Systemic Antifungal Treatment Research Articles

Optimized Antifungal Therapy for Chronic Pulmonary Aspergillosis.

Chronic pulmonary aspergillosis (CPA) represents a spectrum of lung disorders caused by local proliferation of Aspergillus hyphae in individuals with non-systemic or mildly systemic immunodepression or altered pulmonary integrity due to underlying disease. While long-term systemic antifungal treatment is still the mainstay for management, surgery is considered mainly in rarer invasive disease manifestations such as sinusitis and osteomyelitis. Optimal application of existing antifungal agents with suitable pharmacokinetic properties is important for the treatment of diseases such as CPA, which requires long-term use. Appropriate management of side effects by therapeutic drug monitoring, maintenance of adherence, and assessment of drug resistance to Aspergillus can provide safe and effective treatment in the future. Most available antifungal agents for the management of mycoses in humans have disadvantages that can limit their use in clinical practice. By contrast, second generation antifungals such as triazoles have advantages of extended antifungal spectrum and availability in both oral and intravenous formulations. Isavuconazole, a new extended spectrum triazole, has been shown to be effective against Aspergillus. The safety profile and excellent pharmacokinetic characteristics of isavuconazole make it an attractive option for treatment of invasive fungal infections including CPA. With this drug now available in Japan, new evidence is expected to expand treatment options. This review focuses on the selection of antifungal agents based on national and international guidelines and the characteristics of each agent for their appropriate use in CPA.

Dermatomycoses: topical and systemic antifungal treatment

Topical antifungals with activity against dermatophytes include amorolfine, allylamines, azoles, ciclopiroxolamine, and tolnaftate. Polyene antimycotics, such as amphotericinB and nystatin, alternatively, miconazole are suitable for yeast infections of the skin and mucous membranes. For severe yeast infections of the skin and mucous membranes, oral triazole antimycotics, such as fluconazole and itraconazole, are used. Pityriasis versicolor is treated topically with antimycotics, and in severe forms also orally with itraconazole, alternatively fluconazole. Terbinafine, itraconazole and fluconazole are currently available for the systemic treatment of severe dermatophytoses, tinea capitis and onychomycosis. In addition to proven therapeutic regimens, unapproved (off-label use) intermittent low-dose therapies are increasingly being used, particularly in onychomycosis. Oral antimycotics for the treatment of tinea capitis and onychomycosis in children and adolescents can only be used off-label in Germany. In general, any oral antifungal treatment should always be combined with topical antifungal therapy. In tinea corporis and tinea cruris caused by Trichophyton (T.) mentagrophytes ITS (internal transcribed spacer) genotype VIII (T.indotineae), there is usually terbinafine resistance. Identification of the species and genotype of the dermatophyte and resistance testing are required. The drug of choice for T.mentagrophytes ITS genotype VIII dermatophytoses is itraconazole. In individual cases, treatment-refractory onychomycosis may be due to terbinafine resistance of T.rubrum. Here too, resistance testing and alternative treatment with itraconazole should be considered. Therapy monitoring should be carried out culturally and, if possible, using molecular methods (polymerase chain reaction). Alternative treatment options include laser application, and photodynamic therapy (PDT).

Application and evaluation of topical amphotericin B for the treatment of respiratory fungal infections

BackgroundIn recent years, the prevalence of respiratory fungal diseases has increased. Polyene antifungal drugs play a pivotal role in the treatment of these conditions, with amphotericin B (AmB) being the most representative drug. This study aimed to evaluate the efficacy and safety of topical administration of AmB in the treatment of respiratory fungal infections.MethodsWe conducted a retrospective study on hospitalized patients treated with topical administered AmB for respiratory fungal infections from January 2014 to June 2023.ResultsData from 36 patients with invasive pulmonary fungal infections treated with topical administration of AmB were collected and analyzed. Nebulization was administered to 27 patients. After the treatment, 17 patients evidenced improved conditions, whereas 10 patients did not respond and died in the hospital. One patient experienced an irritating cough as an adverse reaction. Seven patients underwent tracheoscopic instillation, and two received intrapleural irrigation; they achieved good clinical therapeutic efficacy without adverse effects.ConclusionThe combined application of systemic antifungal treatment and topical administration of AmB yielded good therapeutic efficacy and was well-tolerated by the patients. Close monitoring of routine blood tests, liver and kidney function, and levels of electrolytes, troponin, and B-type natriuretic peptide supported this conclusion.

