatment

Invasive fungal infections are increasingly common in the nosocomial setting. Furthermore, because risk factors for these infections continue to increase in frequency, it is likely that nosocomial fungal infections will continue to increase in frequency in the coming decades. The predominant nosocomial fungal pathogens include Candida spp., Aspergillus spp., Mucorales, Fusarium spp., and other molds, including Scedosporium spp. These infections are difficult to diagnose and cause high morbidity and mortality despite antifungal therapy. Early initiation of effective antifungal therapy and reversal of underlying host defects remain the cornerstones of treatment for nosocomial fungal infections. In recent years, new antifungal agents have become available, resulting in a change in standard of care for many of these infections. Nevertheless, the mortality of nosocomial fungal infections remains high, and new therapeutic and preventative strategies are needed.

Novel perspectives on mucormycosis: pathophysiology, presentation, and management

Mucormycosis is a life-threatening fungal infection that occurs in immunocompromised patients. These infections are becoming increasingly common, yet survival remains very poor. A greater understanding of the pathogenesis of the disease may lead to future therapies. For example, it is now clear that iron metabolism plays a central role in regulating mucormycosis infections and that deferoxamine predisposes patients to mucormycosis by inappropriately supplying the fungus with iron. These findings raise the possibility that iron chelator therapy may be useful to treat the infection as long as the chelator does not inappropriately supply the fungus with iron. Recent data support the concept that high-dose liposomal amphotericin is the preferred monotherapy for mucormycosis. However, several novel therapeutic strategies are available. These options include combination therapy using lipid-based amphotericin with an echinocandin or with an azole (largely itraconazole or posaconazole) or with all three. The underlying principles of therapy for this disease remain rapid diagnosis, reversal of underlying predisposition, and urgent surgical debridement.