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Cheng X, Li T, Wu F, Liu D. Clinical Manifestation, mNGS Based Diagnosis and Treatment of Pulmonary Mucormycosis with Rhizopus delemar in a Diabetic Patient. Infect Drug Resist 2024; 17:1379-1384. [PMID: 38618581 PMCID: PMC11011641 DOI: 10.2147/idr.s454029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/23/2024] [Indexed: 04/16/2024] Open
Abstract
Pulmonary mucormycosis is a severe and often fatal disease that commonly affects patients with underlying conditions, such as diabetes. Early diagnosis and appropriate treatment are crucial for improving survival rates. However, clinical diagnosis remains challenging due to difficulty in obtaining etiological evidence. In this particular case, the patient presented with a cough-producing bloody sputum, and a chest CT revealed lesions in the right upper lobe of the lung. The patient was ultimately diagnosed with pulmonary mucormycosis caused by Rhizopus delemar through clinical bronchoscopy biopsy and metagenomic next-generation sequencing (mNGS) analysis of bronchoalveolar lavage fluid sample. Subsequently, antifungal therapy using the less toxic Amphotericin B cholesterol Organosulfate complex was initiated, improving the patient's condition. In conclusion, our findings underscore the potential of mNGS to provide an accurate and rapid etiological diagnosis of pulmonary mucormycosis, offering a foundation for treatment.
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Affiliation(s)
- Xuesong Cheng
- The Department of Pulmonary and Critical Care Medicine, Anhui No.2 Provincial People’s Hospital, Hefei, People’s Republic of China
| | - Tianyu Li
- Genoxor Medical Science and Technology Inc., Shanghai, People’s Republic of China
| | - Fengsheng Wu
- Genoxor Medical Science and Technology Inc., Shanghai, People’s Republic of China
| | - Dandan Liu
- The Department of Pulmonary and Critical Care Medicine, Anhui No.2 Provincial People’s Hospital, Hefei, People’s Republic of China
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Lamoth F, Prakash K, Beigelman-Aubry C, Baddley JW. Lung and sinus fungal infection imaging in immunocompromised patients. Clin Microbiol Infect 2024; 30:296-305. [PMID: 37604274 DOI: 10.1016/j.cmi.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Imaging is a key diagnostic modality for suspected invasive pulmonary or sinus fungal disease and may help to direct testing and treatment. Fungal diagnostic guidelines have been developed and emphasize the role of imaging in this setting. We review and summarize evidence regarding imaging for fungal pulmonary and sinus disease (in particular invasive aspergillosis, mucormycosis and pneumocystosis) in immunocompromised patients. OBJECTIVES We reviewed data on imaging modalities and findings used for diagnosis of invasive fungal pulmonary and sinus disease. SOURCES References for this review were identified by searches of PubMed, Google Scholar, Embase and Web of Science through 1 April 1 2023. CONTENT Computed tomography imaging is the method of choice for the evaluation of suspected lung or sinus fungal disease. Although no computed tomography radiologic pattern is pathognomonic of pulmonary invasive fungal disease (IFD) the halo sign firstly suggests an angio-invasive pulmonary aspergillosis while the Reversed Halo Sign is more suggestive of pulmonary mucormycosis in an appropriate clinical setting. The air crescent sign is uncommon, occurring in the later stages of invasive aspergillosis in neutropenic patients. In contrast, new cavitary lesions should suggest IFD in moderately immunocompromised patients. Regarding sinus site, bony erosion, peri-antral fat or septal ulceration are reasonably predictive of IFD. IMPLICATIONS Imaging assessment of the lung and sinuses is an important component of the diagnostic work-up and management of IFD in immunocompromised patients. However, radiological features signs have sensitivity and specificity that often vary according to underlying disease states. Periodic review of imaging studies and diagnostic guidelines characterizing imaging findings may help clinicians to consider fungal infections in clinical care thereby leading to an earlier confirmation and treatment of IFD.
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Affiliation(s)
- Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Microbiology, Department of Laboratory Medicine and Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Katya Prakash
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Catherine Beigelman-Aubry
- Radiodiagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Laurent F, Benlala I, Dournes G. Radiological Diagnosis of Pulmonary Aspergillosis. Semin Respir Crit Care Med 2024; 45:50-60. [PMID: 38286137 DOI: 10.1055/s-0043-1776998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Imaging plays an important role in the various forms of Aspergillus-related pulmonary disease. Depending on the immune status of the patient, three forms are described with distinct imaging characteristics: invasive aspergillosis affecting severely immunocompromised patients, chronic pulmonary aspergillosis affecting less severely immunocompromised patients but suffering from a pre-existing structural lung disease, and allergic bronchopulmonary aspergillosis related to respiratory exposure to Aspergillus species in patients with asthma and cystic fibrosis. Computed tomography (CT) has been demonstrated more sensitive and specific than chest radiographs and its use has largely contributed to the diagnosis, follow-up, and evaluation of treatment in each condition. In the last few decades, CT has also been described in the specific context of cystic fibrosis. In this particular clinical setting, magnetic resonance imaging and the recent developments in artificial intelligence have shown promising results.
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Affiliation(s)
- François Laurent
- Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
| | - Ilyes Benlala
- Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
| | - Gael Dournes
- Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
- CHU Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Centre de Recherche Cardio-thoracique de Bordeaux, University of Bordeaux, Pessac, France
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4
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Alqarihi A, Kontoyiannis DP, Ibrahim AS. Mucormycosis in 2023: an update on pathogenesis and management. Front Cell Infect Microbiol 2023; 13:1254919. [PMID: 37808914 PMCID: PMC10552646 DOI: 10.3389/fcimb.2023.1254919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Mucormycosis (MCR) is an emerging and frequently lethal fungal infection caused by the Mucorales family, with Rhizopus, Mucor, and Lichtheimia, accounting for > 90% of all cases. MCR is seen in patients with severe immunosuppression such as those with hematologic malignancy or transplantation, Diabetes Mellitus (DM) and diabetic ketoacidosis (DKA) and immunocompetent patients with severe wounds. The recent SARS COV2 epidemy in India has resulted in a tremendous increase in MCR cases, typically seen in the setting of uncontrolled DM and corticosteroid use. In addition to the diversity of affected hosts, MCR has pleiotropic clinical presentations, with rhino-orbital/rhino-cerebral, sino-pulmonary and necrotizing cutaneous forms being the predominant manifestations. Major insights in MCR pathogenesis have brought into focus the host receptors (GRP78) and signaling pathways (EGFR activation cascade) as well as the adhesins used by Mucorales for invasion. Furthermore, studies have expanded on the importance of iron availability and the complex regulation of iron homeostasis, as well as the pivotal role of mycotoxins as key factors for tissue invasion. The molecular toolbox to study Mucorales pathogenesis remains underdeveloped, but promise is brought by RNAi and CRISPR/Cas9 approaches. Important recent advancements have been made in early, culture-independent molecular diagnosis of MCR. However, development of new potent antifungals against Mucorales remains an unmet need. Therapy of MCR is multidisciplinary and requires a high index of suspicion for initiation of early Mucorales-active antifungals. Reversal of underlying immunosuppression, if feasible, rapid DKA correction and in selected patients, surgical debulking are crucial for improved outcomes.
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Affiliation(s)
- Abdullah Alqarihi
- Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, CA, United States
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, United States
| | - Ashraf S Ibrahim
- Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, CA, United States
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Lewis RE, Stanzani M, Morana G, Sassi C. Radiology-based diagnosis of fungal pulmonary infections in high-risk hematology patients: are we making progress? Curr Opin Infect Dis 2023; 36:250-256. [PMID: 37431554 PMCID: PMC10351900 DOI: 10.1097/qco.0000000000000937] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
PURPOSE OF REVIEW In patients with hematological malignancies, high-resolution computed tomography (CT) is the recommended imaging approach for diagnosis, staging and monitoring of invasive fungal disease (IFD) but lacks specificity. We examined the status of current imaging modalities for IFD and possibilities for more effective applications of current technology for improving the specificity of IFD diagnosis. RECENT FINDINGS Although CT imaging recommendations for IFD are largely unchanged in the last 20 years, improvements in CT scanner technology and image processing algorithms now allow for technically adequate examinations at much lower radiation doses. CT pulmonary angiography can improve both the sensitivity and specificity of CT imaging for angioinvasive molds in both neutropenic and nonneutropenic patients, through detection of the vessel occlusion sign (VOS). MRI-based approaches also show promise not only for early detection of small nodules and alveolar hemorrhage but can also be used to detect pulmonary vascular occlusion without radiation and iodinated contrast media. 18F-fluorodeoxyglucose (FDG) PET/computed tomography (FDG-PET/CT) is increasingly used to monitor long-term treatment response for IFD, but could become a more powerful diagnostic tool with the development of fungal-specific antibody imaging tracers. SUMMARY High-risk hematology patients have a considerable medical need for more sensitive and specific imaging approaches for IFD. This need may be addressable, in part, by better exploiting recent progress in CT/MRI imaging technology and algorithms to improve the specificity of radiological diagnosis for IFD.
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Affiliation(s)
- Russell E Lewis
- Infectious Diseases, Department of Molecular Medicine, University of Padua, Gabelli, Padua
| | - Marta Stanzani
- Hematopoietic Stem Cell Transplantation and Cellular Therapy, Hematology Unit, Regional Hospital Ca’ Foncello, AULSS 2- Marca Trevigiana, Piazza Ospedale
| | - Giovanni Morana
- Department of Radiology, Regional Hospital Ca’ Foncello, AULSS 2- Marca Trevigiana. Piazza Ospedale 1, Treviso
| | - Claudia Sassi
- Pediatric and Adult CardioThoracic and Vascular, Oncohematologic and Emergency Radiology Unit, DIMEC-Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
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Pham D, Howard-Jones AR, Sparks R, Stefani M, Sivalingam V, Halliday CL, Beardsley J, Chen SCA. Epidemiology, Modern Diagnostics, and the Management of Mucorales Infections. J Fungi (Basel) 2023; 9:659. [PMID: 37367595 DOI: 10.3390/jof9060659] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023] Open
Abstract
Mucormycosis is an uncommon, yet deadly invasive fungal infection caused by the Mucorales moulds. These pathogens are a WHO-assigned high-priority pathogen group, as mucormycosis incidence is increasing, and there is unacceptably high mortality with current antifungal therapies. Current diagnostic methods have inadequate sensitivity and specificity and may have issues with accessibility or turnaround time. Patients with diabetes mellitus and immune compromise are predisposed to infection with these environmental fungi, but COVID-19 has established itself as a new risk factor. Mucorales also cause healthcare-associated outbreaks, and clusters associated with natural disasters have also been identified. Robust epidemiological surveillance into burden of disease, at-risk populations, and emerging pathogens is required. Emerging serological and molecular techniques may offer a faster route to diagnosis, while newly developed antifungal agents show promise in preliminary studies. Equitable access to these emerging diagnostic techniques and antifungal therapies will be key in identifying and treating mucormycosis, as delayed initiation of therapy is associated with higher mortality.
