Mucormycosis in Mato Grosso, Brazil: A Case Reports, Caused by Rhizopus microsporus var. oligosporus and Rhizopus microsporus var. rhizopodiformis

We identified the etiological agents responsible for two fatal cases of rhinocerebral mucormycosis with the classical risk factor for uncontrolled type II diabetes mellitus. Their initial symptoms did not point immediately to the suspicion of mucormycosis. Case 1, caused by Rhizopus microsporus var. oligosporus, was a 52-year-old man who presented with a painful pimple on his nose, which evolved with swelling, erythema, and a central pustule on his right hemiface suspected to be cellulitis. After 7 days of antibiotic treatment, the patient worsened with signs of sepsis and the lesion evolved to necrosis involving all his right face. Case 2, caused by Rhizopus microsporus var. rhizopodiformis, was a 57-year-old woman placed on continuous therapy with azathioprine and corticoids after a renal transplant due to chronic arterial hypertension and uncontrolled type II diabetes mellitus. Because she was suspected to have sepsis, the patient was treated with broad-spectrum antibiotics and mechanical ventilation, yet she deteriorated. Because Candida spp. were isolated from urine and a BAL, she was treated with fluconazole for 10 days, then substituted by caspofungin. Two weeks later, she presented with exophthalmus of the left eye that was surrounded by a large inflammatory and necrotic area. Both patients were the diagnosed with mucormycosis via direct microscopy of necrotic material prior to their death.     

Successful posaconazole salvage therapy for rhinocerebral mucormycosis in a child with leukemia. Review of the literature

BackgroundMucormycosis is a fungal infection caused by species of the Mucorales order. These microorganisms are angioinvasive, with rapid disease progression and potentially lethal in its rhinocerebral form.Case reportWe present the case of a 12-year-old female with trisomy 21, acute lymphoblastic leukemia and diabetes, with fever and neutropenia who developed rhinocerebral mucormicosis. After treatment with amphotericin B lipid complex and extensive surgery, disease progressed and posaconazole was added as salvage treatment with full remission of the infection. Four years after diagnosis the patient continues without relapse of mucormycosis or leukemia.ConclusionsThis case highlights the use of posaconazole as either monotherapy or combined therapy. Although it is still debated, it can be considered an option for salvage treatment in children with non-responding mucormycosis, despite lack of standard dosage in pediatric patients.     

Bronchopulmonary infection due to Branhamella catarrhalis.

Over six months Branhamella catarrhalis was isolated in pure culture from the sputum of 81 patients with symptoms of acute respiratory tract infection. Of 38 patients who were infected in the community, over half required admission to hospital. The remaining 43 patients acquired the infection in hospital. Forty one of the 81 isolates produced beta-lactamase, 24 of these being hospital acquired infections. As a result 40% of patients who were treated with ampicillin did not respond. Most patients had chronic lung diseases or lung cancer or were taking corticosteroids. Three patients died and one required assisted ventilation; strains producing beta-lactamase were isolated in each case. Acute bronchitis developed in one previously healthy young non-smoker. It is concluded that B catarrhalis is an important pathogen of the lower respiratory tract which should be reported, and strains producing beta-lactamase should be identified. Otherwise, treatment with inappropriate antibiotics may result in increased morbidity or mortality.     

伊曲康唑注射剂治疗伴有肺结核史的侵袭性真菌感染2例

目的报道2例伴有肺结核史的侵袭性真菌感染经伊曲康唑注射剂治疗经过,探讨伴有肺结核史患者的抗真菌治疗经验。方法例1为49岁＂支气管肺囊肿合并感染,陈旧性肺结核＂男性患者,诊断为侵袭性肺曲霉感染确诊病例。例2为51岁＂右侧自发性气胸,慢性阻塞性肺病,陈旧性肺结核＂男性患者,诊断为侵袭性肺念珠菌感染拟诊病例。均予伊曲康唑注射剂治疗2周结合抗细菌治疗,并作临床和真菌学疗效监测。结果治疗两周后两患者临床症状和体征均得到明显改善,标本真菌镜检转阴,培养仍为阳性。结论在有肺结核病史存在的侵袭性真菌感染抗真菌治疗时间可能需要延长。合理应用抗生素、激素,严格掌握用药指针、时机、剂量与疗程是控制真菌感染的重要因素。     

