Terveen ihmisen immuunovaste pärjäilee luonnon sieni- ja homeluokan mikrobeja vastaan. Kuitenkin Covidpandemian aikana on esim mukormykoosin määrä paikoitellen maailmassa kovasti noussut.
2.4. Vuonna 2022.
Immunokompetentin traumapotilaan mucormycoositulehdus hoidettu ja
ISA-terapiaa käytetty. Tapauskuvaus.
Successful
management of mucormycosis infection secondary to motor vehicle
accident in a healthy adolescent: A case report. Shah H, Chisena
E, Nguyen B, Tristram D, Bialowas C. Med Mycol Case Rep. 2022 Nov
2;38:36-40. doi: 10.1016/j.mmcr.2022.10.004. eCollection 2022 Dec.
PMID: 36393995 Free PMC article. Abstract Mucormycosis in healthy
adolescents is a rare etiology of infection that does not have a
commonly known protocol for management. This report describes an
adolescent male who developed soft tissue mucormycosis secondary to
a motor vehicle accident with severe lower extremity injuries.
Treatment involved topical amphotericin B washouts and beads, serial
aggressive debridement, and isavuconazole. To our knowledge, this is
one of few documented cases of successful lower extremity salvage in
an immunocompetent adolescent infected with mucormycosis and treated
with isavuconazole. Keywords: Immunocompetent;
Limb salvage; Motor vehicle accident; Mucormycosis; Wound.
2.5. Vuonna 2022 Post Covid-19
Rhinokerebraalinen mukormykoosi. Tapauskuvaus.
Post
COVID-19 rhinocerebral mucormycosis: a case report and literature
review. El Korbi A, Bhar S, Bergaoui E, Harrathi K, Koubaa J.
Pan Afr Med J. 2022 Jul 14;42:202. eCollection 2022. PMID: 36284570
Free PMC article. Review. See all "Cited by" articles
DOI: 10.11604/pamj.2022.42.202.33690
Ear, Nose, and Throat (ENT), Fattouma
Bourguiba Teaching Hospital, Monastir, Tunisia, Research Unit,
Quality and Security of Care, University of Monastir, Monastir,
Tunisia
Abstract.
The pandemic of coronavirus disease 2019 (COVID-19) still remains
on an upsurge trend. The second and the waves of this disease have
led to panic in many countries, and some parts of the world
suffering from the fourth wave. In the midst of this pandemic,
COVID-19 patients are acquiring secondary infections such as
mucormycosis also known as “black fungus disease”.
Mucormycosis is a serious, but rare opportunistic fungal
infection that spreads rapidly, and hence prompt diagnosis and
treatment are necessary to avoid mortality and morbidity rate. We
report in this paper, a case of a diabetic patient who presented
with bilateral nasal obstruction, anosmia, and frontal
headache diagnosed with rhinocerebral mucormycosis developing
after COVID-19 infection with a favorable outcome after a
medico-surgical treatment. Through this case, we aim to aware
patricians of this possible association and the importance of early
diagnosis to optimize treatment outcomes.
Introduction
Mucormycosis
is a rare life-threatening invasive fungal infection caused by mold
fungi of the genus which belong to the Mucorales order of the
zygomycetes class [1].
It was possibly first described by Friedrich Küchenmeister in 1855
[1].
The most common type was Rhizopus oryzae responsible for
approximately 60% of mucormycosis cases in humans; and 90% of the
rhinocerebral form [2].
Over this pandemic of coronavirus disease (COVID-19), we observed a
worldwide increasing mucormycosis in COVID-19 infected patients.
It is frequently observed in immunosuppressed patients, particularly
with diabetes, hematological malignancy, and immunosuppressive and
corticosteroid therapy. It is rarely seen in healthy individuals.
Here we report a case of rhinocerebral mucormycosis developed after
COVID-19 infection in a diabetic patient who presented with
bilateral nasal obstruction, anosmia, and frontal headache. Through
this case, we aim to aware patricians of this possible association
and the importance of early diagnosis to optimize treatment
outcomes.
Patient and observation. Patient information: a
62-year-old male patient with a history of type 2 diabetes,
hypertension and coronary artery disease was referred to our
department for persistent nasal obstruction and frontal headache.
