Mucormycosis and COVID-19: An epidemic within a pandemic in India

Incidence and Mortality of COVID-19-Associated Invasive Fungal Infections Among Critically Ill Intubated Patients: A Multicenter Retrospective Cohort Analysis

Background

An association between coronavirus disease 2019 (COVID-19)-associated invasive fungal infections (CAIFIs) and high mortality among intubated patients has been suggested in previous research. However, some of the current evidence was derived from small case series and multicenter studies conducted during different waves of the COVID-19 pandemic. We examined the incidence of CAIFIs and their associated mortality using a large, multicenter COVID-19 database built throughout the pandemic.

Methods

We conducted a retrospective analysis of the National COVID Cohort Collaborative (N3C) database collected from 76 medical centers in the United States between January 2020 and August 2022. Patients were 18 years or older and intubated after severe acute respiratory syndrome coronavirus 2 infection. The primary outcomes were incidence and all-cause mortality at 90 days. To assess all-cause mortality, we fitted Cox proportional hazard models after adjusting for confounders via inverse probability weighting.

Results

Out of the 4 916 229 patients with COVID-19 diagnosed during the study period, 68 383 (1.4%) met our cohort definition. The overall incidence of CAIFI was 2.80% (n = 1934/68 383). Aspergillus (48.2%; n = 933/1934) and Candida (41.0%; n = 793/1934) were the most common causative organisms. The incidence of CAIFIs associated with Aspergillus among patients who underwent BAL was 6.2% (n = 83/1328). Following inverse probability weighting, CAIFIs caused by Aspergillus (hazard ratio [HR], 2.0; 95% CI, 1.8-2.2) and Candida (HR, 1.7; 95% CI, 1.5-1.9) were associated with increased all-cause mortality. Systemic antifungals reduced mortality in 17% of patients with CAIFI with Aspergillus and 24% of patients with CAIFI with Candida.

Conclusions

The incidence of CAIFI was modest but associated with higher 90-day all-cause mortality among intubated patients. Systemic antifungals modified mortality.

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.

A Comparative Study of Acute Invasive Fungal Sinusitis During the First and Second Waves of the COVID-19 Pandemic

We aimed to compare the demography, clinical profile, histopathology, fungal culture, radiology, surgery performed, medical therapy and outcomes of patients with acute invasive fungal sinusitis seen during the first and second waves of the COVID-19 pandemic by retrospectively reviewing their case records. Of 238 patients, 43(18.1%) presented during the first wave and 195(81.9%) during the second wave. Patients seen during the first wave were older (p = 0.04) and more likely to have visual impairment (p = 0.004), frozen eye (p = 0.012), altered sensorium (p = 0.007) and stage 3 disease (p = 0.03). Those seen during the second wave were more often COVID-19 positive and had newly diagnosed diabetes mellitus (p = 0.04)and stage 1 disease (p = 0.03). Most patients had a positive culture for Rhizopus species during both waves. Histopathology showed broad aseptate hyphae in all patients but angioinvasion was seen more often during the first wave (p = 0.04). The majority of patients were treated with endoscopic+/- open debridement followed by intravenous amphotericin B and oral posaconazole. While the overall survival rate was similar (first wave 65.1%; second wave 79%; p = 0.106), mortality after discharge was greater during the first wave (11.6% vs 1.5%; p = 0.001). Mortality was higher in patients with stage 3 disease (p = 0.003). Significant differences in clinical presentation, histopathology, radiological stage of disease and post-discharge survival were noted between the two waves of the COVID-19 pandemic, the causes for which were multi-factorial.

Nanotechnology-based fungal detection and treatment: current status and future perspective

Fungal infections impose a significant impact on global health and encompass major expenditures in medical treatments. Human mycoses, a fungal co-infection associated with SARS-CoV-2, is caused by opportunistic fungal pathogens and is often overlooked or misdiagnosed. Recently, there is increasing threat about spread of antimicrobial resistance in fungus, mostly in hospitals and other healthcare facilities. The diagnosis and treatment of fungal infections are associated with several issues, including tedious and non-selective detection methods, the growth of drug-resistant bacteria, severe side effects, and ineffective drug delivery. Thus, a rapid and sensitive diagnostic method and a high-efficacy and low-toxicity therapeutic approach are needed. Nanomedicine has emerged as a viable option for overcoming these limitations. Due to the unique physicochemical and optical properties of nanomaterials and newer biosensing techniques, nanodiagnostics play an important role in the accurate and prompt differentiation and detection of fungal diseases. Additionally, nano-based drug delivery techniques can increase drug permeability, reduce adverse effects, and extend systemic circulation time and drug half-life. This review paper is aimed at highlighting recent, promising, and unique trends in nanotechnology to design and develop diagnostics and treatment methods for fungal diseases.

Exploratory Research for New Diagnostic Markers of Mucormycosis

Mucormycosis is a fungal infectious disease caused by Rhizopus oryzae and other members of the order Mucorales, and it is known as one of the most lethal fungal infections. Early diagnosis of mucormycosis improves prognosis because of limited effective treatments and the rapid progression of the disease. On the other hand, the lack of characteristic clinical findings in mucormycosis and the challenge of early definitive diagnosis make early treatment difficult. Our goal was to establish a serodiagnostic method to detect Rhizopus specific antigen (RSA), and we have developed a diagnostic kit by Enzyme-linked immuno-sorbent assay (ELISA) using a monoclonal antibody against this antigen. RSA increased over time in the serum and alveolar lavage fluid of R. oryzae-infected mice. RSA was also detected in serum and alveolar fluid, even at an early stage (Day 1), when the tissue invasion of R. oryzae mycelium was not histopathologically detectable in the lungs of R. oryzae-infected mice. Further evaluation is needed to determine the feasibility of using this assay in clinical practice.

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.

Role of histopathology in severity assessments of post-COVID-19 rhino-orbital cerebral mucormycosis - A case-control study

BACKGROUND

There was an upsurge in rhino-orbital-cerebral mucormycosis (ROCM) during the second wave of the COVID-19 pandemic in India. Histopathological examination of the biopsies witnessed greater tissue invasion in these cases. The present study aimed to evaluate the histopathological scoring system in the severity assessment and to compare the scores between ROCM that required orbital exenteration (cases) and those that were treated conservatively (controls).

MATERIAL AND METHODS

A retrospective study was conducted to analyze the histopathological features using a scoring system in patients diagnosed with mucormycosis on sino nasal biopsies. The scoring was based on the following parameters: the extent of necrosis (score 1 <50% and score 2 >50%), degree of angioinvasion (score 1 <3 vessels in 10 fields and score 2 > 3 vessels in 10 fields), degree of inflammation (mild, moderate or severe), and fungal load(score 1 to 4), based on which three grades (I to III) were given. The scores were compared between the case group and the control group. The data obtained were analyzed statistically.

