COVID-19 associated rhinomaxillary mucormycosis: a case series and review of literature

During COVID-19 pandemic, fulminant deep fungal infection started emerging in India, known as Mucormycosis. This type of mucormycosis was termed as COVID-19 associated mucormycosis (CAM). These patients had previous history of COVID-19 infection. Such cases were mainly reported in immunocompromised patients such as patients with poorly controlled diabetes and chronic renal diseases etc. Rhinomaxillary mucormycosis is an aggressive, fulminant, fatal deep fungal infection of head and neck region. Early diagnosis and prompt treatment can reduce the mortality and morbidity associated with the disease; hence we present case series of rhinomaxillary mucormycosis to create awareness amongst dental surgeons

Maxilectomia em paciente diabética tipo II, diagnosticada com Mucormicose rinomaxilar, com posterior reabilitação protética: relato de caso / Maxillectomy in a type II diabetic patient, diagnosed with rhinomaxillary mucormycosis, with subsequent prosthetic rehabilitation: case report / Maxilectomía en paciente diabética tipo II diagnosticada de mucormicosis rinomaxilar, con posterior rehabilitación protésica: reporte de caso

A mucormicose é uma infecção fúngica angioinvasiva que afeta uma ampla faixa etária, geralmente imunodeprimidos, sem predileção por gênero ou raça e com alta taxa de mortalidade. Essa infecção inicia se no nariz, devido à inalação dos esporos, podendo-se espalhar pelos seios paranasais, órbita e estruturas intracranianas. As características clínicas incluem parestesia perinasal, celulite periorbitária, rinorréia, obstrução nasal, epistaxe e diminuição de peso. O tratamento efetivo dessa comorbidade compoe uma combinação de manejo clínico e medicamentoso, conjuntamente com desbridamento cirúrgico radical do tecido infectado e/ou necrótico. O caso clínico descrito nesse trabalho refere-se a uma paciente diagnosticada com Mucormicose rino maxilar e diabetes do tipo II, a qual foi submetida a procedimento cirúrgico de hemimaxilectomia do lado esquerdo com posterior reabilitação protética para selamento de comunicação buco-naso-sino-etmoidal... (AU)

Mucormycosis is an angioinvasive fungal infection that affects a wide age group, usually immunocompromised, with no gender or race predilection, and with a high mortality rate. This infection starts in the nose, due to the inhalation of spores, and can spread through the paranasal sinuses, orbit and intracranial structures. Clinical features include perinasal paresthesia, periorbital cellulitis, rhinorrhea, nasal obstruction, epistaxis and weight loss. Effective treatment of this comorbidity comprises a combination of clinical and drug management, together with radical surgical debridement of infected and/or necrotic tissue. The clinical case described in this work refers to a patient diagnosed with Mucormycosis Rhinomaxilla and Type II diabetes, who underwent a surgical procedure of left hemimaxillectomy with subsequent prosthetic rehabilitation for sealing of the bucco nasal-sino-ethmoidal communication... (AU)

La mucormicosis es una micosis angioinvasiva que afecta a un amplio grupo de edad, habitualmente inmunodeprimidos, sin predilección de género ni raza, y con una alta tasa de mortalidad. Esta infección comienza en la nariz, debido a la inhalación de esporas, y puede extenderse a través de los senos paranasales, la órbita y las estructuras intracraneales. Las características clínicas incluyen parestesia perinasal, celulitis periorbitaria, rinorrea, obstrucción nasal, epistaxis y pérdida de peso. El tratamiento eficaz de esta comorbilidad comprende una combinación de manejo clínico y farmacológico, junto con un desbridamiento quirúrgico radical del tejido infectado y / o necrótico. El caso clínico descrito en este trabajo se refiere a una paciente diagnosticada de Mucormicosis Rinomaxilar y diabetes Tipo II, que fue sometida a un procedimiento quirúrgico de hemimaxilectomía izquierda con posterior rehabilitación protésica para sellar la comunicación buco-nasal-sino-etmoidal... (AU)

Analysis of nicotine-induced metabolic changes in Blakeslea trispora by GC-MS / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

Blakeslea trispora is a natural source of carotenoids, including β-carotene and lycopene, which have industrial applications. Therefore, classical selective breeding techniques have been applied to generate strains with increased productivity, and microencapsulated β-carotene preparation has been used in food industry (Li et al., 2019). In B. trispora, lycopene is synthesized via the mevalonate pathway (Venkateshwaran et al., 2015). Lycopene cyclase, which is one of the key enzymes in this pathway, is a bifunctional enzyme that can catalyze the cyclization of lycopene to produce β-carotene and exhibit phytoene synthase activity (He et al., 2017).

