Mucormycosis during COVID-19 era: A retrospective assessment.

In a retrospective view, this review examines the impact of mucormycosis on health workers and researchers during the COVID era. The diagnostic and treatment challenges arising from unestablished underlying pathology and limited case studies add strain to healthcare systems. Mucormycosis, caused by environmental molds, poses a significant threat to COVID-19 patients, particularly those with comorbidities and compromised immune systems. Due to a variety of infectious Mucorales causes and regionally related risk factors, the disease's incidence is rising globally. Data on mucormycosis remains scarce in many countries, highlighting the urgent need for more extensive research on its epidemiology and prevalence. This review explores the associations between COVID-19 disease and mucormycosis pathology, shedding light on potential future diagnostic techniques based on the fungal agent's biochemical components. Medications used in ICUs and for life support in ventilated patients have been reported, revealing the challenge of managing this dual onslaught. To develop more effective treatment strategies, it is crucial to identify novel pharmacological targets through "pragmatic" multicenter trials and registries. In the absence of positive mycology culture data, early clinical detection, prompt treatment, and tissue biopsy are essential to confirm the specific morphologic features of the fungal agent. This review delves into the history, pathogens, and pathogenesis of mucormycosis, its opportunistic nature in COVID or immunocompromised individuals, and the latest advancements in therapeutics. Additionally, it offers a forward-looking perspective on potential pharmacological targets for future drug development.

Mucormycosis, the Black Fungus in the Post-COVID-19 Pandemic: A Case Report with Review of Literature.

Mucormycosis, a concerning and often fatal fungal infection, has shown a significant rise in cases following the COVID-19 pandemic in India, particularly affecting patients with uncontrolled comorbidities such as diabetes mellitus and other immunocompromised individuals. Our case series examines five instances of mucormycosis, supported by appropriate radiographic and histopathological evidence correlating with clinical observations. Our review indicated that patients were experiencing ailments or undergoing treatments that compromised their immune systems. We analyzed additional epidemiological data, including common infection sites, gender predispositions, and mortality rates. Treatments were tailored based on symptom severity, encompassing both surgical and medical approaches. The primary reason for the rise in cases was linked to elevated glycaemic levels and weakened immunity among post-COVID-19 patients. The report provides a detailed explanation of the factors contributing to this correlation. Our findings underscore the critical importance of timely surgical intervention and advocate for further investigation into treatment efficacy and symptom monitoring specific to mucormycosis in post-COVID-19 patients in India.

A rare case of pulmonary mucormycosis and broncho-esophageal fistula in a patient with poorly controlled diabetes.

Key Clinical Message: In patients with poorly controlled diabetes, early recognition of rare fungal infections like pulmonary mucormycosis, especially when presenting with unusual complications such as broncho-esophageal fistula, is critical. Prompt intervention with antifungal therapy and consideration for surgical debridement significantly impact outcomes. Multidisciplinary management is paramount for such complex cases. Abstract: Mucormycosis is a rare fungal infection caused by the Mucorales. This infection is mostly observed among those with poorly controlled diabetes or immunodeficiency. The most common presentation of the infection among those with poorly controlled diabetes is rhino-orbit-cerebral involvement. In this case report, we provide the history and outcome of a rare case of pulmonary mucormycosis in a patient with poorly controlled diabetes who was simultaneously diagnosed with broncho-esophageal fistula. Our patient was a 32-year-old male with a history of poorly controlled diabetes. Over the months, he had complained of productive coughs and dyspnea, which had lately been joined by dysphagia. He also claimed to have lost considerable weight (10 kg) during the previous 3 months. Barium swallow showed an abnormal flow of contrast between the bronchus and esophagus, suggesting a broncho-esophageal fistula. Computed tomography of the thorax revealed a broncho-esophageal fistula between the left main bronchus (LMB) and esophagus. He had a bronchoscopy the next day, which revealed necrosis and a broncho-esophageal fistula in the LMB. A bronchial biopsy showed typical hyphae with necrotic tissue, indicating mucormycosis. The patient's antimycotic medication (liposomal amphotericin) was started and a prompt surgery consult was ordered. The patient, however, passed away from massive hemoptysis. We described a rare case of pulmonary mucormycosis with broncho-esophageal fistula in a patient with poorly controlled diabetes. The rarity of this combination highlights the associated diagnostic and treatment hurdles. Early detection, antifungal medication, as soon as possible surgical debridement of involved tissues, and a multidisciplinary approach could improve patient outcomes.