RESULTS

The study included 40 controls and 10 cases. The median age of patients in the control group was 52 with 82.5%males (n = 43) and 17.5 % females (n = 7) while in the case group, the median age was 51 years, and all were males. The predominant inflammatory response was of mixed suppurative type (70 %, n = 28). The degree of necrosis was scored 2 in 57.5 % (n = 23) of controls and 70 %(n = 7) in the case group. All the samples in the case group showed scores of 2 for angioinvasion and scores of 3 and 4 for fungal load. There was a statistically significant difference in the degree of necrosis, angioinvasion, the severity of neutrophilic infiltrates, and fungal load between the cases and controls (p-value <0.05).

CONCLUSION

The present study analyses the predictive role of histopathology in invasive mucormycosis. Higher fungal load, degree of angioinvasion, and the absence of granulomas are associated with advanced disease in sinonasal mucormycosis. The study findings recommend incorporating the histopathological scoring criteria in evaluating patients with sinonasal mucormycosis.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Radiological features of COVID-19-associated mucormycosis: A report of 36 cases along with a literature review

The pandemic of COVID-19 along with high use of corticosteroids resulted in the emergence of invasive fungal infection. Here, we reported the radiologic feature of mucormycosis in COVID-19-infected cases and reviewed with available literature.

Fungal pathogens and COVID-19

COVID-19 pandemic highlighted the complications of secondary fungal infections that occurred globally in severe cases of coronavirus disease managed in the intensive care units. Furthermore, varied underlying host factors, such as preexisting immunosuppression, the use of immunomodulatory agents, and invasive procedures predisposing lung tissues to fungal colonization and proliferation, caused increased susceptibility to fungal infections in COVID-19 patient populations. These invasive fungal infections directly impact the overall length of hospitalization and mortality. The most commonly reported fungal infections in patients with COVID-19 include aspergillosis, invasive candidiasis, and mucormycosis. An overall worldwide increase in the prevalence of candidiasis and aspergillosis was observed in COVID-19 patients , whereas outbreaks of mucormycosis were mainly recorded from India. Diagnostic challenges and limited antifungal treatment options make secondary fungal infections among COVID-19 patients more burdensome, which results in improper management and increased mortality.

Comparative genomics predict specific genes in potential mucorales identification

Mucoralean fungi could cause mucormycosis in humans, particularly in immunodeficient individuals and those with diabetes mellitus or trauma. With plenty of species and genera, their molecular identification and pathogenicity have a large deviation. Reported cases of mucormycosis showed frequent occurrence in Rhizopus species, Mucor species, and Lichtheimia species. We analyzed the whole genome sequences of 25 species of the top 10 Mucorales genera, along with another 22 important pathogenic non-Mucorales species, to dig the target genes for monitoring Mucorales species and identify potential genomic imprints of virulence in them. Mucorales-specific genes have been found in various orthogroups extracted by Python script, while genus-specific genes were annotated covering cellular structure, biochemistry metabolism, molecular processing, and signal transduction. Proteins related to the virulence of Mucorales species varied with distinct significance in copy numbers, in which Orthofinder was conducted. Based on our fresh retrospective analysis of mucormycosis, a comparative genomic analysis of pathogenic Mucorales was conducted in more frequent pathogens. Specific orthologs between Mucorales and non-Mucoralean pathogenic fungi were discussed in detail. Referring to the previously reported virulence proteins, we included more frequent pathogenic Mucorales and compared them in Mucorales species and non-Mucorales species. Besides, more samples are needed to further verify the potential target genes.

COVID-19-associated mucormycosis in India: Why such an outbreak?

An unprecedented mucormycosis outbreak occurred in India during the second COVID-19 wave in spring 2021. COVID-19-associated mucormycosis (CAM) was observed, mainly rhino-orbito-cerebral mucormycosis (ROCM), in patients with poorly controlled diabetes and treated with inappropriate doses of glucocorticoids. The aim of this mini-review was to compare the characteristics of the CAM epidemic in India with (i) mucormycosis cases before the COVID-19 pandemic and (ii) CAM in the rest of the world (particularly in France) in order to identify the reasons for this outbreak. In India, the major mucormycosis epidemiologic change during the COVID-19 pandemic was an increase in the percentage of patients treated with corticosteroids who developed CAM. Compared with the rest of the world, India reported a higher mucormycosis incidence even before the COVID-19 pandemic. Moreover, in India, patients with CAM were more likely to have diabetes mellitus and ROCM; conversely, mortality rates were lower. The reasons for such a localized epidemic in India have remained unclear, but some hypotheses can be put forward, particularly the combination of high prevalence of uncontrolled diabetes mellitus and frequent indiscriminate corticosteroid utilization in a country that already had a high mucormycosis burden before the COVID-19 pandemic.

A Retrospective Study to Evaluate the Perioperative Clinical Characteristics and Outcomes of Rhino-Orbital Cerebral Mucormycosis in COVID-19 Patients at a Tertiary Care Hospital in India

Background and aims A descriptive analysis of patients who underwent surgical debridement for coronavirus disease 2019 (COVID-19) related mucormycosis was described, which aimed at the evaluation of perioperative clinical characteristics, perioperative complications, and outcomes. Methods We conducted a retrospective study on patients who underwent surgical intervention for mucormycosis during the COVID-19 pandemic at a tertiary care institute in India from March 1, 2021, to June 30, 2021. The medical records of 92 patients were reviewed and analyzed. Results There was a male predominance with a mean age of 50.86 years. The most common comorbidity was diabetes mellitus (DM) (98.9%). Intra-operative complications included hypotension, hyperglycemia, and hypokalemia. Most of the patients (88%) were extubated inside the operation theater, and 48% of patients had mortality. Serum ferritin levels, computed tomography severity score (CTSS), and D-dimers were significantly high in the patient who had mortality. Conclusion The perioperative mortality in patients with COVID-19 associated mucormycosis was very high. DM was the most common comorbidity followed by hypertension. Pre-operative elevated serum ferritin, D-dimer, and high CTSS were associated with higher mortality; hypokalemia, followed by hypocalcemia, was the most common perioperative and post-operative electrolyte imbalance. Thorough pre-operative optimization, multidisciplinary involvement, and perioperative care are of the utmost importance to decrease mortality and improve outcomes.

COVID-related mucormycosis mimicking dental infection

A recent increase in the prevalence of mucormycosis of the head and neck in patients who have recovered from COVID-19 following hospitalization has been reported. A Majority of the cases have been reported from India. Conditions such as diabetes mellitus, use of corticosteroids for other autoimmune conditions, organ transplant, immunosuppression, immunodeficiency, and malignancies especially hematologic ones, are all known risk factors for mucormycosis. Recently, hospitalization for COVID-19 has been added to the list of risk factors for opportunistic mucormycosis infection. This is likely attributable to the high doses and prolonged use of corticosteroids in the treatment of hospitalized COVID-19 patients. Case Description: Two patients with post-COVID-19 associated rhinocerebral mucormycosis presented with profound unexplained dental disease including tooth mobility and dental abscess mimicking periodontal disease. The patients were previously hospitalized for COVID-19 and received prolonged treatment with high doses of corticosteroids. The patients responded well to the surgical debridement with or without antifungal therapy. Conclusion: Oral healthcare providers including oral and maxillofacial surgeons, dentists, dental hygienists, and other dental practitioners can play a vital role in the recognition and early diagnosis of rhinocerebral mucormycosis given the large number of patients with severe COVID-19 infection who have recovered following hospitalization and/or received long-term high doses of immunosuppressive treatment.

Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies

The incidence rate of invasive mucormycosis (IM) in patients with hematological malignancies (HMs) is increasing year by year, ranging from 0.07% to 4.29%, and the mortality rate is mostly higher than 50%. With the ongoing pandemic of COVID-19, COVID-19-associated mucormycosis (CAM) also became a global health threat. Patients with high risk factors such as active HMs, relapsed/refractory leukemia, prolonged neutropenia may still develop breakthrough mucormycosis (BT-MCR) even under the prophylaxis of Mucorales-active antifungals, and such patients often have higher mortality. Rhizopus spp. is the most common genus associated with IM, followed by Mucor spp. and Lichtheimia spp. Pulmonary mucormycosis (PM) is the most common form of IM in patients with HMs, followed by rhino-orbital-cerebral mucormycosis (ROCM) and disseminated mucormycosis. The prognosis of IM patients with neutrophil recovery, localized IM and receiving early combined medical-surgical therapy is usually better. As for management of the disease, risk factors should be eliminated firstly. Liposome amphotericin B (L-AmB) combined with surgery is the initial treatment scheme of IM. Those who are intolerant to L-AmB can choose intravenous formulations or tablets of isavuconazole or posaconazole. Patients who are refractory to monotherapy can turn to combined antifungals therapy.

Sphenoid sinus anatomical variants and pathologies: pictorial essay

The sphenoid sinus (SS) is one of the four paired paranasal sinuses (PNSs) within the sphenoid bone body. Isolated pathologies of sphenoid sinus are uncommon. The patient may have various presentations like headache, nasal discharge, post nasal drip, or non-specific symptoms. Although rare, potential complications of sphenoidal sinusitis can range from mucocele to skull base or cavernous sinus involvement, or cranial neuropathy. Primary tumors are rare and adjoining tumors secondarily invading the sphenoid sinus is seen. Multidetector computed tomography (CT) scan and magnetic resonance imaging (MRI) are the primary imaging modalities used to diagnose various forms of sphenoid sinus lesions and complications. We have compiled anatomic variants and various pathologies affecting sphenoid sinus lesions in this article.

COVID-19 and Mucormycosis of Orofacial Region: A Scoping Review

During the second wave of coronavirus disease, or COVID-19, infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in the year 2021 around the globe, there is a surge in the number of cases of mucormycosis or "Black Fungus" that is directly/indirectly associated with COVID-19. In this review article, mucormycosis of the orofacial region has gained importance from the maximum published literature (45 articles) from various databases like PubMed, Google Scholar, Scopus, Web of Science, and Embase. Rhino-orbital cerebral mucormycosis (ROCM) is a fatal condition associated with COVID-19 among categories of mucormycosis such as pulmonary, oral, gastrointestinal, cutaneous, and disseminated. ROCM targets the maxillary sinus, also involving teeth of the maxilla, orbits, and ethmoidal sinus. These are of particular interest to dentists and oral pathologists for proper diagnosis and identification. Co-morbid conditions, especially diabetes mellitus type II, have to be monitored carefully in COVID-19 patients as they have a higher risk of developing mucormycosis. In this review article, various presentations of COVID-19-linked mucormycosis are mentioned having particular emphasis on pathogenesis, signs and symptoms, clinical presentation, various diagnostic modalities including histopathology, radiology like CT and MRI, serology, tissue culture, various laboratory investigations, treatment protocols, management with prognosis, and so on. Any suspected case of mucormycosis needs quick detection and treatment since it progresses quickly due to the destructive course of infection. Long-term follow-up along with proper care is a must to detect any kind of recurrence.

Recommendations and guidelines for the diagnosis and management of Coronavirus Disease-19 (COVID-19) associated bacterial and fungal infections in Taiwan

Coronavirus disease-19 (COVID-19) is an emerging infectious disease caused by SARS-CoV-2 that has rapidly evolved into a pandemic to cause over 600 million infections and more than 6.6 million deaths up to Nov 25, 2022. COVID-19 carries a high mortality rate in severe cases. Co-infections and secondary infections with other micro-organisms, such as bacterial and fungus, further increases the mortality and complicates the diagnosis and management of COVID-19. The current guideline provides guidance to physicians for the management and treatment of patients with COVID-19 associated bacterial and fungal infections, including COVID-19 associated bacterial infections (CABI), pulmonary aspergillosis (CAPA), candidiasis (CAC) and mucormycosis (CAM). Recommendations were drafted by the 7th Guidelines Recommendations for Evidence-based Antimicrobial agents use Taiwan (GREAT) working group after review of the current evidence, using the grading of recommendations assessment, development, and evaluation (GRADE) methodology. A nationwide expert panel reviewed the recommendations in March 2022, and the guideline was endorsed by the Infectious Diseases Society of Taiwan (IDST). This guideline includes the epidemiology, diagnostic methods and treatment recommendations for COVID-19 associated infections. The aim of this guideline is to provide guidance to physicians who are involved in the medical care for patients with COVID-19 during the ongoing COVID-19 pandemic.

An insight into endophytic antimicrobial compounds: an updated analysis

Resistance in micro-organisms against antimicrobial compounds is an emerging phenomenon in the modern era as compared to the traditional world which brings new challenges to discover novel antimicrobial compounds from different available sources, such as, medicinal plants, various micro-organisms, like, bacteria, fungi, algae, actinomycetes, and endophytes. Endophytes reside inside the plants without exerting any harmful impact on the host plant along with providing ample of benefits. In addition, they are capable of producing diverse antimicrobial compounds similar to their host, allowing them to serve as useful micro-organism for a range of therapeutic purposes. In recent years, a large number of studies on the antimicrobial properties of endophytic fungi have been carried out globally. These antimicrobials have been used to treat various bacterial, fungal, and viral infections in humans. In this review, the potential of fungal endophytes to produce diverse antimicrobial compounds along with their various benefits to their host have been focused on. In addition, classification systems of endophytic fungi as well as the need for antimicrobial production with genetic involvement and some of the vital novel antimicrobial compounds of endophytic origin can further be utilized in the pharmaceutical industries for various formulations along with the role of nanoparticles as antimicrobial agents have been highlighted.

The current state of laboratory mycology in Asia/Pacific: A survey from the European Confederation of Medical Mycology (ECMM) and International Society for Human and Animal Mycology (ISHAM)

INTRODUCTION

Invasive fungal infections (IFIs) in Asia/Pacific are a particular threat to patients with malignancies, uncontrolled diabetes mellitus or undiagnosed/untreated human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS). Adequate and early access to diagnostic tools and antifungals is essential for IFI clinical management and patient survival.

METHODS

Details on institution profile, self-perception on IFI, and access to microscopy, culture, serology, antigen detection, molecular testing, and therapeutic drug monitoring for IFI were collected in a survey.

