Mucormycosis: Difference between revisions

Mucormycosis
Mucormycosis
Other names	Zygomycosis, black fungus
	Micrograph of pulmonary mucormycosis
Specialty	Oral and maxillofacial surgery, Infectious disease, Emergency medicine
Symptoms	Depends on location: runny nose, black area of skin, facial swelling, headache, fever, cough, blurred vision
Complications	Blindness, thrombosis
Usual onset	Rapid
Types	Sinuses and brain, lung, stomach and intestine, skin, disseminated, miscellaneous
Causes	Fungi of the Mucorales type
Risk factors	Diabetes, iron overload, low white cells, cancer, organ transplant, kidney problems, immunosuppressants, long-term steroids
Diagnostic method	Biopsy, culture, medical imaging
Differential diagnosis	Orbital cellulitis, cavernous sinus thrombosis, aspergillosis
Prevention	Face masks, avoiding contact with soil or water-damaged buildings, good diabetic control
Treatment	Antifungals, surgical debridement, treat underlying medical conditions
Medication	Amphotericin B, isavuconazole, posaconazole
Prognosis	Poor
Frequency	Rare

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Mucormycosis, also known as black fungus,^[3]^[4] is a severe fungal infection^[11] that comes under fulminant fungal sinusitis,^[12] usually in people who are immunocompromised.^[9]^[13] It is curable only when diagnosed early.^[12] Symptoms depend on where in the body the infection occurs.^[14]^[15] 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.^[1]^[6] Other forms of disease may infect the lungs, stomach and intestines, and skin.^[6] The fatality rate is about 54%.

It is spread by spores of molds of the order Mucorales, most often through inhalation, contaminated food, or contamination of open wounds.^[16] These fungi are common in soils, decomposing organic matter (such as rotting fruit and vegetables), and animal manure, but usually do not affect people.^[17] It is not transmitted between people.^[15] 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 in HIV/AIDS.^[7]^[9]

Diagnosis is by biopsy and culture, with medical imaging to help determine the extent of disease.^[5] It may appear similar to aspergillosis.^[18] Treatment is generally with amphotericin B and surgical debridement.^[8] 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.^[10] It tends to progress rapidly and is fatal in about half of sinus cases and almost all cases of the widespread type.^[2]^[19]

Mucormycosis is usually rare,^[8] but is now ~80 times more common in India.^[20] People of any age may be affected, including premature infants.^[8] The first known case of mucormycosis was possibly the one described by Friedrich Küchenmeister in 1855.^[1] The disease has been reported in natural disasters, including the 2004 Indian Ocean tsunami and the 2011 Joplin tornado.^[21] During the COVID-19 pandemic, an association between mucormycosis and COVID-19 has been reported. This association is thought to relate to reduced immune function during the course of the illness and may also be related to glucocorticoid therapy for COVID-19.^[4]^[22] A rise in cases was particularly noted in India.^[23]

Classification

Generally, mucormycosis is classified into five main types according to the part of the body affected.^[15]^[24] A sixth type has been described as mucormycosis of the kidney,^[1] or miscellaneous, i.e., mucormycosis at other sites, although less commonly affected.^[24]

Sinuses and brain (rhinocerebral); most common in people with poorly controlled diabetes and in people who have had a kidney transplant.^[15]
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.^[15]
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.^[15]
Skin (cutaneous); after a burn, or other skin injury, in people with leukaemia, poorly controlled diabetes, graft-versus-host disease, HIV and intravenous drug use.^[5]^[15]
Widespread (disseminated); when the infection spreads to other organs via the blood.^[15]

Signs and symptoms

Signs and symptoms of mucormycosis depend on the location in the body of the infection.^[6] Infection usually begins in the mouth or nose and enters the central nervous system via the eyes.^[5]

If the fungal infection begins in the nose or sinus and extends to 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.^[25] 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.^[6]^[25]^[26]

Fever, cough, chest pain, and difficulty breathing, or coughing up blood, can occur when the lungs are involved.^[6] A stomach ache, nausea, vomiting and bleeding can occur when the gastrointestinal tract is involved.^[6]^[27] Affected skin may appear as a dusky reddish tender patch with a darkening centre due to tissue death.^[13] There may be an ulcer, and it can be very painful.^[5]^[7]^[13]

Invasion of the blood vessels can result in thrombosis and subsequent death of surrounding tissue due to a loss of blood supply.^[7] 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.^[28]^[29]

Cause

Mucormycosis is a fungal infection caused by fungi in the order Mucorales.^[5] In most cases it is due to an invasion of the genera Rhizopus and Mucor, common bread molds.^[30] Most fatal infections are caused by Rhizopus oryzae.^[18] It is less likely due to Lichtheimia, and rarely due to Apophysomyces.^[31] Others include Cunninghamella, Mortierella, and Saksenaea.^[5]^[32]

The fungal spores are present in the environment, can be found on items such as moldy bread and fruit, and are breathed in frequently, but cause disease only in some people.^[5] 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.^[15]^[32] Once deposited, the fungus grows branch-like filaments which invade blood vessels, causing clots to form and surrounding tissues to die.^[5] Other reported causes include contaminated wound dressings.^[5] Mucormycosis has been reported following the use of elastoplast and the use of tongue depressors for holding in place intravenous catheters.^[5] Outbreaks have also been linked to hospital bed sheets, negative-pressure rooms, water leaks, poor ventilation, contaminated medical equipment, and building works.^[33] 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.^[34]

Risk factors

Predisposing factors for mucormycosis include immune deficiencies, a low neutrophil count, and metabolic acidosis.^[13]^[9] Risk factors include poorly controlled diabetes mellitus (particularly DKA), organ transplant, iron overload, such cancers as lymphomas, kidney failure, liver disease, severe malnutrition, and long term corticosteroid and immunosuppressive therapy.^[32]^[10] Other risk factors include tuberculosis (TB),^[21] deferoxamine^[1] and to a lesser extent HIV/AIDS.^[1]^[7] Cases of mucormycosis in fit and healthy people are less common.^[7]

Corticosteroids are commonly used in the treatment of COVID-19 and reduce damage caused by the body's own immune response to the virus. They are immunosuppressant and increase blood sugar levels in both diabetic and non-diabetic patients. It is thought that both these effects may contribute to cases of mucormycosis.^[35]^[36]^[22]

Mechanism

Most people are frequently exposed to Mucorales without developing the disease.^[32] Mucormycosis is generally spread by breathing in, eating food contaminated by, or getting spores of molds of the Mucorales type in an open wound.^[16] It is not transmitted between people.^[15]

The precise mechanism by which diabetics become susceptible is unclear. In vivo, a high sugar level alone does not permit the growth of the fungus, but acidosis alone does.^[1]^[7] People with high sugar levels frequently have high iron levels, also known to be a risk factor for developing mucormycosis.^[7] In people taking deferoxamine, the iron removed is captured by siderophores on Rhizopus species, which then use the iron to grow.^[37]

Diagnosis

There is no blood test that can confirm the diagnosis.^[38] Diagnosis requires identifying the mold in the affected tissue by biopsy and confirming it with a fungal culture.^[8] Because the causative fungi occur all around and may therefore contaminate cultures underway, a culture alone is not decisive.^[5] Tests may also include culture and direct detection of the fungus in lung fluid, blood, serum, plasma and urine.^[21] Blood tests include a complete blood count to look specifically for neutropenia.^[38] Other blood tests include iron levels, blood glucose, bicarbonate, and electrolytes.^[38] Endoscopic examination of the nasal passages may be needed.^[38]

Imaging

Imaging is often performed, such as CT scan of lungs and sinuses.^[39] Signs on chest CT scans, such as nodules, cavities, halo signs, pleural effusion and wedge-shaped shadows, showing invasion of blood vessels, may suggest a fungal infection, but do not confirm mucormycosis.^[18] A reverse halo sign in a person with a blood cancer and low neutrophil count is highly suggestive of mucormycosis.^[18] CT scan images of mucormycosis can be useful to distinguish mucormycosis of the orbit and cellulitis of the orbit, but images may appear identical to those of aspergillosis.^[18] MRI may also be useful.^[40] Currently,^[when?] MRI with gadolinium contrast is the investigation of choice in rhinoorbito-cerebral mucormycosis.^{[citation needed]}

Culture and biopsy

To confirm the diagnosis, biopsy samples can be cultured.^[14]^[38] Culture from biopsy samples does not always give a result as the organism is very fragile.^[18] Microscopy can usually determine the genus and sometimes the species, but may require an expert mycologist.^[18] The appearance of the fungus under the microscope can vary but generally shows wide (10–20 micron), ribbon-like filaments that generally do not have septa and that—unlike in aspergillosis—branch at right angles, resembling antlers of a moose, which may be seen to be invading blood vessels.^[13]^[38]

Ribbon-like hyphae which branch at 90°
Hyphae in blood vessel
Mature sporangium of a Mucor^[41]

Other

Matrix-assisted laser desorption/ionization may be used to identify the species.^[38] A blood sample from an artery may be useful to assess for metabolic acidosis.^[38]

Differential diagnosis

Other filamentous fungi may however look similar.^[33] It may be difficult to differentiate from aspergillosis.^[42] Other possible diagnoses include anthrax, cellulitis, bowel obstruction, ecthyma gangrenosum, lung cancer, clot in lungs, sinusitis, tuberculosis and fusariosis.^[43]

Prevention

Preventive measures include wearing a face mask in dusty areas, washing hands, avoiding direct contact with water-damaged buildings, and protecting skin, feet, and hands where there is exposure to soil or manure, such as gardening or certain outdoor work.^[10] In high risk groups, such as organ transplant patients, antifungal drugs may be given as a preventative.^[10]

Treatment

Treatment involves a combination of antifungal drugs, surgically removing infecting tissue and correcting underlying medical problems, such as diabetic ketoacidosis.^[1]

Medication

Once mucormycosis is suspected, amphotericin B at an initial dose of 1 mg is initially given slowly over 10–15 minutes into a vein, then given as a once daily dose according to body weight for the next 14 days.^[44] It may need to be continued for longer.^[42] Isavuconazole and Posaconazole are alternatives.^[21]^[45]

Surgery

Surgery can be very drastic, and, in some cases of disease involving the nasal cavity and the brain, removal of infected brain tissue may be required. Removal of the palate, nasal cavity, or eye structures can be very disfiguring.^[27] Sometimes more than one operation is required.^[32]

Other considerations

The disease must be monitored carefully for any signs of reemergence.^[32]^[46] Treatment also requires correcting sugar levels and improving neutrophil counts.^[1]^[7] Hyperbaric oxygen may be considered as an adjunctive therapy, because higher oxygen pressure increases the ability of neutrophils to kill the fungus.^[7] The efficacy of this therapy is uncertain.^[33]

Prognosis

It tends to progress rapidly and is fatal in about half of sinus cases, two thirds of lung cases, and almost all cases of the widespread type.^[19] Skin involvement carries the lowest mortality rate of around 15%.^[32] Possible complications of mucormycosis include the partial loss of neurological function, blindness, and clotting of blood vessels in the brain or lung.^[27]

As treatment usually requires extensive and often disfiguring facial surgery, the effect on life after surviving, particularly sinus and brain involvement, is significant.^[32]

Epidemiology

The true incidence and prevalence of mucormycosis may be higher than appears.^[37] Mucormycosis is rare, affecting fewer than 1.7 people per million population each year in San Francisco.^[8]^[47] It is around 80 times more prevalent in India, where it is estimated that there are around 0.14 cases per 1000 population,^[20] and where its incidence has been rising.^[48] Causative fungi are highly dependent on location. Apophysomyces variabilis has its highest prevalence in Asia and Lichtheimia spp. in Europe.^[21] It is the third most common serious human fungal infection, after aspergillosis and candidiasis.^[49]

Diabetes is the main underlying disease in low and middle-income countries, whereas, blood cancers and organ transplantation are the more common underlying problems in developed countries.^[20] As new immunomodulating drugs and diagnostic tests are developed, the statistics for mucormycosis have been changing.^[20] In addition, the figures change as new genera and species are identified, and new risk factors reported such as tuberculosis and kidney problems.^[20]

COVID-19–associated mucormycosis

During the COVID-19 pandemic in India, the Indian government reported that more than 11,700 people were receiving care for mucormycosis as of 25 May 2021. Many Indian media outlets called it "black fungus" because of the black discoloration of dead and dying tissue the fungus causes. Even before the COVID-19 pandemic, rates of mucormycosis in India were estimated to be about 70 times higher than in the rest of the world.^[3]^[50] Due to its rapidly growing number of cases some Indian state governments have declared it an epidemic.^[51] One treatment was a daily injection for eight weeks of anti-fungal intravenous injection of amphotericin B which was in short supply. The injection could be standard amphotericin B deoxycholate or the liposomal form. The liposomal form cost more but it was considered "safer, more effective and [with] lesser side effects".^[52] The major obstacle of using antifungal drugs in black fungus is the lack of clinical trials.^[29]

Recurrence of mucormycosis during COVID-19 second wave in India

Pre-COVID mucormycosis was a very rare infection, even in India. It is so rare that an ENT (ear, nose, throat) doctor would not witness often a case during their university time. So, the documentation available on the treatment of mucormycosis is limited. In fact, there used to be a couple of mucormycosis expert ENT surgeons for millions of people before the pandemic. The sudden rise in mucormycosis cases has left a majority of the ENT doctors with no option but to accept mucormycosis cases, as the expert doctors were very much occupied and the patient would die if left untreated. The majority of the ENT doctors had to manage with minimal or no experience on mucormycosis, this has led to the recurrence of mucormycosis in the patients they treated. When a highly experienced doctor in mucormycosis treats a patient even he cannot guarantee that the individual is completely cured and will not have a relapse of mucormycosis; an inexperienced ENT surgeon will definitely have a high number of patients with recurrence due to which there were many recurrent cases of mucormycosis although it did not get the limelight of media or the Indian Government.

