Primary cutaneous mucormycosis of the lower extremity in a male patient with diabetes.

INTRODUCTION: Mucormycosis is a rare but serious angioinvasive fungal infection that can affect the cutaneous system. Primary cutaneous mucormycosis is caused by direct inoculation and is most prevalent in immunocompromised hosts, particularly those with diabetes. A high index of suspicion is necessary for this condition in patients with rapid and deep extension of necrosis despite aggressive surgical intervention. Deep tissue specimens should be sent for fungal culture and histologic analysis for confirmation of the diagnosis. Early and aggressive debridement to prevent spread to deeper tissues and organs, concurrent antifungal therapy, and medical management of comorbidities are paramount to the treatment of primary cutaneous mucormycosis. CASE REPORT: This case report highlights the presentation and recommended treatment of primary cutaneous mucormycosis in 1 patient for reduced morbidity and mortality associated with this type of infection.

Saksenaea mucormycosis: a rare and dangerous cause of necrotising fasciitis.

Necrotising fasciitis is a rapidly progressing soft tissue infection requiring early and adequate surgical debridement and appropriate antibiotic cover. The present case highlights bacterial fasciitis associated with fungal (Mucor) infection with insidious angioinvasive nature (Saksenaea vasiformis) which required amputation, negative-pressure vacuum dressings and amphotericin B for definitive treatment. This demonstrates a relatively rare case of the group IV classification of necrotising fasciitis, which we must consider when there is slowly progressing tissue death despite seemingly adequate treatment.

Multiple maxillary periodontal abscesses as a manifestation of post-coronavirus disease 2019 mucormycosis: a case report.

BACKGROUND: Coronavirus disease 2019 makes patients more susceptible to superinfection of fungal disease as a consequence of immunological system impairment. Mucormycosis is a fungal infection that is rare but has a high mortality rate and mostly affects patients with poorly controlled diabetes mellitus or those receiving corticosteroids. CASE PRESENTATION: Here, we present a case of post-coronavirus disease 2019 mucormycosis in a 37-year-old Persian male presenting with multiple periodontal abscess with purulent discharge and necrosis of maxillary bone (without oroantral communication). Surgical debridement following antifungal therapy was the treatment of choice. CONCLUSION: Early diagnosis and immediate referral are the cornerstone of comprehensive treatment.

Disseminated Mucormycosis from Marijuana Use in a Renal Transplant Patient.

Mucormycosis is a serious fungal infection that typically affects immunocompromised patients. We present a case of disseminated mucormycosis infection in a 34-year-old male with a history of marijuana use and focal segmental glomerulosclerosis who underwent living unrelated kidney transplant. After his transplant, he developed recurrent focal segmental glomerulosclerosis. Two months later, he developed pleuritic chest pain and imaging revealed a ground glass opacity with a surrounding dense consolidation within the right upper lobe, concerning for an angioinvasive fungal infection. During the hospitalization, his creatinine increased, and a biopsy of the allograft kidney demonstrated acute tubulointerstitial nephritis, acute vasculitis, and glomerular intracapillary fibrin thrombi with angioinvasive Mucorales fungal infection. The patient subsequently underwent transplant nephrectomy. Grossly, the allograft was pale white to dusky tan-red with poorly delineated cortical medullary junctions. Microscopic examination revealed necrotic tubules with a dense neutrophilic infiltrate, multinucleated giant cells, and ribbon-like, aseptate hyphae. A Gomori's methenamine silver stain highlighted the fungal elements, which were morphologically consistent with Mucorales. Review of the literature revealed that the incidence of mucormycosis within the first year is low at approximately 0.07% for renal transplant patients with an estimated overall mortality of 40-50%. Additionally, few case reports have been published demonstrating marijuana use as a cause of pulmonary mucormycosis or even disseminated disease. The purpose of our case report is to add knowledge to the presenting symptoms and investigate the association of marijuana use with pulmonary and disseminated mucormycosis.

Rhino-orbital mucormycosis in a Mexican patient with COVID-19: Case report.

BACKGROUND: A variety of bacterial and fungal co-infections may be attributed to the coronavirus disease 2019 (COVID-19), particularly in people who already have a medical condition such diabetes mellitus or those who received large dosages of steroids. CASE REPORT: We described a 52-year-old diabetic man who was receiving high doses of dexamethasone and antibiotics while receiving ambulatory care for COVID-19 pneumonia. His anterior rhinoscopy revealed a necrotic scab, and a sample confirmed Mucor spp. He underwent surgery and was given amphotericin as a result of the severity of the condition, palpebral ptosis, and right ocular palsy he was experiencing. The patien ́s progression was satisfactory. CONCLUSIONS: pre-existing diabetes mellitus, previous steroid and antimicrobial use, as well as SARS-CoV-2 infection are some of the risk factors associated with Mucor spp. infection. Prompt detection of mucormycosis is important in the management of these affected patients.

