The double-edged sword of systemic corticosteroid therapy in viral pneumonia: A case report and comparative review of influenza-associated mucormycosis versus COVID-19 associated mucormycosis

Case Report: Pulmonary mucormycosis caused by Rhizopus microsporus in a patient with chronic obstructive pulmonary disease

Background

We report a rare case of pulmonary mucormycosis caused by Rhizopus microsporus, which is rare in patients with chronic obstructive pulmonary disease. Rhizopus microsporus had been reported as the most common etiological agent associated with human infections, except Rhizopus oryzae in some studies.

Case presentation

We described a case of 81-year-old man with pulmonary mucormycosis caused by Rhizopus microsporus but no other apparent risk factors including diabetes. The diagnosis mainly relied on sputum cultures and clinical manifestations. Despite antifungal therapy, his condition worsened, resulting in mortality.

Conclusion

In this case, the patient had no underlying diseases such as diabetes or solid tumors. Clinicians should be aware of routine pathogenic microbiological tests of pulmonary mucormycosis in patients with chronic obstructive pulmonary disease. Early and aggressive treatment can lead to improved prognosis.

Utility of intraoperative scoring system in rhino-orbital mucormycosis as a prognostic tool

Objective

To assess the utility of an intraoperative scoring system for mucormycosis and to predict prognosis by comparing the score with postoperative outcomes.

Methods

This study was conducted among 80 patients with mucormycosis who underwent surgical management with mandatory pterygopalatine fossa and infratemporal fossa exploration. All cases were scored using our intraoperative scoring assessment tool. Postoperative outcomes in terms of favourable prognosis and mortality were evaluated and compared with demographics, clinical history and intraoperative findings.

Results

An intraoperative score of more than 25 was statistically significant in predicting mortality (p < 0.0001). In all, 86.7% of patients with a score above 25 succumbed to the disease. Statistical significance of mortality (p < 0.05) was observed in those with involvement of pterygopalatine fossa (78.9%), orbit (73.7%), infratemporal fossa (57.9%), cribriform plate (36.8%) and those with history of intake of antiviral drugs (47.4%), use of supplemental oxygen (31.6%) and renal failure (26.3%).

Conclusions

This study enabled better prediction of postoperative prognosis in mucormycosis and reiterated the importance of exploration of pterygopalatine fossa and infratemporal fossa in management and prognostication of invasive fungal sinusitis.

[Medical clinical diagnostics for indoor mould exposure - Update 2023 (AWMF Register No. 161/001)]

This article is an abridged version of the updated AWMF mould guideline "Medical clinical diagnostics in case of indoor mould exposure - Update 2023", presented in July 2023 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with German and Austrian scientific medical societies, and experts. Indoor mould growth is a potential health risk, even if a quantitative and/or causal relationship between the occurrence of individual mould species and health problems has yet to be established. There is no evidence for a causal relationship between moisture/mould damage and human diseases, mainly because of the ubiquitous presence of fungi and hitherto inadequate diagnostic methods. Sufficient evidence for an association between moisture/mould damage and the following health effects has been established for: allergic respiratory diseases, allergic rhinitis, allergic rhino-conjunctivitis, allergic bronchopulmonary aspergillosis (ABPA), other allergic bronchopulmonary mycosis (ABPM), aspergilloma, Aspergillus bronchitis, asthma (manifestation, progression, exacerbation), bronchitis (acute, chronic), community-acquired Aspergillus pneumonia, hypersensitivity pneumonitis (HP; extrinsic allergic alveolitis (EEA)), invasive Aspergillosis, mycoses, organic dust toxic syndrome (ODTS) [workplace exposure], promotion of respiratory infections, pulmonary aspergillosis (subacute, chronic), and rhinosinusitis (acute, chronically invasive, or granulomatous, allergic). In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitization prevalence of 3-22,5 % in the general population across Europe. Limited or suspected evidence for an association exist with respect to atopic eczema (atopic dermatitis, neurodermatitis; manifestation), chronic obstructive pulmonary disease (COPD), mood disorders, mucous membrane irritation (MMI), odor effects, and sarcoidosis. (iv) Inadequate or insufficient evidence for an association exist for acute idiopathic pulmonary hemorrhage in infants, airborne transmitted mycotoxicosis, arthritis, autoimmune diseases, cancer, chronic fatigue syndrome (CFS), endocrinopathies, gastrointestinal effects, multiple chemical sensitivity (MCS), multiple sclerosis, neuropsychological effects, neurotoxic effects, renal effects, reproductive disorders, rheumatism, sick building syndrome (SBS), sudden infant death syndrome, teratogenicity, thyroid diseases, and urticaria.The risk of infection posed by moulds regularly occurring indoors is low for healthy persons; most species are in risk group 1 and a few in risk group 2 (Aspergillus fumigatus, A. flavus) of the German Biological Agents Act (Biostoffverordnung). Only moulds that are potentially able to form toxins can be triggers of toxic reactions. Whether or not toxin formation occurs in individual cases is determined by environmental and growth conditions, water activity, temperature and above all the growth substrates.In case of indoor moisture/mould damage, everyone can be affected by odor effects and/or mood disorders.However, this is not an acute health hazard. Predisposing factors for odor effects can include genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for mood disorders may include environmental concerns, anxiety, condition, and attribution, as well as various diseases. Risk groups to be protected particularly regarding infection risk are immunocompromised persons according to the classification of the German Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, KRINKO) at the Robert Koch-Institute (RKI), persons suffering from severe influenza, persons suffering from severe COVID-19, and persons with cystic fibrosis (mucoviscidosis); with regard to allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma must be protected. The rational diagnostics include the medical history, physical examination, and conventional allergy diagnostics including provocation tests if necessary; sometimes cellular test systems are indicated. In the case of mould infections, the reader is referred to the specific guidelines. Regarding mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medical point of view, it is important that indoor mould infestation in relevant magnitudes cannot be tolerated for precautionary reasons.For evaluation of mould damage in the indoor environment and appropriate remedial procedures, the reader is referred to the mould guideline issued by the German Federal Environment Agency (Umweltbundesamt, UBA).

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.

Concomitant tuberculosis and aspergillosis in patients with COVID-19: a case report

Coexisting pulmonary aspergillosis and tuberculosis in a post-COVID-19 patient is rare. Here, we are going to report a case of combined pulmonary aspergillosis and tuberculosis in a 51-year-old female who was previously diagnosed with COVID-19 pneumonia. The patient was treated with voriconazole and anti-tuberculosis agents.

Risk Factors Associated with Mortality in Patients with Mucormycosis Post Severe Acute Respiratory Syndrome Coronavirus-2 (Sars-Cov-2) Infection

To study the potential risk factors associated with mortality in patients with mucormycosis. A retrospective study of 490 patients with diagnosis of sinonasal mucormycosis was done. They were divided in two groups-Group A included 87 patients that expired during the study period and Group B included 403 control patients. All the demographic, clinical and outcome parameters were collected from the patient's record files and noted in a structured case proforma and were analysed. During the mean hospital stay of 22 ± 6 days, 17.7% patients expired during the treatment course. Multiple risk factors like uncontrolled diabetes, dyselectrolytemia, underlying renal disease and extensive nature of the disease involving orbit, intracranium and with pulmonary dissemination, all were associated with high mortality in Mucormycosis. Early recognition and appropriate management of the secondary factors can grossly reduce the risk of mortality in patients with mucormycosis.

AWMF mold guideline "Medical clinical diagnostics for indoor mold exposure" - Update 2023 AWMF Register No. 161/001

None.