Management and Outcomes of Necrotizing Otitis Externa: A Retrospective Cohort Study in a Tertiary Referral Center.

Necrotizing otitis externa (NOE) is a rare infection of the ear that causes osteomyelitis. We aimed to evaluate treatment outcomes and the role of imaging in diagnosing and monitoring disease resolution in a single-center study of patients with NOE. In this retrospective cohort study, patients with NOE who were diagnosed and treated in a tertiary otology center in Utrecht, The Netherlands, between January 1, 2013 and August 1, 2022, were included. Data were retrieved from the medical records on demographics, symptoms, physical and diagnostic findings, type and duration of treatment, and course of disease. A total of 24 cases were included. Patients were often elderly (mean age = 75 years) and diabetic (88%). Pseudomonas aeruginosa was the most commonly found microorganism (63%). Twenty-two cases (92%) received intravenous antibiotic treatment, and 7 cases (29%) received additional systemic antifungal treatment. The mean duration of systemic treatment was 29 weeks. In 20 out of 22 cases (91%), imaging was used to determine the end point of treatment. None of the cases with a total resolution of disease activity (n = 5) on 18F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging at the time of cessation of therapy showed clinical relapse, compared with 1 out of 4 cases on gallium single-photon emission computerized tomography. Based on the experience from our center, we demonstrated that patients with NOE can successfully be treated with prolonged systemic treatment. Molecular imaging is reasonably successful for disease evaluation and decision-making on the eradication of disease.

Severe fusarium oxysporum keratomycosis: About 2 Cases

Fungal keratitis is a destructive ocular infection, representing a serious diagnostic and therapeutic problem, difficult to treat and with poor results. It can cause irreversible damage. Keratomycoses are rare and may be under-diagnosed. Direct microscopic examination and culture are essential for early specific diagnosis and must be taken into consideration to establish the most effective treatment and avoid serious complications. The pathogenesis of this infection is based on three factors: colonization, tissue damage and immunosuppression. We report 2 cases of Fusarium oxysporum keratomycosis treated with amphotericin B. The diagnosis of corneal abscess was made after ophthalmological examination in 2 adult males with no previous ophthalmological history, referred to the Omar Drissi hospital in Fez for decreased visual acuity, photophobia, redness and intense pain in the right/left eye. Corneal scrapings were taken for microbiological analysis, and after initial mycological results, local and systemic antifungal treatment was initiated with amphotericin B and natamycin eye drops. The evolution was marked by a corneal perforation with a tenon patch graft for the first patient, and healing for the 2nd

Botryosphaeria dothidea Mycotic Keratitis: A Novel Phytopathogen Causing Human Infection.

The aim of this study was to report the first case of mycotic keratitis caused by Botryosphaeria dothidea . A 29-year-old man developed a fungal infection after being hit with chestnut thorns in the left eye. In vivo confocal microscopy, microbial culture, and next-generation sequencing (NGS) were used in the diagnosis of mycotic keratitis. The patient was provisionally diagnosed with mycotic keratitis based on IVCM and promptly received local and systemic antifungal treatment with voriconazole and amphotericin B. Although microbial culture failed to identify the pathogen, NGS revealed B. dothidea as the causative agent. Although the infection was quickly contained, corneal perforation still occurred. Owing to the lack of fresh donor corneas, the patient underwent multilayer amniotic membrane and conjunctival pedicle graft surgery. The infection was successfully controlled, and during the 6-month follow-up, the cornea remained clear in the inferotemporal optical zone. We report a novel phytopathogen- B. dothidea -causing mycotic keratitis . Our case indicates that B. dothidea responds well to voriconazole and amphotericin therapy. This case broadens the spectrum of fungal keratitis and highlights the application of NGS in identifying molds.

The fate of fungal periprosthetic joint infection after total knee arthroplasty.

