Missingness: Or why are some people failing to engage with foot services in time?

Introduction: The Covid-19 pandemic has led to an uncomfortable and often recurrent situation in foot care services in the UK which frequently manifests in the older, White British, overweight, lone male population who often are manual workers. Result(s): These patients are unaware of local or national health promotion campaigns (e.g. iDEAL group's ACT NOW campaign, Diabetes UK's Putting Feet First) so have little awareness and education regarding potential foot problems. They are not aware of 5-to drive, eat 5 portions of fruit and vegetables a day, check your feet every day or walk 10,000 steps initiatives. They do not access public health materials and do not follow social media platforms, magazines, or newspapers. Therefore when they present in clinic, often after an emergency appointment with their GP, or an attendance at A&E, they present with significant soft tissue damage or systemic infection, frequently catastrophic tissue loss and serious co-morbidity (often in the form of renal or cardiac failure). Many require immediate hospital admission, intra-venous antibiotics, surgical debridement, vascular intervention and/or amputation. Unfortunately for some early mortality (often from an overwhelming cardio-vascular event) is the reality before they get as far as a major amputation. Discussion(s): Patients with more long-term conditions have increased risk of missing GP appointments (after controlling for number of appointments made) and are at increased risk of all-cause mortality, with those with long-term mental-health conditions who miss >2 appointments per year having >8x risk of all-cause mortality compared with those similar diagnoses who missed no appointments (McQueenie et al. 2019).

Novel role of 18F- FDG PET/CT in rhinosinonasal mucormycosis in the era of covid-19 infection

Objectives: In the Covid-19 era, there was a surge in the cases of a life-threatening infection of rhinosinonasal mucormycosis. Mucormycosis, popularly known as black fungus, is an infection caused by mycetes mucorales, an aseptate hyphae. Presently, computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used imaging modalities for the management of patients with rhinosinonasal mucormycosis. The present study was aimed to evaluate the role of 18F- FDG PET/CT in the detection of recurrent or residual disease in post-surgical or post antifungal therapy in these patients for further management. Method(s): A total of 10 patients were included in this pilot study of Covid-19 positive patients and histologically proven mucormycosis (by KOH mount). 18F- FDG PET/CT was performed to assess the disease status in 6 postoperative/ post debridement patients and response to antifungal therapy in 4 patients, at an interval of 40 (range = 27-66) days post intervention. Result(s): The mean age of the patients was 45.0 +/- 11.65 years. The male: female ratio was 9:1. The common clinical presentation was ipsilateral facial or orbital pain and swelling. Covid-19 infection was positive in all the patients except one who had CT finding with HRCT score of 10/25 and hence was considered as post Covid-19 infection. Six out of 10 patients were diabetic on oral hypoglycaemic agents or insulin. All patients had a baseline CT/MRI for staging the initial extent of the disease. Surgical debridement was done in 6 out of the 10 patients followed by antifungal therapy (Liposomal Amphotericin B and Pozaconazole). Remaining four patients were treated with antifungal therapy. PET/CTwas performed after an average of 40 days of surgical/medical intervention, in whom clinical symptoms persisted or worsened even on antifungal therapy. 18F-FDG PET/CT showed metabolically active residual disease in all the patients with a mean SUVmax of 9.78 +/- 4.03. Conclusion(s): In the era of ongoing Covid-19 infection, black fungus has been a debilitating disease with high mortality and morbidity. Present study demonstrated that 18F-FDG PET/CT can be an efficient imaging tool for an early surgical/ medical treatment response assessment and restaging.

Photodynamic inactivation of Rhizopus oryzae - in vitro study

During the COVID-19 pandemic, several complications arose in infected patients, one of them being mucormycosis, which is an extremely aggressive fungal disease with a high mortality rate, especially in patients with compromised immune systems. Most cases of mucormycosis are caused by the fungus Rhizopus oryzae, also known as black fungus, with 90% of cases affecting the rhinocerebral site. The treatment tools used are based on high doses of amphotericin B and posaconazole, associated with surgical resections when possible. However, even with aggressive antifungal treatment, the estimated attributable mortality rate is high [1]. In the absence of surgical debridement of the infected tissue, antifungal treatment alone is not curative. So there is a need for development of adjuvant treatments. Antimicrobial Photodynamic Therapy (aPDT) may constitute an auxiliary therapeutic option for mucormycosis [2]. Due to the lack of reports on the photodynamic inactivation of R. oryzae, we investigated different protocols Photodithazine (PDZ) as a photosensitizer. The response on the fungus growing rate under distinct treatment parameters as photosensitizer concentration, incubation time, and association with surfactant, will be presented for both white and black hyphal phases, and infective spore phase. Preliminary results show the potential use of photodynamic therapy for the inactivation and growth control of the R. oryzae.Copyright © 2023