嗜麦芽窄食单胞菌感染危险因素与其耐药特征的研究

目的　研究嗜麦芽窄食单胞菌感染危险因素及其耐药特征,以提高临床对嗜麦芽窄食单胞菌防治水平。方法　对6 8例嗜麦芽窄食单胞菌感染者的临床资料进行统计分析,并用K- B法测其耐药情况。结果　嗜麦芽窄食单胞菌占非发酵革兰阴性杆菌的9.5 2 % ,居铜绿假单胞菌与不动杆菌之后,列第3位。药敏试验表明,该菌广泛耐药,敏感率>5 0 %者仅有复方新诺明、替卡西林-克拉维酸与头孢哌酮-舒巴坦,在感染者中,有85 .3%患者有基础病,98.5 %使用过广谱抗生素,70 .6 %曾接受侵入性检查和治疗。结论　嗜麦芽窄食单胞菌已成为医院感染重要致病菌,多发生在免疫功能低下的老人,慢性疾病、长期疾病、长期接受激素及使用抗菌药物、施行各种侵入性检查和治疗的患者。嗜麦芽窄食单胞菌对多种抗生素耐药,一旦感染,治疗颇为困难     

Coronavirus Disease (Covid-19) Associated Mucormycosis (CAM): Case Report and Systematic Review of Literature

Severe coronavirus disease (COVID-19) is currently managed with systemic glucocorticoids. Opportunistic fungal infections are of concern in such patients. While COVID-19 associated pulmonary aspergillosis is increasingly recognized, mucormycosis is rare. We describe a case of probable pulmonary mucormycosis in a 55-year-old man with diabetes, end-stage kidney disease, and COVID-19. The index case was diagnosed with pulmonary mucormycosis 21 days following admission for severe COVID-19. He received 5 g of liposomal amphotericin B and was discharged after 54 days from the hospital. We also performed a systematic review of the literature and identified seven additional cases of COVID-19 associated mucormycosis (CAM). Of the eight cases included in our review, diabetes mellitus was the most common risk factor. Three subjects had no risk factor other than glucocorticoids for COVID-19. Mucormycosis usually developed 10–14 days after hospitalization. All except the index case died. In two subjects, CAM was diagnosed postmortem. Mucormycosis is an uncommon but serious infection that complicates the course of severe COVID-19. Subjects with diabetes mellitus and multiple risk factors may be at a higher risk for developing mucormycosis. Concurrent glucocorticoid therapy probably heightens the risk of mucormycosis. A high index of suspicion and aggressive management is required to improve outcomes.

     

Zygomycosis: A report of eleven cases and a review of the Brazilian literature

Eleven cases of zygomycosis (mucormycosis) observed throughout an eighteen year period (1982-2000) have been reviewed. The most important demographic and clinical data of seven patients were tabulated. The remaining four are related as illustrative cases. Seven patients presented with the pulmonary form of the disease; two patients presented with the pulmonary manifestation associated with sinusitis; and two patients presented with the rhinocerebral form. Predisposing conditions, in decreasing order of frequency, were diabetes mellitus (6), renal transplantation (2), associated with pancreas-kidney transplantation and diabetes (1), bone marrow aplasia (1), and chronic obstructive lung disease treated with corticosteroids (1). The diagnoses were based on the detection of characteristic zygomycetous hyphae in tissue. The causative organim was isolated and identified in only four cases; three were due to Rhizopus arrhizus, and one to Absidia corymbifera. In addition the Brazilian literature on zygomycosis is reviewed.     

A Case of Rhinoorbital Mucormycosis in a Leukemic Patient with a Literature Review from Turkey

Mucormycosis (Zygomycosis) is a rare, invasive, opportunistic fungal infection of the paranasal sinuses, caused by a fungus of the order Mucorales. We report a case of rhinoorbital mucormycosis caused by Rhizopus oryzae in an acute lymphoblastic leukemia patient and review the 79 Mucormycosis cases reported in the last decade from Turkey. In our case, the diagnosis was made with endoscopic appearance, computerized tomography of the paranasal sinuses, and culture of the surgical materials. Following aggressive surgical debridement and parenteral amphotericin B therapy, the patient recovered completely. In Turkish literature, rhinocerebral manifestations were the most common form of the mucormycosis (64 cases), followed by pulmonary form (6 cases). The most common risk factor was hematologic malignancies (32 cases) and diabetes mellitus (32 cases), similar to those reported from the rest of the world. The etiologic agents responsible for the review cases were Rhizopus sp., Mucor spp., Rhizomucor spp., Rhizopus oryzae, Mucor circinelloides, and Lichtheimia corymbifera. Although various treatment modalities were used, amphotericin B was the mainstay of therapy. Mortality rate was found to be 49.4% in review cases. It seems that strong clinical suspicion and early diagnosis, along with aggressive antifungal therapy and endoscopic sinus surgery, have great importance for better prognosis in mucormycosis.     

