Mucormycosis is a highly aggressive angio-invasive disease of humans caused by Mucorales fungi. Prior to the COVID-19 pandemic, mucormycosis was a rare mycosis typically seen in immunocompromised patients with hematological malignancies or in transplant recipients. During the second wave of the pandemic, there was a dramatic increase in the disease, especially in India where a unique set of circumstances led to large numbers of life-threatening and disfiguring rhino-orbital-cerebral mucormycosis (ROCM) infections. The review examines mucormycosis as a super-infection of COVID-19 patients, and the risk factors for COVID-19-associated mucormycosis (CAM) that drove the ROCM epidemic in India. The limitations of current diagnostic procedures are identified, and the measures needed to improve the speed and accuracy of detection discussed. Despite increased awareness, global healthcare systems remain unprepared for further outbreaks of ROCM. Current diagnosis of the disease is slow and inaccurate, negatively impacting on patient survival. This is most evident in low- to middle-income countries which lack suitably equipped diagnostic facilities for rapid identification of the infecting pathogens. Rapid antigen testing using point-of-care lateral-flow assays could potentially have aided in the quick and accurate diagnosis of the disease, allowing earlier intervention with surgery and Mucorales-active antifungal drugs.

Invasive mucormycosis is a rare mycosis that affects most cases of uncontrolled diabetes and has a high mortality rate. Patients with COVID-19 are at high risk of developing invasive mucormycosis due to the consumption of anti-inflammatory drugs such as corticosteroids and dexamethasone. Rhizopus species followed by Rhizomucor spp. and Mucor spp. are the main common etiological agents of rhino-orbital mucormycosis. Therefore, this study aimed to present a case of mucormycosis due to Syncephalastrum racemosum in a diabetic patient with COVID-19 for the first time in Iran. A 73-year-old diabetic female was referred to Ayatollah Rouhani Hospital in Babol, Iran, with a confirmed COVID-19 diagnosis, based on positive RT-PCR and computed tomography of the lungs. She has received methylprednisolone due to severe lung complications. Nasal involvement and left orbital swelling were observed 20 days after the hospitalization. By sinus endoscopic surgery, debridement was done and histopathology indicated wide hyphae (without septa). The sequenced PCR products displayed Syncephalastrum racemosum. In the antifungal susceptibility test, amphotericin B showed good activity against S. racemosum and the patient survived with timely treatment. This is the first case report of rhino-orbital mucormycosis due to S. racemosum in COVID-19 patient; therefore, S. racemosum can be considered one of the etiological factors of rhino-orbital mucormycosis in COVID-19 cases.

Dermatophytosis is the most common type of superficial fungal infection caused by dermatophytes. Occasionally, the fungus invades deep into the dermis or other tissues, causing deep dermatophytosis. Deep dermatophytosis is often associated with Caspase Recruitment Domain-containing protein 9 (CARD9) deficiency in patients. Here, we report the first case of deep dermatophytosis with a rare mycosis fungoides manifestation caused by T. tonsurans in a patient with a novel mutation in exon 4 of CARD9. The condition presented with heterozygous K196E mutation, which leads to deficiency of innate and adaptive immune responses in the patient, and caused intractable severe lesions. The patient received treatment with multiple antifungal drugs and was ultimately alleviated by posaconazole. These findings extend the pathogen spectrum of deep dermatophytosis linked with CARD9 deficiency and enriched their phenotypic spectrum.

Conidiobolomycosis is an uncommon, chronic, localized subcutaneous mycosis primarily affecting rhinofacial region. It is reported mainly from tropical and subtropical countries. The condition is underreported due to the lack of clinical suspicion and usually mismanaged. This rare mycosis is due to the genus Conidiobolus within the order Entomophthorales of class Zygomycetes. Here we present 3 cases of rhinofacial conidiobolomycosis in otherwise healthy adults from different parts of Sri Lanka over 1-year period. All patients had disfiguring subcutaneous lesions in the rhinofacial area. The diagnoses were based on isolation of Conidiobolus coronatus in clinical specimens.