A case of COVID-19-associated rhino-orbito-cerebral mucormycosis caused by Apophysomyces variabilis with a review of the literature

Invasive Candidiasis Coinfection in Patients with Severe COVID-19 Disease: Scoping Review

Coinfection rates of candidiasis in patients affected by COVID-19 had a significantly increase during the sanitary contingency. The objective of this scoping review is to analyze the available scientific evidence around the coinfection of invasive candidiasis in hospitalized patients with severe COVID-19 disease. Online databases such as PubMed, EBSCO, SciFinder, Scopus, and SciELO were used to analyze the different scientific studies published from January 2020 to December 2022, selecting 48 publications that reported comorbidity between invasive candidiasis and COVID-19 as a study variable. Based on the PRISMA-ScR extension for scoping reviews, we identified more than half of the publications (57%) as observational, descriptive, and analytic studies, while 43% were systematic reviews. Overall, up to 169,468 adult patients admitted to the intensive care unit were examined. Coinfection was due mainly to Candida albicans (75%), but some more species were reported such as Meyerozyma parapsilosis (formerly Candida parapsilosis); Meyerozyma guilliermondii (formerly Candida guilliermondii); Nakaseomyces glabratus (formerly Candida glabrata); Candida tropicalis; Candida dubliniensis; Clavispora lusitaniae (formerly Candida lusitaniae); and Pichia kudriavzevii (formerly Candida krusei). We concluded that patients infected by SARS-CoV-2 had a higher incidence of fungal coinfections, thus increasing the mortality rate, disease severity, and length of hospital stay in the intensive care unit.

Mucormycosis Caused by Apophysomyces elegans-A Case Report and Systematic Review of the Literature of Rhino-Orbito-Cerebral Cases of the Genus Apophysomyces

INTRODUCTION

Orbitocerebral mucormycosis, caused by Apophysomyces, is a rare infection, usually occurring in tropical and subtropical climates, with a high mortality rate. We report a case of orbitocerebral mucormycosis caused by A. elegans in a person living with HIV (PLWHIV) from Africa alongside a systematic literature review updating current diagnostic and treatment strategies for orbitocerebral mucormycosis caused by Apophysomyces.

METHODS

The presented case was treated in our hospital for polytrauma following a motor vehicle accident (MVA) with aggressive surgical debridement and therapy with liposomal Amphotericin B (AMB). We evaluated clinical presentation, imaging, surgery, and postoperative outcomes. A systematic review of English or German language articles (published between 1985 and 2025) was performed according to PRISMA guidelines. Articles describing patients with mucormycosis due to Apophysomyces were summarized. Quantitative values for relevant parameters that indicated a reduction in mortality and morbidity were obtained.

RESULTS

The systematic search initially identified 452 publications, from which 79 studies were retrieved. Seventeen publications comprising 21 cases were included, along with one additional case from our institution, for a total of 22 rhino-orbito-cerebral infections caused by the genus Apophysomyces. Apophysomyces elegans (A. elegans) was the most frequently isolated species (n = 17), followed by A. variabilis (n = 4) and A. ossiformis (n = 1); A. trapeziformis was not reported. The majority of patients were male (72.7%), with a mean age of 40.7 ± 15.9 years. Trauma (27.3%) and diabetes mellitus (18.2%) were the most common underlying risk factors, with SARS-CoV-2 infection identified in 13.6% of cases.

CONCLUSION

Mucormycosis due to Apophysomyces is a rare but potentially devastating condition. Based on our experience and the literature, we suggest that the early diagnosis of Apophysomyces treated with liposomal AMB and aggressive surgical debridement is essential to reduce morbidity and mortality.

Molecular Assays Versus Mycological Methods for Diagnosis of Rhino Orbital Mucormycosis: Analysis of 120 Clinical Specimens from COVID-19 Patients

BACKGROUND

Mucormycosis, a fungal emergency, poses a serious threat to both COVID-19 and non-COVID-19 individuals due to its invasive nature, rapid progression, and high rates of morbidity and mortality. This underscores the crucial need for timely detection and management. In this study, we investigated the utility of real-time PCR (RT-qPCR) assays for detecting Mucorales in clinical specimens, and assessed the performance of both SYBR Green and TaqMan probe RT-qPCR in amplifying Mucorales-specific 18S rDNA genes. We conducted accuracy analyses using direct examination with KOH as a standard for the laboratory diagnosis of mucormycosis. Additionally, we compared the results with culture and duplex PCR.