Isavuconazole in a Successful Combination Treatment of Disseminated Mucormycosis in a Child with Acute Lymphoblastic Leukaemia and Generalized Haemochromatosis: A Case Report and Review of the Literature

Invasive mucormycosis in immunocompromised children is a life-threatening fungal infection. We report a case of a 7-year-old girl treated for acute lymphoblastic leukaemia complicated by disseminated mucormycosis during induction therapy. Microscopic examination of surgically removed lung tissue revealed wide, pauci-septate hyphae suggesting a Mucorales infection. This diagnosis was confirmed immunohistochemically and by PCR analysis followed by a final identification of Cunninghamella sp. The patient was treated successfully with surgical debridement and antifungal combination therapy with amphotericin B, caspofungin and isavuconazole. The use of isavuconazole in a child was not previously reported. Additionally, case reports concerning pulmonary mucormycoses in paediatric population published after 2010 were reviewed. Nineteen out of 26 identified patients suffered from haematological diseases. Reported mortality reached 38.5%. By the fact of rising morbidity, unsatisfactory results of treatment and remaining high mortality of mucormycoses in immunocompromised patients, new therapeutic options are warrant. Isavuconazole, with its broad-spectrum activity, good safety profile and favourable pharmacokinetics, is a promising drug. However, further studies are necessary to confirm positive impact of isavuconazole on mucormycosis treatment in children.

     

COVID-19–associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic’s second wave in India

Coronavirus Disease 2019 (COVID-19), during the second wave in early 2021, has caused devastating chaos in India. As daily infection rates rise alarmingly, the number of severe cases has increased dramatically. The country has encountered health infrastructure inadequacy and excessive demand for hospital beds, drugs, vaccines, and oxygen. Adding more burden to such a challenging situation, mucormycosis, an invasive fungal infection, has seen a sudden surge in patients with COVID-19. The rhino-orbital-cerebral form is the most common type observed. In particular, approximately three-fourths of them had diabetes as predisposing comorbidity and received corticosteroids to treat COVID-19. Possible mechanisms may involve immune and inflammatory processes. Diabetes, when coupled with COVID-19–induced systemic immune change, tends to cause decreased immunity and an increased risk of secondary infections. Since comprehensive data on this fatal opportunistic infection are evolving against the backdrop of a major pandemic, prevention strategies primarily involve managing comorbid conditions in high-risk groups. The recommended treatment strategies primarily included surgical debridement and antifungal therapy using Amphotericin B and selected azoles. Several India-centric clinical guidelines have emerged to rightly diagnose the infection, characterise the clinical presentation, understand the pathogenesis involved, and track the disease course. Code Mucor is the most comprehensive one, which proposes a simple but reliable staging system for the rhino-orbital-cerebral form. A staging system has recently been proposed, and a dedicated registry has been started. In this critical review, we extensively analyse recent evidence and guidance on COVID-19–associated mucormycosis in India.     

激素治疗大疱性疾病引起真菌感染回顾性分析

目的研究糖皮质激素治疗大疱性疾病患者发生医院真菌感染的病原菌分类、危险因素和防治对策。方法收集67例大疱性类天疱疮和38例天疱疮患者糖皮质激素治疗的临床资料,计算医院真菌感染率,分析相关危险因素。结果大疱性疾病患者糖皮质激素治疗出现医院真菌感染率达32.38%,口腔真菌感染率为27.61%,肺部真菌感染率为13.33%,主要病原菌分别为白念珠菌(69.77%),热带念珠菌(11.63%)和近平滑念珠菌(6.98%)。糖皮质激素剂量、免疫抑制剂、抗生素、住院日及糖尿病病史明显增加真菌感染危险,其中免疫抑制剂、抗生素和糖尿病病史为独立危险因素。结论糖皮质激素治疗大疱性疾病患者院内真菌感染发生率高,免疫抑制剂、抗生素和糖尿病病史是其主要危险因素。     

Cutaneous Mucormycosis in Tornado Survivors

A total of 18 suspected cases of cutaneous mucormycosis were identified in survivors of the May 2011 tornado in Joplin, Missouri. Apophysomyces trapeziformis was identified in 13 of the patients with microbiologically or histologically proven infection by DNA sequencing. Apophysomyces are classically associated with necrotizing skin and soft-tissue infections following traumatic inoculation of the fungal spores. Although cases of Apophysomyces infection were previously reported in survivors of tsunamis and volcanic eruptions, this is believed to be the first reported case series of cutaneous mucormycosis in tornado survivors.     

