Mucormycosis associated with COVID-19 in two kidney transplant patients

Mucormycosis and COVID-19: Unraveling the Interplay of Fungal Infection in a Global Health Crisis: An Overview

The healthcare system has been greatly affected by the COVID-19 pandemic, resulting in an increase in secondary and co-infections among patients. Factors like pulmonary damage and weakened immune systems make patients more susceptible to fungal infections. Mucormycosis, an opportunistic fungal infection, prospers in environments with limited oxygen, and elevated glucose levels due to conditions such as diabetes and steroid use, as well as in acidic environments from metabolic acidosis and diabetic ketoacidosis, where it demonstrates heightened germination ability. Recognizing these complications is critical to minimize harm to patients. The insights gained from this review can improve our understanding of how fungal infections develop in connection to COVID-19, leading to better predictive algorithms, tailored care plans, enhanced antifungal treatments, quicker diagnostics, and improved management strategies.

Epidemiology, Clinical Manifestations, and Outcome of Mucormycosis in Solid Organ Transplant Recipients: A Systematic Review of Reported Cases

Mucormycosis is an emerging disease primarily affecting the immunocompromised host, but scarce evidence is available for solid organ transplant recipients (SOTRs). We systematically reviewed 183 cases occurring in SOTRs, exploring epidemiology, clinical characteristics, causative pathogens, therapeutic approaches, and outcomes. Kidney transplants accounted for half of the cases, followed by heart (18.6%), liver (16.9%), and lung (10.4%). Diagnosis showed a dichotomous distribution, with 63.7% of cases reported within 100 days of transplantation and 20.6% occurring at least 1 year after transplant. The 90-day and 1-year mortality rates were 36.3% and 63.4%, respectively. Disseminated disease had the highest mortality at both time points (75% and 93%). Treatment with >3 immunosuppressive drugs showed a significant impact on 90-day mortality (odds ratio [OR], 2.33; 95% CI, 1.02-5.66; P = .0493), as did a disseminated disease manifestation (OR, 8.23; 95% CI, 2.20-36.71; P = .0027) and the presence of diabetes (OR, 2.35; 95% CI, 1.01-5.65; P = .0497). Notably, prophylaxis was administered to 12 cases with amphotericin B. Further investigations are needed to validate these findings and to evaluate the potential implementation of prophylactic regimens in SOTRs at high risk.

COVID-19-Associated Rhino-Orbito-Cerebral Mucormycosis: A Single Tertiary Care Center Experience of Imaging Findings With a Special Focus on Intracranial Manifestations and Pathways of Intracranial Spread

Background and objective The COVID-19 pandemic and mucormycosis epidemic in India made research on the radiological findings of COVID-19-associated mucormycosis imperative. This study aims to describe the imaging findings in COVID-19-associated mucormycosis, with a special focus on the intracranial manifestations.  Methodology Magnetic resonance imaging (MRI) scans of all patients with laboratory-proven mucormycosis and post-COVID-19 status, for two months, at an Indian Tertiary Care Referral Centre, were retrospectively reviewed, and descriptive statistical analysis was carried out. Results A total of 58 patients (47 men, 81%, and 11 women, 19%) were evaluated. Deranged blood glucose levels were observed in 47 (81%) cases. The intracranial invasion was detected in 31 (53.4%) patients. The most common finding in cases with intracranial invasion was pachymeningeal enhancement (28/31, 90.3%). This was followed by infarcts (17/31, 55%), cavernous sinus thrombosis (11/58, 18.9%), fungal abscesses (11/31, 35.4%), and intracranial hemorrhage (5/31, 16.1% cases). The perineural spread was observed in 21.6% (11/51) cases. Orbital findings included extraconal fat and muscle involvement, intraconal involvement, orbital apicitis, optic neuritis, panophthalmitis, and orbital abscess formation in decreasing order of frequency. Cohen's kappa coefficient of interrater reliability for optic nerve involvement and cavernous sinus thrombosis was 0.7. Cohen's coefficient for all other findings was 0.8-0.9. Conclusions COVID-19-associated rhino-orbito-cerebral mucormycosis has a plethora of orbital and intracranial manifestations. MRI, with its superior soft-tissue resolution and high interrater reliability, as elucidated in this study, is the imaging modality of choice for expediting the initial diagnosis, accurately mapping out disease extent, and promptly identifying and scrupulously managing its complications.

The potential for rapid antigen testing for mucormycosis in the context of COVID-19

INTRODUCTION

Mucormycosis is a highly aggressive angio-invasive disease of humans caused by Mucorales fungi. Prior to the COVID-19 pandemic, mucormycosis was a rare mycosis typically seen in immunocompromised patients with hematological malignancies or in transplant recipients. During the second wave of the pandemic, there was a dramatic increase in the disease, especially in India where a unique set of circumstances led to large numbers of life-threatening and disfiguring rhino-orbital-cerebral mucormycosis (ROCM) infections.

AREAS COVERED

The review examines mucormycosis as a super-infection of COVID-19 patients, and the risk factors for COVID-19-associated mucormycosis (CAM) that drove the ROCM epidemic in India. The limitations of current diagnostic procedures are identified, and the measures needed to improve the speed and accuracy of detection discussed.

EXPERT OPINION

Despite increased awareness, global healthcare systems remain unprepared for further outbreaks of ROCM. Current diagnosis of the disease is slow and inaccurate, negatively impacting on patient survival. This is most evident in low- to middle-income countries which lack suitably equipped diagnostic facilities for rapid identification of the infecting pathogens. Rapid antigen testing using point-of-care lateral-flow assays could potentially have aided in the quick and accurate diagnosis of the disease, allowing earlier intervention with surgery and Mucorales-active antifungal drugs.