Conversion of renewable substrates for biosurfactant production by Rhizopus arrhizus UCP 1607 and enhancing the removal of diesel oil from marine soil

BACKGROUND: The use of agro-industrial wastes to produce high value-added biomolecules such as biosurfactants is a promising approach for lowering the total costs of production. This study aimed to produce biosurfactants using Rhizopus arrhizus UCP 1607, with crude glycerol (CG) and corn steep liquor (CSL) as substrates. In addition, the biomolecule was characterized, and its efficiency in removing petroderivatives from marine soil was investigated. RESULTS: A 22 factorial design was applied, and the best condition for producing the biosurfactant was determined in assay 4 (3% CG and 5% CSL). The biosurfactant reduced the surface tension of water from 72 to 28.8 mN/m and produced a yield of 1.74 g/L. The preliminary biochemical characterization showed that the biosurfactant consisted of proteins (38.0%), carbohydrates (35.4%), and lipids (5.5%). The compounds presented an anionic character, nontoxicity, and great stability for all conditions tested. The biomolecule displayed great ability in dispersing hydrophobic substrates in water, thereby resulting in 53.4 cm2 ODA. The best efficiency of the biosurfactant in removing the pollutant diesel oil from marine soil was 79.4%. CONCLUSIONS: This study demonstrated the ability of R. arrhizus UCP1607 to produce a low-cost biosurfactant characterized as a glycoprotein and its potential use in the bioremediation of the hydrophobic diesel oil pollutant in marine soil

Micosis rino-orbito-cerebral: coinfección por Aspergillus sclerotiorum y Rhizopus microsporum en un huésped inmunosuprimido. Reporte de un caso / Rhino-orbital-cerebral mycoses: Aspergillus sclerotiorum infection and Rhyzopus microsporum in an immunosuppres sed host. A case report

Las micosis rino-cerebral, rino-orbito-cerebral y sinusopulmonar ocasionadas por especies de Mucorales y de Aspergillus se constituyen como una causa importan te de infección fúngica invasora asociada a una mortalidad mayor al 30%. La coinfección por dos o más especies en la forma rino-orbito-cerebral es infrecuente. Se describe un paciente con linfoma no Hodgkin, expuesto a múltiples esquemas quimioterápicos, en remisión completa, que presentó micosis con compromiso rino-orbito-cerebral por Aspergillus sclerotiorum y Rhizopus microsporum de rápida progresión con necesidad de tratamiento quirúrgico agresivo y terapia anti fúngica sistémica y local.

Rhino-orbital-cerebral and pulmonary mycosis caused by Mucorales and Aspergillus species have become an important cause of invasive fungal infection, with a 30% overall mortality rate. Rhino-orbital-cerebral disease caused by two or more species is uncommon. We present a patient with non-Hodgkin lymphoma, ex posed to aggressive chemotherapy, under complete remission, with acute onset of rhino-orbital-cerebral disease caused by Aspergillus sclerotiorum and Rhizopus microsporum, treated with aggressive surgery and both local and systemic antifungal therapy.

Mucormicosis rino-órbito-cerebral de origen dental / Rhino-orbito-cerebral mucormycosis from dental origin: Case report

Resumen La mucormicosis es una infección aguda causada por hongos oportunistas pertenecientes al orden de los mucorales, que afecta principalmente a pacientes diabéticos e inmunosuprimidos. Se reporta el caso de un hombre diabético de 63 años de edad, que se extrajo una pieza dental por sus propios medios y, posteriormente, desarrolló una mucormicosis rino-órbito-cerebral con afección cutánea y palatina. La especie aislada mediante cultivos micológicos fue Rhizopus sp.

Abstract Rhino-orbito-cerebral mucormycosis from dental origin is an acute infection caused by opportunistic fungi belonging to the order of Mucorales, which affects mainly diabetic and immunocompromised patients. We report the case of a 63-year old diabetic man who performed a dental extraction on himself by his own means and subsequently developed a rhino-orbito-cerebral mucormycosis with cutaneous and palatal affection. The species isolated in the mycological culture was Rhizopus sp.