To demonstrate the clinical outcomes of patients with fungal periprosthetic joint infections (PJIs) after two-stage exchange arthroplasty combined with antifungal therapy. We retrospectively reviewed the outcomes of 41 patients with fungal PJIs after primary total knee arthroplasty (TKA) in a single centre from January 1999 to October 2017. During the first stage of resection arthroplasty, antifungal-impregnated cement spacers (AICSs) were implanted in all patients. After systemic antifungal treatment during the interval between the two surgeries, delayed reimplantation as part of a two-stage exchange protocol was performed when patients were clinically stable. We defined treatment success as a well-functioning arthroplasty without any signs of PJI after a minimum follow-up of two years without antimicrobial suppression. Successful treatment was confirmed by repeat negative cultures as well as a return of inflammatory markers to normal levels. The treatment success rate was 63.4% at the final follow-up. Thirty-six of 41 patients (87.8%) met the criteria for second-stage revision after confirmation of complete infection control. The mean prosthesis-free interval was 6.6 months (range, 2.0-30.0 months). During follow-up after two-stage exchange arthroplasty, ten patients (27.7% of 36 patients) unfortunately experienced recurrence or relapse of infection after an average of 31.3 months (range, 2.7-135.6 months). The rate of survivorship free from reinfection was 94.4% at six months, 84.8% at one year, and 73.6% at two years. Cox proportional hazard regression analysis demonstrated that the prosthesis-free interval (HR = 1.016, p = 0.037) and mean length of antifungal treatment (HR = 0.226, p = 0.046) were potential risk factors for failure. Fungal PJIs led to devastating clinical outcomes despite even two-stage revision arthroplasty with the use of AICSs and antifungal medications.

Optical coherence tomography findings in fungal uveitis.

The purpose of the study was to describe the vitreal, retinal, and choroidal features of eyes affected by endogenous endophthalmitis (EE) and evaluate the effects of systemic antifungal drug treatment and pars plana vitrectomy by using spectral domain optical coherence tomography (SD-OCT). Medical records and SD-OCT images of eyes diagnosed with EE at a single uveitis tertiary referral center in Brazil were acquired at the time of diagnosis, after 7 days of high-dose antifungal drug treatment, and at follow-up assessments performed 30days after resolution. Thirteen eyes were enrolled in the study. All patients showed hyperreflective round-shaped lesions on SD-OCT and pre-retinal aggregates. Five eyes responded to antifungal systemic oral drugs despite showing vitreous opacity. The response to treatment was observable on optical coherence tomography (OCT) images. Fungal endophthalmitis showed typical features on SD-OCT, facilitating early diagnosis and treatment despite the absence of vitreous culture or biopsy. This study suggests that OCT images can be used to support diagnosis by physicians who do not have access to vitreoretinal surgery.

Joint fluid concentrations of amphotericin B after local application with calcium sulphate-report of 2 cases.

Fungal periprosthetic joint infections (PJI) are difficult to treat, due to important biofilm formation and limited local penetration of systemically administered antifungals. Calcium sulphate (CaSO4 ) might be a promising carrier to increase local concentration of antifungals. We hypothesized that local amphotericin B release from CaSO4 is high enough to significantly contribute to treatment of fungal PJI. We report joint fluid and serum concentrations of amphotericin B after local application with CaSO4 as an implanted resorbable carrier material as adjunct to standard surgical and systemic antifungal treatment in two cases of PJI with Candida spp. Maximal joint fluid amphotericin B concentration was 14.01 mg/L 5 days after the second local administration of liposomal amphotericin in Case One and 25.77 mg/L 14 days after the second local administration in Case Two. Concentrations higher than minimal inhibitory concentrations (MIC) could be measured for 21 days and 17 days after local administration in Case One and Two, respectively. In Case Two, serum concentration of amphotericin B was <0.01 mg/L 3 days after local administration of 450 mg liposomal amphotericin B. No local or systemic adverse reaction was observed. Fungal PJI was successfully eradicated in both cases with a follow-up of 12 months in Case One and 20 months in Case Two. Application of amphotericin B-loaded CaSO4 was associated with joint fluid concentrations higher than minimal inhibitory concentrations for Candida spp. for approximately 3 weeks, with the advantage that the carrier material dissolves spontaneously and does not require secondary removal. Relapse of fungal infections did not occur in these two patients.

Functional Endoscopic Sinus Surgery and Recurrence of Post-COVID Mucormycosis.