History

The first case of mucormycosis was possibly one described by Friedrich Küchenmeister in 1855.^[1] Fürbringer first described the disease in the lungs in 1876.^[53] In 1884, Lichtheim established the development of the disease in rabbits and described two species; Mucor corymbifera and Mucor rhizopodiformis, later known as Lichtheimia and Rhizopus, respectively.^[1] In 1943, its association with poorly controlled diabetes was reported in three cases with severe sinus, brain and eye involvement.^[1]

In 1953, Saksenaea vasiformis, found to cause several cases, was isolated from Indian forest soil, and in 1979, P. C. Misra examined soil from an Indian mango orchard, from where they isolated Apophysomyces, later found to be a major cause of mucormycosis.^[1] Several species of mucorales have since been described.^[1] When cases were reported in the United States in the mid-1950s, the author thought it to be a new disease resulting from the use of antibiotics, ACTH and steroids.^[53]^[54] Until the latter half of the 20th century, the only available treatment was potassium iodide. In a review of cases involving the lungs diagnosed following flexible bronchoscopy between 1970 and 2000, survival was found to be better in those who received combined surgery and medical treatment, mostly with amphotericin B.^[53]

Naming

Arnold Paltauf coined the term "Mycosis Mucorina" in 1885, after describing a case with systemic symptoms involving the sinus, brain and gastrointestinal tract, following which the term "mucormycosis" became popular.^[1] "Mucormycosis" is often used interchangeably with "zygomycosis", a term made obsolete following changes in classification of the kingdom Fungi. The former phylum Zygomycota included Mucorales, Entomophthorales, and others. Mucormycosis describes infections caused by fungi of the order Mucorales.^[42]

COVID-19–associated mucormycosis

COVID-19 associated mucormycosis cases were reported during first and second(delta) wave, with maximum number of cases in delta wave.^[12] There were no cases reported during the Omicron wave.^[12] A number of cases of mucormycosis, aspergillosis, and candidiasis, linked to immunosuppressive treatment for COVID-19 were reported during the COVID-19 pandemic in India in 2020 and 2021.^[4]^[40] One review in early 2021 relating to the association of mucormycosis and COVID-19 reported eight cases of mucormycosis; three from the U.S., two from India, and one case each from Brazil, Italy, and the UK.^[22] The most common underlying medical condition was diabetes.^[22] Most had been in hospital with severe breathing problems due to COVID-19, had recovered, and developed mucormycosis 10–14 days following treatment for COVID-19. Five had abnormal kidney function tests, three involved the sinus, eye and brain, three the lungs, one the gastrointestinal tract, and in one the disease was widespread.^[22] In two of the seven deaths, the diagnosis of mucormycosis was made at postmortem.^[22] That three had no traditional risk factors led the authors to question the use of steroids and immunosuppressive drugs,^[22] although there were cases without diabetes or use of immunosuppressive drugs. There were cases reported even in children.^[12] In May 2021, the BBC reported increased cases in India.^[35] In a review of COVID-19-related eye problems, mucormycosis affecting the eyes was reported to occur up to several weeks following recovery from COVID-19.^[40] It was observed that people with COVID-19 were recovering from mucormycosis a bit easily when compared to non-COVID-19 patients. This is because unlike non-COVID-19 patients with severe diabetes, cancer or HIV, the recovery time required for the main cause of immune suppression is temporary.^[12]

Other countries affected included Pakistan,^[55] Nepal,^[56] Bangladesh,^[57] Russia,^[58] Uruguay,^[59] Paraguay,^[60] Chile,^[61] Egypt,^[62] Iran,^[63] Brazil,^[64] Iraq,^[65] Mexico,^[66] Honduras,^[67] Argentina^[68] Oman,^[69] and Afghanistan.^[70] One explanation for why the association has surfaced remarkably in India is high rates of COVID-19 infection and high rates of diabetes.^[71] In May 2021, the Indian Council of Medical Research issued guidelines for recognising and treating COVID-19–associated mucormycosis.^[72] In India, as of 28 June 2021, over 40,845 people have been confirmed to have mucormycosis, and 3,129 have died. From these cases, 85.5% (34,940) had a history of being infected with SARS-CoV-2 and 52.69% (21,523) were on steroids, also 64.11% (26,187) had diabetes.^[73]^[74]

Society and culture

The disease has been reported in natural disasters and catastrophes; 2004 Indian Ocean tsunami and the 2011 Missouri tornado.^[21]^[75] The first international congress on mucormycosis was held in Chicago in 2010, set up by the Hank Schueuler 41 & 9 Foundation, which was established in 2008 for the research of children with leukaemia and fungal infections.^[1] A cluster of infections occurred in the wake of the 2011 Joplin tornado. By July 19, 2011, a total of 18 suspected cases of mucormycosis of the skin had been identified, of which 13 were confirmed. A confirmed case was defined as 1) necrotizing soft-tissue infection requiring antifungal treatment or surgical debridement in a person injured in the tornado, 2) with illness onset on or after May 22 and 3) positive fungal culture or histopathology and genetic sequencing consistent with a mucormycete. No additional cases related to that outbreak were reported after June 17. Ten people required admission to an intensive-care unit, and five died.^[76]^[77]

In 2014, details of a lethal mucormycosis outbreak that occurred in 2008 emerged after television and newspaper reports responded to an article in a pediatric medical journal.^[78]^[79] Contaminated hospital linen was found to be spreading the infection. A 2018 study found many freshly laundered hospital linens delivered to U.S. transplant hospitals were contaminated with Mucorales.^[80] Another study attributed an outbreak of hospital-acquired mucormycosis to a laundry facility supplying linens contaminated with Mucorales. The outbreak stopped when major changes were made at the laundry facility. The authors raised concerns on the regulation of healthcare linens.^[81]

Other animals

Mucormycosis in other animals is similar, in terms of frequency and types, to that in people.^[82] Cases have been described in cats, dogs, cows, horses, dolphins, bison, and seals.^[82]

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^ ^a ^b Biswas S (May 9, 2021). "Mucormycosis: The 'black fungus' maiming Covid patients in India". BBC News. British Broadcasting Corporation. Retrieved May 11, 2021.
^ Koehler P, Bassetti M, Chakrabarti A, Chen SC, Colombo AL, Hoenigl M, et al. (June 2021). "Defining and managing COVID-19–associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance". The Lancet. Infectious Diseases. 21 (6): e149 – e162. doi:10.1016/s1473-3099(20)30847-1. PMC 7833078. PMID 33333012.
^ ^a ^b Prakash H, Chakrabarti A (March 2019). "Global Epidemiology of Mucormycosis". Journal of Fungi. 5 (1): 26. doi:10.3390/jof5010026. PMC 6462913. PMID 30901907.
^ ^a ^b ^c ^d ^e ^f ^g ^h McDonald PJ. "Mucormycosis (Zygomycosis) Workup: Approach Considerations, Laboratory Tests, Radiologic Studies". emedicine.medscape.com. Retrieved May 25, 2021.
^ "Diagnosis and Testing of Mucormycosis | Mucormycosis | CDC". www.cdc.gov. January 14, 2021.
^ ^a ^b ^c Sen M, Honavar SG, Sharma N, Sachdev MS (March 2021). "COVID-19 and Eye: A Review of Ophthalmic Manifestations of COVID-19". Indian Journal of Ophthalmology. 69 (3): 488–509. doi:10.4103/ijo.IJO_297_21. PMC 7942063. PMID 33595463.
^ "Details – Public Health Image Library (PHIL)". phil.cdc.gov. Retrieved May 26, 2021.
^ ^a ^b ^c Cornely OA, Alastruey-Izquierdo A, Arenz D, Chen SC, Dannaoui E, Hochhegger B, et al. (December 2019). "Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium". The Lancet. Infectious Diseases. 19 (12): e405 – e421. doi:10.1016/S1473-3099(19)30312-3. PMC 8559573. PMID 31699664. (several authors)
^ McDonald PJ. "Mucormycosis (Zygomycosis) Differential Diagnoses". emedicine.medscape.com. Retrieved May 25, 2021.
^ BNF (80 ed.). BMJ Group and the Pharmaceutical Press. September 2020 – March 2021. pp. 629–635. ISBN 978-0-85711-369-6.
^ McDonald PJ (September 10, 2018). "What is the role of isavuconazole (Cresemba) in the treatment of mucormycosis (zygomycosis)?". www.medscape.com. Retrieved May 25, 2021.
^ Rebecca J. Frey. "Mucormycosis". Health A to Z. Archived from the original on May 18, 2008. Retrieved May 19, 2008.
^ "Mucormycosis Statistics | Mucormycosis | Fungal Diseases | CDC". www.cdc.gov. June 5, 2020. Archived from the original on May 21, 2021. Retrieved May 22, 2021.
^ Vallabhaneni S, Mody RK, Walker T, Chiller T (2016). "1. The global burden of fungal disease". In Sobel J, Ostrosky-Zeichner L (eds.). Fungal Infections, An Issue of Infectious Disease Clinics of North America. Philadelphia: Elsevier. pp. 5–12. ISBN 978-0-323-41649-8.
^ Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP (February 2012). "Epidemiology and clinical manifestations of mucormycosis". Clinical Infectious Diseases. 54 (suppl_1): S23–34. doi:10.1093/cid/cir866. PMID 22247442.
^ Schwartz I, Chakrabarti A (June 2, 2021). "'Black fungus' is creating a whole other health emergency for Covid-stricken India". The Guardian. Retrieved June 3, 2021.
^ Wadhawan DW, Jain P, Shrivastava S, Kunal K (May 19, 2021). "Rajasthan declares black fungus an epidemic; cases pile up in several states | 10 points". India Today. Retrieved May 20, 2021.
^ "Black fungus in India: Concern over drug shortage as cases rise". BBC News. May 19, 2021. Retrieved July 8, 2021.
^ ^a ^b ^c Yamin HS, Alastal AY, Bakri I (January 2017). "Pulmonary Mucormycosis Over 130 Years: A Case Report and Literature Review". Turkish Thoracic Journal. 18 (1): 1–5. doi:10.5152/TurkThoracJ.2017.16033. PMC 5783164. PMID 29404149.
^ Baker RD (March 1957). "Mucormycosis; a new disease?". Journal of the American Medical Association. 163 (10): 805–8. doi:10.1001/jama.1957.02970450007003. PMID 13405736.
^ "'Cases of Black Fungus emerge across Pakistan'". The News International. May 12, 2021.
^ "Focused COVID-19 Media Monitoring, Nepal (May 24, 2021)". ReliefWeb. May 24, 2021.
^ "Bangladesh reports 1st death by black fungus". Anadolu Agency. May 25, 2021.
^ "Russia Confirms Rare, Deadly 'Black Fungus' Infections Seen in India". The Moscow Times. May 17, 2021.
^ "Paciente con COVID-19 se infectó con el "hongo negro"". EL PAÍS Uruguay (in Spanish). May 25, 2021.
^ "Confirman dos casos de "hongo negro" en Paraguay". RDN (in Spanish). May 27, 2021.
^ "Detectan primer caso de "hongo negro" en Chile en paciente con Covid-19: es el segundo reportado en Latinoamérica". El Mostrador (in Spanish). May 28, 2021.
^ "Mansoura University Hospital reports black fungus cases". Egypt Independent. May 28, 2021.
^ "Coronavirus in Iran: Power outages, black fungus, and warnings of a fifth surge". Track Persia. May 29, 2021. Archived from the original on May 29, 2021. Retrieved June 1, 2021.
^ "Casos suspeitos de fungo preto são investigados no Brasil; entenda". Catraca Livre (in Portuguese). May 31, 2021.
^ "Iraq detects five cases of the deadly "black fungus" among coronavirus patients". Globe Live Media. June 1, 2021.
^ "Detectan en Edomex posible primer caso de hongo negro en México". Uno TV (in Spanish). June 3, 2021.
^ "Salud confirma primer caso de hongo negro en Honduras". Diario El Heraldo (in Spanish). June 7, 2021.
^ ""Hongo negro": advierten que hay que estar atentos a la coinfección fúngica en pacientes con covid". Clarín (in Spanish). June 16, 2021.
^ "'Black fungus' detected in 3 COVID-19 patients in Oman". Al Jazeera. June 15, 2021.
^ "Afghanistan finds deadly 'black fungus' in virus patients – latest updates". TRT World. Retrieved July 17, 2021.
^ Runwal P (May 14, 2021). "A rare black fungus is infecting many of India's COVID-19 patients—why?". National Geographic. Archived from the original on May 14, 2021.
^ "ICMR releases diagnosis and management guidelines for COVID-19-associated Mucormycosis". Firstpost. May 17, 2021.
^ "India reports 40,854 cases of black fungus so far". Mint. June 28, 2021. Retrieved July 16, 2021.
^ "Delhi has more black fungus infections than active Covid-19 cases: Govt data". Mint. July 14, 2021. Retrieved July 16, 2021.
^ Fanfair, Robyn Neblett; et al. (July 29, 2011). "Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado – Joplin, Missouri, 2011". MMWR Weekly. 60 (29): 992.
^ Williams, Timothy (June 10, 2011) Rare Infection Strikes Victims of a Tornado in Missouri. New York Times.
^ Neblett Fanfair R, Benedict K, Bos J, Bennett SD, Lo YC, Adebanjo T, et al. (December 2012). "Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011". The New England Journal of Medicine. 367 (23): 2214–25. doi:10.1056/NEJMoa1204781. PMID 23215557.
^ Catalanello, Rebecca (April 16, 2014). "Mother believes her newborn was the first to die from fungus at Children's Hospital in 2008". NOLA.com.
^ "5 Children's Hospital patients died in 2008, 2009 after contact with deadly fungus". We acknowledge that Children's Hospital is Hospital A in an upcoming article in The Pediatric Infectious Disease Journal. The safety and well-being of our patients are our top priorities, so as soon as a problem was suspected, the State Health Department and CDC were notified and invited to assist in the investigation. The hospital was extremely aggressive in trying to isolate and then eliminate the source of the fungus.
^ Sundermann AJ, Clancy CJ, Pasculle AW, Liu G, Cumbie RB, Driscoll E, et al. (February 2019). "How Clean Is the Linen at My Hospital? The Mucorales on Unclean Linen Discovery Study of Large United States Transplant and Cancer Centers". Clinical Infectious Diseases. 68 (5): 850–853. doi:10.1093/cid/ciy669. PMC 6765054. PMID 30299481.
^ Sundermann, Alexander J.; Clancy, Cornelius J.; Pasculle, A. William; Liu, Guojun; Cheng, Shaoji; Cumbie, Richard B.; Driscoll, Eileen; Ayres, Ashley; Donahue, Lisa; Buck, Michael; Streifel, Andrew (July 20, 2021). "Remediation of Mucorales-contaminated Healthcare Linens at a Laundry Facility Following an Investigation of a Case Cluster of Hospital-acquired Mucormycosis". Clinical Infectious Diseases. 74 (8): 1401–1407. doi:10.1093/cid/ciab638. ISSN 1537-6591. PMID 34282829.
^ ^a ^b Seyedmousavi S, Bosco SM, de Hoog S, Ebel F, Elad D, Gomes RR, et al. (April 2018). "Fungal infections in animals: a patchwork of different situations". Medical Mycology. 56 (suppl_1): 165–187. doi:10.1093/mmy/myx104. PMC 6251577. PMID 29538732.

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[pmid35357212-34] Skaria J, John TM, Varkey S, Kontoyiannis DP (April 2022). "Are Unique Regional Factors the Missing Link in India's COVID-19–Associated Mucormycosis Crisis?". mBio. 13 (2): e0047322. doi:10.1128/mbio.00473-22. PMC 9040830. PMID 35357212.

[bbc-black-fungus-covid19-35] Biswas S (May 9, 2021). "Mucormycosis: The 'black fungus' maiming Covid patients in India". BBC News. British Broadcasting Corporation. Retrieved May 11, 2021.