RESULTS

As of June 2022, 235 centres from 40 countries/territories in Asia/Pacific answered the questionnaire. More than half the centres were from six countries: India (25%), China (17%), Thailand (5%), Indonesia, Iran, and Japan (4% each). Candida spp. (93%) and Aspergillus spp. (75%) were considered the most relevant pathogens. Most institutions had access to microscopy (98%) or culture-based approaches (97%). Furthermore, 79% of centres had access to antigen detection, 66% to molecular assays, and 63% to antibody tests. Access to antifungals varied between countries/territories. At least one triazole was available in 93% of the reporting sites (voriconazole [89%] was the most common mould-active azole), whereas 80% had at least one amphotericin B formulation, and 72% had at least one echinocandin.

CONCLUSION

According to the replies provided, the resources available for IFI diagnosis and management vary among Asia/Pacific countries/territories. Economical or geographical factors may play a key role in the incidence and clinical handling of this disease burden. Regional cooperation may be a good strategy to overcome shortcomings.

A critical appraisal of mucormycosis in COVID- 19 patients in a tertiary care centre in India

Background and Purpose

Morbidity and mortality of opportunistic fungal infections in COVID-19 patients are less studied and defined. The patients receiving immunosuppressive therapy, broad-spectrum antibiotics, corticosteroids, and invasive and non-invasive ventilation are the high-risk groups.

Materials and Methods

The demographic profile as well as clinical and radiological findings of all the patients with COVID-19 suspected of Mucormycosis (MM) were recorded. The tissue samples from all the patients were sent for microbiological (KOH mount and culture) and histopathological analysis for confirmation of MM.

Results

In total, 45 COVID-19 patients suspected of MM were included in the study and MM was confirmed in 42 patients. The mean age of the patients was 50.30±14.17 years with a female: male ratio of 1.1:1. The most common symptom was headache (52.38%) followed by purulent nasal discharge (38.09%) and facial pain in 33.33% of the cases. The ocular symptoms included a diminution of vision (33.33%) and redness of the eye (2.38%). The most common site of involvement was rhino-orbital (42.85%) followed by sinonasal (23.80%) and rhino cerebral (19.04%). Majority (38.09%) of the patients were diagnosed with stage II of Rhino-orbital-cerebral Mucormycosis (ROCM) based on radiology. A history of diabetes mellitus and steroids was present in 97.61% and 85.71% of the cases, respectively. Moreover, KOH was positive for MM in 97.61% of the cases while the culture was positive in only 35.71% of the cases. In addition, on histopathology, MM was confirmed in 64.28 % of the cases. Mixed growth with Aspergillus species and Rhizopus species was observed in 14.28% of the cases in culture and 11.90% of the cases in histopathology test. Furthermore, angioinvasion was found in 23.80% of the cases according to the histopathology test.

Conclusion

Based on the results, the most common conditions associated with MM in COVID-19 patients were diabetes mellitus and steroid therapy. A high level of clinical suspicion aided with diagnostic tests, including KOH mount, culture, histopathology, and radiology which helped the early detection of opportunistic fungal infection in COVID-19 patients to ensure timely treatment.

Perturbations of immune landscape in COVID-19 associated mucormycosis

BACKGROUND

A rise in secondary fungal infections during the COVID-19 pandemic necessitates a deeper understanding of the associated immunological perturbations.

OBJECTIVES

To evaluate the clinical and immunological characteristics observed in patients with COVID-19 associated mucormycosis (CAM) infection.

PATIENTS/ METHODS

Cases of mucormycosis with or post-COVID-19 infection were compared with cases of acute COVID-19 and convalescent COVID-19. Lymphocyte subsets, cytokines and other laboratory markers were compared between the groups.

RESULTS

The frequency of proposed risk factors for CAM was diabetes mellitus (77%), recent history of steroid use (69%) and hypoxia during COVID-19 infection (52%). Iron metabolism was dysregulated in CAM patients with low TIBC and total iron. Further, CAM was accompanied with lymphopenia with drastic reduction in B cell counts; however, plasmablasts were not altered. Further, CAM patients had low immunoglobulin levels and antibodies specific to mucor peptide did not increase in CAM suggesting dysfunction in B-cell response. There was increase in activated effector cytotoxic CD8 T cells and NK cells in CAM compared with COVID-19 infection and healthy controls. Among T helper cells, Tregs were reduced and Th-1 frequency was increased in CAM compared with COVID-19 infection. A distinct cytokine signature was evident in CAM with increase in IL-1β, IFN-γ, IL-6, IL-22, IL-17A, IL-10, IL-2, IL-8, IL-7, IL-21 and GM-CSF.

CONCLUSION

This is the first study on immunophenotyping in CAM suggesting the need for long-term monitoring of B-cell function after SARS-CoV-2 in patients with dysregulated glycaemic control and the possible benefit of therapeutic supplementation with intravenous immunoglobulins in CAM.

Spotlight on the Mucormycosis Outbreak: A Deadly Fungal Infection That Followed the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic along with its treatment has brought myriad potential complications including the heightened risk of secondary fungal infections like mucormycosis. Mucormycosis is a rare angioinvasive fungal infection that has traditionally been highly fatal despite surgical intervention and antifungal medications.

AIM

To re-evaluate the risk factors, epidemiology, and possible COVID-19-associated conditions on a larger sample size than the existing data.

METHODOLOGY

We studied the possible risk factors, clinical presentations, treatment, and outcome of 203 patients with mucormycosis in a single-center retrospective-prospective observational study for three months at a tertiary care hospital after obtaining due permission from the institutional ethics committee.

RESULTS

The mean age of patients was 52 ± 11.5 years, and 92.61% had a history of COVID-19 infection. Around 86.7% of patients were suffering from diabetes mellitus with 50% being already known cases whereas the other 50% developed post-COVID-19 infection; 65.02% of patients were administered corticosteroids during their COVID-19 treatment. About 51.72% of patients required hospital admission and among them, 16.25% of patients required ICU support. The mean oxygen saturation (SpO2) levels on admission were 84.61 ± 12.96%, and 38.92% of patients required mechanical respiratory support. The mean duration between COVID-19 infection and the onset of mucormycosis was 18.80 ± 16.61 days. The most common clinical presentations were facial pain and swelling (26.6%) and ophthalmic symptoms including eye swelling, pain, and ptosis (25.12%). Antifungal treatment was given to all the patients and 89.36% of the patients underwent surgical debridement of fungal mass. At the end of three months, 60.59% of the 188 patients survived with improvement, 13.30% had no improvement and/or deterioration of health, and 18.72% succumbed to mucormycosis. Intracranial involvement and leukocytosis were positively associated with mortality whereas surgical intervention was significant for positive outcomes at the end of three months in patients with mucormycosis (p<0.05).

CONCLUSION

The sudden rise of mucormycosis during the second wave of COVID-19 can be attributed to uncontrolled blood sugar levels along with high corticosteroid usage as well as various nosocomial factors during the COVID-19 treatment. Early and aggressive treatment with surgical intervention and antifungal drugs can improve disease outcomes.

