Intravenous Amphotericin Research Articles

P288 Rhinocerebral mucormycosis due to Saksenaea vasiformis in a Sri Lankan patient: A rare fungal infection

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMBackground: Rhizopus, Rhizomucor, and Mucor species are renowned agents causing rhinocerebral mucormycosis; a disease with a high mortality rate. Saksenaea vasiformis is extremely rarely observed in this clinical entity. Minimal sporulation in common laboratory media might be responsible for the under-reporting of this organism. Here we present an uncommon case of rhinocerebral mucormycosis due to S. vasiformis. in a Sri Lankan patient with diabetes mellitus.Case History: A 66-year-old female with diabetes mellitus was admitted with frontal headache, right-sided nasal block, anosmia, and right-side facial swelling. Examination revealed facial edema, maxillary sinus tenderness, and a white patch over the hard palate. Thick pus in postnasal space, growth in posterior tongue base, inflamed palate, and oropharynx, were revealed by rigid nasal endoscopy. She developed ophthalmoplegia along with right V and XII cranial nerve palsies irrespective of antibacterial therapy. Right side pansinusitis was observed in non-contrast computed tomography. She was subjected to right-side full house functional endoscopic sinus surgery with right orbital and optic nerve decompression. Irregular wide, ribbon-like, non-septate hyphae suggestive of Zygomycete fungi were observed in the direct microscopy of a deep surgical tissue sample and started with intravenous amphotericin B. After 5 days of incubation, the culture grew a zygomycetes-like mold with a lack of sporulation on Sabouraud dextrose agar, potato dextrose agar, and slide culture. However, the floating agar technique succeeded in producing flasks-shaped sporangium on a short sporangiophore with brown pigmented rhizoids after 14 days of incubation. The phenotypic features were suggestive of S. vasiformis. She was subjected to repeated debridement surgeries and treatment with amphotericin B was continued. She was clinically improving however, refractory hypokalemia along with hypernatremia interrupted her antifungal therapy resulting return of severe symptoms. Contrast-enhanced computed tomography of the brain revealed multiple micro-abscesses in the right temporal lobe. She clinically deteriorated and succumbed to the illness.Discussion: Saksenaea vasiformis, a member of Mucorales, is largely bounded to cutaneous and subcutaneous infections. Rhino-orbital-cerebral infection is relatively uncommon and most of the reported cases were fatal irrespective of optimal therapy. Prompt diagnosis through fungal investigations of deep biopsy is mandatory. The delayed identification of this organism is attributed to its nature of poor sporulation on routine media. Special culture techniques and nutritionally deprived media enhance sporulation. Saksenaea vasiformis is usually sensitive to amphotericin B, high minimum inhibitory concentration has been reported though.ConclusionSpecific culture techniques should be used to induce sporulation if non-sporulating mucormycetes are encountered. Rhinocerebral mucormycosis is associated with a high degree of mortality even with effective antifungal therapy.

P181 Mucor in the land of the liver: a case report

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Introduction and ObjectivesMucormycosis is a rare, highly lethal opportunistic fungal infection affecting immune-compromised patients. It accounts for about 2% of invasive fungal infections occurring within 1 year after solid organ transplantation. Among renal recipients, Rhinocerebral is the commonest manifestation and Rhizopus species is the most frequent pathogen.The objectives are:To report a case of Hepatic mucormycosis in a renal transplant recipient.To resolve the dilemma in identification of Mucorale species detected on microscopy but culture negative.MethodA 29-year-old male patient was admitted with severe abdominal pain on day 28 post-live related renal transplantation. Patient was hypertensive, on oral steroids for idiopathic thrombocytopenic purpura, chronic kidney disease with venous thromboembolism-presumed chronic interstitial nephritis, and maintained on hemodialysis for the last 1 year. Post-transplant he was on triple immunosuppressants.Initial ultrasound of abdomen and transplant doppler were normal. CT of abdomen in view of worsening hypotension and non-resolving abdominal pain, revealed hepatomegaly with multiple discrete, coalescing hypodense areas in both lobes of liver with minimal subcapsular extension. Initial cultures included interventional radiology-guided liver aspirate and blood culture. Patient was started on antibiotics and antifungals. Patient continued to deteriorate and a repeat abdominal CT revealed an increase in liver size and rupture of liver abscess. Sample collected on pigtail catheter insertion was also sent for culture.ResultsThe pus aspirate was received for bacterial and fungal culture. Aerobic bacterial culture yielded Klebsiella species. Examination with KOH Calcofluor revealed broad aseptate fungal hyphae. However, fungal culture did not yield any growth. Pain resistant (PDR) Klebsiella species was isolated from blood culture. Pigtail catheter sample also yielded the same. Aseptate fungal hyphae were observed in the pigtail catheter sample also. The team decided on conservative management and patient was started on intravenous amphotericin B deoxycholate(50 mg/day), tigecycline, and meropenem. Immunosuppressants were withheld. The clinical course worsened and the patient succumbed to illness after 18 days of antifungal therapy. The pus sample was then sent to the referral center PGIMER for PCR and sequencing where it was identified as Lichtheimia species.ConclusionMucormycosis is an increasingly emerging invasive fungal infection especially in immune-compromised patients, including solid organ transplant recipients. Though uncommon it is frequently a fatal mycosis in transplant patients. Hepatic mucormycosis in renal transplant recipients has been reported in three patients so far. None are due to Lichtheimia species. The diagnosis of hepatic mucormycosis was confirmed as microscopy was positive in two successive samples. Our patient also had bacteremia with PDR Klebsiella.Diagnosis is challenging and often delayed, as the clinical presentation is non-specific. Although mucormycosis in a renal transplant recipient is rare, a high index of suspicion and critical microscopic examination is warranted for early initiation of specific therapy which includes liposomal amphotericin B and surgery. Often cultures yield no growth and gene sequencing proves to be efficient and time-saving. This probably is the way ahead, especially for culture-negative samples to establish the etiological diagnosis.