Development of a machine learning model to predict risk of development of COVID-19-associated mucormycosis

Aim: The study aimed to identify quantitative parameters that increase the risk of rhino-orbito-cerebral mucormycosis, and subsequently developed a machine learning model that can anticipate susceptibility to developing this condition. Methods: Clinicopathological data from 124 patients were used to quantify their association with COVID-19-associated mucormycosis (CAM) and subsequently develop a machine learning model to predict its likelihood. Results: Diabetes mellitus, noninvasive ventilation and hypertension were found to have statistically significant associations with radiologically confirmed CAM cases. Conclusion: Machine learning models can be used to accurately predict the likelihood of development of CAM, and this methodology can be used in creating prediction algorithms of a wide variety of infections and complications.

Proven Cutaneous Mucormycosis in a COVID-19 Patient: A Case Report and Literature Review

There has been a rise in COVID-19-associated mucormycosis (CAM) cases, particularly in low-income countries. We describe a case of primary cutaneous mucormycosis after recovering from COVID-19 in a kidney transplant recipient who had a known case of diabetes mellitus. The patient developed cutaneous ulcers due to Rhizopus oryzae in the right hand. She did not recall any trauma or injury at the affected site. Based on the appearance of the wound we suspected that healthcare-associated mucormycosis could be the causative agent. Due to the initial misdiagnosis as a bacterial infection, the appropriate treatment was delayed, and the lesions progressed rapidly to necrotic ulcers with jagged margins that deteriorated during hospitalization. She underwent consecutive surgical interventions and received broad-spectrum antifungal therapy. Finally, the patient deceased after 32 days of hospital stay. We reviewed the previous case reports of cutaneous mucormycosis occurring in COVID-19 patients and described patient characteristics, predisposing factors, location of ulcers, clinical presentation, management, and outcome. This report and existing published literature indicate a poor outcome for cutaneous mucormycosis in COVID-19 patients and the importance of early diagnosis, aggressive multidisciplinary management, and regular follow-up as a life-saving measure, especially in immunocompromised patients.

Post-COVID mucormycosis osteomyelitis and its imaging manifestations in the North of Iran: case series

Mucormycosis is an invasive fungal infection that usually affects patients with immunocompromised conditions. In the context of the COVID-19 pandemic and the following corticosteroid therapy, mucormycosis prevalence has increased. The situation may be more complicated with some underlying diseases such as diabetes mellitus. In addition, due to the vicinity of maxillary bone to the nasal cavity and paranasal sinuses, which are the main routes for the infection to spread, dentists, maxillofacial radiologists, and surgeons may be the first to encounter these patients. Post-COVID mucormycosis osteomyelitis is one of the complications of this infection Bone destruction and the erosion or breach of cortical boundaries of the maxilla and the bone structures in the vicinity of paranasal sinuses are the most critical radiographic findings of post-covid osteomyelitis. Herein, there are some cases of post-covid mucormycosis osteomyelitis involving the maxillary and other facial bones.

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.

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.

Epidemiology, Clinical Profile, and Analysis of Risk Factors in COVID Associated Rhino-orbito-cerebral Mucormycosis Patients - An Observational Study

Aim of Study

To study the clinico-epidemiological profile and identify risk factors for the development of COVID-19-associated mucormycosis (CAM) among the patients treated at our regional mucormycosis center.

Materials and Methods

This was a cross-sectional single-centre observational study. All CAM patients admitted to Government Rajaji Hospital, Madurai from April 2021- August 2021 were included in the study. Information regarding clinical features, potential risk factors, diagnostic workup, and comorbid illness was collected.

Results

A total of 164 patients of CAM were admitted to our hospital with a mean age of 51.7 years. Out of 164 patients, 12 patients were not covid positive, based on imaging and RT-PCR, however subclinical infection could not be ruled out. Out of the 164 patients studied, 160 patients had diabetes, out of which 66% (n = 105) patients had a previous history of diabetes, and 34% (n = 55) had newly detected diabetes. Most of the patients admitted with mucormycosis had uncontrolled diabetes (94%) and were not on insulin therapy, but were on oral antidiabetic drugs alone. The majority of the patients (68%) have received steroids (IV/oral) during the COVID-19 illness. 74% of these patients were under hospitalization for COVID-19 disease. Only 30% (n = 50) of CAM patients had a history of oxygen therapy and 7% of these patients were treated in ICU during active COVID-19 illness. 59% of patients used cloth masks without adequate hygiene, rest 41% (n = 67) patients reused disposable masks. We also found that 87% of the patients developing mucormycosis had exposure to organic material in the convalescence period of COVID-19 illness.

Conclusions

From our study, we found steroid use, poorly controlled diabetes mellitus, reuse of masks, daily steam inhalation, and exposure to organic matter to be more associated with CAM, but oxygen therapy was less associated with CAM. Hence, we could suggest screening for hyperglycemia and daily use of disposable surgical masks to be continued for at least 4 weeks post-COVID-19. It is preferable to continue insulin in titrated doses along with OHA for at least 4 weeks following steroid cessation in the post-COVID-19 period as there is are considerably increased inflammatory cytokine levels in the convalescence phase. Clean environmental hygiene would also help prevent CAM.

COVID-19 Associated Rhino-Orbital-Cerebral Mucormycosis: Clinical Features, Antifungal Susceptibility, Management and Outcome in a Tertiary Hospital in Iran

BACKGROUND

Despite the unprecedented surge in the incidence of mucormycosis in the COVID-19 era, the antifungal susceptibility patterns (ASPs) of COVID-19 associated mucormycosis (CAM) isolates have not been investigated so far and it is unclear if the high mortality rate associated with CAM is driven by decreased susceptibility of Mucorales to antifungal drugs.

OBJECTIVES

To describe the clinical, mycological, outcome and in vitro ASPs of CAM cases and their etiologies from Iran.

PATIENTS/METHODS

A prospective study from January 2020 to January 2022 at a referral tertiary hospital in Tehran, Iran was conducted for screening mucormycosis through histopathology and mycological methods. The identity of Mucorales isolates was revealed with ITS-panfungal PCR& sequencing and MALDI-TOF. The AS for amphotericin B, itraconazole, isavuconazole and posaconazole was cleared according to the EUCAST antifungal susceptibility testing protocol.

RESULT

A total of 150 individuals were diagnosed with CAM. Males constituted 60.7% of the population. The mean age was 54.9 years. Diabetes was the leading risk factor (74.7%). The median interval between diagnosis of COVID-19 and CAM was 31 days. The recovery rate of culture was as low as 41.3% with Rhizopus arrhizus being identified as the dominant (60; 96.7%) agent. Amphotericin B (MIC50 = 0.5 µg/ml) demonstrated the highest potency against Mucorales.

CONCLUSION

Majority of the cases had either diabetes, history of corticosteroid therapy or simultaneously both conditions. Accordingly, close monitoring of blood glucose should be considered. The indications for corticosteroids therapy are recommended to be optimized. Also, an anti Mucorales prophylaxis may be necessitated to be administrated in high risk individuals. Although amphotericin B was the most active agent, a higher rate of resistance to this antifungal was noted here in comparison with earlier studies on mucormycetes from non-CAM cases.