PurposeTo evaluate the value and limitation of functional endoscopic sinus surgery alone for the management of post-COVID mucormycosis and need for adjunctive invasive procedure.Materials and MethodsThis is a clinical observational study that included a total of 17 patients who underwent FESS for post-COVID mucormycosis from April 2021 to May 2021. These patients reported to our institute with no improvement in their symptoms post-FESS from June 2021 to July 2021. Aggressive Surgical debridement of the involved sinuses, removal of surrounding necrotic bone and orbital exenteration (wherever necessary) was done in these patients. A regular follow-up till six months was done for every patient. Sixteen out of 17 patients did not report with any fresh complaint or recurrence.ResultsThe study included male and female in ratio of 12:5, with a mean age of 62.5 ± 7.7 years (range: 50–75 years). These patients underwent functional endoscopic sinus surgery, one to two months before reporting to our institute. Post-FESS, there was no improvement in the symptoms. All these patients were given systemic antifungal treatment post-operatively. The specimen was sent for histopathological as well as microbiological examination. All the FESS operated patients required a secondary more aggressive surgical intervention.ConclusionPost-COVID mucormycosis is an aggressive fungal infection, for which FESS proves inadequate. It requires an aggressive surgical debridement of the necrotic bone along with the debridement of the sinuses.

P320 Ten cases of tinea incognito due to Trichophyton rubrum, and literature review on the pathogenic characteristics

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjectiveWe present ten tinea incognito (TI) patients caused by Trichophyton rubrum combined with a review of the characteristics of tinea incognito infections reported worldwide over the past 20 years, leading to clinical requirements for diagnosis and treatment.Patients and MethodsPatients were scraped for direct KOH microscopy of the skin lesions at the initial visit, isolates were cultured in SDA medium for 14 days and species were identified by morphology and molecular analysis using ITS regions. Literature review by searching articles on ‘PubMed’ and ‘Web of Science’, using the keywords ‘Tinea incognito or Incognito’, Set the year as ‘2002-2022’, and screened the literature for cases with clear types of TI infecting pathogens. Clinical, mycological, and treatment data of all cases were collected and analyzed.ResultsWe report 10 cases of tinea incognito caused by T. rubrum, ranging in age from 5 to 70 years, with clinical manifestations of eczema-like (Figs. 1a, b, and f), SLE-like (Fig. 1d) and pustular psoriasis-like (Figure 1c, e, g, h, i and j), seen in multiple sites. All of our patients had either tinea pedis or onychomycosis themselves or in their family members.A total of 660 cases reported in the last 20 years, T. rubrum (279/660) was the main anthropophilic dermatophytes causing TI, T. mentagrophytes (162/660) and Microsporum canis (135/660) were the common zoophilic pathgens. There were median age differences in patients infected with T. rubrum, T. mentagrophytes, M. canis, and Nannizzia gypsea, at 56, 22.5, 23, and 5.5 years old, respectively (Fig. 2a). The TI patients infected by T. rubrum often had cutaneous or non-cutaneous underlying diseases (27/41), TI patients with zoophilic or geophilic dermatophyte infections had a definite animal or soil contact history (114/136). The face and trunk are the most frequently affected areas, followed by the extremities and the whole body (Fig. 2b). TI appears on the face and is often thought of as eczema, rosacea, DLE, photosensitive rash, and when it occurs on the trunk is misdiagnosed as eczema, pyoderma, psoriasis (Fig. 2c). In Asia and the Americas, anthropophilic dermatophytes are by far the most reported pathogens, especially T. rubrum. In Europe, zoonotic pathogens have been reported in excess of the anthropophilic (Fig. 2d). For patients in whom the nature of the lesions cannot be determined and with negative direct microscopic examination, dermoscopy can be used to aid in the diagnosis. Our review of all cases found that topical or systemic antifungal treatment always gave good efficacy.ConclusionTI has a broad spectrum of mimics, and an unrestricted range of target audiences, zoonotic pathogens are adapting to the human host, so the history of illness and contact is essential at the time of the initial visit. A definitive diagnosis must be obtained in a mycological laboratory, multiple modalities can be used to diagnose TI, and systemic antifungal treatment is often necessary.

Use of Fluconazole-impregnated Beads to Treat Osteomyelitis Caused by Coccidioides in a Pigtailed Macaque (Macaca nemestrina).