Anesthetic management of toxic epidermal necrolysis: a report of two cases

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

A peek behind the curtain in the diagnosis and management of COVID­19­Associated Mucormycosis (CAM).

Coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) is responsible for a high mortality rate due to its unique and severe host-pathogen interactions. Critically ill or immunocompromised COVID-19 patients are more prone to suffer from aggressive mycoses. Probable victims include those with uncontrolled diabetes mellitus (DM), metabolic acidosis, prolonged neutropenia, increased ferritin levels, hypoxia, and prolonged hospitalization with/without mechanical ventilators and corticosteroids administration. The current review aims to outline the journey of patients with CAM as well as the advantages and disadvantages of the currently available diagnostic techniques. It also discussed the current status of treatment options and caveats in the management of mucormycosis. Multidisciplinary team, early diagnosis, controlling the predisposing condition(s), complete surgical debridement, effective antifungal therapies (e.g., amphotericin B, isavuconazole, and posaconazole), and implementing antifungal stewardship programs are imperative in CAM cases.

Isolated tracheobronchial mucormycosis: Report of a case and systematic review of literature

Background: Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature. Case description and systematic review: A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky haemoptysis, and hoarseness of voice 2 weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycaemic control, posaconazole, and inhaled amphotericin B (8 weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in two lung transplant recipients), post-viral illness (post-COVID-19 [n = 3], and influenza [n = 1]), and post-intubation mucormycosis (n = 1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26;19.2%) or bronchoscopic instillation (1/26;3.8%) of amphotericin B and surgery (6/26;23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive haemoptysis. Conclusion: Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible. © 2022 Wiley-VCH GmbH.

Rhino-Orbital Mucormycosis in a COVID-19 Patient: A Dreadful Challenge

Coronavirus disease 2019 (COVID-19) is a pandemic disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). COVID-19 infections may be associated with a wide range of bacterial and fungal co-infections. Recent studies are reporting invasive fungal infection associated with severe COVID-19. Herein, we report a case of COVID-19 rhino-orbital mucormycosis infection caused by Rhizopus sps in a 32 year old diabetic patient who was successfully managed with early aggressive debridement of infected tissue endoscopically with extended ethmoidectomy by modified Denker's approach along with orbital decompression and antifungal therapy with Liposomal Amphotericin B and Posaconazole. Serial diagnostic nasal endoscopy showed no evidence of progression of the infection. The patient was discharged on 21st day of hospitalization still on oral Posaconazole for a total of 3 months. Copyright © 2022, Kathmandu University. All rights reserved.

Mucormycosis in the COVID-19 Era - A Natural Calamity or Man-Made Disaster? Current Evidence and Review of the Literature

Mucormycosis is a potentially fatal disease caused by a fungus of the order Mucorales, most commonly involving the nasal sinuses, orbits, brain, lungs, and skin. The disease affects mostly immunosuppressed individuals and patients with chronic diseases such as diabetes. The prevalence of mucormycosis is 80 times higher (0.14 per 1000) in India compared to developed countries. Since the outbreak of the COVID-19 pandemic, there has been a sudden surge in the number of mucormycosis cases, especially on the Indian subcontinent. This can be attributed to what we consider to be the perfect iatrogenic recipe: a combination between the immunosuppression caused by COVID-19, the large prevalence of uncontrolled diabetes and the simultaneous use of corticosteroids. Other factors include the excessive use of antibiotics, antifungal drugs and zinc supplements, invasive ventilation, poor hygiene and sanitization as well as the use of industrial oxygen in hospitals. As a result, an overwhelmingly large number of COVID-19 patients have developed mucormycosis during the pandemic. A review of the literature suggests that all efforts should be made to keep tight control of glycemia in COVID-19 patients along with judicious use of corticosteroids. The treatment of mucormycosis involves a combination of medical and surgical therapy, with the early initiation of antifungal drugs and aggressive surgical debridement of the affected tissues. Copyright © 2022 Mandip Singh Bhatia et al., published by Sciendo.