Clinical findings: clinical exam found a frontal swelling
associated with edema of the upper right eyelid (Figure
1). Nasal endoscopy showed the presence of pus in the middle
meatuses and necrotic appearance of the middle turbinates (Figure
2).
Timeline of current episode: in fact, the patient
was hospitalized for COVID-19 infection the third of January 2021
then he was referred to an intensive care unit where he received a
high-flow oxygen for thirteen days combined with corticosteroid
therapy, then the patient was transferred to the pandemic ward and
discharged the 29th of January after a stay of 14 days.
The patient presented since leaving the hospital with bilateral
nasal obstruction, anosmia and frontal headaches. He consulted an
otolaryngologist doctor who referred the patient to our department
on the sixth of March 2021. Diagnostic assessment: biopsy of
the middle turbinate and microbiological sampling were performed,
with a presumed diagnosis of mucormycosis. Paranasal sinus computed
tomography (CT) revealed pansinusitis with frontal osteitis and bone
sequester surrounded by soft tissue edema (Figure
3).
A cerebral magnetic resonance imaging (MRI) showed a
frontal meningeal contrast enhancement without intracranial
collection. Diagnosis: the diagnosis of mucormycosis was
confirmed on histopathologic and direct microscopy examination of
the specimen that showed typical Mucorales hyphae. Whereas, culture
was not contributed in the specie identification.
Therapeutic
interventions: intravenous liposomal amphotericin B at the dose
of 5 mg/kg/day was started early and debridement of the infection
site was done. The antifungal treatment was extended for two months.
Follow-up and outcome of interventions: during the
hospitalization, the patient refused to take treatment for three
days explained to side effects such as hypokalemia and vomiting that
were corrected by an intravenous supplementation, and the antifungal
was reintroduced. After one month, an improvement of nasal symptoms
and headache with the regression of the frontal swelling were
observed. However, the post-therapeutic MRI showed stability of the
radiological findings. The patient was discharged after a clinical
improvement. After a follow-up of seven months, we noted the
persistence of the frontal swelling without any other sign. Nasal
endoscopy did not show any sign of mucosa necrosis.
Patient
perspective: globally, despite the problem of antifungals
intolerance, the patient showed satisfaction with his pathology´s
care, and he adhered perfectly to the follow-up. Informed
consent: written informed consent was obtained from the patient
for publication of this case report. A copy of the written consent
is available for review.
Discussion: Two thousand twenty
(2020) is a memorable, devastating year for global health, as an
uncommon virus raced worldwide, emerging rapidly. It is one of the
top killers, laying bare the inadequacies of the health systems.
Today, worldwide health services are struggling to tackle COVID-19
and provide people with vital care. As the global COVID-19 pandemic
enters the third year, countries around the world are racing to
vaccinate their populations as novel variants emerge.
In the midst
of this pandemic; the COVID-19 patients are acquiring secondary
infections such as mucormycosis also known as “black
fungus disease” [1].
Habitually, mucormycosis is a rare, opportunistic life-threatening
fungal disease. However, with COVID-19 infection, we have seen an
explosion of cases. In fact, in March 2021, only 41 cases of
mucormycosis associated with COVID-19 infection have been reported
worldwide and 70% were from India [1],
contrasting with more than 47,000 cases reported in India from
May to July 2021 [3].
Rhino-orbital and rhino-orbito-cerebral forms were the most common
presentations. Patel et al. [4],
reports in their multicenter epidemiologic study a predominance of
rhino-orbital mucormycosis associated with COVID-19 with 62.6% of
cases followed by rhino-orbito-cerebral (ROC) in 23.5% and
pulmonary form in 8.6% [3].
The main mode of transmission of mucormycosis is the inhalation
of spores, ingestion of contaminated food and
inoculation of the fungi into abrasions or cuts on the skin
[1].
In healthy people, mononuclear and polymorphonuclear phagocytes
eliminate fungal spores and hyphae [5],
which is not the case of immunocompromised patients. A recent
meta-analysis of 600 publications reported as major risk factors of
mucormycosis: diabetes mellitus, trauma, hematological
malignancies, diabetic ketoacidosis, neutropenia and prolonged
corticosteroid therapy [6].
In the particular context of COVID-19 in infected patients, we
observed an immune dysregulation with reduced numbers of T
lymphocytes, CD4+T, and CD8+T cells that compromise innate immunity
and enhance the risk of invasive fungal occurrence [7].