Hospital-acquired gangrenous mucormycosis

A post-operative diabetic patient who had been treated for Serratia marcescens bacterial sepsis developed recurrent thrombosis of the left femoral artery following intra-arterial instrumentation. Pathological examination of arterial thrombus ultimately demonstrated invasive mucormycosis of the femoral artery and cultures of this material grew Rhizopus oryzae. The occurrence of cutaneous and subcutaneous mucormycosis is reviewed, as well as recently recognized nosocomial risk factors for mucormycosis, such as elasticized bandages and wound dressings.     

108例鼠伤寒沙门氏菌医院内感染临床分析

1988年8月至1991年6月在我院婴儿室及儿科病房发生和收治鼠伤寒沙门氏菌病153例,其中108例占64.1％为医院内感染。发病率龄以12个月以内婴幼儿为主占85.6％。连续两年于8月份在婴儿室呈爆发流行共48例占44.4％。本病全年均可发病,以8～10月为发病高峰。医院内感染的主要传染源为院外感染的散发病例收住院的患者及陪住家属的带菌者。消毒隔离制度不严格是引起传播的重要因素。该病原菌耐药性强,尤其院内感染菌株。院内感染延长住院时间,增加病人痛苦及经济负担,因此医院内感染必须引起重视,急待控制。     

医院内感染422例的微生态学分析

本文对我院在１９９２年６月至１９９３年５月８５２０例出院病人中,参照卫生部医政司院内感染监控协调小组确定的标准分类的４２２例院内感染进行调查和微生态分析。院内感染总发生率为４．９５％,依次以肾移植血液透析中心、血液病科、监护中心较高,分别为５０．８８％、２６．２９％、２４．０７％,按年龄分组以大于５０岁组院内感染率最高,为４４．３９％。院内感染部位以下呼吸道感染最高（３９．６３％）,其次为手术伤口感染（２９．０７％）,泌尿道感染（１１．５８％）。院内感染病医学检查以“Ｇ￣－”杆菌为主（５１．５％）,真菌感染为３３．５３％。药敏试验对抗茵素都有不同程度耐药。提示要高度重视院内感染监测,严格控制抗生素应用,重视对手术室、病区环境净化和对病人的保护性措施,以预防和治疗院内感染。     

急性血源性骨髓炎全身与局部抗生素治疗体会及重症病例分析

目的:总结急性血源性骨髓炎尤其是重症患者治疗中全身及局部抗生素应用的经验、方法及临床疗效。方法:回顾性分析空军军医大学第二附属医院2016年11月至2019年4月收治的12例急性血源性骨髓炎患者,其中3例为合并肺脓肿的重症败血症患者。对患者首先进行经验性全身抗生素治疗,并进行细菌学分析,然后根据药敏结果进行系统抗生素调整,采用万古霉素负载的硫酸钙/磷酸钙复合物进行局部抗生素缓释治疗,分析治疗前后实验室指标变化、局部影像学变化。结果:细菌学培养显示金黄色葡萄球菌10例,人葡萄球菌1例,阴沟肠杆菌1例;平均随访56.6周;治疗后患者白细胞(WBC)、中性粒细胞百分比(NEUT%)、红细胞沉降率(ESR)、高敏C反应蛋白(hs-CRP)等指标均恢复到正常范围内;影像学显示患者病灶处骨重建及新骨形成良好,无感染复发迹象;12例患者中成功治愈11例,治愈率91.7%;1例转为慢性骨髓炎,二期手术后痊愈;其中3例骨髓炎合并重症败血症、肺脓肿患者经系统抗生素及外科治疗,全部治愈。结论:急性血源性骨髓炎的致病菌主要为甲氧西林敏感金黄色葡萄球菌(MSSA),其治疗要在早诊断的前提下,率先经验性应用抗生素,然后根据药敏结果合理选择足量敏感抗生素。苯唑西林在3例合并败血症、肺脓肿的重症患者治疗中起到了关键作用,同时局部采用硫磷复合物负载万古霉素进行治疗,既可以实现局部抗感染作用,又可以促进新骨形成,有效控制全身感染、消除败血症,临床疗效满意。     

Hyperthyroidism Secondary to Disseminated Mucormycosis in a Child with Acute Lymphoblastic Leukemia: Case Report and a Review of Published Reports

