Risk factors affecting outcome of rhino-orbital-cerebral mucormycosis in COVID-19 patients

Background: Mucormycosis is a serious life-threatening fungal infection that recently made severe sudden and devastating surge during the second wave of the COVID-19 epidemic with a mortality rate of up to 50%. Although the causality link between COVID-19 and rhino-orbito-cerebral mucormycosis (ROCM) remains unclear, many factors including poor diabetes control, high doses of steroids, viral-induced lymphopenia, and cytokine storm have been attributed to ROCM in patients with COVID-19. Orienting to risk factors and early recognition of this potentially fatal opportunistic infection is the key to optimal management and improved outcomes. In these contexts, we conducted a prospective study for 33 patients admitted to our tertiary hospital to determine the risk factors for ROCM in patients with COVID-19 and the cumulative mortality rates. Result(s): This study found a statistically significant relation between the fate of death in COVID-MUCOR patients who had presented fever, ophthalmoplegia, facial skin necrosis, and visual loss with those who received dose of steroid to control their respiratory symptoms P < 0.001. Death from COVID-MUCOR was statistically significant related to the prolonged interval from the onset of the symptoms to start of treatment and intervention. Also, it was found that there was a significant decrease in duration between COVID-19 infection and the start of mucormycosis (days) with incidence of DKA on admission. Nineteen (57.6%) of the patients had uncontrolled diabetes mellitus (hemoglobin A1C (HbA1c) of > 7.0%). Conclusion(s): Mucormycosis epidemic was precipitated by a unique confluence of risk factors: diabetes mellitus, widespread use of steroids, and perhaps SARS-CoV-2 infection itself. Restricting steroid use in patients with severe COVID-19 requiring oxygen therapy, and screening for and optimally controlling hyperglycemia, can prevent COVID-MUCOR in a large majority.Copyright © 2023, The Author(s).

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

A fatal case of COVID-19-associated mucormycosis (CAM) affected a 40-year-old woman who was initially admitted to our hospital due to a SARS-CoV-2 infection. Her clinical condition worsened, and she finally died because of respiratory failure, hemodynamic instability, and mucormycosis with invasion into the orbit and probably the brain. According to DNA sequence analysis of the fungus isolated from the patient, Apophysomyces variabilis was involved. This is the first published case of CAM and the third case of mucormycosis due to this mold.

Fungal Infections in the ICU during the COVID-19 Pandemic in Mexico.

Background: Invasive Fungal Infections (IFI) are emergent complications of COVID-19. In this study, we aim to describe the prevalence, related factors, and outcomes of IFI in critical COVID-19 patients. Methods: We conducted a nested case-control study of all COVID-19 patients in the intensive care unit (ICU) who developed any IFI and matched age and sex controls for comparison (1:1) to evaluate IFI-related factors. Descriptive and comparative analyses were made, and the risk factors for IFI were compared versus controls. Results: We found an overall IFI prevalence of 9.3% in COVID-19 patients in the ICU, 5.6% in COVID-19-associated pulmonary aspergillosis (CAPA), and 2.5% in invasive candidiasis (IC). IFI patients had higher SOFA scores, increased frequency of vasopressor use, myocardial injury, and more empirical antibiotic use. CAPA was classified as possible in 68% and 32% as probable by ECMM/ISHAM consensus criteria, and 57.5% of mortality was found. Candidemia was more frequent for C. parapsilosis Fluconazole resistant outbreak early in the pandemic, with a mortality of 28%. Factors related to IFI in multivariable analysis were SOFA score > 2 (aOR 5.1, 95% CI 1.5-16.8, p = 0.007) and empiric antibiotics for COVID-19 (aOR 30, 95% CI 10.2-87.6, p = <0.01). Conclusions: We found a 9.3% prevalence of IFIs in critically ill patients with COVID-19 in a single center in Mexico; factors related to IFI were associated with higher SOFA scores and empiric antibiotic use for COVID-19. CAPA is the most frequent type of IFI. We did not find a mortality difference.

Mucormycosis following COVID-19: clinical case and literature review.