A Comparative Study of Topical Antifungal Therapy in COVID-19-Associated Mucormycosis (CAM): A New Hope?

Introduction: COVID-19-associated mucormycosis (CAM) is an ongoing epidemic that adds to COVID-19 woes in several countries. Mucormycosis is a fulminant angioinvasive fungal disease for which surgical debridement with systemic antifungal therapy is advocated. The efficacy of using topical antifungal therapy in the form of lipid-based amphotericin B gel and povidone-iodine is compared in the trial. Method(s): This is a multiarm, parallel randomized control trial. Microbiologically and histologically proven cases of mucormycosis in patients who underwent open or endoscopic surgical debridement were included in the study. The trial was conducted in the in-patient ear, nose, throat department of a tertiary care referral hospital in eastern India, All India Institute of Medical Sciences, Bhubaneswar, from May to December 2021. The postoperative cavity was treated according to the intervention arm in the form of lipid-based amphotericin B gel, povidone-iodine ointment, or saline nasal douching according to the allotted group. The aim was (1) to compare the efficacy of 0.1% w/w liposomal amphotericin B gel with 10% w/w povidone-iodine and saline nasal douching in preventing revision surgery in patients with CAM and (2) to develop the AIIMS Bhubaneswar Endoscopic Scoring System (AMESS) to quantify response to treatment. The requirement of revision surgery in postoperative cases of CAM was assessed. Result(s): Fifteen participants were analyzed in each group. The control arm's risk of revision surgery was 4.50 (95% CI, 1.16-17.44) times than the lipid-based amphotericin B gel arm and 1.50 (95% CI, 0.71-3.16) times than povidone-iodine arm. The difference was statistically significant (P=.02) for amphotericin but not for povidone-iodine. The absolute risk reduction of applying amphotericin gel is 46.7%, and number needed to treat is 2.14. Conclusion(s): Topical amphotericin B gel application in the postoperative cavity can decrease the need for revision surgery and help in early recovery. However, long-term studies with greater sample size are required to confirm our findings.

Evaluation of Clinical, Laboratory Findings, Treatment and Prognosis of Cases with Rhinoserebral Mucormycosis

Introduction: Mucormycosis is an opportunistic filamentous fungal infection that can progress rapidly. Different clinical pictures may occur depending on tissue and organ where the involvement is seen. Rhinoserebral mucormycosis, is the most common clinical form. We aimed to examine the patients diagnosed with rhinocerebral mucormycosis followed in our hospital with literature. Materials and Methods: Patients treating in our hospital between August 2009 and November 2020 with microbiologically and / or histopathologically confirmed rhinocerebral mucormycosis were evaluated retrospectively. Results: 2 (25%) of the patients were female and 6 (75%) of them were male. The average age was 56.37 ± 9.318. All patients had at least one predisposing factor. Fever and headache symptoms were the most common. Surgical debridement and antifungal treatment were applied to all patients. 4 (50%) of the patients developed diffuse visual impairment and were discharged with sequelae. One (12.5%) of them was discharged with full recovery. 3 (37.5 %) of them died on the 12th day of hospitalization. Hemoglobin and Glaskow coma scores of patients with ex were significantly lower than the patients who were discharged, and SOFA scores were higher (p= 0.025, 0.031, 0.023, respectively). Conclusion: Nowadays, when the COVID-19 pandemic has not been controlled yet, most of the patients who receive immunosuppression due to COVID-19 also carry additional risk factors such as DM in terms of mucormycosis. Our article has contributed to raising awareness by drawing attention to risk factors, clinical signs and symptoms in mucormycosis. Training meetings should be organized for all medical doctors on this subject. In this way, mortality and sequelae rates can be improved with early diagnosis and treatment.