Isolation and Characterization of Two Rare Mucoralean Species with Specific Habitats

The order Mucorales, the largest in number of species within the Mucoromycotina, comprises typically fast-growing saprotrophic fungi. During a study of the fungal diversity of undiscovered taxa in Korea, two novel mucoralean strains, CNUFC-GWD3-9 and CNUFC-EGF1-4, were isolated from specific habitats including freshwater and fecal samples, respectively. On the basis of their morphological characteristics and sequence analyses of internal transcribed spacer and large subunit ribosomal DNA, the CNUFC-GWD3-9 and CNUFC-EGF1-4 isolates were confirmed to be Gilbertella persicaria and Pilobolus crystallinus, respectively. It is ecologically, pathologically, and mycologically significant to find such rare zygomycetous fungi in such specific habitats.

Coprophilous Mucorales (ex Zygomycota) from three areas in the semi-arid of Pernambuco, Brazil

Abstract Mucorales comprises fungi commonly isolated as saprobes from soil, dung, stored grains and plants. Although these fungi have been studied in several countries, there are relatively a few reports of them in semi-arid areas. Therefore, the aims of the present study were to assess and compare the Mucorales communities in dung from different species and breeds of herbivores in the semi-arid of Pernambuco, based on the frequency of occurrence and species richness of these fungi. Samples of dung collected in the cities of Arcoverde, Serra Talhada and Sertânia were incubated in moist chambers in triplicate. Altogether, 24 taxa of Mucorales distributed in the genera Absidia, Circinella, Cunninghamella, Lichtheimia, Mucor, Pilobolus, Rhizopus and Syncephalastrum were identified. The highest species richness was found in sheep excrement. Mucor circinelloides f. griseo-cyanus was the most common taxon, followed by M. ramosissimus. The similarity of the composition of Mucorales species was greatest between the excrements of Guzerá and Sindi breeds (bovine). All mucoralean species isolated are being cited for the first time from animal dung found in Caatinga and a new species of Mucor was recorded. An identification key for species of Mucorales from dung in the semi-arid region of Brazil is provided.

Phylogenetic Status of Two Undescribed Zygomycete Species from Korea: Actinomucor elegans and Mucor minutus

During a survey of fungal diversity of the order Mucorales, three zygomycete isolates, CNUFC-YR113-1, CNUFC-KNU16-7, and CNUFC-BS1-1 were isolated from freshwater and soil samples in Korea. The strains were analyzed both morphologically and phylogenetically based on internal transcribed spacer and 28S rDNA gene sequences. Based on their morphology and phylogeny, the CNUFC-YR113-1 and CNUFC-KNU16-7 isolates were identified as Actinomucor elegans, and CNUFC-BS1-1 was identified as Mucor minutus. To the best of our knowledge, the species A. elegans and M. minutus, belonging to an undiscovered taxon, have not been previously described in Korea.

Molecular diagnosis and intraspecific genetic variability of root pathogens of arid legumes in Western Rajasthan, India / Diagnóstico molecular y la variabilidad genética intraespecífica de patógenos de raíces en leguminosas resistentes a sequías del oeste de Rajasthan, India

Abstract:The productivity of arid legumes, such as Clusterbean (Cyamopsis tetragonoloba), Cowpea (Vigna unguiculata), Moth bean (Vigna aconitifolia) and Horse gram (Macrotyloma uniflorum), may remain stagnant over decades because of their high susceptibility to root diseases. Besides, there is a limitation on the information about molecular diagnosis and intraspecific genetic variability of root pathogens in arid legumes. To contribute in this field, we assessed a total of 52 isolates from 88 root samples that were found infected with fungal pathogens in Jodhpur, Jaipur and Bikaner Districts of Rajasthan. Diseased roots samples were analyzed following standard microbiological methods for fungus extraction and purification, and for genetic studies. Irrespective of the geographical location from where the diseased samples were collected, all pathogen isolates were clustered in RAPD dendrograms as per their respective genera. Phylogram, based on multiple sequence alignment, revealed that different genera (i.e. Fusarium, Neocosmospora and Syncephalastrum), separated from each other, and species within the same genera, clustered together with their reference sequences with apreciable bootstrap values. Out of 20 representative isolates representing each cluster and all outgroups sequenced, eight were molecularly identified as Neocosmospora vasinfecta, five as Fusarium solani, two as Neocosmospora striata, two as Fusarium acutatum, one as Syncephalastrum monosporum, one as Fusarium oxysporum and one as Fusarium species. The root pathogens of the arid legumes were found neither restricted to a geographical location nor were host specific in nature. Fusarium solani wilt in cowpea and seedling rot in moth bean, F. oxysporum wilt in moth bean, F. acutatum damping off in cowpea and Clusterbean, Fusarium sp. seedling rot in Clusterbean, Neocosmospora striata root rot in cowpea and wilt in Clusterbean and Syncephalastrum monosporum root rot in Clusterbean were molecularly identified as new fungal records as pathogens causing root diseases in arid legumes. Rev. Biol. Trop. 64 (4): 1505-1518. Epub 2016 December 01.