[Koehler-36] Koehler P, Bassetti M, Chakrabarti A, Chen SC, Colombo AL, Hoenigl M, et al. (June 2021). "Defining and managing COVID-19–associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance". The Lancet. Infectious Diseases. 21 (6): e149 – e162. doi:10.1016/s1473-3099(20)30847-1. PMC 7833078. PMID 33333012.

[Prakash2019-37] Prakash H, Chakrabarti A (March 2019). "Global Epidemiology of Mucormycosis". Journal of Fungi. 5 (1): 26. doi:10.3390/jof5010026. PMC 6462913. PMID 30901907.

[McDonaldWork-38] ^ ^a ^b ^c ^d ^e ^f ^g ^h McDonald PJ. "Mucormycosis (Zygomycosis) Workup: Approach Considerations, Laboratory Tests, Radiologic Studies". emedicine.medscape.com. Retrieved May 25, 2021.

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[McDonaldTreat-45] McDonald PJ (September 10, 2018). "What is the role of isavuconazole (Cresemba) in the treatment of mucormycosis (zygomycosis)?". www.medscape.com. Retrieved May 25, 2021.

[HealthAtoZ-46] Rebecca J. Frey. "Mucormycosis". Health A to Z. Archived from the original on May 18, 2008. Retrieved May 19, 2008.

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[Petrikkos-49] Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP (February 2012). "Epidemiology and clinical manifestations of mucormycosis". Clinical Infectious Diseases. 54 (suppl_1): S23–34. doi:10.1093/cid/cir866. PMID 22247442.

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[51] Wadhawan DW, Jain P, Shrivastava S, Kunal K (May 19, 2021). "Rajasthan declares black fungus an epidemic; cases pile up in several states | 10 points". India Today. Retrieved May 20, 2021.

[52] "Black fungus in India: Concern over drug shortage as cases rise". BBC News. May 19, 2021. Retrieved July 8, 2021.

[Yamin-53] Yamin HS, Alastal AY, Bakri I (January 2017). "Pulmonary Mucormycosis Over 130 Years: A Case Report and Literature Review". Turkish Thoracic Journal. 18 (1): 1–5. doi:10.5152/TurkThoracJ.2017.16033. PMC 5783164. PMID 29404149.

[Baker1957-54] Baker RD (March 1957). "Mucormycosis; a new disease?". Journal of the American Medical Association. 163 (10): 805–8. doi:10.1001/jama.1957.02970450007003. PMID 13405736.

[55] "'Cases of Black Fungus emerge across Pakistan'". The News International. May 12, 2021.

[56] "Focused COVID-19 Media Monitoring, Nepal (May 24, 2021)". ReliefWeb. May 24, 2021.

[57] "Bangladesh reports 1st death by black fungus". Anadolu Agency. May 25, 2021.

[58] "Russia Confirms Rare, Deadly 'Black Fungus' Infections Seen in India". The Moscow Times. May 17, 2021.

[59] "Paciente con COVID-19 se infectó con el "hongo negro"". EL PAÍS Uruguay (in Spanish). May 25, 2021.

[60] "Confirman dos casos de "hongo negro" en Paraguay". RDN (in Spanish). May 27, 2021.

[61] "Detectan primer caso de "hongo negro" en Chile en paciente con Covid-19: es el segundo reportado en Latinoamérica". El Mostrador (in Spanish). May 28, 2021.

[62] "Mansoura University Hospital reports black fungus cases". Egypt Independent. May 28, 2021.

[63] "Coronavirus in Iran: Power outages, black fungus, and warnings of a fifth surge". Track Persia. May 29, 2021. Archived from the original on May 29, 2021. Retrieved June 1, 2021.

[64] "Casos suspeitos de fungo preto são investigados no Brasil; entenda". Catraca Livre (in Portuguese). May 31, 2021.

[65] "Iraq detects five cases of the deadly "black fungus" among coronavirus patients". Globe Live Media. June 1, 2021.

[66] "Detectan en Edomex posible primer caso de hongo negro en México". Uno TV (in Spanish). June 3, 2021.

[67] "Salud confirma primer caso de hongo negro en Honduras". Diario El Heraldo (in Spanish). June 7, 2021.

[68] ""Hongo negro": advierten que hay que estar atentos a la coinfección fúngica en pacientes con covid". Clarín (in Spanish). June 16, 2021.

[69] "'Black fungus' detected in 3 COVID-19 patients in Oman". Al Jazeera. June 15, 2021.

[70] "Afghanistan finds deadly 'black fungus' in virus patients – latest updates". TRT World. Retrieved July 17, 2021.

[71] Runwal P (May 14, 2021). "A rare black fungus is infecting many of India's COVID-19 patients—why?". National Geographic. Archived from the original on May 14, 2021.

[72] "ICMR releases diagnosis and management guidelines for COVID-19-associated Mucormycosis". Firstpost. May 17, 2021.

[73] "India reports 40,854 cases of black fungus so far". Mint. June 28, 2021. Retrieved July 16, 2021.

[74] "Delhi has more black fungus infections than active Covid-19 cases: Govt data". Mint. July 14, 2021. Retrieved July 16, 2021.

[75] Fanfair, Robyn Neblett; et al. (July 29, 2011). "Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado – Joplin, Missouri, 2011". MMWR Weekly. 60 (29): 992.

[76] Williams, Timothy (June 10, 2011) Rare Infection Strikes Victims of a Tornado in Missouri. New York Times.

[Neblett2012-77] Neblett Fanfair R, Benedict K, Bos J, Bennett SD, Lo YC, Adebanjo T, et al. (December 2012). "Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011". The New England Journal of Medicine. 367 (23): 2214–25. doi:10.1056/NEJMoa1204781. PMID 23215557.

[78] Catalanello, Rebecca (April 16, 2014). "Mother believes her newborn was the first to die from fungus at Children's Hospital in 2008". NOLA.com.

[79] "5 Children's Hospital patients died in 2008, 2009 after contact with deadly fungus". We acknowledge that Children's Hospital is Hospital A in an upcoming article in The Pediatric Infectious Disease Journal. The safety and well-being of our patients are our top priorities, so as soon as a problem was suspected, the State Health Department and CDC were notified and invited to assist in the investigation. The hospital was extremely aggressive in trying to isolate and then eliminate the source of the fungus.

[80] Sundermann AJ, Clancy CJ, Pasculle AW, Liu G, Cumbie RB, Driscoll E, et al. (February 2019). "How Clean Is the Linen at My Hospital? The Mucorales on Unclean Linen Discovery Study of Large United States Transplant and Cancer Centers". Clinical Infectious Diseases. 68 (5): 850–853. doi:10.1093/cid/ciy669. PMC 6765054. PMID 30299481.

[81] Sundermann, Alexander J.; Clancy, Cornelius J.; Pasculle, A. William; Liu, Guojun; Cheng, Shaoji; Cumbie, Richard B.; Driscoll, Eileen; Ayres, Ashley; Donahue, Lisa; Buck, Michael; Streifel, Andrew (July 20, 2021). "Remediation of Mucorales-contaminated Healthcare Linens at a Laundry Facility Following an Investigation of a Case Cluster of Hospital-acquired Mucormycosis". Clinical Infectious Diseases. 74 (8): 1401–1407. doi:10.1093/cid/ciab638. ISSN 1537-6591. PMID 34282829.