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

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

Effects of Lactobacilli acidophilus and/or spiramycin as an adjunct in toxoplasmosis infection challenged with diabetes

The current study assessed the anti-parasitic impact of probiotics on Toxoplasma gondii infection either solely or challenged with diabetes in Swiss albino mice. The study design encompassed group-A (diabetic), group-B (non-diabetic), and healthy controls (C). Each group was divided into infected-untreated (subgroup-1); infected and spiramycin-treated (subgroup-2); infected and probiotic-treated (subgroup-3); infected and spiramycin+ probiotic-treated (subgroup-4). Diabetic-untreated animals exhibited acute toxoplasmosis and higher cerebral parasite load. Overall, various treatments reduced intestinal pathology, improved body weight, and decreased mortalities; nevertheless, probiotic + spiramycin exhibited significant differences. On day 7 post-infection both PD-1 and IL-17A demonstrated higher scores in the intestine of diabetic-untreated mice compared with non-diabetics and healthy control; whereas, claudin-1 revealed worsening expression. Likewise, on day 104 post-infection cerebral PD-1 and IL-17A showed increased expressions in diabetic animals. Overall, treatment modalities revealed lower scores of PD-1 and IL-17A in non-diabetic subgroups compared with diabetics. Intestinal and cerebral expressions of IL-17A and PD-1 demonstrated positive correlations with cerebral parasite load. In conclusion, toxoplasmosis when challenged with diabetes showed massive pathological features and higher parasite load in the cerebral tissues. Probiotics are a promising adjunct to spiramycin by ameliorating IL-17A and PD-1 in the intestinal and cerebral tissues, improving the intestinal expression of claudin-1, and efficiently reducing the cerebral parasite load.

Successful treatment of pulmonary mucormycosis (Lichtheimia spp.) in a post-partum patient with COVID-19 ARDS requiring extra-corporeal membrane oxygenation using salvage therapy

Case Summary: A 31-year-old female presented to a regional hospital at 27 weeks pregnant and was found to have COVID-19 ARDS. She underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was refractory to proning requiring ECMO and transfer to a tertiary care center. Admission chest radiography showed a new right lower lobe cavitating lesion with computed tomography scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with final respiratory cultures growing Lichtheimia spp. Source control was discussed via possible open thoracostomy, but medical management alone was continued. Total ECMO support was 3 weeks. At the time of discharge to acute rehab, 1 month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant. Conclusion: Pulmonary mucormycosis, even in the non-ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable.

COVID-19-Associated Rhino-Orbital Mucormycosis in a Tertiary Health Care Center in Odisha, India

Background Mucormycosis is an opportunistic infection that mainly affects immunocompromised individuals, including those with uncontrolled diabetes, malignancies, or those who have exposure to high-dose corticosteroids for a long time. Western Odisha, India, witnessed a significant rise in post-COVID-19 rhino-orbital mucormycosis (ROM), which created a need for comprehensive research on post-COVID-19 ROM. Objective This study aimed to investigate the prevalence, clinical characteristics, and outcomes of post-COVID-19 ROM in a tertiary care hospital in Western Odisha, India, with the objective of understanding ROM as a nationally notifiable disease. Subjects and methods A prospective hospital-based study was conducted. Mucormycosis cases were reported within the period, from May 17, 2021, to July 31, 2021, including all post-COVID-19 patients who exhibited clinical manifestations of mucormycosis. Patients with histopathologically negative reports of mucormycosis were excluded. Results Of the 35 included, 25 were diagnosed with ROM. The age group of 46-50 years showed a predominance (n=6), with a mean age of 50.53 years. The male-to-female ratio was 2:1. Specifically, 88% of the patients included had diabetes mellitus, 8% had chronic kidney diseases, 8% had sepsis, and 4% had hypertension. ROM was the predominant manifestation (60%, n=15), with the majority presenting with orbital cellulitis (80%), followed by unilateral orbital apex syndrome (12%), bilateral orbital apex syndrome (4%), ophthalmic vein involvement (4%), and osteomyelitis of the maxillary sinus (4%). Irrigation of the wound was performed, and all 25 ROM patients received IV liposomal amphotericin B (L-AMB). Conclusion Post-COVID-19 status with elevated blood sugar levels was a major risk factor for ROM. Early diagnosis, debridement, L-AMB, retrobulbar AMB deoxycholate, and exenteration are the possible solutions.

Drugs in primary care that may alter COVID-19 risk and severity

ABSTRACT

This article describes drugs used in primary care that could alter patients' risk for and severity of COVID-19. The risks and benefits of each drug class were differentiated according to the strength of evidence from 58 selected randomized controlled trials, systematic reviews, and meta-analyses. Most of the studies reported on drugs affecting the renin-angiotensin-aldosterone system. Other classes included opioids, acid suppressants, nonsteroidal anti-inflammatory drugs, corticosteroids, vitamins, biguanides, and statins. Current evidence has not fully differentiated drugs that may increase risk versus benefits in COVID-19 infection. Further studies are needed in this area.

Mucormycosis: An Epidemic Complicating the COVID-19 Pandemic

COVID-19 is a relatively new disease whose complete pathogenesis and complications have not been elucidated. Apart from the morbidity and mortality caused by the virus itself, it is noted that patients affected with this virus have a higher susceptibility to bacterial and fungal co-infections. Mucormycosis is a rare and life-threatening fungal infection generally associated with uncontrolled diabetes mellitus and immunosuppression. It tends to rapid disease progression and poor prognosis if not diagnosed and managed promptly. There has been a sudden increase in the number of mucormycosis cases in patients with moderate to severe COVID-19 infection in the past few months. Herein, we present a series of 10 mucormycosis cases diagnosed over one week.

Multiple maxillary periodontal abscesses as a manifestation of post-coronavirus disease 2019 mucormycosis: a case report

BACKGROUND

Coronavirus disease 2019 makes patients more susceptible to superinfection of fungal disease as a consequence of immunological system impairment. Mucormycosis is a fungal infection that is rare but has a high mortality rate and mostly affects patients with poorly controlled diabetes mellitus or those receiving corticosteroids.

CASE PRESENTATION

Here, we present a case of post-coronavirus disease 2019 mucormycosis in a 37-year-old Persian male presenting with multiple periodontal abscess with purulent discharge and necrosis of maxillary bone (without oroantral communication). Surgical debridement following antifungal therapy was the treatment of choice.

CONCLUSION

Early diagnosis and immediate referral are the cornerstone of comprehensive treatment.

A peek behind the curtain in the diagnosis and management of COVID‑19‑Associated Mucormycosis (CAM)

Coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) is responsible for a high mortality rate due to its unique and severe host-pathogen interactions. Critically ill or immunocompromised COVID-19 patients are more prone to suffer from aggressive mycoses. Probable victims include those with uncontrolled diabetes mellitus (DM), metabolic acidosis, prolonged neutropenia, increased ferritin levels, hypoxia, and prolonged hospitalization with/without mechanical ventilators and corticosteroids administration. The current review aims to outline the journey of patients with CAM as well as the advantages and disadvantages of the currently available diagnostic techniques. It also discussed the current status of treatment options and caveats in the management of mucormycosis. Multidisciplinary team, early diagnosis, controlling the predisposing condition(s), complete surgical debridement, effective antifungal therapies (e.g., amphotericin B, isavuconazole, and posaconazole), and implementing antifungal stewardship programs are imperative in CAM cases.

Mucormycosis infection associated with global COVID-19 pandemic - an institutional histopathological study

BACKGROUND

Coronavirus disease 2019 (COVID-19) in the recent times have instilled signs of immunosuppression globally which has further precipitated increasing range of opportunistic infections. Mucormycosis is a distressing opportunistic fungal infection with a high incidence and is the third commonest acute invasive infection following candidiasis and aspergillosis. The aim of the present observational study is to delineate the enigmatic histopathological profile between mucormycosis cases seen prior to pandemic (PPM) and pandemic associated mucormycosis (PAM).

MATERIAL AND METHODS

Tissue archives of 105 histopathologically diagnosed cases of mucormycosis were included and analysed for demographical details and histopathological parameters like fungal load and localization, granuloma formation, necrosis, inflammatory infiltrate and tissue invasion.

RESULTS

0ut of 105 included cases, 11/105 (10.48%) were reported PPM and 94/105 (89.52%) PAM. Among 94 cases of PAM, 51/94 (54%) cases also showed COVID-19 positivity, while 43/94 (46%) did not. Of all the histological variables, increased fungal load and necrosis were observed in PAM relative to PPM cases.

