Category: 8. Health

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A proper race nutrition plan can be the difference between a “DNF” and a smiling finish line photo. Keeping a steady flow of carbohydrates and electrolytes in the system is particularly integral to the success of endurance runners. That’s why ultramarathoners need to train their guts, and why nutrition is called “the fourth discipline” among triathletes. While it’s difficult enough to nail down a nutrition plan that keeps your stomach, tastebuds, and body happy all at once, adding allergens to the mix can make it even more difficult. Some products, like gels, are generally safe for most runners to consume, but energy bars, protein bars, stroopwafels, and protein powders can be rife with common allergens. 

We talked to Susan Kitchen, a board-certified sports dietitian, athlete, author, triathlon coach, and owner of Race Smart, a service that helps athletes hone their training and eating habits. Joining her is Shelly Bloom, a multisport athlete and coach as well as a neuropharmacologist and professor at Duke University. Here, they talk about the precautions that runners with allergies must take and offer assessments to help you sift through the myriad performance nutrition products on the market.

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What Are Food Allergies and Intolerances?

To start, let’s be clear on what allergies and intolerances are. According to Bloom, 11 percent of adults in the United States live with food allergies, while 20 percent experience food intolerances. Food intolerances are often confused with food allergies because their symptoms can appear similar to one another. However, they do not have the same causes and therefore require different responses. “In a nutshell, food allergies involve the immune system, while food intolerances involve the digestive system,” Bloom says. A food intolerance, such as a FODMAP sensitivity, is “generally due to the reduced ability to absorb or digest the ingredient appropriately; instead, gut bacteria do the digesting, giving off gas and generating [symptoms like] bloating and diarrhea.” Receiving a professional diagnosis of a food intolerance can help you better manage symptoms and learn about other ingredients that might quietly be causing harm; for instance, knowing that you have an intolerance to polyols (the “P” in FODMAPs) might mean avoiding sugar alcohols like sorbitol and erythritol.

In contrast, food allergies follow an immune system roadmap. “A food allergy is a specific immune reaction to the offending ingredient (an allergen – typically a protein), resulting in a ‘hypersensitivity’ to that ingredient,” Bloom says. When IgE antibodies are produced to combat an allergen, immune cells are triggered to release histamine. With repeated exposure, the histamine contributes to “an immediate, larger, allergic response, usually in the skin (rash) and bronchioles (wheezing), but also in the GI tract (GI distress), and in certain cases, in the cardiovascular system (profound hypotension).” When allergies are especially severe, Bloom said, “anaphylaxis can occur quickly within minutes or even up to four hours after eating.” After receiving a professional diagnosis, you can use oral antihistamines and/or epi-pens to help mitigate symptoms.

Non-IgE reactions, which are less common in adults and often delayed by a few days, are usually more inflammatory in nature. Bloom said that such reactions “can occur primarily in the GI tract (abdominal pain, diarrhea, vomiting, gastric reflux, etc.), but can also affect the skin and lungs. Although sometimes severe, they do not cause anaphylaxis; an epi-pen will not help!”

Bloom further explained that because allergens (in the form of proteins) must be metabolized into smaller peptides before passing through intestinal membranes and triggering antibodies, “some breach of the intestinal barrier, i.e., a leaky gut” must have occurred. So if your gut has been damaged in the past by “toxins, bacterial infections, or other disorders that damage the small intestinal barrier, including celiac disease,” or even vigorous physical activity like that performed by elite athletes, you may be more at risk.

With professional consultation, and oftentimes some experimentation, runners can gauge whether they are suffering from food intolerances or food allergies and make a plan to eliminate offending ingredients from their diets. While food intolerances can sometimes be forgiving, especially in smaller amounts, repeat exposure to allergens can result in increasingly severe reactions, so it is crucial to accurately understand your situation. Equipped with that knowledge, you can then make informed decisions on what and how much to eat.

The Best Sports Nutrition Products for Food Sensitivities

Let’s take a closer look at the potential allergens in each type of performance nutrition product. But before we do, here’s how to interpret the charts in this article:

• X demarcates allergens contained
• * demarcates ingredients that may be present according to the ingredient label, whether due to potential substitutions, shared manufacturing equipment, or shared facilities
• Companies are not required to explicitly state on packaging if a product was manufactured in the same facility as other allergens – sometimes they do, and sometimes they don’t, and messaging is not even consistent within the same brand. So, for example, if a brand offers a peanut butter flavor and you are allergic to peanuts, you may want to exercise caution around its other flavors, too, even if no mention of peanuts is made on their wrappers.