ANTECEDENTES: A la enfermedad por coronavirus (COVID-19) se le han atribuido diversas coinfecciones bacterianas y fúngicas, especialmente en sujetos con enfermedades preexistentes (diabetes mellitus) o en quienes han recibido altas dosis de corticosteroides. REPORTE DE CASO: Paciente masculino de 52 años, con antecedente de diabetes mellitus, quien recibió altas dosis de dexametasona y antibióticos mientras recibía atención ambulatoria por neumonía secundaria a COVID-19. La rinoscopia anterior reveló una costra necrótica, y una muestra de exudado confirmó la coexistencia de Mucor spp. Debido a la complicación del cuadro clínico, ptosis palpebral y parálisis ocular derecha, se le administró anfotericina B y fue intervenido quirúrgicamente. La evolución del paciente fue satisfactoria. CONCLUSIONES: La diabetes mellitus preexistente, el consumo de corticosteroides y antimicrobianos, además de la infección por SARS-CoV-2 son factores de riesgo asociados con la infección por Mucor spp. Es importante la detección oportuna de mucormicosis en el tratamiento de estos pacientes.

An autopsy case of disseminated Cunninghamella bertholletiae infection in an immunocompetent patient: a case report.

BACKGROUND: Recently, deaths due to mucormycosis in immunocompromised hosts have increased; however, the clinical and pathological features of mucormycosis are not fully understood, especially in view of the associated high mortality and rare incidence in immunocompetent patients. CASE PRESENTATION: We have described a rare autopsy case of a 67-year-old Japanese man with chronic obstructive pulmonary disease who contracted mucormycosis. He had not been on any immunosuppressants, and his immune functions were intact. Since 3 days prior to admission to our hospital, he had experienced progressive dyspnea, productive cough, and fever. Chest computed tomography revealed pleural effusion in the left lower hemithorax and consolidation in the right lung field. Although he was administered with tazobactam-piperacillin hydrate (13.5 g/day), renal dysfunction occurred on the ninth disease day. Therefore, it was switched to cefepime (2 g/day). However, his general condition and lung-field abnormality worsened gradually. Cytological analysis of the sputum sample at admission mainly revealed sporangiophores and unicellular sporangioles, while repeated sputum culture yielded Cunninghamella species. Therefore, he was diagnosed with pulmonary mucormycosis. Liposomal amphotericin B (5 mg/kg/day) was initiated on the 28th disease day. However, chest radiography and electrocardiography detected cardiomegaly and atrial fibrillation, respectively, and he died on the 37th disease day. A postmortem examination revealed clusters of fungal hyphae within the arteries of the right pulmonary cavity wall, the subpericardial artery, intramyocardial capillary blood vessels, and the esophageal subserosa vein. Direct sequencing revealed that all fungal culture samples were positive for Cunninghamella bertholletiae. CONCLUSIONS: Cunninghamella bertholletiae could rapidly progress from colonizing the bronchi to infecting the surrounding organs via vascular invasion even in immunocompetent patients.

Isolated renal mucormycosis masquerading as emphysematous pyelonephritis.

Mucormycosis is an acute, life-threatening infection and isolated renal involvement is rare. Due to the angioinvasive nature of the disease, it is rapidly progressive and can be lethal if not managed expeditiously. In patients with underlying conditions of immunosuppression, diabetes mellitus, transplantation, COVID-19, intravenous drug and substance use and pyelonephritis, which is unable to be controlled via regular antibiotics, mucormycosis must be considered on the differential and antifungals must be empirically started. Most cases are often diagnosed on histopathology, which causes delayed treatment and resolution. We present a case of emphysematous pyelonephritis diagnosed on imaging and was later found to have mucormycosis on histopathological examination.

Detection and identification of Mucorales and Aspergillus in paraffin-embedded samples by real-time quantitative PCR.