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@@ Line 6: / Line 6: @@
 | image         = Zygomycosis.jpg
 | image_size    =
-| caption       = Periorbital mucormycosis
+| caption       = [[Micrograph]] of pulmonary mucormycosis
 | pronounce     =
-| field         = [[Infectious disease (medical specialty)|Infectious disease]], [[Emergency medicine]]
+| field         = [[Oral and maxillofacial surgery]], [[Infectious disease (medical specialty)|Infectious disease]], [[Emergency medicine]]
 | symptoms      = Depends on location: runny nose, black area of skin, facial swelling, [[headache]], [[fever]], cough, blurred vision<ref name=Gros2012/><ref name=CDC2021Sym/>
 | complications = Blindness, [[thrombosis]]<ref name=Spel2005/>
@@ Line 27: / Line 27: @@
 <!-- Definition and symptoms -->
-'''Mucormycosis''', also known as '''black fungus''',<ref name=Dyer2021>{{cite journal | vauthors = Dyer O | title = Covid-19: India sees record deaths as "black fungus" spreads fear | journal = BMJ | volume = 373 | pages = n1238 | date = May 2021 | pmid = 33985993 | doi = 10.1136/bmj.n1238 | doi-access = free }}</ref><ref name=QC2020>{{cite book|title=Quarterly Current Affairs Vol. 4 - October to December 2020 for Competitive Exams|url=https://books.google.com/books?id=8_gQEAAAQBAJ&pg=PA173|volume=4|year=2020|publisher=Disha Publications|isbn=978-93-90486-29-8|page=173}}</ref> is a serious [[mycosis|fungal infection]] that comes under '''fulminant fungal sinusitis'''<ref name=":0" />, usually in people who are [[immunodeficiency|immunocompromised]].<ref name=Stat2021>{{cite journal | title = Mucormycosis | date = January 2021 | pmid = 31335084 | last1 = Hernández | first1 = J. L. | last2 = Buckley | first2 = C. J. }}</ref><ref name=John2017/> It is curable only when diagnosed early<ref name=":0" />. Symptoms depend on where in the body the infection occurs.<ref name=ICD-11>{{cite web |title=ICD-11 - ICD-11 for Mortality and Morbidity Statistics |url=https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1676389165 |website=icd.who.int |access-date=25 May 2021}}</ref><ref name=CDC2021About/> It most commonly infects the [[nose]], [[paranasal sinus|sinuses]], [[eye]], and [[brain]] resulting in a [[rhinorrhoea|runny nose]], one-sided facial swelling and pain, [[headache]], [[fever]], [[diplopia|blurred vision]], bulging or displacement of the eye (proptosis), and [[necrosis|tissue death]].<ref name="Chand2018" /><ref name="CDC2021Sym" /> Other forms of disease may infect the [[lungs]], [[gastrointestinal tract|stomach and intestine]]s, and [[skin]].<ref name=CDC2021Sym>{{cite web |title=Symptoms of Mucormycosis |url=https://www.cdc.gov/fungal/diseases/mucormycosis/symptoms.html |website=www.cdc.gov |access-date=25 May 2021 |language=en-us |date=14 January 2021}}</ref>
+'''Mucormycosis''', also known as '''black fungus''',<ref name=Dyer2021>{{cite journal | vauthors = Dyer O | title = Covid-19: India sees record deaths as "black fungus" spreads fear | journal = BMJ | volume = 373 | pages = n1238 | date = May 2021 | pmid = 33985993 | doi = 10.1136/bmj.n1238 | doi-access = free }}</ref><ref name=QC2020>{{cite book|title=Quarterly Current Affairs Vol. 4 – October to December 2020 for Competitive Exams|url=https://books.google.com/books?id=8_gQEAAAQBAJ&pg=PA173|volume=4|year=2020|publisher=Disha Publications|isbn=978-93-90486-29-8|page=173}}</ref> is a severe [[mycosis|fungal infection]]<ref>Li N, Bowling J, de Hoog S, Aneke CI, Youn J, Shahegh S, Cuellar-Rodriguez J, Kanakry CG, Rodriguez Pena M, Ahmed SA, Al-Hatmi AMS, Tolooe A, Walther G, Kwon-Chung KJ, Kang Y, Lee HB, Seyedmousavi A.2024.Mucor germinans, a novel dimorphic species resembling Paracoccidioides in a clinical sample: questions on ecological strategy. mBio15:e00144-24.https://doi.org/10.1128/mbio.00144-24</ref> that comes under '''fulminant fungal sinusitis''',<ref name=":0" /> usually in people who are [[immunodeficiency|immunocompromised]].<ref name=Stat2021>{{cite book | title = Mucormycosis | date = January 2021 | pmid = 31335084 | last1 = Hernández | first1 = J. L. | last2 = Buckley | first2 = C. J. }}</ref><ref name=John2017/> It is curable only when diagnosed early.<ref name=":0" /> Symptoms depend on where in the body the infection occurs.<ref name=ICD-11>{{cite web |title=ICD-11 – ICD-11 for Mortality and Morbidity Statistics |url=https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1676389165 |website=icd.who.int |access-date=25 May 2021}}</ref><ref name=CDC2021About/> It most commonly infects the [[Human nose|nose]], [[paranasal sinus|sinuses]], [[Human eye|eye]]s and [[Human brain|brain]] resulting in a [[rhinorrhoea|runny nose]], one-sided facial swelling and pain, [[headache]], [[fever]], [[diplopia|blurred vision]], bulging or displacement of the eye (proptosis), and [[necrosis|tissue death]].<ref name="Chand2018" /><ref name="CDC2021Sym" /> Other forms of disease may infect the [[lungs]], [[gastrointestinal tract|stomach and intestine]]s, and [[Human skin|skin]].<ref name=CDC2021Sym>{{cite web |title=Symptoms of Mucormycosis |url=https://www.cdc.gov/fungal/diseases/mucormycosis/symptoms.html |website=www.cdc.gov |access-date=25 May 2021 |language=en-us |date=14 January 2021}}</ref> The fatality rate is about 54%.
 <!-- Cause and mechanism -->
-It is spread by spores of [[mucoromycotina|molds]] of the order [[Mucorales]], most often through [[inhalation]], contaminated food, or contamination of open [[wounds]].<ref name="Reid2020">{{cite journal|vauthors=Reid G, Lynch JP, Fishbein MC, Clark NM|date=February 2020|title=Mucormycosis|journal=Seminars in Respiratory and Critical Care Medicine|volume=41|issue=1|pages=99–114|doi=10.1055/s-0039-3401992|pmid=32000287|s2cid=210984392}}</ref> These fungi are common in soils, decomposing organic matter (such as rotting fruit and vegetables), and [[animal manure]], but usually do not affect people.<ref name=CDCOrigin>{{cite web |title=Where Mucormycosis Comes From |url=https://www.cdc.gov/fungal/diseases/mucormycosis/causes.html |website=www.cdc.gov |access-date=25 May 2021|date=1 February 2021}}</ref> It is not transmitted between people.<ref name=CDC2021About/> Risk factors include [[diabetes]] with persistently high blood sugar levels or [[diabetic ketoacidosis]], [[neutropenia|low white cells]], [[cancer]], [[organ transplant]], [[iron overload]], [[renal failure|kidney problems]], long-term [[corticosteroid|steroids]] or use of [[immunosuppressant]]s, and to a lesser extent in [[HIV/AIDS]].<ref name=Spel2005>{{cite journal | vauthors = Spellberg B, Edwards J, Ibrahim A | title = Novel perspectives on mucormycosis: pathophysiology, presentation, and management | journal = Clinical Microbiology Reviews | volume = 18 | issue = 3 | pages = 556–69 | date = July 2005 | pmid = 16020690 | pmc = 1195964 | doi = 10.1128/CMR.18.3.556-569.2005 }}</ref><ref name=Stat2021/>
+It is spread by spores of [[mucoromycotina|molds]] of the order [[Mucorales]], most often through [[inhalation]], contaminated food, or contamination of open [[wounds]].<ref name="Reid2020">{{cite journal|vauthors=Reid G, Lynch JP, Fishbein MC, Clark NM|date=February 2020|title=Mucormycosis|journal=Seminars in Respiratory and Critical Care Medicine|volume=41|issue=1|pages=99–114|doi=10.1055/s-0039-3401992|pmid=32000287|s2cid=210984392}}</ref> These fungi are common in soils, decomposing organic matter (such as rotting fruit and vegetables), and [[animal manure]], but usually do not affect people.<ref name=CDCOrigin>{{cite web |title=Where Mucormycosis Comes From |url=https://www.cdc.gov/fungal/diseases/mucormycosis/causes.html |website=www.cdc.gov |access-date=25 May 2021|date=1 February 2021}}</ref> It is not transmitted between people.<ref name=CDC2021About/> Risk factors include [[diabetes]] with persistently high blood sugar levels or [[diabetic ketoacidosis]], [[neutropenia|low white blood cells]], [[cancer]], [[organ transplant]], [[iron overload]], [[renal failure|kidney problems]], long-term [[corticosteroid|steroids]] or use of [[immunosuppressant]]s, and to a lesser extent in [[HIV/AIDS]].<ref name=Spel2005>{{cite journal | vauthors = Spellberg B, Edwards J, Ibrahim A | title = Novel perspectives on mucormycosis: pathophysiology, presentation, and management | journal = Clinical Microbiology Reviews | volume = 18 | issue = 3 | pages = 556–569 | date = July 2005 | pmid = 16020690 | pmc = 1195964 | doi = 10.1128/CMR.18.3.556-569.2005 }}</ref><ref name=Stat2021/>
 <!-- Diagnosis and treatment-->
@@ Line 36: / Line 36: @@
 <!-- Epidemiology and history -->
-Mucormycosis is usually rare, affecting fewer than 2 people per million people each year in [[San Francisco]],<ref name=NORD2021/> but is now ~80 times more common in India.<ref name=Ski2020>{{cite journal | vauthors = Skiada A, Pavleas I, Drogari-Apiranthitou M | title = Epidemiology and Diagnosis of Mucormycosis: An Update | journal = Journal of Fungi | volume = 6 | issue = 4 | page = 265 | date = November 2020 | pmid = 33147877 | pmc = 7711598 | doi = 10.3390/jof6040265 | doi-access = free }}</ref> People of any age may be affected, including [[premature infants]].<ref name=NORD2021/>  The first known case of mucormycosis was possibly the one described by [[Friedrich Küchenmeister]] in 1855.<ref name=Chand2018/> The disease has been reported in [[natural disaster]]s; [[2004 Indian Ocean earthquake and tsunami|2004 Indian Ocean tsunami]] and the [[2011 Joplin tornado|2011 Missouri tornado]].<ref name=Dan2020>{{cite journal | vauthors = Dannaoui E, Lackner M | title = Special Issue: Mucorales and Mucormycosis | journal = Journal of Fungi | volume = 6 | issue = 1 | pages = 6 | date = December 2019 | pmid = 31877973 | pmc = 7151165 | doi = 10.3390/jof6010006 | doi-access = free }}</ref> During the [[COVID-19 pandemic]], an association between mucormycosis and [[COVID-19]] has been reported. This association is thought to relate to reduced immune function during the course of the illness and may also be related to [[glucocorticoid]] therapy for COVID-19.<ref name=QC2020/><ref name=Garg2021/> A rise in cases was particularly noted in India.<ref name=Singh2021>{{cite journal | vauthors = Singh AK, Singh R, Joshi SR, Misra A | title = Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India | journal = Diabetes & Metabolic Syndrome | volume = 15 | issue = 4 | pages = 102146 | date = May 2021 | pmid = 34192610 | pmc = 8137376 | doi = 10.1016/j.dsx.2021.05.019 }}</ref>
+Mucormycosis is usually rare,<ref name=NORD2021/> but is now ~80 times more common in India.<ref name=Ski2020>{{cite journal | vauthors = Skiada A, Pavleas I, Drogari-Apiranthitou M | title = Epidemiology and Diagnosis of Mucormycosis: An Update | journal = Journal of Fungi | volume = 6 | issue = 4 | page = 265 | date = November 2020 | pmid = 33147877 | pmc = 7711598 | doi = 10.3390/jof6040265 | doi-access = free }}</ref> People of any age may be affected, including [[premature infants]].<ref name=NORD2021/>  The first known case of mucormycosis was possibly the one described by [[Friedrich Küchenmeister]] in 1855.<ref name=Chand2018/> The disease has been reported in [[natural disaster]]s, including the [[2004 Indian Ocean earthquake and tsunami|2004 Indian Ocean tsunami]] and the [[2011 Joplin tornado]].<ref name=Dan2020>{{cite journal | vauthors = Dannaoui E, Lackner M | title = Special Issue: Mucorales and Mucormycosis | journal = Journal of Fungi | volume = 6 | issue = 1 | pages = 6 | date = December 2019 | pmid = 31877973 | pmc = 7151165 | doi = 10.3390/jof6010006 | doi-access = free }}</ref> During the [[COVID-19 pandemic]], an association between mucormycosis and [[COVID-19]] has been reported. This association is thought to relate to reduced immune function during the course of the illness and may also be related to [[glucocorticoid]] therapy for COVID-19.<ref name=QC2020/><ref name=Garg2021/> A rise in cases was particularly noted in India.<ref name=Singh2021>{{cite journal | vauthors = Singh AK, Singh R, Joshi SR, Misra A | title = Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India | journal = Diabetes & Metabolic Syndrome | volume = 15 | issue = 4 | pages = 102146 | date = May 2021 | pmid = 34192610 | pmc = 8137376 | doi = 10.1016/j.dsx.2021.05.019 }}</ref>
 == Classification ==
@@ Line 47: / Line 47: @@
 ==Signs and symptoms==
-[[File:Periorbital fungal infection known as mucormycosis, or phycomycosis PHIL 2831 lores.jpg|200px|thumb|Periorbital fungal infection]]
+[[File:Periorbital fungal infection known as mucormycosis, or phycomycosis PHIL 2831 lores.jpg|200px|thumb|Early stages of periorbital mucormycosis]]
 Signs and symptoms of mucormycosis depend on the location in the body of the infection.<ref name=CDC2021Sym/> Infection usually begins in the mouth or nose and enters the central nervous system via the eyes.<ref name=Gros2012/>
@@ Line 54: / Line 54: @@
 Fever, cough, chest pain, and [[dyspnea|difficulty breathing]], or [[hemoptysis|coughing up blood]], can occur when the lungs are involved.<ref name=CDC2021Sym/> A [[Abdominal pain|stomach ache]], nausea, vomiting and bleeding can occur when the gastrointestinal tract is involved.<ref name=CDC2021Sym/><ref name="medplus">{{cite web |url=https://www.nlm.nih.gov/medlineplus/ency/article/000649.htm |title=MedlinePlus Medical Encyclopedia: Mucormycosis |access-date = 19 May 2008 }}</ref> Affected skin may appear as a dusky reddish tender patch with a [[eschar|darkening centre]] due to [[necrosis|tissue death]].<ref name="John2017">{{cite book| vauthors = Johnstone RB |title=Weedon's Skin Pathology Essentials |url=https://books.google.com/books?id=NTE_DAAAQBAJ|year=2017|publisher=Elsevier |edition=2nd|isbn=978-0-7020-6830-0|page=461|chapter=25. Mycoses and Algal infections}}</ref> There may be an [[Ulcer (dermatology)|ulcer]], and it can be very painful.<ref name=Gros2012/><ref name=Spel2005/><ref name="John2017"/>
-Invasion of the [[vascular|blood vessels]] can result in [[thrombosis]] and subsequent [[necrosis|death of surrounding tissue]] due to a [[ischemia|loss of blood supply]].<ref name=Spel2005/> 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 [[Altered state of consciousness|changes in mental status]] or lapse into a [[coma]].<ref>{{cite journal | vauthors = Lewis RE, Kontoyiannis DP | title = Epidemiology and treatment of mucormycosis | journal = Future Microbiology | volume = 8 | issue = 9 | pages = 1163–75 | date = September 2013 | pmid = 24020743 | doi = 10.2217/fmb.13.78 }}</ref><ref name="Novel perspectives on mucormycosis">{{cite journal | vauthors = Spellberg B, Edwards J, Ibrahim A | title = Novel perspectives on mucormycosis: pathophysiology, presentation, and management | journal = Clinical Microbiology Reviews | volume = 18 | issue = 3 | pages = 556–69 | date = July 2005 | pmid = 16020690 | pmc = 1195964 | doi = 10.1128/cmr.18.3.556-569.2005 }}</ref>
+Invasion of the [[Blood vessel|blood vessels]] can result in [[thrombosis]] and subsequent [[necrosis|death of surrounding tissue]] due to a [[ischemia|loss of blood supply]].<ref name=Spel2005/> 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 [[Altered state of consciousness|changes in mental status]] or lapse into a [[coma]].<ref>{{cite journal | vauthors = Lewis RE, Kontoyiannis DP | title = Epidemiology and treatment of mucormycosis | journal = Future Microbiology | volume = 8 | issue = 9 | pages = 1163–75 | date = September 2013 | pmid = 24020743 | doi = 10.2217/fmb.13.78 }}</ref><ref name="Novel perspectives on mucormycosis">{{cite journal | vauthors = Spellberg B, Edwards J, Ibrahim A | title = Novel perspectives on mucormycosis: pathophysiology, presentation, and management | journal = Clinical Microbiology Reviews | volume = 18 | issue = 3 | pages = 556–69 | date = July 2005 | pmid = 16020690 | pmc = 1195964 | doi = 10.1128/cmr.18.3.556-569.2005 }}</ref>