Black fungus outbreak in India - A direct consequence of COVID-19 surge: A myth or reality

The deadly second wave of COVID-19 has seen an unprecedented surge in mucormycosis associated mortality in India, overwhelming the heath authorities with challenges beyond measure. Also known as black fungus, this life-threatening fungal infection usually manifests in the nose, spreads to the eyes, and in some cases also to the brain. Immune suppression, pre-existing conditions, prolonged and indiscriminate use of steroids, and unhygienic environments are some of the widely recognized risk factors for contracting black fungus in individuals recovered from COVID-19. However, diagnosis of the infection remains insufficient due to the lack a holistic understanding of the possible risks, symptoms, and exposure pathways and therefore no definite protocol exists for managing this fatal infection. Here, we synthesize the current state of knowledge on black fungus outbreak in India and identify key gaps in its understanding with respect to potential risk factors leading to the widespread infection. We looked at 3354 black fungus cases in India, enlisting ailment history (particularly diabetes) and steroid usage in COVID-19 patients as the key factors responsible for exacerbating risks associated with the disease. However, we also press on the possibilities that other less studied non-traditional risk factors may also have a role in causing the infection. Black fungus is therefore a reality of COVID-19, with or without diabetes or steroid use needs to be investigated. We believe such a review is imperative for making informed decisions specially around timely diagnosis and channelizing efforts in controlling the spread of COVID-19 associated mucormycosis.

Surgical Challenges in the Management of Post COVID-19 Midface Mucormycosis (PCoMM): An Institutional Protocol

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has posed another serious threat, mucormycosis infection, affecting the maxilla and orbitocerebral region. This condition has not spared world population from its merciless claws. This article addresses the challenges faced by the maxillofacial surgeons in setting the protocols from preoperative diagnosis, surgical management to postoperative care, including short-term and long-term rehabilitation. To manage this relentlessly progressing condition, a multispecialty team approach is to be activated in diagnosing, managing, and rehabilitating the patients.

PURPOSE

The purpose of this clinical study is to document and analyze the clinical and demographic data, presentation of the lesion, the diagnostic methods followed for early clinical detection, and management of post COVID-19 midface mucormycosis. The article also discusses postoperative medical management and prosthetic rehabilitation.

RESULTS

Most of the mucormycosis cases reporting to our center were treated and recovered patients of Severe Acute Respiratory Syndrome Coronavirus 2 infection. Thirty-four (n=34) case were operated for post COVID-19 midface mucormycosis between October 2020 and December 2021. Male to Female ratio is 1:42. The average age of the patients was 57.5 years. Maximum patients were in fifth and sixth decade of life. Maxilla was the involved bone. Treatment was primarily surgical debridement to extended or radical maxillectomy. All patients were treated with Liposomal Amphotericin B and tab posaconazole for 3 to 4 weeks depending upon the age, weight, and physiological state of the patients to attain an optimal cumulative load. Three patients succumbed to illness postoperatively (n=3, 1.02%). Average duration of hospital stay was 47 days. The average review period was 5.1 months.

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 Phenotypes of COVID-19 Associated Mucormycosis (CAM): A Comprehensive Review

A mucormycosis surge was reported during the COVID-19 pandemic in India. A literature search until 14 July 2022, with the aim of updating COVID-19-associated mucormycosis (CAM), identified 663 studies and 88 met inclusion criteria (8727 patients). India reported 8388 patients, Egypt 208 and Europe 40. Rhino-orbito-cerebral mucormycosis (ROCM) was identified among 8082 (98.3%) patients, followed by 98 (1.2%) with pulmonary. In India, 82.6% of patients had diabetes mellitus, with 82% receiving corticosteroids. In Europe, 75% presented pulmonary CAM, 32.5% had diabetes and 40% were immunocompromised. CAM was identified at a median of 17.4 days (IQR 7.5 days) post COVID-19 diagnosis, and PCR was performed in five studies. Rhino-orbital invasion is clinically obvious, while cerebral involvement presents with cavernous sinus thrombosis, meningitis and cerebrovascular disease. Symptoms of pulmonary CAM usually overlap with severe COVID-19 pneumonia. High-dose liposomal Amphotericin B (and early surgical debridement in ROCM) are the mainstay of therapy. The median mortality rate was estimated to be 21.4% (IQR 31.9%), increased by the presence of pulmonary (80% (IQR 50%) or cerebral involvement (50% (IQR 63.9%). In summary, different CAM clinical phenotypes need to be distinguished, influenced by geographical presentation. Opportunities exist for diagnosis and therapy optimization, based on earlier high-dose antifungal therapy, early source control, strict glycemic control and restriction of steroids to COVID-19 patients with oxygen requirements.

Evaluation of the effect of the COVID-19 pandemic on mucormycosis studies with bibliometric analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) is a relatively new concept in the literature that emerged during the pandemic. Bibliometric analysis is a type of analysis that uses mathematical and statistical methods to study the formal properties of knowledge areas. This study aimed to reveal the main themes, conceptual structures, and trends of bibliometric studies on mucormycosis in 2 different periods, pre-and during the pandemic.

METHODS

This study consisted of 2 periods: pre-COVID-19 and COVID-19. Articles were collected from the Web of Science (WOS) Core Collection database. We provided AND and OR connectors for the keyword query and selected studies based on relevant keywords. Collected data were classified based on their publication date and examined using the R programming language (Version 4.0.3) package Bibliometrix and SciMAT Software.

RESULTS

A total of 1261 articles were investigated, and performance and information structure analyses were conducted. Based on Bradford's law, the Journal of Fungi was the top-ranked journal in both periods. Cureus and mycoses were placed 2nd and 3rd in the second period. India is the largest contributor. In performance analysis, conceptual structures such as Rhizopus oryzae, epidemiology, diagnosis, management, treatment, and outcomes were at the forefront of mucormycosis publications during the COVID-19 period.

CONCLUSIONS

Research trends have shifted to the clinical treatment and management of COVID-19. Therefore, pathogenesis, diagnosis, follow-up, and treatment strategies for CAM should be developed in the future.

Deadly Fungi: Invasive Fungal Rhinosinusitis in the Head and Neck

Invasive fungal rhinosinusitis (IFRS) is a serious infection that is associated with high morbidity and mortality rates. The incidence of IFRS has been increasing, mainly because of the increased use of antibiotics and immunosuppressive drugs. Rhino-orbital cerebral mucormycosis has recently reemerged among patients affected by COVID-19 and has become a global concern. The detection of extrasinus involvement in its early stage contributes to improved outcomes; therefore, imaging studies are essential in establishing the degree of involvement and managing the treatment properly, especially in immunocompromised patients. The common sites of extrasinus fungal invasion are the intraorbital, cavernous sinus, and intracranial regions. Fungi spread directly to these regions along the blood vessels or nerves, causing devastating complications such as optic nerve ischemia or compression, optic neuritis or perineuritis, orbital cellulitis, cavernous sinus thrombosis, mycotic aneurysm, vasculitis, internal carotid arterial occlusion, cerebral infarction, cerebritis, and brain abscess. IFRS has a broad imaging spectrum, and familiarity with intra- and extrasinonasal imaging features, such as loss of contrast enhancement of the affected region, which indicates tissue ischemia due to angioinvasion of fungi, and the surrounding anatomy is essential for prompt diagnosis and management. The authors summarize the epidemiology, etiology, risk factors, and complications of IFRS and review the anatomy and key diagnostic imaging features of IFRS beyond the sinonasal regions. ^©RSNA, 2022.