COVID-19-Associated Rhinocerebral Mucormycosis, an Incidental Finding or a Matter of Concern - Mixed-Method Systematic Review

With the advent of COVID-19, the number of patients diagnosed with mucormycosis has increased, especially in developing countries. The reason behind this increase is that COVID-19 causes hypoxia that promotes the growth of fungus. To identify the association between mucormycosis and COVID-19, in critically ill or immunocompromised COVID-19 patients. The literature included in the review was researched from October 1, 2021, to November 1, 2022, by using the Google Scholar database as the search engine. Of the 20 articles included, there were 4 case reports, 2 case series, 10 narrative reviews, and 4 quantitative studies. Mucormycetes growth is caused by several factors, including hyperglycemia owing to previously existing diabetes or excessive use of steroids, increased ferritin levels owing to the inflammatory cascade initiated by COVID-19, and immunosuppression caused by the use of steroids or other immunosuppressive therapy. Reduced white-cell count and activity in COVID-19 leads to increased germination of fungal spores hence developing a catastrophic picture of rhinocerebral mucormycosis. Considering that the hematological patient is frequently treated with cortisone, immunosuppressed due to the underlying condition, but also through the administered therapy, the association with a possible diabetes makes this patient susceptible to developing rhinocerebral mucormycosis during COVID-19 infection. Despite being severe, the association between mucormycosis and COVID-19 is specific and treatable. Development of mucormycosis in hematological patients suffering from severe COVID-19 disease is dangerous, yet not compulsory and can be prevented. Using a common steroid-dose protocol with hyperbaric oxygen and necessary preventive measure reveals the disease as a superadded infection. Hypoxia, poor glycemic control and overuse of steroids or immunosuppressive drugs cause it.

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.

Case report: The clinical utility of metagenomic next-generation sequencing in mucormycosis diagnosis caused by fatal Lichtheimia ramosa infection in pediatric neuroblastoma

Lichtheimia ramosa (L. ramosa) is an opportunistic fungal pathogen of the order Mucorales that may result in a rare but serious mucormycosis infection. Mucormycosis could be angioinvasive, causing thrombosis and necrosis in the nose, brain, digestive tract, and respiratory tract. The infection is highly lethal, especially in immunocompromised hosts, and the incidence has been on the rise. However, due to its relatively low incidence in pediatric population and the challenges with diagnosis, the awareness and management experience for pediatric mucormycosis are extremely limited, which might lead to poor outcomes. In this study, we comprehensively reviewed the course of a fatal rhinocerebral mucormycosis case in a pediatric neuroblastoma patient receiving chemotherapy. Due to a lack of awareness of the infection, the standard care of amphotericin B treatment was delayed and not administered until the identification of L. ramosa by metagenomic next-generation sequencing (mNGS)-based pan-pathogen detection of the patient's peripheral blood sample. We also reviewed the literature on L. ramosa infection cases reported worldwide between 2010 and 2022, with an analysis of clinical manifestation, prognosis, and epidemiological data. Our study not only highlighted the clinical value of comprehensive mNGS in rapid pathogen detection but also raised awareness of recognizing lethal fungal infection early in immunocompromised hosts including pediatric cancer patients.

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.

COVID-19 and Fungal Infections: A Double Debacle

Fungal infections remain hardly treatable because of unstandardized diagnostic tests, limited antifungal armamentarium, and more specifically, potential toxic interactions between antifungals and immunosuppressants used during anti-inflammatory therapies, such as those set up in critically ill COVID-19 patients. Taking into account pre-existing difficulties in treating vulnerable COVID-19 patients, any co-occurrence of infectious diseases like fungal infections constitutes a double debacle for patients, healthcare experts, and the public economy. Since the first appearance of SARS-CoV-2, a significant rise in threatening fungal co-infections in COVID-19 patients has been testified in the scientific literature. Better management of fungal infections in COVID-19 patients is, therefore, a priority and requires highlighting common risk factors, relationships with immunosuppression, as well as challenges in fungal diagnosis and treatment. The present review attempts to highlight these aspects in the three most identified causative agents of fungal co-infections in COVID-19 patients: Aspergillus, Candida, and Mucorales species.

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.

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.

COVID-19-Associated Mucormycosis: A Matter of Concern Amid the SARS-CoV-2 Pandemic

Mucormycosis is an invasive fungal infection caused by fungi belonging to order Mucorales. Recently, with the increase in COVID-19 infections, mucormycosis infections have become a matter of concern globally, because of the high morbidity and mortality rates associated with them. Due to the association of mucormycosis with COVID-19 disease, it has been termed COVID-19-associated mucormycosis (CAM). In the present review, we focus on mucormycosis incidence, pathophysiology, risk factors, immune dysfunction, interactions of Mucorales with endothelial cells, and the possible role of iron in Mucorales growth. We review the limitations associated with current diagnostic procedures and the requirement for more specific, cost-effective, convenient, and sensitive assays, such as PCR-based assays and monoclonal antibody-based assays for the effective diagnosis of mucormycosis. We discuss the current treatment options involving antifungal drug therapies, adjunctive therapy, surgical treatment, and their limitations. We also review the importance of nutraceuticals-based therapy for the prevention as well as treatment of mucormycosis. Our review also highlights the need to explore the potential of novel immunotherapeutics, which include antibody-based therapy, cytokine-based therapy, and combination/synergistic antifungal therapy, as treatment options for mucormycosis. In summary, this review provides a complete overview of COVID-19-associated mucormycosis, addressing the current research gaps and future developments required in the field.

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.

Fungal Infection in Co-infected Patients With COVID-19: An Overview of Case Reports/Case Series and Systematic Review

