Features and evaluation of mucormycosis in COVID-19 patients from two referral hospitals in Iran.

OBJECTIVES: The present study aimed to assess the features, clinical characteristics, and species diversity among patients admitted to referral Hospitals for SARS-CoV-2 pneumonia and mucormycosis in Tehran, Iran, and the relationship between seasonal and species diversity was considered. METHODS: Confirmed COVID-19 patients with a positive reverse-transcriptase real-time (rRT-PCR) test for SARS-CoV2 were primarily included based on clinically suspected mucormycosis infection and confirmed by histopathology and mycology examination of biopsy specimens. The PCR technique was performed by the amplification of the high-affinity iron permease 1 (FTR1) gene for identification and discrimination between Rhizopus arrhizus and non- Rhizopus arrhizus isolates. In contrast, species identification of non-Rhizopus arrhizus was performed by sequencing of ITS rDNA region. RESULTS: Rhino-sino-orbital mucormycosis was identified in the majority of cases (n = 33), with 66 % and 34 % of the cases involving male and female patients, respectively. Rhizopus arrhizus was found to be the most prevalent (84.6 %), followed by Mucor circinelloides (7.6 %). Rhizopus arrhizus was the most prevalent species and present in all the seasons; however, Mucor circinelloides was only present in the autumn. The overall mortality of the total population was 24.6 % (16/ 65); the mortality rates occurring in patients diagnosed with rhino-sino-orbital infection and rhino-sinusal form were 21.4 % and 25 %, respectively. CONCLUSION: CAM can be a serious complication of severe COVID-19, especially in patients with uncontrolled diabetes. It is important to monitor the epidemiology of mucormycosis to raise awareness of the disease and improve diagnosis, treatment and prognosis, particularly in the setting of pandemic.

First report of chronic invasive fungal rhinosinusitis in a patient with ovarian cancer caused by Didymella pedeiae and successful treatment with voriconazole: A case report.

BACKGROUND AND PURPOSE: Didymella pedeiae is a dematiaceous fungus that belongs to the Coelomycetes class. While species within this class are known to cause human infection,  D. pedeiae had previously only been known as phytopathogens and had never been isolated from a human sample. CASE REPORT: A 51-year-old Iranian female patient with ovarian cancer was admitted with unilateral lesions in paranasal sinuses and a five-month history of nasal obstruction, headache, postnasal drainage, swelling on the left side of the face, and orbital pain. Paranasal sinus computerized tomography scan revealed a soft tissue mass that filled the left nasal cavity, ethmoid, sphenoid, and frontal sinuses with more involvement in the maxillary and ethmoid sinuses. Antifungal treatment was simultaneously initiated with itraconazole+prednisolone 15 mg/day, and levofloxacin. Due to poor clinical response, IV voriconazole and amphotericin B were added to the treatment as well. The patient recovered completely after 10 weeks of therapy. CONCLUSION: Here, we report the first case of human D. pedeiae infection in a patient with ovarian cancer.

Molecular identification and clinical features of fungal rhinosinusitis: A 3-year experience with 108 patients.

This study aimed to determine the prevalence, the causative agents, clinical features, and the risk factors associated with the fungal rhinosinusitis in a tertiary health center with a view to providing valid grounds that may guide healthcare professionals to effectively prevent, control, and treat fungal infections. All patients were subjected to diagnostic nasal endoscopy and CT scan of paranasal sinuses and FRS were confirmed by routine and complementary mycological and molecular methods. The inclusion criteria for invasive FRS were: confirmed diagnosis of IFRS according to the guidelines of the EORTC/MSG criteria (i.e., clinical, microbiological, and histological evidence of invasive fungal infection). From a total of 512 suspected patients, FRS was confirmed in 108 cases (21.1%). Our results showed FB (38/108; 35.2%) is the most common form of FRS followed by AIFRS (33/108; 30.6%), AFS (32/108; 29.6%), and CIFRS (5/108; 4.6%). A. flavus and Rhizopus oryzae were the most common causes of infection in AFS, FB, CIFRS, and AIFRS, respectively. Univariate analysis of variables predictive of AIFRS revealed 3 variables significantly associated with AIFRS. These included mucosal abnormalities of the middle turbinate and septum, and specifically, necrosis of the middle turbinate (P < .0001). Microbiological cultures, although useful for mycological speciation, are less sensitive. Furthermore, we used molecular methods to confirm the identity of some isolates that were not detectable using routine methods. Our data showed that the molecular methods and histologic diagnosis in all patients were more sensitive than the unenhanced sinus CT scan, and conventional microbiological methods.

The double-edged sword of systemic corticosteroid therapy in viral pneumonia: A case report and comparative review of influenza-associated mucormycosis versus COVID-19 associated mucormycosis.