 ==Cause==
-Mucormycosis is a [[Mycosis|fungal infection]] caused by [[Fungus|fungi]] in the order [[Mucorales]].<ref name=Gros2012/> In most cases it is due to an invasion of the [[genus|genera]] ''[[Rhizopus]]'' and ''[[Mucor]]'', common bread molds.<ref name="Lee2018">{{cite book | vauthors = Lee SC, Idmurm A | veditors = Heitman J, Howlett BJ, Crous PW, Stukenbrock EH, James TY, Gow NA |title=The Fungal Kingdom |date=2018 |publisher=Wiley |isbn=978-1-55581-958-3 |pages=177–192 |chapter-url=https://books.google.com/books?id=VILwDwAAQBAJ&pg=PA177 |language=en |chapter=8. Fingal sex: The Mucoromycota}}</ref> Most fatal infections are caused by ''[[Rhizopus oryzae]]''.<ref name="Thornton2020">{{cite book | vauthors = Thornton CR |editor1-link=Geoffrey Michael Gadd | veditors = Gadd GM, Sariaslani S |title=Advances in Applied Microbiology |date=2020|publisher=Academic Press |isbn=978-0-12-820703-1 |url=https://books.google.com/books?id=RXfhDwAAQBAJ&pg=PA1 |language=en |chapter=1. Detection of the 'Big Five' mold killers of humans: Aspergillus, Fusarium, Lomentospora, Scedosporium and Mucormycetes|pages=4–22}}</ref> It is less likely due to ''[[Lichtheimia]]'', and rarely due to ''[[Apophysomyces]]''.<ref name="Martínez2020">{{cite journal | vauthors = Martínez-Herrera E, Frías-De-León MG, Julián-Castrejón A, Cruz-Benítez L, Xicohtencatl-Cortes J, Hernández-Castro R | title = Rhino-orbital mucormycosis due to Apophysomyces ossiformis in a patient with diabetes mellitus: a case report | journal = BMC Infectious Diseases | volume = 20 | issue = 1 | pages = 614 | date = August 2020 | pmid = 32811466 | pmc = 7437167 | doi = 10.1186/s12879-020-05337-4 }}</ref> Others include ''[[Cunninghamella]]'', ''[[Mortierella]]'', and ''[[Saksenaea]]''.<ref name=Gros2012/><ref name=McDonaldBackground>{{cite journal | vauthors = McDonald PJ |title=Mucormycosis (Zygomycosis): Background, Etiology and Pathophysiology, Epidemiology |url=https://emedicine.medscape.com/article/222551-overview#a4 |website=Medscape |date=10 September 2018|url-access=subscription}}</ref>
+Mucormycosis is a [[Mycosis|fungal infection]] caused by [[Fungus|fungi]] in the order [[Mucorales]].<ref name=Gros2012/> In most cases it is due to an invasion of the [[genus|genera]] ''[[Rhizopus]]'' and ''[[Mucor]]'', common bread molds.<ref name="Lee2018">{{cite book | vauthors = Lee SC, Idmurm A | veditors = Heitman J, Howlett BJ, Crous PW, Stukenbrock EH, James TY, Gow NA |title=The Fungal Kingdom |date=2018 |publisher=Wiley |isbn=978-1-55581-958-3 |pages=177–192 |chapter-url=https://books.google.com/books?id=VILwDwAAQBAJ&pg=PA177 |language=en |chapter=8. Fingal sex: The Mucoromycota}}</ref> Most fatal infections are caused by ''[[Rhizopus oryzae]]''.<ref name="Thornton2020">{{cite book | vauthors = Thornton CR |editor1-link=Geoffrey Michael Gadd | veditors = Gadd GM, Sariaslani S |title=Advances in Applied Microbiology |date=2020|publisher=Academic Press |isbn=978-0-12-820703-1 |url=https://books.google.com/books?id=RXfhDwAAQBAJ&pg=PA1 |language=en |chapter=1. Detection of the 'Big Five' mold killers of humans: Aspergillus, Fusarium, Lomentospora, Scedosporium and Mucormycetes|pages=4–22}}</ref> It is less likely due to ''[[Lichtheimia]]'', and rarely due to ''[[Apophysomyces]]''.<ref name="Martínez2020">{{cite journal | vauthors = Martínez-Herrera E, Frías-De-León MG, Julián-Castrejón A, Cruz-Benítez L, Xicohtencatl-Cortes J, Hernández-Castro R | title = Rhino-orbital mucormycosis due to Apophysomyces ossiformis in a patient with diabetes mellitus: a case report | journal = BMC Infectious Diseases | volume = 20 | issue = 1 | pages = 614 | date = August 2020 | pmid = 32811466 | pmc = 7437167 | doi = 10.1186/s12879-020-05337-4 | doi-access = free }}</ref> Others include ''[[Cunninghamella]]'', ''[[Mortierella]]'', and ''[[Saksenaea]]''.<ref name=Gros2012/><ref name=McDonaldBackground>{{cite journal | vauthors = McDonald PJ |title=Mucormycosis (Zygomycosis): Background, Etiology and Pathophysiology, Epidemiology |url=https://emedicine.medscape.com/article/222551-overview#a4 |website=Medscape |date=10 September 2018|url-access=subscription}}</ref>
-The fungal spores are in the environment, can be found on, for instance, moldy bread and fruit, and are breathed in frequently, but cause disease only in some people.<ref name=Gros2012/> In addition to being breathed in to be deposited in the nose, sinuses and lungs, the spores can also enter the skin via blood or directly through a cut or open wound, or grow in the intestine if eaten.<ref name=CDC2021About/><ref name=McDonaldBackground/> Once deposited, the fungus grows [[hyphae|branch-like filaments]] which invade [[blood vessel]]s, causing [[thrombosis|clots to form]] and surrounding [[necrosis|tissues to die]].<ref name=Gros2012/> Other reported causes include contaminated wound dressings.<ref name=Gros2012/> Mucormycosis has been reported following the use of [[elastoplast]] and the use of [[tongue depressor]]s for holding in place intravenous catheters.<ref name=Gros2012/> Outbreaks have also been linked to hospital bed sheets, negative-pressure rooms, water leaks, poor ventilation, contaminated medical equipment, and building works.<ref name="CDCInfo">{{cite web |title=For Healthcare Professionals {{!}} Mucormycosis {{!}} CDC |url=https://www.cdc.gov/fungal/diseases/mucormycosis/health-professionals.html |website=www.cdc.gov |access-date=25 May 2021|language=en-us |date=17 June 2020}}</ref>
+The fungal spores are present in the environment, can be found on items such as moldy bread and fruit, and are breathed in frequently, but cause disease only in some people.<ref name=Gros2012/> 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.<ref name=CDC2021About/><ref name=McDonaldBackground/> Once deposited, the fungus grows [[hyphae|branch-like filaments]] which invade [[blood vessel]]s, causing [[thrombosis|clots to form]] and surrounding [[necrosis|tissues to die]].<ref name=Gros2012/> Other reported causes include contaminated wound dressings.<ref name=Gros2012/> Mucormycosis has been reported following the use of [[elastoplast]] and the use of [[tongue depressor]]s for holding in place intravenous catheters.<ref name=Gros2012/> Outbreaks have also been linked to hospital bed sheets, negative-pressure rooms, water leaks, poor ventilation, contaminated medical equipment, and building works.<ref name="CDCInfo">{{cite web |title=For Healthcare Professionals {{!}} Mucormycosis {{!}} CDC |url=https://www.cdc.gov/fungal/diseases/mucormycosis/health-professionals.html |website=www.cdc.gov |access-date=25 May 2021|language=en-us |date=17 June 2020}}</ref> 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.<ref name="pmid35357212">{{cite journal | vauthors = Skaria J, John TM, Varkey S, Kontoyiannis DP | title = Are Unique Regional Factors the Missing Link in India's COVID-19–Associated Mucormycosis Crisis? | journal = mBio | volume = 13 | issue = 2 | pages = e0047322 | date = April 2022 | pmid = 35357212 | pmc = 9040830 | doi = 10.1128/mbio.00473-22 }}</ref>
 ===Risk factors===
-Predisposing factors for mucormycosis include conditions where people are [[immunodeficiency|less able to fight infection]], have a [[neutropenia|low neutrophil count]] or [[metabolic acidosis]].<ref name="John2017"/><ref name=Stat2021/> Risk factors include poorly controlled [[diabetes mellitus]] (particularly [[diabetic ketoacidosis|DKA]]), [[organ transplant]], [[iron overload]], such [[cancer]]s as [[lymphoma]]s, [[kidney failure]], long term [[corticosteroid]] and [[immunosuppressant|immunosuppressive therapy]], [[cirrhosis|liver disease]] and severe [[malnutrition]].<ref name=McDonaldBackground/><ref name=CDC2021Prev/> Other risk factors include [[tuberculosis]] (TB),<ref name=Dan2020/> [[deferoxamine]]<ref name="Chand2018"/> and to a lesser extent [[HIV/AIDS]].<ref name="Chand2018"/><ref name=Spel2005/> Cases of mucormycosis in fit and healthy people are rare.<ref name=Spel2005/>
+Predisposing factors for mucormycosis include [[immunodeficiency|immune deficiencies]], a [[neutropenia|low neutrophil count]], and [[metabolic acidosis]].<ref name="John2017"/><ref name=Stat2021/> Risk factors include poorly controlled [[diabetes mellitus]] (particularly [[diabetic ketoacidosis|DKA]]), [[organ transplant]], [[iron overload]], such [[cancer]]s as [[lymphoma]]s, [[kidney failure]], [[cirrhosis|liver disease]], severe [[malnutrition]], and long term [[corticosteroid]] and [[immunosuppressant|immunosuppressive therapy]].<ref name=McDonaldBackground/><ref name=CDC2021Prev/> Other risk factors include [[tuberculosis]] (TB),<ref name=Dan2020/> [[deferoxamine]]<ref name="Chand2018"/> and to a lesser extent [[HIV/AIDS]].<ref name="Chand2018"/><ref name=Spel2005/> Cases of mucormycosis in fit and healthy people are less common.<ref name=Spel2005/>
-Corticosteroids are commonly used in the treatment of COVID-19 and reduce damage caused by the body's own immune response to the virus. They are immunosuppressant and increase blood sugar levels in both diabetic and non-diabetic patients. It is thought that both these effects may contribute to cases of mucormycosis.<ref name="bbc-black-fungus-covid19">{{cite news | vauthors = Biswas S |title=Mucormycosis: The 'black fungus' maiming Covid patients in India |url=https://www.bbc.com/news/world-asia-india-57027829 |access-date=11 May 2021 |work=BBC News |publisher=British Broadcasting Corporation |date=9 May 2021}}</ref><ref name=Koehler>{{cite journal | vauthors = Koehler P, Bassetti M, Chakrabarti A, Chen SC, Colombo AL, Hoenigl M, Klimko N, Lass-Flörl C, Oladele RO, Vinh DC, Zhu LP, Böll B, Brüggemann R, Gangneux JP, Perfect JR, Patterson TF, Persigehl T, Meis JF, Ostrosky-Zeichner L, White PL, Verweij PE, Cornely OA | display-authors = 6 | title = Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance | journal = The Lancet. Infectious Diseases | volume = 21 | issue = 6 | pages = e149–e162 | date = June 2021 | pmid = 33333012 | pmc = 7833078 | doi = 10.1016/s1473-3099(20)30847-1 | doi-access = free }}</ref><ref name=Garg2021>{{cite journal | vauthors = Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, Puri GD, Chakrabarti A, Agarwal R | display-authors = 6 | title = Coronavirus Disease (Covid-19) Associated Mucormycosis (CAM): Case Report and Systematic Review of Literature | journal = Mycopathologia | volume = 186 | issue = 2 | pages = 289–298 | date = May 2021 | pmid = 33544266 | pmc = 7862973 | doi = 10.1007/s11046-021-00528-2 }}</ref>
+Corticosteroids are commonly used in the treatment of COVID-19 and reduce damage caused by the body's own immune response to the virus. They are immunosuppressant and increase blood sugar levels in both diabetic and non-diabetic patients. It is thought that both these effects may contribute to cases of mucormycosis.<ref name="bbc-black-fungus-covid19">{{cite news | vauthors = Biswas S |title=Mucormycosis: The 'black fungus' maiming Covid patients in India |url=https://www.bbc.com/news/world-asia-india-57027829 |access-date=11 May 2021 |work=BBC News |publisher=British Broadcasting Corporation |date=9 May 2021}}</ref><ref name=Koehler>{{cite journal | vauthors = Koehler P, Bassetti M, Chakrabarti A, Chen SC, Colombo AL, Hoenigl M, Klimko N, Lass-Flörl C, Oladele RO, Vinh DC, Zhu LP, Böll B, Brüggemann R, Gangneux JP, Perfect JR, Patterson TF, Persigehl T, Meis JF, Ostrosky-Zeichner L, White PL, Verweij PE, Cornely OA | display-authors = 6 | title = Defining and managing COVID-19–associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance | journal = The Lancet. Infectious Diseases | volume = 21 | issue = 6 | pages = e149–e162 | date = June 2021 | pmid = 33333012 | pmc = 7833078 | doi = 10.1016/s1473-3099(20)30847-1 | doi-access = free }}</ref><ref name=Garg2021>{{cite journal | vauthors = Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, Puri GD, Chakrabarti A, Agarwal R | display-authors = 6 | title = Coronavirus Disease (Covid-19) Associated Mucormycosis (CAM): Case Report and Systematic Review of Literature | journal = Mycopathologia | volume = 186 | issue = 2 | pages = 289–298 | date = May 2021 | pmid = 33544266 | pmc = 7862973 | doi = 10.1007/s11046-021-00528-2 }}</ref>
 ==Mechanism==
 Most people are frequently exposed to Mucorales without developing the disease.<ref name=McDonaldBackground/> Mucormycosis is generally spread by [[inhalation|breathing in]], eating food contaminated by, or getting spores of molds of the [[Mucorales]] type in an open [[wound]].<ref name=Reid2020/> It is not transmitted between people.<ref name=CDC2021About/>
-The precise mechanism by which diabetics become susceptible is unclear. ''[[In vivo]]'', a high sugar alone does not permit the growth of the fungus, but [[acidosis]] alone does.<ref name="Chand2018"/><ref name=Spel2005/> People with high sugars frequently have higher iron levels, also known to be a risk factor for developing mucormycosis.<ref name=Spel2005/> In people on deferoxamine, the iron removed is captured by [[siderophore]]s on ''Rhizopus'' species, which uses the iron to grow.<ref name=Prakash2019/>
+The precise mechanism by which diabetics become susceptible is unclear. ''[[In vivo]]'', a high sugar level alone does not permit the growth of the fungus, but [[acidosis]] alone does.<ref name="Chand2018"/><ref name=Spel2005/> People with high sugar levels frequently have high iron levels, also known to be a risk factor for developing mucormycosis.<ref name=Spel2005/> In people taking deferoxamine, the iron removed is captured by [[siderophore]]s on ''Rhizopus'' species, which then use the iron to grow.<ref name=Prakash2019/>
 ==Diagnosis==
-There is no blood test that can confirm the diagnosis.<ref name="McDonaldWork"/> Diagnosis requires identifying the mold in the affected tissue by [[biopsy]] and confirming it with a fungal culture.<ref name=NORD2021/> Because the causative fungi occur all around, a culture alone is not decisive.<ref name=Gros2012/> Tests may also include culture and direct detection of the fungus in [[bronchoalveolar lavage|lung fluid]], blood, serum, plasma and urine.<ref name=Dan2020/> Blood tests include a [[complete blood count]] to look specifically for neutropenia.<ref name="McDonaldWork"/> Other blood tests include [[ferritin|iron levels]], [[blood glucose]], bicarbonate, and [[kidney function|electrolytes]].<ref name="McDonaldWork"/> Endoscopic examination of the nasal passages may be needed.<ref name="McDonaldWork"/>
+There is no blood test that can confirm the diagnosis.<ref name="McDonaldWork"/> Diagnosis requires identifying the mold in the affected tissue by [[biopsy]] and confirming it with a fungal culture.<ref name=NORD2021/> Because the causative fungi occur all around and may therefore contaminate cultures underway, a culture alone is not decisive.<ref name=Gros2012/> Tests may also include culture and direct detection of the fungus in [[bronchoalveolar lavage|lung fluid]], blood, serum, plasma and urine.<ref name=Dan2020/> Blood tests include a [[complete blood count]] to look specifically for neutropenia.<ref name="McDonaldWork"/> Other blood tests include [[ferritin|iron levels]], [[blood glucose]], bicarbonate, and [[kidney function|electrolytes]].<ref name="McDonaldWork"/> Endoscopic examination of the nasal passages may be needed.<ref name="McDonaldWork"/>