Pathogenesis and Pathology of COVID-Associated Mucormycosis: What Is New and Why

Purpose of Review

There is global increase in the incidence of mucormycosis. However, a sudden increase in the COVID-associated mucormycosis (CAM) was noted, particularly in India, during the second wave of the COVID-19 pandemic. The interplay of factors involved in the pathogenesis is complex. In this review, the influence of pre-existing disease, exaggerated risk factors, altered milieu due to COVID-19 itself and the consequences of its treatment on the host pathogen interactions leading to the disease and morphology of the fungus will be highlighted.

Recent Findings

Hyperglycemia, acidosis, available free iron, lowered host defenses, and the fungal virulence factors promote the growth of Mucorales. There is a high background prevalence of diabetes mellitus (DM) in India. Uncontrolled or undiagnosed DM, COVID-19 itself, and inappropriate administration of corticosteroids in high doses and for prolonged periods result in hyperglycemia. Diabetic ketoacidosis (DKA) and metabolic acidosis due to hypoxia or renal failure contribute to acidic pH and dissociate bound iron from serum proteins. The host defenses are lowered due to COVID-19-induced immune dysregulation, hyperglycemia itself, and administration of corticosteroids and immune suppressants for the treatment of COVID-19. The altered metabolic milieu in the local microenvironment of nose and paranasal sinuses (PNS) promotes specific interaction of glucose-regulated protein-78 (GRP-78) on host cells with spore coat protein homologue (CotH 3) on Mucorales resulting in rhino-orbito-cerebral mucormycosis (ROCM) as the predominant clinical form in CAM. The pathology is extensive soft tissue involvement with angioinvasion and perineural invasion. Melanized hyphae and sporangia were seen on histopathology, which is unique to CAM. While many factors favor the growth of Mucorales in CAM, hyperglycemia, hyperferritinemia, and administration of hyperbaric oxygen result in reactive oxygen species (ROS) and inadequate humidification results in dehydration. Melanization is possibly the adaptive and protective mechanism of Mucorales to escape the unfavorable conditions due to the treatment of COVID-19.

Summary

High background prevalence of DM, inappropriate administration of corticosteroids and immune dysregulation due to COVID-19 favor the growth of Mucorales in CAM. Melanization of Mucorales hyphae and sporangia on histopathology probably represent adaptive and protective mechanism due to the treatment with hyperbaric oxygen with inadequate humidification as well as the metabolic alterations.

Rhino-orbital-cerebral mucormycosis as a complication of coronavirus disease 2019

Coronavirus disease 2019 is a highly contagious respiratory disease caused by severe acute respiratory syndrome coronavirus 2. This disease as well as its various treatments like steroids, antivirals, and antibacterials can alter the immune state of the affected individuals and result in secondary infections such as mucormycosis. Mucormycosis is a well-known opportunistic fungal infection that affects immunocompromised subjects, particularly those with diabetes mellitus, prolonged antibiotic or steroid use, and patients with organ trans-plantation, neutropenia, and hematological malignancies. Rhino-orbital-cerebral mucormycosis is an aggressive disease owing to its ability to invade the blood vessels by fungal hyphae, leading to necrosis of the involved structures. Large cases were reported from India, indicating that this clinical entity shows a geographical variation. The affected patients are suffering on a clinical spectrum depending on the stage of the disease. Radiological assessment, including computerized tomography and magnetic resonance imaging, is necessary to evaluate the stage of the disease and choose the appropriate surgical treatment. A multidisciplinary approach is required to treat rhino-orbital-cerebral mucor-mycosis and includes local or intravenous antifungal drugs, debridement of the dead tissues, and appropriate management of any predisposing conditions. The disease has a very poor prognosis with a death rate of 50%. This review aimed to sum-marize the demographic and clinical risk factors, investigations, treatments, and outcomes of coronavirus disease 2019 patients with rhino-orbital-cerebral mucormycosis.

Changing Trend of Risk Factors of Mucormycosis Including Diabetes, Acidosis, and Serum Iron in the Second Wave of COVID-19

To analyze the clinic-pathological profile of patients presenting with mucormycosis infection to a tertiary care center during the second wave of the COVID-19 pandemic in India. This descriptive cross-sectional study was conducted in a hospital setting from April 2021 to July 2021 and analysis was carried out to find associations between the stratified data and the extent of the disease involvement based on radiological findings. Statistical tests like percentage, average, chi-square test, etc. were used wherever relevant using software called Minitab13. All the 51 patients had involvement of at least one paranasal sinus. The incidence of previously established risk factors was diabetes (66.67%), history of severe COVID-19 disease (5.88%), raised serum iron levels (1.96%), Acidosis (3.92%), steroid administration (62.75%), oxygen administration (25.49%). Elevated serum urea levels (76.47%), alkalosis in 50.98% and hyperglycemia on multiple occasions (41.17%) were observed. The mean days between start of treatment for COVID-19 and appearance of first symptom suggesting mucormycosis were found to be 27.59 days. Only in 5.88% participants mucormycosis preceded COVID-19 infection detection. The current work finds presence of traditional risk factors and associations in significantly lower frequencies than the reviewed literature. However, blood urea was elevated in three fourths of the participants. Larger scale studies in mucormycosis patients are warranted for finding the role of other risk factors including possible role of elevated blood urea and hyperglycemia in the present era.

Mucormycosis co-infection in COVID-19 patients: An update

Mucormycosis (MCM) is a rare fungal disorder that has recently been increased in parallel with novel COVID-19 infection. MCM with COVID-19 is extremely lethal, particularly in immunocompromised individuals. The collection of available scientific information helps in the management of this co-infection, but still, the main question on COVID-19, whether it is occasional, participatory, concurrent, or coincidental needs to be addressed. Several case reports of these co-infections have been explained as causal associations, but the direct contribution in immunocompromised individuals remains to be explored completely. This review aims to provide an update that serves as a guide for the diagnosis and treatment of MCM patients' co-infection with COVID-19. The initial report has suggested that COVID-19 patients might be susceptible to developing invasive fungal infections by different species, including MCM as a co-infection. In spite of this, co-infection has been explored only in severe cases with common triangles: diabetes, diabetes ketoacidosis, and corticosteroids. Pathogenic mechanisms in the aggressiveness of MCM infection involves the reduction of phagocytic activity, attainable quantities of ferritin attributed with transferrin in diabetic ketoacidosis, and fungal heme oxygenase, which enhances iron absorption for its metabolism. Therefore, severe COVID-19 cases are associated with increased risk factors of invasive fungal co-infections. In addition, COVID-19 infection leads to reduction in cluster of differentiation, especially CD4+ and CD8+ T cell counts, which may be highly implicated in fungal co-infections. Thus, the progress in MCM management is dependent on a different strategy, including reduction or stopping of implicit predisposing factors, early intake of active antifungal drugs at appropriate doses, and complete elimination via surgical debridement of infected tissues.

Diabetes mellitus and other underlying conditions in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis: a systematic review and meta-analysis

OBJECTIVE

This study aimed to compute the pooled prevalence of diabetes mellitus and other underlying conditions in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis.