Post COVID-19 Rhino Orbito Cerebral Mucormycosis: Who is the Real Culprit

Aim and background: Coronavirus disease 2019 (COVID-19) pneumonia has been frequently associated with symptoms such as shortness of breath, cough, loss of sense of smell, fever, and fatigue. Patients with preexisting conditions such as hypertension, diabetes mellitus, or coronary artery disease are especially susceptible to compilations arising from COVID-19 pneumonia. Patients with poorly controlled diabetes mellitus or those that are immunocompromised are at an increased risk of developing mucormycosis. Objective: To study the possible association between invasive fungal sinusitis (mucormycosis) and COVID-19. Materials and methods: A retrospective observational study was conducted at a tertiary care centre over 4 months, involving all patients with rhino orbito cerebral mucormycosis suffering from or having a history of coronavirus disease infection. Results: Seventy patients presented with mucormycosis, 65 had an association with COVID-19. The maxillary sinus and the anterior ethmoidal sinuses were the most common sinuses affected. Intra-orbital extension was seen in 30% of cases, while intracranial extension was only seen in 6%. Diabetes mellitus was present in 65 cases and was uncontrolled in 45 cases. All patients had a history of steroid use during their coronavirus treatment and 10% had tocilizumab administration. All 70 patients underwent surgical debridement, of which 21 had undergone orbital exenteration. Overall mortality was 7.6%, but with significant morbidity in survivors. Conclusion: Multiple manifestations and complications of COVID-19 are emerging as the pandemic is progressing. Mucormycosis emerged as a major health care problem with lots of morbidity and mortality, especially in the Indian subcontinent. Overzealous use of immunosuppressants along with uncontrolled diabetes was the major causative factor. Early diagnosis and early surgical debridement was the key to survival.

Pulmonary Artery Aneurysm in a Teenager with Diabetes and COVID-19 Infection

Introduction: Pulmonary artery aneurysms (PAAs) are exceedingly rare. Etiology includes congenital, idiopathic, and acquired. Bacterial and fungal infections are the most common acquired causes. Herein described is a patient with new-onset diabetes mellitus I (DM1) with COVID-19 infection complicated by PAA and mucormycosis. Case Description: A 17-year-old female with new-onset DM1 was admitted to the PICU with diabetic ketoacidosis, and COVID-19 infection complicated by multifocal necrotizing pneumonia. She was treated with remdesivir, antibiotics, systemic glucocorticoids, and discharged on inhaled glucocorticoids. Two weeks later she presented with hemoptysis. Chest computed tomography angiography (CTA) showed a resolving necrotizing pneumonia with a 16 mm aneurysmal dilatation of the proximal portion of the right inferior pulmonary artery (RIPA). Hemoptysis resolved, with no intervention required. One month later she presented again with hemoptysis. Repeat chest CTA demonstrated increasing aneurysmal dilatation, measuring 20 mm in diameter. Echocardiography showed no evidence of endocarditis, congenital heart defects, or elevated right ventricular pressures. A comprehensive infectious workup was negative (Table 1). Due to recurrent symptoms, progressive aneurysmal enlargement, and concerns for rupture, patient underwent RIPA occlusion by cardiac catheterization. Two months later hemoptysis recurred. Chest CTA revealed erosion of the occlusion device into the right inferior segmental bronchus. She underwent emergent right middle and lower lobectomy, and arterial bronchial fistula repair. Lung histology revealed non-septate hyphae with peribronchial and perivascular necrotizing granulomas concerning for mucormycosis (Figure 1). She was treated with amphotericin B and discharged on oral posaconazole. Discussion: The incidence of PAA in adults is estimated to be 1 in 14,000 patients. In adults, the upper limit of normal of an interlobar PA by CTA is 17mm. Our patient's RIPA was dilated up to 20 mm, for which she underwent occlusion of the RIPA. The proinflammatory state generated by COVID-19 can result in vascular inflammation and ultimately aneurysmal dilatation. Desnos et al. reported four cases of hemothorax secondary to PAA rupture in COVID-19 patients on ECMO for severe ARDS. The etiology for PAA formation in our patient had a complex interplay of factors including new-onset diabetes, COVID-19 vasculitis, exposure to systemic glucocorticoids, and an opportunistic infection with Mucor spp. Mucormycosis in diabetic patients with COVID-19 has a mortality of 31% in adults. We believe that the lobectomy performed for the management of PAA in our patient led to better outcomes since surgical debridement is a mainstay of mucormycosis treatment, along with antifungal therapy. Conclusion: PAA in children is uncommon. We describe a diabetic patient with COVID-19 pneumonia, complicated by PAA and mucormycosis. In patients with COVID-19 presenting with hemoptysis, it is important to have a high index of suspicion for PAA. Furthermore, diabetic patients with COVID-19 treated with systemic steroids can be at increased risk for mucormycosis. (Table Presented).