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Allergen-Friendly Energy Bars

Carbohydrate-rich energy bars work well as pre-run snacks consumed an hour or two before your run.Many such bars contain protein, fiber, and fat in them, Bloom says, all of which are slow to be absorbed into the bloodstream. Bloom cautioned that chicory root fiber is a common energy bar ingredient that is also a FODMAP; therefore, people with insulin sensitivity may have difficulty digesting it.

Krono energy bars are among the best choices for those who experience intense allergies. Every single product sold by the brand is vegan, gluten-free, dairy-free, soy-free, and nut-free. With flavors ranging from chocolate and espresso to strawberry and pineapple, there’s something for everyone in this energy bar line. Maurten bars and BPN endurance bars are also fantastic choices across the board; just note that a handful of allergens are present in each of their respective manufacturing facilities.

When it comes to long endurance events, Kitchen says, “Clif Bars contain protein, carbohydrates, and fat, and help increase satiety due to a decreased gastric emptying rate. But beware: Clif Bars [can] contain wheat (gluten), soy, milk, peanuts, tree nuts, and barley.” Bloom also stressed that Clif Energy Bars are not suitable for those with soybean allergies or intolerances, and many flavors include either tree nuts or peanuts. Meanwhile, all Skratch Labs energy bars contain tree nuts, even in unassuming flavors like cinnamon + oatmeal, and raspberry + lemon.

Product	Flavor	Milk	Eggs	Fish	Crustacean shellfish	Tree nuts	Peanuts	Wheat	Soybeans	Sesame
Clif Bar Energy Bar	Cool mint chocolate (with caffeine)	*				*	*	*	X	*
	Peanut butter banana dark chocolate	*				*	X	*	X	*
	Blueberry almond crisp	*				X	*	*	X	*
Krono Bar energy bars	Raspberry and lemon
	Cherry and chocolate
	Apricot and cranberry
Maurten	Solid 160	*				*	*	*	*	*
Skratch Labs Energy Bar	Peanut butter chocolate					X	X
	Cinnamon and oatmeal					X
	Cherries and pistachios					X
BPN Go Bar Endurance Bars	Original oat	*	*			*	*

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Allergen-friendly Protein Bars

Protein bars, which are different than energy bars in that they provide much more protein and fewer carbs, can replenish glycogen stores and provide the building blocks to start rebuilding protein in damaged muscle fibers from exercise. “However, some people use them as snacks or ‘mini meals’ to add protein to their daily load,” Bloom says. When consuming plant-based protein bars, she recommends ensuring that all nine essential amino acids are accounted for. However you incorporate protein bars into your diet, there are plenty from which to choose.

Like its energy bars, each of Krono’s three protein bar flavors—brownie, crunchy salted caramel, and chocolate and banana—are free of all major allergens. That means they are gluten-free, soy-free, nut-free, dairy-free, and vegan. Similarly, each Styrkr recovery bar (also known as Bar+) is generally safe for those with allergies, except if you need to avoid soybeans or are especially sensitive to potential cross-contamination. Finally, while some flavors do contain peanuts or tree nuts, GoMacro bars are certified vegan, gluten-free, and soy-free.

Be more cautious around RX protein bars, all of which contain eggs and nuts (some flavors contain peanuts, while others contain cashews and/or almonds). Finally, Clif Builders bars are a mixed bag when it comes to peanuts and tree nuts, and they are all soy-based.

Product	Flavor	Milk	Eggs	Fish	Crustacean shellfish	Tree nuts	Peanuts	Wheat	Soybeans	Sesame
Krono Bar Protein Bar	All flavors
Styrkr Recovery Bar (Bar+)	All flavors	*	*			*	*		X	*
RXBar	Blueberry cashew butter		X			X
	Honey cinnamon peanut butter		X				X
	Strawberry		X			X
Clif Builders	Chocolate peanut butter	*				*	X		X	*
	Chocolate mint	*				*	*		X	*
	Vanilla almond	*				X	*		X	*
GoMacro	Oatmeal chocolate chip					*	*
	Peanut butter chocolate chip					*	X
	Dark chocolate + almonds					X	*

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Allergen-Friendly Protein Powder

Kitchen and Bloom agree that protein powder is best used when other protein-rich foods like yogurt or chocolate milk are not available. Bloom suggests that people with allergies and intolerances look for products containing amino acids, which are not usually allergenic—they are used by cells to make new proteins. She points to Tailwind Recovery Mix as an example, which contains an assortment of essential amino acids in addition to organic rice protein powder.