Diagnosis of mucormycosis from nasal swabs using commercial PCR platforms; a feasible alternative?

Rhino-orbital-cerebral mucormycosis (ROCM) is linked to uncontrolled diabetes, diabetic ketoacidosis, iron overload, corticosteroid therapy, and neutropenia. This study evaluated a commercial real-time PCR system's effectiveness in detecting Mucorales from nasal swabs in 50 high-risk patients. Nasal swab PCR showed 30% positivity, compared to 8% with KOH microscopy. Despite its improved sensitivity, nasal swab PCR has limitations, highlighting the importance of established sampling methods in mucormycosis diagnosis. Participants were predominantly male (64%), with diabetes (78%) and amphotericin B use (96%). Prior COVID-19 was 42%, with 30% positive for Mucorales by PCR, compared to 8% with KOH microscopy.

A Rare Case of Maxillary Mucormycosis in a Child With Juvenile Diabetes Mellitus.

Mucor and Rhizopus species are recognized as the primary culprits responsible for mucormycosis, a severe fungal infection known for its opportunistic nature. This infection primarily targets individuals with compromised immune systems, including those with diabetes mellitus and patients undergoing glucocorticoid therapy, where the immune response is weakened. This article aims to underscore the pivotal role of prompt diagnosis and intensive treatment in managing mucormycosis, particularly in pediatric patients, as it can avert death and mitigate serious morbidity. This case report emphasizes the urgency of identifying fungal infections in patients with diabetes early on and subsequently treating them aggressively to prevent adverse outcomes. It highlights the potential for excellent treatment outcomes when mucormycosis is promptly diagnosed and managed with intensive therapy. By doing so, significant morbidity and mortality associated with this condition can be effectively prevented, underscoring the importance of vigilance and proactive management in patients with predisposing factors for fungal infections.

Case report: Disseminated mucormycosis misdiagnosed as malignancy developed from allergic bronchopulmonary mycosis caused by Rhizopus microsporus following SARS-CoV-2 infection in a woman.

Mucormycosis has become more prevalent during the COVID-19 pandemic and is associated with a high mortality rate. However, concurrent host allergic reactions, invasive pulmonary mucormycosis, and disseminated mucormycosis are rarely reported. Herein, we describe a case of disseminated mucormycosis initially misdiagnosed as a malignancy that developed from allergic bronchopulmonary mycosis caused by Rhizopus microsporus in a woman with post-SARS-CoV-2 infection. The previously healthy patient presented with a sizeable mass in the right middle lobe and multiple lesions across the lungs, brain, spleen, kidneys, pancreas, and subcutaneous tissue 6 months after SARS-CoV-2 infection, mimicking an extensive metastatic malignancy. Eosinophilia, elevated total plasma immunoglobulin E, and significant eosinophilic lung tissue infiltration were observed. Rhizopus microsporus was isolated from subcutaneous tissue, and hyphae were detected in the lung tissue. Sequential amphotericin B liposomes followed by isavuconazole antifungal therapy combined with systemic corticosteroids improved symptoms, significantly reduced the sizes of pulmonary lesions, and reduced eosinophil count. However, it failed to halt the overall progression of the disease, and the patient died. The absence of asthma-like symptoms and delayed recognition of invasive fungal infection signs contributed to poorer outcomes, highlighting the need for a thorough post-COVID-19 follow-up.

Primary renal mucormycosis in a type 2 diabetic patient: A case report from Syria.

