Mucocutaneous manifestations of COVID-19-associated mucormycosis: A retrospective cross-sectional study

Background: Cutaneous mucormycosis has shown a significant upsurge during the COVID-19 pandemic. Due to the rapid progression and high mortality of cutaneous mucormycosis in this context, it is important to identify it early. However, very few studies report detailed clinical descriptions of cutaneous mucormycosis in COVID-19 patients. Objectives: To describe mucocutaneous lesions of COVID-19-associated mucormycosis based on clinical morphology and attempt to correlate them with radiological changes. Methods: A retrospective cross-sectional study was conducted at a tertiary care centre from 1st April to 31st July 2021. Eligibility criteria included hospitalised adult patients of COVID-19-associated mucormycosis with mucocutaneous lesions. Results: All subjects were recently recovering COVID-19 patients diagnosed with cutaneous mucormycosis. One of fifty-three (2%) patients had primary cutaneous mucormycosis, and all of the rest had secondary cutaneous mucormycosis. Secondary cutaneous mucormycosis lesions presented as cutaneous-abscess in 25/52 (48%), nodulo-pustular lesions in 1/52 (2%), necrotic eschar in 1/52 (2%) and ulcero-necrotic in 1/52 (2%). Mucosal lesions were of three broad sub-types: ulcero-necrotic in 1/52 (2%), pustular in 2/52 (4%) and plaques in 1/52 (2%). Twenty out of fifty-two patients (38%) presented with simultaneous mucosal and cutaneous lesions belonging to the above categories. Magnetic resonance imaging of the face showed variable features of cutaneous and subcutaneous tissue involvement, viz. peripherally enhancing collection in the abscess group, “dot in circle sign” and heterogeneous contrast enhancement in the nodulo-pustular group; and fat stranding with infiltration of subcutaneous tissue in cases with necrotic eschar and ulcero-necrotic lesions. Limitations: The morphological variety of cutaneous mucormycosis patients in a single-centre study like ours might not be very precise. Thus, there is a need to conduct multi-centric prospective studies with larger sample sizes in the future to substantiate our morphological and radiological findings. Conclusions: COVID-19-associated mucormycosis patients in our study presented with a few specific types of mucocutaneous manifestations, with distinct magnetic resonance imaging findings. If corroborated by larger studies, these observations would be helpful in the early diagnosis of this serious illness.

Mucormicosis periostomal posoperatoria, a propósito de un caso / Mucormycosis periostomal: case report

Resumen Introducción: La mucormicosis en una enfermedad infrecuente y oportunista que afecta, principalmente, a pacientes inmunocomprometidos. Pocas veces se han reportado casos de afectación periostomal. Clínicamente puede ser confundida con otras patologías, pudiendo tener una evolución fulminante, por lo que un adecuado y pronto diagnóstico son necesarios para una instauración precoz del tratamiento. Caso Clínico: Se presenta el caso de una paciente de 62 años inmunocomprometida, que tras complicaciones quirúrgicas evoluciona con mucormicosis periostomal de la pared abdominal. A pesar de un tratamiento quirúrgico con múltiples resecciones de tejido asociado a antifúngico local y sistémico, la paciente fallece, concordante a la letalidad expresada en la literatura.

Introduction: Mucormycosis is a rare and opportunistic disease that mainly affects immunocompromised patients. Few cases of peristomal involvement have been reported. Clinically it can be confused with other pathologies and may have a fulminant evolution, so an adequate and prompt diagnosis is necessary for an early establishment of treatment. Clinical Case: We present the case of a 62-year-old immunocompromised patient who, after surgical complications, evolves with periostomal mucormycosis of the abdominal wall. Despite surgical treatment with multiple tissue resections, associated with local and systemic antifungal agents, the patient died, consistent with the lethality expressed in the literature.

A Case of Cutaneous Mucormycosis Occurring after Systemic Steroid Therapy / 대한의진균학회지

Cutaneous mucormycosis is a rare disease caused by zygomycetes such as Rhizomucor, Mucor, Absidia, and Rhizopus. The disease usually occurs in immunocompromised individuals, and the organism is rarely pathogenic in an immunocompetent host. Herein, we report a 77-year-old female patient who had multiple erythematous papules and pustules on the left 3rd finger. She had received systemic steroid therapy prior to the occurrence of the skin lesions. The histopathological examination of Periodic Acid Schiff stained section showed chronic granulomatous inflammation and fungal hyphae. Rhizopus species was isolated on the fungal culture of the tissue specimen. The patient was finally diagnosed with cutaneous mucormycosis and was treated with itraconazole.