Fungal co-infections are frequent in patients with coronavirus disease 2019 (COVID-19) and can affect patient outcomes and hamper therapeutic efforts. Nonetheless, few studies have investigated fungal co-infections in this population. This study was performed to assess the rate of fungal co-infection in patients with COVID-19 as a systematic review. EMBASE, MEDLINE, and Web of Science were searched considering broad-based search criteria associated with COVID-19 and fungal co-infection. We included case reports and case series studies, published in the English language from January 1, 2020 to November 30, 2021, that reported clinical features, diagnosis, and outcomes of fungal co-infection in patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Totally, 54 case reports and 17 case series were identified, and 181 patients (132 men, 47 women, and 2 not mentioned) co-infected with COVID-19 and fungal infection enrolled. The frequency of fungal co-infection among patients with COVID-19 was 49.7, 23.2, 19.8, 6.6, and 0.5% in Asia, America, Europe, Africa, and Australia, respectively. Diabetes (59.6%) and hypertension (35.9%) were found as the most considered comorbidities in COVID-19 patients with fungal infections. These patients mainly suffered from fever (40.8%), cough (30.3%), and dyspnea (23.7%). The most frequent findings in the laboratory results of patients and increase in C-reactive protein (CRP) (33.1%) and ferritin (18.2%), and lymphopenia (16%) were reported. The most common etiological agents of fungal infections were Aspergillus spp., Mucor spp., Rhizopus spp., and Candida spp. reported in study patients. The mortality rate was 54.6%, and the rate of discharged patients was 45.3%. Remdesivir and voriconazole were the most commonly used antiviral and antifungal agents for the treatment of patients. The global prevalence of COVID-19-related deaths is 6.6%. Our results showed that 54.6% of COVID-19 patients with fungal co-infections died. Thus, this study indicated that fungal co-infection and COVID-19 could increase mortality. Targeted policies should be considered to address this raised risk in the current pandemic. In addition, fungal infections are sometimes diagnosed late in patients with COVID-19, and the severity of the disease worsens, especially in patients with underlying conditions. Therefore, patients with fungal infections should be screened regularly during the COVID-19 pandemic to prevent the spread of the COVID-19 patients with fungal co-infection.

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.

Rare and Unusual Follow-up Sequelae of Coronavirus Disease 2019: Splenic Mucormycosis in a Renal Transplant Recipient

BACKGROUND

Coronavirus disease 2019 (COVID-19) is associated with adverse outcomes in transplantation communities. Mucormycosis, although a rare infection, has been classically linked to organ transplantation and is associated with exceptionally high morbidity and mortality rates. In this pandemic era, the double infection of mucormycosis and COVID-19 is a lethal combination but is rarely described in the literature on organ transplantation.

CASE PRESENTATION

This article presents the case of a young kidney transplant recipient with diabetes who acquired severe COVID-19, followed by disseminated mucormycosis. The patient was a health care worker who developed severe COVID-19, for which he received remdesivir, anticoagulation, and dexamethasone. No immunomodulatory therapy was used. His maximum oxygen support was bilevel positive airway pressure ventilation. His sugar levels were frequently deranged during the stay. He developed secondary sepsis with Klebsiella, followed by nonhealing lung consolidation. He later developed pleural effusion and splenic abscess, which was detected incidentally. He underwent an emergency splenectomy, the culture of which yielded mucormycosis. Liposomal amphotericin B 5 mg/kg was administered. The patient deteriorated, and a repeat laparotomy yielded gastric perforation, with pus culture showing mucormycosis. The patient died after a long hospital stay.

CONCLUSIONS

The diagnosis and management of this dual infection during the pandemic is extremely challenging. In this case, the unusual location of mucormycosis complicating COVID-19 calls for a meticulous approach to opportunistic fungal infections in organ transplant recipients who are positive for COVID-19, especially in those patients with diabetes.

Mucormycosis as SARS-CoV2 sequelae in kidney transplant recipients: a single-center experience from India

PURPOSE

Coronavirus disease (COVID-19) sequelae in the transplant population are scarcely reported. Post-COVID-19 mucormycosis is one of such sequelae, which is a dreadful and rare entity. The purpose of this report was to study the full spectrum of this dual infection in kidney transplant recipients (KTR).

METHODS

We did a comprehensive analysis of 11 mucormycosis cases in KTR who recovered from COVID-19 in IKDRC, Ahmedabad, Gujarat, India during the study period from Nov 2020 to May 2021. We also looked for the risk factors for mucormycosis with a historical cohort of 157 KTR who did not develop mucormycosis.

RESULTS

The median age (interquartile range, range) of the cohort was 42 (33.5-50, 26-60) years with 54.5% diabetes. COVID-19 severity ranged from mild (n = 10) to severe cases (n = 1). The duration from COVID-19 recovery to presentation was 7 (7-7, 4-14) days. Ten cases were Rhino-orbital-cerebral-mucormycosis (ROCM) and one had pulmonary mucormycosis. Functional endoscopic sinus surgery (FESS) was performed in all cases of ROCM. The duration of antifungal therapy was 28 (24-30, 21-62) days. The mortality rate reported was 27%. The risk factors for post-transplant mucormycosis were diabetes (18% vs 54.5%; p-value = 0.01), lymphopenia [12 (10-18) vs 20 (12-26) %; p-value = 0.15] and a higher neutrophil-lymphocyte ratio [7 (4.6-8.3) vs 3.85 (3.3-5.8); p-value = 0.5].

CONCLUSION

The morbidity and mortality with post-COVID-19 mucormycosis are high. Post-transplant patients with diabetes are more prone to this dual infection. Preparedness and early identification is the key to improve the outcomes.

COVID-19, rejection, and cutaneous mucormycosis in a long-term liver transplant recipient - the vicious cycle of immunosuppression and opportunistic infections

Opportunistic infections, including fungal infections, are dreaded complications of liver transplantation, particularly early after transplant. We describe the case of a patient that presented 6 years after liver transplant with a Lichtheimia corymbifera-infected leg ulcer, following previous COVID-19 infection and moderate rejection requiring steroid pulses. The patient required long-term antifungal therapy, repeated surgical debridement and eventually wound coverage with meshed split-thickness skin graft. Our case illustrates the challenges in the treatment of cutaneous mucormycosis and highlights the difficulties in achieving an accurate balance between the risk of opportunistic infections and rejection in this population.

COVID-19-Associated Fungal Infections: An Urgent Need for Alternative Therapeutic Approach?

Secondary fungal infections may complicate the clinical course of patients affected by viral respiratory diseases, especially those admitted to intensive care unit. Hospitalized COVID-19 patients are at increased risk of fungal co-infections exacerbating the prognosis of disease due to misdiagnosis that often result in treatment failure and high mortality rate. COVID-19-associated fungal infections caused by predominantly Aspergillus and Candida species, and fungi of the order Mucorales have been reported from several countries to become significant challenge for healthcare system. Early diagnosis and adequate antifungal therapy is essential to improve clinical outcomes, however, drug resistance shows a rising trend highlighting the need for alternative therapeutic agents. The purpose of this review is to summarize the current knowledge on COVID-19-associated mycoses, treatment strategies and the most recent advancements in antifungal drug development focusing on peptides with antifungal activity.