Mucormycosis is an opportunistic fungal infection that primarily affects immunocompromised individuals and rarely presents as renal mucormycosis (RM). Diagnosis can be challenging for many physicians. We report a rare case of primary, unilateral RM which triggered diabetic ketoacidosis in a type 2 diabetic patient. The case was later complicated by a bronchopleural fistula and a meropenem-resistant Klebsiella infection. The patient was ultimately treated with surgical intervention, liposomal amphotericin B, and polymyxine E. Early diagnosis and timely treatment of this life-threatening disease and its complications are significant in reducing mortality.

Cerebritis, optic ischemia, and cavernous sinus thrombosis arising from sinonasal mucormycosis.

Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients. We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis.

Secondary bacterial infections in post-COVID-19 mucormycosis cases: a retrospective study at Imam Khomeini Hospital Complex, March 2020-April 2021.

Background and Objectives: To explore the prevalence and characteristics of secondary bacterial infections among patients suffering from mucormycosis following COVID-19 infection. Materials and Methods: We conducted a cross-sectional, retrospective analysis from March 2020 to April 2022 at Imam Khomeini Hospital Complex in Tehran. The study included patients with histopathologically confirmed mucormycosis and documented secondary bacterial infections. We extracted and analyzed data from hospital records using SPSS software, version 26. Results: The study comprised 27 patients, with a predominance of females (70.4%) and an average age of 56 years. The majority of these patients (63%) had pre-existing diabetes mellitus. The severity of their COVID-19 infections varied. Treatment regimens included immunosuppressive drugs and antibiotics. Rhinocerebral mucormycosis was the most common form observed. The predominant secondary infections involved the urinary tract, respiratory system, bloodstream (bacteremia), and soft tissues, with resistant strains of Acinetobacter baumannii, Escherichia coli, and Klebsiella pneumoniae being the most frequently identified microorganisms. Notably, cases of bacteremia and pneumonia exhibited a higher mortality rate. Ultimately, 55.6% of patients were discharged, while 44.4% succumbed to their infections. Conclusion: Patients recovering from COVID-19 with mucormycosis are significantly susceptible to secondary bacterial infections, particularly those with diabetes mellitus or those undergoing immunosuppressive therapy. Such infections compound the morbidity and mortality risks in this vulnerable patient cohort.

Maxillary Mucormycotic Osteonecrosis as a Manifestation of Post-COVID-19 Infection in Non-diabetic Patients: Report of Two Cases.

Mucormycosis is a rare, opportunistic fungal infection prevalent in the elderly, especially in patients with uncontrolled diabetes or a compromised immune system. However, the outbreak of the pandemic declared by the World Health Organization in late 2019 increased the incidence of mucormycosis cases in COVID-19 patients due to increased steroid usage that resulted in an immunocompromised state. The current report presents two cases of oral mucormycotic osteomyelitis in patients who developed diabetes post-COVID infection, along with a review and relevant literature.

Successful Treatment of Sternal Osteomyelitis and Mediastinitis Caused by Rhizopus Following Cardiac Surgery.

Sternal osteomyelitis and mediastinitis are rare yet severe complications post-cardiac surgery, often associated with significant morbidity and mortality. Fungal etiologies, particularly those caused by Rhizopus spp., are infrequent but can lead to aggressive infections. Here, we present the case of a 68-year-old male who developed sternal osteomyelitis and mediastinitis caused by Rhizopus spp. two weeks following coronary artery bypass grafting surgery. Debridement and pectoralis flap reconstruction were performed following clinical identification and confirmation with microbiological examinations and a CT scan. Prompt recognition, aggressive surgical intervention, and targeted antifungal therapy were crucial for successful management. This case underscores the importance of considering fungal pathogens, such as Rhizopus, in the differential diagnosis of post-cardiac surgery infections, as well as aggressive treatment to improve outcomes for affected patients.

Resurgence of orbital mucormycosis during COVID-19 pandemic: Study from a tertiary care center in Eastern India.