P086 Clinical outcome and in vitro antifungal susceptibility of clinical isolates of rhino-orbito-cerebral mycosis associated with post COVID 19 from North India

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM ObjectivesThis study aimed primarily to determine the etiology, clinical features, and comorbidities of patients with rhino-orbito-cerebral mycosis. Secondly, antifungal susceptibility pattern of the isolates and lineage by ITS-sequencing was also studied.MethodsThe study was conducted from May to December 2021 on all suspected cases of rhino-orbito-cerebral mycosis in post-COVID-19 patients at a tertiary care center. Data pertaining to demographics, recent COVID-19 infection, clinical features, comorbidities, laboratory, radiological investigations, management, and outcomes were collected after obtaining informed consent from all patients. Staging of ROCM was done using the proposed code Mucor and diagnosis of COVID-19 was done on basis of real-time polymerase chain reaction (RT-PCR) test. KOH Mount examination, fungal culture, and histopathological examination was performed on samples collected endoscopically or post-debridement. Mucormycosis was proven based on fungal culture or specific histological features from biopsy specimens. In vitro susceptibility profiles for antifungal drugs as per CLSI microbroth dilution method (M38-A2) was studied by HiMIC™ plate (HiMedia) for amphotericin B, voriconazole, posaconazole, itraconazole, and isavuconazole. MIC ranges and the drug concentrations required to inhibit 50% (MIC50) or 90% of isolates (MIC90) were determined. ITS Sequencing was also performed on representative isolates.ResultsA total of 70 patients were diagnosed with mucormycosis. Rhino-orbital and rhino-orbito-cerebral forms were observed in 35.7% of cases each. Diabetes mellitus (DM) was present in 95.7% patients while 78.5% of the patients were treated with corticosteroids in recent past, and 25.7% presented with active COVID-19 pneumonia. Most cases showed onset of symptoms of mucormycosis between 29 ± 17 days from diagnosis of COVID-19. On imaging, orbit was involved in 52.8% and cranial involvement is seen in 35.7% of patients. Diagnosis of mucormycosis was established on KOH direct microscopy 68.6%, culture 47.14%, histopathology 55.7%. Isolates obtained were Rhizopus arrhizus (42.4%), Apophysomyces variabilis (3.03%), and Aspergillus spp (69.7%) while mixed infection was seen in 42.4%. The MIC50 and MIC90 of amphotericin B for R. arrhizus strains were 0.25 and 4 μg/ml; and MIC50 and MIC90 results for itraconazole, posaconazole, and isavuconazole were 8 and 8, 2 and 2, and 2 and 8 μg/ml respectively. Aspergillus spp was susceptible to amphotericin B (38.8%), itraconazole (50%), voriconazole (50%), posaconazole (11.1%), and isavuconazole (44.4%). Overall treatment included intravenous amphotericin B along with functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 68.2%, orbital exenteration in 4.2%, orbital decompression in 11.4% patients and partial maxillectomy in 22.8% cases. Intraorbital injection of amphotericin B was administered in 15.7%. At final follow-up, mortality was 19.7%. In vitro MICs showed that amphotericin B was the most active compound against most species.ConclusionHigh index of suspicion, early diagnosis, and appropriate management of mucormycosis can improve survival. Rational use of steroids and strict glycemic control in diabetic patients can prevent occurrence of mucormycosis. Use of standard methods for antifungal susceptibility testing to guide antifungal treatment may be clinically useful in cases of treatment failure.