“Incidence, Clinical Profile, Treatment Protocol and Outcome of Rhino-Maxillary Orbital Mucormycosis in Government Medical College Hospital, Nizamabad, Telangana, India: A Prospective Study and Mini – Review of Literature”

Introduction: mucormycosis (ROCM) is a aggressive infection and in patient with co-morbidities, the mortality rises upto 50%. Rhino-orbitocerebral mucormycosis (ROCM) is the more common in patients with poor diabetic control and usually manifests itself as nasal stuffiness, nasal discharge, facial pain. Eye signs involve opthalmoplagia, proptosis and in advanced stages loss of vision. Material & Methods: This is a prospective, cross-sectional study involving patients who reported to our centre and those patients who were referred from other hospital for treatment of mucormycosis during the second of COVID-19 during april – june 2021. Results:Majority of the patients were above 50 years of age and the most common co-morbidity was diabetes. Maxilla was more commonly involved than mandible. Posaconazole along with surgical debridement effectively controlled the disease process. All the patients were disease free at 6 months follow up Discussion: Combined team work, creating a task force team for mucormycosis, effective anti-fungal therapy along with surgical debridement played a key role in management of mucormycosis with no recurrence. Control of co-morbidities remained as part of the patient care and has helped in control of the disease process and prevention of secondary infections.

CLINICAL STUDY OF SURGE OF MUCORMYCOSIS IN COVID-19 PANDEMIC: A TERTIARY CARE CENTER STUDY

Background: Mucormycosis is a serious and rare fungal infection that mostly affects the immunocompromised. The symptoms depend on the body part affected or the site of infection. By infecting the nose, sinuses, eye, lungs, and brain, it produces a runny nose, one-sided facial swelling and pain, headache, fever, poor vision, bulging or displacement of the eye (proptosis), and tissue death. Various ailments may cause problems with the skin, stomach and intestines, and lungs. The objective of this research is to assess the prevalence, aetiology, treatment, and prognosis of mucormycosis in post-covid patients at our covid-specific tertiary care hospital. Materials and Methods: A prospective cross-sectional study was conducted on 50 patients admitted to the GGH/Government Medical College's Nizamabad covid department between May 2021 and August 2021 and diagnosed with mucormycosis. Result: The age groups most often affected by mucormycosis ranged from middle-aged to elderly. As a consequence of the ongoing covid pandemic outbreak, few of the affected population, who were mainly diabetic and had a range of hospital presentations, were discovered to have mucormycosis. Covid infection had significant impact on endocrine system as seen by uncontrolled blood glucose levels. The important components of efficient therapy of this condition include early detection, medical care, surgical debridement, proper antifungal medication, and treatment of associated disorders such as diabetes mellitus. Conclusion: Mucormycosis is a rapidly progressing sickness that has been demonstrated to be incurable in late presentation and can cause death;however, early detection and therapy may minimise mortality.