Background: In this study, we used real-time quantitative PCR (RQ-PCR) to rapidly detect Mucorales and Aspergillus in formalin-fixed, paraffin-embedded (FFPE) samples, targeting 18SrRNA gene and 28SrRNA gene. Identification of Mucorales and Aspergillus was analysed by combining Mucorales RQ-PCR (Mucorales18SrRNA and Mucorales28SrRNA) with Aspergillus RQ-PCR (Aspergillus18SrRNA and Aspergillus28SrRNA). Objectives: The aims of this study were to compare the diagnostic performances of four RQ-PCR assays as single and combined diagnostic and identification tools. Methods: We collected 12 control group samples and 81 experimental group samples diagnosed by histopathology, including mucormycosis (19 patients, 21 FFPE samples), aspergillosis (54 patients, 57 FFPE samples) and mucormycosis with aspergillosis (3 patients, 3 FFPE samples). All samples were detected by four RQ-PCR tests to compare and analyze diagnostic performance. Results: The sensitivities of Mucorales18SrRNA and Mucorales28SrRNA were both 75%, with the tests having specificities of 97.10% and 94.20%. The sensitivities of Aspergillus18SrRNA and Aspergillus28SrRNA were 73.33% and 65%, with the tests having specificities of 87.88% and 81.82%. The values of the evaluation indexes of the combined detection of Mucorales28SrRNA and Aspergillus18SrRNA (M28A18) were the highest with a kappa coefficient value of 0.353, followed by M18A18. M28A18 had a sensitivity of 67.90% and a specificity of 100%. Conclusions: We recommend using the combination of Mucorales RQ-PCR and Aspergillus RQ-PCR as a screening tool to detect samples suspected of mucormycosis and/or aspergillosis.

Mucormycosis as Post Coronavirus Disease Complication.

Mucormycosis is called as black fungus, which is caused by fungus belonged to Mucorales. If this fungus, effects healthy individuals it won't cause any serious complications, but it may cause life-threatening issues when Mucorales affects individuals who have low immunity. The mortality rate of black fungus is more than 50%, and it may also range till 100% if the individual is having any preexisting or chronic disease. This was the case of a 55-year-old male patient complaint of having generalized pain in the maxillary teeth bilaterally and suffering fullness in the maxillary sinus. To check on other possible diseases, doctors have conducted other diagnosis tests, and orthopantomogram revealed in the diagnosis that there was the presence of haziness in the left maxillary sinus, which looked like an incompletely formed soap bubble and additionally he diagnosed with coronavirus disease positive. Then, doctors suggested a chest computerized tomography (CT) along with head CT excluding the brain and further investigation of this case was given below in detail. The report reveals acute necrotizing suppurative sinusitis with dead bony tissue, soft-tissue necrosis with fungal infestation showing broad hyphae with right-angle branching suggestive of mucormycosis.

Mucormycosis of the Middle Ear and Neck Post COVID 19.

Mucormycosis is an opportunistic infection caused by fungi of order Mucorales and affect immunosuppressed patients. The cases of mucormycosis have surged during the COVID pandemic, especially in cases requiring steroids and mechanical ventilation. Here we present a case of a 40-year-old diabetic post COVID female patient. She presented with right earache, right facial paralysis (grade four) of two weeks duration and right sided neck swelling for ten days. Ultrasonography and computed tomography revealed multiple abscesses in the right side of the neck. Histopathological examination of tissue from the neck and middle ear confirmed the diagnosis of mucormycosis. This is a rare case of concurrent neck and middle ear mucormycosis in a post COVID patient. Keywords: Coronavirus; COVID 19; middle ear; mucormycosis; neck.

Mucormycosis in a Patient with Severe COVID-19 Disease-The First Case Report in Romania and a Literature Review.

INTRODUCTION: COVID-19 infection is often associated with a vast spectrum of opportunistic bacterial and fungal infections. Herein, we share a summary of the first case of COVID-19-associated mucormycosis (CAM) in a patient from Romania. CASE PRESENTATION: A 51-year-old male non-smoker, with no known relevant medical history, who denied any previous alcohol use and was vaccinated against COVID-19 (complete scheme with Vaxzevria), was admitted to the hospital for severe COVID-19 infection. The first mucormycosis-related symptoms were reported on the eighth day of admission and were followed by the rapid deterioration of the patient's condition and, consequently, death. The main aggravating factors, which were identified to be associated with the development of mucormycosis and with the poor outcome, were the association of severe COVID-19, new-onset COVID-19-triggered type 2 diabetes, and corticoid treatment for severe COVID-19. CONCLUSION: The association between severe COVID-19 and newly diagnosed type 2 diabetes, triggered by COVID-19 infection, increases the risk of severe opportunistic fungal infections and the associated mortality rates.