Non-Mucormycetes Causes of Fungal Rhino Sinusitis With Periocular Swelling in COVID-19 With Delta Variant.

Objective: To highlight fungi other than mucormycetes as causative agents of rhinosinusitis with periocular swelling in coronavirus (COVID-19) infection caused by Delta variant of SARS-CoV-2 virus and identify the presenting features, risk factors, intervention, and outcomes.Methods and analysis: A retrospective interventional study of 96 patients with fungal rhinosinusitis and periocular swelling was done in patients with concurrent or recovered COVID-19 infection with the Delta variant (B.1.617.2) of SARS-CoV-2 virus in India. All patients with mucormycetes infection were excluded. Clinical presentation, medical history, blood reports, and imaging were analyzed. Management was by intravenous (IV) liposomal amphotericin B and functional endoscopic sinus surgery (FESS) with paranasal sinus debridement. Limited orbital debridement with or without transcutaneous retrobulbar liposomal amphotericin B (TRAMB) was done in patients with orbital involvement. Postoperative antifungal therapy was decided on the basis of the causative fungi.Results: Four cases of Aspergillus and one each of Fusarium, Curvularia, and Penicillium-associated fungal rhinosinusitis with periocular swelling were seen. Signs of orbital involvement on MRI were present in all four of them. Two of these showed partial third-nerve palsy while one case with aspergillosis suffered cavernous sinus thrombosis. Proptosis was not witnessed in any case. History of diabetes and use of steroids was seen in all patients. All patients had mild to moderate COVID-19 with oxygen supplementation needed in one. No mortality, acute vision loss, or exenteration took place.Conclusion: Aspergillus, Fusarium, Curvularia, and Penicillium were non-mucormycetes causes of fungal rhinosinusitis with periocular swelling in COVID-19 infection with the Delta variant (B.1.617.2) of SARS COV-2 virus. Few cases showed orbital and intracranial involvement.

POS-098 MILKY URINE IN RENAL ALLOGRAFT RECIPIENT - CAN NATIVE KIDNEY BE THE CULPRIT ?

Milky urine can be caused due to both infectious and non-infectious causes. We present a case of 48 years old male, 6 years post kidney transplant who presented as milky urine and was initially managed with diethylcarbamazine (DEC) and intravenous antibiotics. As he was not responding he was evaluated further to be diagnosed as candiduria arising from left native kidney. He had a quick response to left native nephrectomy and liposomal amphotericin. 48 years old male patient, who was 6 years post kidney transplant (Basic disease - diabetic nephropathy), with normal graft function on triple drug immunosupressants ( tacrolimus, mycophenolate and pednisolone) presented with complaint of milky white urine during morning hours only. He was afebrile and had no symptoms of burning or pain during micturition. His urine examination showed few pus cells and was hazy in appearance. Urine cytology for malignant cells showed no evidence of atypical cells. Urine for fat globules was negative though triglycerides were 470 mg/dl and urine was labelled as chylous. His ultrasound was suggestive of mild pelvicalyceal fullness of transplant kidney which was confirmed by CT scan. His leucocyte counts, calcium and phosphorus were within normal range. His early morning smear sample showed no evidence of wuchereria bancrofti microfilariae. He was emperically started on DEC 6mg/kg. After 5 days his urine culture yielded growth of klebsiella species and was treated with injectable ceftriaxone-sulbactum combination as per culture sensitivity report for 2 weeks. He was asymptomatic till the time he was on antibiotics and again developed episodes of milky urine. He also passed some fleshy material in urine was sent for histology. He was posted for cystoscopy which revealed whitish efflux from left native uretric orifice, which was sent for cytology and left uretric catheterization was done. Both the tissue and fluid showed colonies of budding yeast cell and pseudohyphae suggestive of candida species. Considering the non functional status of left native kidney (by imaging and history of anuria pre transplant), left laproscopic native nephrectomy was done and in view of post transplant immunosupressed state, intravenous liposomal amphotericin was given for 2 weeks. He had a quick response to the treatment. In post transplant urinary tract infections, we should also focus on native kidneys especially in diabetic population. There are many case reports of recurrent urinary tract infections post transplant due to native pyelonephritis requiring native nephrectomy.