Current Treatment Options for COVID-19 Associated Mucormycosis: Present Status and Future Perspectives

Mucormycosis has become increasingly associated with COVID-19, leading to the use of the term “COVID-19 associated mucormycosis (CAM)”. Treatment of CAM is challenging due to factors such as resistance to many antifungals and underlying co-morbidities. India is particularly at risk for this disease due to the large number of patients with COVID-19 carrying comorbidities that predispose them to the development of mucormycosis. Additionally, mucormycosis treatment is complicated due to the atypical symptoms and delayed presentation after the resolution of COVID-19. Since this disease is associated with increased morbidity and mortality, early identification and diagnosis are desirable to initiate a suitable combination of therapies and control the disease. At present, the first-line treatment involves Amphotericin B and surgical debridement. To overcome limitations associated with surgery (invasive, multiple procedures required) and amphotericin B (toxicity, extended duration and limited clinical success), additional therapies can be utilized as adjuncts or alternatives to reduce treatment duration and improve prognosis. This review discusses the challenges associated with treating CAM and the critical aspects for controlling this invasive fungal infection—early diagnosis and initiation of therapy, reversal of risk factors, and adoption of a multipronged treatment strategy. It also details the various therapeutic options (in vitro, in vivo and human case reports) that have been used for the treatment of CAM.

An overview of COVID-19 related to fungal infections: what do we know after the first year of pandemic?

In 2019, severe acute respiratory syndrome caused by CoV-2 virus became a pandemic worldwide, being the fast spread of the disease due to the movement of infected people from one country to another, from one continent to another, or within the same country. Associated comorbidities are important factors that predispose to any fungal coinfections. Because of the importance of fungal infections in COVID-19 patients, the aim of this work was to collect data of the more encountered mycoses related to patients undergoing this disease. Aspergillosis was the first COVID-19-related fungal infection reported, being A. fumigatus the most frequent species for CAPA. Other fungal infections related include mainly candidiasis and mucormycosis, being Rhizopus spp. the more prevalent species found. Influenza-associated pulmonary aspergillosis is well documented; thus, similar complications are expected in severe forms of COVID-19 pneumonia. Therefore, in patients with COVID-19, it is important to take special attention to the surveillance and suspicion of fungal coinfections that might worsen the patient's prognosis.

Clinical Features and Mortality of COVID-19-Associated Mucormycosis: A Systematic Review and Meta-Analysis

The recent increase of COVID-19-associated mucormycosis (CAM) has been commanding global attention. However, basic epidemiologic characteristics have not firmly been established. In this systematic review and meta-analysis, we sought to determine the clinical manifestations, potential risk factors, and outcomes of CAM. Observational studies reporting CAM were searched with PubMed and EMBASE databases in January 2022. We collected data on comorbidities and treatment for COVID-19, and performed a one-group meta-analysis on the frequency of orbital exenteration procedure and mortality of CAM using a random-effect model. Fifty-one observational studies, including a total of 2,312 patients with proven CAM, were identified. Among the 51 studies, 37 were conducted in India, 8 in Egypt, and 6 in other countries. The most common comorbidity was diabetes mellitus (82%). While 57% required oxygenation, 77% received systemic corticosteroids. Among CAM, 97% were rhino-orbital-cerebral (ROCM), and 2.7% were pulmonary mucormycosis. Usual presentations were headache (54%), periorbital swelling/pain (53%), facial swelling/pain (43%), ophthalmoplegia (42%), proptosis (41%), and nasal discharge/congestion (36%). Regarding the outcomes, orbital exenteration was performed in 17% (95% CI: 12–21%, I² = 83%) of the COVID-19-associated ROCM patients. The mortality of CAM was 29% (95% CI; 22–36%, I² = 92%). In conclusion, this systematic review and meta-analysis indicated that the most prevalent type of CAM was ROCM, and most CAM patients had diabetes mellitus and received systemic glucocorticoids. Clinicians in the endemic areas should have a high index of suspicion for this invasive fungal complication of COVID-19 when a diabetic patient who received high-dose systemic glucocorticoids developed rhino-orbital symptoms.

Mucormycosis infection in patients with COVID-19: A systematic review

INTRODUCTION

Several reports previously described mucormycosis co-infection in patients with COVID-19. As mucormycosis and COVID-19 co-infection might adversely affect patients' outcomes, we aimed to systematically review the related evidence and the subsequent outcomes.

METHODS

We conducted a systematic review of relevant articles searching the keywords in the online databases of PubMed, Scopus, Embase, Cochrane, and Web of Science. All the records from the start of the pandemic until June 12th, 2021 underwent title/abstract and then full-text screening process, and the eligible studies were included. We did not include any language or time restrictions for the included studies.

RESULTS

We found 31 eligible studies reporting 144 total cases of COVID-19 and mucormycosis co-infection. The nose, cranial sinuses, and orbital cavity were the most commonly involved organs, although the cerebrum, lungs, and heart were also involved in the studies. Pre-existing diabetes mellitus (DM), as well as corticosteroid use, were the most commonly identified risk factors, but other underlying conditions and immunomodulatory drug use were also present in several cases. Aspergillus was the most commonly reported micro-organism that caused further co-infections in patients with concurrent COVID-19 and mucormycosis. As most of the studies were case reports, no reliable estimate of the mortality rate could be made, but overall, 33.6% of the studied cases died.

CONCLUSION

Early diagnosis of mucormycosis co-infection in COVID-19 patients and selecting the right treatment plan could be a challenge for physicians. Patients with underlying co-morbidities, immunocompromised patients, and those receiving corticosteroids are at higher risk of developing mucormycosis co-infection and it is crucial to have an eye examination for early signs and symptoms suggesting a fungal infection in these patients.