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Affiliation(s)
- David Pham
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Annaleise R Howard-Jones
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
| | - Rebecca Sparks
- Douglass Hanly Moir Pathology, Sydney, NSW 2113, Australia
| | - Maurizio Stefani
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Varsha Sivalingam
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Catriona L Halliday
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Justin Beardsley
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Sydney, NSW 2145, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
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7
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Yang N, Zhang L, Feng S. Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies. J Fungi (Basel) 2023; 9:jof9050592. [PMID: 37233303 DOI: 10.3390/jof9050592] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
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.
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Affiliation(s)
- Nuobing Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
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8
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Liu J, Ma X. Amphotericin B colloidal dispersion: an effective drug for the treatment of mucormycosis in China. Front Cell Infect Microbiol 2023; 13:1147624. [PMID: 37265502 PMCID: PMC10230081 DOI: 10.3389/fcimb.2023.1147624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023] Open
Abstract
Objective Mucormycosis has emerged as an increasingly important cause of morbidity and mortality in immunocompromised patients, but the effective drugs for the treatment are limited. Hence, the study aimed to summarize the characteristics of mucormycosis in patients with hematological malignancies, and investigate the efficacy and safety of Amphotericin B Colloidal Dispersion (ABCD) in treating mucormycosis. Methods In this study, patients with mucormycosis complicated by hematological malignancies who received ABCD at the First Affiliated Hospital of Zhengzhou University from April 2021 to May 2022 were retrospectively enrolled. The clinical data of the enrolled patients were collected, and then, the drug response at 2 weeks, 4 weeks, and the end of treatment; the survival rate at 4, 8, and 12 weeks; and the laboratory-related indicators and adverse events (AEs) associated with ABCD were evaluated. Results In total, 9 patients with mucormycosis complicated by hematological malignancies were enrolled. The main symptoms were fever, cough, and chest pain. In addition, reversed halo signs (RHS) were found on chest CTs. The responses to ABCD at 2 weeks, 4 weeks, and the end of treatment were 100% (9/9), 77.8% (7/9), and 77.8% (7/9), respectively. The survival rates of the patients at 4, 8, and 12 weeks were 77.8% (7/9), 66.7% (6/9), and 66.7% (6/9), respectively. Among laboratory-related indicators, white blood cell (WBC) counts were significantly increased from baseline after 1 and 2 weeks of ABCD treatment (P<0.05), whereas neutrophil counts were only increased significantly from baseline at 2 weeks post-treatment (P<0.05). The most common AEs were infusion-related AEs manifesting as fever, chills, and pruritus. Moreover, none of the patients suffered from renal injury once again. Conclusion ABCD is a promising treatment strategy for patients with mucormycosis complicated by hematologic malignancies, showing remarkable efficacy and safety.
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Affiliation(s)
- Juntao Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiaoxu Ma
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Prakash S, Kumar A. Mucormycosis threats: A systemic review. J Basic Microbiol 2023; 63:119-127. [PMID: 36333107 DOI: 10.1002/jobm.202200334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/28/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
During the catastrophic wave of Coronavirus disease 2019, health agencies started to report an infrequent but lethal mucormycosis or black fungal infection. Primarily, it causes sinusitis by affecting nasal, oral, lung, brain, ocular, and other body tissues. It becomes more fatal, especially in diabetic, cancer, and immune-compromised patients. Before 2020, the prevalence of mucormycosis was very rare but it has rapidly emerged globally from late 2020 to mid-2021. Recently, the mucormycosis got worse and epidemic with more than 30,000 cases reported across India. The etiology of infection can be diagnosed by molecular, serological, microscopic, and clinical methods. However, early diagnosis of this ailment is still a challenging task due to no standalone diagnostic tool available along with clinical manifestations of the ailment resembling other fungal diseases. The treatment of mucormycosis is also challenging and frequently requires long-term treatment. Amphotericin B was found to be an effective antifungal for preventing mucormycosis but it failed if infection disseminated to necrotizing tissues or adjacent organs. Removal of infected tissue/organ by surgery is an alternative treatment to control mucormycosis. In addition, reversal of underlying predisposing conditions based on therapy is also in practice for its prevention. This review highlights different aspects of mucormycosis such as pathogenesis, diagnosis, treatment, and their challenges and so on. We also emphasized the epidemiological shift during the recent outbreak and its influence on the different regions of India.
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Affiliation(s)
- Shaurya Prakash
- Department of Biochemistry, Central University of Haryana, Haryana, India
| | - Antresh Kumar
- Department of Biochemistry, Central University of Haryana, Haryana, India
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10
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Ankrah AO, Lawal IO, Dierckx RAJO, Sathekge MM, Glaudemans AWJM. Imaging of Invasive Fungal Infections- The Role of PET/CT. Semin Nucl Med 2023; 53:57-69. [PMID: 35933165 DOI: 10.1053/j.semnuclmed.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 01/28/2023]
Abstract
Over the last decades, the population at risk for invasive fungal disease (IFD) has increased because of medical therapy advances and diseases compromising patients' immune systems. The high morbidity and mortality associated with invasive fungal disease in the immunocompromised present the challenge of early diagnosis of the IFD and the need to closely monitor the infection during treatment. The definitive diagnosis of invasive fungal disease based on culture or histopathological methods often has reduced diagnostic accuracy in the immunocompromised and may be very invasive. Less invasive and indirect evidence of the fungal infection by serology and imaging has been used for the early diagnosis of fungal infection before definitive results are available or when the definitive methods of diagnosis are suboptimal. Imaging in invasive fungal disease is a non-invasive biomarker that helps in the early diagnosis of invasive fungal disease but helps follow-up the infection during treatment. Different imaging modalities are used in the workup to evaluate fungal disease. The different imaging modalities have advantages and disadvantages at different sites in the body and may complement each other in the management of IFD. Positron emission tomography integrated with computed tomography with [18F]Fluorodeoxyglucose (FDG PET/CT) has helped manage IFD. The combined functional data from PET and anatomical data from the CT from almost the whole body allows noninvasive evaluation of IFD and provides a semiquantitative means of assessing therapy. FDG PET/CT adds value to anatomic-based only imaging modalities. The nonspecificity of FDG uptake has led to the evaluation of other tracers in the assessment of IFD. However, these are mainly still at the preclinical level and are yet to be translated to humans. FDG PET/CT remains the most widely evaluated radionuclide-based imaging modality in IFD management. The limitations of FDG PET/CT must be well understood, and more extensive prospective studies in uniform populations are needed to validate its role in the management of IFD that can be international guidelines.
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Affiliation(s)
- Alfred O Ankrah
- National Centre for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra GA, Ghana; Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa; Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands.
| | - Ismaheel O Lawal
- Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa; Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA
| | - Rudi A J O Dierckx
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Andor W J M Glaudemans
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands
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11
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Lee SO. Diagnosis and Treatment of Invasive Mold Diseases. Infect Chemother 2022; 55:10-21. [PMID: 36603818 PMCID: PMC10079437 DOI: 10.3947/ic.2022.0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/09/2022] [Indexed: 12/05/2022] Open
Abstract
Although invasive fungal diseases are relatively less common than superficial diseases, there has been an overall increase in their incidence. Here, I review the epidemiology, diagnosis, and treatment of invasive mold diseases (IMDs) such as aspergillosis, mucormycosis, hyalohyphomycosis, and phaeohyphomycosis. Histopathologic demonstration of tissue invasion by hyphae or recovery of mold by the culture of a specimen obtained by a sterile procedure provides definitive evidence of IMD. If IMD cannot be confirmed through invasive procedures, IMD can be diagnosed through clinical criteria such as the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Instituteof Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) definitions. For initial primary therapy of invasive aspergillosis, voriconazole or isavuconazole is recommended and lipid formulations of amphotericin B are useful primary alternatives. Echinocandins are representative antifungal agents for salvage therapy. Treatment of invasive mucormycosis involves a combination of urgent surgical debridement of involved tissues and antifungal therapy. Lipid formulations of amphotericin B are the drug of choice for initial therapy. Isavuconazole or posaconazole can be used as salvage or step-down therapy. IMDs other than aspergillosis and mucormycosis include hyalohyphomycosis and phaeohyphomycosis, for which there is no standard therapy and the treatment depends on the clinical disease and status of the patient.
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Affiliation(s)
- Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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12
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Mansoor S, Ahmed TI, Happa K, Sultan M, Manhas S, Shamas S. Spectrum of Mucormycosis Before and During COVID-19: Epidemiology, Diagnosis, and Current Therapeutic Interventions. Curr Fungal Infect Rep. [PMID: 35967987 PMCID: PMC9364274 DOI: 10.1007/s12281-022-00438-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
Purpose of Review More than half a billion people have been infected and 6.2 million killed by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) since the start of the pandemic in 2019. Systemic glucocorticoids are a double-edged sword, on the one hand, life-saving in treating COVID-19 complications while on the other hand, potentially leading to life-and-limb-threatening opportunistic fungal infections. Mucormycosis (MM) is caused by the mucormycetes family. Although rare, it is characterized by high mortality and significant morbidity. The gross similarities observed with other fungal infections which respond to different treatment regimens have made it all the more imperative to quickly and sensitively diagnose and treat MM. This review discusses the epidemiology of MM before and during the COVID-19 pandemic, associated risk factors, COVID-19-associated MM, diagnosis, and current therapeutic interventions. Recent Findings There has been a widespread and worrisome trend of rising in cases of MM, worldwide, but more so in the Indian subcontinent, where it is nicknamed the “black fungus.” This upsurge has picked up the pace ever since the start of the COVID-19 pandemic. Necrosis is secondary to the angio-invasive and pro-thrombotic nature of the mold resulting in extensive lesions presenting mostly as rhino-orbital MM (ROM) and rhino-orbito-cerebral MM (ROCM). Infection is mostly observed in subjects with underlying risk factors such as uncontrolled diabetes, those receiving hematopoietic stem cell transplant, and/or on corticosteroid or immunosuppressive therapy, although it is widely suspected that other factors such as iron and zinc may play a role in the pathogenesis of MM. The “One world one guideline” strategy advocates both prophylactic anti-fungal therapy along with aggressive, prompt, and individualized treatment with anti-fungal drugs such as amphotericin B in addition to vigorous surgical intervention. High-risk groups need particularly rapid diagnosis although empirical anti-fungal therapy may not be delayed. Speeding diagnostic turnaround times are essential to institute early therapy, and there is much scope for newer modalities such as PCR, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and whole-genome sequencing in such endeavors. The results of strict monitoring of blood glucose levels along with rational and limited use of steroids and immunomodulatory drugs have proven to be a significant preventive measure. Summary The significant rise in cases of MM worldwide has necessitated viewing each case with a strong index of suspicion. Adoption of rapid diagnostics, early antifungal therapy, and prompt surgical interventions are essential, while high-risk groups need particular focused care which may include prophylactic anti-fungal therapy, limited steroid use, and meticulous control of the underlying disease. Developing quicker and more sensitive diagnostic modalities has great potential to improve the detection and management of MM.