CONCLUSIONS

The histopathological variables like fungal load, necrosis, granuloma formation and tissue invasion, could help the clinician in assessing the clinical status at the time of tissue diagnosis and improve the treatment accordingly.

Statement des Netzwerkes Schimmelpilzberatung Deutschland zu gesundheitlichen Risiken durch Schimmel im Innenraum in Zusammenhang mit Armutsgefährdung

Das Netzwerk Schimmelpilzberatung Deutschland kam bei seinem Treffen am 20. Juni 2022 zu dem Schluss, dass armutsgefährdete Menschen einem erhöhten gesundheitlichen Risiko durch Feuchte-/Schimmelschäden im Innenraum ausgesetzt sind, und hat hierzu eine ausführliche Stellungnahme verfasst, die in der Zeitschrift Umweltmedizin – Hygiene – Arbeitsmedizin 2022; 27(5): 249–252 veröffentlicht wurde. Im Folgenden sind die Kernaussagen des Statements dargestellt.

Clinical profile of COVID-19-associated mucormycosis patients and the clinical suspects: a descriptive audit

Background

India witnessed a massive surge of rhino orbital cerebral mucormycosis (ROCM) cases during the second wave of COVID-19, recording the highest number of cases in the world, indeed, an epidemic within the pandemic.

Objectives

To describe the clinical profile of patients with COVID-19-associated mucormycosis (CAM) and the clinical suspects for mucormycosis.

Methods

This single-center descriptive, observational study/audit was done at Indira Gandhi Medical College, Pondicherry, South India. This study is about the clinical profile of 7 CAM patients and 14 COVID-19 patients who were suspects of CAM, based on their risk factors and clinical symptoms, and were referred to the ENT department.

Statistical analysis

All the descriptive variables were summarized as mean, frequency, and percentages for qualitative data.

Results

All 7 CAM patients were COVID-19 positive and were not vaccinated against COVID-19, All 7 were known diabetic, all 7 had steroid therapy for their COVID status, and 5 out of 7 (71%) had uncontrolled diabetes mellitus at the time of diagnosis. Facial pain, nasal discharge, and eye swelling were the presenting symptoms of CAM. Maxillary and ethmoid sinuses were the most commonly involved para nasal sinuses. Four out of seven (57.1%) CAM patients survived after 16 months of follow-up, after surgical and medical treatment for CAM. Of the 14 clinical suspects who were negative for CAM, 2 were negative for COVID-19, their risk factors were brought under control, 3 expired due to COVID complications, and 9 patients are alive till date.

Conclusion

Uncontrolled diabetes is a risk factor for ROCM/CAM, another possible risk factor is steroid therapy, and we hypothesize that COVID infection could also be a possible risk factor that needs to be studied more extensively in a larger sample. Early clinical suspicion, withdrawal of steroids, rapid control of diabetes mellitus, appropriate investigations, and early surgical intervention combined with medical treatment offers better outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43163-023-00430-2.

Impact of the COVID-19 pandemic on dispensing medicines in the community pharmacy

BACKGROUND

The world has faced an unprecedented challenge since COVID-19 emerged as a pandemic, which has led to quarantine and disruptions in drug services. During the pandemic, drug use habits and availability changed, causing a shift in behaviors and, in turn, medicine misuse. In Iraq, this is a major problem because many medicines can be easily obtained.

OBJECTIVE

The study aims to describe the pattern of dispensing medications during the pandemic and to evaluate the biochemical and pathological consequences.

METHOD

The analytical, observational, cross-sectional study was performed via a compiled questionnaire for 400 random pharmacists, and the analysis and interpretation of the biochemical changes and medical reports.

RESULTS

Results revealed that dispensing of medications since the COVID-19 outbreak has increased by 74%, and the demand for medicines seems higher than required in comparison to the periods before the pandemic, while 60% of the dispensed medicines were taken just in case needed. In addition, the availability of medicines decreased by 61%, and the dispensing of common medicines increased due to the belief in their prophylactic action. Several biochemical abnormalities and pathological consequences were recorded due to the irrational use of medicines, and the highest percentage (12%) was seen in hepatic and liver enzymatic dysfunction and 8% for the endocrine and hormonal abnormalities.

CONCLUSION

It can be concluded that most of the dispensed medicines were not used on a therapeutic or scientific basis during the pandemic.

Non-Aspergillus mould lung infections

Non-Aspergillus filamentous fungi causing invasive mould infections have increased over the last years due to the widespread use of anti-Aspergillus prophylaxis and increased complexity and survival of immunosuppressed patients. In the few studies that have reported on invasive mould infection epidemiology, Mucorales are the most frequently isolated group, followed by either Fusarium spp. or Scedosporium spp. The overall incidence is low, but related mortality is exceedingly high. Patients with haematological malignancies and haematopoietic stem cell transplant recipients comprise the classical groups at risk of infection for non-Aspergillus moulds due to profound immunosuppression and the vast use of anti-Aspergillus prophylaxis. Solid organ transplant recipients also face a high risk, especially those receiving lung transplants, due to direct exposure of the graft to mould spores with altered mechanical and immunological elimination, and intense, associated immunosuppression. Diagnosing non-Aspergillus moulds is challenging due to unspecific symptoms and radiological findings, lack of specific biomarkers, and low sensitivity of cultures. However, the advent of molecular techniques may prove helpful. Mucormycosis, fusariosis and scedosporiosis hold some differences regarding clinical paradigmatic presentations and preferred antifungal therapy. Surgery might be an option, especially in mucormycosis. Finally, various promising strategies to restore or enhance the host immune response are under current evaluation.

Clinical and Neuroimaging Characteristics of Ischemic Stroke in Rhino-Orbito-Cerebral Mucormycosis Associated with COVID-19

PURPOSE

The aim of this study was to compare clinical, neuroimaging, and laboratory features of rhino-orbito-cerebral mucormycosis (ROCM) in COVID-19 patients with and without ischemic stroke complications.

METHODS

This observational study was conducted between August and December 2021 and 48 patients who had confirmed ROCM due to COVID-19, according to neuroimaging and histopathology/mycology evidence were included. Brain, orbit and paranasal sinus imaging was performed in all included patients. Data pertaining to clinical, neuroimaging, and laboratory characteristics and risk factors were collected and compared between patients with and without ischemic stroke complications.

RESULTS

Of the patients 17 were diagnosed with ischemic stroke. Watershed infarction was the most common pattern (N = 13, 76.4%). Prevalence of conventional risk factors of stroke showed no significant differences between groups (patients with stroke vs. without stroke). Cavernous sinus (p = 0.001, odds ratio, OR = 12.8, 95% confidence interval, CI: 2.3-72) and ICA (p < 0.001, OR = 16.31, 95%CI: 2.91-91.14) involvement was more common in patients with stroke. Internal carotid artery (ICA) size (on the affected side) in patients with ischemic stroke was significantly smaller than in patients without stroke (median = 2.4 mm, interquartile range, IQR: 1.3-4 vs. 3.8 mm, IQR: 3.2-4.3, p = 0.004). Superior ophthalmic vein (SOV) size (on the affected side) in patients with stroke was significantly larger than patients without stroke (2.2 mm, IQR: 1.5-2.5 vs. 1.45 mm IQR: 1.1-1.8, p = 0.019). Involvement of the ethmoid and frontal sinuses were higher in patients with stroke (p = 0.007, OR = 1.85, 95% CI: 1.37-2.49 and p = 0.011, OR = 5, 95% CI: 1.4-18.2, respectively). Patients with stroke had higher D‑dimer levels, WBC counts, neutrophil/lymphocyte ratios, and BUN/Cr ratio (all p < 0.05).