Mucormycosis in COVID-19: A systematic review of literature

Coronavirus disease 2019 (COVID-19) is an acute viral illness caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Opportunistic infections such as mucormycosis have been reported among COVID-19 patients particularly in South Asian countries during the second wave of this pandemic. It is necessary to re-evaluate any changes in traditional risk factors associated with mucormycosis such as diabetes mellitus, organ transplant, etc in the precedent of ongoing COVID-19 pandemic. We conducted a systematic review using electronic databases. A total of 115 COVID-19 patients who were diagnosed with mucormycosis were included in this study. Diabetes mellitus was the most common co-morbidity with 77.1%, followed by hypertension (29.5%) and renal disease (14.3%). 55.2% of the patients had received dexamethasone for COVID-19 infection. Ten patients (11.5%) had received tocilizumab. Sinuses were the most common site of mucormycosis among COVID-19 patients at 79.4% with maxillary sinus (47.4%) being most commonly infected. Orbits were the second most prevalent site at 56.7% and lungs were infected with mucor at 11.3%. The mean duration between the diagnosis of COVID-19 infection and mucormycosis was 16.15 days (range 2-90 days). Cavernous sinus was either infiltrated or encased in 14 patients (14.4%). Cerebral involvement was seen in terms of abscess, infarcts, or edema in 12 patients (12.4%). Only 76 patients had data on the outcomes, out of which 37 (48.7%) patients had died. Diabetes mellitus is still the most common co-morbidity similar to non-COVID-19 patients. More than 90% of the patients with COVID-19 infection had received steroids. Complications such as cavernous sinus thrombosis, cerebral infarcts, abscesses were common. Indiscriminate use of steroids in patients needs to be avoided and focus needs to be put on tight blood sugar control in diabetic patients. Studies are needed to confirm the role of the SARS-CoV-2 virus in causing immune dysfunction and mucormycosis.

COVID-19 associated mucormycosis - An emerging threat

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly become a global threaten since its emergence in the end of 2019. Moreover, SARS-CoV-2 infection could also present with co-infection or secondary infection by other virus, bacteria, or fungi. Among them, mucormycosis is a rare but aggressive fungal disease and it mainly affects patients particularly with poorly controlled diabetes mellitus with diabetic ketoacidosis (DKA). We here did a comprehensive review of literature reporting COVID-19 associated with mucormycosis (CAM) cases, which have been reported worldwide. The prevalence is higher in India, Iran, and Egypt than other countries, particularly highest in the states of Gujarat and Maharashtra in India. Poor diabetic control and the administration of systemic corticosteroids are the common precipitating factors causing mucormycosis in the severe and critical COVID-19 patients. In addition, COVID-19 itself may affect the immune system resulting in vulnerability of the patients to mucormycosis. Appropriate treatments of CAM include strict glycemic control, extensive surgical debridement, and antifungal therapy with amphotericin B formulations.

COVID-19-associated mucormycosis of head-and-neck region: A systematic review

BACKGROUND AND AIM

With the second wave of COVID-19, there has been a substantial rise in opportunistic infections like mucormycosis. Mucormycosis is a fatal fungal infection and understanding the associated risk factors and their management plays a key role to reduce mortality and morbidity caused due to such infections. This systematic review was conducted to assess the risk factors, clinical characteristics and to understand the pathogenesis of COVID-19-associated mucormycosis (CAM) affecting the head-and-neck region.

METHODS

The PubMed database was searched with the keywords; ((Mucormycosis) OR (invasive fungal sinusitis)) AND (COVID-19) and the PRISMA chart was prepared for the selection of the reports based on the inclusion and exclusion criteria.

RESULTS

A total of 261 cases of CAM affecting the head-and-neck region were analyzed in this systematic review. Most of the patients presented with rhino-orbital/rhino-orbito-cerebral form of mucormycosis (rhino-orbital mucormycosis/rhino-orbital-cerebral mucormycosis). Pulmonary mucormycosis along with rhino-orbital form, involvement of hard palate, and maxillary sinus was seen in one case each. A total of 224 (85.8%) patients were diabetic, 68 (30.3%) of them had poor glycemic control. Steroids were administered in 210 (80.4%) patients. Except for two, antifungal treatment was given to all patients. Follow-up data revealed 67 (25.6%) deaths and 193 (73.9%) were alive with one patient lost during follow-up.

CONCLUSION

The findings of this systematic review suggested that the occurrence of mucormycosis in COVID-19 patients is related to the inherent effects of COVID-19 infection on the immune system, comorbidities especially diabetes, and treatment aspects. Hence, a detailed understanding of these factors may aid in the personalized management of CAM and improve the disease outcome.

RELEVANCE FOR PATIENTS

The risk factors in patients affected by CAM should be recognized and closely monitored in post-COVID-19 patients. A multidisciplinary team must be in place to reduce the mortality and morbidity in such patients.

COVID-19-Related Rhino-Orbital-Cerebral Mucormycosis in a Renal Transplant Recipient

Coronavirus disease 2019 increases transplant recipients' susceptibility to rare opportunistic infections as a consequence of the impairment that COVID-19 can cause in the immune system. Mucormycosis is a rare complication but has a high risk of fatal outcome. A 50-year-old woman who received a kidney transplant 10 years previously was admitted to the hospital with COVID-19. During follow-up by the inpatient service, the patient developed pain, edema, and proptosis in the right eye. She was diagnosed with rhino-orbitalcerebral mucormycosis. This is the first reported case of rhino-orbital-cerebral mucormycosis in a renal transplant recipient with COVID-19 infection.

Impact of COVID-19-associated Mucormycosis in Kidney Transplant Recipients: A Multicenter Cohort Study

BACKGROUND

COVID-19-associated mucormycosis (CAM) is a recently emerging entity. There is a lack of reports of CAM in organ transplant recipients.

METHODS

We conducted a multicenter (n = 18) retrospective research in India during November 2020 to July 2021. The purpose of this study was to explore the clinical spectrum, outcome and risk factors for mortality of CAM in kidney transplant recipients (KTRs).