PATIENTS/METHODS

Both SYBR Green and TaqMan RT-qPCR were optimized using Mucorales-specific oligonucleotides to amplify the conserved 18S rDNA targets. DNAs extracted from 120 rhino sinus specimens, which all were collected from COVID-19 patients upon suspicion of invasive fungal infections, were used for molecular diagnosis. The results of both RT-qPCR assays were compared with the result of direct microscopy, culture, and duplex Mucorales-specific PCR assay.

RESULTS

SYBR Green real-time PCR produced a distinct melting temperature (Tm) pattern (80.24 ± 0.70 °C) and detected Mucorales in 51 out of 120 clinical samples. When compared to direct examination with KOH, the standard method for diagnosing mucormycosis, SYBR Green PCR demonstrated a sensitivity of 91.67% (95% confidence interval (CI): 86.7-96.5%) and a specificity of 90.28% (95% CI: 84.9-95.5%). In contrast, TaqMan-probe PCR identified Mucorales in 34 out of 120 samples, with a sensitivity of 64.58% (95% CI: 56-73.1%) and a specificity of 95.83% (95% CI: 92.26-99.39%).

CONCLUSION

SYBR Green-based PCR can be used as a reliable confirmatory test for diagnosing mucormycosis, particularly in cases with atypical hyphae, mixed infections (featuring both septate and non-septate hyphae), or when the direct examination is positive but culture results are negative. The lower sensitivity of the TaqMan-probe PCR may be attributed to factors such as using a degenerate probe, which can lead to false-negative results.

Rhinocerebral mucormycosis in immunocompetent patients: a case report and review of literature

INTRODUCTION

Mucormycosis of the head and neck region is a rare but aggressive fungal infection that usually involves immunocompromised patients. More infrequently, this infection can also occur in people with no otherwise known underlying immunological deficit. This rarity usually causes a delay in diagnosis and may severely decrease the chance of survival in these patients. In this study, we present an extreme case of mucormycosis in an immunocompetent patient. By conducting a thorough review of the literature, we aim to increase our knowledge on this matter. Our goal is to improve diagnosis and start treatment at an earlier stage.

CASE PRESENTATION AND METHODS

Our patient was a 31-year-old man who presented with bilateral face numbness, neck pain, headache, and a necrotic palatal lesion 45 days after a dental root canal procedure. There was extensive involvement of facial and skull base bony and soft tissues. Through two debridement sessions and intravenous antifungal treatment, the patient was discharged with near-complete disease resolution. We identified 48 cases in the literature that matched our study criteria. We searched the current literature for proven cases of mucormycosis in the head and neck region who didn't have any underlying disease. We extracted their data and added the data of our patient. Then, we re-analyzed them using descriptive analysis, chi-square, and binary logistic regression to better understand the different factors for survival and disease burden in these patients.

RESULTS

49 patients were analyzed in this study. The mean age was 46.93 ± 15.75 (min 16 and max78 years old). The most prevalent subsite to be involved was the sino-nasal mucosa, followed by the surrounding soft tissues and the orbit. While both orbit and intracranial tissue involvement differed significantly between surviving and deceased patients, only intracranial tissue involvement could be used to predict survival. The overall survival rate was 91.8%.

CONCLUSION

Although very rare, mucormycosis can occur in immunocompetent patients. Physicians should consider mucormycosis when faced with refractory conditions and unusual symptoms such as exposed bones, facial numbness, headaches, and intractable pain. Complementary imaging (CT scan with or without MRI) and histopathological examination are critical for timely diagnosis or exclusion of this potentially fatal yet treatable disease.

A case of COVID-19-associated mucormycosis due to Lichtheimia ramosa

BACKGROUND

Mucormycosis is a life-threatening invasive fungal infection in immunocompromised and COVID-19 patients.

