Invasive pulmonary coinfection with Mucor and Aspergillus is rare. Bilateral vocal cord paralysis resulting from coinfection with these two fungi to our knowledge has not been reported in the literature. We report a young woman with diabetes who presented with symptoms of community acquired pneumonia in association with hoarseness of voice. Investigations revealed air space consolidation of the right upper lobe, evidence of mediastinal involvement extending into the paratracheal space and entrapment of right upper lobe pulmonary artery. Bronchoscopy revealed bilateral vocal cord paralysis and sloughing of mucosa of the right upper lobe bronchus and the bronchus intermedius. Microbiological and pathological results confirmed Mucor and Aspergillus. Extensive vascular and mediastinal involvement precludes surgical debridement. Despite aggressive medical management the patient deteriorated and died of respiratory failure. Strong suspicion of invasive fungal infections in immune compromised patients presenting with unresolving pneumonia and hoarseness of voice, early aggressive treatment is crucial for the patient survival.

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Background Childhood diarrhea remains a major disease burden, particularly in developing countries, and is a leading cause of death in children aged < 5 years, worldwide. Treatment of acute diarrhea now includes probiotics to potentially reduce the duration and severity of the illness. This phase 3, randomized, placebo-controlled, double-blind study assessed the efficacy and safety of four strains (O/C, N/R, SIN, T) of Bacillus clausii probiotic (Enterogermina®) plus oral rehydration therapy (ORT) and zinc, versus placebo plus ORT and zinc, in infants and children in India with acute moderate diarrhea. Methods Patients aged 6 months to 5 years with acute moderate diarrhea (WHO 2005 definition) of < 48 h’ duration were randomly assigned to receive one mini bottle of either polyantibiotic-resistant B. clausii (oral suspension of 2 billion spores per 5 mL bottle) or matching placebo twice daily (morning and evening) for 5 days. Exclusion criteria included known hypersensitivity to B. clausii or excipients in the study treatment, or to other probiotics. Patients were admitted to hospital from Day 1 and discharged ≥6 h after diarrhea resolution, or a maximum of 5 days. The primary endpoint was duration of acute diarrhea from randomization to recovery. Secondary endpoints included frequency of stools, diapers with stools, or dehydration status. Results In total, 457 patients were randomized; 454 were treated. Similar proportions of patients showed recovery from diarrhea over the 120 h after randomization (97.0% in the B. clausii group [n = 227]; 98.0% on placebo [n = 227]). Median time to recovery was also similar: 42.83 (95% CI: 40.90–44.90) hours for B. clausii and 42.13 (95% CI: 39.80–43.87) hours for placebo. However, no statistically significant difference was observed between groups (hazard ratio = 0.93 [95% CI: 0.77–1.13]; p = 0.6968); nor were there statistically significant differences between groups for the secondary endpoints. Treatment with B. clausii was well tolerated with incidence of adverse events (9.7%) similar to that for placebo (12.3%). Conclusions No significant difference in efficacy between B. clausii and placebo was demonstrated. Sample size may have been inadequate to allow detection of a between-group difference in efficacy, given the mild/moderate severity (only ~ 20% of patients had nausea/vomiting or abdominal pains) and short duration of disease among subjects, the relatively late start of treatment (most were already on Day 2 of their disease episode when study treatment started) and the effectiveness of the standard of care with ORT and zinc in both treatment groups. Trial registration CTRI number CTRI/2018/10/016053. Registered on 17 October 2018. EudraCT number 2016-005165-31. Registered 14 May 2020 (retrospectively registered).

Invasive aspergillus and mucormycosis infection are not uncommon in immunocompromised individuals. Endobronchial fungal infections have been reported in the literature, especially in patient's with diabetes complicated by diabetic ketoacidosis, but end bronchial coinfection with aspergillus and mucormycosis without pulmonary involvement has not been described in the literature. We report the case of a woman with diabetes who presented with gastrointestinal symptoms, ketoacidosis and respiratory distress, with an apparently normal chest X-ray. Investigations revealed a cavitatory lesion in the left lower lobe of the lungs on CT scan. Bronchoscopy revealed intense mucosal oedema and whitish plaques at the lower end of the trachea and right main stem bronchus with a normal left bronchial tree. Microbiological and pathological results confirmed aspergillus and mucormycosis. Despite aggressive medical management, the patient deteriorated and died of respiratory failure. Strong suspicion of invasive fungal infections in immunocompromised patients with respiratory failure and minimal chest infiltrates, early fibreoptic bronchoscopy and early aggressive treatment is crucial for the patient's survival.