Mucormycosis is one of the most aggressive invasive mycoses. The mortality rate of patients with mucormycosis, depending on clinical form and background disease, varies from 30% to 100%. This article provides the first description of mucormycosis in Russia after infection caused by SARS-CoV-2, as well as a review of literature reports on mucormycosis in patients with COVID-19 (as of September 2021).Copyright © 2021, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

Gastric Necrosis: A Rare Complication of Gastric Mucormycosis.

Mucormycosis is an invasive fungal infection. The prevalence is low for this disease, and the most common site of its occurrence in the gastrointestinal system is the stomach. The clinical signs and symptoms of gastric mucormycosis are vague such as pain in the abdomen, nausea, vomiting, haematemesis, etc. In the current study, a 42-year-old male patient came with complaints of pain in the abdomen associated with vomiting and mild-grade fever based on vague clinical presentation and imaging like upper gastrointestinal endoscopy and computer tomography angiography of the abdomen. Our preoperative diagnosis was gastrocolic fistula secondary to acute on chronic pancreatitis, which was managed by emergency exploratory laparotomy, resection, and anastomosis. Histopathological examination was successful in confirming the diagnosis of mucormycosis. Through this case report, we intend to draw surgeons' and physicians' attention to gastrointestinal mucormycosis, an emerging cause of gastric necrosis in young patients in the post-coronavirus disease era, and that physicians need to be more aware of the consequent high mortality and morbidity. Early diagnosis followed by aggressive debridement, antifungal therapy, and managing the underlying disease is the most efficient way to reduce mortality associated with the disease.

Contribution of voriconazole N-oxide plasma concentration measurements to voriconazole therapeutic drug monitoring in patients with invasive fungal infection.

BACKGROUND: Voriconazole (VRC), a widely used triazole antifungal, exhibits significant inter- and intra-individual pharmacokinetic variability. The main metabolite voriconazole N-oxide (NOX) can provide information on the patient's drug metabolism capacity. OBJECTIVES: Our objectives were to implement routine measurement of NOX concentrations and to describe the metabolic ratio (MR), and the contribution of the MR to VRC therapeutic drug monitoring (TDM) by proposing a suggested dosage-adjustment algorithm. PATIENTS AND METHODS: Sixty-one patients treated with VRC were prospectively included in the study, and VRC and NOX levels were assayed by LC-MS/MS. A mixed logistic model on repeated measures was implemented to analyse risk factors for the patient's concentration to be outside the therapeutic range. RESULTS: Based on 225 measurements, the median and interquartile range were 2.4 µg/ml (1.2; 4.2), 2.1 µg/ml (1.5; 3.0) and 1.0 (0.6; 1.9) for VRC, NOX and the MR, respectively. VRC Cmin <2 µg/ml were associated with a higher MR during the previous visit. MR values >1.15 and <0.48 were determined to be the best predictors for having a VRC Cmin lower than 2 µg/ml and above 5.5 µg/ml, respectively, at the next visit. CONCLUSIONS: Measurement of NOX resulted useful for TDM of patients treated with VRC. The MR using NOX informed interpretation and clinical decision-making and is very interesting for complex patients. VRC phenotyping based on the MR is now performed routinely in our institution. A dosing algorithm has been suggested from these results.

COVID-19 associated mucormycosis. A case in Argentina.

SARS-CoV-2 virus disease presents (CAM) has been observed, mainly in patients with diabetes mellitus, diabetic ketoacidosis or under steroids treatment. The highest number of cases have been reported in India, with a prevalence of 0.27 % in hospitalized patients with COVID-19 during year 2020, which implies a 2.1-fold increase in the prevalence of mucormycosis compared to year 2019. Although corticosteroids treatment reduces mortality in patients with severe COVID-19, its prolonged use, in combination with other clinical and immunological factors, could increase the risk of invasive fungal infection. We report a case of CAM in Argentina. This report represents a warning for considering the diagnosis of invasive fungal infection in patients with severe COVID-19.Copyright © 2021, Instituto de Investigaciones Medicas. All rights reserved.

