Mucormycosis, also known as black fungus, is a severe fungal infection that may cause fulminant fungal sinusitis, usually in people who are immunocompromised. It is mostly curable when diagnosed early. Symptoms depend on where in the body the infection occurs. It most commonly infects the nose, sinuses, eyes and brain resulting in a runny nose, one-sided facial swelling and pain, headache, fever, blurred vision, bulging or displacement of the eye (proptosis), and tissue death. Other sites of infection may include the lungs, stomach and intestines, and skin. It tends to progress rapidly and is fatal in about half of sinus cases and almost all cases of the widespread type. It is spread by spores of molds of the order Mucorales, most often through inhalation, contaminated food, or contamination of open wounds. These fungi are common in soils, decomposing organic matter (such as rotting fruit and vegetables), and animal manure, but usually do not affect people. It is not transmitted between people. Preventive measures include wearing a face mask in dusty areas, avoiding contact with water-damaged buildings, and protecting the skin from exposure to soil such as when gardening or certain outdoor work. Risk factors include diabetes with persistently high blood sugar levels or diabetic ketoacidosis, low white blood cells, cancer, organ transplant, iron overload, kidney problems, long-term steroids or use of immunosuppressants, and to a lesser extent HIV/AIDS. Diagnosis is by biopsy and culture, with medical imaging to help determine the extent of disease. It may appear similar to aspergillosis. Treatment is generally with amphotericin B and surgical debridement. Mucormycosis is usually rare. A recent rise in cases was particularly noted in India, where it may be about 80 times more common than in developed countries. People of any age may be affected, including premature infants. The disease has been reported in natural disasters, including the 2004 Indian Ocean tsunami and the 2011 Joplin tornado. During the COVID-19 pandemic, an association between mucormycosis and COVID-19 was reported, thought to result from reduced immune function during the illness or from glucocorticoid therapy for COVID-19.
Classification Generally, mucormycosis is classified into five main types according to the part of the body affected. A sixth type has been described as mucormycosis of the kidney, or miscellaneous, i.e., mucormycosis at other sites, although less commonly affected.
Sinuses and brain (rhinocerebral); most common in people with poorly controlled diabetes and in people who have had a kidney transplant. Lungs (pulmonary); the most common type of mucormycosis in people with cancer and in people who have had an organ transplant or a stem cell transplant. Stomach and intestine (gastrointestinal); more common among young, premature, and low birth weight infants, who have had antibiotics, surgery, or medications that lower the body's ability to fight infection. Skin (cutaneous); after a burn, or another skin injury, in people with leukaemia, poorly-controlled diabetes, graft-versus-host disease, HIV and intravenous drug use. Widespread (disseminated); when the infection spreads to other organs via the blood.
Signs and symptoms
Signs and symptoms of mucormycosis depend on the location of the infection in the body. Infection usually begins in the mouth or nose and enters the central nervous system via the eyes. If the fungal infection begins in the nose or sinus and extends to the brain, symptoms and signs may include one-sided eye pain or headache and may be accompanied by pain in the face, numbness, fever, loss of smell, a blocked nose or runny nose. The person may appear to have sinusitis. The face may look swollen on one side, with rapidly progressing "black lesions" across the nose or upper inside of mouth. One eye may look swollen and bulging, and vision may be blurred. Fever, cough, chest pain, and difficulty breathing, or coughing up blood, can occur when the lungs are involved. A stomach ache, nausea, vomiting, and bleeding can occur when the gastrointestinal tract is involved. Affected skin may appear as a dusky reddish tender patch with a darkening centre due to tissue death. There may be an ulcer, and it can be very painful. Invasion of the blood vessels can result in thrombosis and subsequent death of surrounding tissue due to a loss of blood supply. Widespread (disseminated) mucormycosis typically occurs in people who are already sick from other medical conditions, so it can be difficult to know which symptoms are related to mucormycosis. People with disseminated infection in the brain can develop changes in mental status or lapse into a coma.
Cause Mucormycosis is a fungal infection caused by fungi in the order Mucorales. In most cases it is due to an invasion of the genera Rhizopus and Mucor, common bread molds. Most fatal infections are caused by Rhizopus oryzae. It is less likely due to Lichtheimia, and rarely due to Apophysomyces. Others include Cunninghamella, Mortierella, and Saksenaea. The fungal spores are present in the environment. Once inside the body, the fungus grows branch-like filaments which invade blood vessels, causing clots to form and surrounding tissues to die. Spores can be found on items such as moldy bread and fruit, and are breathed in frequently, but cause disease only in some people. In addition to being breathed in and deposited in the nose, sinuses, and lungs, the spores can also enter the skin via blood or directly through a cut or open wound, and can also grow in the intestine if eaten. Other reported causes include contaminated wound dressings. Mucormycosis has been reported following the use of elastoplast and the use of tongue depressors for holding in place intravenous catheters. Outbreaks have also been linked to hospital bed sheets, negative-pressure rooms, water leaks, poor ventilation, contaminated medical equipment, and building works. One hypothesis suggests that the spread of fungal spores in India could be due to fumes generated from the burning of Mucorales-rich biomass, like cow dung and crop stubble.
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