Thyroiditis due to fungal infection is an extremely rare cause of hyperthyroidism. The most common etiological factor of thyroiditis is Aspergillus. Infections due to members of the Mucorales have been an increasing clinical problem in recent years, and the prognosis in generalized infections due to those fungi is usually very poor. No hyperthyroidism in a child with thyroiditis due to mucormycosis has been reported in the literature so far. We describe a clinical course of generalized mucormycosis with thyroid involvement in a 12-year-old girl treated for acute lymphoblastic leukemia. The child underwent a hyperthyroidism connected with thyroid involvement due to a fungal process. The diagnosis was based on the clinical signs, laboratory findings and typical ultrasound scan; however, later attempt to amplify the fungi DNA from the tissue block has failed. The child died because of multiorgan failure due to general fungal infection 49 days after the invasive fungal infection was diagnosed. The generalized mucormycosis is always connected with poor prognosis and the mortality is high.     

Successful Treatment of Pulmonary Mucormycosis Caused by <Emphasis Type="Italic">Cunninghamella bertholletiae</Emphasis> with High-Dose Liposomal Amphotericin B (10 mg/kg/day) Followed by a Lobectomy in Cord Blood Transplant Recipients

Infection caused by Cunninghamella bertholletiae carries one of the highest mortality rates among mucormycosis, and there are no reported cases that survived from the infection in allogeneic hematopoietic stem cell transplantation recipients occurring before neutrophil engraftment. Here, we present two cases of pulmonary mucormycosis caused by C. bertholletiae occurring before neutrophil engraftment after cord blood transplantation. Both were successfully treated with high-dose liposomal amphotericin B (10 mg/kg/day) combined with micafungin, which was then followed by neutrophil recovery, reduction in immunosuppressive agents, and a subsequent lobectomy. The intensive antifungal therapy immediately administered upon suspicion of mucormycosis greatly suppressed the infection in its early stage and was well tolerated despite its prolonged administration and simultaneous use of nephrotoxic agents after transplantation. Although the synergic effect of micafungin remains unclear, these cases highlight the importance of prompt administration of high-dose lipid polyene when suspecting mucormycosis in highly immunocompromised patients, which enables subsequent diagnostic and therapeutic interventions, resulting in a favorable outcome.     

烧伤病房MRSA医院感染暴发的PFGE分型研究

利用表型分型和基因分型的方法解析医院感染常见致病菌——耐甲氧西林金黄色葡萄球菌(MRSA)造成医院感染暴发的可能传播途径。本实验对某医院烧伤科、ICU、肿瘤科病房内从患者和环境分离的19株MRSA,进行了16种抗生素的耐药性实验和全基因组稀有位点限制性内切酶酶切脉冲凝胶电泳(PFGE)分析,并聚类分析归纳了菌株之间的相关性。结果发现在19株MRSA中有11株属于同一个菌种A型,在这些菌株中,有8株属于相同的克隆亚型A1型,分别来自烧伤科和ICU患者以及烧伤科医生、护士的手。4株属于B型,均分离自同一烧伤病房。这暗示该医院可能存在MRSA(A型)院内感染的暴发,并且存在B型流行的潜在危险。MRSA很有可能通过医护工作人员的手及鼻腔等媒介在患者间传播。因此,加强医护人员的感染控制观念,利用灵敏、可靠且分辨率强的分型技术加强MRSA感染监控至关重要。     

Mathematical modeling of severe acute respiratory syndrome nosocomial transmission in Japan: the dynamics of incident cases and prevalent cases

An outbreak of Severe Acute Respiratory Syndrome (SARS) occurred in Hong Kong in late February 2003, resulting in 8,096 cumulative cases with 774 deaths. The outbreak was amplified by nosocomial transmission in many hospitals. Using mathematical modeling, we simulated the number of new incident and prevalent cases of SARS after one infected person was admitted to a hospital (index case). The simulation was tested stochastically using the SEIR model based on previously reported Gamma distributions. We estimated the duration time until 10 beds in negative pressure rooms in Chiyoda-ku, one of the 23 wards in Tokyo, were fully occupied with SARS-infected patients. We determined the impact of an increasing number of days on the number of prevalent cases until the index case was isolated. The prevalent cases increase exponentially along with the increase of the non-isolation period of the index case, and all the beds were fully occupied if the index case was not isolated until more than 6 days. However even 2 days non-isolation period of the index case could fill up all the beds when 16% of secondary infections are transmitted outside the hospital. There is a possibility that an epidemic will occur with the isolation of the index case even at early days if the infection is transmitted outside the hospital. The simulation results revealed that it was important to recognize and isolate SARS patients as early as possible and also to prevent the transmission spreading outside the hospital to control an epidemic.