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Chandley P, Subba P, Rohatgi S. COVID-19-Associated Mucormycosis: A Matter of Concern Amid the SARS-CoV-2 Pandemic. Vaccines (Basel) 2022; 10:1266. [PMID: 36016154 DOI: 10.3390/vaccines10081266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 12/16/2022] Open
Abstract
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.
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Boyer J, Kriegl L, Krause R, Hoenigl M. Dark Mold Infections in Solid Organ Transplant Recipients. Curr Fungal Infect Rep. [DOI: 10.1007/s12281-022-00436-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Katal S, Eibschutz LS, Radmard AR, Naderpour Z, Gupta A, Hejal R, Gholamrezanezhad A. Black Fungus and beyond: COVID-19 associated infections. Clin Imaging 2022; 90:97-109. [PMID: 36007282 PMCID: PMC9308173 DOI: 10.1016/j.clinimag.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 12/15/2022]
Abstract
Globally, many hospitalized COVID-19 patients can experience an unexpected acute change in status, prompting rapid and expert clinical assessment. Superimposed infections can be a significant cause of clinical and radiologic deviations in this patient population, further worsening clinical outcome and muddling the differential diagnosis. As thrombotic, inflammatory, and medication-induced complications can also trigger an acute change in COVID-19 patient status, imaging early and often plays a vital role in distinguishing the cause of patient decline and monitoring patient outcome. While the common radiologic findings of COVID-19 infection are now widely reported, little is known about the clinical manifestations and imaging findings of superimposed infection. By discussing case studies of patients who developed bacterial, fungal, parasitic, and viral co-infections and identifying the most frequently reported imaging findings of superimposed infections, physicians will be more familiar with common infectious presentations and initiate a directed workup sooner. Ultimately, any abrupt changes in the expected COVID-19 imaging presentation, such as the presence of new consolidations or cavitation, should prompt further workup to exclude superimposed opportunistic infection.
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Affiliation(s)
- Sanaz Katal
- Department of Nuclear Medicine, Shiraz Kowsar Hospital, Tehran University of Medical Sciences
| | - Liesl S Eibschutz
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Iran
| | - Zeinab Naderpour
- Department of Pulmonology, Shariati Hospital, Tehran University of Medical Sciences, Iran
| | - Amit Gupta
- Department of Radiology, University Hospital Cleveland Medical Center, Cleveland, OH, United States of America
| | - Rana Hejal
- Department of Internal Medicine, Division of Pulmonary Critical Care, University Hospital Cleveland Medical Center, Cleveland, OH, United States of America
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America.
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Marinelli T, van Hal S. The Evolving Landscape of Diagnostics for Invasive Fungal Infections in Lung Transplant Recipients. Curr Fungal Infect Rep. [DOI: 10.1007/s12281-022-00433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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17
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Sharma A, Goel A. Mucormycosis: risk factors, diagnosis, treatments, and challenges during COVID-19 pandemic. Folia Microbiol (Praha) 2022; 67:363-387. [PMID: 35220559 PMCID: PMC8881997 DOI: 10.1007/s12223-021-00934-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Mucormycosis is a deadly opportunistic disease caused by a group of fungus named mucormycetes. Fungal spores are normally present in the environment and the immune system of the body prevents them from causing disease in a healthy immunocompetent individual. But when the defense mechanism of the body is compromised such as in the patients of diabetes mellites, neustropenia, organ transplantation recipients, and other immune-compromised states, these fungal spores invade our defense mechanism easily causing a severe systemic infection with approximately 45-80% of case fatality. In the present scenario, during the COVID-19 pandemic, patients are on immunosuppressive drugs, glucocorticoids, thus are at high risk of mucormycosis. Patients with diabetes mellitus are further getting a high chance of infection. Usually, the spores gain entry through our respiratory tract affecting the lungs and paranasal sinuses. Besides, they can also enter through damage into the skin or through the gastrointestinal route. This review article presents the current statistics, the causes of this infection in the human body, and its diagnosis with available recent therapies through recent databases collected from several clinics and agencies. The diagnosis and identification of the infection were made possible through various latest medical techniques such as computed tomography scans, direct microscopic observations, MALDI-TOF mass spectrometry, serology, molecular assay, and histopathology. Mucormycosis is so uncommon, no randomized controlled treatment studies have been conducted. The newer triazoles, posaconazole (POSA) and isavuconazole (ISAV) (the active component of the prodrug isavuconazonium sulfate) may be beneficial in patients who are refractory to or intolerant of Liposomal Amphotericin B. but due to lack of early diagnosis and aggressive surgical debridement or excision, the mortality rate remains high. In the course of COVID-19 treatments, there must be more vigilance and alertness are required from clinicians to evaluate these invasive fungal infections.
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Affiliation(s)
- Ayushi Sharma
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India
| | - Anjana Goel
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India.
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18
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Godoy MC, Ferreira Dalla Pria HR, Truong MT, Shroff GS, Marom EM. Invasive Fungal Pneumonia in Immunocompromised Patients. Radiol Clin North Am 2022; 60:497-506. [DOI: 10.1016/j.rcl.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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19
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Hershman M, Simpson S. Thoracic Infections in Solid Organ Transplants. Radiol Clin North Am 2022; 60:481-95. [DOI: 10.1016/j.rcl.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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20
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Muthu V, Agarwal R, Patel A, Kathirvel S, Abraham OC, Aggarwal AN, Bal A, Bhalla AS, Chhajed PN, Chaudhry D, Garg M, Guleria R, Krishnan RG, Kumar A, Maheshwari U, Mehta R, Mohan A, Nath A, Patel D, Rudramurthy SM, Saxena P, Sethuraman N, Singhal T, Soman R, Thangakunam B, Varghese GM, Chakrabarti A. Definition, diagnosis, and management of COVID-19-associated pulmonary mucormycosis: Delphi consensus statement from the Fungal Infection Study Forum and Academy of Pulmonary Sciences, India. The Lancet Infectious Diseases 2022. [PMID: 35390293 PMCID: PMC8979562 DOI: 10.1016/s1473-3099(22)00124-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 12/16/2022]
Abstract
COVID-19-associated pulmonary mucormycosis (CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus (≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B (5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4–6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but under-reported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required.
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21
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Jethani V, Sharma D, Pant S, Joshi S. Pulmonary mucormycosis: a rare case report. J Assoc Chest Physicians 2022. [DOI: 10.4103/jacp.jacp_7_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Chan J, Duong PAT. Imaging of Endemic and Opportunistic Fungal Pulmonary Disease. Semin Roentgenol 2022; 57:53-66. [DOI: 10.1053/j.ro.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/09/2021] [Indexed: 11/11/2022]
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23
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Janjua OS, Shaikh MS, Fareed MA, Qureshi SM, Khan MI, Hashem D, Zafar MS. Dental and Oral Manifestations of COVID-19 Related Mucormycosis: Diagnoses, Management Strategies and Outcomes. J Fungi (Basel) 2021; 8:44. [PMID: 35049983 DOI: 10.3390/jof8010044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 12/14/2022] Open
Abstract
It has been nearly two years since the pandemic caused by the novel coronavirus disease (COVID-19) has affected the world. Several innovations and discoveries related to COVID-19 are surfacing every day and new problems associated with the COVID-19 virus are also coming to light. A similar situation is with the emergence of deep invasive fungal infections associated with severe acute respiratory syndrome 2 (SARS-CoV-2). Recent literature reported the cases of pulmonary and rhino-cerebral fungal infections appearing in patients previously infected by COVID-19. Histopathological analysis of these cases has shown that most of such infections are diagnosed as mucormycosis or aspergillosis. Rhino-orbital-cerebral mucormycosis usually affects the maxillary sinus with involvement of maxillary teeth, orbits, and ethmoidal sinuses. Diabetes mellitus is an independent risk factor for both COVID-19 as well as mucormycosis. At this point, there is scanty data on the subject and most of the published literature comprises of either case reports or case series with no long-term data available. The aim of this review paper is to present the characteristics of COVID-19 related mucormycosis and associated clinical features, outcome, diagnostic and management strategies. A prompt diagnosis and aggressive treatment planning can surely benefit these patients.
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Ma X, Li A, Cao W, Li H, Zhang S, Li L, Xing H, Tian W, Jiao P, Chen J, Zhang Q, Xu A, Xing L. Characteristics of Mucormycosis in Hematological Patients and a Death Prediction Model. Front Microbiol 2021; 12:784974. [PMID: 34975805 PMCID: PMC8714886 DOI: 10.3389/fmicb.2021.784974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/18/2021] [Indexed: 11/18/2022] Open
Abstract
Mucormycosis is an angioinvasive fungal infection, associated with high mortality. The aim of our study was to explore the high-risk factors and predict the death of hematological disease complicated with mucormycosis. We retrospectively analyzed clinical data of 31 patients with hematological disease complicated with mucormycosis, adopted random forest to establish the death prediction model, and validated the model in another 15 patients. The median age of the 31 cases was 46 (28–51) years, male to female ratio 1.38:1, and 90-day mortality rate 54.8%. The most common underlying disease was acute myeloid leukemia (58.1%). The main clinical symptoms were fever (100%), cough (87.1%), sputum (80.6%), chest pain (61.3%), and hemoptysis (19.4%). Reversed halo sign (83.9%) was the most common computed tomography sign. A total of 48.4% of patients also had aspergillus or bacterial infections. Discriminative models were constructed by random forest with 17 non-survivors and 14 survivors. Procalcitonin, the duration of intravenous administration of amphotericin B or amphotericin B liposomes, and neutropenia at death or 90 days of survival were the leading risk factors for poor prognosis, with area under the curve of 0.975 (95% CI 0.934–1). We chose 0.6775 as death prediction threshold (with 82.3% sensitivity and 100% specificity) and validated the model successfully in another 15 patients. Chest pain and reversed halo sign are specific clinical and image signs of hematological disease complicated with mucormycosis. Neutropenia, elevated procalcitonin, and insufficient use time of amphotericin B or amphotericin B liposomes are risk factors for death.