A 3-y-old male pigtailed macaque (Macaca nemestrina) presented for swelling of the left distal forearm and decreased use of the arm. The monkey had been raised at an indoor-outdoor facility in Arizona and transferred to an indoor facility in Washington 2 mo prior to presentation. A preliminary diagnosis of fungal osteomyelitis of the radius was made based on radiographs and Coccidioides titers. In addition to systemic antifungal treatment, surgery was performed to debride the bony lesion and implant polymethylmethacrylate beads impregnanted with the anti-fungal fluconazole. Histologic examination of the debrided material confirmed the diagnosis of fungal osteomyelitis. The surgical procedure resulted in clinical improvement, as evidenced by weight gain and decreased Coccidioides titers. The beads were removed in a second surgery, and the bony lesion completely resolved. With continued systemic fluconazole treatment, the monkey remained healthy with no further evidence of osteomyelitis. Coccidioides is an emerging pathogen that causes significant morbidity and mortality in both humans and animals. Bone infections can be resistant to systemic treatment, and the implantation of fluconazoleimpregnated beads may offer a successful treatment strategy for fungal osteomyelitis.

Aspergillus wound infection in an immune-competent patient – A case report

• Abdominal surgical site aspergillosis can be seen in an immunocompetent patient. • Surgical site aspergillosis is a form of cutaneous aspergillosis. • Prevention of surgical site aspergillosis combines clinical and environmental considerations. • Therapy involves medical and surgical approach for optimal outcomes. Abdominal aspergillosis is a life-threatening, opportunistic fungal infection that mainly affects immunocompromised patients. In this report, we present a case of abdominal surgical site aspergillosis in an immunocompetent patient. A 74-year-old immune-competent woman that had a prolonged hospitalization in the Intensive Care (ICU) Unit with several abdominal surgeries and multiple antibiotic treatment regimens. The abdomen remained open between interventions. 21 days following ICU admission a diagnosis of surgical site aspergillosis was made, treated with systemic and topical antifungal treatment. While nosocomial aspergillosis typically affects immunocompromised patients, immunocompetent patients also become susceptible when the skin barrier is broken and tissue is exposed to the environment. Treatment consisted with surgical debridement and systemic antifungal therapy. This case provides an example of extensive and rare surgical infection.

Systemic antifungal strategies in allogeneic hematopoietic stem cell recipients hospitalized in french hematology units: a post-hoc analysis of the cross-sectional observational AFHEM study\ufeff

BackgroundInvasive fungal diseases (IFD) remain a major complication of allogeneic hematopoietic stem cell transplantation (alloHSCT) and are associated with high mortality rates in patients receiving alloHSCT. Antifungal prophylaxis is increasingly being used in the management of IFDs in patients receiving alloHSCT.MethodsA post-hoc analysis of the cross-sectional observational AFHEM study was carried out to describe the use of antifungal drugs in real-life clinical practice in alloHSCT recipients hospitalized in French hematological units.ResultsA total of 147 alloHSCT recipients were enrolled; most were adults (n = 135; 92%) and had received alloHSCT < 6 months prior to enrollment (n = 123; 84%). Overall, 119 (81%) patients received a systemic antifungal therapy; of these, 95 (80%) patients received antifungal prophylaxis. Rates of patients receiving systemic antifungal treatment were similar irrespective of transplant time, neutropenic, and graft-versus-host disease status. Among patients on systemic antifungal treatment, 83 (70%) received an azole, 22 (18%) received an echinocandin, and 16 (13%) received a polyene.ConclusionsThis work provides evidence of the antifungal strategies used in alloHSCT recipients hospitalized in French hematological units. Unlike earlier studies, the AFHEM study showed that prophylaxis appears to be the leading antifungal strategy used in alloHSCT recipients in France.