PURPOSE: A sudden surge of Mucormycosis cases during the second wave of Covid 19 was observed in certain parts of India. The reasons for this upsurge remain unknown. However its impact on the overall healthcare system was quite overwhelming. In this context this study was decided to estimate and assess the spectrum of orbital involvement in patients with Mucormycosis, to find its association with coexisting disease entities if any, and at the same time evaluate the therapeutic response to established treatment regimens. MATERIALS AND METHODS: This descriptive longitudinal study was conducted over a period of six months. Patients presenting with symptoms of Mucormycosis were jointly evaluated by a multi speciality team. After confirmation of diagnosis, patients were treated with intravenous Amphotericin B, surgical debridement of affected sinuses and orbital exenteration when indicated. They were followed up for three months after discharge. RESULTS: Forty-three patients were enrolled in this study. Thirty-seven (86.04%) were COVID positive. All of them had history of steroid exposure during COVID treatment. Ninety five percent of study participants had diabetes mellitus. Twenty-seven (62.79%) patients had orbital involvement. Most common clinical presentation was peri-orbital or facial pain and edema. Besides medical treatment, thirty-nine patients (90.69%) required sinus debridement and nine patients (20.9%) required orbital exenteration. Thirteen patients (30.23%) expired during the follow up period. With treatment disease regressed in twenty patients (46.51%). CONCLUSION: Diabetes and use of steroids to prevent anticipated cytokine storm may be the inciting factors for Orbital Mucormycosis in COVID patients. Early diagnosis, treatment and control of risk factors are keys for recovery and survival..

Rehabilitation of the Surgical Defect Secondary to Mucormycosis With a Definitive Obturator: A Case Report.

Neglect initially starts as an infection, evolving into a disease. During the COVID-19 pandemic, lifestyle changes and disturbed food intake have weakened immune systems, making individuals more susceptible to secondary infections. Mucormycosis poses a significant threat, especially during the COVID-19 pandemic when immune systems may be compromised. The impact of the disease extends beyond physical health, affecting psychological and social well-being due to the challenges, such as difficulties in mastication, speech, and swallowing post-surgery. The mention of maxillectomy highlights the severe nature of some cases, necessitating surgical intervention to remove the affected tissue. Anatomical and functional losses following surgical excision of the maxilla and surrounding tissues need to be recovered as soon as possible. After surgery, prostheses can and should be used to restore speech, mastication, and deglutition - three essential physiological activities. Thus, a patient's treatment approach should include prosthetic planning before surgical intervention and rehabilitation after the surgery. If they are carefully handled at the moment of surgery, the overall continuity created by maxilla resection includes at least the oral, nasal, and maxillary sinus cavities, which may prove to be a useful future location for prosthesis retention. As a result, the prosthodontist's role becomes crucial in assisting the surgeon in taking all necessary precautions that are beneficial to the patient.

Mucor germinans, a novel dimorphic species resembling Paracoccidioides in a clinical sample: questions on ecological strategy.

Dimorphism is known among the etiologic agents of endemic mycoses as well as in filamentous Mucorales. Under appropriate thermal conditions, mononuclear yeast forms alternate with multi-nucleate hyphae. Here, we describe a dimorphic mucoralean fungus obtained from the sputum of a patient with Burkitt lymphoma and ongoing graft-versus-host reactions. The fungus is described as Mucor germinans sp. nov. Laboratory studies were performed to simulate temperature-dependent dimorphism, with two environmental strains Mucor circinelloides and Mucor kunryangriensis as controls. Both strains could be induced to form multinucleate arthrospores and subsequent yeast-like cells in vitro. Multilateral yeast cells emerge in all three Mucor species at elevated temperatures. This morphological transformation appears to occur at body temperature since the yeast-like cells were observed in the lungs of our immunocompromised patient. The microscopic appearance of the yeast-like cells in the clinical samples is easily confused with that of Paracoccidioides. The ecological role of yeast forms in Mucorales is discussed.IMPORTANCEMucormycosis is a devastating disease with high morbidity and mortality in susceptible patients. Accurate diagnosis is required for timely clinical management since antifungal susceptibility differs between species. Irregular hyphal elements are usually taken as the hallmark of mucormycosis, but here, we show that some species may also produce yeast-like cells, potentially being mistaken for Candida or Paracoccidioides. We demonstrate that the dimorphic transition is common in Mucor species and can be driven by many factors. The multi-nucleate yeast-like cells provide an effective parameter to distinguish mucoralean infections from similar yeast-like species in clinical samples.