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Affiliation(s)
- Xiaoxu Ma
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ang Li
- Gene Hospital of Henan Province, Precision Medicine Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weijie Cao
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huiling Li
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Suping Zhang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Li
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haizhou Xing
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenliang Tian
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengfei Jiao
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiajun Chen
- College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Qingxian Zhang
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aiguo Xu
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Aiguo Xu,
| | - Lihua Xing
- Department of Respiration, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Lihua Xing,
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Naranje P, Bhalla AS, Jana M, Garg M, Nair AD, Singh SK, Banday I. Imaging of Pulmonary Superinfections and Co-Infections in COVID-19. Curr Probl Diagn Radiol 2021; 51:768-778. [PMID: 34903396 PMCID: PMC8580558 DOI: 10.1067/j.cpradiol.2021.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/11/2021] [Accepted: 09/19/2021] [Indexed: 01/20/2023]
Abstract
New challenges in imaging and management of COVID-19 pneumonia emerge as the pandemic continues across the globe. These arise not only due to the COVID-19 pneumonia but also related to various superinfections and co-infections. Limited use of bronchoscopic and other aerosol generating procedures to obtain representative lower respiratory samples from these patient groups for accurate identification of organism, increases the responsibility of radiologists in suggesting the most likely cause of secondary infection. Imaging features of many of these infections overlap with features of COVID-19 pneumonia. In this review, we highlight imaging findings that can aid in the diagnosis of superinfections and co-infections in patients with COVID-19 pneumonia, and also help in predicting the likely causative organism.
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Affiliation(s)
- Priyanka Naranje
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashu Seith Bhalla
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India..
| | - Manisha Jana
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankita Dhiman Nair
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Swish Kumar Singh
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Irshad Banday
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
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Raghav A, Ali SG, Jeong GB, Gautam KA, Banday S, Mateen QN, Tripathi P, Giri R, Agarwal S, Singh M, Khan HM. Newer Horizon of Mesenchymal Stem Cell-Based Therapy in the Management of SARS-CoV-2-Associated Mucormycosis: A Safe Hope for Future Medicine. Front Microbiol 2021; 12:738983. [PMID: 34707590 PMCID: PMC8543035 DOI: 10.3389/fmicb.2021.738983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/26/2021] [Indexed: 12/27/2022] Open
Abstract
SARS-CoV-2-infected patients are reported to show immunocompromised behavior that gives rise to a wide variety of complications due to impaired innate immune response, cytokine storm, and thrombo-inflammation. Prolonged use of steroids, diabetes mellitus, and diabetic ketoacidosis (DKA) are some of the factors responsible for the growth of Mucorales in such immunocompromised patients and, thus, can lead to a life-threatening condition referred to as mucormycosis. Therefore, an early diagnosis and cell-based management cosis is the need of the hour to help affected patients overcome this severe condition. In addition, extended exposure to antifungal drugs/therapeutics is found to initiate hormonal and neurological complications. More recently, mesenchymal stem cells (MSCs) have been used to exhibit immunomodulatory function and proven to be beneficial in a clinical cell-based regenerative approach. The immunomodulation ability of MSCs in mucormycosis patient boosts the immunity by the release of chemotactic proteins. MSC-based therapy in mucormycosis along with the combination of short-term antifungal drugs can be utilized as a prospective approach for mucormycosis treatment with promising outcomes. However, preclinical and in mucormyIn mucormycosis, the hyphae of clinical trials are needed to establish the precise mechanism of MSCs in mucormycosis treatment.
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Affiliation(s)
- Alok Raghav
- Multidiscplinary Research Unit, Department of Health Research, MoHFW, GSVM Medical College, Kanpur, India
| | - Syed Ghazanfar Ali
- Viral Research Diagnostic Laboratory, Department of Microbiology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
| | - Goo-Bo Jeong
- Department of Anatomy and Cell Biology, College of Medicine, Gachon University, Getbeol-ro Yeonsu-gu, Incheon, Korea
| | - Kirti Amresh Gautam
- Multidiscplinary Research Unit, Department of Health Research, MoHFW, GSVM Medical College, Kanpur, India
| | - Shahid Banday
- Department of Molecular, Cell and Cancer Biology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Qazi Noorul Mateen
- Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology Delhi, New Delhi, India
| | | | - Richa Giri
- Department of Medicine, GSVM Medical College, Kanpur, India
| | | | - Manish Singh
- Department of Neurosciences, GSVM Medical College, Kanpur, India
| | - Haris M Khan
- Viral Research Diagnostic Laboratory, Department of Microbiology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
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Asdaq SMB, Rajan A, Damodaran A, Kamath SR, Nair KS, Zachariah SM, Sahu RK, Fattepur S, Sreeharsha N, Nair A, Jacob S, Albahrani HA, Alkhaldi EH, Mohzari Y, Alrashed AA, Imran M. Identifying Mucormycosis Severity in Indian COVID-19 Patients: A Nano-Based Diagnosis and the Necessity for Critical Therapeutic Intervention. Antibiotics (Basel) 2021; 10:1308. [PMID: 34827246 PMCID: PMC8615244 DOI: 10.3390/antibiotics10111308] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 01/01/2023] Open
Abstract
The COVID-19 infection caused by the new SARS-CoV-2 virus has been linked to a broad spectrum of symptoms, from a mild cough to life-threatening pneumonia. As we learn more about this unusual COVID-19 epidemic, new issues are emerging and being reported daily. Mucormycosis, also known as zygomycosis or phycomycosis, causes severe fungal illness to individuals with a weakened immune system. It is a devastating fungal infection, and the most frequent kind is the rhino cerebral type. As a devastating second wave of COVID-19 sweeps India, doctors report several instances involving a strange illness-sometimes known as the "black fungus"-among returning and recovered COVID-19 patients. This paper analyzes the existing statistical data to address the severity of prevalence and further notes the nano-based diagnostic parameters, clinical presentations, its connection with other conditions like diabetes, hypertension, and GI disorders, and the importance of anti-fungal therapy in treating the same. Anti-fungal therapies, as well as surgical interventions, are currently used for the treatment of the disease. Proper and timely diagnosis is necessary, along with the reduction in the spread of COVID-19. From the review, it was found that timely pharmacologic interventions and early diagnosis by using a nano-based diagnostic kit can help control the disease. Additionally, this paper provides novel information about the nanotechnology approaches such as fungal detection biosensors, nucleic acids-based testing, point-of-care tests, and galactomannans detection, in the diagnosis of mucormycosis, and thereby reinforces the need for further research on the topic.
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Affiliation(s)
| | - Arya Rajan
- Amrita School of Pharmacy, AIMS Health Science Campus, Amrita Vishwa Vidyapeetham, Kochi 682041, India; (A.R.); (A.D.); (S.R.K.); (K.S.N.)
| | - Aswin Damodaran
- Amrita School of Pharmacy, AIMS Health Science Campus, Amrita Vishwa Vidyapeetham, Kochi 682041, India; (A.R.); (A.D.); (S.R.K.); (K.S.N.)
| | - Shivali R. Kamath
- Amrita School of Pharmacy, AIMS Health Science Campus, Amrita Vishwa Vidyapeetham, Kochi 682041, India; (A.R.); (A.D.); (S.R.K.); (K.S.N.)
| | - Krishnanjana S. Nair
- Amrita School of Pharmacy, AIMS Health Science Campus, Amrita Vishwa Vidyapeetham, Kochi 682041, India; (A.R.); (A.D.); (S.R.K.); (K.S.N.)
| | - Subin Mary Zachariah
- Amrita School of Pharmacy, AIMS Health Science Campus, Amrita Vishwa Vidyapeetham, Kochi 682041, India; (A.R.); (A.D.); (S.R.K.); (K.S.N.)
| | - Ram Kumar Sahu
- Department of Pharmaceutical Science, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia;
- Department of Pharmaceutical Science, Assam University (A Central University), Silchar 788011, India
| | - Santosh Fattepur
- School of Pharmacy, Management and Science University, Shah Alam 40100, Malaysia;
| | - Nagaraja Sreeharsha
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Hofuf 31982, Saudi Arabia; (N.S.); (A.N.)
- Department of Pharmaceutics, Vidya Siri College of Pharmacy, Bangalore 560035, India
| | - Anroop Nair
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Hofuf 31982, Saudi Arabia; (N.S.); (A.N.)
| | - Shery Jacob
- Department of Pharmaceutical Sciences, College of Pharmacy, Gulf Medical University, Ajman 4184, United Arab Emirates;
| | | | - Eman H. Alkhaldi
- Pharmaceutical Care Services, King Saud Medical City, Riyadh 12746, Saudi Arabia;
| | - Yahya Mohzari
- Clinical Pharmacy Department, King Saud Medical City, Riyadh 12746, Saudi Arabia;
| | - Ahmed A. Alrashed
- Pharmaceutical Services Administration, Inpatient Department, Main Hospital, King Fahad Medical City, Riyadh 11564, Saudi Arabia;
| | - Mohd. Imran
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Northern Border University, Rafha 91911, Saudi Arabia;
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Khera S, Singh V, Pattanayak S. Favourable outcome in a child with acute lymphoblastic leukaemia and pulmonary mucormycosis managed with combination antifungal therapy of liposomal amphotericin B and caspofungin. BMJ Case Rep 2021; 14:e245329. [PMID: 34667044 PMCID: PMC8527156 DOI: 10.1136/bcr-2021-245329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/04/2022] Open
Abstract
Pulmonary mucormycosis (PM) accounts for more than half the cases of mucormycosis in paediatric haematological malignancies, with mortality reaching as high as 90%. Surgical debridement of lesion along with liposomal amphotericin B (L-AMB) constitutes the mainstay of management of mucormycosis and offers best chances of survival. There are no reliable data available in the literature justifying the use of combination antifungal therapy (CAfT). We describe a child with acute lymphoblastic leukaemia (ALL) who developed multiple localised PM during induction chemotherapy. He was managed with CAfT with L-AMB and caspofungin in view of progressive PM on high-dose L-AMB monotherapy. There was complete resolution of PM after 6 months of CAfT at the end of intensive chemotherapy of ALL. There were no significant side effects of CAfT. CAfT may be of value in cases of mucormycosis refractory to high doses of L-AMB, where surgical debridement is not feasible.