Comparative characteristics of different methods of treatment of microsporia

Microsporia is the most common disease of fungal etiology, most often caused by the pathogen Microsporum canis. Treatment of this disease requires a comprehensive approach, because the disease is dangerous to humans. Therefore, in the treatment of microspores, it is important not only to carry out therapeutic measures, but also to prevent the spread of the pathogen of the fungus in the environment and increase the immune status of the organism in the fight against infection. The main source of infection is cats. In order to determine the effectiveness of treatment of microsporia by various methods, studied of the blood and skin of guinea pigs infected with the pathogen M. canis. Sick animals were divided into three groups. The first group was treated with the systemic antifungal itraconazole and topical treatment with a solution of clotrimazole. Treatment of the second group was performed with a topical antifungal agent (1% solution of clotrimazole) with vaccination with the antifungal vaccine “Vakderm”. For the third group, the developed drugs were used – antifungal agent “Micromar” and immunostimulant “Biogluk”. During treatment, hematological and immunological blood researches and histological skin examinations were performed. During treatment with antifungal drugs (itraconazole and clotrimazole) the number of leukocytes decreases from 11.13 ± 0.72 to 7.13 ± 0.22, rod-shaped neutrophils from 15.76 ± 1.29 to 5.50 ± 0.76, and segmental increases from 12.17 ± 1.47 to 24.17 ± 2.27, decreases ESR from 5.67 ± 0.67 to 2.33 ± 0.42, which occurs when inhibiting the inflammatory response of the organism to infection. Thrombocytopenia (from 231.17 ± 7.60 to 184.33 ± 7.65) and eosinophilia (from 2.70 ± 0.73 to 7.33 ± 1.33) are also noted. There is a slight increase in T-helpers and a decrease in T-suppressors. Histologically, the infiltration of the dermis by histiocytes and eosinophils under skin persists. In the treatment of microsporia by treatment with 1 % solution of clotrimazole and vaccination with the vaccine “Vakderm” the results of studies showed that the number of leukocytes decreases from 11.13 ± 0.72 to 5.35 ± 0.31 (P &lt; 0.01), rod-shaped neutrophils from 15.76 ± 1.29 to 7.67 ± 0.56, and segmental increases from 12.17 ± 1.47 to 22.17 ± 0.91 (P &lt; 0.001), decreases). The number of T-helpers is increasing. The histological picture on day 7 is characterized by hyperkeratosis, and on day 14 the hyperemia of the basal layer of the epidermis persists. When using the antifungal drug “Micromar” and immunostimulant “Biogluk” the results of studies showed that the number of leukocytes decreases from 11.13 ± 0.72 to 6.95 ± 0.10, rod-shaped neutrophils from 15.76 ± 1.29 to 6.17 ± 0.65, and segmental increases from 12.17 ± 1.47 to 22.00 ± 0.86, decreases ESR from 5.67 ± 0.67 to 2.17 ± 0.31. Increases the number of T-helpers and the number of natural killers and T-suppressors is gradually decreasing. Histological changes are presented in the form of dilation of blood vessels and visualization of single erythrocytes in the dermis on day 14 of treatment.

Eumycetoma and disseminated phaeohyphomycosis in a Sumatran tiger.

A 16-y-old female Sumatran tiger (Panthera tigris sumatrae) was evaluated for hyporexia. Examination revealed chronic kidney disease and a large subcutaneous axillary mass with draining tracts that contained numerous small black grains. Histologic examination revealed the presence of intralesional fungal hyphae. Persistent hyporexia and pyogranulomatous disease, as well as progressive cachexia and azotemia occurred despite treatment, and euthanasia was performed. Disseminated phaeohyphomycosis was diagnosed on postmortem examination, additionally affecting various lymph nodes, the nasal cavity, mesenteric adipose tissue, abdominal aorta, pericardium, and kidney. Fungal culture from a deep-tissue sample isolated a pure growth of Curvularia sp., a dematiaceous opportunistic fungus able to cause eumycetomas and/or phaeohyphomycosis. Phaeohyphomycosis is a rare but emerging condition, not previously reported as disseminated disease in an exotic carnivore, to our knowledge. Aggressive systemic antifungal treatment was unsuccessful, likely complicated by diagnostic challenges and concurrent renal disease. The presence of a swelling with abundant grains exiting draining tracts should direct clinicians to the diagnosis of a mycetoma, warranting early and aggressive treatment.

Invasive Fungal Rhinosinusitis with and without Orbital Complications: Clinical and Laboratory Differences.

Background: Invasive fungal rhinosinusitis (IFS) is a rare but often fatal disease. There are limited studies regarding IFS with orbital complications (IFSwOC). The present study aimed to identify the clinical signs associated with IFSwOC and prognosticators of the disease. Methods: A retrospective case series was conducted of patients histopathologically confirmed IFS or fungal rhinosinusitis with clinically apparent neuro-orbital complications who underwent surgery between 2008 and 2018. Demographic data, presenting symptoms and signs, culture data, laboratory results, and patient outcomes were obtained from medical records. Results: A total of 38 patients were identified, including 9 patients with IFSwOC, and 29 patients with IFS without orbital complications (IFSsOC). The clinical signs associated with developing orbital complications include headache, fever, sphenoid sinus, or posterior ethmoid sinus involvement, CRP level ≥ 1.025 mg/dL, or ESR level ≥ 46.5 mm/h. In IFSwOC group, male, posterior ethmoid sinus involvement, WBC count ≥ 9000 μL, CRP level ≥ 6.91 mg/dL, or ESR level ≥ 69 mm/h were correlated with a significantly poorer prognosis. Conclusion: IFS patients with sphenoid or posterior ethmoid sinus involvement, headache or fever as presenting symptoms, elevated CRP, and ESR level were at risk of developing orbital complications. Timely surgical debridement followed by systemic antifungal treatment may improve treatment outcomes.