Clinico-epidemiological profile of Mucormycosis patients admitted in VIMS hospital, Ballari: Case series

Background: Mucormycosis is caused by the fungi belonging to the order Mucorales. Humans acquire the infection predominantly by inhalation of sporangiospores, occasionally by ingestion of contaminated food or traumatic inoculation. In the backdrop of COVID-19 expression, there has been notable increase in the incidence of invasive fungal infection (IFI), namely Mucormycosis and aspergillosis. In the present study we aim to know the Clinico-epidemiological profile of Mucormycosis patients admitted in Vijayanagar institute of medical sciences (VIMS), Ballari, Karnataka. Methodology: A descriptive study was carried out at VIMS Hospital, Ballari, Karnataka after obtaining ethical clearance. The data was collected using structured questionnaires through interview and case records on risk factors, clinical profile and management of patients who were suspected of Mucormycosis. Frequencies and Proportion were used to describe the variables. Study period was from April 2021-June 2021. Result(s): Out of 52 patients, 45(86.5%) were male and 7(13.5%) were female. Age group between 41-50 years (40.4%) were most commonly affected followed by 31-40 years (28.8%) and 50% were positive for COVID 19, 26.9% were post COVID and 23.1% were NON COVID. Twenty two patients were on steroids, 21 (95.5%) of them due to COVID 19 and 1(4.5%) due to asthma. Comorbid conditions like diabetes mellitus 38(73.1%) and hypertension 12(23.1%) were most commonly present. 12(31.6%) out of 38 patients had uncontrolled diabetes mellitus. Mucormycosis was confirmed by KOH and histopathological results and were positive in 21(43.7%) and 27(77.1%) patients respectively. Management of Mucormycosis included both medical and surgical intervention. Conclusion(s): Mucormycosis is a life threatening fungal infection. The present study emphasizes the need for further understanding of the disease and to take aggressive measures for early diagnosis and management.Copyright © 2023, Institute of Medico-legal Publication. All rights reserved.

Secondary invasive fungal infection in hospitalised patients with COVID-19 in the United States.

BACKGROUND: Invasive fungal infections (IFIs) have been identified as a complication in patients with Coronavirus disease 2019 (COVID-19). To date, there are few US studies examining the excess humanistic and economic burden of IFIs on hospitalised COVID-19 patients. OBJECTIVES: This study investigated the incidence, risk factors, clinical and economic burden of IFIs in patients hospitalised with COVID-19 in the United States. PATIENTS/METHODS: Data from adult patients hospitalised with COVID-19 during 01 April 2020-31 March 2021 were extracted retrospectively from the Premier Healthcare Database. IFI was defined either by diagnosis or microbiology findings plus systemic antifungal use. Disease burden attributable to IFI was estimated using time-dependent propensity score matching. RESULTS: Overall, 515,391 COVID-19 patients were included (male 51.7%, median age: 66 years); IFI incidence was 0.35/1000 patient-days. Most patients did not have traditional host factors for IFI such as hematologic malignancies; COVID-19 treatments including mechanical ventilation and systemic corticosteroid use were identified as risk factors. Excess mortality attributable to IFI was estimated at 18.4%, and attributable excess hospital costs were $16,100. CONCLUSIONS: Invasive fungal infection incidence was lower than previously reported, possibly due to a conservative definition of IFI. Typical COVID-19 treatments were among the risk factors identified. Furthermore, diagnosis of IFIs in COVID-19 patients may be complicated because of the several non-specific shared symptoms, leading to underestimation of the true incidence rate. The healthcare burden of IFIs was significant among COVID-19 patients, including higher mortality and greater cost.

Invasive fungal infections after respiratory viral infections in lung transplant recipients are associated with lung allograft failure and chronic lung allograft dysfunction within 1 year.