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Affiliation(s)
- Sanjeev Khera
- Department of Pediatrics, Army Hospital Research and Referral, New Delhi, Delhi, India
| | - Vikram Singh
- Department of Pathology, Army Hospital Research & Referral, New Delhi, Delhi, India
| | - Somali Pattanayak
- Department of Radiodiagnosis, Army Hospital Research and Referral, New Delhi, Delhi, India
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29
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Kharbanda R, Mehndiratta A, Chatterjee R, Marak RSK, Aggarwal A. Pulmonary mucormycosis in systemic lupus erythematosus: successful management of a case along with review of literature. Clin Rheumatol 2021. [PMID: 34606036 DOI: 10.1007/s10067-021-05941-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/12/2022]
Abstract
Pulmonary mucormycosis is rare in systemic lupus erythematosus. A 20-year-old lady with lupus nephritis and neuropsychiatric lupus was treated with injection methylprednisolone and cyclophosphamide. After few days, she developed fever, breathlessness, and hoarseness of voice. After neck and chest imaging, possibility of mucormycosis was considered which was later confirmed on microbiological test. Patient was treated with conventional amphotericin B. Literature review was done, and 8 patients with disseminated or pulmonary mucormycosis were identified with SLE. In patients with high index of suspicion, early imaging can help in diagnosis and early and aggressive management even with conventional amphotericin B can result in favorable outcome.Key Points • Pulmonary mucormycosis in systemic lupus erythematosus is rare. • Radiological investigation can guide towards diagnosis. • Early and aggressive treatment can lead to good outcome. |
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Sahu RK, Salem-Bekhit MM, Bhattacharjee B, Almoshari Y, Ikbal AMA, Alshamrani M, Bharali A, Salawi A, Widyowati R, Alshammari A, Elbagory I. Mucormycosis in Indian COVID-19 Patients: Insight into Its Patho-Genesis, Clinical Manifestation, and Management Strategies. Antibiotics (Basel) 2021; 10:1079. [PMID: 34572661 PMCID: PMC8468123 DOI: 10.3390/antibiotics10091079] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/21/2022] Open
Abstract
Mucormycosis in patients who have COVID-19 or who are otherwise immunocompromised has become a global problem, causing significant morbidity and mortality. Infection is debilitating and fatal, leading to loss of organs and emotional trauma. Radiographic manifestations are not specific, but diagnosis can be made through microscopic examination of materials collected from necrotic lesions. Treatment requires multidisciplinary expertise, as the fungus enters through the eyes and nose and may even reach the brain. Use of the many antifungal drugs available is limited by considerations of resistance and toxicity, but nanoparticles can overcome such limitations by reducing toxicity and increasing bioavailability. The lipid formulation of amphotericin-B (liposomal Am-B) is the first-line treatment for mucormycosis in COVID-19 patients, but its high cost and low availability have prompted a shift toward surgery, so that surgical debridement to remove all necrotic lesions remains the hallmark of effective treatment of mucormycosis in COVID-19. This review highlights the pathogenesis, clinical manifestation, and management of mucormycosis in patients who have COVID-19.
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Affiliation(s)
- Ram Kumar Sahu
- Department of Pharmaceutical Science, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia; (R.K.S.); (R.W.)
- Department of Pharmaceutical Science, Assam University (A Central University), Silchar 788011, India
| | - Mounir M. Salem-Bekhit
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
- Department of Microbiology and Immunology, Faculty of Pharmacy, Al-Azhar University, Cairo 11884, Egypt
| | - Bedanta Bhattacharjee
- Department of Pharmaceutical Sciences, Faculty of Science and Engineering, Dibrugarh University, Dibrugarh 786004, India;
| | - Yosif Almoshari
- Department of Pharmaceutics, College of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia; (Y.A.); (M.A.); (A.S.)
| | - Abu Md Ashif Ikbal
- Department of Pharmacy, Tripura University (A Central University), Suryamaninagar 799022, India
| | - Meshal Alshamrani
- Department of Pharmaceutics, College of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia; (Y.A.); (M.A.); (A.S.)
| | - Alakesh Bharali
- Department of Pharmaceutics, Girijananda Chowdhury Institute of Pharmaceutical Sciences, Azara, Hatkhowapara, Guwahati 781017, India;
| | - Ahmad Salawi
- Department of Pharmaceutics, College of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia; (Y.A.); (M.A.); (A.S.)
| | - Retno Widyowati
- Department of Pharmaceutical Science, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia; (R.K.S.); (R.W.)
| | - Abdulrahman Alshammari
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Ibrahim Elbagory
- College of Pharmacy, Northern Border University, Arar 1321, Saudi Arabia;
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Penner JC, Dyster TG, Babik JM. The Reverse Halo Sign in an Immunocompromised Host. J Gen Intern Med 2021; 36:2452-3. [PMID: 33904050 DOI: 10.1007/s11606-021-06795-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
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Astashchanka A, Ryan J, Lin E, Nokes B, Jamieson C, Kligerman S, Malhotra A, Mandel J, Joshua J. Pulmonary Complications in Hematopoietic Stem Cell Transplant Recipients-A Clinician Primer. J Clin Med 2021; 10:3227. [PMID: 34362012 PMCID: PMC8348211 DOI: 10.3390/jcm10153227] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 12/15/2022] Open
Abstract
Hematopoietic stem cell transplants (HSCT) are becoming more widespread as a result of optimization of conditioning regimens and prevention of short-term complications with prophylactic antibiotics and antifungals. However, pulmonary complications post-HSCT remain a leading cause of morbidity and mortality and are a challenge to clinicians in both diagnosis and treatment. This comprehensive review provides a primer for non-pulmonary healthcare providers, synthesizing the current evidence behind common infectious and non-infectious post-transplant pulmonary complications based on time (peri-engraftment, early post-transplantation, and late post-transplantation). Utilizing the combination of timing of presentation, clinical symptoms, histopathology, and radiographic findings should increase rates of early diagnosis, treatment, and prognostication of these severe illness states.
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Affiliation(s)
- Anna Astashchanka
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Joseph Ryan
- Division of Hematology & Oncology, Scripps Clinic, La Jolla, CA 92037, USA;
| | - Erica Lin
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Brandon Nokes
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Catriona Jamieson
- Sanford Stem Cell Clinical Center, Moores Cancer Center, Department of Medicine, Division of Regenerative Medicine, University of California San Diego, La Jolla, CA 92093, USA;
| | - Seth Kligerman
- Division of Cardiothoracic Radiology, University of California San Diego, La Jolla, CA 92121, USA;
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jess Mandel
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jisha Joshua
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
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Foppiano Palacios C, Spichler Moffarah A. Diagnosis of Pneumonia Due to Invasive Molds. Diagnostics (Basel) 2021; 11:diagnostics11071226. [PMID: 34359309 PMCID: PMC8304515 DOI: 10.3390/diagnostics11071226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 12/20/2022] Open
Abstract
Pneumonia is the most common presentation of invasive mold infections (IMIs), and is pathogenetically characterized as angioinvasion by hyphae, resulting in tissue infarction and necrosis. Aspergillus species are the typical etiologic cause of mold pneumonia, with A. fumigatus in most cases, followed by the Mucorales species. Typical populations at risk include hematologic cancer patients on chemotherapy, bone marrow and solid organ transplant patients, and patients on immunosuppressive medications. Invasive lung disease due to molds is challenging to definitively diagnose based on clinical features and imaging findings alone, as these methods are nonspecific. Etiologic laboratory testing is limited to insensitive culture techniques, non-specific and not readily available PCR, and tissue biopsies, which are often difficult to obtain and impact on the clinical fragility of patients. Microbiologic/mycologic analysis has limited sensitivity and may not be sufficiently timely to be actionable. Due to the inadequacy of current diagnostics, clinicians should consider a combination of diagnostic modalities to prevent morbidity in patients with mold pneumonia. Diagnosis of IMIs requires improvement, and the availability of noninvasive methods such as fungal biomarkers, microbial cell-free DNA sequencing, and metabolomics-breath testing could represent a new era of timely diagnosis and early treatment of mold pneumonia.
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Abstract
Mucormycosis is a rare but aggressive fungal disease that mainly affects patients with poorly controlled diabetes mellitus and those who are severely immunocompromised, including patients with hematological malignancies and solid organ transplant recipients. Early recognition of infection is critical for treatment success, followed by prompt initiation of antifungal therapy with lipid formulation amphotericin B. Posaconazole and isavuconazole should be used for stepdown and salvage therapy. Surgical debridement is key for tissue diagnosis and treatment and should be pursued urgently whenever possible. In addition to surgery and antifungal therapy, reverting the underlying risk factor for infection is important for treatment response.
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Affiliation(s)
- Julie M Steinbrink
- Division of Infectious Diseases, Department of Internal Medicine, Duke University Medical Center, Hanes House, Duke University Medical Center, 315 Trent Drive, Durham, NC 27710, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, F4005 UH-South- SPC 5226, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
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35
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Chen F, Zhong Y, Li N, Wang H, Tan Y, Zhang H, Hua W, Mao Y, Huang H. Dynamic monitor of CT scan within short interval in invasive pulmonary aspergillosis for nonneutropenic patients: a retrospective analysis in two centers. BMC Pulm Med 2021; 21:142. [PMID: 33941132 PMCID: PMC8091757 DOI: 10.1186/s12890-021-01512-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background In nonneutropenic patients with underlying respiratory diseases (URD), invasive pulmonary aspergillosis (IPA) is a life-threatening disease. Yet establishing early diagnosis in those patients remains quite a challenge. Methods A retrospective series of nonneutropenic patients with probable or proven IPA were reviewed from January 2014 to May 2018 in Department of Respiratory Medicine of two Chinese hospitals. Those patients were suspected of IPA and underwent lung computed tomography (CT) scans twice within 5–21 days. The items required for IPA diagnosis were assessed by their host factors, mycological findings and CT scans according to the European Organization for Research and Treatment of Cancer (EORTC) and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (MSG) criteria (EORTC/MSG criteria). Results Together with the risk factors, mycological findings and nonspecific radiological signs on first CT, ten patients were suspected of IPA. With the appearance of cavities on second CT scan in the following days, all patients met the criteria of probable or possible IPA. Except one patient who refused antifungal treatment, nine patients received timely antifungal treatment and recovered well. One of the nine treated IPA cases was further confirmed by pathology, one was confirmed by biopsy. Conclusions Dynamic monitor of CT scan provided specific image evidences for IPA diagnosis. This novel finding might provide a noninvasive and efficient strategy in IPA diagnosis with URD.