COVID-19 Associated Mucormycosis in Head and Neck Region: Our Experiences at a Tertiary Care Teaching Hospital of Eastern India

Objective: To study the COVID-19 associated mucormycosis in the head and neck region of the patients along with patient details, clinical manifestations and management.Materials and Methods: This is a descriptive and retrospective study of COVID-19 associated mucormycosis (CAM) carried out at a postgraduate teaching hospital. This study was conducted between March 2020 to April 2021. A patient profile such as age, sex, comorbidities, clinical presentations, diagnosis and treatment of the CAM were analyzed.Results: There were 11 patients of CAM were enrolled in this study. There were eight male and three female patients, aged from 3 years to 72 years. Out of the 11 patients, 8 were diabetic (72.72%). Three patients (27.27%) were taking prolonged systemic steroids with a long hospital ICU stay. One child (9.09%) was under chemotherapy for acute leukemia. The common clinical symptoms were facial swelling, facial pain, nasal block and nasal discharge. The diagnosis was confirmed by histological examination and fungal culture with Sabouraud dextrose agar (SDA) showing Rhizopus oryzae. All were treated with endoscopic surgical debridement and amphotericin B. One case died because of cerebral involvement.Conclusion: Early diagnosis and prompt treatment for CAM are required. Aggressive endoscopic surgical debridement for local control and appropriate systemic antifungal treatment will help to improve the prognosis and survival of the patients.

Comparative study between topical clotrimazole manufactured by nanotechnology alone and with neodymium‐doped yttrium aluminum garnet laser (1064 nm) compared with neodymium‐doped yttrium aluminum garnet laser alone in the treatment of onychomycosis

Background Onychomycosis is defined as a fungal infection of the nail. It is caused by dermatophytes, nondermatophytes, and yeasts. Nanosuspension is defined as a submicron colloidal dispersion of any of the drug particles. Neodymium‐doped yttrium aluminum garnet (Nd : YAG) laser has been reported to be effective for treating onychomycosis. The aim was to compare topical clotrimazole-loaded gel alone and with Nd : YAG laser compared with Nd : YAG laser only in patients with mycologically proven onychomycosis. Patients and methods A total of 60 patients presented with onychomycosis. All patients were subjected to a full history taking, dermoscopic and clinical examination, assessment of severity by using the onychomycosis severity index, and culture. Results There was a statistically significant response (decrease in onychomycosis severity index, dermoscopic features, and mycological clearance) in patients treated by both topical clotrimazole and Nd : YAG laser compared with laser alone or topical clotrimazole-loaded gel alone. Conclusion Clotrimazole-loaded gel showed high efficacy against Candida and can be used as an adjuvant to systemic or topical antifungal treatment for onychomycosis or laser system.

COVID-19 associated mucormycosis in head and neck region of pediatric patients: a life-threatening disease in current pandemic

Mucormycosis is a severe form of fungal infection and often affect immunocompromised patients. It is associated with high morbidity and mortality and characterized by extensive angioinvasion and necrosis of the affected tissue. It is potentially fatal invasive fungal infection in the pediatric age group. It results in rapid spread of the disease with tissue destruction and its nature of angioinvasion can cause wide-spread dissemination. Currently this dreaded mucormycosis is rising among COVID-19 pediatric patients during their treatment period or after their discharge from hospital. It is also called COVID-19 associated mucormycosis (CAM) or black fungus. Classically, uncontrolled diabetes mellitus (DM) and other immunosuppressive conditions or corticosteroid therapy during COVID -19 treatment are known risk factors for causing mucormycosis in pediatric patients. Early identification and prompt treatment in pediatric patients with CAM are required. In the head and neck area, rhino-orbital-cerebral mucormycosis is a fatal clinical entity associated with COVID-19 infections result in higher morbidity and mortality of the pediatric patients. Aggressive endoscopic surgical debridement for local control and appropriate systemic antifungal treatment will help to improve the prognosis and survival of the patients. The aim of this review article is to discuss the detail of epidemiology, etiopathology, clinical profile, diagnosis and current treatment options of the CAM in children.