CONCLUSION

Stroke-related ROCM was not associated with conventional ischemic stroke risk factors. Neuroimaging investigations including qualitative and quantitative parameters of cavernous sinus, ICA and SOV are useful to better understand the mechanism of stroke-related ROCM in COVID-19 patients.

Nitric Oxide and its Derivatives Containing Nasal Spray and Inhalation Therapy for the Treatment of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major health concern worldwide and has evolved into different variants. SARS-CoV-2 possesses a spike glycoprotein on its envelope that binds to the angiotensin-converting enzyme 2 (ACE-2) receptor of the host cell via the receptor-binding domain (RBD) in the upper respiratory tract. Since the SARS-CoV-2 virus variants change the severity of the diesease and treatment scenarios, repurposing current medicines may provide a quick and appealing method with established safety features. The efficacy and safety of antiviral medicines against the coronavirus disease 2019 (COVID-19) have been investigated, and several of them are now undergoing clinical studies. Recently, it has been found that nitric oxide (NO) shows antiviral properties against SARS-CoV-2 and prevents the virus from binding to a host cell. In addition, NO is a well-known vasodilator and acts as an important coagulation mediator. With the fast-track development of COVID-19 treatments and vaccines, one avenue of research aimed at improving therapeutics is exploring different forms of drug delivery, including intranasal sprays and inhalation therapy. The nasal mucosa is more prone to be the site of infection as it is in more direct contact with the physical environment via air during inhalation and exhalation. Thus, the use of exogenous nasal NO therapy via the intranasal route displays a distinct advantage. Therefore, the objective of this review is to summarize the relevant actions of NO via the intranasal spray and inhalation delivery, its mechanism of action, and its use in the treatment of COVID-19.

Multidisciplinary approach in diagnosis and treatment of COVID-19-associated mucormycosis: a description of current reports

Background

We reviewed the epidemiology, risk factors, pathophysiology, and clinical presentations of coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM), then discussed the importance of rapid diagnosis and treatment facilitated by multidisciplinary approach.

Main body

India has reported world’s highest number of CAM cases where Rhizopus arrhizus was the most predominant etiology. CAM caused by Rhizopus microsporus was the most common from the rest of the world. Multiple risk factors for CAM were identified including diabetes mellitus, inappropriate corticosteroid use, COVID-19-related hypoxia, and lung damage.

Rhino-orbito-cerebral mucormycosis (ROCM) accounted for almost 90% of CAM in India while 64% of global cases were ROCM. Less than 10% of CAM from India were pulmonary while the rest of the world reported 21% of pulmonary CAM.

CAM is diagnosed by confirmed SARS-CoV2 infection along with clinical, radiological, histopathological, and/or microbiological evidence of mucormycosis. In patients with risks of CAM and associated symptoms, CT or MRI are recommended. If ROCM is suspected, endoscopy and biopsy are recommended. If pulmonary CAM is suspected, tissue biopsies, nasal samples, or bronchoalveolar lavage is recommended with histopathological exams.

Early diagnosis, surgical, and pharmaceutical interventions are key to treat mucormycosis. Upon diagnosis, antifungal therapy with liposomal amphotericin B (IV) is considered first-line of therapy. Alternatively, posaconazole (PO/IV) or isavuconazole (PO/IV) can be used.

Conclusion

Treating CAM requires a multidisciplinary approach for early diagnosis and prompt initiation of interventions to maximize patient’s chance of survival.

Rhino-Orbital Cerebral Mucormycosis in a Non-diabetic Patient Following COVID-19 Infection: A Case Report and Literature Review

Rhino-orbital cerebral mucormycosis has been commonly seen during the coronavirus disease 2019 (COVID-19) pandemic. Several factors responsible for etiology and pathophysiology have been identified, among which corticosteroids and diabetes have contributed to the lion's share of the outbreak of mucormycosis. In this report, we discuss a case of a 41-year-old non-diabetic male with a recent convalescence from COVID-19 infection presented with gradual vision loss and loss of sensations in his right eye. He was found to have periorbital swelling, restriction of extraocular movements in all gazes, chemosis, ptosis of the right eye, and right maxillary sinus tenderness. His serum investigations, radiologic findings, and blood culture were indicative of rhino-orbital cerebral mucormycosis. He was started on systemic liposomal amphotericin B immediately and underwent aggressive surgical debridement. A high index of clinical suspicion, aggressive multifaceted management, and follow-up are needed to have successful outcomes, thereby lowering the morbidity of coronavirus-associated mucormycosis.

Liposomal amphotericin B—the future

Advances in medicine have led to a growing number of people with compromised or suppressed immune systems who are susceptible to invasive fungal infections. In particular, severe fungal infections are becoming increasingly common in ICUs, affecting people within and outside of traditional risk groups alike. This is exemplified by the emergence of severe viral pneumonia as a significant risk factor for invasive pulmonary aspergillosis, and the recognition of influenza-associated pulmonary aspergillosis and, more recently, COVID-19-associated pulmonary aspergillosis.

The treatment landscape for haematological malignancies has changed considerably in recent years, and some recently introduced targeted agents, such as ibrutinib, are increasing the risk of invasive fungal infections. Consideration must also be given to the risk of drug–drug interactions between mould-active azoles and small-molecule kinase inhibitors.

At the same time, infections caused by rare moulds and yeasts are increasing, and diagnosis continues to be challenging. There is growing concern about azole resistance among both moulds and yeasts, mandating continuous surveillance and personalized treatment strategies.

It is anticipated that the epidemiology of fungal infections will continue to change and that new populations will be at risk. Early diagnosis and appropriate treatment remain the most important predictors of survival, and broad-spectrum antifungal agents will become increasingly important. Liposomal amphotericin B will remain an essential therapeutic agent in the armamentarium needed to manage future challenges, given its broad antifungal spectrum, low level of acquired resistance and limited potential for drug–drug interactions.

When to Initiate Antifungal Treatment in COVID-19 Patients with Secondary Fungal Co-infection

Purpose of Review

Severe-acute respiratory coronavirus 2 (SARS-CoV-2) has been driving the health care delivery system for over 2 years. With time, many issues related to co-infections in COVID-19 patients are constantly surfacing. There have been numerous reports about various fungal co-infections in patients with COVID-19. The extent of severity of fungal pathogens has been recognized as a substantial cause of morbidity and mortality in this population. Awareness, understanding, and a systematic approach to managing fungal co-infections in COVID-19 patients are important. No guidelines have enumerated the stepwise approach to managing the fungal infections co-occurring with COVID-19. This review is intended to present an overview of the fungal co-infections in COVID-19 patients and their stepwise screening and management.

Recent Findings

The most common fungal infections that have been reported to co-exist with COVID-19 are Candidemia, Aspergillosis, and Mucormycosis. Prevalence of co-infections in COVID-19 patients has been reported to be much higher in hospitalized COVID-19 patients, especially those in intensive care units. While clear pathogenetic mechanisms have not been delineated, COVID-19 patients are at a high risk of invasive fungal infections.

Summary

As secondary fungal infections have been challenging to treat in COVID-19 patients, as they tend to affect the critically ill or immunocompromised patients, a delay in diagnosis and treatment may be fatal. Antifungal drugs should be initiated with caution after carefully assessing the immune status of the patients, drug interactions, and adverse effects. The crucial factors in successfully treating fungal infections in COVID-19 patients are optimal diagnostic approach, routine screening, and timely initiation of antifungal therapy.