RESULTS

The incidence of CAM was 4.4% (61/1382 COVID-19-positive KTRs) with 26.2% mortality. The median age of the cohort was 45 (38-54) y. Twenty (32%) were not hospitalized and 14 (22.9%) were on room air during COVID-19. The proportion of postdischarge CAM was 59.1%, while concurrent CAM was reported in 40.9%. The presentation of CAM was 91.8% rhino-orbital-cerebral mucormycosis and 8.2% pulmonary with 19.6% and 100% mortality, respectively. In the univariable analysis, older age, obesity, difficulty of breathing, high-flow oxygen requirement, and delay in starting therapy were significantly associated with mortality. In the multivariable logistic regression analysis, patients requiring high-flow oxygen therapy [odds ratio (95% confidence interval) = 9.3 (1.6-51); P = 0.01] and obesity [odds ratio (95% confidence interval) = 5.2 (1-28); P = 0.05] was associated with mortality. The median follow-up of the study was 60 (35-60) d.

CONCLUSIONS

We describe the largest case series of CAM in KTRs. Morality in pulmonary CAM is extremely high. Severe COVID-19 pose extra risk for the development of CAM and associated mortality. Our report will help in better understanding the conundrum and management of CAM.

Risk factors and outcomes of COVID associated mucormycosis in kidney transplant recipients

BACKGROUND

Invasive Mucormycosis (IM) is a life-threatening fungal infections occurring mostly in solid organ transplant (SOT)recipients, patients with haematological malignancies, and diabetes. A sudden spurt of mucormycosis has been reported in severe acute respiratory syndrome coronavirus-2 (SARS-COV2) pandemic in India, however there is little data about Coronavirus disease 2019 (COVID -19) associated mucormycosis (CAM) in kidney transplant recipients (KTRs).

METHODS

We describe the clinical presentations, risk factors, treatment and outcomes of 11 mucormycosis cases in Kidney transplant recipients (KTRs) post COVID 19 infection from February 2020 to June 2021 at a single centre in India.

RESULTS

Mucormycosis was seen in 11/102 (10.7%) KTRs during the pandemic. Six patients had mild disease and rest five had moderate disease. Seven patients had pre-existing diabetes mellitus and four developed new onset hyperglycemia after receiving steroids for COVID-19 infection. All had poorly controlled sugars at the time of presentation. Most common presentation was Rhino-orbital-cerebral mucormycosis (ROCM) in 10/11 (89%) patients and one ha pulmonary mucormycosis. All patients received combination of Amphotericin B and surgical debridement/excision of affected tissue followed by Posaconazole prophylaxis. Nine patients recovered, however two patient succumbed to their illness after median of 14(7-21) days from diagnosis. One patient developed acute T cell mediated rejection during the course of recovery. At last follow up, the mean serum creatinine was 2.05 mg/dl as compared to 1.4 mg/dl at presentation.

CONCLUSIONS

Invasive Mucormycosis is a common fungal infection in transplant recipients in India after COVID-19.Early diagnosis and prompt treatment with combination of surgical debridement and liposomal amphotericin B are key to better outcomes in COVID associated mucormycosis. Judicious use of steroids and control of hyperglycemia is key to avoid flaring up of the fungal infection. This article is protected by copyright. All rights reserved.

Epidemiology and Pathophysiology of COVID-19-Associated Mucormycosis: India Versus the Rest of the World

The coronavirus disease 2019 (COVID-19) pandemic has led to a concerning resurgence of mucormycosis. More than 47,000 cases of mucormycosis were reported in three months from India. We update our systematic review on COVID-19-associated mucormycosis (CAM) till June 21st, 2021, comparing cases reported from India and elsewhere. We included individual patient details of 275 cases of CAM, of which 233 were reported from India and 42 from the rest of the world. Diabetes mellitus was the most common underlying risk factor for CAM in India than in other countries. The fatality rate of cases reported from India (36.5%) was less than the globally reported cases (61.9%), probably due to the predominance of rhino-orbital mucormycosis. On a multivariate analysis, we found that pulmonary or disseminated mucormycosis cases and admission to the intensive care unit were associated with increased mortality, while combination medical therapy improved survival. The paucity of pulmonary and disseminated mucormycosis cases from India suggests that these cases were either not diagnosed or reported, further supported by a trend of search data from the Google search engine. In this review, we discuss the factors explaining the substantial rise in cases of CAM. We also propose a hypothetical model describing the epidemiologic triad of CAM.

COVID-19-associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic's second wave in India

Coronavirus Disease 2019 (COVID-19), during the second wave in early 2021, has caused devastating chaos in India. As daily infection rates rise alarmingly, the number of severe cases has increased dramatically. The country has encountered health infrastructure inadequacy and excessive demand for hospital beds, drugs, vaccines, and oxygen. Adding more burden to such a challenging situation, mucormycosis, an invasive fungal infection, has seen a sudden surge in patients with COVID-19. The rhino-orbital-cerebral form is the most common type observed. In particular, approximately three-fourths of them had diabetes as predisposing comorbidity and received corticosteroids to treat COVID-19. Possible mechanisms may involve immune and inflammatory processes. Diabetes, when coupled with COVID-19-induced systemic immune change, tends to cause decreased immunity and an increased risk of secondary infections. Since comprehensive data on this fatal opportunistic infection are evolving against the backdrop of a major pandemic, prevention strategies primarily involve managing comorbid conditions in high-risk groups. The recommended treatment strategies primarily included surgical debridement and antifungal therapy using Amphotericin B and selected azoles. Several India-centric clinical guidelines have emerged to rightly diagnose the infection, characterise the clinical presentation, understand the pathogenesis involved, and track the disease course. Code Mucor is the most comprehensive one, which proposes a simple but reliable staging system for the rhino-orbital-cerebral form. A staging system has recently been proposed, and a dedicated registry has been started. In this critical review, we extensively analyse recent evidence and guidance on COVID-19-associated mucormycosis in India.

COVID-19-associated mucormycosis: Case report and systematic review

BACKGROUND

Increasing number of patients with COVID-19-associated mucormycosis have been reported, especially from India recently. We have described a patient with COVID-19-associated mucormycosis and, searched and analyzed current medical literature to delineate the characteristics of COVID-19-associated mucormycosis.

METHOD

We reported a patient developed mucormycosis during post-COVID period. We searched literature to describe the incidence, clinical features, and outcomes of COVID-19-associated mucormycosis. Demographic features, risk factors, clinical features, diagnostic methods, treatment and outcome were analyzed.