BACKGROUND: Respiratory viral infections (RVI) are associated with chronic lung allograft dysfunction (CLAD) and mortality in lung transplant recipients (LTRs). However, the prevalence and impact of secondary invasive fungal infections (IFIs) post RVIs in LTRs have not been investigated. METHODS: We performed a single center retrospective study including LTRs diagnosed with 5 different respiratory viral pathogens between January 2010 to May 2021 and evaluated their clinical outcomes in 1 year. The risk factors of IFIs were evaluated by logistic regression. The impact of IFIs on CLAD stage progression/death was examined by Cox regression. RESULTS: A total of 202 RVI episodes (50 influenza, 31 severe acute respiratory syndrome coronavirus-2, 30 metapneumovirus, 44 parainfluenza, and 47 respiratory syncytial virus) in 132 patients was included for analysis. Thirty-one episodes (15%) were associated with secondary IFIs, and 27 occurred in LTRs with lower respiratory tract infection (LRTI; 28% from 96 LRTI episodes). Aspergillosis was the most common IFI (80%). LTRs with IFIs had higher disease severity during RVI episodes. In multivariable analysis, RVI with LTRI was associated with IFI (adjusted odds ratio [95% confidence interval (CI)] of 7.85 (2.48-24.9). Secondary IFIs were associated with CLAD stage progression/death after accounting for LRTI, pre-existing CLAD, intensive care unit admission, secondary bacterial pneumonia and underlying lung diseases pre-transplant with adjusted hazard ratio (95%CI) of 2.45 (1.29-4.64). CONCLUSIONS: This cohort demonstrated 15% secondary IFI prevalence in LTRs with RVIs. Importantly, secondary IFIs were associated with CLAD stage progression/death, underscoring the importance of screening for fungal infections in this setting.

Clinicopathological association of mucormycosis in COVID 19 pandemic.

Context: Coinfection and superadded infections in patients with coronavirus disease 2019 (COVID-19) has been reported on multiple series. The emerging second wave of the pandemic has come with a lot of changes, especially in developing countries like India. One of such changes is sudden, significant rise in mucormycosis cases. Aims: To find out clinicopathological association of invasive mucormycosis with COVID-19 infection status and immunocompromised state. Settings and Design: A cross-sectional study done at a tertiary care centre. Methods and Material: All cases admitted in the dedicated mucormycosis ward between 1-06-2021 and 15-06-2021 were included in the study. The cases were admitted with suspicion of mucormycosis. The histopathological results were correlated with KOH mount and radiological reports. The clinicopathological association of occurrence of mucormycosis in post-covid and non-COVID patients along with other risk factors. Statistical Analysis Used: Odds ratio, chi square test were used to find the association using MS Excel 2010 and SPSS. Results: Thirty-six (81.82%) cases were of the post-COVID status, and 8 cases were non-COVID status. Out of 36 post-COVID patients, 33 (91.67%) showed evidence of invasive mucormycosis and of 8 non-COVIDpatients, 7 had evidence of mucormycosis (odds ratio = 1.57). Out of the total diagnosed cases of mucormycosis, 21 (52.5%) patients were known cases of diabetes mellitus (DM), and 7 (17.5%) cases of newly diagnosed hyperglycemia. Thirty (75%) patients out of 40 had some form of immunocompromised state. This shows statistically significant association of DM and immunocompromised state with the occurrence of mucormycosis in post-COVID patients (chi square value2 = 6.891, P value = 0.008). Twenty-five patients had the history of steroid use during the treatment of COVID-19. Conclusions: The infection with COVID-19 definitely increases the odds of contracting mucormycosis, but most of the cases had diabetes mellitus. So, it is possible that COVID-19 virus predisposes individuals to invasive fungal infection by precipitating DM.