Resumen:La producción de leguminosas resistentes a sequías como Cyamopsis tetragonoloba, Vigna unguiculata, Vigna aconitifolia y Macrotyloma uniflorum, puede permanecer inactiva durante décadas debido a su alta susceptibilidad a enfermedades en las raíces. Además, hay información limitada relacionada con el diagnóstico molecular y la variabilidad genética intraespecífica de patógenos de raíces en estas leguminosas resistentes a sequías. Para contribuir en esta área, evaluamos un total de 52 extractos de 88 raíces infectadas con patógenos fúngicos en los distritos de Jodhpur, Jaipur y Bikaner de Rajastán. Las muestras de raíces infectadas se analizaron siguiendo los métodos estándar de microbiología para extracción y purificación de hongos y para estudios genéticos. Independientemente del sitio donde se recolectaron las muestras contaminadas, todos los extractos patógenicos se agruparon en dendrogramas RAPD en cada uno de sus respectivos géneros. El filograma, basado en alineamiento de secuencias múltiples reveló que distintos géneros (Fusarium, Neocosmospora y Syncephalastrum) separados entre ellos y especies del mismo género se agrupan con sus secuencias de referencia con valores de bootstrap significativos. De cada 20 extractos representantes de cada agrupamiento y todos los grupos externos secuenciados, ocho fueron identificados molecularmente como Neocosmospora vasinfecta, dos como Fusarium acutatum, una como Syncephalastrum monosporum, una como Fusarium oxysporum y una como Fusarium. Los patógenos de estas leguminosas resistentes a sequías no están restringidos por la localidad ni por un hospedero específico. Fusarium solani que marchita el frijol de vaca y pudre la semilla de Vigna aconitifolia, F. oxysporum que marchita a Vigna aconitifolia, F. acutatum que marchita a Vigna unguiculata y Cyamopsis tetragonoloba, Fusarium sp. que pudre la semilla de Cyamopsis tetragonoloba, Neocosmospora striata que pudre la raíz de Vigna unguiculata y marchita a Cyamopsis tetragonoloba y, Syncephalastrum monosporum que pudre la raíz en Cyamopsis tetragonoloba, fueron identificados molecularmente como nuevos registros de patógenos fúngicos que causan daños en las raíces de leguminosas resistentes a sequías.

Characterization of Two New Records of Mucoralean Species Isolated from Gut of Soldier Fly Larva in Korea

While surveying the diversity of fungi of the order Mucorales, two isolates, EML-PUKI12-1 and EML-PUKI06-1, were obtained from the gut of soldier fly larvae inhabiting the bulrush at a pond located in the Chonnam National University Arboretum, Gwangju, Korea. The isolates were confirmed as Mucor irregularis and Mucor fragilis species, respectively, based on the morphological characteristics and phylogenetic analysis of rDNA internal transcribed spacer region. Such mucoralean species belonging to undiscovered taxa has not previously been described in Korea.

