A clinico-pathological study of COVID-19 associated rhino-orbital-cerebral mucormycosis

Purpose: Known predisposing factors for mucormycosis are neutropenia and diabetes. Though COVID?19 is associated with hyperinflammatory response, a high surge in rhino?orbital?cerebral mucormycosis (ROCM) cases was observed during the second wave. The histopathological features reflect the background pathogenesis. This study analyzes the histopathological features and clinical presentation of COVID?19?associated ROCM. Methods: In this retrospective observational study, the clinical details of 89 proven ROCM patients treated during May–July 2021 were collected from the case records. Histopathological features were correlated with clinical staging groups and outcomes. The mean neutrophil?to?lymphocyte ratio (NLR) of clinical and outcome groups were compared. Results: The mean age was 54.71 ± 11.03 years, with male patients constituting a majority (78.7%). Uncontrolled diabetes mellitus was noted in 70.8% of patients, and 3.4% had normal range of blood sugar. The mean blood sugar was 298.08 ± 99.51 mg/dL. The mean duration of onset of symptoms of mucormycosis from the diagnosis of COVID?19 was 17.36 ± 7.392 (3–45) days. Poor outcome with disease progression or death occurred in 21.3% of patients. Clinical group II patients (44.9%) with ROCM stages 3c and above had poor outcomes (P = 0.005). Histopathological analysis showed minimal inflammation in 25.8%, neutrophil extracellular trap (NET) in 75.3%, and angio?invasion in 28.1% of patients. Minimal inflammation was associated with clinical group II (P = 0.004) and poor outcome (P = 0.001). Angio?invasion correlated with poor outcome (P = 0.007). Patients with severe clinical group and poor outcome had higher mean NLR with P = 0.017 and P = 0.007, respectively. Conclusion: Vision loss and cerebral involvement had poor outcomes. The histopathologic features such as inflammation and angio?invasion along with NLR aid as prognostic indicators in the management of ROCM. The role of NET in the pathogenesis of COVID?19?associated ROCM needs further studies

Mucormicosis rinocerebral: Una revisión bibliográfica a propósito de un caso clínico / Rhinocerebral mucormycosis: A literature review and report of clinical case

RESUMEN La mucormicosis es una infección fúngica oportunista, poco común causada por hongos del orden de los mucorales. Ocurre a una tasa anual de 1.7 casos por cada millón de personas y presenta una tasa de mortalidad alta que oscila desde el 30 hasta el 90% de acuerdo con el estado sistémico del paciente. Los escenarios más complejos se observan en pacientes inmunosuprimidos, mientras que, en pacientes competentes, la invasión fúngica es bien controlada por el sistema inmune del huésped. La infección comienza luego de la ex-posición, inhalación e invasión de esporas dentro de la cavidad oral y nasal desde donde se puede diseminar a otras partes del cuerpo, permitiendo diferentes presentaciones clínicas en pacientes susceptibles. Actualmente, los registros internacionales de mortalidad de mucormicosis en niños con neoplasias van desde 41.3 a 66.6, por lo que el objetivo de este estudio es presentar un caso raro de mu-cormicosis rinocerebral en un paciente masculino de 4 años quien además presentó como enfermedad base una leucemia linfoblástica aguda B común, tratado con anfotericina B liposomal y debridación quirúrgica de las zonas afectadas. Finalmente, se realizó una revisión sistemática de la literatura disponible con el afán de determinar y describir los signos, síntomas, diagnóstico, tratamiento disponible y pronóstico de esta enfermedad.

ABSTRACT Mucormycosis is an uncommon opportunistic fungal infection caused by fungi of the mucoral order. Occurs at an annual rate of 1.7 cas-es per million people. It has a high mortality rate ranging from 30 to 90% according to the patient's systemic status. The most complex scenarios are observed in immunosuppressed patients, whereas, in competent patients, the fungal invasion is well controlled by the host's immune system. The infection begins after exposure, inhalation and invasion of spores into the oral and nasal cavity from where it can spread to other parts of the body, allowing different clinical presentations in susceptible patients. Currently, international records of mortality of mucormycosis in children with neoplasms range from 41.3 to 66.6. The objective of this study is to present a rare case of rhi-nocerebral mucormycosis in a 4-year-old male patient who also presented as a base disease a leukemia acute B-lymphoblastic disease. Our patient was treated with liposomal amphotericin B and surgical debridement of affected areas. In addition, a systematic review of the available literature was carried out with the aim of determining and describing the signs, symptoms, diagnosis, available treatment and prognosis of this disease.

Unsuspected invasive gastrointestinal mucormycosis masquerading as inflammatory bowel disease: A pathologist's perspective

Mucormycosis is caused by fungi of the order Mucorales and class Zygomycetes. It is a rare opportunistic infection frequently associated with immunocompromised status. It can be disseminated disease or localized, which includes rhinocerebral, pulomonary, cutaneous, and gastrointestinal mucormycosis. Gastrointestinal mucormycosis is the most uncommon usually fatal disease accounting for 4–7% of all cases. We present a rare case of unusual presentation of angioinvasive colonic mucormycosis in a seemingly immunocompetent female masquerading as inflammatory bowel disease. It is very important to differentiate between both because treatment with steroids may lead to dissemination of disease ultimately resulting in a fatal outcome. A surgeon should maintain a high index of suspicion as timely appropriate surgical intervention along with effective antifungal treatment remains the cornerstone of treatment for this highly fatal disease. The definitive diagnosis is possible only by histopathological demonstration of tissue invasion. This requires a quantitatively and qualitatively adequate tissue biopsy.