 ===Imaging===
-[[Radiology|Imaging]] is often performed, such as [[CT scan]] of lungs and sinuses.<ref name=CDCImag>{{cite web |title=Diagnosis and Testing of Mucormycosis {{!}} Mucormycosis {{!}} CDC |url=https://www.cdc.gov/fungal/diseases/mucormycosis/diagnosis.html |website=www.cdc.gov |language=en-us |date=14 January 2021}}</ref> Signs on chest CT scans, such as nodules, cavities, halo signs, pleural effusion and wedge-shaped shadows, showing invasion of blood vessels, may suggest a fungal infection, but do not confirm mucormycosis.<ref name="Thornton2020"/> A reverse halo sign in a person with a blood cancer and low neutrophil count, is highly suggestive of mucormycosis.<ref name="Thornton2020"/> CT scan images of mucormycosis can be useful to distinguish mucormycosis of the orbit and cellulitis of the orbit, but images may appear identical to those of aspergillosis.<ref name="Thornton2020"/> [[MRI]] may also be useful.<ref name=Sen2021/> Currently (when?), MRI with gadolinium contrast is the investigation of choice in rhinoorbito cerebral mucormycosis.{{citation needed|date=June 2021}}
+[[Radiology|Imaging]] is often performed, such as [[CT scan]] of lungs and sinuses.<ref name=CDCImag>{{cite web |title=Diagnosis and Testing of Mucormycosis {{!}} Mucormycosis {{!}} CDC |url=https://www.cdc.gov/fungal/diseases/mucormycosis/diagnosis.html |website=www.cdc.gov |language=en-us |date=14 January 2021}}</ref> Signs on chest CT scans, such as nodules, cavities, halo signs, pleural effusion and wedge-shaped shadows, showing invasion of blood vessels, may suggest a fungal infection, but do not confirm mucormycosis.<ref name="Thornton2020"/> A reverse halo sign in a person with a blood cancer and low neutrophil count is highly suggestive of mucormycosis.<ref name="Thornton2020"/> CT scan images of mucormycosis can be useful to distinguish mucormycosis of the orbit and cellulitis of the orbit, but images may appear identical to those of aspergillosis.<ref name="Thornton2020"/> [[MRI]] may also be useful.<ref name=Sen2021/> Currently,{{when|date=October 2022}} MRI with gadolinium contrast is the investigation of choice in rhinoorbito-cerebral mucormycosis.{{citation needed|date=June 2021}}
 ===Culture and biopsy===
-To confirm the diagnosis, [[biopsy]] samples can be [[Microbiological culture|cultured]].<ref name=ICD-11/><ref name="McDonaldWork">{{cite web | vauthors = McDonald PJ |title=Mucormycosis (Zygomycosis) Workup: Approach Considerations, Laboratory Tests, Radiologic Studies |url=https://emedicine.medscape.com/article/222551-workup |website=emedicine.medscape.com |access-date=25 May 2021|url-access=subscription}}</ref> Culture from biopsy samples does not always give a result as the organism is very fragile.<ref name="Thornton2020"/> To precisely identify the species requires an expert.<ref name="Thornton2020"/> The [[Morphology (biology)|appearance]] of the fungus [[histopathology|under the microscope]] will determine the [[genus]] and [[species]].<ref name="McDonaldWork"/> The appearances can vary but generally show wide, ribbon-like filaments that generally do not have septa and that—unlike in aspergillosis—branch at [[right angle]]s, resembling antlers of a [[moose]], which may be seen to be invading [[blood vessel]]s.<ref name="John2017"/>
+To confirm the diagnosis, [[biopsy]] samples can be [[Microbiological culture|cultured]].<ref name=ICD-11/><ref name="McDonaldWork">{{cite web | vauthors = McDonald PJ |title=Mucormycosis (Zygomycosis) Workup: Approach Considerations, Laboratory Tests, Radiologic Studies |url=https://emedicine.medscape.com/article/222551-workup |website=emedicine.medscape.com |access-date=25 May 2021|url-access=subscription}}</ref> Culture from biopsy samples does not always give a result as the organism is very fragile.<ref name="Thornton2020"/> Microscopy can usually determine the genus and sometimes the species, but may require an expert mycologist.<ref name="Thornton2020"/> The [[Morphology (biology)|appearance]] of the fungus [[histopathology|under the microscope]] can vary but generally shows wide (10–20 micron), ribbon-like filaments that generally do not have septa and that—unlike in aspergillosis—branch at [[right angle]]s, resembling antlers of a [[moose]], which may be seen to be invading [[blood vessel]]s.<ref name="John2017"/><ref name="McDonaldWork"/>
 <gallery mode="packed" widths="360px" heights="220">
 File:Zygomycosis, mucormycosis 2.jpg|Ribbon-like hyphae which branch at 90°
 File:Zygomycosis Mucormycosis (13430751363).jpg|Hyphae in blood vessel
-File:Mature sporangium of a Mucor sp. fungus.jpg|Mature sporangium of a Mucor<ref name="cdcimage">{{cite web |title=Details - Public Health Image Library(PHIL) |url=https://phil.cdc.gov/details.aspx?pid=3960 |website=phil.cdc.gov |access-date=26 May 2021}}</ref>
+File:Mature sporangium of a Mucor sp. fungus.jpg|Mature sporangium of a Mucor<ref name="cdcimage">{{cite web |title=Details – Public Health Image Library (PHIL) |url=https://phil.cdc.gov/details.aspx?pid=3960 |website=phil.cdc.gov |access-date=26 May 2021}}</ref>
 </gallery>
@@ Line 113: / Line 113: @@
 ==Epidemiology==
-The true incidence and prevalence of mucormycosis may be higher than appears.<ref name=Prakash2019>{{cite journal | vauthors = Prakash H, Chakrabarti A | title = Global Epidemiology of Mucormycosis | journal = Journal of Fungi | volume = 5 | issue = 1 | pages = 26 | date = March 2019 | pmid = 30901907 | pmc = 6462913 | doi = 10.3390/jof5010026 | doi-access = free }}</ref> Mucormycosis is rare, affecting fewer than 1.7 people per million population each year in San Francisco.<ref name=NORD2021/><ref name="CDCStats">{{cite web |title=Mucormycosis Statistics {{!}} Mucormycosis {{!}} Fungal Diseases {{!}} CDC |url=https://www.cdc.gov/fungal/diseases/mucormycosis/statistics.html |website=www.cdc.gov |access-date=22 May 2021 |archive-url=https://web.archive.org/web/20210521023735/https://www.cdc.gov/fungal/diseases/mucormycosis/statistics.html |archive-date=21 May 2021 |language=en-us |date=5 June 2020}}</ref> It is around 80 times more prevalent in India, where it is estimated that there are around 0.14 cases per 1000 population,<ref name=Ski2020/> and where its incidence has been rising.<ref name="Vallab2016">{{cite book | vauthors = Vallabhaneni S, Mody RK, Walker T, Chiller T | veditors = Sobel J, Ostrosky-Zeichner L |title=Fungal Infections, An Issue of Infectious Disease Clinics of North America |date=2016 |publisher=Elsevier |location=Philadelphia |isbn=978-0-323-41649-8 |pages=5–12 |chapter-url=https://books.google.com/books?id=uwndCwAAQBAJ&pg=PA5 |language=en |chapter=1. The global burden of fungal disease}}</ref> Causative fungi are highly dependent on location. ''[[Apophysomyces variabilis]]'' has its highest prevalence in Asia and ''[[Lichtheimia|Lichtheimia spp.]]'' in Europe.<ref name=Dan2020/> It is the third most common serious fungal infection to infect people, after [[aspergillosis]] and [[candidiasis]].<ref name=Petrikkos>{{cite journal | vauthors = Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP | title = Epidemiology and clinical manifestations of mucormycosis | journal = Clinical Infectious Diseases | volume = 54 | issue = suppl_1 | pages = S23-34 | date = February 2012 | pmid = 22247442 | doi = 10.1093/cid/cir866 | doi-access = free }}</ref>
+The true incidence and prevalence of mucormycosis may be higher than appears.<ref name=Prakash2019>{{cite journal | vauthors = Prakash H, Chakrabarti A | title = Global Epidemiology of Mucormycosis | journal = Journal of Fungi | volume = 5 | issue = 1 | pages = 26 | date = March 2019 | pmid = 30901907 | pmc = 6462913 | doi = 10.3390/jof5010026 | doi-access = free }}</ref> Mucormycosis is rare, affecting fewer than 1.7 people per million population each year in San Francisco.<ref name=NORD2021/><ref name="CDCStats">{{cite web |title=Mucormycosis Statistics {{!}} Mucormycosis {{!}} Fungal Diseases {{!}} CDC |url=https://www.cdc.gov/fungal/diseases/mucormycosis/statistics.html |website=www.cdc.gov |access-date=22 May 2021 |archive-url=https://web.archive.org/web/20210521023735/https://www.cdc.gov/fungal/diseases/mucormycosis/statistics.html |archive-date=21 May 2021 |language=en-us |date=5 June 2020}}</ref> It is around 80 times more prevalent in India, where it is estimated that there are around 0.14 cases per 1000 population,<ref name=Ski2020/> and where its incidence has been rising.<ref name="Vallab2016">{{cite book | vauthors = Vallabhaneni S, Mody RK, Walker T, Chiller T | veditors = Sobel J, Ostrosky-Zeichner L |title=Fungal Infections, An Issue of Infectious Disease Clinics of North America |date=2016 |publisher=Elsevier |location=Philadelphia |isbn=978-0-323-41649-8 |pages=5–12 |chapter-url=https://books.google.com/books?id=uwndCwAAQBAJ&pg=PA5 |language=en |chapter=1. The global burden of fungal disease}}</ref> Causative fungi are highly dependent on location. ''[[Apophysomyces variabilis]]'' has its highest prevalence in Asia and ''[[Lichtheimia]]'' {{abbr|spp.|species}} in Europe.<ref name=Dan2020/> It is the third most common serious human fungal infection, after [[aspergillosis]] and [[candidiasis]].<ref name=Petrikkos>{{cite journal | vauthors = Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP | title = Epidemiology and clinical manifestations of mucormycosis | journal = Clinical Infectious Diseases | volume = 54 | issue = suppl_1 | pages = S23–34 | date = February 2012 | pmid = 22247442 | doi = 10.1093/cid/cir866 | doi-access = free }}</ref>
 Diabetes is the main underlying disease in low and middle-income countries, whereas, blood cancers and organ transplantation are the more common underlying problems in developed countries.<ref name=Ski2020/> As new immunomodulating drugs and diagnostic tests are developed, the statistics for mucormycosis have been changing.<ref name=Ski2020/> In addition, the figures change as new genera and species are identified, and new risk factors reported such as tuberculosis and kidney problems.<ref name=Ski2020/>
@@ Line 120: / Line 120: @@
 [[File:Map of COVID-associated Mucormycosis (Black fungus) cases.png|thumb|{{legend|#000000|India}}
 {{legend|#FF0000|Countries where COVID-associated mucormycosis has been detected as of June 2021}}]]
-During the [[COVID-19 pandemic in India]], the Indian government reported that more than 11,700 people were receiving care for mucormycosis as of 25 May 2021. Many Indian media outlets called it "black fungus" because of the black discoloration of dead and dying tissue the fungus causes. Even before the COVID-19 pandemic, rates of mucormycosis in India were estimated to be about 70 times higher than in the rest of the world.<ref name="Dyer2021" /><ref name="'Black fungus' is creating a whole other health emergency for Covid-stricken India">{{cite news | vauthors = Schwartz I, Chakrabarti A |title='Black fungus' is creating a whole other health emergency for Covid-stricken India |url=https://www.theguardian.com/commentisfree/2021/jun/02/black-fungus-covid-india-mucormycosis |access-date=3 June 2021 |work=The Guardian |date=2 Jun 2021}}</ref> Due to its rapidly growing number of cases some Indian state governments have declared it an [[epidemic]].<ref>{{Cite web | date = 19 May 2021 | vauthors = Wadhawan DW, Jain P, Shrivastava S, Kunal K |title=Rajasthan declares black fungus an epidemic; cases pile up in several states {{!}} 10 points|url=https://www.indiatoday.in/coronavirus-outbreak/story/rajasthan-declares-black-fungus-an-epidemic-cases-pile-up-in-several-states-10-points-1804470-2021-05-19|access-date=2021-05-20|website=India Today|language=en}}</ref> One treatment was a daily injection for eight weeks of anti-fungal intravenous injection of amphotericin B which was in short supply. The injection could be standard [[amphotericin B deoxycholate]] or the liposomal form. The liposomal form cost more but it was considered "safer, more effective and [with] lesser side effects".§<ref>{{Cite news|date=2021-05-19|title=Black fungus in India: Concern over drug shortage as cases rise|language=en-GB|work=BBC News|url=https://www.bbc.com/news/world-asia-india-57167322|access-date=2021-07-08}}</ref> The major obstacle of using antifungal drugs in black fungus is the lack of clinical trials.<ref name="Novel perspectives on mucormycosis"/>
+During the [[COVID-19 pandemic in India]], the Indian government reported that more than 11,700 people were receiving care for mucormycosis as of 25 May 2021. Many Indian media outlets called it "black fungus" because of the black discoloration of dead and dying tissue the fungus causes. Even before the COVID-19 pandemic, rates of mucormycosis in India were estimated to be about 70 times higher than in the rest of the world.<ref name="Dyer2021" /><ref name="'Black fungus' is creating a whole other health emergency for Covid-stricken India">{{cite news | vauthors = Schwartz I, Chakrabarti A |title='Black fungus' is creating a whole other health emergency for Covid-stricken India |url=https://www.theguardian.com/commentisfree/2021/jun/02/black-fungus-covid-india-mucormycosis |access-date=3 June 2021 |work=The Guardian |date=2 Jun 2021}}</ref> Due to its rapidly growing number of cases some Indian state governments have declared it an [[epidemic]].<ref>{{Cite web | date = 19 May 2021 | vauthors = Wadhawan DW, Jain P, Shrivastava S, Kunal K |title=Rajasthan declares black fungus an epidemic; cases pile up in several states {{!}} 10 points|url=https://www.indiatoday.in/coronavirus-outbreak/story/rajasthan-declares-black-fungus-an-epidemic-cases-pile-up-in-several-states-10-points-1804470-2021-05-19|access-date=2021-05-20|website=India Today|language=en}}</ref> One treatment was a daily injection for eight weeks of anti-fungal intravenous injection of amphotericin B which was in short supply. The injection could be standard [[amphotericin B deoxycholate]] or the liposomal form. The liposomal form cost more but it was considered "safer, more effective and [with] lesser side effects".<ref>{{Cite news|date=2021-05-19|title=Black fungus in India: Concern over drug shortage as cases rise|language=en-GB|work=BBC News|url=https://www.bbc.com/news/world-asia-india-57167322|access-date=2021-07-08}}</ref> The major obstacle of using antifungal drugs in black fungus is the lack of clinical trials.<ref name="Novel perspectives on mucormycosis"/>
 ===Recurrence of mucormycosis during COVID-19 second wave in India===