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Affiliation(s)
- Fei Chen
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yonghong Zhong
- Yuhang Branch, the Second Affiliated Hospital, Zhejiang University School of medicine, Zhejiang, Hangzhou, China
| | - Na Li
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Huijie Wang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yanbin Tan
- Department of Radiology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hao Zhang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wen Hua
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yanxiong Mao
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Huaqiong Huang
- Key Laboratory of Respiratory Disease of Zhejiang Province, Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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36
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Alexander BD, Lamoth F, Heussel CP, Prokop CS, Desai SR, Morrissey CO, Baddley JW. Guidance on Imaging for Invasive Pulmonary Aspergillosis and Mucormycosis: From the Imaging Working Group for the Revision and Update of the Consensus Definitions of Fungal Disease from the EORTC/MSGERC. Clin Infect Dis 2021; 72:S79-S88. [PMID: 33709131 DOI: 10.1093/cid/ciaa1855] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinical imaging in suspected invasive fungal disease (IFD) has a significant role in early detection of disease and helps direct further testing and treatment. Revised definitions of IFD from the EORTC/MSGERC were recently published and provide clarity on the role of imaging for the definition of IFD. Here, we provide evidence to support these revised diagnostic guidelines. METHODS We reviewed data on imaging modalities and techniques used to characterize IFDs. RESULTS Volumetric high-resolution computed tomography (CT) is the method of choice for lung imaging. Although no CT radiologic pattern is pathognomonic of IFD, the halo sign, in the appropriate clinical setting, is highly suggestive of invasive pulmonary aspergillosis (IPA) and associated with specific stages of the disease. The ACS is not specific for IFD and occurs in the later stages of infection. By contrast, the reversed halo sign and the hypodense sign are typical of pulmonary mucormycosis but occur less frequently. In noncancer populations, both invasive pulmonary aspergillosis and mucormycosis are associated with "atypical" nonnodular presentations, including consolidation and ground-glass opacities. CONCLUSIONS A uniform definition of IFD could improve the quality of clinical studies and aid in differentiating IFD from other pathology in clinical practice. Radiologic assessment of the lung is an important component of the diagnostic work-up and management of IFD. Periodic review of imaging studies that characterize findings in patients with IFD will inform future diagnostic guidelines.
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Affiliation(s)
- Barbara D Alexander
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Frédéric Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claus Peter Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik gGmbH, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research.,Diagnostic and Interventional Radiology, Ruprecht-Karls-University, Heidelberg, Germany
| | | | - Sujal R Desai
- Department of Radiology, Royal Brompton and Harefield National Health Service Foundation Trust, London and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Muthu V, Gandra RR, Dhooria S, Sehgal IS, Prasad KT, Kaur H, Gupta N, Bal A, Ram B, Aggarwal AN, Chakrabarti A, Agarwal R. Role of flexible bronchoscopy in the diagnosis of invasive fungal infections. Mycoses 2021; 64:668-677. [PMID: 33719109 DOI: 10.1111/myc.13263] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND There are sparse data on the role of flexible bronchoscopy (FB) in diagnosing invasive mould infections (IMIs). OBJECTIVE To investigate the safety and usefulness of FB in IMI. We evaluate the factors associated with a successful diagnosis of IMI using FB. Further, we compare subjects of invasive pulmonary aspergillosis (IPA) with pulmonary mucormycosis (PM). METHODS We retrospectively reviewed the clinical features, imaging data, bronchoscopy, microbiology and pathology details of subjects who underwent FB for suspected IMI. We categorised FB as diagnostic if it contributed to the diagnosis of IMI. We performed a multivariate analysis to identify the factors associated with a diagnostic bronchoscopy. RESULTS Of the 3521 FB performed over 18 months, 132 (3.7%) were done for suspected IMIs. We included 107 subjects for the final analysis. The risk factors for IMI included renal transplantation (29.0%), diabetes (27.1%), haematological malignancy (10.3%) and others. We found bronchoscopic abnormalities in 33 (30.8%) subjects, and these were more frequent in those with confirmed PM (67%) than IPA (27%). IMI was confirmed in 79 (14 proven, 48 probable and 17 possible) subjects. FB was diagnostic in 71%. We experienced major complications in three cases (2.7%), including one death. On multivariate analysis, the visualisation of endobronchial abnormalities during FB (OR [95%, CI], 8.5 [1.4-50.4]) was the only factor associated with a diagnostic FB after adjusting for age and various risk factors. CONCLUSIONS Flexible bronchoscopy is a useful and safe procedure in diagnosing IMIs. The presence of endobronchial abnormalities predicts a successful diagnostic yield on FB.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Raghava Rao Gandra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nalini Gupta
- Department of Cytology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Babu Ram
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Jain A, Knoll B, Lim S, Kleinman G, Epelbaum O. For Whom the Atoll Tolls: Targeting the Reversed Halo Sign. Am J Med 2021; 134:e150-e152. [PMID: 33353726 DOI: 10.1016/j.amjmed.2020.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/12/2020] [Accepted: 09/14/2020] [Indexed: 01/15/2023]
Affiliation(s)
| | | | | | | | - Oleg Epelbaum
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Westchester Medical Center, Valhalla, NY
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39
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Khawar MU, Tiwana M, Sengupta R, Wang J, Indihar V. The reverse halo sign and spontaneous pneumothorax due to pulmonary mucormycosis. Respirol Case Rep 2021; 9:e00712. [PMID: 33532075 PMCID: PMC7829633 DOI: 10.1002/rcr2.712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/19/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022] Open
Abstract
Pulmonary mucormycosis (PM) is a rare opportunistic fungal infection that commonly affects immunocompromised patients. Early diagnosis and initiation of appropriate anti-fungal therapy are crucial, as delay in diagnosis leads to increased mortality. However, the diagnosis is often challenging because of the lack of utility of serum markers and low culture sensitivity. Definitive diagnosis often requires invasive tissue sampling, which may delay treatment. Therefore, chest imaging findings play an important role in the diagnosis of suspected cases. This case highlights the importance of classic reverse halo sign and presence of necrotizing cystic changes resulting in spontaneous pneumothorax in a patient who was later found to have invasive PM.
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Affiliation(s)
- Muhammad Umair Khawar
- Department of Internal Medicine, Division of Pulmonary, Critical Care & Sleep MedicineUniversity of CincinnatiCincinnatiOHUSA
| | - Maida Tiwana
- Division of Public Health, Department of Environmental HealthUniversity of CincinnatiCincinnatiOHUSA
| | - Ruchira Sengupta
- Division of Pulmonary & Critical Care MedicineSpectrum Health Medical GroupGrand RapidsMIUSA
| | - Jiang Wang
- Division of Pathology & Laboratory MedicineUniversity of CincinnatiCincinnatiOHUSA
| | - Veronica Indihar
- Department of Internal Medicine, Division of Pulmonary, Critical Care & Sleep MedicineUniversity of CincinnatiCincinnatiOHUSA
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Suwatanapongched T, Visoottiviseth Y, Watcharananan SP, Kanoksil W, Muntham D, Pornsuriyasak P. Clinical characteristics and CT manifestations of invasive pulmonary aspergillosis in hospitalised patients with systemic lupus erythematosus. Clin Radiol 2021; 76:548.e13-548.e23. [PMID: 33610288 DOI: 10.1016/j.crad.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 01/13/2021] [Indexed: 11/17/2022]
Abstract
AIM To investigate clinical and computed tomography (CT) findings of invasive pulmonary aspergillosis (IPA) in patients with systemic lupus erythematosus (SLE) and to explore the relationships of CT findings with clinical characteristics and outcomes. MATERIALS AND METHODS Clinical and CT findings of 14 SLE patients with proven (n=4) and probable (n=10) IPA between January 2006 and April 2013 were reviewed retrospectively and related to patients' outcomes. RESULTS All patients (mean age, 42.3 ± 15.1 years; 11 women, three men) had active SLE, prior corticosteroid, and/or immunosuppressive therapy. Dominant CT findings performed within 10 days of the clinical onset consisted of nodules/masses (100%, 14/14), consolidations (92.9%, 13/14), and ground-glass opacity (85.7%, 12/14). Bilateral, multilobar, and upper-lobe involvement was common. Regardless of dominant patterns, the halo, reversed halo, air-crescent, hypodense, and feeding vessel signs were found in 12 (85.7%), one (7.1%), three (21.3%), seven (50%), and seven (50%) patients, respectively. There was no significant difference in CT findings between the IPA alone (n=5) and co-infection (n=9) groups and between survived (n=4) and non-survived (n=10) patients. The IPA-alone group more frequently had alcohol consumption (p=0.018), haemoptysis (p=0.023), and disseminated aspergillosis (p=0.027) than did the co-infection group. Non-survived patients tended to be older and have a history of recent hospitalisation. CONCLUSIONS IPA is a rare, life-threatening disease affecting SLE patients in the early course of disease with high disease activity requiring corticosteroid and/or immunosuppressive therapy. Dominant CT findings are characteristics of angio-invasive form with a high frequency of the halo sign and bilateral, multilobar, and upper-lobe involvement.
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Affiliation(s)
- T Suwatanapongched
- Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Y Visoottiviseth
- Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S P Watcharananan
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - W Kanoksil
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - D Muntham
- Section for Mathematics, Faculty of Science and Technology, Rajamangala University of Technology, Phranakhon Si Ayutthaya Province, Thailand
| | - P Pornsuriyasak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Muthu V, Agarwal R, Dhooria S, Sehgal IS, Prasad KT, Aggarwal AN, Chakrabarti A. Has the mortality from pulmonary mucormycosis changed over time? A systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:538-549. [PMID: 33418022 DOI: 10.1016/j.cmi.2020.12.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/25/2020] [Accepted: 12/31/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Pulmonary mucormycosis (PM) is increasingly being reported in immunocompromised patients and has a high mortality. Our aim was to assess the mortality of PM and its trend over time. We also evaluated the role of combined medical-surgical therapy in PM. METHODS We performed a systematic review of Pubmed, Embase, and Cochrane central databases. Studies were eligible if they described at least five confirmed cases of PM and reported mortality. We also assessed the effect of combined medical-surgical therapy versus medical treatment alone on PM mortality. We used a random-effects model to estimate the pooled mortality of PM and compared it across three time periods. The factors influencing mortality were assessed using meta-regression. We evaluated the risk difference (RD) of death in the following: subjects undergoing combined medical-surgical therapy versus medical therapy alone, subjects with isolated PM versus disseminated disease, and PM in diabetes mellitus (DM) versus non-DM as a risk factor. RESULTS We included 79 studies (1544 subjects). The pooled mortality of PM was 57.1% (95% confidence interval [CI] 51.7-62.6%). Mortality improved significantly over time (72.1% versus 58.3% versus 49.8% for studies before 2000, 2000-2009, and 2010-2020, respectively, p 0.00001). This improved survival was confirmed in meta-regression after adjusting for the study design, the country's income level, and the sample size. Combined medical-surgical therapy was associated with a significantly lower RD (95%CI) of death: -0.32 (-0.49 to -0.16). The disseminated disease had a higher risk of death than isolated PM, but DM was not associated with a higher risk of death than other risk factors. CONCLUSIONS While PM is still associated with high mortality, we noted improved survival over time. Combined medical-surgical therapy improved survival compared to medical treatment alone.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Garg M, Prabhakar N, Bhatia H, Dhooria S, Debi U, Muthu V, Maralkunte M, Sehgal I, Agarwal R, Sandhu MS. CT findings in sequel of COVID-19 pneumonia and its complications. BJR Open 2021; 3:20210055. [PMID: 36570781 PMCID: PMC9754056 DOI: 10.1259/bjro.20210055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/19/2021] [Indexed: 12/27/2022] Open
Abstract
A significant number of patients after initial recovery from COVID-19 continue to experience lingering symptoms of the disease that may last for weeks or even months. Lungs being the most commonly affected organ by COVID-19, bear the major brunt of the disease and thus it is imperative to be aware of the evolution of the pulmonary parenchymal changes over time. CT chest is the imaging modality of choice to evaluate post-COVID lungs. Persistent ground-glass opacities, septal thickening, parenchymal bands, crazy-paving, traction bronchiectasis and consolidation constitute the commonly encountered imaging patterns seen on CT in post-COVID-19 lungs. Few vulnerable patients can develop lung fibrosis and show honeycombing on CT. Additionally, many complications like superadded infections (bacterial and fungal), pulmonary thromboembolism and pseudoaneurysm formation are also being reported. In the present pictorial review, we have tried to show the entire CT spectrum of sequelae of COVID-19 pneumonia and commonly associated infections and vascular complications.