PULMONARY MUCORMYCOSIS AS A COMPLICATION OF SARS COV-2 PNEUMONIA - CASE REPORT AND REVIEW OF LITERATURE

CASE: A 31-year-old woman G4P2204 was admitted with respiratory failure. Her hemoglobin was 9.7 g/dl, D-dimer 1349 ng/mL feu, procalcitonin 0.44 ng/ mL, CRP 91.4 mg/L, normal white count and nasal RT-PCR positive for COVID-19. Chest x-ray showed bilateral patchy airspace opacities. She underwent emergent C-section, was intubated and placed on mechanical ventilation, received Remdesivir, dexamethasone, vancomycin and piperacillintazobactam. On day 11, she developed bilateral pneumothorces and had chest tubes placed. She had new elevation in white blood count (16,000/ul) and inflammatory markers. She was put on extracorporeal membrane oxygenation (ECMO). Computed Tomography ( CT) chest on day 15 showed large multiloculated cavity. She underwent bronchoscopy with bronchoalveolar lavage cultures positive for Mucorales. She had CT abdomen-pelvis, CT head and nasal endoscopy without evidence of invasive disease. She was started on amphotericin B and posaconazole. She had tracheostomy on day 21 and underwent successful ECMO weaning and decannulation on day 35. Chest tubes were removed. Amphotericin B was discontinued. She was discharged on nasal cannula and oral posaconazole and continued to improve. IMPACT/DISCUSSION: There are 6 other cases reported in literature with isolated pulmonary mucormycosis associated with SARS-CoV-2. All of these patients had clinical improvement before deteriorating again with SARS Cov-2 treatment. The timeline of new imaging findings like cavities, changing opacities, pleural effusions or bronchopleural fistula was usually 2 to 3 weeks from diagnosis of SARS-CoV-2 pneumonia. On analysis 5/7 of these patients were not diabetic, 6/7 received steroids, 3/7 received Tocilizumab and 4/7 received Remdesivir. 2 patients received surgical intervention with medical management although it did not change the outcome. Unfortunately despite aggressive medical and surgical treatment, there were poor outcomes. 4/7 patients died, 1/7 was permanently ventilator dependent and 2/7 survived. The diagnosis of isolated pulmonary mucormycosis is challenging. This might be secondary to hesitance of invasive diagnostic tests like bronchoscopy, lack of rapid diagnostic tests and fewer autopsies. Amphotericin B, posaconazole and isavuconazole remain the main treatment options along with surgical debridement of necrotic tissue. The pathology of mucormycosis in COVID-19 has been attributed to impaired T-cell function, impaired phagocytosis and more availability of fungal heme oxygenase which facilitates iron uptake for its metabolism. Glucocorticoids, IL-6 inhibitors and monoclonal antibodies further increase the risk of secondary infections. CONCLUSION: Mucormycosis is a lifethreatening disease with high morbidity and mortality. Based on our case and literature review, it is important to have high index of suspicion for pulmonary mucormycosis in patients who are recently treated with immunosuppressants for SARS-CoV-2 pneumonia and suddenly deteriorate after treatment.

ANTIMICROBIAL PHOTODYNAMIC THERAPY: AN ALTERNATIVE FOR THE TREATMENT OF OSTEORADIONECROSIS

Introduction Osteoradionecrosis (ORN) is a side effect after head and neck radiotherapy (RT) that is difficult to control. Antimicrobial photodynamic therapy (aPDT) promotes bacterial lysis through photosensitization, aiming at stimulating the affected area, promoting healing of the oral mucosa. Methods We performed a retrospective cohort analysis of patients with head and neck cancer, treated with RT, who developed ORN after RT and who underwent the treatment with aPDT concomitant with irrigation with 0.12% chlorhexidine digluconate and surgical debridement. Results Thirty-six patients who had lesions by ORN in the mandible or maxilla, with a mean development time of 30.9 months, were included. Of them, 77.8% were male, with a median age of 58 years. All of them were diagnosed with malignant neoplasms of oral cavity and oropharyx that received local RT as part of cancer treatment. In 22 patients, chemotherapy was used as part of the treatment. The main etiologie of ORN was prosthetic trauma (61.2%). All patients underwent the proposed protocol and 75% of patients were successful in treatment with total healing of the affected area and presented with no symptoms. Conclusions The protocol used suggests successful healing of the area in 75% of cases. The others suffered some complication of the ORN, such as pathological fracture, oro-cutaneous fistula and bucosinusal fistula and 16.6% patients treatment were affected by the COVID-19 pandemic and had the continuity of treatment impaired, still maintaining, a chronic ORN.

Management of Fournier's gangrene during the Covid-19 pandemic era: make a virtue out of necessity.