A Case of Gastric Mucormycosis Induced Necrotic Gastric Ulcer in Patients with Diabetic Ketoacidosis

Mucormycosis is a rare invasive disease with high mortality rates caused by fungi of the zygomycetes class and Mucorales order. Mucormycosis is manifested by a variety of clinical presentations according to the involved site and occurs in immunocompromised conditions such as diabetes mellitus and other conditions. Rhino-orbital-cerebral and pulmonary infection is known as commonly involved areas. Primary gastrointestinal mucormycosis is a very rare and life-threatening invasive fungal infection. Gastrointestinal mucormycosis may occur in any alimentary tract, with the stomach being most involved part. The early diagnosis and appropriate treatment including surgical debridement of involved tissues and antifungal agents is needed to improve survival rates. We report a case of gastric mucormycosis successfully treated with radical debridement and antifungal agents in a 45-year-old man with diabetic ketoacidosis.

Gastric Mucormycosis Followed by Traumatic Cardiac Rupture in an Immunocompetent Patient / 대한소화기학회지

Gastric mucormycosis is a rare and life-threatening fungal disease, caused by fungus in the order Mucorales. While rhino-cerebral and pulmonary forms are common, gastric mucormycosis is an uncommon site for the disease. We diagnosed gastric mucormycosis in a 41-year-old female who had severe multiple trauma, including cardiac rupture, due to a traffic accident. Eighteen days after hospitalization, she passed 800 mL of melena over one day. We performed upper esophagogastroduodenoscopy (EGD) and found a huge gastric ulcer with bleeding. Histopathological examination identified non-septated and right-angled branching fungal hyphae, and we diagnosed gastric mucormycosis. We recommended total gastrectomy to her but she refused the operation, so she was treated with liposomal amphotericin B for 53 days. After two months of treatment with liposomal amphotericin B, we again performed EGD and found a healed gastric ulcer. After four months, with another EGD, we found that the gastric mucormycosis was completely healed.

A Case of Multiple Primary Cutaneous Mucormycosis Caused by Cunninghamella Species / 대한의진균학회지

A 71-year-old female presented with erythematous ulcerative patches on her right cheek, chest and right upper arm. She admitted to neurosurgery intensive care unit (NSICU) with mental change related to intracerebral hemorrhage. She had no underlying disease. Histopathologic examination of her right upper arm showed multiple non-septated broad hyphae with right-angled branching in dermis. She was diagnosed as primary cutaneous mucormycosis. The fungal culture demonstrated Cunninghamella species. We postulated that mucormycosis occurred after inoculation of fungi following fall down trauma. Mucormycosis, which commonly affects immunocompromised patient, is a rare fungal infection caused by the order Mucorales. Cutaneous mucormycosis is caused either by direct inoculation of fungal spores or by hematologic spread from another primary source. Clinical manifestations are various from indolent ulceration to rapidly progressive necrosis. Mucormycosis can be diagnosed based on the histologic findings and the fungal culture. Mucormycosis by Cunninghamella species have been increasingly reported, but most of them are pulmonary mucormycosis in immunocompromised patients. Herein, we report a rare case of multiple primary cutaneous mucormycosis caused by Cunninghamella species in a patient without underlying disease.

Identification of Mucorales From Clinical Specimens: A 4-Year Experience in a Single Institution

Mucormycosis, a fatal opportunistic infection in immunocompromised hosts, is caused by fungi belonging to the order Mucorales. Early diagnosis based on exact identification and multidisciplinary treatments is critical. However, identification of Mucorales fungi is difficult and often delayed, resulting in poor prognosis. This study aimed to compare the results of phenotypic and molecular identification of 12 Mucorales isolates collected from 4-yr-accumulated data. All isolates were identified on the basis of phenotypic characteristics such as growth rate, colony morphology, and reproductive structures. PCR and direct sequencing were performed to target internal transcribed spacer (ITS) and/or D1/D2 regions. Target DNA sequencing identified five Lichtheimia isolates, two Rhizopus microsporus isolates, two Rhizomucor pusillus isolates, one Cunninghamella bertholletiae isolate, one Mucor fragilis isolate, and one Syncephalastrum racemosum isolate. Five of the 12 (41.7%) isolates were incorrectly identified on the basis of phenotypic identification. DNA sequencing showed that of these five isolates, two were Lichtheimia isolates, one was Mucor isolate, one was Rhizomucor isolate, and one was Rhizopus microspores. All the isolates were identified at the species level by ITS and/or D1/D2 analyses. Phenotypic differentiation and identification of Mucorales is difficult because different Mucorales share similar morphology. Our results indicate that the molecular methods employed in this study are valuable for identifying Mucorales.