Antifungal use via outpatient parenteral antimicrobial therapy.

Antifungal administration via outpatient parenteral antimicrobial therapy (OPAT) is infrequent. As patients with invasive fungal infections (IFIs) receiving OPAT are at high risk of readmissions, careful, risk-based patient selection and monitoring is important. To describe our experience managing IFIs via OPAT, including assessment of risk factors associated with unplanned readmissions. A retrospective cohort study of outpatients from two tertiary hospitals in Western Australia managed with parenteral antifungals for the treatment of IFIs from 2012 to 2020. Outcomes assessed were unplanned OPAT-related readmissions; adverse events and achievement of treatment aim at the completion of OPAT. Forty-six patients were included, encompassing 696 OPAT days. Twenty-three (50%) patients received intravenous (IV) liposomal amphotericin B (L-AmB), 23 (50%) received IV echinocandins and one (2%) patient received IV fluconazole. One patient received both IV L-AmB and an echinocandin. Unplanned OPAT-related readmissions occurred in 13 (28%) patients and any adverse event occurred in 19 (41%), most commonly nephrotoxicity amongst patients receiving L-AmB. On univariate analysis, unplanned OPAT-related readmissions were more common in Mucorales infection, L-AmB doses of ≥5mg/kg and otorhinolaryngologic (ENT) infections. At the completion of OPAT, attainment of treatment aims occurred in 28 (61%) patients. Patients receiving parenteral antifungals via OPAT experience high rates of unplanned readmissions and adverse events. Risk factor identification may facilitate optimal patient selection and establishment of treatment aims.

Post Covid-19 Mixed Fungal Orbito-Pansinusitis Caused by Rhizopus Oryzae and Exophiala Jeanselmei-Review and Reports

We report a rare case of mixed fungal orbito-pansinusitis caused by Rhizopus oryzae and Exophiala jeanselmei in post-COVID-19 individuals. A 65-year-old patient was COVID-19-positive and treated as per the protocols. Following recovery after 3 weeks presents to the otorhinolaryngology outpatient department with complaints of nasal obstruction, stuffiness, pain over the maxilla, occasional fever spikes, and swelling over eyelids. He was diagnosed with a case of orbito-pansinusitis mucormycosis based on magnetic resonance imaging, nasal endoscopy, and microbiological findings. Intravenous (IV) fluconazole and amphotericin B were the conservative management initially followed by surgical debridement later. There was minimal residual deformity after patient recovery. Generally, secondary to immunosuppression or debilitating diseases leads to mucormycosis. The mode of entry for molds and spores of zygomycetes are through the respiratory tract through the nose and then reaches the sinuses, orbit, and intracranial structures. Hence, a good prognosis and to reduce morbidity by zygomycosis can be achieved by early clinical diagnosis, direct smears, and proper interventions. The diagnosis of fungal infections at the earliest is very important because the therapeutic management of fungal infection is quite challenging, especially in the case of R. oryzae and E. jeanselmei with immunocompromised state. The prophylactic drugs, steroids, and immunosuppressants for the treatment of COVID-19 should not be misused and must be used as per protocol and guidelines judiciously.

Rhino-orbito-cerebral with cutaneous mucormycosis

<p>"Mucormycosis" term is used for a group of fungal diseases caused by the order mucorales. It typically presents as sino-nasal-orbital involvement and rarely involves skin. Management of such cases is quite challenging. Reported here is a case of a young girl, who presented with right eye swelling and reduced vision and got detected with type 1 diabetes mellitus on admission with rare occurrence of cutaneous lesions while on treatment. Direct nasal endoscopy with biopsy was undertaken. KOH and histopathology report was suggestive of mucormycosis, for which the patient was administered intravenous amphotericin B and surgical debridement was carried out. With the accurate application of a multidisciplinary approach with timely investigations, imaging studies, antifungals and debridement, successful outcome in mucormycosis is well within our reach.</p>

A 40-Year-Old Woman With COVID-19 and Bilateral Vision Loss.