METHOD

A systematic literature review was performed in PubMed, Scopus, Web of Science, Embase and Google Scholar. The cross-sectional studies that reported the frequency of diabetes mellitus in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis were included.

RESULTS

Eighteen eligible studies with a total number of 3718 patients were included in the current study. The pooled prevalence of diabetes in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis was 89 per cent and with new-onset diabetes was 32 per cent. The pooled prevalence of steroid use was high (79 per cent) too. The all-cause mortality rate was 24 per cent.

CONCLUSION

Diabetes mellitus was the most frequent underlying condition in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis. The second most frequent underlying condition was steroid use during coronavirus disease 2019 infection. The appropriate control of hyperglycaemia and rational prescription of steroids during the treatment of coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis is recommended.

Comparative risk assessment of COVID‐19 associated mucormycosis and aspergillosis: A systematic review

COVID‐19 is not only limited to a defined array but also has expanded with several secondary infections. Two uncommon opportunistic fungal infections, COVID‐19 associated mucormycosis (CAM) and aspergillosis (CAA), have recently been highly acquainted by many worldwide cases. Two immune response deteriorating factors are considered to be responsible for immunosuppression: comorbidities and medication. Due to unlike infection sites and patterns, CAM and CAA‐associated factors deflect a few degrees of proximity, and the present study is for its assessment. The study evaluated 351 CAM cases and 191 CAA cases retrieved from 65 and 53 articles based on inclusion criteria, respectively. Most of the CAM reported from India and CAA were from four South‐European and West‐European neighbor countries. The mean ages of CAM and CAA were 52.72 ± 13.74 and 64.81 ± 11.14, correspondingly. Mortality of CAA (56.28%) was two times greater than CAM (26.02%). Nevertheless, the count of diabetes cases was very high in CAM compared to CAA. The main comorbidities of CAM were diabetes (nearly 80%) and hypertension (more than 38%). All noticeable complications were higher in CAA except diabetes, and these were diabetes (34.55%), hypertension (45.03%), and obesity (18.32%). Moreover, pre‐existing respiratory complications like asthma and chronic obstructive pulmonary disease are visible in CAA. The uses of steroids in CAM and CAA were nearly 70% and 66%, respectively. Almost one‐fourth of CAA cases were reported using immunosuppressant monoclonal antibodies, whereas only 7.69% were for CAM. The overall finding highlights diabetes, hypertension, and steroids as the risk factors for CAM, whereas obesity, chronic pulmonary disease, and immunosuppressants for CAA.

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.

Bronchial wall necrosis secondary to mucormycosis following SARS-Cov2 infection: A case report

Coronavirus 2019 infection (COVID-19) has a broad spectrum of clinical complications, some unrecognized. Herein, a case of a diabetic patient with multiple episodes of hemoptysis 2 months following her recovery from SARS-CoV-2 infection is reported. The initial computed tomography (CT scan) revealed the left lower lobe collapsed secondary to bronchial narrowing and obliteration. Bronchoscopy was performed, indicating necrotic endobronchial tissue, which was confirmed histopathologically as invasive mucormycosis. Bronchial necrosis due to mucormycosis is an unusual presentation of COVID-19-associated pulmonary mucormycosis. The accurate diagnosis could be challenging as it can resemble other pathologies such as malignancies. Therefore, it is crucial to identify this fatal complication in patients with prolonged COVID-19 and lung collapse.

Computer-Aided Tools and Resources for Fungal Pathogens: An Application of Reverse Vaccinology for Mucormycosis

Increasing fungal infections in immunocompromised hosts are a growing concern for global public health. Along with treatments, preventive measures are required. The emergence of reverse vaccinology has opened avenues for using genomic and proteomic data from pathogens in the design of vaccines. In this work, we present a comprehensive collection of various computational tools and databases with potential to aid in vaccine development. The ongoing pandemic has directed attention toward the increasing number of mucormycosis infections in COVID-19 patients. As a case study, we developed a computational pipeline for assisting vaccine development for mucormycosis. We obtained 6 proteins from 29,447 sequences from UniProtKB as potential vaccine candidates against mucormycosis, fulfilling multiple criteria. These criteria included potential characteristics, namely adhesin properties, surface or extracellular localization, antigenicity, no similarity to any human proteins, nonallergenicity, stability in vitro, and expression in fungal cells. These six proteins were predicted to have B cell and T cell epitopes, proinflammatory inducing peptides, and orthologs in several mucormycosis-causing species. These data could aid in vaccine development against mucormycosis for at-risk individuals.

COVID-19-Associated Pulmonary Mucormycosis

COVID-19-associated mucormycosis (CAM) emerged as an epidemic in certain parts of the world amidst the global COVID-19 pandemic. While rhino–orbital mucormycosis was well reported during the pandemic, in the absence of routine diagnostic facilities including lower airway sampling, pulmonary mucormycosis was probably under-recognized. In this review, we have focused on the epidemiology and management of COVID-19-associated pulmonary mucormycosis (CAPM). CAPM is a deadly disease and mortality can be as high as 80% in the absence of early clinical suspicion and treatment. While histopathological examination of tissue for angio-invasion and cultures have remained gold standard for diagnosis, there is an increasing interest in molecular and serological methods to facilitate diagnosis in critically ill patients and often, immune-suppressed hosts who cannot readily undergo invasive sampling. Combined medical and surgical treatment offers more promise than standalone medical therapy. Maintaining adequate glycemic control and prudent use of steroids which can be a double-edged sword in COVID-19 patients are the key preventative measures. We would like to emphasize the urgent need for the development and validation of reliable biomarkers and molecular diagnostics to facilitate early diagnosis.

COVID ‐19‐associated facial cutaneous mucormycosis superinfection: A potentially life‐threatening disease

A 49‐year‐old male was involved in an accident and an abdominal computer tomographic examination revealed papillary renal cell carcinoma of the right kidney. During hospitalization, the patient was infected with COVID‐19. In the following COVID‐19 treatment, a black dot developed on the right side of the head and face. Antifungal therapy and surgical debridement were initiated and gradual improvement was observed.

COVID‐19 infection is spreading rapidly and mucormycosis is an invasive fungal infection which causes a high rate of mortality. Early diagnosis and prompt treatment can result in better outcome of the patient.

Histomorphological features of mucormycosis with rise and fall of COVID-19 pandemic

Introduction

Due to Corona Virus disease -19, India saw a surge of mucormycosis cases, associated with high death rate. India, during the month of May to July 2021 saw a surge of mucormycosis from all states, with close to 50,000 cases just in a span of 3 months.

Objective

To examine the histopathological appearances of rhino-orbital/rhino-maxillary/sino-nasal mucormycosis in the backdrop of the ongoing COVID 19 pandemic.

Material and methods

The study involved analysis of 60 biopsy samples of suspected rhino-maxillary /rhino-orbital mucormycosis received from post-COVID-19 patients. A preliminary review of the slides showing hyphal forms of fungal organisms with un-doubtful tissue / mucosal invasion was included. All samples were examined under Hematoxylin and Eosin stains along with special fungal stains. Data thus obtained were analyzed statistically. Special stains for fungus namely Periodic Acidic Schiff (PAS) and Gomori Methenamine silver (GMS) were utilized to confirm and/or to differentiate the fungal organisms and to highlight the cell wall of the fungus.