Production of beta-glucosidase on solid-state fermentation by Lichtheimia ramosa in agroindustrial residues: characterization and catalytic properties of the enzymatic extract

Background β-Glucosidases catalyze the hydrolysis of cellobiose and cellodextrins, releasing glucose as the main product. This enzyme is used in the food, pharmaceutical, and biofuel industries. The aim of this work is to improve the β-glucosidase production by the fungus Lichtheimia ramosa by solid-state fermentation (SSF) using various agroindustrial residues and to evaluate the catalytic properties of this enzyme. Results A high production of β-glucosidase, about 274 U/g of dry substrate (or 27.4 U/mL), was obtained by cultivating the fungus on wheat bran with 65% of initial substrate moisture, at 96 h of incubation at 35°C. The enzymatic extract also exhibited carboxymethylcellulase (CMCase), xylanase, and β-xylosidase activities. The optimal activity of β-glucosidase was observed at pH 5.5 and 65°C and was stable over a pH range of 3.5-10.5. The enzyme maintained its activity (about 98% residual activity) after 1 h at 55°C. The enzyme was subject to reversible competitive inhibition with glucose and showed high catalytic activity in solutions containing up to 10% of ethanol. Conclusions β-Glucosidase characteristics associated with its ability to hydrolyze cellobiose, underscore the utility of this enzyme in diverse industrial processes.

Hydroxylation of 1,8-cineole by Mucor ramannianus and Aspergillus niger

The monoterpenoid 1,8-cineole is obtained from the leaves of Eucalyptus globulus and it has important biological activities. It is a cheap natural substrate because it is a by-product of the Eucalyptus cultivation for wood and pulp production. In this study, it was evaluated the potential of three filamentous fungi in the biotransformation of 1,8-cineole. The study was divided in two steps: first, reactions were carried out with 1,8-cineole at 1 g/L for 24 h; afterwards, reactions were carried out with substrate at 5 g/L for 5 days. The substrate was hydroxylated into 2-exo-hydroxy-1,8-cineole and 3-exo-hydroxy-1,8-cineole by fungi Mucor ramannianus and Aspergillus niger with high stereoselectivity. Trichoderma harzianum was also tested but no transformation was detected. M. ramannianus led to higher than 99% of conversion within 24 h with a starting high substrate concentration (1 g/L). When substrate was added at 5 g/L, only M. ramannianus was able to catalyze the reaction, but the conversion level was 21.7% after 5 days. Both products have defined stereochemistry and could be used as chiral synthons. Furthermore, biological activity has been described for 3-exo-hydroxy-1,8-cineol. To the best of our knowledge, this is the first report on the use of M. ramannianus in this reaction.

Pulmonary Mucormycosis Treated Successfully with Posaconazole as Salvage Therapy / 계명의대학술지

Mucormycosis (formerly known as zygomycosis) is a life-threatening opportunistic mycosis that infects a broad range of hosts with qualitative or quantitative defects in innate immunity. The overall mortality rate of pulmonary mucormycosis is above 70%. The prognosis and outcome of pulmonary mucormycosis have not improved significantly over the last decade, mainly because of difficulty in early diagnosis and the limited activity of current antifungal agents against members of the order Mucorales. We report a case of pulmonary mucormycosis treated successfully with posaconazole as salvage therapy. We suggest that posaconazole may be considered as an alternative therapeutic approach in patients with invasive pulmonary mucormycosis who are unable to tolerate surgical treatment.

Fatal Breakthrough Mucormycosis in an Acute Myelogenous Leukemia Patient while on Posaconazole Prophylaxis / 감염과화학요법

Posaconazole is a new oral triazole with broad-spectrum antifungal activity. Posaconazole has also shown a significant advantage of preventing invasive fungal infection compared to fluconazole or itraconazole in patients with prolonged neutropenia. Indeed, posaconazole has been commonly used for antifungal prophylaxis in patients undergoing remission induction chemotherapy for acute myelogenous leukemia or myelodysplastic syndrome. We experienced a case of fatal mucormycosis despite posaconazole prophylaxis. To our knowledge, this is the first reported case of fatal breakthrough mucormycosis in a patient receiving posaconazole prophylaxis during remission induction chemotherapy in Korea. This case demonstrated that breakthrough fungal infection can occurs in patients receiving posaconazole prophylaxis because of its limited activity against some mucorales.