BACKGROUND: Fournier's gangrene (FG) is a necrotizing fasciitis caused by aerobic and anaerobic bacterial infection that involves genitalia and perineum. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year. Main risk factors are diabetes, malignancy, inflammatory bowel disease. FG is a potentially lethal disease with a rapid and progressive involvement of subcutaneous and fascial plane. A multimodal approach with surgical debridement, antibiotic therapy, intensive support care, and hyperbaric oxygen therapy (HBOT) is often needed. We present the inpatient management of an FG case during the Covid-19 pandemic period. A narrative review of the Literature searching "Fournier's gangrene", "necrotizing fasciitis" on PubMed and Scopus was performed. CASE PRESENTATION: A 60 years old man affected by diabetes mellitus, with ileostomy after colectomy for ulcerative colitis, was admitted to our Emergency Department with fever and acute pain, edema, dyschromia of right hemiscrotum, penis, and perineal region. Computed tomography revealed air-gas content and fluid-edematous thickening of these regions. Fournier's Gangrene Severity Index was 9. A prompt broad-spectrum antibiotic therapy with Piperacillin/Tazobactam, Imipenem and Daptomycin, surgical debridement of genitalia and perineal region with vital tissue exposure, were performed. Bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, were performed until discharge on the 40th postoperative day. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60th postoperative day. CONCLUSIONS: FG is burdened by a high mortality rate, up to 30%. In the literature, HBOT could improve wound restoration and disease-specific survival. Unfortunately, in our center, we do not have HBOT. Moreover, one of the pandemic period problems was the patient's displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management. Daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding surgical graft and hyperbaric oxygen chamber therapy, without foregoing optimal outcomes.

RéSUMé: CONTEXTE: La gangrène de Fournier (GF) est une fasciite nécrosante causée par une infection bactérienne aérobie et anaérobie qui implique les organes génitaux et le périnée. Les hommes, dans la soixantaine, sont plus touchés avec 1,6 nouveau cas/100 000/an. Les principaux facteurs de risque sont le diabète, les tumeurs malignes, et les maladies inflammatoires de l'intestin. La GF est une maladie potentiellement mortelle avec une atteinte rapide et progressive du plan sous-cutané et fascial. Une approche multimodale, avec débridement chirurgical, antibiothérapie, soins de soutien intensif et oxygénothérapie hyperbare (OHB), est souvent nécessaire. Nous présentons la prise en charge en milieu hospitalier d'un cas de GF pendant la période de pandémie de Covid-19. Une revue narrative de la littérature, recherchant «gangrène de Fournier¼, «fasciite nécrosante¼ sur PubMed et Scopus, a été réalisée. CAS CLINQUE: Un homme de 60 ans, atteint d'un diabète sucré et porteur d'une iléostomie après colectomie pour colite ulcéreuse, a été admis dans notre service d'urgences, avec fièvre et des douleurs aiguës, œdème et dyschromie de l'hémiscrotum droit, du pénis et de la région périnéale. La tomodensitométrie a révélé une teneur en air-gaz et un épaississement fluide-œdémateux de ces régions. L'indice de gravité de la gangrène de Fournier était de 9. Une antibiothérapie rapide à large spectre avec Pipéracilline/tazobactam, imipénème et daptomycine, et un débridement chirurgical des organes génitaux et de la région périnéale avec exposition des tissus vitaux, ont été effectués. Ont été réalisés au chevet du patient, un traitement quotidien des plaies chirurgicales, avec débridement de la fibrine, irrigation par solution saline normale et solution de povidone-iode, et application de gaze iodoforme et grasse, jusqu'à la décharge au 40èmejour postopératoire. Tous les 3 jours, un traitement à base de médicaments d'officine avec pansement à l'argent a été réalisé après irrigation par solution saline normale et solution de povidone-iode, et débridement de la fibrine des tissus, jusqu'à la ré-épithélialisation complète du scrotum au 60ème jour postopératoire. CONCLUSIONS: La GF est grevée d'un taux de mortalité élevé, jusqu'à 30%. Dans la littérature, l'OHB pourrait améliorer la restauration des plaies et la survie spécifique de la maladie. Malheureusement, dans notre centre, nous n'avons pas d'OHB. En outre, l'un des problèmes de la période pandémique était le déplacement du patient et la prise en charge ambulatoire des hôpitaux. Pour toutes ces raisons, nous avons opté pour une prise en charge conservatrice en milieu hospitalier. Le nettoyage quotidien de la plaie chirurgicale a permis d'obtenir sa restauration complète en évitant la greffe chirurgicale et la thérapie en chambre à oxygène hyperbare, sans renoncer à des résultats optimaux. MOTS-CLéS: Gangrène de Fournier, fasciite nécrosante, urgence urologique, débridement chirurgical.