Antifungal Effect of Nanoparticles against COVID-19 Linked Black Fungus: A Perspective on Biomedical Applications

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and pathogenic coronavirus that has caused a 'coronavirus disease 2019' (COVID-19) pandemic in multiple waves, which threatens human health and public safety. During this pandemic, some patients with COVID-19 acquired secondary infections, such as mucormycosis, also known as black fungus disease. Mucormycosis is a serious, acute, and deadly fungal infection caused by Mucorales-related fungal species, and it spreads rapidly. Hence, prompt diagnosis and treatment are necessary to avoid high mortality and morbidity rates. Major risk factors for this disease include uncontrolled diabetes mellitus and immunosuppression that can also facilitate increases in mucormycosis infections. The extensive use of steroids to prevent the worsening of COVID-19 can lead to black fungus infection. Generally, antifungal agents dedicated to medical applications must be biocompatible, non-toxic, easily soluble, efficient, and hypoallergenic. They should also provide long-term protection against fungal growth. COVID-19-related black fungus infection causes a severe increase in fatalities. Therefore, there is a strong need for the development of novel and efficient antimicrobial agents. Recently, nanoparticle-containing products available in the market have been used as antimicrobial agents to prevent bacterial growth, but little is known about their efficacy with respect to preventing fungal growth, especially black fungus. The present review focuses on the effect of various types of metal nanoparticles, specifically those containing silver, zinc oxide, gold, copper, titanium, magnetic, iron, and carbon, on the growth of various types of fungi. We particularly focused on how these nanoparticles can impact the growth of black fungus. We also discussed black fungus co-infection in the context of the global COVID-19 outbreak, and management and guidelines to help control COVID-19-associated black fungus infection. Finally, this review aimed to elucidate the relationship between COVID-19 and mucormycosis.

COVID-19-related Rhino-orbital-cerebral Mucormycosis

BACKGROUND

There is an increasing number of COVID-19-related Rhino-orbital-cerebral mucormycosis (ROCM), especially from India.

OBJECTIVES

To evaluate the demographic, clinical, radiological, and outcome of the COVID-19-related ROCM cases in a single center.

MATERIALS AND METHODS

The medical records of the patients with COVID-19-related ROCM were retrospectively reviewed. The study covered 22 months duration from March 2020 to December 2021 in Imam Hussain Medical City, Karbala city, Iraq.

RESULTS

Of the 14 patients with COVID-19-related ROCM, there were 71.4% males with a male-to-female ratio of 2.5:1. The median age was 61 years (age range: 27-80 years). There were 42.9% of patients with a history of being a current smoker. All patients had a history of DM, and 57.1% of patients had a history of hypertension. All patients were without a history of the previous episode of COVID-19 or taking the vaccine. The median duration from the COVID-19 diagnosis to the diagnosis of ROCM was 19 days (duration range of 10-40 days). Most of the cases were of severe type (57.1%). All of the patients were taking corticosteroid and oxygen therapy. Nasal obstruction, nasal discharge, cheek swelling, and necrotic tissue were clinical features in all patients. The majority of the cases were on the left side (71.4%). Stage 3 was found in 42.9%. Amphotericin B was used for all patients and surgical debridement in 13 cases. Five patients have died (35.7%).

CONCLUSION

COVID-19-related ROCM is an aggressive disease associated with a high mortality rate of 35.7%. Early diagnosis and on-time initiation of treatment are recommended to get the best outcome.

Co-infection associated with SARS-CoV-2 and their management

SARS-CoV-2 was discovered in Wuhan, China and quickly spread throughout the world. This deadly virus moved from person to person, resulting in severe pneumonia, fever, chills and hypoxia. Patients are still experiencing problems after recovering from COVID-19. This review covers COVID-19 and associated issues following recovery from COVID-19, as well as multiorgan damage risk factors and treatment techniques. Several unusual illnesses, including mucormycosis, white fungus infection, happy hypoxia and other systemic abnormalities, have been reported in recovered individuals. In children, multisystem inflammatory syndrome with COVID-19 (MIS-C) is identified. The reasons for this might include uncontrollable steroid usage, reduced immunity, uncontrollable diabetes mellitus and inadequate care following COVID-19 recovery.

Tracing, Tracking and Treating COVID-19 Associated Rhino-Orbito Cerebral Mucormycosis (ROCM)

Surge in the number of mucormycosis cases following second wave of coronavirus disease-19 (COVID-19) infection posed several diagnostic and prognostic challenges. This study was aimed to describe clinical, diagnostic features and survival outcomes among patients of mucormycosis in post COVID-19 context. Retrospective chart review. This study included 44 COVID-19 positive screened cases who presented with clinical features suggestive of mucormycosis. Demography, clinical profile, diagnostic findings, and the treatment outcome are studied. Medical and surgical outcomes are summarised as frequencies and percentages. The reliability of microbiological, and radiological findings against the pathological findings was analyzed using Kappa statistics (k). Based on constellation of microbiological, pathological and radiological findings 28 cases (63%) confirmed with mucormycosis infection. The mean (SD) age was 54.9 (12.9) years and two-third were males. The majority (90%) of cases presented with the feature of facial swelling, headache nasal blockade. Inpatient care for treatment of COVID-19 was recorded in 33 (75%). Diabetes mellitus was the commonest comorbidity in 27 (61.4%), 38 (86.4%) cases were treated by steroids and 30 (68.2%) were given oxygen therapy. There is a strong agreement (k = 0.83) between pathological and microbiological investigations. In thirty-eight cases (86.3%) remission was achieved when assessed after 8 weeks. Of the 44 cases, four patients died. The results of the current study suggest that the disease residues and/or recurrences in critical areas are frequent in mucormycosis. However, using the strategy of screening at risk patients, diagnosing, treating them with combination of antifungals, surgical debridement, and timely follow up may help in improving outcomes as compared to pre COVID-19 era.

Identifying Independent Predictors of Mortality in COVID-19 Patients with Mucormycosis

Background: Coronavirus disease 2019 (COVID-19) may lead to immunosuppression, leaving patients vulnerable to secondary invasive fungal infection like mucormycosis. The present study aimed to determine whether there are any risk factors associated with mortality in mucormycosis among COVID-19 patients. Patients and Methods: Patients with COVID-19 diagnosed with mucormycosis who received treatment at University Hospitals were included in the study. Complete blood count (CBC), glycated hemoglobin (HBA1c), C-reactive protein (CRP), serum albumin level, creatinine, ferritin levels, lactate dehydrogenase (LDH), D-dimer and histopathological observations were performed for all participants’ specimens. Results: The number (N) of patients included in the study was 46. About 85 % (39/46) of patients had post-COVID-19 syndrome and the other 7 cases were in the active phase of the disease. CRP, serum ferritin, D-dimer, CRP/albumin ratio and CRP/absolute lymphocyte counts were statistically significant (P<0.05) within non-survivors as compared to survivors. After analysis of multivariate analysis that patients had oxygen support, while elevated CRP/albumin ratios were independent predictors of mortality in COVID-19 patients associated with mucormycosis. Conclusions: Mucormycosis can be caused by immunosuppression conditions associated with COVID-19 infection. Oxygen levels and C-reactive protein/albumin are independent predictors of mortality and morbidity in post COVID-19 patients.