Mucor infection associated with global COVID-19 pandemic - an institutional histopathological study

Background: Coronavirus disease 2019 (COVID-19) in the recent times have instilled signs of immunosuppression globally which has further precipitated increasing range of opportunistic infections. Mucormycosis is a distressing opportunistic fungal infection with a high incidence and is the third commonest acute invasive infection following candidiasis and aspergillosis. The aim of the present observational study is to delineate the enigmatic histopathological profile between mucormycosis cases seen prior to pandemic (PPM) and pandemic associated mucormycosis (PAM). Material and methods: Tissue archives of 105 histopathologically diagnosed cases of mucormycosis were included and analysed for demographical details and histopathological parameters like fungal load and localization, granuloma formation, necrosis, inflammatory infiltrate and tissue invasion. Results: 0ut of 105 included cases, 11/105 (10.48%) were reported PPM and 94/105 (89.52%) PAM. Among 94 cases of PAM, 51/94 (54%) cases also showed COVID-19 positivity, while 43/94 (46%) did not. Of all the histological variables, increased fungal load and necrosis were observed in PAM relative to PPM cases. Conclusions: The histopathological variables like fungal load, necrosis, granuloma formation and tissue invasion, could help the clinician in assessing the clinical status at the time of tissue diagnosis and improve the treatment accordingly. (AU)

Mucormycosis infection associated with global COVID-19 pandemic - an institutional histopathological study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) in the recent times have instilled signs of immunosuppression globally which has further precipitated increasing range of opportunistic infections. Mucormycosis is a distressing opportunistic fungal infection with a high incidence and is the third commonest acute invasive infection following candidiasis and aspergillosis. The aim of the present observational study is to delineate the enigmatic histopathological profile between mucormycosis cases seen prior to pandemic (PPM) and pandemic associated mucormycosis (PAM). MATERIAL AND METHODS: Tissue archives of 105 histopathologically diagnosed cases of mucormycosis were included and analysed for demographical details and histopathological parameters like fungal load and localization, granuloma formation, necrosis, inflammatory infiltrate and tissue invasion. RESULTS: 0ut of 105 included cases, 11/105 (10.48%) were reported PPM and 94/105 (89.52%) PAM. Among 94 cases of PAM, 51/94 (54%) cases also showed COVID-19 positivity, while 43/94 (46%) did not. Of all the histological variables, increased fungal load and necrosis were observed in PAM relative to PPM cases. CONCLUSIONS: The histopathological variables like fungal load, necrosis, granuloma formation and tissue invasion, could help the clinician in assessing the clinical status at the time of tissue diagnosis and improve the treatment accordingly.

Comparative Evaluation of COVID-19 Associated Mucormycosis (CAM) and Non-COVID-19-associated Mucormycosis (non-CAM).

OBJECTIVE: To compare COVID-19 associated mucormycosis cases (CAM) with non-COVID-19 associated mucormycosis (non-CAM) cases followed as in-patients. STUDY DESIGN: Observational Study. PLACE AND DURATION OF STUDY: Department of Infectious Diseases and Clinical Microbiology, Adana City Training and Research Hospital, Health Sciences University (HSU), Adana, Turkey, between January 2018 and March 2022. METHODOLOGY: Patients with a diagnosis of mucormycosis (proven and probable) were dichotomised as COVID-19 associated mucormycosis and non-COVID-19 associated mucormycosis cases. Both groups were compared for underlying malignancy, chemotherapy, antifungal therapy related side effects and overall survival. RESULTS: Of the 35 cases enrolled in the study, 17 (48.6%) had CAM and 18 (51.4%) had non-CAM. A statistically significant difference was detected between non-CAM and CAM cases in terms of haematological malignancy, receiving chemotherapy, and antifungal therapy-related side effects (p=0.019, p=0.019, and p=0.027 respectively). Steroid use was found as a risk factor for the diabetic CAM cases (p<0.0001). The difference between the CAM and non-CAM cases in terms of overall survival was not statistically significant (p=0.088). CONCLUSION: Because of the ongoing COVID-19 pandemic and the increasing number of critical patients, treatment of COVID-19 should be performed cautiously in patients who have the risk of developing CAM, particularly those with diabetes and immunosuppression (haematologic malignancy, receiving steroid or chemotherapy, etc.) and these patients should be monitored closely. KEY WORDS: Mucormycosis, COVID-19, Mucormycosis associated with COVID-19, Diabetes mellitus, Turkey.