Rhino-orbito-cerebral invasive fungal sinusitis associated with COVID-19 infection in a malnurished child

Background: Corona virus disease has been associated with a wide variety of fungal and bacterial co-infections. These secondary infections could be due to the irrational use of antibiotics, immunosuppressive therapy, pre-existing co morbidities, and immune modulator effects of the virus. But here, we report a very rare occurring of rhino-orbito-cerebral invasive fungal sinusitis in a malnourished child and no other co morbidities. Case presentation: This is a case of a 6-year-old boy with severe thinness and no other co-morbidities, with mild COVID-19 infection, during the course of illness developed rhino-orbito-cerebral invasive fungal sinusitis. The child's mother had COVID-19 1 week prior to child's illness. The child then developed fever followed by headache. The child reported to hospital on seventh day of illness and RTPCR for COVID-19, turned positive. The child's vitals were stable and maintaining saturation. Child was being treated with supplements and symptomatic treatment for fever. On his second day of stay at hospital, he started to develop gradually progressive left-sided peri-orbital swelling. Due to the association of COVID-19 with fungal infection, child was started on AMPHOTERICIN-B and given for 4 days and referred to a higher center for further management. Radiological imaging was suggestive of rhino-sinusitis with orbital cellulitis with meningeal enhancement suggestive of fungal etiology. Debridement was done, child was adequately treated with anti-fungal, and the child showed significant improvement along with radiological clearing. Conclusion: Invasive fungal infection can occur in association with COVID-19 among malnourished pediatric age groups with no other comorbidities.

Mucormycosis—The Rising Epidemic in a Pandemic: An Observational Case Study in a Tertiary Care Hospital

Mucormycosis is a rare and ominous fungal disease caused by the order Mucorales fungi. As per Indian data, uncontrolled diabetes is the main risk factor associated with mucormycosis. But during this SARS COV-2 pandemic, a huge rise in the number of mucormycosis cases has been observed in different states in India in last 10-12 months in the second wave. The immune dysfunction caused by this virus and the use of high doses of steroids appears to be a double-edged sword and causes immunosuppression with hyperglycemia, increasing the risk of secondary bacterial and invasive fungal infections (IFIs). Objective We conducted a prospective observational study involving individuals with proven mucormycosis in ABVIMS & Dr RML Hospital, New Delhi. The demographic profile with various clinical presentations, histopathological findings, predisposing factors, management, and final outcomes were recorded. Results We included 53 patients in our study. Rhino-orbital-cerebral mucormycosis was the most common (21/53, 39.6%) presentation followed by rhino-orbital (17/53, 32.0%), rhino-cerebral (10/53, 18.8% ) rhinosinusitis (4/53, 7.5%) and pulmonary involvement in 1/53, (1.8%). The cutaneous involvement was seen in 8 patients (15.0%), disseminated mucormycosis as meningitis in 2 patients (3.7%), and dual fungal infection with aspergillosis was seen in 2 patients (3.7%). The predisposing factors being diabetes mellitus (40/53, 75.4%), with newly diagnosed diabetes in previously undiagnosed (10/ 53, 18.8%), SARS-COV-2 (33/53, 62.2%), steroid intake (30/53, 56.6% ), prolonged hospital stay (29/53, 54.7%), use of oxygen therapy (19/53, 35.8%), and diabetic ketoacidosis in 2 patients (3.7%) Amphotericin B (liposomal form) was the primary therapy in all 53 patients. Hypokalemia (8/53, 15.0%) was seen as side effect of amphotericin-B although renal functions were normal in all patients. Surgical debridement was performed in 43(77.3%) patients and transcutaneous retrobulbar amphotericin-B (TRAMB) was given in 16 patients (30.1%). Total mortality in our study is of 9 patients (16.9%). Conclusions Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis which also includes newly diagnosed diabetes. Hyperglycemia and immune dysregulation by SARS-CoV-2 and high dose corticosteroid use on large scale served a favorable environment for this invasive fungus.

COVID-19 associated mucormycosis. A case in Argentina

SARS-CoV-2 virus disease presents (CAM) has been observed, mainly in patients with diabetes mellitus, diabetic ketoacidosis or under steroids treatment. The highest number of cases have been reported in India, with a prevalence of 0.27 % in hospitalized patients with COVID-19 during year 2020, which implies a 2.1-fold increase in the prevalence of mucormycosis compared to year 2019. Although corticosteroids treatment reduces mortality in patients with severe COVID-19, its prolonged use, in combination with other clinical and immunological factors, could increase the risk of invasive fungal infection. We report a case of CAM in Argentina. This report represents a warning for considering the diagnosis of invasive fungal infection in patients with severe COVID-19. Copyright © 2021, Instituto de Investigaciones Medicas. All rights reserved.