Invasive Mucormycosis and Aspergillosis Coinfection Associated with Post-COVID-19 Pneumonia in a Tertiary Care Hospital

Acute invasive fungal rhinosinusitis is a rare infection primarily affecting patients with co-morbidities like immunosuppression and poorly controlled diabetes. Mucormycosis is increasingly being reported in patients with SARS-CoV-2 (COVID-19). However, reports of coinfection of aspergillosis and mucormycosis involving nose, paranasal sinuses, orbit, and brain are rare in literature. We aimed to evaluate the patient demographics, clinical presentation, and management of cases presenting with mixed infection. We carried out retrospective analysis of 12 patients with confirmed diagnosis of mixed invasive fungal infections post-COVID-19 disease out of 70 cases of COVID-19-associated mucormycosis (CAM) presenting to a tertiary-level hospital in North India from May to June 2021. All patients had diabetes mellitus; the mean age was 48 years. The common presenting features were headache, nasal congestion, palatal ulcer, and vision loss accompanied by facial pain and swelling. Two patients developed cerebral abscess during the course of treatment; three patients had concurrent COVID-19 pneumonia. All patients received systemic liposomal amphotericin B and serial surgical debridements. The overall mortality rate was 16.7%. Our study demonstrates that mucormycosis and aspergillosis are angioinvasive mycoses that are clinically and radiologically identical. KOH direct mount of clinical sample showing septate hyphae should be extensively searched for aseptate hyphae after digestion and clearing of the tissue. A high index of suspicion of mixed infection post-COVID-19 and early initiation of liposomal amphotericin B followed by prompt surgical intervention can reduce the overall morbidity and mortality among patients with this condition.

Onset of Mucormycosis in Patients with COVID-19: A Systematic Review on Patients' Characteristics

Mucormycosis has a significant impact on patients' standard of living and, therefore, a high clinical suspicion, prediagnosis, and rapid treatment are critical in easing patients' suffering and fast recovery. Our focus is to conduct an organized review based on various variables on the patients' characteristics having mucormycosis in severe novel coronavirus disease 2019 (COVID-19). We examined Embase, PubMed-Medline, LitCovid, Web of Science, Scopus, and the reference lists of included case reports up to September 20, 2021, using the Medical Subject Heading (MeSH) phrases and other keywords related to this topic. Subsequently, we investigated associated comorbidities, patient characteristics, position of mucormycosis, steroids use, body involvements, and outcomes. Overall, 77 studies were conducted and among these, 72 studies mentioned that the patients' age to be 48.13±14.33 (mean±standard deviation [SD]) years. Diabetes mellitus (DM) was reported in 77.9% (n=60) of cases. Studies showed that central nervous system (CNS) and bone involvement were reported in 62.3 (n=48) and 53.2% (n=41), respectively. More fatalities were observed in patients with mucormycosis with the active form of COVID-19. Also, men infected with mucormycosis significantly affected by COVID-19. In the end, mortality was higher in males with mucormycosis. As a result, a solid investigation into the root cause of mucormycosis, especially in COVID-19, should be included in the study plan. If the patient is COVID-19-positive and immunosuppressed, this opportunistic pathogen diagnostic test should not be overlooked.

Comparison of mucormycosis infection between patients with and without a history of COVID-19 infection: a retrospective cohort study

BACKGROUND

Mucormycosis infection is a complication seen in some coronavirus disease 2019 (COVID-19) patients. This study compares the characteristics of mucormycosis infection between COVID-19 and non-COVID-19 patients.

METHODS

This retrospective cohort comprised 87 patients with mucormycosis divided into two groups. The first included 44 patients who had COVID-19 recently before hospitalization due to mucormycosis at Namazi Hospital, Shiraz, Iran, between February 2019 and August 2021. The second group included all 43 patients hospitalized at the same hospital due to mucormycosis between 2010 and 2019 (pre-pandemic).

RESULTS

Mucormycosis patients with a history of recent COVID-19 infection had a higher rate of diabetes mellitus, fewer malignancies and higher blood glucose, erythrocyte sedimentation rate and C-reactive protein levels (p<0.05). Glucocorticoid use was common (77%) in the COVID-19 group.

CONCLUSIONS

In the pre-COVID-19 era, mucormycosis mainly affected immunodeficient patients like those receiving chemotherapy due to malignancy but now seems to affect COVID-19 patients with uncontrolled blood glucose and glucocorticoids use. Special care must be taken in prescribing glucocorticoids and controlling the blood glucose levels of COVID-19 patients.

Isolated tracheobronchial mucormycosis: report of a case and systematic review of literature

BACKGROUND

Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature.

CASE DESCRIPTION AND SYSTEMATIC REVIEW

A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky hemoptysis, and hoarseness of voice two weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycemic control, posaconazole, and inhaled amphotericin B (eight weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in 2 lung transplant recipients), post-viral illness (post-COVID-19 [n=3], and influenza [n=1]), and post-intubation mucormycosis (n=1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26; 19.2%) or bronchoscopic instillation (1/26; 3.8%) of amphotericin B and surgery (6/26; 23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive hemoptysis.

CONCLUSION

Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible.

Distinguishing Characteristics of COVID-19-Associated Mucormycosis; a Case Series

INTRODUCTION

Since the emergence of COVID-19 pandemic, several articles have reported the co-existence of mucormycosis and COVID-19. This study aimed to distinguish the characteristics of COVID-19-associated rhinocerebral mucormycosis.

METHODS

In this case series, 18 patients with COVID-19-associated rhinocerebral mucormycosis and unique clinical manifestations and outcomes, who were referred to Amiralam Hospital, a tertiary otorhinolaryngology center, Tehran, Iran, during the COVID-19 era, were reported.

RESULTS

Eighteen patients with the mean age of 62.0 ± 11.6 (range: 42 - 83) years were studied (50% males). The mean time interval between diagnosis of COVID-19 and first manifestation of mucormycosis was 15.5 ± 9.7 days. The most common presenting symptom was facial paresthesia (72.2%). Fifty percent of patients developed frozen eye. Palatal necrosis was seen in 7 cases (38.8%). Remarkably, facial paralysis was observed in 5 (27.7%) patients. Another notable clinical picture was cavernous sinus thrombosis, seen in 7 patients. We also had two cases of carotid artery occlusion. Three patients, unfortunately, passed away.

CONCLUSION

Rhinocerebral mucormycosis is one of the most important complications of COVID-19 patients, especially those with underlying diseases. It seems that the key to proper management of mucormycosis is early diagnosis and timely intervention, which could give a patient a chance to live more.

Mortality-Related Risk Factors for Coronavirus Disease (COVID-19)-Associated Mucormycosis: a systematic review and meta-analysis

Purpose of Review

Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) can increase the susceptibility of individuals to contracting mucormycosis through several mechanisms. Nowadays, coronavirus disease (COVID-19)-associated mucormycosis (CAM) is a serious public health concern, particularly in developing countries. This meta-analysis aims to identify the risk factors that affect the mortality rate of patients with CAM.

Recent Findings

We systematically searched PubMed, Google Scholar, Scopus, Cochrane library, and preprint databases using pertinent keywords and the reference lists of the included relevant articles from inception till October 27, 2021. In order to reduce the effects of small-scale studies, we only selected cross-sectional, case–control, and cohort studies and case series with at least four patients. We identified 26 articles that included 821 patients with CAM. The effect size (ES) of mortality rate was 28% (95% confidence interval (CI) 20%–38%; I² =82.28%; p for Cochran Q<0.001). The CAM patients with a history of comorbidities other than diabetes (malignancies, transplant, or renal failure), mechanical ventilation due to COVID-19, pulmonary and cerebral mucormycosis, and those who only received medical treatment for mucormycosis had the highest mortality rate.

Summary

Coronavirus disease (COVID-19)-associated mucormycosis (CAM) is a major public health problem, particularly in developing countries. Severe COVID-19 infection, history of mechanical ventilation, early CAM, comorbidities other than diabetes (malignancies, transplant, or renal failure), pulmonary and rhino-orbito-cerebral mucormycosis, and delivering only medical treatment for mucormycosis were the worst prognostic factors in CAM patients. Identifying the mortality-related risk factors in CAM patients may help reduce the mortality rate by implementing optimized treatment approaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12281-022-00440-2.