This risk is majored by the use of corticosteroid medications that
magnify the effect of hyperglycemia in an eventual
preexisting diabetic, and mechanical ventilation that contribute
to inhalation of spores in immunocompromised individuals [1,8].
Moreover, cytokines released during COVID-19 increases intracellular
iron and leakage of iron into the circulation, leading to
high ferritin levels that permit the growth of Mucorales
[3
In our case, diabetes and corticosteroids firstly
prescribed to manage the COVID-19 pulmonary disease were the risk
factors of mucormycosis coinfection. Clinical manifestations depend
on the extension of a disease. The symptoms of rhino-orbital
mucormycosis are similar to complicated rhinosinusitis with nasal
obstruction, headache, facial pain, bloody nasal discharge, swelling
of periorbital tissues, orbital cellulitis, chemosis, proptosis,
blurry vision, and local eschar that is explained by a propensity of
blood vessels invasion by Mucorales leading to thrombosis, ischemia
and tissue necrosis [9-11].
Intracranial involvement may manifests neurological signs or altered
mental status [9].
Mucormycosis is usually suspected based on results of direct
microscopy of clinical specimens and confirmed the diagnosis on
histological features when showing tissue invasion by non-pigmented
hyphae in tissue sections stained with haematoxylin-eosin [12].
Culture are recommended for genus and species identification, not
for diagnosis [12].
In the study of Patel et al. [4],
mucormycosis diagnosis was made by direct microscopy in 82.6%
of patients and histopathology in 90.5%. Culture identified
the etiologic pathogen in 4<8.1% of cases [4].
In our case, the diagnosis was made on microscopy and histopathology
constitutions, however the culture was not able to identify the
specie of the Mucorales. Refer to the 2019 global guidelines for the
diagnosis and treatment of mucormycosis published by the European
Confederation of Medical Mycology in cooperation with the Mycoses
Study Group Education and research Consortium, the treatment of
mucormycosis is based on early and complete surgical debridement of
the infected area associated with a systemic antifungal drugs [12].
Mucorales are resistant to many antifungal agents. The most active
ones are liposomal amphotericin B (LAB) and triazoles (isavuconazole
and posaconazole), thus they are considered as first-line therapy in
mucomycosis [5].
The recommended dose of LAB is 5 mg/kg per day in cases of
non-central nervous system involvement [12].
Otherwise, a prescription of high dose of LAB at 10 mg/kg/day could
be supported in cases of intracranial invasion [12].
Triazoles are reported to be more frequently used in patients with
COVID-19 associated mucormycosis than those with isolated
mucormycosis [4].
The duration of treatment with active antifungal agents has not been
determined, in general weeks to months of therapy are given [12,13].
The mortality rate of mucormycosis is about 50% [1].
In their study, comparing mucormycosis associated with COVID-19 to
isolated mucormycosis, Patel et al. p2 found similar
mortality rates in both groups. In our case, we observed favorable
outcomes after a follow-up of seven months. Conclusion Through
our case, we highlight the possibility of invasive secondary fungal
infections in patients with COVID-19 infection. Physicians should be
aware of early symptoms of mucormycosis to enable prompt diagnosis
and adequate treatment to avoid as possible as can bad outcomes.
MeSH terms Antifungal Agents / therapeutic use; Combined Modality
Therapy ; Debridement / methods ; Humans ; Lung Diseases, Fungal /
diagnosis* ; Lung Diseases, Fungal / therapy* ; Mucorales ;
Mucormycosis / diagnosis* ; Mucormycosis / therapy* ; Practice
Guidelines as Topic ; Randomized Controlled Trials as Topic ; Stem
Cell Transplantation / adverse effects ; Substances : Antifungal
Agents
Muistiin invasiivisista home- ja sieni infektioista Fokus
lähinnä invasiivisessa mukomykoosissa (IM).
Lisäys 26.7. 2025. Vuonna 2024 Ruotsin Lääkärilehti kuvasi teerveeltä traumapotilaalta Saksenaea- homesienen aiheuttamaan invasiivisen tulehduksen. Kts kirjoitukseni 26.7. 2025. MUCORALES , Mucormysis , Saksanea vasiformis.