Preliminary Experience in Post-COVID-19 Mycoses: A Pathologist's Perspective.

Background Coronavirus disease is caused by the severe acute respiratory syndrome coronavirus-19. Because of co-morbidities and indiscriminate use of steroids and antibiotics, the incidence of opportunistic fungal infections has increased in COVID-affected individuals. Aims and objectives The aim of the study is to analyze the various tissue reaction patterns of COVID-19-associated mucormycosis in the surgical debridement specimens using routine hematoxylin and eosin (H&E) stain and special stains like periodic acid-Schiff (PAS), Grocott-Gomori's methenamine silver (GMS), Masson trichrome (MT) and Prussian blue (PB), and to understand the pathogenesis of COVID-19 sequelae. Materials and methods This retrospective observational study was conducted after the approval from the Institute Human Ethical Committee (IHEC) on 45 tissue samples of COVID-associated mucormycosis using routine H&E and histochemical stains such as PAS, GMS, MT, and PB. Detailed demographic profiles, clinical information, radiological findings, and relevant microbiological data in available cases, like reports on potassium hydroxide (KOH) mount preparation, and fungal culture reports on Saboraud's Dextrose Agar (SDA) medium were collected. The different histomorphological tissue reaction patterns were observed and analyzed. Results All the surgical debridement specimens from post-COVID cases had histomorphology of mucormycosis displaying broad, aseptate, ribbon-like fungal hyphae with right-angle branching (45/45). Six of the 45 cases also reveal thin, narrow septate, acute angle branching hyphae, indicating co-existing Aspergillosis (6/45). The histological tissue reaction patterns observed were categorized as extensive tissue necrosis (100%), vascular proliferation (82%), angioinvasion (58%), giant cell reaction (53%), fibrin thrombi (47%), septic thrombi and angiodestruction (40%), fungal osteomyelitis (33%), necrotizing granulomas (31%). Conclusion This study infers that post-COVID-19 associated mucormycosis, alterations in the local tissue microenvironment are found to have a favorable effect on colonizing fungi and result in destructive tissue reactions such as angioinvasion, angiodestruction, necrosis, necrotizing granulomas, suppurative inflammation, and iron pigment deposition. The spectrum of morphological changes reflects the host's immune status.

Disseminated fusariosis in children: Report of two cases in girls with leukemia.

Background and Purpose: Disseminated fusariosis is an opportunistic infection caused by the hyaline fungus Fusarium spp. and occurs mainly in patients with leukemia. Case report: Two cases of disseminated fusariosis in pediatric patients are presented. Profound and prolonged neutropenia, fever, myalgia, and skin lesions in the legs were present in two girls with leukemia undergoing chemotherapy. In the first case, infection by Fusarium spp. was confirmed by anatomopathological findings, pathogen isolation, and polymerase chain reaction. In the second case, Fusarium solani infection was confirmed by mass spectrometry using blood cultures and skin lesion samples. Conclusion: It is important to consider disseminated fusariosis in high-risk patients who present with profound and prolonged neutropenia and persistent fever that does not resolve after broad-spectrum antibiotics to initiate antifungal therapy in a timely manner.

Disseminated mucormycosis in a patient with severe COVID-19 on venovenous extracorporeal membrane oxygenation: A case report.

Background: Since the global outbreak of coronavirus disease 2019 (COVID-19), there have been several reports of mucormycosis as a secondary complication. However, the disseminated type of mucormycosis is extremely rare. Case: A 58-year-old male patient with COVID-19 started receiving venovenous extracorporeal membrane oxygenation because of severe respiratory failure. During hospitalization, intra-abdominal hemorrhage occurred and an emergency laparotomy was performed. Subsequently, the patient suffered septic shock, and part of the small intestines and the abdominal wall became necrotic. Finally, the patient died. At autopsy, he was diagnosed with disseminated mucormycosis. Conclusion: Disseminated mucormycosis should be considered in patients with COVID-19 with refractory sepsis unresponsive to broad-spectrum antimicrobial therapy.