RESULTS

We describe a 54-year-old male, hospitalized due to severe COVID-19 pneumonia. He was given long-term, high doses of systemic steroids. He developed maxillo-fascial mucormycosis and died of sepsis. Our literature search found 30 publications describing 100 patients including present case report. The majority (n = 68) were reported from India. 76% were male. The most commonly seen risk factors were corticosteroid use (90.5%), diabetes (79%), and hypertension (34%). Also, excessive use of broad-spectrum antibiotics were noted in cases. Most frequent involvements were rhino-orbital (50%), followed by rhino-sinusal (17%), and rhino-orbito-cerebral (15%). Death was reported as 33 out of 99 patients (33,3%).

CONCLUSIONS

Steroid use, diabetes, environmental conditions, excessive use of antibiotics, and hypoxia are main risk factors. Despite medical and surgical treatment, mortality rate is high. A multidisciplinary approach is essential to improve the conditions facilitating the emergence of COVID-19-associated mucormycosis.

Invasive Fungal Infections Complicating COVID-19: A Narrative Review

Invasive fungal infections (IFIs) can complicate the clinical course of COVID-19 and are associated with a significant increase in mortality, especially in critically ill patients admitted to an intensive care unit (ICU). This narrative review concerns 4099 cases of IFIs in 58,784 COVID-19 patients involved in 168 studies. COVID-19-associated invasive pulmonary aspergillosis (CAPA) is a diagnostic challenge because its non-specific clinical/imaging features and the fact that the proposed clinically diagnostic algorithms do not really apply to COVID-19 patients. Forty-seven observational studies and 41 case reports have described a total of 478 CAPA cases that were mainly diagnosed on the basis of cultured respiratory specimens and/or biomarkers/molecular biology, usually without histopathological confirmation. Candidemia is a widely described secondary infection in critically ill patients undergoing prolonged hospitalisation, and the case reports and observational studies of 401 cases indicate high crude mortality rates of 56.1% and 74.8%, respectively. COVID-19 patients are often characterised by the presence of known risk factors for candidemia such as in-dwelling vascular catheters, mechanical ventilation, and broad-spectrum antibiotics. We also describe 3185 cases of mucormycosis (including 1549 cases of rhino-orbital mucormycosis (48.6%)), for which the main risk factor is a history of poorly controlled diabetes mellitus (>76%). Its diagnosis involves a histopathological examination of tissue biopsies, and its treatment requires anti-fungal therapy combined with aggressive surgical resection/debridement, but crude mortality rates are again high: 50.8% in case reports and 16% in observational studies. The presence of other secondary IFIs usually diagnosed in severely immunocompromised patients show that SARS-CoV-2 is capable of stunning the host immune system: 20 cases of Pneumocystis jirovecii pneumonia, 5 cases of cryptococcosis, 4 cases of histoplasmosis, 1 case of coccidioides infection, 1 case of pulmonary infection due to Fusarium spp., and 1 case of pulmonary infection due to Scedosporium.

COVID-19-Associated Mucormycosis (CAM): Case-Series and Global Analysis of Mortality Risk Factors

BACKGROUND

Since the novel coronavirus disease (COVID-19) outbreak, the cases of COVID-19 co-infections have been increasingly reported worldwide. Mucormycosis, an opportunistic fungal infection caused by members of the Mucorales order, had been frequently isolated in severely and critically ill COVID-19 patients.

METHODS

Initially, the anamnestic, clinical, and paraclinical features of seven COVID-19-associated mucormycosis (CAM) cases from Egypt were thoroughly reported. Subsequently, an extensive review of the literature was carried out to describe the characteristics of CAM cases globally, aiming to explore the potential risk factors of mortality in CAM patients.

RESULTS

Out of the seven reported patients in the case series, five (71.4%) were males, six (85.7%) had diabetes mellitus, and three (42.9%) had cardiovascular disease. All patients exhibited various forms of facial deformities under the computed tomography scanning, and two of them tested positive for Mucorales using the polymerase chain reaction (PCR) testing. Liposomal amphotericin B (LAmB) was prescribed to all cases, and none of them died until the end of the follow-up. On reviewing the literature, 191 cases were reported worldwide, of which 74.4% were males, 83.2% were from low-middle income countries, and 51.4% were aged 55 years old or below. Diabetes mellitus (79.1%), chronic hypertension (30%), and renal disease/failure (13.6%) were the most common medical comorbidities, while steroids (64.5%) were the most frequently prescribed medication for COVID-19, followed by Remdesivir (18.2%), antibiotics (12.7%), and Tocilizumab (5.5%).

CONCLUSIONS

As the majority of the included studies were observational studies, the obtained evidence needs to be interpreted carefully. Diabetes, steroids, and Remdesivir were not associated with increased mortality risk, thus confirming that steroids used to manage severe and critical COVID-19 patients should not be discontinued. Lung involvement, bilateral manifestation, and Rhizopus isolation were associated with increased mortality risk, thus confirming that proactive screening is imperative, especially for critically ill patients. Finally, surgical management and antimycotic medications, e.g., amphotericin B and posaconazole, were associated with decreased mortality risk, thus confirming their effectiveness.

COVID-19-Associated Mucormycosis (CAM): An Updated Evidence Mapping

Mucormycosis, a serious and rare fungal infection, has recently been reported in COVID-19 patients worldwide. This study aims to map all the emerging evidence on the COVID-19-associated mucormycosis (CAM) with a special focus on clinical presentation, treatment modalities, and patient outcomes. An extensive literature search was performed in MEDLINE (Ovid), Embase (Ovid), Cochrane COVID-19 Study Register, and WHO COVID-19 database till 9 June 2021. The primary outcome was to summarize the clinical presentation, treatment modalities, and patient outcomes of CAM. Data were summarized using descriptive statistics and presented in tabular form. This evidence mapping was based on a total of 167 CAM patients with a mean age of 51 ± 14.62 years, and 56.28% of them were male. Diabetes mellitus (73.65% (n = 123)), hypertension (22.75% (n = 38)), and renal failure (10.77% (n = 18)) were the most common co-morbidities among CAM patients. The most common symptoms observed in CAM patients were facial pain, ptosis, proptosis, visual acuity, and vision loss. Survival was higher in patients who underwent both medical and surgical management (64.96%). Overall mortality among CAM patients was found to be 38.32%. In conclusion, this study found a high incidence of CAM with a high mortality rate. Optimal glycemic control and early identification of mucormycosis should be the priority to reduce the morbidity and mortality related to CAM.