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Affiliation(s)
- Mandeep Garg
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | - Nidhi Prabhakar
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | - Harsimran Bhatia
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | | | - Uma Debi
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | | | | | | | - Ritesh Agarwal
- Department
of Pulmonary Medicine, PGIMER,
Chandigarh, India
| | - MS Sandhu
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
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Hata A, Yanagawa M, Yoshida Y, Miyata T, Kikuchi N, Honda O, Tomiyama N. The image quality of deep-learning image reconstruction of chest CT images on a mediastinal window setting. Clin Radiol 2021; 76:155.e15-23. [PMID: 33220941 DOI: 10.1016/j.crad.2020.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/23/2020] [Indexed: 11/22/2022]
Abstract
AIM To assess the image quality of deep-learning image reconstruction (DLIR) of chest computed tomography (CT) images on a mediastinal window setting in comparison to an adaptive statistical iterative reconstruction (ASiR-V). MATERIALS AND METHODS Thirty-six patients were evaluated retrospectively. All patients underwent contrast-enhanced chest CT and thin-section images were reconstructed using filtered back projection (FBP); ASiR-V (60% and 100% blending setting); and DLIR (low, medium, and high settings). Image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were evaluated objectively. Two independent radiologists evaluated ASiR-V 60% and DLIR subjectively, in comparison with FBP, on a five-point scale in terms of noise, streak artefact, lymph nodes, small vessels, and overall image quality on a mediastinal window setting (width 400 HU, level 60 HU). In addition, image texture of ASiR-Vs (60% and 100%) and DLIR-high was analysed subjectively. RESULTS Compared with ASiR-V 60%, DLIR-med and DLIR-high showed significantly less noise, higher SNR, and higher CNR (p<0.0001). DLIR-high and ASiR-V 100% were not significantly different regarding noise (p=0.2918) and CNR (p=0.0642). At a higher DLIR setting, noise was lower and SNR and CNR were higher (p<0.0001). DLIR-high showed the best subjective scores for noise, streak artefact, and overall image quality (p<0.0001). Compared with ASiR-V 60%, DLIR-med and DLIR-high scored worse in the assessment of small vessels (p<0.0001). The image texture of DLIR-high was significantly finer than that of ASIR-Vs (p<0.0001). CONCLUSIONS DLIR-high improved the objective parameters and subjective image quality by reducing noise and streak artefacts and providing finer image texture.
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Abstract
Mucormycosis is one of the most complicated to diagnose and treat invasive fungal diseases. Diagnostic techniques have not significantly advanced in years, and recent international consensus treatment guidelines offer some insight into the current best approaches to treating this deadly invasive mold.
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Affiliation(s)
- William J Steinbach
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA.,Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina, USA.,Duke Pediatric Immunocompromised Host Program, Durham, North Carolina, USA.,International Pediatric Fungal Network, Duke University Medical Center, Durham, North Carolina, USA
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Skiada A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and Diagnosis of Mucormycosis: An Update. J Fungi (Basel) 2020; 6:jof6040265. [PMID: 33147877 PMCID: PMC7711598 DOI: 10.3390/jof6040265] [Citation(s) in RCA: 256] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 12/17/2022] Open
Abstract
Mucormycosis is an angioinvasive fungal infection, due to fungi of the order Mucorales. Its incidence cannot be measured exactly, since there are few population-based studies, but multiple studies have shown that it is increasing. The prevalence of mucormycosis in India is about 80 times the prevalence in developed countries, being approximately 0.14 cases per 1000 population. Diabetes mellitus is the main underlying disease globally, especially in low and middle-income countries. In developed countries the most common underlying diseases are hematological malignancies and transplantation. Τhe epidemiology of mucormycosis is evolving as new immunomodulating agents are used in the treatment of cancer and autoimmune diseases, and as the modern diagnostic tools lead to the identification of previously uncommon genera/species such as Apophysomyces or Saksenaea complex. In addition, new risk factors are reported from Asia, including post-pulmonary tuberculosis and chronic kidney disease. New emerging species include Rhizopus homothallicus, Thamnostylum lucknowense, Mucor irregularis and Saksenaea erythrospora. Diagnosis of mucormycosis remains challenging. Clinical approach to diagnosis has a low sensitivity and specificity, it helps however in raising suspicion and prompting the initiation of laboratory testing. Histopathology, direct examination and culture remain essential tools, although the molecular methods are improving. The internal transcribed spacer (ITS) region is the most widely sequenced DNA region for fungi and it is recommended as a first-line method for species identification of Mucorales. New molecular platforms are being investigated and new fungal genetic targets are being explored. Molecular-based methods have gained acceptance for confirmation of the infection when applied on tissues. Methods on the detection of Mucorales DNA in blood have shown promising results for earlier and rapid diagnosis and could be used as screening tests in high-risk patients, but have to be validated in clinical studies. More, much needed, rapid methods that do not require invasive procedures, such as serology-based point-of-care, or metabolomics-based breath tests, are being developed and hopefully will be evaluated in the near future.
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Affiliation(s)
- Anna Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Correspondence: ; Tel.: +30-2107-462-607
| | | | - Maria Drogari-Apiranthitou
- Fourth Department of Internal Medicine, General University Hospital “Attikon”, National and Kapodistrian University of Athens, 12462 Athens, Greece;
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Donnelly JP, Chen SC, Kauffman CA, Steinbach WJ, Baddley JW, Verweij PE, Clancy CJ, Wingard JR, Lockhart SR, Groll AH, Sorrell TC, Bassetti M, Akan H, Alexander BD, Andes D, Azoulay E, Bialek R, Bradsher RW, Bretagne S, Calandra T, Caliendo AM, Castagnola E, Cruciani M, Cuenca-Estrella M, Decker CF, Desai SR, Fisher B, Harrison T, Heussel CP, Jensen HE, Kibbler CC, Kontoyiannis DP, Kullberg BJ, Lagrou K, Lamoth F, Lehrnbecher T, Loeffler J, Lortholary O, Maertens J, Marchetti O, Marr KA, Masur H, Meis JF, Morrisey CO, Nucci M, Ostrosky-Zeichner L, Pagano L, Patterson TF, Perfect JR, Racil Z, Roilides E, Ruhnke M, Prokop CS, Shoham S, Slavin MA, Stevens DA, Thompson GR, Vazquez JA, Viscoli C, Walsh TJ, Warris A, Wheat LJ, White PL, Zaoutis TE, Pappas PG. Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clin Infect Dis 2020; 71:1367-1376. [PMID: 31802125 PMCID: PMC7486838 DOI: 10.1093/cid/ciz1008] [Citation(s) in RCA: 1271] [Impact Index Per Article: 317.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Invasive fungal diseases (IFDs) remain important causes of morbidity and mortality. The consensus definitions of the Infectious Diseases Group of the European Organization for Research and Treatment of Cancer and the Mycoses Study Group have been of immense value to researchers who conduct clinical trials of antifungals, assess diagnostic tests, and undertake epidemiologic studies. However, their utility has not extended beyond patients with cancer or recipients of stem cell or solid organ transplants. With newer diagnostic techniques available, it was clear that an update of these definitions was essential. METHODS To achieve this, 10 working groups looked closely at imaging, laboratory diagnosis, and special populations at risk of IFD. A final version of the manuscript was agreed upon after the groups' findings were presented at a scientific symposium and after a 3-month period for public comment. There were several rounds of discussion before a final version of the manuscript was approved. RESULTS There is no change in the classifications of "proven," "probable," and "possible" IFD, although the definition of "probable" has been expanded and the scope of the category "possible" has been diminished. The category of proven IFD can apply to any patient, regardless of whether the patient is immunocompromised. The probable and possible categories are proposed for immunocompromised patients only, except for endemic mycoses. CONCLUSIONS These updated definitions of IFDs should prove applicable in clinical, diagnostic, and epidemiologic research of a broader range of patients at high-risk.