Isavuconazole for COVID-19-Associated Invasive Mold Infections.

Isavuconazole is a broad-spectrum antifungal drug recently approved as a first-line treatment for invasive aspergillosis and as a first or alternative treatment for mucormycosis. The purpose of this review was to report and discuss the use of isavuconazole for the treatment of COVID-19-associated aspergillosis (CAPA), and COVID-19-associated mucormycosis (CAM). Among all studies which reported treatment of CAPA, approximately 10% of patients were reportedly treated with isavuconazole. Considering 14 identified studies that reported the use of isavuconazole for CAPA, isavuconazole was used in 40% of patients (95 of 235 treated patients), being first-line monotherapy in over half of them. We identified six studies that reported isavuconazole use in CAM, either alone or in combination therapy. Overall, isavuconazole was used as therapy in 13% of treated CAM patients, frequently as combination or sequential therapy. The use of isavuconazole in CAPA and CAM is complicated by the challenge of achieving adequate exposure in COVID-19 patients who are frequently obese and hospitalized in the ICU with concomitant renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO). The presence of data on high efficacy in the treatment of aspergillosis, lower potential for drug-drug interactions (DDIs) and for subtherapeutic levels, and no risk of QT prolongation compared to other mold-active azoles, better safety profile than voriconazole, and the possibility of using an intravenous formulation in the case of renal failure are the advantages of using isavuconazole in this setting.

Autopsy approach in diagnosis of Mucormycosis

Management of systemic fungal infection has always been a challenging task for medical practitioners. There has been an exponential increase in the number of fungal infections during the COVID-19 pandemic. In India, cases of invasive mucormycosis are being encountered in large numbers. Injudicious use of steroids has been considered as one of the reasons for the rise in mucormycosis cases. Mucormycosis is a difficult diagnosis in its early stages. Most of the times the patients present in advanced disease conditions. There has been considerable mortality in such cases. Forensic pathologists may encounter such cases in their autopsy practice, particularly during COVID-19 pandemic. This article discusses the etiopathogenesis, autopsy features and postmortem diagnostic approach in cases of mucormycosis. © 2022

Clinico-epidemiological Profile of COVID-19 Associated Invasive Fungal Rhinosinusitis Reported in the Teaching Hospital of Diwaniya, Qadisiya Province, Iraq: A Case Series

Introduction: With the current COVID-19 pandemic, the increasing use of glucocorticoids has resulted in more adverse effects and secondary bacterial or fungal infections. Objective: To find out the clinic-epidemiological profile of patients having COVID-19 associated invasive fungal rhinosinusitis in Diwaniya teaching hospital- Qadisiya province - Iraq. Method: Retrospective case series study of 24 patients with COVID-19 who were admitted to Alshafa centre in Al-Diwaniyah Province from 1st of May 2020 to end of August 2021. Patients were moderate to severe COVID-19 received treatment according to local guidelines. Patients who developed signs and symptoms of nose and paranasal sinuses disorder were seen by otolaryngologists and treated by a multidisciplinary team if invasive mucormycosis and its comorbidities were detected. Results: Out of 24 patients, 8 were female and two patients were excluded because their histopathological examination hasn’t confirmed acute invasive fungal rhinosinusitis. The average age was 54 years old, they all had diabetes, 2 patients had chronic kidney diseases, and 2 patients had malignancy (leukaemia). Furthermore, 19 patients were with severe SARS-COV-2 while 5 patients had moderate symptoms. All patients were confirmed COVID-19 positive by PCR test. Conclusion: Invasive fungal infections of the nose and paranasal sinuses are highly lethal conditions with significant morbidity. Early recognition and high index of suspicion are needed in the case of COVID-19 patients who complain features of sinusitis with careful prescription of drugs that affect immune response in COVID-19 patients. Copyright (c) 2022: Author(s).