COVID-19 en receptores de trasplante renal: ¿qué hemos aprendido tras 18 meses de pandemia?

La infección por el SARS-CoV-2 (COVID-19) ha supuesto un importante impacto en la actividad trasplantadora en nuestro país. En su condición de paciente inmunodeprimido y con frecuentes comorbilidades, era esperable que la mortalidad y el riesgo de complicaciones asociadas a la COVID-19 en el receptor de trasplante renal (TR) fueran mayores en comparación con la población general, si bien la información al respecto en los primeros meses de la pandemia era muy limitada. Desde marzo de 2020 hemos mejorado rápidamente nuestro conocimiento acerca de la epidemiología, características clínicas y manejo de la COVID-19 post-trasplante. La presente revisión pretende recopilar la información disponible a julio de 2021 en respuesta a una serie de cuestiones relevantes: ¿cómo se manifiesta clínicamente la infección por SARS-CoV-2 en receptores de TR?, ¿cuáles son sus factores pronósticos?, ¿es más grave la COVID-19 en el contexto del TR respecto a los pacientes inmunocompetentes?, ¿de qué opciones de tratamiento antiviral disponemos actualmente para el receptor de TR?, ¿cuál es la experiencia disponible con los tratamientos inmunomoduladores? y, por último, ¿son eficaces las vacunas frente a la COVID-19 basadas en ARN mensajero en esta población?. A pesar de los avances realizados aún son varios los aspectos que debemos mejorar en nuestro abordaje de la infección por SARS-CoV-2 en el ámbito específico del TR.

COVID-19 Associated Mucormycosis: A Systematic Review from Diagnostic Challenges to Management

The coronavirus disease 2019 (COVID-19) outbreak has caused significant destruction, claiming over three million lives worldwide. Post SARS-COV-2 invasion, immunosuppression with hyperglycemia and elevated ferritin levels along with steroidal treatment creates a perfect storm for opportunistic infections. There is increasing evidence of mucormycosis co-infection in COVID-19 patients, during or post-treatment. A worse prognosis, a late diagnosis, and limited guidelines of screening and management of COVID-19 associated mucormycosis have made healthcare professionals fear an epidemic alongside a pandemic. This review geographically reports cases of COVID-19 associated mucormycosis (CAM), evaluates characteristics, clinical manifestations, and outcomes of mucormycosis in COVID-19 active or recovered patients. It further describes preventive strategies and recommendations for optimal management therapy that can be adopted worldwide to curtail an impending threat to the healthcare system.

A case report of rhino-facial mucormycosis in a non-diabetic patient with COVID-19: a systematic review of literature and current update

BACKGROUND

COVID-19 disease may be associated with a wide range of bacterial and fungal infections. We report a patient with COVID-19 infection who developed rhino-facial mucormycosis during treatment with corticosteroids.

CASE PRESENTATION

A 59-year-old non-diabetic male patient was admitted with a diagnosis of COVID-19 based on positive RT-PCR and CT of the lungs. Due to sever lung involvement, he was treated with methylprednisolone. The patient was re-admitted to hospital, due to nasal obstruction and left side facial and orbital swelling, several days after discharge. In sinus endoscopic surgery, debridement was performed and the specimens were sent to pathology and mycology laboratories. A nasal biopsy showed wide hyphae without septa. The sequenced PCR product revealed Rhizopus oryzae. Despite all medical and surgical treatment, the patient died. In addition, the characteristics of patients with COVID-19-associated mucormycosis were reviewed in 44 available literatures. In most studies, diabetes mellitus was the most common predisposing factor for mucormycosis.

CONCLUSION

Our report highlights the need for assessing the presence of mucormycosis in patients with COVID-19 and also it shows that physicians should consider the potential for secondary invasive fungal infections in COVID-19 cases.

Overview on the Prevalence of Fungal Infections, Immune Response, and Microbiome Role in COVID-19 Patients

Patients with severe COVID-19, such as individuals in intensive care units (ICU), are exceptionally susceptible to bacterial and fungal infections. The most prevalent fungal infections are aspergillosis and candidemia. Nonetheless, other fungal species (for instance, Histoplasma spp., Rhizopus spp., Mucor spp., Cryptococcus spp.) have recently been increasingly linked to opportunistic fungal diseases in COVID-19 patients. These fungal co-infections are described with rising incidence, severe illness, and death that is associated with host immune response. Awareness of the high risks of the occurrence of fungal co-infections is crucial to downgrade any arrear in diagnosis and treatment to support the prevention of severe illness and death directly related to these infections. This review analyses the fungal infections, treatments, outcome, and immune response, considering the possible role of the microbiome in these patients. The search was performed in Medline (PubMed), using the words "fungal infections COVID-19", between 2020-2021.

COVID-19 and mucormycosis superinfection: Exploring the missing pathophysiological links

The coronavirus disease 2019 continues to unearth new facets that portend grave clinical implications. In recent times, there has been mounting fervor regarding coronavirus disease 2019 and mucormycosis superinfection. While the correlation between the two is conspicuous, the underlying pathophysiological mechanisms that render a patient with coronavirus disease 2019 susceptible to mucormycosis, or vice versa, are still elusive.

Mucormycosis associated with COVID-19 in two kidney transplant patients

Coronavirus disease 2019 (COVID‐19) predisposes patients to bacterial and fungal superinfections due to the impairment of the immunological system. Among the associated opportunistic fungal infections, mucormycosis is one of the least frequent but with the highest mortality. We describe two cases of mucormycosis in two kidney transplant recipients, while they were hospitalized for SARS‐CoV‐2 pneumonia, with rhinosinusal and musculoskeletal involvement, respectively.