Mucormicosis cutánea en un paciente inmunocomprometido / Cutaneous mucormycosis in an immunocompromised patient

Mucormycosis is an increasingly emerging life-threatening infection and is an important cause of morbidity and mortality in patients with leukemia. We present the case of a 4-year-old boy with an acute lymphoblastic leukemia complicated by severe and prolonged neutropenia during induction chemotherapy, who developed cutaneous mucormycosis of the elbow. Direct microscopy with KOH and the histopathologic observation of the skin revealed fungal hyphae without septations. The cultures were positive for Rhizopus microsporus var oligosporus. The patient was treated succefully with amphotericin B during 40 days, surgical debridement and dermoepidermic graft. Early recognition and prompt intervention with combined medical and surgical treatment may improve the outcome. The most common management strategy in survivors involves a combination of antifungal therapy with amphotericin B and surgical debridement.

La mucormicosis es una enfermedad emergente grave, producida por hongos saprófitos del orden Mucorales, que afecta fundamentalmente a pacientes inmunocom-prometidos. La forma cutánea se origina por inoculación de esporas dentro de la dermis con el subsecuente desarrollo de una lesión tipo ectima, generalmente única y de evolución rápidamente progresiva, por las características angioinvasoras del hongo, que determina amplias zonas de infartos y necrosis en los tejidos. Presentamos el caso de un paciente con cuatro años de edad, con diagnóstico de leucemia linfoblástica aguda, en quimioterapia de inducción, que cursó con neutropenia profunda y prolongada, presentando una lesión cutánea en el codo compatible con ectima gangrenoso. Recibió tratamiento antimicrobiano y antifúngico, asociado a un aseo quirúrgico. El cultivo para hongos demostró crecimiento de Rhizopus microsporus var oligosporus, y la histología concluyó presencia de hifas no septadas. El estudio de extensión descartó compromiso óseo, sinusal y cerebral. Completó 40 días de terapia antifúngica con anfotericina B deoxicolato, evolucionando satisfactoriamente. Posteriormente requirió injerto dermo-epidérmico. Si bien esta patología es infrecuente, debemos sospecharla en pacientes con neoplasias hematológicas, para establecer un diagnóstico etiológico oportuno, ya que el tratamiento contempla el desbridamiento quirúrgico precoz asociado a antifúngicos sistémicos, siendo de elección anfotericina B.

Mucormicosis cutánea primaria: a propósito de dos casos. Revisión de la literatura / Primary cutaneous mucormycosis: two case reports and literature

Mucormycosis or zygomycosis is a rare opportunistic infection caused by aerobic saprophytic fungus that belongs to the class of Zygomycetes Mucorales family. These organisms live in the environment and enter the body by air, gastrointestinal or skin routes, through solutions of continuity of the skin. This microorganism is generally not pathogenic for immunocompetent hosts, being the development of the disease linked with the immune status of the subject. Its mortality is around 50-60 percent; sometimes in spite of early diagnosis and treatment initiation it has a fatal course. Six clinical forms of mucormycosis are described: rhinocerebral, cutaneous, pulmonary, disseminated, gastrointestinal and miscellaneous form. Two cases of patients with primary cutaneous mucormycosis diagnosed in the Pathology Unit of Hernan Henriquez Aravena Hospital of Temuco, Chile are presented here.

La mucormicosis o zigomicosis es una infección oportunista poco frecuente, causada por un hongo sapró-fito aeróbico que pertenece a la clase Zygomycetes de la familia Mucorales. Estos microorganismos viven en el ambiente y penetran en el organismo por vía aérea, gastrointestinal o cutánea a través de soluciones de continuidad de la piel. Este agente generalmente no es patógeno para el hospedero inmunocompetente estando relacionado el desarrollo de la enfermedad con el estado inmune del sujeto. Su mortalidad es cercana a 50-60 por ciento; en ocasiones, a pesar del precoz diagnóstico e instauración del tratamiento, tiene un curso fatal. Se describen seis formas clínicas de mucormicosis: rinocerebral, cutánea, pulmonar, diseminada, gastrointestinal y una forma miscelánea. Se presentan dos casos de pacientes con mu-cormicosis cutánea primaria diagnosticados en la Unidad de Anatomía Patológica del Hospital Hernán Henríquez Aravena de Temuco.