A retrospective analysis for the management of oromaxillofacial invasive mucormycosis and systematic literature review.

PURPOSE: Mucormycosis is a type of fatal infectious disease, rarely involved in the oromaxillofacial region. This study aimed to describe a series of 7 cases with oromaxillofacial mucormycosis and to discuss the epidemiology, clinical features, and treatment algorithm thereof. METHODOLOGY: Seven patients in the author's affiliation have been treated. They were assessed and presented as per their diagnostic criteria, surgical approach, and mortality rates. Reported cases of mucormycosis originally happened in craniomaxillofacial region were synthesized through a systematic review so as to better discuss its pathogenesis, epidemiology, and management. RESULTS: Six patients had a primary metabolic disorder, and one immunocompromised patient had a history of aplastic anemia. The criteria for a positive diagnosis of invasive mucormycosis were based on clinical presentation of signs and symptoms, and a biopsy for microbiological culture and histopathologic analysis. Each patient used antifungal drugs and five of them also underwent surgical resection at the same time. Four patients died due to the unregulated spread of mucormycosis, and one patient died owing to her main disease. CONCLUSIONS: Although uncommon in clinical practice setting, mucormycosis should be of great concern in oral and maxillofacial surgery, due to the life-threatening possibility of this disease. The knowledge of early diagnosis and prompt treatment is of utmost importance for saving lives.

Increase in mucormycosis hospitalizations in southeastern Brazil during the COVID-19 pandemic: a 2010-2021 time series.

BACKGROUND: Mucormycosis is a severe invasive fungal disease. During the coronavirus disease 2019 (COVID-19) pandemic, outbreaks have been reported worldwide, but epidemiological studies are still scarce in Brazil. METHODS: We conducted a time-series cohort hospitalization study (2010-2021) in southeastern Brazil. RESULTS: There were 311 cases (85 during the pandemic), with significant (P < 0.05) involvement of patients older than 40 years (84%), white patients (78%), rhinocerebral site (63%), and São Paulo State residents (84%). CONCLUSIONS: Mucormycosis hospitalizations were highly prevalent. Further studies are needed to assess the burden of COVID-19 on mucormycosis in Brazil.

Long-term outcomes of transcutaneous retrobulbar amphotericin B in COVID-19-associated mucormycosis.

Purpose: To describe the long-term outcomes of transcutaneous retrobulbar amphotericin B (TRAMB) in COVID-19-associated mucormycosis. Methods: In total, 18 cases of COVID-19-associated mucormycosis were reviewed. In addition to the recommended treatment protocol, all patients were to be given 3.5 mg/ml/day of TRAMB for five days. Results: Of the 18 patients, 2 presented with stage 3a disease, 13 had stage 3c disease, and 3 patients had central nervous system (CNS) involvement (stage 4a and 4c). In addition to planned retrobulbar doses, five patients were given more while two patients received fewer injections (i.e., <5). At the last mean follow-up of 34.67 (±8.88) weeks, 11 patients were in radiological regression and 4 had stable disease while 2 patients had to undergo exenteration; one mortality was observed because of disease progression. Clinical regression in terms of visual and ptosis improvement was seen in seven and nine patients, respectively. Conclusion: Rhino-orbito-cerebral mucormycosis is a serious condition which warrants an aggressive treatment strategy. In unprecedented situations witnessed recently, TRAMB turned out to be an effective and economical alternative. Though large randomized studies are needed to establish its efficacy, TRAMB still manages to halt progression and salvage the globe in significant number of patients, and hence its use should be encouraged on a case-to-case basis especially in developing countries with limited resources.

Disseminated Cunninghamella elegans Infection Diagnosed by mNGS During Induction Therapy in a Child With Intermediate-risk Acute Lymphoblastic Leukemia: A Case Report and Review of Literature.

We described a 14-year-old girl with acute lymphoblastic leukemia who developed disseminated mucormycosis during induction therapy. Disseminated Cunninghamella elegans infection was confirmed by histopathology, microbiological culture, and metagenomic next-generation sequencing analysis of skin tissue, blood, and cerebrospinal fluid. Subsequently, the patient received a combination of liposomal amphotericin B, posaconazole, and caspofungin for antifungal treatment, but eventually died because of severe fungal pneumonia, respiratory failure, and septic shock. Moreover, case reports of pulmonary mucormycosis in children published since 1959 were reviewed. In summary, metagenomic next-generation sequencing is an effective diagnostic method for Cunninghamella with high speed and sensitivity.