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Affiliation(s)
| | - Sharon C Chen
- Centre for Infectious Diseases and Microbiology, Laboratory Services, Institute of Clinical Pathology and Medical Research, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Carol A Kauffman
- Division of Infectious Diseases, University of Michigan, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - William J Steinbach
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - John W Baddley
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul E Verweij
- Center of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | | | - John R Wingard
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology University Children’s Hospital, Münster, Germany
| | - Tania C Sorrell
- University of Sydney, Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney School of Medicine Faculty of Medicine and Health, Westmead Institute for Centre for Infectious Diseases and Microbiology, Western Sydney Local Health District, Sydney, Australia
| | - Matteo Bassetti
- Infectious Disease Clinic, Department of Medicine University of Udine and Department of Health Sciences, DISSAL, University of Genoa, Genoa, Italy
| | - Hamdi Akan
- Ankara University, Faculty of Medicine, Cebeci Campus, Hematology Clinical Research Unit, Ankara, Turkey
| | - Barbara D Alexander
- Department of Medicine and Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - David Andes
- Division of Infectious Diseases, Departments of Medicine, Microbiology and Immunology School of Medicine and Public Health and School of Pharmacy, University of Wisconsin, Madison, Wisconsin, USA
| | - Elie Azoulay
- Médicine Intensive et Réanimation Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France
| | - Ralf Bialek
- Molecular Diagnostics of Infectious Diseases, Microbiology, LADR Zentrallabor Dr. Kramer & Kollegen, Geesthacht, Germany
| | - Robert W Bradsher
- Division of Infectious Diseases, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Stephane Bretagne
- Institut Pasteur, Molecular Mycology Unit, CNRS UMR2000, Mycology Laboratory, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Angela M Caliendo
- Department of Medicine, Alpert Warren Medical School of Brown University, Providence, Rhode Island, USA
| | - Elio Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Mario Cruciani
- Infectious Diseases Unit, G. Fracastoro Hospital, San Bonifacio, Verona, Italy
| | | | - Catherine F Decker
- Infectious Diseases Division, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sujal R Desai
- National Heart & Lung Institute, Imperial College London, the Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Brian Fisher
- Pediatric Infectious Diseases Division at the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Thomas Harrison
- Centre for Global Health, Institute for Infection and Immunity, St Georges University of London, London, UK
| | - Claus Peter Heussel
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Translational Lung Research Center and Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik Heidelberg, Heidelberg, Germany
| | - Henrik E Jensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Bart-Jan Kullberg
- Radboud Center for Infectious Diseases and Department of Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation and Department of Laboratory Medicine and National Reference Centre for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine and Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University of Frankfurt, Frankfurt, Germany
| | - Jurgen Loeffler
- Molecular Biology and Infection, Medical Hospital II, WÜ4i, University Hospital Würzburg, Würzburg, Germany
| | - Olivier Lortholary
- Paris University, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, IHU Imagine & Institut Pasteur, Molecular Mycology Unit, CNRS UMR 2000, Paris, France
| | - Johan Maertens
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, K.U. Leuven, Leuven, Belgium
| | - Oscar Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kieren A Marr
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School
| | - Henry Masur
- Critical Care Medicine Department NIH-Clinical Center, Bethesda, Maryland, USA
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases and Centre of Expertise in Mycology Radboudumc/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Marcio Nucci
- Department of Internal Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Livio Pagano
- Istituto di Ematologia, Università Cattolica S. Cuore, Rome, Italy
| | - Thomas F Patterson
- UT Health San Antonio and South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - John R Perfect
- Department of Medicine and Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Zdenek Racil
- Department of Internal Medicine–Hematology and Oncology, Masaryk University and University Hospital Brno, Brno, Czech Republic
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
| | - Marcus Ruhnke
- Department of Hematology & Oncology, Lukas Hospital, Buende, Germany
| | - Cornelia Schaefer Prokop
- Meander Medical Center Amersfoort and Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Shmuel Shoham
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Center and the National Centre for Infections in Cancer, The University of Melbourne, Melbourne, Victoria, Australia
| | - David A Stevens
- Division of Infectious Diseases and Geographic Medicine, Stanford University Medical School, Stanford, California
- California Institute for Medical Research, San Jose, California, USA
| | - George R Thompson
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, Sacramento, California, USA
| | - Jose A Vazquez
- Division of Infectious Diseases, Medical College of Georgia/Augusta University, Augusta, Georgia, USA
| | - Claudio Viscoli
- Division of Infectious Disease, University of Genova and San Martino University Hospital, Genova, Italy
| | - Thomas J Walsh
- Weill Cornell Medicine of Cornell University, Departments of Medicine, Pediatrics, Microbiology & Immunology, New York, New York, USA
| | - Adilia Warris
- MRC Centre for Medical Mycology at the University of Aberdeen, Aberdeen, UK
| | | | - P Lewis White
- Public Health Wales Mycology Reference Laboratory, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Theoklis E Zaoutis
- Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia and Roberts Center for Pediatric Research, Philadelphia, Pennsylvania, USA
| | - Peter G Pappas
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Abstract
INTRODUCTION Fungal infections are increasingly encountered in clinical practice due to more favorable environmental conditions and increasing prevalence of immunocompromised individuals. The diagnostic approach for many fungal pathogens continues to evolve. Herein, we outline available diagnostic tests for the most common fungal infections with a focus on recent advances and future directions. AREAS COVERED We discuss the diagnostic testing methods for angioinvasive molds (Aspergillus spp. and Mucor spp.), invasive yeast (Candida spp. and Cryptococcus ssp.), Pneumocystis, and endemic fungi (Blastomyces sp., Coccidioides ssp., and Histoplasma sp.). The PubMed-NCBI database was searched within the past 5 years to identify the most recent available literature with dates extended in cases where literature was sparse. Diagnostic guidelines were utilized when available with references reviewed. EXPERT OPINION Historically, culture and/or direct visualization of fungal organisms were required for diagnosis of infection. Significant limitations included ability to collect specimens and delayed diagnosis associated with waiting for culture results. Antigen and antibody testing have made great strides in allowing quicker diagnosis of fungal infections but can be limited by low sensitivity/specificity, cross-reactivity with other fungi, and test availability. Molecular methods have a rich history in some fungal diseases, while others continue to be developed.
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Affiliation(s)
- Bryan T Kelly
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
| | - Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
- Department of Internal Medicine, Robert D. And Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, MN, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
- Department of Internal Medicine, Robert D. And Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, MN, USA
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Agrawal R, Yeldandi A, Savas H, Parekh ND, Lombardi PJ, Hart EM. Pulmonary Mucormycosis: Risk Factors, Radiologic Findings, and Pathologic Correlation. Radiographics 2020; 40:656-666. [PMID: 32196429 DOI: 10.1148/rg.2020190156] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary mucormycosis (PM) is an uncommon fungal infection most often seen in immunocompromised patients. The fungus grows on decaying food, soil, and animal excrement. Patients usually become infected by inhalation of spores. The most common risk factors include diabetes mellitus, hematologic malignancy, and solid organ or stem cell transplant. PM can have a nonspecific appearance at imaging. For example, early imaging may show peribronchial ground-glass opacity. Later, the disease progresses to consolidation, nodules, or masses. Because patients are usually immunocompromised, the differential diagnosis often includes invasive pulmonary aspergillosis (IPA). Various radiologic findings suggestive of PM have been identified to help differentiate it from IPA. For example, the reverse halo sign is more closely associated with PM than with IPA. The reverse halo sign is an area of ground-glass opacity surrounded by a rim of consolidation. In addition, the presence of pleural effusions and more than 10 nodules is more suggestive of PM than it is of IPA. PM can progress rapidly in neutropenic patients. Identification of the hyphae in tissue by using endobronchial or percutaneous sampling can allow differentiation from IPA and help confirm the diagnosis of mucormycosis. Because of the high mortality rate associated with PM, early identification of the disease is critical for an improved likelihood of survival. A multimodality treatment approach with antifungal agents and surgical débridement has been shown to improve outcomes. The authors review the risk factors for PM, describe its imaging appearance and disease process, and describe the treatment of the disease. ©RSNA, 2020.
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Affiliation(s)
- Rishi Agrawal
- From the Departments of Radiology (R.A., H.S., N.D.P., P.J.L., E.M.H.) and Pathology (A.Y.), Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Anjana Yeldandi
- From the Departments of Radiology (R.A., H.S., N.D.P., P.J.L., E.M.H.) and Pathology (A.Y.), Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Hatice Savas
- From the Departments of Radiology (R.A., H.S., N.D.P., P.J.L., E.M.H.) and Pathology (A.Y.), Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Nishant D Parekh
- From the Departments of Radiology (R.A., H.S., N.D.P., P.J.L., E.M.H.) and Pathology (A.Y.), Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Pamela J Lombardi
- From the Departments of Radiology (R.A., H.S., N.D.P., P.J.L., E.M.H.) and Pathology (A.Y.), Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
| | - Eric M Hart
- From the Departments of Radiology (R.A., H.S., N.D.P., P.J.L., E.M.H.) and Pathology (A.Y.), Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611
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Nichols L, Rios DA. How could hypoglycemia-inducing glycogen storage disease lead to hyperglycemia-induced mucormycosis? Autops Case Rep 2020; 10:e2020149. [PMID: 32185145 PMCID: PMC7061730 DOI: 10.4322/acr.2020.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 01/19/2020] [Indexed: 11/23/2022] Open
Abstract
Mucormycosis is an increasingly frequent, difficult to diagnose, difficult to treat, often fatal infection, especially in patients with hyperglycemia from uncontrolled diabetes. Type I (von Gierke) glycogen storage disease is due to inherited deficiency of enzymes in glycogen metabolism, which causes hypoglycemia. This report is the case of a patient with von Gierke disease and a missed diagnosis of pulmonary mucormycosis. This report illustrates the importance of having a high index of suspicion for mucormycosis in the appropriate clinical context.
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Affiliation(s)
- Larry Nichols
- Mercer University School of Medicine, Department of Pathology. Macon, GA, United States of America
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Abstract
Background Pulmonary mucormycosis (PM) is a relatively rare but often fatal and rapidly progressive disease. Most studies of PM are case reports or case series with limited numbers of patients, and focus on immunocompromised patients. We investigated the clinical manifestations, imaging features, treatment, and outcomes of patients with PM with a focus on the difference in clinical manifestations between patients with different immune status. Methods Clinical records, laboratory results, and computed tomography scans of 24 patients with proven or probable PM from January 2005 to December 2018 in Peking Union Medical College Hospital were retrospectively analyzed. Results Ten female and 14 male patients were included (median age, 43.5 years; range, 13-64 years). Common presenting symptoms were fever (70.8%), cough (70.8%), sputum production (54.2%), and hemoptysis (41.7%). Radiological findings included consolidation (83.3%), ground-glass opacities (58.3%), nodules (50.0%), masses (37.5%), cavities (33.3%), mediastinal lymphadenopathy (29.2%), and halo sign (12.5%); one patient had a reversed halo sign. Seven patients (29.2%) had no obvious predisposing risk factors, and 17 (70.8%) had underlying diseases including diabetes, hematological malignancy, and use of immunosuppressants. Compared with immunocompromised patients, immunocompetent patients with PM were younger {23 [13-46] vs. 48 [17-64] years, P=0.023}, comprised a higher proportion of men (100.0% vs. 41.2%, P=0.019), had a longer disease course {34 [8-47] vs. 9 [2-102] weeks, P=0.033}, had a higher eosinophil count [0.66 (0.07-2.00) ×109/L vs. 0.04 (0.00-0.23) ×109/L, P=0.001], and had a lower erythrocyte sedimentation rate {12 [1-88] vs. 74 [9-140] mm/h, P=0.032}. Conclusions PM can occur in heterogeneous patients with different immune status, and the clinical phenotype differs between immunocompetent and immunocompromised patients. Because of the lack of specific clinic and imaging manifestations, aggressive performance of invasive procedures to obtain histopathological and microbial evidence is crucial for a definitive diagnosis.
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Affiliation(s)
- Min Peng
- Division of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hua Meng
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yinghao Sun
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yu Xiao
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hong Zhang
- Division of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ke Lv
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Baiqiang Cai
- Division of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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