A Case of Cutaneous Mucormycosis Mimicking Sporotrichosis / 대한피부과학회지

Mucormycosis is a rare invasive fungal infection that chiefly occurs in immunocompromized patients and the outcome is generally fatal. Primary cutaneous mucormycosis is a rare phenotype of mucormycosis, and it usually follows direct inoculation of fungi on damaged skin. Many cutaneous infections mimic sprotrichosis, including virus, bacteria, acid-fast bacilli, fungi and protozoa, yet mucormycosis is very rare. We report on a case of cutaneous mucormycosis that mimicked sporotrichosis in a 77 years old woman.

Chronic Recurrent Cutaneous Mucormycosis due to Rhizopus arrhizus / 대한의진균학회지

Mucormycosis occurs primarily in patients with severe underlying illness, especially leukemia, lymphoma, and uncontrolled diabetes mellitus. Cutaneous mucormycosis is somewhat less frequently associated with systemic illness than other forms of mucormycosis. It develops where a break in the integrity of the skin has occurred as a result of surgery, burn, or other forms of trauma. We report herein a case of primary cutaneous mucormycosis due to Rhizopus arrhizus in a 24-year-old healthy man without systemic illness, who developed recurrent, prograssively extending, weeping and tender swollen ulcerative patches at the artificial trauma site on the right side of his face since 9 years of age. It was successfully treated with amphotericin B ointment combined with oral itraconazole and ketoconazole.

Primary Cutaneous Mucormycosis in a Immunocompetent Elderly Woman Showing Sporotrichoid Distribution / 대한피부과학회지

Primary cutaneous mucormycosis, a rare form of mucormycosis, develops where a break in the integrity of the skin has occurred as a result of surgery, burns, or other forms of trauma. It is mainly seen in immunocompromised hosts, but can sometimes also occur in immunocompetent hosts too. Various kinds of pathogens including viruses, bacteria, nontuberculous mycobacteria, protozoa, and fungi can show a sporotrichoid spread. However, there has been no report of mucormycosis showing a sporotrichoid distribution. We report a case of primary cutaneous mucormycosis occurring on the dorsal aspect of the right wrist in a 69-year-old immunocompetent woman. In our case, newlydeveloped lesions were distributed in sporotrichoid pattern 5 months after the initial lesion. The patient was successfully treated with a combined therapy of amphotericin B and itraconazole.

Primary Cutaneous Mucormycosis Associated with Trauma / 대한피부과학회지

We report a case of primary cutaneous mucormycosis, one of five clinical forms of mucormycosis, in a 68-year-old immunocompetent woman, which developed after trauma. We treated her successfully with amphotericin B for 23 days.

A Considered Case as Primary Cutaneous Mucormycosis / 대한의진균학회지

Mucormycosis is an invasive fungal infection, caused by members of the order Mucorales, that usually occurs in immunocompromised individuals. It manifests itself in a variety of ways and rarely may be confined to the cutaneous tissues. We report a case of primary cutaneous mucormycosis associated with longstanding diabetes mellitus and liver cirrhosis. A 53-year-old woman was presented because of cutaneous discoloration and bullae on the both lower extremities. Cutaneous lesions consisted of necrotic blackish discoloration with bullae and ill-defined margins with extending nature. A biopsy specimen from the cutaneous lesion revealed large, broad, nonseptate hyphae branched at right angles. Our patient was successfully treated with intravenous administration of amphotericin B and surgical debridement of necrotic tissue.

A Case of Cutaneous Mucormycosis / 대한의진균학회지

Mucormycosis occurs primarily in patients with severe underlying illness, especially leukemia, lymphoma, and uncontrolled diabetes mellitus. Cutaneous mucormycosis is somewhat less frequently associated with systemic illness than other forms of mucormycosis. The associated mortality is significantly less than that related to rhinocerebral form. More recent reports have shown that primary cutaneous mucormycosis has emerged as an important form of the disease. It develops where a break in the integrity of the skin has occurred as a result of surgery, bum, or other forms of trauma. We report a case of primary cutaneous mucormycosis in a healthy person without systemic illness, which was successfully treated with amphotericin B therapy for 2 weeks.

A Case of Cutaneous Mucormycosis in a patient with Acute Lymphocytic Leukemia / 대한피부과학회지

54-year-old male patient with acute lymphocytic leukemia was consulted to our department. He had had a few painful erythematous necrotic plaques on the chest, which suggested initslly vasculitis or pyoderma. On histological examination, characterisitic histological findings of non-septated large hyphae were observed in the dermis and subcutaneoustissue, Although organism was not isolated on Sabouraud agar media containing cycloheximide, the diagnosis of cutaneous mucormycosis was made by the characteristic histological nattlre. He died after 2 weeks with amphotericin B intravenous injections so that additional fungus culture was not performed.