Mucormycosis: Battle with the Deadly Enemy over a Five-Year Period in India

Abstract

Mucormycosis is an emerging opportunistic fungal infection. Increasing immunocompromization, widespread use of antibacterial and antifungal agents (such as voriconazole prophylaxis), carcinomas, transplantation and lifestyle diseases such as diabetes are the main contributors to this situation. The predominant clinical manifestations of mucormycosis vary from host to host, with rhino-orbital-cerebral, pulmonary, cutaneous, and gastrointestinal infections being the most common. In India, the prevalence of mucormycosis is approximately 0.14 cases/1000 population, which is about 70 times the worldwide-estimated rate for mucormycosis. The present study was undertaken over a period of five years (January 2009–December 2014) to determine the prevalence of mucormycosis. The samples suspected of mucormycosis were examined by direct KOH wet mount and cultured on Sabouraud’s dextrose agar without actidione and on blood agar as per standard mycological techniques. Histopathological correlation was done for most of the cases. Antifungal susceptibility testing was performed by the EUCAST reference method. We identified a total of 82 cases of mucormycosis out of a total of 6365 samples received for mycological culture and examination during the said time period. Out of these, 56 were male patients and 27 were females. Most common presentation was rhino-orbito-cerebral (37), followed by cutaneous (25), pulmonary (14), oral cavity involvement (4) and gastrointestinal (2). The most common risk factors were diabetes and intramuscular injections. The fungi isolated were Rhizopus arrhizus (17), Apophysomyces variabilis (12), R. microsporus (9), Lichtheimia ramosa (8), Saksenaea erythrospora (5), Syncephalastrum racemosus (4), R. homothallicus (2), Rhizomucor pusillus (1), Mucor irregularis (1) and A. elegans (1). The mainstay of the treatment was amphotericin B, along with extensive surgical debridement whenever feasible. Most of the patients (50) recovered, but 25 died. The rest of the patients left against medical advice. “Nip in the Bud” should be the mantra for clinicians/surgeons for a favorable prognosis. Early diagnosis, prompt institution of appropriate antifungal therapy, surgical debridement whenever necessary, knowledge of risk factors and their timely reversal is the key for management.

Mucormycosis in South America: A review of 143 reported cases

“…Most cases in South America occurred in the 18‐44 years and 45‐64 years age groups (74.8%). Additionally, most patients were males (61.5%), which is also consistent with findings (60%‐70% male) across studies from other regions …”

“…A number of different factors are associated with an increased risk of mucormycosis . Globally, mucormycosis is particularly common in patients with diabetes mellitus, and the risk is much higher in patients with uncontrolled diabetes, in whom the resultant ketoacidosis interferes with the normal activity of lymphocytes, increasing risk of infection . In addition, as with other IFD, patients with an impaired immune system following the use of immunosuppressive treatments are also vulnerable.…”

“…Prompt diagnosis and rapid initiation of antifungal therapy combined with surgical removal of infected tissue are required for optimal outcomes. In addition, control of the underlying condition and/or reduction of immunosuppression are important components of treatment …”

Mucormycosis in the Middle East and North Africa: Analysis of the FungiScope® registry and cases from the literature

“…17 The proportion of males (58.4%) was largely consistent with the range observed in other studies (58-70%). [5][6][7]17,23,24 The most frequent underlying condition in the MENA region was diabetes mellitus, followed by corticosteroid use, solid organ transplants, haematological malignancy and long-term neutropenia.…”

Environmental interactions with amoebae as drivers of bacterial-fungal endosymbiosis and pathogenicity

“…Mucorales virulence has been shown to be affected by spore size and immunogenicity, germination rate, hyphal biomass, and hyphal resistance to killing 26-30 . The species Rhizopus microsporus is among the most frequent causes of mucormycosis 31,32 , but fails to mask cell wall ligands in swollen spores, has a slow germination rate, and produces relatively low biomass 26,33 . This raises questions about how R. microsporus evades the innate immune response to cause disease.…”