-Pre-COVID mucormycosis was a very rare infection, even in India. It is so rare that an ENT doctor would have been considered lucky if they witnessed a case during their university time. So, the documentation available on the treatment of mucormycosis is limited. In fact, there used to be a couple of mucormycosis expert ENT surgeons for millions of people pre-pandemic. The sudden rise in mucormycosis cases has left a majority of the ENT doctors with no option but to accept mucormycosis cases, as the expert doctors were very much occupied and the patient would die if left untreated. The majority of the ENT doctors had to manage with minimal or no experience on mucormycosis, this has led to the recurrence of mucormycosis in the patients they treated. When a highly experienced doctor in mucormycosis treats a patient even he cannot guarantee that the individual is completely cured and will not have a relapse of mucormycosis; an inexperienced ENT surgeon will definitely have a high number of patients with recurrence due to which there were many recurrent cases of mucormycosis although it did not get the limelight of media or the Indian Government.<ref>{{Cite web|title=Recurrence of Mucormycosis due to partial treatments|url=https://www.medyblog.com/post/recurrence-of-mucormycosis-in-discharged-patients-due-to-partial-treatments}}</ref>{{Unreliable medical source|reason=Blog|date=February 2022}}
+Pre-COVID mucormycosis was a very rare infection, even in India. It is so rare that an [[Otorhinolaryngology|ENT (ear, nose, throat)]] doctor would not witness often a case during their university time. So, the documentation available on the treatment of mucormycosis is limited. In fact, there used to be a couple of mucormycosis expert ENT surgeons for millions of people before the pandemic. The sudden rise in mucormycosis cases has left a majority of the ENT doctors with no option but to accept mucormycosis cases, as the expert doctors were very much occupied and the patient would die if left untreated. The majority of the ENT doctors had to manage with minimal or no experience on mucormycosis, this has led to the recurrence of mucormycosis in the patients they treated. When a highly experienced doctor in mucormycosis treats a patient even he cannot guarantee that the individual is completely cured and will not have a relapse of mucormycosis; an inexperienced ENT surgeon will definitely have a high number of patients with recurrence due to which there were many recurrent cases of mucormycosis although it did not get the limelight of media or the Indian Government.
 ==History==
@@ Line 134: / Line 134: @@
 ===COVID-19–associated mucormycosis===
-COVID-19 associated mucormycosis cases were reported during first and second(delta) wave, with maximum number of cases in delta wave.<ref name=":0" /> There were no cases reported during the Omicron wave.<ref name=":0" /> A number of cases of mucormycosis, [[aspergillosis]], and [[candidiasis]], linked to immunosuppressive treatment for COVID-19 were reported during the COVID-19 pandemic in India in 2020 and 2021.<ref name="QC2020" /><ref name="Sen2021">{{cite journal | vauthors = Sen M, Honavar SG, Sharma N, Sachdev MS | title = COVID-19 and Eye: A Review of Ophthalmic Manifestations of COVID-19 | journal = Indian Journal of Ophthalmology | volume = 69 | issue = 3 | pages = 488–509 | date = March 2021 | pmid = 33595463 | pmc = 7942063 | doi = 10.4103/ijo.IJO_297_21 }}</ref> One review in early 2021 relating to the association of mucormycosis and COVID-19 reported eight cases of mucormycosis; three from the U.S., two from India, and one case each from Brazil, Italy, and the UK.<ref name="Garg2021" /> The most common underlying medical condition was diabetes.<ref name="Garg2021" /> Most had been in hospital with [[acute respiratory distress syndrome|severe breathing problems]] due to COVID-19, had recovered, and developed mucormycosis 10–14 days following treatment for COVID-19. Five had abnormal kidney function tests, three involved the sinus, eye and brain, three the lungs, one the gastrointestinal tract, and in one the disease was widespread.<ref name="Garg2021" /> In two of the seven deaths, the diagnosis of mucormycosis was made at postmortem.<ref name="Garg2021" /> That three had no traditional risk factors led the authors to question the use of steroids and [[immunosuppressive drug]]s.<ref name="Garg2021" />  Although, there were cases without diabetes or use of immunosuppressive drugs.  There were cases reported even in children.<ref name=":0">{{Cite web |date=2021-05-15 |title=Mucormycosis / Black fungus infection |url=https://www.medyblog.com/post/mucormycosis-black-fungus-infection-in-post-covid-patients-symptoms-treatment |access-date=2021-06-27 |website=Medy Blog |language=en |vauthors=Meghanadh KR}}</ref> In May 2021, the BBC reported increased cases in India.<ref name="bbc-black-fungus-covid19" /> In a review of COVID-19-related eye problems, mucormycosis affecting the eyes was reported to occur up to several weeks following recovery from COVID-19.<ref name="Sen2021" /> It was observed that people with COVID-19 were recovering from mucormycosis a bit easily when compared to non-COVID-19 patients. This is because unlike non-COVID-19 patients with severe diabetes, cancer or HIV, the recovery time required for the main cause of immune suppression is temporary.<ref name=":0" />
+COVID-19 associated mucormycosis cases were reported during first and second(delta) wave, with maximum number of cases in delta wave.<ref name=":0" /> There were no cases reported during the Omicron wave.<ref name=":0" /> A number of cases of mucormycosis, [[aspergillosis]], and [[candidiasis]], linked to immunosuppressive treatment for COVID-19 were reported during the COVID-19 pandemic in India in 2020 and 2021.<ref name="QC2020" /><ref name="Sen2021">{{cite journal | vauthors = Sen M, Honavar SG, Sharma N, Sachdev MS | title = COVID-19 and Eye: A Review of Ophthalmic Manifestations of COVID-19 | journal = Indian Journal of Ophthalmology | volume = 69 | issue = 3 | pages = 488–509 | date = March 2021 | pmid = 33595463 | pmc = 7942063 | doi = 10.4103/ijo.IJO_297_21 | doi-access = free }}</ref> One review in early 2021 relating to the association of mucormycosis and COVID-19 reported eight cases of mucormycosis; three from the U.S., two from India, and one case each from Brazil, Italy, and the UK.<ref name="Garg2021" /> The most common underlying medical condition was diabetes.<ref name="Garg2021" /> Most had been in hospital with [[acute respiratory distress syndrome|severe breathing problems]] due to COVID-19, had recovered, and developed mucormycosis 10–14 days following treatment for COVID-19. Five had abnormal kidney function tests, three involved the sinus, eye and brain, three the lungs, one the gastrointestinal tract, and in one the disease was widespread.<ref name="Garg2021" /> In two of the seven deaths, the diagnosis of mucormycosis was made at postmortem.<ref name="Garg2021" /> That three had no traditional risk factors led the authors to question the use of steroids and [[immunosuppressive drug]]s,<ref name="Garg2021" /> although there were cases without diabetes or use of immunosuppressive drugs.  There were cases reported even in children.<ref name=":0">{{Cite web |date=2021-05-15 |title=Mucormycosis / Black fungus infection |url=https://www.medyblog.com/post/mucormycosis-black-fungus-infection-in-post-covid-patients-symptoms-treatment |access-date=2021-06-27 |website=Medy Blog |language=en |vauthors=Meghanadh KR}}</ref> In May 2021, the BBC reported increased cases in India.<ref name="bbc-black-fungus-covid19" /> In a review of COVID-19-related eye problems, mucormycosis affecting the eyes was reported to occur up to several weeks following recovery from COVID-19.<ref name="Sen2021" /> It was observed that people with COVID-19 were recovering from mucormycosis a bit easily when compared to non-COVID-19 patients. This is because unlike non-COVID-19 patients with severe diabetes, cancer or HIV, the recovery time required for the main cause of immune suppression is temporary.<ref name=":0" />
-Other countries affected included Pakistan,<ref>{{cite web |title= 'Cases of Black Fungus emerge across Pakistan' |url=https://www.thenews.com.pk/print/834117-cases-of-black-fungus-emerge-across-pakistan |website=The News International |language=en |date=2021-05-12}}</ref> Nepal,<ref>{{cite web |title= Focused COVID-19 Media Monitoring, Nepal (May 24, 2021) |url=https://reliefweb.int/report/nepal/focused-covid-19-media-monitoring-nepal-may-24-2021 |website=ReliefWeb |language=en |date=2021-05-24}}</ref> Bangladesh,<ref>{{cite web |title= Bangladesh reports 1st death by black fungus |url=https://www.aa.com.tr/en/asia-pacific/bangladesh-reports-1st-death-by-black-fungus/2253604 |website=Anadolu Agency |language=en |date=2021-05-25}}</ref> Russia,<ref>{{cite web |title=Russia Confirms Rare, Deadly 'Black Fungus' Infections Seen in India |url=https://www.themoscowtimes.com/2021/05/17/russia-confirms-rare-deadly-black-fungus-infections-seen-in-india-reports-a73922 |website=The Moscow Times |language=en |date=2021-05-17}}</ref> Uruguay,<ref>{{cite web |title=Paciente con COVID-19 se infectó con el "hongo negro" |url=https://www.elpais.com.uy/informacion/salud/paciente-covid-infecto-hongo-negro.html |website=EL PAÍS Uruguay |language=es |date=2021-05-25}}</ref> Paraguay,<ref>{{cite web |title=Confirman dos casos de "hongo negro" en Paraguay |url=https://www.rdn.com.py/2021/05/27/confirman-dos-casos-de-hongo-negro-en-paraguay/ |website=RDN |language=es |date=2021-05-27}}</ref> Chile,<ref>{{cite web |title= Detectan primer caso de "hongo negro" en Chile en paciente con Covid-19: es el segundo reportado en Latinoamérica  |url=https://www.elmostrador.cl/dia/2021/05/28/detectan-primer-caso-de-hongo-negro-en-chile-en-paciente-con-covid-19-es-el-segundo-reportado-en-latinoamerica/ |website=El Mostrador |language=es |date=2021-05-28}}</ref> Egypt,<ref>{{cite web |title=Mansoura University Hospital reports black fungus cases |url=https://www.egyptindependent.com/mansoura-university-hospital-reports-black-fungus-cases/ |website=Egypt Independent |language=en |date=2021-05-28}}</ref> Iran,<ref>{{cite web |title= Coronavirus in Iran: Power outages, black fungus, and warnings of a fifth surge |url=https://www.trackpersia.com/coronavirus-in-iran-power-outages-black-fungus-and-warnings-of-a-fifth-surge/ |website=Track Persia |language=en |date=2021-05-29}}</ref> Brazil,<ref>{{cite web |title=Casos suspeitos de fungo preto são investigados no Brasil; entenda |url=https://catracalivre.com.br/saude-bem-estar/casos-suspeitos-de-fungo-preto-sao-investigados-no-brasil-entenda/ |website=Catraca Livre |language=pt |date=2021-05-31}}</ref> Iraq,<ref>{{cite web |title=Iraq detects five cases of the deadly "black fungus" among coronavirus patients |url=https://globelivemedia.com/world/iraq-detects-five-cases-of-the-deadly-black-fungus-among-coronavirus-patients/ |website=Globe Live Media |language=en |date=2021-06-01}}</ref> Mexico,<ref>{{cite web |title=Detectan en Edomex posible primer caso de hongo negro en México |url=https://www.unotv.com/estados/estado-de-mexico/hongo-negro-en-mexico-detectan-posible-primer-caso-en-edomex/ |website=Uno TV |language=es |date=2021-06-03}}</ref> Honduras,<ref>{{cite web |title=Salud confirma primer caso de hongo negro en Honduras |url=https://www.elheraldo.hn/pais/1468999-466/confirman-primer-caso-hongo-negro-honduras-covid |website=Diario El Heraldo |language=es |date=2021-06-07}}</ref> Argentina<ref>{{cite web|url=https://www.clarin.com/buena-vida/-hongo-negro-advierten-atento-coinfeccion-fungica-pacientes-covid_0_7ovY9ZQP3.html|title="Hongo negro": advierten que hay que estar atentos a la coinfección fúngica en pacientes con covid|date=2021-06-16|website=Clarín|language=es}}</ref> Oman,<ref>{{cite web|url=https://www.aljazeera.com/news/2021/6/15/black-fungus-detected-covid-19-patients-oman|title='Black fungus' detected in 3 COVID-19 patients in Oman|date=2021-06-15|website=Al Jazeera|language=en}}</ref> and Afghanistan.<ref>{{Cite web|title=Afghanistan finds deadly 'black fungus' in virus patients – latest updates|url=https://www.trtworld.com/life/afghanistan-finds-deadly-black-fungus-in-virus-patients-latest-updates-48039|work=[[TRT World]]|language=en|access-date=July 17, 2021}}</ref> One explanation for why the association has surfaced remarkably in India is high rates of COVID-19 infection and high rates of diabetes.<ref>{{cite web | vauthors = Runwal P |title=A rare black fungus is infecting many of India's COVID-19 patients—why? |url=https://www.nationalgeographic.com/science/article/a-rare-black-fungus-is-infecting-many-of-indias-covid-19-patientswhy |website=[[National Geographic]] |language=en |date=2021-05-14}}</ref> In May 2021, the [[Indian Council of Medical Research]] issued guidelines for recognising and treating COVID-19–associated mucormycosis.<ref>{{cite web |title=ICMR releases diagnosis and management guidelines for COVID-19-associated Mucormycosis |url=https://www.firstpost.com/india/icmr-releases-diagnosis-and-management-guidelines-for-covid-19-associated-mucormycosis-9628341.html |website=[[Firstpost]] |date=2021-05-17}}</ref> In India, as of 28 June 2021, over 40,845 people have been confirmed to have mucormycosis, and 3,129 have died. From these cases, 85.5% (34,940) had a history of being infected with SARS-CoV-2 and 52.69% (21,523) were on steroids, also 64.11% (26,187) had diabetes.<ref>{{cite web |title=India reports 40,854 cases of black fungus so far|url=https://www.livemint.com/news/india-records-over-40k-cases-of-mucormycosis-11624875874985.html |work=[[Mint (newspaper)|Mint]] |date=June 28, 2021 |access-date=16 July 2021}}</ref><ref>{{cite web|title=Delhi has more black fungus infections than active Covid-19 cases: Govt data|url=https://www.livemint.com/news/india/delhi-has-more-infections-of-black-fungus-than-active-covid-19-cases-govt-data/amp-11626227610032.html|work=[[Mint (newspaper)|Mint]]|date=July 14, 2021|access-date=16 July 2021}}</ref>