Rare Bilateral Invasive Pulmonary Mucormycosis with Tracheo-Esophageal Fistula and Left Mainstem Bronchus Disruption

Introduction: Mucormycosis is a rare invasive opportunistic fungal infection caused by Zygomycetes. [1,2] It is associated with worse outcomes in immunocompromised patients.[3,4] Invasive pulmonary infections can lead to bronchial necrosis from angioinvasion.[1,3] Here, we present a case of invasive pulmonary mucormycosis (IPM) caused by Rhizopus spp, resulting in tracheo-esophageal fistula. Case : An 18-year-old male with uncontrolled type 1 diabetes was admitted to the intensive care unit for diabetic ketoacidosis (DKA) and acute hypoxia due to COVID 19 pneumonia requiring ventilatory support. Chest imaging showed bilateral opacities. He was treated with dexamethasone for COVID 19 and broad-spectrum antibiotics for superimposed bacterial pneumonia. Clinical course was complicated by acute respiratory distress syndrome and pneumomediastinum. Computed tomography of the chest showed large pneumomediastinum with air leak within the distal thoracic trachea. Bronchoscopy revealed a disfigured main carina with erosions (figure 1), a tracheo-esophageal fistula, necrotic blood-tinged left mainstem bronchus tissue, and a necrotic pus-filled superior segment of the right lower lobe. Left mainstem bronchial tissue specimen culture grew Rhizopus and Klebsiella spp. Liposomal amphotericin was initiated. Given his poor prognosis, the patient's family refused aggressive thoracic surgical intervention and pursued palliative care. Discussion: Rhizopus spp is the most common cause of mucormycosis in immunocompromised populations.[6] IPM is the second most common clinical form reported after the central nervous system.[3,6] Typically, IPM lesions are localized, and invasive presentations are infrequent. Rarely, IPM can cause invasive disease by angioinvasion, obstructing blood flow, and ischemic tissue necrosis.[6] Airway tissue necrosis can lead to fistulas between the airway and adjacent structures, including pleura, pericardium, and mediastinum.[2,3,4,5] Published clinical literature review revealed only a few cases due to IPM. Common predisposing factors include diabetes, DKA, and immunosuppressive medications, as observed in our patient.[3] Lobar bronchi are the usual locations of endobronchial erosions, with a predilection for the upper lobes.[3] In contrast, the left mainstem bronchus and right lower lobe were involved in the case presented here. In addition to antifungal treatment, surgical debridement is the mainstay of therapy due to necrosis.[7] The survival rate is between 35-46% in medically managed compared to 51-90% in surgically treated patients.[3]Conclusion: IPM is a life-threatening invasive disease associated with high mortality rates. Clinicians should suspect it in immunocompromised patients, including diabetes. The clinical history may include uncontrolled diabetes, recent DKA, and infections predisposing patients to develop superimposed fungal infections. The concurrent use of systemic steroids may also contribute to worse outcomes. (Figure Presented).

A Systematic Review Of Clinical Profile Of Cerebral Abscess In Post Covid Rhino Orbital Cerebral Mucormycosis

Objective: To analyse demographic data, provide an overview of the diverse clinico-radiological presentations of cerebral abscess in post covid ROCM. Background: The vulnerability of COVID-19 patients to ROCM, a spectrum of limited sinonasal, rhino-orbital and rhino-orbital-cerebral disease, often has underlying uncontrolled diabetes, immunosuppressive therapy in moderate to severe cases Design/Methods: We systematically reviewed 65 patients diagnosed with post covid ROCM with cerebral abscess admitted to the hospital during MAY 2021 to AUGUST 2021.Data pertaining to demographic variables, clinico-radiological features were analysed using percentage of total cases Results: Of 65 patients, incidence is more in the age group of 40-60yrs, males are more affected than females. Risk factors - inadvertent steroid use [ 89%], diabetes mellitus [ 81%], CKD [0.07%], HIV[ 0.03%].clinical profile include headache [97%], seizure [80%], vomitings [60%], focal neurologic deficit [18%], encephalopathy [3%]. Radiological profile showed abscess in temporal lobe [49%], frontal lobe [28%], occipital [14%], parietal [6%], optic nerve[ 3%]. Conclusions: Caution needs to be exercised with regard to Glycemic control, widespread usage of corticosteroids to reduce super infections. Expedient commencement of antifungal therapy together with surgical debridement help to improve the survival of these patients. In a country with prevalence of high risk factors and relatively poor resources, covid vaccination programmes should be the topmost priority to avoid massive outbreaks, complications and mortality.