Mucormycosis is a fast-spreading angioinvasive fungal infection with a very high mortality rate. It is associated with immunodeficiency, diabetes mellitus, iron overload, stem cell transplantation and the use of steroids. As cultures and histopathological biopsy may have low yield in invasive fungal infections, new generation sequencing of cfDNA (cell free deoxyribonucleic acid) has become a cornerstone for diagnosis. Over the past 18 months, increasing reports of COVID-19 associated Mucormycosis have emerged, most specifically in India and other nearby developing countries. Awareness and knowledge of this newly discovered association is of high importance and clinical relevance as the global COVID-19 pandemic continues. Herein, we present a case of a patient who was treated with steroids for COVID-19 in the outpatient setting and presented with unilateral periorbital pain and blurry vision. She progressively developed bilateral vision loss, fixed bilateral mydriasis, ophthalmoplegia and coma. Imaging findings included leptomeningeal, vascular, and subcortical enhancement accompanied with multifocal infarction. Subsequent biopsy of the paranasal sinuses revealed broad type fungal elements and cfDNA sequencing identified the pathogen as Rhizopus species. She was treated with intravenous amphotericin B, but succumbed to the infection.

Endovascular Infusion of Amphotericin B for the Treatment of Rhino-Orbito-Cerebral Mucormycosis: A Pilot Study Assessing Technical Feasibility and Safety

Abstract Objectives The aim of this study was to assess the technical feasibility and safety of intra-arterial infusion of amphotericin B for the management of rhino-orbito-cerebral mucormycosis in patients unable to receive full dose and schedule of intravenous amphotericin B and/or unsuitable for surgery. Materials and Methods Five consecutive patients underwent five sessions of intra-arterial infusion each via both external carotid arteries on alternate days. Liposomal amphotericin B (50 mg) was infused at each session. The baseline and follow-up investigations as well as local and systemic complications were charted. Results Procedure could be completed for all participants without any local complications. One patient had transient and another had progressive deterioration in renal parameters during the follow-up period of 30 days. Conclusions Authors conducted successfully a pilot study of multisession intra-arterial infusion of amphotericin B, with the premise that it can provide high concentration of drug at the desired site with reduced systemic complications. They recommend further larger randomized studies to evaluate its efficacy for the management of advanced rhino-oculo-cerebral mucormycosis.

Fungal Endophthalmitis in a Case of Rhino-Orbito-Cerebral Mucormycosis: Successfully Treated With Amphotericin B Colloidal Dispersion.

BackgroundRhino-orbito-cerebral mucormycosis (ROCM) is an acute, fulminant, opportunistic fungal infection that usually occurs in diabetes or immunocompromised patients. Amphotericin B combined with surgical debridement remains the standard treatment, although it is controversial due to its lager nephrotoxicity. Thus far, no studies have reported the treatment for ROCM-associated fungal endophthalmitis because the exact pathogenesis and transmission routes in ROCM remain unclear. Here, we reported a case of ROCM complicated with fungal endophthalmitis treated favorably with amphotericin B colloidal dispersion (ABCD) in combination with other antifungals and surgical debridement.Case PresentationA 34-year-old woman with diabetes was admitted to our hospital owing to right-sided headache for 8 days, blindness with swelling in the right eye for 5 days, and blindness in the left eye for 1 day. MRI showed that the patient had sphenoid sinus, sinuses, frontal lobe lesions, and proptosis of the right eye. Metagenomic sequencing revealed that the patient had Rhizopus oryzae infection. During hospitalization, the patient received intravenous ABCD, oral posaconazole, and topical amphotericin B and underwent surgical debridement. After 67 days of treatment, the patient’s condition was significantly improved, and limb muscle strength showed grade V. Rhizopus oryzae showed negative results, and conjunctival swelling decreased. Additionally, no nephrotoxicity occurred during treatment. After discharge, the patient’s treatment was transitioned to oral posaconazole and she was free of complaints during the 30-day follow-up without any additional treatment for ROCM.ConclusionTreatment with ABCD combined with other antifungal drugs and surgical debridement for ROCM complicated with fungal endophthalmitis showed remarkable efficacy and good safety. Hence, this regimen is a promising treatment strategy for this fatal disease.