Results

The mean age of the patients with mucormycosis was 51.68 years and 72 (83.33%) of them were males. Acute type of inflammation was noted in 44 (73.33%), granulomatous inflammation in 14 (23.33%) of cases. Bony invasion and perineural invasion was observed in 5 (8.33%) and 55 (91.67%) cases, respectively. The dominant fungus were mucorales in 58 (96.67%), aspergillous, along with mucorales in 12 (20%) and combination of mucorales and candida identified in 8 (13.33%) cases.

Conclusion

Besides all the histological appearance of angioinvasion, bone, and soft tissue invasion, a notable aspect was the shift in inflammatory pattern, which was more granulomatous in nature, with a decrease in fungal load correlating with the drop of COVID second wave. This proves that as immunity develops, the host's response to secondary opportunistic infections changes.

How Does SARS-CoV-2 Affect Our Eyes-What Have We Learnt So Far about the Ophthalmic Manifestations of COVID-19?

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection has become a worldwide threat resulting in a pandemic in 2020. SARS-CoV-2 infection manifests itself as coronavirus disease 2019 (COVID-19) that is evidenced in a vast number of either specific or nonspecific symptoms. Except for typical (but nonspecific) symptoms such as fever, dry cough, or muscle weakness, the infected patients might also present atypical symptoms including neurological, dermatological, or ophthalmic manifestations. This paper summarizes the current state of knowledge regarding the onset, progression, and types of ophthalmic symptoms induced by SARS-CoV-2 infection recognized amongst the infected patients.

Rhino-orbito-cerebral mucormycosis caused by Rhizopus microsporus var. microsporus in a diabetic patient with COVID-19

COVID-19 disease caused by the SARS-CoV-2 coronavirus causes a wide range of clinical manifestations, ranging from mild to severe, with the main ones affecting the respiratory tract, such as pneumonia. In patients with greater severity, the high frequency of bacterial and fungal coinfection stands out, a situation related both to the patient's pre-existing comorbidities and due to the hospitalization itself. Cases of mucormycosis associated with COVID-19 were highlighted in the lay and scientific media, with the increase in mycosis cases being directly and indirectly attributed to the viral infection. This report describes a case of rhino-orbito-cerebral mucormycosis in a diabetic patient hospitalized for COVID-19, whose diagnosis was confirmed by identifying the agent Rhizopus microsporus var. microsporus through culture for fungi and PCR examination.

Pneumonitis and Pulmonary Mucormycosis in a Covid-19 Positive Patient-A Case Report

In the wake of second wave of coronavirus disease (Covid-19), an increased number of mucormycosis cases were reported by the Ministry of Health and Family Welfare in India. A total of 45 432 cases of mucormycosis were reported till mid-July 2021, with 4252 fatalities. Mucormycosis and other fungal infections are most commonly seen as an opportunistic infection. They are found in those with low underlying immunity either due to a diabetes, cancers particularly hematological malignancies, and so on, or as a side effect of prolonged/irrational use of certain drugs like steroids, immunosuppressive drugs for management of other disorders including Covid-19. The Health Authorities in India stated that although it is not a new disease, its true incidence during the beginning of the second wave was unknown as it was not a notifiable disease. As per reports, the most common presentations of mucormycosis included rhinocerebral (77.6%), cutaneous (4.3%), and pulmonary (3.0%). We present a case of pulmonary mucormycosis and pneumonitis in a Covid-19 positive patient brought for autopsy. The patient was an under trial prisoner sent for treatment to our facility who was reported Covid positive.

Unnecessary Use of Corticosteroids for managing early mild symptoms of COVID-19 may lead to Rhino-ortibal-cerebral mucormycosis in Patients with Diabetes – a case series from Lahore, Pakistan

Rhino-orbital-cerebral mucormycosis (ROCM), a rare but fatal fungal infection, has recently emerged as a serious complication after corticosteroids therapy in COVID-19 patients, predominantly in diabetic and immunocompromised patients. The World Health Organization (WHO) COVID-19 current guidelines recommend corticosteroids administration in hospitalized COVID-19 patients requiring supplementary oxygen or mechanical ventilation. Herein, we report a case series of seven patients with COVID-19; three mild, three moderate, and one severe, from Lahore, Pakistan; all were using corticosteroids for managing their early mild symptoms of COVID-19 at home for around 2–3 weeks without a physician’s advise, presented, and admitted with ROCM to Mayo hospital, Lahore, from March to June 2021. Out of the seven patients, five patients had uncontrolled diabetes mellitus (DM) as comorbidity. Eye pain, facial swelling and pain, nasal blockage, and black coloration around eyes, on palate, and oral mucosa were the presenting complaints at the time of admission. All the patients had radiographic imaging, including computed tomography (CT), paranasal sinuses (PNS), or brain magnetic resonance imaging (MRI) carried out at the hospital, which confirmed mucosal thickening and adjacent sinus bony erosions with intracranial extension. All the patients were treated with local debridement of the infected necrotic tissue along with intravenous liposomal Amphotericin B and Posaconazole or Amphotericin B depending on the case. Due to timely management, in six out of seven patients, prognosis was good due to early diagnosis and treatment, while one patient with severe COVID-19 illness deteriorated and died. The misuse of corticosteroids for managing early mild symptoms of COVID-19 in diabetic and other immunocompromised patients can lead to fatal ROCM, which can further increase their risk of developing severe COVID-19 and mortality. It is stressed that only physician’s recommended therapeutic advice should be followed for managing early mild symptoms of COVID-19 in self-isolation and avoid the unnecessary use of corticosteroids. This case series also emphasizes that COVID-19 diabetic patients treated with corticosteroids need more vigilant monitoring and high suspicion of early diagnosis and treatment of invasive fungal infection. Early diagnosis and management can reduce morbidity and mortality.

Mucormycosis and COVID-19-Associated Mucormycosis: Insights of a Deadly but Neglected Mycosis

The ongoing COVID-19 pandemic has quickly become a health threat worldwide, with high mortality and morbidity among patients with comorbidities. This viral infection promotes the perfect setting in patients for the development of opportunistic infections, such as those caused by fungi. Mucormycosis, a rare but deadly fungal infection, has recently increased its incidence, especially in endemic areas, since the onset of the pandemic. COVID-19-associated mucormycosis is an important complication of the pandemic because it is a mycosis hard to diagnose and treat, causing concern among COVID-19-infected patients and even in the already recovered population. The risk factors for the development of mucormycosis in these patients are related to the damage caused by the SARS-CoV-2 itself, the patient’s overstimulated immune response, and the therapy used to treat COVID-19, causing alterations such as hyperglycemia, acidosis, endothelial and lung damage, and immunosuppression. In this review, the molecular aspects of mucormycosis and the main risk factors for the development of COVID-19-associated mucormycosis are explained to understand this virus–fungi–host interaction and highlight the importance of this neglected mycosis.