Epidemiology, Clinical Manifestations, and Outcome of Mucormycosis in Solid Organ Transplant Recipients: A Systematic Review of Reported Cases.

Mucormycosis is an emerging disease primarily affecting the immunocompromised host, but scarce evidence is available for solid organ transplant recipients (SOTRs). We systematically reviewed 183 cases occurring in SOTRs, exploring epidemiology, clinical characteristics, causative pathogens, therapeutic approaches, and outcomes. Kidney transplants accounted for half of the cases, followed by heart (18.6%), liver (16.9%), and lung (10.4%). Diagnosis showed a dichotomous distribution, with 63.7% of cases reported within 100 days of transplantation and 20.6% occurring at least 1 year after transplant. The 90-day and 1-year mortality rates were 36.3% and 63.4%, respectively. Disseminated disease had the highest mortality at both time points (75% and 93%). Treatment with >3 immunosuppressive drugs showed a significant impact on 90-day mortality (odds ratio [OR], 2.33; 95% CI, 1.02-5.66; P = .0493), as did a disseminated disease manifestation (OR, 8.23; 95% CI, 2.20-36.71; P = .0027) and the presence of diabetes (OR, 2.35; 95% CI, 1.01-5.65; P = .0497). Notably, prophylaxis was administered to 12 cases with amphotericin B. Further investigations are needed to validate these findings and to evaluate the potential implementation of prophylactic regimens in SOTRs at high risk.

Exploring Prevalence Trends of Jaw Bone Pathologies: A Three-Year Institutional Study.

Background Head and neck bone pathologies cover various conditions with diverse causes. Infections like osteomyelitis and dental abscesses can spread to soft tissues and bones, causing tissue death, inflammation, and systemic effects. Benign and malignant tumors can develop from soft tissue, cartilage, or bone, posing challenges for diagnosis and treatment. Studies on their prevalence in local populations are rare, obscuring our understanding of regional health dynamics. Aim In this study, we aimed to assess the prevalence of bone pathologies documented over the last three years from 2021 to 2023. Materials and methods Histopathologically confirmed cases of bone pathologies at Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India, were gathered from the institutional database (DIAS: Dental Information Archiving Software) from January 1, 2021, to December 31, 2023. They were categorized into groups of infectious and inflammatory lesions, fibro-osseous lesions, malignancies originating from bone, malignancies invading bone, and miscellaneous conditions. The data was then compiled into a Google spreadsheet (Google, Inc., Mountain View, USA) for further analysis. Graphs were created to visualize the prevalence of bone pathologies enabling a descriptive exploration of temporal trends. Results A total of 2626 biopsy records were reviewed. Among these, 242 (9.21%) cases of bone-related pathologies were included, and the remaining 2384 (90.79%) entities without any mention of bone were excluded. Overall, considering all three years, 43.8% (100) bone-related lesions were reported in 2021, 30.3% (77) in 2022 and 25.9% (65) in the year 2023. Under each category, infectious and inflammatory lesions for 40.5% (98), fibro-osseous lesions for 14.9% (36), benign lesions for 2.9% (7), malignancies originating from bone for 1.7% (4), malignancies invading bone for 38% (93), and miscellaneous conditions for 1.65% (4) were reported. The highest number of infectious and inflammatory pathologies (53%) were reported in 2021. A steep fall was observed in 2022 and 2023 under the infectious and inflammatory category. The malignancies invading the bone showed almost similar distribution in all three years. Conclusion The observed variations highlight the unpredictability of bone pathologies, involving the jaw bones. We emphasize continuous observation and analysis to comprehend changing patterns in bone health.