INVASIVE MOLD INFECTION AFTER LUNG TRANSPLANTATION PRESENTING AS A SINGLE PULMONARY NODULE

TYPE: Case Report TOPIC: Transplantation INTRODUCTION: Lung transplant recipients commonly develop invasive fungal infections, particularly in the early postoperative course, despite appropriate antifungal prophylaxis. CASE PRESENTATION: The patient is a 68-year-old woman who received a bilateral lung transplant (09/2020) due to idiopathic pulmonary fibrosis. She received antifungal prophylaxis as deemed appropriate by our transplant center. She presented 10 months after transplant with acute cough. DISCUSSION: The patient had an uncomplicated early postoperative course without evidence of acute cellular rejection or infection leading up to her presentation. At 10 months, she was admitted for acute cough and radiographic imaging concerning for a new pulmonary nodule. Chest CT confirmed a 7 × 7 mm superior segment, left lower lobe, solid, non-calcified pulmonary nodule. Bronchoscopic tissue biopsy revealed Aspergillus spp, and the patient was switched from itraconazole to isavuconazole. In the same admission, mold was identified, which prompted repeat chest CT showing a small cluster of nodules around the initial left lower lobe nodule. Biopsy confirmed acute, granulomatous pneumonitis with fungal elements consistent with Zygomycetes spp. Intravenous amphotericin was initiated, and repeat chest CT four weeks later showed a reduction in the cluster of nodules. Notably, the Cylex ImmuKnow (IK) assay measurements remained low, with values below 100 ng/mL, confirming her high levels of immunosuppression. CONCLUSIONS: A single pulmonary nodule in an immunosuppressed patient requires prompt diagnostic efforts, as fungal airway colonization is common and can progress rapidly despite prophylaxis. IK assays may provide objective evidence of over-immunosuppression, placing patients at higher risk of infection. DISCLOSURE: Nothing to declare. KEYWORD: Lung transplantation

Analysis of COVID-19-associated rhino-orbital-cerebral mucormycosis patients in a tertiary care center in Northern India.

Purpose:An unprecedented surge has been noted in rhino-orbital-Cerebral mucormycosis (ROCM) in times of current COVID-19 pandemic. The present prospective study aims to evaluate clinico-epidemiological profile, risk factors, management, and outcome of the cases of ROCM that presented to our tertiary care center during the study period from April to June 2021.Methods:All patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were staged and were treated with intravenous liposomal amphotericin B (AMB) and sino-nasal debridement of local necrotic tissue. Transcutaneous retrobulbar AMB (TRAMB), orbital decompression, and exenteration were instituted as indicated. All patients were followed up for a minimum of 6 months before arriving at the final outcome. Statistical analysis was performed.Results:A total of 49 patients presented during the study period, with a mean age of 42.2 years. The major risk factors included uncontrolled diabetes (89.8%), COVID-19 positivity (51.02%), and concurrent steroid use (38.77%). The most common presenting symptom was facial pain/swelling (43.65%), while the most common presenting sign was deterioration in vision (75.51%). Intravenous liposomal AMB was given to all patients along with sino-nasal debridement (85.71%), TRAMB (57.14%), orbital decompression (14.28%), and exenteration (12.24%). Overall, mortality at 6 months was 22.45% (11 patients). Age more than 60 years, intracranial extension, and HbA1c of more than 8.0% were observed to be statistically significant indicators of mortality.Conclusion:Early suspicion and timely diagnosis of mucormycosis at rhino-orbital stage is warranted in order to salvage life as well as visual function. TRAMB may prove as potentially favorable treatment modality in cases with limited orbital involvement.

Adjunctive use of saturated solution of potassium iodide (SSKI) with liposomal amphotericin B (L-AMB) in mucormycosis achieves favorable response, shortened dose and duration of amphotericin: A retrospective study from a COVID-19 tertiary care center

PurposeSecond wave of COVID-19 pandemic was associated with an unprecedented rise in cases of mucormycosis, treatment of which has been challenging owing to the availability and side effects associated with amphotericin. MethodsAll patients presenting with rhino-orbital cerebral mucormycosis (ROCM) following COVID-19 infection between April 2021 to June 2021 were included in this retrospective interventional study. Primary objective was to assess the clinical response with combination of intravenous liposomal amphotericin B (4–5 mg/kg/day) and saturated solution of potassium iodide (SSKI) given orally along with surgical debridement. ResultsTwenty-five patients of ROCM were treated with the regimen. Mean age and fasting blood sugar levels were 53.48 years and 239.64 mg/dL respectively. All patients had history of intake of steroids with a mean daily dose of 86.39 mg of prednisolone equivalent. 88% of patients had a “proven” diagnosis of mucormycosis. Cultures were positive in 52% of patients with Rhizopus arrhizus as the predominant species. The mean daily dose of amphotericin received was 268 mg/day with a mean duration of 9.52 days. Mean daily dose of SSKI was 2.57 g. 21 patients (84%) had stabilization of disease at week 8 and achieved cure at the end of treatment whereas the mortality rate was 16%. Factors that significantly affected outcome were eye and central nervous system (CNS) involvement on presentation. ConclusionSSKI, with its remarkably low cost and safety profile, makes it a potential adjuvant drug that may help achieve the twin benefits of shortened duration and dose of LAMB.