Acute respiratory distress syndrome is a common complication of severe viral pneumonia, such as influenza and COVID-19, that requires critical care including ventilatory support, use of corticosteroids and other adjunctive therapies to arrest the attendant massive airways inflammation. Although recommended for the treatment of viral pneumonia, steroid therapy appears to be a double-edged sword, predisposing patients to secondary bacterial and invasive fungal infections (IFIs) whereby impacting morbidity and mortality. Mucormycosis is a fungal emergency with a highly aggressive tendency for contiguous spread, associated with a poor prognosis if not promptly diagnosed and managed. Classically, uncontrolled diabetes mellitus (DM) and other immunosuppressive conditions including corticosteroid therapy are known risk factors for mucormycosis. Upon the background lung pathology, immune dysfunction and corticosteroid therapy, patients with severe viral pneumonia are likely to develop IFIs like aspergillosis and mucormycosis. Notably, the combination of steroid therapy and DM can augment immunosuppression and hyperglycaemia, increasing the risk of mucormycosis in a susceptible individual. Here, we report a case of sinonasal mucormycosis in a 44-year-old woman with hyperglycaemia secondary to poorly controlled diabetes following dexamethasone therapy on a background of influenza pneumonia and review 15 available literatures on reported cases of influenza and COVID-19 associated mucormycosis.

The coronavirus disease 2019: the prevalence, prognosis, and recovery from olfactory dysfunction (OD).

BACKGROUND: Many patients with coronavirus disease 2019 (COVID-19) complain from olfactory dysfunction (OD). Aims/objectives: To evaluate the prevalence, prognosis, and recovery from OD in COVID-19 patients. MATERIAL AND METHODS: In this study, patients with COVID-19 symptoms who were referred to six different tertiary referral centres were recruited after positive results for COVID-19. All patients were assessed for a one-month follow-up after the initial diagnosis of COVID-19. RESULTS: Three hundred and eleven patients with COVID-19 were recruited in the present study. Two hundred and seven patients (66.6%) had a recent history of OD. One hundred and seventy-eight patients had experienced OD as a primary symptom intercurrent to other COVID-19 symptoms or solely. Sixty-nine patients had OD at the time of presentation to referral centres. Headache and nasal obstruction had significant relationships with recovery from OD in this subgroup, and the platelet count was the most important predictor for the recovery from OD. One hundred seventy-nine (86.4%) patients were nearly or fully recovered from OD approximately a month after the onset of OD. CONCLUSION: Headache, nasal obstruction, and platelet count may have specific roles as prognostic factors in the recovery from OD.

An effective technique for endoscopic resection of advanced stage angiofibroma.

INTRODUCTION: In recent years, the surgical management of angiofibroma has been greatly influenced by the use of endoscopic techniques. However, large tumors that extend into difficult anatomic sites present major challenges for management by either endoscopy or an open-surgery approach which needs new technique for the complete en block resection. MATERIALS AND METHODS: In a prospective observational study we developed an endoscopic transnasal technique for the resection of angiofibroma via pushing and pulling the mass with 1/100000 soaked adrenalin tampons. Thirty two patients were treated using this endoscopic technique over 7 years. The mean follow-up period was 36 months. The main outcomes measured were tumor staging, average blood loss, complications, length of hospitalization, and residual and/or recurrence rate of the tumor. RESULTS: According to the Radkowski staging, 23,5, and 4 patients were at stage IIC, IIIA, and IIIB, respectively. Twenty five patients were operated on exclusively via transnasal endoscopy while 7 patients were managed using endoscopy-assisted open-surgery techniques. Mean blood loss in patients was 1261± 893 cc. The recurrence rate was 21.88% (7 cases) at two years following surgery. Mean hospitalization time was 3.56 ± 0.6 days. CONCLUSION: Using this effective technique, endoscopic removal of more highly advanced angiofibroma is possible. Better visualization, less intraoperative blood loss, lower rates of complication and recurrence, and shorter hospitalization time are some of the advantages.

A case of fungus ball type pansinusitis caused by Schizophillum commune.

Schizophillum commune has been increasingly reported from allergic bronchopulmonary mycosis (ABPM) as well as fungus ball, brain abscess and several cases of maxillary or allergic fungal sinusitis. In the present study, we reported a case of fungus ball type pansinusitis from a 32-year-old woman in Iran. According to computed tomography (CT) scan, fungus ball type pan-sinusitis was likely to be the first diagnosis. Mycological examination revealed hyaline hyphae with small projection and also clamp connection structures on PDA medium. To identify the obtained isolate properly, molecular analysis of the internal transcribed spacer region was performed and indicated that the causing agent of the infection is surely Schizophillum commune. The patient completely recovered after surgical endoscopic operation and consequent post-operation MRI revealed clearance of sinuses.