CASE REPORT

Here, we report a fatal rhino-orbito-cerebral mucormycosis caused by Lichtheimia ramosa, in a 79-year-old diabetic female. She was initially admitted to the hospital for COVID-19 infection and received broad-spectrum antibiotics and corticosteroids. After 1 month, she was admitted again because of persistent headaches and decreased right eye movement when the computed tomography scan showed mucosal thickening and opacification of paranasal sinuses. Microbiological investigations, including culture and direct microscopy, and histopathological findings confirmed the diagnosis of proven mucormycosis. The isolated causal agent was identified as Lichtheimia ramosa by sequencing the entire ITS region of nuclear ribosomal DNA. Despite surgical debridement and administration of liposomal amphotericin B 5 mg/kg/day, the patient's level of consciousness suddenly deteriorated; she was intubated and mechanically ventilated in the ICU and died on the same day.

CONCLUSION

To our knowledge, this is the first worldwide case of COVID-19-associated rhino-orbito-cerebral mucormycosis due to Lichtheimia ramosa.

Case report: COVID-19-associated mucormycosis co-infection with Lomentospora prolificans: The first case and review on multiple fungal co-infections during COVID-19 pandemic

Along with the pandemic COVID-19 spreads, new clinical challenges have emerged in the health care settings, among which there is a high risk of secondary invasive fungal infections with significant mortality. Here, we report a case of invasive fungal rhino orbital sinusitis due to the simultaneous co-infection by Rhizopus oryzae and Lomentospora prolificans, both identified by sequencing, in a 70-year-old Afghanistanian female with COVID-19. The patient was subjected to surgical debridement as well as taking liposomal amphotericin B, voriconazole, and on discharge, her condition was good. As far as we know, this is the first case of co-infection of COVID-19-associated mucormycosis (CAM) and Lomentospora prolificans infection. Multiple fungal co-infections in COVID-19 patients are reviewed.

Microbial and clinical epidemiology of invasive fungal rhinosinusitis in hospitalized COVID-19 patients, the divergent causative agents

Since COVID-19 spread worldwide, invasive fungal rhinosinusitis (IFRS) has emerged in immunocompromised patients as a new clinical challenge. In this study, clinical specimens of 89 COVID-19 patients who presented clinical and radiological evidence suggestive of IFRS were examined by direct microscopy, histopathology, and culture, and the isolated colonies were identified through DNA sequence analysis. Fungal elements were microscopically observed in 84.27% of the patients. Males (53.9%) and patients over 40 (95.5%) were more commonly affected than others. Headache (94.4%) and retro-orbital pain (87.6%) were the most common symptoms, followed by ptosis/proptosis/eyelid swelling (52.8%), and 74 patients underwent surgery and debridement. The most common predisposing factors were steroid therapy (n = 83, 93.3%), diabetes mellitus (n = 63, 70.8%), and hypertension (n = 42, 47.2%). The culture was positive for 60.67% of the confirmed cases, and Mucorales were the most prevalent (48.14%) causative fungal agents. Different species of Aspergillus (29.63%) and Fusarium (3.7%) and a mix of two filamentous fungi (16.67%) were other causative agents. For 21 patients, no growth was seen in culture despite a positive result on microscopic examinations. In PCR-sequencing of 53 isolates, divergent fungal taxons, including 8 genera and 17 species, were identified as followed: Rhizopus oryzae (n = 22), Aspergillus flavus (n = 10), A. fumigatus (n = 4), A. niger (n = 3), R. microsporus (n = 2), Mucor circinelloides, Lichtheimia ramosa, Apophysomyces variabilis, A. tubingensis, A. alliaceus, A. nidulans, A. calidoustus, Fusarium fujikuroi/proliferatum, F. oxysporum, F. solani, Lomentospora prolificans, and Candida albicans (each n = 1). In conclusion, a diverse set of species involved in COVID-19-associated IFRS was observed in this study. Our data encourage specialist physicians to consider the possibility of involving various species in IFRS in immunocompromised and COVID-19 patients. In light of utilizing molecular identification approaches, the current knowledge of microbial epidemiology of invasive fungal infections, especially IFRS, may change dramatically.