Role of orbital exenteration in rhino-orbital-cerebral mucormycosis

Purpose–Mucormycosis is an uncommon, rapidly progressive, commonly fatal, opportunistic serious fungal infection.The high mortality rate highlights the importance of early detection and treatment. The purpose of this study to determine theoutcome of orbital exenteration in Rhino-orbital-cerebral mucormycosis(ROCM) patients. Methods and materials–This study includesall proven ROCM patients who had underwent orbital exenteration based on SION Scoring system from 1st may 2021 to 30 june 2021 in MYH hospital, Indore.Those patients were reviewedand the outcome of orbital exenterationwas analysed. Results- Total 29ROCM patients were underwent for orbital exenteration based on SION Scoring system. 19(65.5 %)out of 29 patients had intracranial extension and 10 (34.480%) did not have intracranial extension.
 Out of 29, 6 (20.68%) patients hadsuccumbed to death within 10 days of orbital exenteration was having bilateral orbital involvement with intracranial extension.23(79.34%) patientshave favorable outcome with regular follow up. Conclusion- Survival of mucormycosis patients depends on the their good glycemic control,immune status, laterality of the orbital involvement and early detection of intracranial extensionof the disease.With prompt medical (high dose intravenous amphotericin B) and early aggressive surgical intervention involving FESS and orbital exenteration can preventintracranial extension and may improve survival rate .Intracranial extension of the disease has invariably been associated with high mortality.

Treatment of Bolivian Leishmania braziliensis Cutaneous and Mucosal Leishmaniasis.

Although infection with Leishmania braziliensis is perhaps the key reason to treat New World cutaneous leishmaniasis (CL) and mucosal leishmaniasis (ML), the total literature contains relatively few reported cases. With the aim of supplementing the meager clinical information available, we searched the records of Jorochito (Dermatology) Hospital, Bolivia, for the years 1999-2020 and identified treatment records for 1,696 naive CL patients and 355 naive ML patients. Because follow-up was poor for this real-world treatment experience in the developing world, only 255 CL patients (15%) and 114 ML patients (32%) attended follow-up at Hospital. We therefore engaged in an Active Search for "lost" patients, located a further 542 CL patients (32%) and 142 ML patients (44%), thus eventually accomplished follow up on 697 CL patients (41%) and 256 ML patients (72%). Granular adverse event data derived from hospital records is listed for the 902 CL and 86 ML patients administered Glucantime intramuscularly, the 401 CL and 202 ML patients administered Glucantime intravenously, and the 163 CL and 89 ML patients administered miltefosine orally. Efficacy was obtained from hospital records for patients seen at hospital and from patient recall communicated by telephone for the patients found in the Active Search. The overall CL cure rate was 508 of 697 CL patients (73%) with follow-up: intramuscular Glucantime-196/293 (67%); intravenous Glucantime-90/126 (71%); intralesional Glucantime-34/54 (63%); oral miltefosine-52/69 (75%). The overall ML cure rate was 161 of 256 ML patients (63%) with follow-up: intramuscular Glucantime-26/48 (54%); intravenous Glucantime-66/104 (63%); intravenous amphotericin B deoxycholate-19/35 (54%); oral miltefosine-50/71 (70%). We offer this extensive adverse event and efficacy experience as useful guides for clinicians presented with a L. braziliensis infection. The cure rates also illustrate the quandary of New World CL and ML chemotherapy: sufficiently high to be useful but nevertheless needing augmentation with new agents.

A rare case of cutaneous mucormycosis in the forearm: A case report.

Introduction and importanceCutaneous Mucormycosis (CM) is a less frequent type of fungal infection that can present with different skin lesions. Although these lesions appear to be benign and silent, CM rapidly progresses into the deeper layers. Given that no specific laboratory or imaging finding is described for the disease, the diagnosis is mainly based on history and physical examination. In addition, immediate debridement and antifungal agents must be commenced.Case presentationWe present a 43-year-old septic man who was hospitalized for his forefoot infection. During his admission, he developed a necrotic-like ulcer in his antecubital fossa. After initial debridement, pathology examination revealed the infection with mucormycosis. We administered intravenous liposomal Amphotericin B, and also multiple surgeries were performed. Unfortunately, the sepsis progressed to multiorgan failure, and the patient passed away.ConclusionCM requires emergent diagnosis and treatment. Early surgical interventions like extensive debridement and repetitive wound irrigation alongside systemic antifungal therapy are the key steps to preventing the progression of the disease.