Successful treatment of primary cerebral mucormycosis: Role of microbiologist.

Fungal brain abscess is rare with a rapidly progressive disease with fulminant course and invariably fatal outcome, unless diagnosed early and treated rapidly. We report a 56‑year‑old woman diagnosed to have fungal abscess who recovered completely following amphotericin B treatment. She presented with weakness of the right hand, deviation of mouth to left and aphasia for 2 days. Computed tomography of the brain revealed a left frontal capsuloganglionic hypodense lesion. Stereotactic biopsy was performed, and microbiological confirmation of non‑septate fungal hyphae from pus from aspirate within 2 h helped initiate timely and appropriate treatment leading to cure. Histopathology and culture later confirmed mucormycosis.

En plaque meningioma with angioinvasion.

En plaque meningioma is a rare type of meningioma characterized by infiltrative nature, sheet-like growth and at times invading the bone. We report here a case of en plaque meningioma with typical grade I histomorphology along with unusual feature of angioinvasion. The patient was a 55-year-old man presenting with headache and painful proptosis of right eye. Imaging modalities revealed an en -plaque meningioma extending into the right sylvian fissure, with thickening of right temporal calvarium, greater wing of sphenoid and extension into the orbit. Magnetic resonance angiography showed medial displacement of right middle cerebral artery. The tumor was removed from the sylvian fissure and right temporal convexity. However, only subtotal removal of the intraorbital part was possible. Histology showed a meningothelial meningioma with low tumor cell proliferation, but infiltration into the bone, skeletal muscle and angioinvasion. Recognition of meningiomas en plaque is useful, as these tumors are difficult to resect completely, and are more prone to undergo recurrence or malignant change. In addition, angioinvasion seen in this tumor may have additional prognostic significance.

Histologic Degree of Invasion and Prognosis in Follicular Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: Follicular thyroid carcinoma (FTC) is the second most common malignancy of the thyroid after papillary thyroid carcinoma, constituting about 10% of all thyroid malignancies. The objective of the current investigation was to determine whether there was a direct relationship between the histologic degree of invasion, tumor recurrence, and patient survival. METHODS: We retrospectively reviewed the records of 55 patients with a histologic diagnosis of pure follicular carcinoma of the thyroid who were treated from 1990 to 2003 at the Presbyterian Medical Center in Jeonju, Korea. Their mean follow-up period was 8.4 years (range, 1~15 years). The following criteria were used to histologically define malignant follicular neoplasms: 1) minimally invasive, tumor invasion through the entire thickness of the tumor capsule; 2) moderately invasive, tumor with angioinvasion (with or without capsular invasion); and 3) widely invasive, broad area or areas of transcapsular invasion of thyroid and extrathyroid tissue. RESULTS: Among 33 patients with capsular invasion only, 2 patients (6%) developed recurrent disease. Of the 16 patients who had angioinvasion with or without capsular invasion, 4 patients (25%) developed recurrent disease. Among 6 patients who had widely invasive FTC, 5 patients (83%) developed recurrent disease, and 2 of those 6 patients (33%) with widely invasive FTC died of the disease. Patients who had widely invasive FTC had greater recurrence rates than patients who had a capsular or angioinvasion (P<0.001). The overall death rate for patients with widely invasive FTC was 33%. CONCLUSION: This study shows that patients with widely invasive FTC had greater recurrence rates and poorer survival than patients who had capsular or angioinvasion; this difference was statistically significant. The authors conclude that patients who had widely invasive FTC need close follow-up and active treatment.

Expression of vascular endothelial growth factor (VEGF) in hepatocellular carcinoma / 한국간담췌외과학회지

BACKGROUND/AIMS: Vascular endothelial growth factor (VEGF) is one of the most potent angiogentic factors in several tumors including hepatocellular carcinoma (HCC). This study was planned to evaluate the correlation between the expression patterns of VEGF and the clinicopathologic features of patients with HCC. METHODS: Twenty-seven patients with curatively resected HCCs were included in this study. To determine the expression patterns of VEGF, western blotting and immunohistochemical staining were performed using polyclonal rabbit VEGF IgG (Santa Cruz, CA) as a primary antibody. These results were compared and analyzed to clinicopathologic features of patients. RESULTS: In Western blotting, Only 5 cases exhibited higher VEGF expression (T/N > or = 0.8) in tumorous region, which was well correlated to the immunohistochemical staining. Between higher and lower VEGF expression group, there were no significant differences in the hypervascularities on angiography or microangiogenic invasions on histologic finding. Other clinicopathologic factors had no significances on VEGF expression. Two year disease-free suvival rate in higher VEGF expression group was 20.0%, which was significantly lower than 73.7% in lower VEGF expression group (p=0.02). But, in two year overall suvival rate, there were no differences between two groups (80.0% vs 82.8%; p=0.80). CONCLUSION: In this study, higher VEGF expression seems to be correlated with higher recurrence rate of HCC. Wide-based prospective study is needed to confirm the potentiality of VEGF expression as a prognostic factor of HCC.