The role of SARS-CoV-2 immunosuppression and the therapy used to manage COVID-19 disease in the emergence of opportunistic fungal infections: A review

Since December 2019 SARS-CoV-2 infections have affected millions of people worldwide. Along with the increasing number of COVID-19 patients, the number of cases of opportunistic fungal infections among the COVID-19 patients is also increasing. There have been reports of the cases of aspergillosis and candidiasis in the COVID-19 patients. The COVID-19 patients have also been affected by rare fungal infections such as histoplasmosis, pneumocystosis, mucormycosis and cryptococcosis. These fungal infections are prolonging the stay of COVID-19 patients in hospital. In this study several published case reports, case series, prospective and retrospective studies were investigated to explore and report the updated information regarding candidiasis, crytptococcosis, aspergillosis, mucormycosis, histoplasmosis, and pneumocystosis infections in COVID-19 patients. In this review, the risk factors of these co-infections in COVID-19 patients have been reported. There have been reports that the comorbidities and the treatment with corticoids, monoclonal antibodies, use of mechanical ventilation, and use of antibiotics during COVID-19 management are associated with the emergence of fungal infections in the COVID-19 patients. Hence, this review analyses the role of these therapies and comorbidities in the emergence of these fungal infections among COVID-19 patients. This review will help to comprehend if these fungal infections are the result of the co-morbidities, and treatment protocol followed to manage COVID-19 patients or directly due to the SARS-CoV-2 infection. The analysis of all these factors will help to understand their role in fungal infections among COVID-19 patients which can be valuable to the scientific community.

First report of rhino-orbital-cerebral mucormycosis after COVID-19 infection in Bulgaria

Mucormycosis is a relatively rare infection but with a high mortality rate due to the difficult and time-consuming diagnostic and therapeutic process. The authors present the first case of rhino-orbital-cerebral mucormycosis, histologically and microbiologically proven, in a patient after COVID-19 infection in Bulgaria.

Knowledge, Attitudes, and Practices concerning Black Fungus during COVID-19 Pandemic among Students of Bangladesh: An Online-Based Cross-Sectional Survey

BACKGROUND

Infection with COVID-19 and its control entailing steroids and immunomodulatory medications disrupted normal immune function. The ensuing immunological disorder led to the rise of another infection-Black Fungus (Mucormycosis). However, the spread of Black Fungus can be minimized through proper knowledge, informed attitude, and conscious preventive practice. This study aimed to assess students' knowledge, attitude, and practice (KAP) regarding Black Fungus amid the COVID-19 pandemic in Bangladesh.

METHODS

This cross-sectional study was carried out among Bangladeshi students from June to July 2021. Using Google Forms, an e-questionnaire was developed for this web-based survey, and the participants were selected through a snowball sampling approach.

RESULTS

Out of the 2009 participants, more than half were female (53.5%), and the majority were at an age between 18 and 25 years (31.5%) and had received higher secondary (HSC) schooling (77.8%), while around 61% resided in urban areas. Findings revealed that most of the students (63.8%) spent around 2 h on electronic and social media to become informed about COVID-19 and Black Fungus. Approximately 33% of the students showed low KAP scores (32.9%), whereas around 26% had high KAP scores. Our results show a significant association between KAP and sex, schooling, living status, residence, and media exposure.

CONCLUSION

The knowledge of Black Fungus considerably varies among Bangladeshi students considering the place of residence, age, sex, living arrangement, and media exposure. Policymakers should emphasize awareness among people focusing on the results of this study to increase deterrent attitudes and protective practices to minimize the risks of being infected.

Development of a Monoclonal Antibody and a Serodiagnostic Lateral-Flow Device Specific to Rhizopus arrhizus (Syn. R. oryzae), the Principal Global Agent of Mucormycosis in Humans

Mucormycosis is a highly aggressive angio-invasive disease of humans caused by fungi in the zygomycete order, Mucorales. Though a number of different species can cause mucormycosis, the principal agent of the disease worldwide is Rhizopus arrhizus, which accounts for the majority of rhino-orbital-cerebral, pulmonary, and disseminated infections in immunocompromised individuals. It is also the main cause of life-threatening infections in patients with poorly controlled diabetes mellitus, and in corticosteroid-treated patients with SARS-CoV-2 infection, where it causes the newly described disease, COVID-19-associated mucormycosis (CAM). Diagnosis currently relies on non-specific CT, a lengthy and insensitive culture from invasive biopsy, and a time-consuming histopathology of tissue samples. At present, there are no rapid antigen tests for the disease that detect biomarkers of infection, and which allow point-of-care diagnosis. Here, we report the development of an IgG1 monoclonal antibody (mAb), KC9, which is specific to Rhizopus arrhizus var. arrhizus (syn. Rhizopus oryzae) and Rhizopus arrhizus var. delemar (Rhizopus delemar), and which binds to a 15 kDa extracellular polysaccharide (EPS) antigen secreted during hyphal growth of the pathogen. Using the mAb, we have developed a competitive lateral-flow device (LFD) that allows rapid (30 min) and sensitive (~50 ng/mL running buffer) detection of the EPS biomarker, and which is compatible with human serum (limit of detection of ~500 ng/mL) and bronchoalveolar lavage fluid (limit of detection of ~100 ng/mL). The LFD, therefore, provides a potential novel opportunity for the non-invasive detection of mucormycosis caused by Rhizopus arrhizus.

Mucormycosis in the COVID-19 Environment: A Multifaceted Complication

The second wave of coronavirus disease 2019 (COVID-19) caused severe infections with high mortality. An increase in the cases of COVID-19-associated mucormycosis (CAM) was reported predominantly in India. Commonly present in immunocompromised individuals, mucormycosis is often a life-threatening condition. Confounding factors and molecular mechanisms associated with CAM are still not well understood, and there is a need for careful research in this direction. In this review, a brief account of the diagnosis, management, and advancement in drug discovery for mucormycosis has been provided. Here, we summarize major factors that dictate the occurrence of mucormycosis in COVID-19 patients through the analysis of published literature and case reports. Major predisposing factors to mucormycosis appear to be uncontrolled diabetes, steroid therapy, and certain cancers. At the molecular level, increased levels of iron in COVID-19 might contribute to mucormycosis. We have also discussed the potential role and regulation of iron metabolism in COVID-19 patients in establishing fungal growth. Other factors including diabetes prevalence and fungal spore burden in India as contributing factors have also been discussed.

COVID-19-associated fungal infections in Iran: A systematic review

Objectives

This systematic review aims to summarize the mycological and clinical features of COVID-19-associated fungal infections (CAFIs) in Iran.

Methods

PubMed, Web of Science, Scopus, Cochrane Library, SID, Magiran, IranDoc, and Google Scholar were searched for Persian and English articles published from January 1, 2020, to November 5, 2021, using a systematic search strategy. Studies on Iranian patients suffering from CAFIs were included in the review.

Results

Twenty-two studies comprising 169 patients were retrieved. Reported CAFIs included candidiasis (85, 50.30%), mucormycosis (35, 20.71%), aspergillosis (29, 17.16%), fusariosis (6, 3.55%), three cases caused by rare pathogens (Rhodotorula mucilaginosa, Diaporthe foeniculina, and Sarocladium kiliense) and 11 (6.51%) uncharacterized mold infections. The most common underlying diseases were diabetes (67/168, 39.88%), cardiovascular diseases (55/168, 32.74%), and hypertension (43/168, 25.59%). The use of antibiotics (111/124, 89.52%), corticosteroids (93/132, 70.44%), and mechanical ventilation (66, 51.16%) were the most common predisposing factors. Totally, 72 (50.35%) of 143 patients with CAFIs died (data were not available for 26 patients).

Conclusion

Fungal infections are evident to be a complication of COVID-19 in Iran; thus, clinicians should consider them as a differential diagnosis, especially in patients with comorbidities and previous antibiotic or corticosteroid use.