Donor Derived Coccidioides in a Lung Transplant Recipient

<h3>Introduction</h3> There are no universal guidelines on screening donors for coccidioides. We describe a fatal case of coccidioides empyema from a donor previously residing in an endemic region. <h3>Case Report</h3> This is a 72 year old male, status post right single lung transplantation 3 weeks prior for chronic hypersensitivity pneumonitis, who presents to clinic with a productive cough. The donor was a 31 year old male with no medical history from the southern inland region of California. A chest X-ray in clinic demonstrated a right pleural effusion. He underwent thoracentesis and bronchoscopy on post-operative day (POD) 22. Pleural fluid was lymphocytic and exudative with negative cultures, and transbronchial biopsies showed mild acute cellular rejection. He was treated with pulse dose steroids. His symptoms worsened one week later when he was seen in the emergency department. Chest CT showed a large right loculated pleural effusion. The patient was started on broad spectrum antibiotics, and a thoracostomy tube was placed, demonstrating a neutrophil predominant exudate. Repeat chest CT showed the effusion extending through the chest wall, and an additional thoracostomy tube was placed. The patient became more hypoxemic requiring mechanical ventilation and VV-ECMO. Pleural cultures taken two-days prior demonstrated mold and the patient underwent irrigation with amphotericin in the operating room, along with intravenous amphotericin. Ultimately, the patient had multi-organ failure and cardiac arrest. Following his passing, pleural fluid cultures confirmed growth of Coccidioides immitis. <h3>Summary</h3> This case describes a patient with initial negative serologies to coccidioides and a donor from the southern inland region of California, where the incidence of coccidioides is increasing. Transmission of donor-derived coccidioides has been shown to be 43% within 30 days post-transplant, with a 29% mortality. Given the high mortality and treatment availability, screening donors in endemic areas with serologies may prevent post-transplant complications.

Anu taila, an herbal nasal drop, suppresses mucormycosis by regulating host TNF-α response and fungal ergosterol biosynthesis.

The intractable, mucormycosis, caused by Mucorales primarily targets immunocompromised individuals. The first-line therapy, intravenous liposomal amphotericin B and surgical debridement of necrotic tissue, is contraindicative in individuals with compromised kidneys. This invokes a pressing need to identify safer treatment options. The antifungal effect of the classical nasal drop, Anu taila, against Mucor spp. was investigated through microbiological, cytological, analytical chemical (HPLC and GS-MS/MS) and scanning electron microscopic (SEM) approaches. Anu taila-pretreated spores germinated late, resulting in reduced infectivity, observed as milder monocytic immune response. Conversely, Anu taila-pretreated human THP-1 cells exhibited an improved immune response against Mucor spores, through TNF-α. Repeated Anu taila application rapidly abolished fungal microarchitectures than amphotericin B, evident from swift replacement of hyphae, sporangiophores and sporangia with fused biomass, in the SEM images. HPLC analysis showed that Anu taila treatment significantly reduced overall ergosterol content in Mucor biomass. Anu taila also downregulated sterol-C5-desaturase-coding ERG3 gene, crucial for ergosterol biosynthesis and resultant structural integrity, in Mucor spp. Taken together, Anu taila was found effective against Mucor spp., with both prophylactic and curative implications, which is attributable to the phytochemical composition of this classical nasal drop. The potential remedial effects of a classical nasal drop against an obdurate and challenging fungal infection are identified.

Breakthrough Penile Mucormycosis in a Patient With Acute Myelogenous Leukemia on Posaconazole Prophylaxis

Abstract In patients with acute myelogenous leukemia, posaconazole prophylaxis has been shown to prevent deep invasive fungal infections, including mucormycosis. In the present case, posaconazole prophylaxis was initiated in a 58-year-old man undergoing induction chemotherapy for acute myelogenous leukemia. Three weeks after initiating chemotherapy, he developed a tender violaceous macule on the shaft of his penis. The initial differential included fixed drug eruption versus pyoderma gangrenosum. However, punch biopsy ultimately showed mucormycosis, and cultures grew Rhizopus species, despite therapeutic posaconazole trough. He was treated with intravenous amphotericin B and required right orchiectomy, penectomy, and hyperbaric oxygen therapy. Oral posaconazole was reinstituted after completion of amphotericin B course, and at 4 months follow-up, his penectomy site was fully healed. As demonstrated by the present case, not all mucormycoses are prevented by posaconazole prophylaxis. A high index of suspicion and early biopsy for prompt diagnosis are of critical importance in improving outcomes.