Oral Isavuconazole Combined with Nebulized Inhalation and Bronchoscopic Administration of Amphotericin B for the Treatment of Pulmonary Mucormycosis: A Case Report and Literature Review.

Pulmonary mucormycosis (PM) is an invasive and potentially fatal fungal infection, with Rhizopus microsporus (R. microsporus) being the most common pathogen. The routine therapy for this infection includes surgery and antifungal agents. However, the therapeutic effects of single agents are unsatisfactory due to the rapid progression of mucormycosis, while not all patients can tolerate surgery. Innovative treatment methods like combination therapy await validations of their clinical efficacy. We report a case of PM that was diagnosed via metagenomics next-generation sequencing (mNGS) of black drainage fluid from the patient's lung. The patient eventually recovered and was discharged after a combination therapy of oral isavuconazole, inhaled amphotericin B, and local perfusion of amphotericin B through bronchoscopy, which may be a promising strategy for the treatment of PM, especially for cases where surgery is not possible. A retrospective study of 297 cases in a literature review highlights the different treatment methods used in clinical practice.

An interesting report of COVID-19 associated mucormycosis (CAM) cases by two different species of Mucorales.

During surge of COVID-19-associated mucormycosis (CAM), we identified five cases of CAM where two different species of Mucorales were isolated. All had history of diabetes mellitus and presented with clinical features suggesting rhino-orbital mucormycosis. The patients grew different species from their nasal scraping/biopsy samples, Rhizopus arrhizus, R. homothallicus (n = 2); R. homothallicus, Lictheimia corymbifera (n = 1); R. arrhizus, Mucor spp (n = 1); and L. corymbifera, Apophysomyces variabilis (n = 1). All patients underwent surgical and medical (liposomal amphotericin B) treatment. All, except one growing A. variabilis and L. corymbifera survived. Mixed infection by more than one Mucorales in CAM is unique and warrants epidemiological investigation.

Sinus fungal balls caused by Syncephalastrum spp.: 2 clinical cases and literature review.

INTRODUCTION: Syncephalastrum spp. is a mucoral that rarely produces pathology. Fungal balls caused by this genus are infrequent. It requires early diagnosis and treatment to avoid associated morbidity and mortality. METHODS: We describe two clinical cases of sinus fungus balls caused by Syncephalastrum spp. and review the literature. RESULTS: Two patients were treated for sinus fungus balls. When their samples were analysed, the aetiology was determined to be Syncephalastrum spp. A case of pulmonary fungus ball due to Syncephalastrum spp. is described in the literature. All cases, including these described in the present study, had a good evolution after treatment. CONCLUSIONS: Syncephalastrum spp. is a filamentous fungus that should be considered as an aetiology of sinus fungus ball.

[Fatal case of rhinocerebral mucormycosis on the background of type II diabetes mellitus]. / Letal'nyi sluchai rinotserebral'nogo mukormikoza na fone sakharnogo diabeta 2-go tipa.

Mucormycosis is a disease caused by fungi of the Mucorales family, widespread in the environment, with pronounced angiotropism and the ability to angioinvasion, leading to thrombosis with surrounding necrosis. The main triggers for the development of mucormycosis are: immunodeficiency states, use of glucocorticosteroid drugs, decompensation of diabetes mellitus, concomitant diseases, age > 65 years. We present a clinical case of rhinocerebral mucormycosis in a 79-year-old patient against the background of uncontrolled type 2 diabetes mellitus with ketoacidosis, a condition after previous glucocorticosteroid therapy for COVID-19 (according to the severity of the disease). After suffering a new coronavirus infection caused by the SARS-CoV-2 virus, she was admitted to the hospital with complaints characteristic of mucormycosis. On the 5th day of hospital stay, the patient's condition worsened significantly, despite the correction of the therapy, and on the 12th day the patient died. According to the results of the autopsy, it was established that the rhinocerebral mucormycosis was complicated by thrombosis of the anterior and posterior left cerebral arteries with subsequent infarctions in the frontal lobe and parieto-occipital region of the brain left hemisphere, cerebral edema, which was the immediate cause of death.