+Other countries affected included Pakistan,<ref>{{cite web |title= 'Cases of Black Fungus emerge across Pakistan' |url=https://www.thenews.com.pk/print/834117-cases-of-black-fungus-emerge-across-pakistan |website=The News International |language=en |date=2021-05-12}}</ref> Nepal,<ref>{{cite web |title= Focused COVID-19 Media Monitoring, Nepal (May 24, 2021) |url=https://reliefweb.int/report/nepal/focused-covid-19-media-monitoring-nepal-may-24-2021 |website=ReliefWeb |language=en |date=2021-05-24}}</ref> Bangladesh,<ref>{{cite web |title= Bangladesh reports 1st death by black fungus |url=https://www.aa.com.tr/en/asia-pacific/bangladesh-reports-1st-death-by-black-fungus/2253604 |website=Anadolu Agency |language=en |date=2021-05-25}}</ref> Russia,<ref>{{cite web |title=Russia Confirms Rare, Deadly 'Black Fungus' Infections Seen in India |url=https://www.themoscowtimes.com/2021/05/17/russia-confirms-rare-deadly-black-fungus-infections-seen-in-india-reports-a73922 |website=The Moscow Times |language=en |date=2021-05-17}}</ref> Uruguay,<ref>{{cite web |title=Paciente con COVID-19 se infectó con el "hongo negro" |url=https://www.elpais.com.uy/informacion/salud/paciente-covid-infecto-hongo-negro.html |website=EL PAÍS Uruguay |language=es |date=2021-05-25}}</ref> Paraguay,<ref>{{cite web |title=Confirman dos casos de "hongo negro" en Paraguay |url=https://www.rdn.com.py/2021/05/27/confirman-dos-casos-de-hongo-negro-en-paraguay/ |website=RDN |language=es |date=2021-05-27}}</ref> Chile,<ref>{{cite web |title= Detectan primer caso de "hongo negro" en Chile en paciente con Covid-19: es el segundo reportado en Latinoamérica  |url=https://www.elmostrador.cl/dia/2021/05/28/detectan-primer-caso-de-hongo-negro-en-chile-en-paciente-con-covid-19-es-el-segundo-reportado-en-latinoamerica/ |website=El Mostrador |language=es |date=2021-05-28}}</ref> Egypt,<ref>{{cite web |title=Mansoura University Hospital reports black fungus cases |url=https://www.egyptindependent.com/mansoura-university-hospital-reports-black-fungus-cases/ |website=Egypt Independent |language=en |date=2021-05-28}}</ref> Iran,<ref>{{cite web |title=Coronavirus in Iran: Power outages, black fungus, and warnings of a fifth surge |url=https://www.trackpersia.com/coronavirus-in-iran-power-outages-black-fungus-and-warnings-of-a-fifth-surge/ |website=Track Persia |language=en |date=2021-05-29 |access-date=June 1, 2021 |archive-date=May 29, 2021 |archive-url=https://web.archive.org/web/20210529185906/https://www.trackpersia.com/coronavirus-in-iran-power-outages-black-fungus-and-warnings-of-a-fifth-surge/ |url-status=dead }}</ref> Brazil,<ref>{{cite web |title=Casos suspeitos de fungo preto são investigados no Brasil; entenda |url=https://catracalivre.com.br/saude-bem-estar/casos-suspeitos-de-fungo-preto-sao-investigados-no-brasil-entenda/ |website=Catraca Livre |language=pt |date=2021-05-31}}</ref> Iraq,<ref>{{cite web |title=Iraq detects five cases of the deadly "black fungus" among coronavirus patients |url=https://globelivemedia.com/world/iraq-detects-five-cases-of-the-deadly-black-fungus-among-coronavirus-patients/ |website=Globe Live Media |language=en |date=2021-06-01}}</ref> Mexico,<ref>{{cite web |title=Detectan en Edomex posible primer caso de hongo negro en México |url=https://www.unotv.com/estados/estado-de-mexico/hongo-negro-en-mexico-detectan-posible-primer-caso-en-edomex/ |website=Uno TV |language=es |date=2021-06-03}}</ref> Honduras,<ref>{{cite web |title=Salud confirma primer caso de hongo negro en Honduras |url=https://www.elheraldo.hn/pais/1468999-466/confirman-primer-caso-hongo-negro-honduras-covid |website=Diario El Heraldo |language=es |date=2021-06-07}}</ref> Argentina<ref>{{cite web|url=https://www.clarin.com/buena-vida/-hongo-negro-advierten-atento-coinfeccion-fungica-pacientes-covid_0_7ovY9ZQP3.html|title="Hongo negro": advierten que hay que estar atentos a la coinfección fúngica en pacientes con covid|date=2021-06-16|website=Clarín|language=es}}</ref> Oman,<ref>{{cite web|url=https://www.aljazeera.com/news/2021/6/15/black-fungus-detected-covid-19-patients-oman|title='Black fungus' detected in 3 COVID-19 patients in Oman|date=2021-06-15|website=Al Jazeera|language=en}}</ref> and Afghanistan.<ref>{{Cite web|title=Afghanistan finds deadly 'black fungus' in virus patients – latest updates|url=https://www.trtworld.com/life/afghanistan-finds-deadly-black-fungus-in-virus-patients-latest-updates-48039|work=[[TRT World]]|language=en|access-date=July 17, 2021}}</ref> One explanation for why the association has surfaced remarkably in India is high rates of COVID-19 infection and high rates of diabetes.<ref>{{cite web | vauthors = Runwal P |title=A rare black fungus is infecting many of India's COVID-19 patients—why? |url=https://www.nationalgeographic.com/science/article/a-rare-black-fungus-is-infecting-many-of-indias-covid-19-patientswhy |archive-url=https://web.archive.org/web/20210514170902/https://www.nationalgeographic.com/science/article/a-rare-black-fungus-is-infecting-many-of-indias-covid-19-patientswhy |url-status=dead |archive-date=May 14, 2021 |website=[[National Geographic]] |language=en |date=2021-05-14}}</ref> In May 2021, the [[Indian Council of Medical Research]] issued guidelines for recognising and treating COVID-19–associated mucormycosis.<ref>{{cite web |title=ICMR releases diagnosis and management guidelines for COVID-19-associated Mucormycosis |url=https://www.firstpost.com/india/icmr-releases-diagnosis-and-management-guidelines-for-covid-19-associated-mucormycosis-9628341.html |website=[[Firstpost]] |date=2021-05-17}}</ref> In India, as of 28 June 2021, over 40,845 people have been confirmed to have mucormycosis, and 3,129 have died. From these cases, 85.5% (34,940) had a history of being infected with SARS-CoV-2 and 52.69% (21,523) were on steroids, also 64.11% (26,187) had diabetes.<ref>{{cite web |title=India reports 40,854 cases of black fungus so far|url=https://www.livemint.com/news/india-records-over-40k-cases-of-mucormycosis-11624875874985.html |work=[[Mint (newspaper)|Mint]] |date=June 28, 2021 |access-date=16 July 2021}}</ref><ref>{{cite web|title=Delhi has more black fungus infections than active Covid-19 cases: Govt data|url=https://www.livemint.com/news/india/delhi-has-more-infections-of-black-fungus-than-active-covid-19-cases-govt-data/amp-11626227610032.html|work=[[Mint (newspaper)|Mint]]|date=July 14, 2021|access-date=16 July 2021}}</ref>
 ==Society and culture==
-The disease has been reported in natural disasters and catastrophes; [[2004 Indian Ocean earthquake and tsunami|2004 Indian Ocean tsunami]] and the [[2011 Joplin tornado|2011 Missouri tornado]].<ref name=Dan2020/><ref>{{cite journal|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6029a5.htm?s_cid=mm6029a5_e%0d%0aref= |title=Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado – Joplin, Missouri, 2011 |author=Fanfair, Robyn Neblett|display-authors=etal|journal=MMWR Weekly |date=July 29, 2011 |volume=60 |issue=29 |pages=992 }}</ref>  The first international congress on mucormycosis was held in Chicago in 2010, set up by the Hank Schueuler 41 & 9 Foundation, which was established in 2008 for the research of children with leukaemia and fungal infections.<ref name="Chand2018"/> A cluster of infections occurred in the wake of the [[2011 Joplin tornado]]. By July 19, 2011, a total of 18&nbsp;suspected cases of mucormycosis of the skin had been identified, of which 13 were confirmed. A confirmed case was defined as 1) [[necrotizing]] soft-tissue infection requiring antifungal treatment or surgical [[debridement]] in a person injured in the tornado, 2) with illness onset on or after May 22 and 3) positive fungal culture or [[histopathology]] and genetic sequencing consistent with a mucormycete. No additional cases related to that outbreak were reported after June 17. Ten people required admission to an intensive-care unit, and five died.<ref>Williams, Timothy (June 10, 2011) [https://www.nytimes.com/2011/06/11/us/11fungus.html?ref=health Rare Infection Strikes Victims of a Tornado in Missouri]. ''New York Times''.</ref><ref name=Neblett2012>{{cite journal | vauthors = Neblett Fanfair R, Benedict K, Bos J, Bennett SD, Lo YC, Adebanjo T, Etienne K, Deak E, Derado G, Shieh WJ, Drew C, Zaki S, Sugerman D, Gade L, Thompson EH, Sutton DA, Engelthaler DM, Schupp JM, Brandt ME, Harris JR, Lockhart SR, Turabelidze G, Park BJ | display-authors = 6 | title = Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011 | journal = The New England Journal of Medicine | volume = 367 | issue = 23 | pages = 2214–25 | date = December 2012 | pmid = 23215557 | doi = 10.1056/NEJMoa1204781 }}</ref>
+The disease has been reported in natural disasters and catastrophes; [[2004 Indian Ocean earthquake and tsunami|2004 Indian Ocean tsunami]] and the [[2011 Joplin tornado|2011 Missouri tornado]].<ref name=Dan2020/><ref>{{cite journal|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6029a5.htm?s_cid=mm6029a5_e%0d%0aref= |title=Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado – Joplin, Missouri, 2011 |author=Fanfair, Robyn Neblett|display-authors=etal|journal=MMWR Weekly |date=July 29, 2011 |volume=60 |issue=29 |pages=992 }}</ref>  The first international congress on mucormycosis was held in Chicago in 2010, set up by the Hank Schueuler 41 & 9 Foundation, which was established in 2008 for the research of children with leukaemia and fungal infections.<ref name="Chand2018"/> A cluster of infections occurred in the wake of the [[2011 Joplin tornado]]. By July 19, 2011, a total of 18&nbsp;suspected cases of mucormycosis of the skin had been identified, of which 13 were confirmed. A confirmed case was defined as 1) [[necrotizing]] soft-tissue infection requiring antifungal treatment or surgical [[debridement]] in a person injured in the tornado, 2) with illness onset on or after May 22 and 3) positive fungal culture or [[histopathology]] and genetic sequencing consistent with a mucormycete. No additional cases related to that outbreak were reported after June 17. Ten people required admission to an intensive-care unit, and five died.<ref>Williams, Timothy (June 10, 2011) [https://www.nytimes.com/2011/06/11/us/11fungus.html?ref=health Rare Infection Strikes Victims of a Tornado in Missouri]. ''New York Times''.</ref><ref name=Neblett2012>{{cite journal | vauthors = Neblett Fanfair R, Benedict K, Bos J, Bennett SD, Lo YC, Adebanjo T, Etienne K, Deak E, Derado G, Shieh WJ, Drew C, Zaki S, Sugerman D, Gade L, Thompson EH, Sutton DA, Engelthaler DM, Schupp JM, Brandt ME, Harris JR, Lockhart SR, Turabelidze G, Park BJ | display-authors = 6 | title = Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011 | journal = The New England Journal of Medicine | volume = 367 | issue = 23 | pages = 2214–25 | date = December 2012 | pmid = 23215557 | doi = 10.1056/NEJMoa1204781 | doi-access = free }}</ref>
-In 2014, details of a lethal mucormycosis outbreak that occurred in 2008 emerged after television and newspaper reports responded to an article in a pediatric medical journal.<ref>{{cite news|title=Mother believes her newborn was the first to die from fungus at Children's Hospital in 2008|url=http://www.nola.com/health/index.ssf/2014/04/mother_believes_her_newborn_so.html| author=Catalanello, Rebecca |work=NOLA.com | date=April 16, 2014}}</ref><ref>{{cite news|title=5 Children's Hospital patients died in 2008, 2009 after contact with deadly fungus|url=http://www.fox8live.com/story/25246258/5-childrens-hospital-patients-died-in-2008-2009-after-contact-with-deadly-fungus|quote=We acknowledge that Children's Hospital is Hospital A in an upcoming article in The Pediatric Infectious Disease Journal. The safety and well-being of our patients are our top priorities, so as soon as a problem was suspected, the State Health Department and CDC were notified and invited to assist in the investigation. The hospital was extremely aggressive in trying to isolate and then eliminate the source of the fungus.}}</ref> Contaminated hospital linen was found to be spreading the infection. A 2018 study found many freshly laundered hospital linens delivered to U.S. transplant hospitals were contaminated with Mucorales.<ref>{{cite journal | vauthors = Sundermann AJ, Clancy CJ, Pasculle AW, Liu G, Cumbie RB, Driscoll E, Ayres A, Donahue L, Pergam SA, Abbo L, Andes DR, Chandrasekar P, Galdys AL, Hanson KE, Marr KA, Mayer J, Mehta S, Morris MI, Perfect J, Revankar SG, Smith B, Swaminathan S, Thompson GR, Varghese M, Vazquez J, Whimbey E, Wingard JR, Nguyen MH | display-authors = 6 | title = How Clean Is the Linen at My Hospital? The Mucorales on Unclean Linen Discovery Study of Large United States Transplant and Cancer Centers | journal = Clinical Infectious Diseases | volume = 68 | issue = 5 | pages = 850–853 | date = February 2019 | pmid = 30299481 | pmc = 6765054 | doi = 10.1093/cid/ciy669 | doi-access = free }}</ref> Another study attributed an outbreak of hospital-acquired mucormycosis to a laundry facility supplying linens contaminated with Mucorales. The outbreak stopped when major changes were made at the laundry facility. The authors raised concerns on the regulation of healthcare linens.<ref>{{Cite journal|last1=Sundermann|first1=Alexander J.|last2=Clancy|first2=Cornelius J.|last3=Pasculle|first3=A. William|last4=Liu|first4=Guojun|last5=Cheng|first5=Shaoji|last6=Cumbie|first6=Richard B.|last7=Driscoll|first7=Eileen|last8=Ayres|first8=Ashley|last9=Donahue|first9=Lisa|last10=Buck|first10=Michael|last11=Streifel|first11=Andrew|date=2021-07-20|title=Remediation of Mucorales-contaminated Healthcare Linens at a Laundry Facility Following an Investigation of a Case Cluster of Hospital-acquired Mucormycosis|url=https://pubmed.ncbi.nlm.nih.gov/34282829|journal=Clinical Infectious Diseases|pages=ciab638|doi=10.1093/cid/ciab638|issn=1537-6591|pmid=34282829}}</ref>
+In 2014, details of a lethal mucormycosis outbreak that occurred in 2008 emerged after television and newspaper reports responded to an article in a pediatric medical journal.<ref>{{cite news|title=Mother believes her newborn was the first to die from fungus at Children's Hospital in 2008|url=http://www.nola.com/health/index.ssf/2014/04/mother_believes_her_newborn_so.html| author=Catalanello, Rebecca |work=NOLA.com | date=April 16, 2014}}</ref><ref>{{cite news|title=5 Children's Hospital patients died in 2008, 2009 after contact with deadly fungus|url=http://www.fox8live.com/story/25246258/5-childrens-hospital-patients-died-in-2008-2009-after-contact-with-deadly-fungus|quote=We acknowledge that Children's Hospital is Hospital A in an upcoming article in The Pediatric Infectious Disease Journal. The safety and well-being of our patients are our top priorities, so as soon as a problem was suspected, the State Health Department and CDC were notified and invited to assist in the investigation. The hospital was extremely aggressive in trying to isolate and then eliminate the source of the fungus.}}</ref> Contaminated hospital linen was found to be spreading the infection. A 2018 study found many freshly laundered hospital linens delivered to U.S. transplant hospitals were contaminated with Mucorales.<ref>{{cite journal | vauthors = Sundermann AJ, Clancy CJ, Pasculle AW, Liu G, Cumbie RB, Driscoll E, Ayres A, Donahue L, Pergam SA, Abbo L, Andes DR, Chandrasekar P, Galdys AL, Hanson KE, Marr KA, Mayer J, Mehta S, Morris MI, Perfect J, Revankar SG, Smith B, Swaminathan S, Thompson GR, Varghese M, Vazquez J, Whimbey E, Wingard JR, Nguyen MH | display-authors = 6 | title = How Clean Is the Linen at My Hospital? The Mucorales on Unclean Linen Discovery Study of Large United States Transplant and Cancer Centers | journal = Clinical Infectious Diseases | volume = 68 | issue = 5 | pages = 850–853 | date = February 2019 | pmid = 30299481 | pmc = 6765054 | doi = 10.1093/cid/ciy669 | doi-access = free }}</ref> Another study attributed an outbreak of hospital-acquired mucormycosis to a laundry facility supplying linens contaminated with Mucorales. The outbreak stopped when major changes were made at the laundry facility. The authors raised concerns on the regulation of healthcare linens.<ref>{{Cite journal|last1=Sundermann|first1=Alexander J.|last2=Clancy|first2=Cornelius J.|last3=Pasculle|first3=A. William|last4=Liu|first4=Guojun|last5=Cheng|first5=Shaoji|last6=Cumbie|first6=Richard B.|last7=Driscoll|first7=Eileen|last8=Ayres|first8=Ashley|last9=Donahue|first9=Lisa|last10=Buck|first10=Michael|last11=Streifel|first11=Andrew|date=2021-07-20|title=Remediation of Mucorales-contaminated Healthcare Linens at a Laundry Facility Following an Investigation of a Case Cluster of Hospital-acquired Mucormycosis|url=https://pubmed.ncbi.nlm.nih.gov/34282829|journal=Clinical Infectious Diseases|volume=74 |issue=8 |pages=1401–1407|doi=10.1093/cid/ciab638|issn=1537-6591|pmid=34282829}}</ref>
 ==Other animals==
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 == References ==
-{{Reflist}}
+{{reflist}}
 == Further reading ==

Classification	D ICD-10: B46.0-B46.5 ICD-9-CM: 117.7 MeSH: D009091 DiseasesDB: 31759 SNOMED CT: 76627001
External resources	MedlinePlus: 000649 Patient UK: Mucormycosis Orphanet: 73263