Today, there are plenty of plant-based protein powders on the market. A few of the most allergen-friendly ones are the SwissRX Total Recovery protein powders, the Momentous plant-based protein powders, and Skratch Labs’ oat milk latte protein powder. If dairy is not a problem for you, Skratch Labs’ recovery sport drink mix comes in three flavors that contain milk. Aside from that, though, no other allergens are listed. The same is true for every flavor of Momentous’ whey protein isolate and Recovery products (though Kitchen notes that depending on the manufacturing facility, Momentous whey protein isolate may cross-contact with soy or nuts).

When it comes to BPN and Podium, those with allergies need to be a bit more careful. BPN protein powders may contain milk, soy, coconut, and/or peanuts. Podium does not carry vegan protein powder, and its whey products might contain peanuts, wheat, and/or soybeans. The presence of these allergens is not always obvious; for instance, Podium’s peanut butter crunch and mint chocolate chip flavors both contain wheat.

Product	Flavor	Milk	Eggs	Fish	Crustacean shellfish	Tree nuts	Peanuts	Wheat	Soybeans	Sesame
Skratch Labs Recovery Sport	Chocolate	X
	Horchata	X
	Oat milk latte
SwissRX Total Recovery	Chocolate Mint
	Vanilla Chai
Momentous Grass-Fed Whey Protein Isolate	All flavors	X
Momentous 100% Plant Protein Powder	All flavors
Momentous Recovery	All flavors	X
BPN Whey Protein	Banana French toast	X							X
	Chocolate peanut butter	X					X		X
BPN Vegan Protein Powder	Oatmeal cookie					X (coconut)
Podium Whey	Mint chocolate chip	X	*	*	*	*	*	X	*
	Peanut butter crunch	X	*	*	*	*	X	X	X
Podium Isolate Whey	Vanilla buttercream	X	*	*	*	*	*	*	*

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Allergen-friendly Stroopwafels

Stroopwafels are popular among athletes because they are an excellent source of carbohydrates; one Honey Stinger waffle, for example, typically contains 16-21 grams of carbohydrates. The rate of glucose absorption from stroopwafels into the bloodstream varies among athletes, Bloom says, but maltodextrin and fat can slow it down.

The main allergens to look out for in stroopwafels are milk, eggs, wheat, and soybeans. While multiple options exist that forgo the first three ingredients, soybeans are more difficult to avoid. Except for Rip Van Wafel’s original line, soybeans are present in most stroopwafels on the market. And if you can find a stroopwafel product that contains neither soybeans nor gluten, let us know! Because we couldn’t find it.

Gluten-free stroopwafels haven’t always been a thing, but in recent years, multiple brands have heard consumers’ pleas and released lines of these sweet treats made with ingredients like rice flour and tapioca flour instead of wheat flour. Gu, Vafels, Honey Stinger, and Rip Van Wafel have all joined the gluten-free party. Plus, vegan stroopwafels are available from brands like Vafels and UnTapped.

Product	Flavor	Milk	Eggs	Fish	Crustacean shellfish	Tree nuts	Peanuts	Wheat	Soybeans	Sesame
Podium Protein Stroopwafel	Caramel	X	X					X	X
	Chocolate Brownie	X	X					X	X
Gu Energy Stroopwafel	All gluten-free flavors	*	X			X (coconut)			X
	Salty’s Caramel	*	X			X (coconut)		X	X
	Campfire S’mores	*	X			X (coconut)		X	X
Vafels Original Stroopvafels	All flavors	*	*					X	X
Vafels Gluten-Free Stroopvafels	All flavors	*	*					*	X
Honey Stinger Energy Waffle	Gluten-free salted caramel	*	X						X
	Original peanut butter	*	X				X	X	X
	Original honey	*	X					X	X
UnTapped Waffles	All varieties							X	X
Rip Van Wafels	Gluten-free snickerdoodle	X	X					X
	Honey & oats	X	X				X
	Chocolate brownie	X	X				X

Based in the College of Veterinary Medicine, the team found that the bacteria can manipulate a protein known as ATF6, which helps cells detect and respond to infection, to support its own growth and survival inside the tick. The findings, published in the journal Proceedings of the National Academy of Sciences, could serve as a launching point for developing methods to eliminate the bacteria in ticks before they are transmitted to humans and other animals.

“Most research has looked at how these bacteria interact with humans and animals and not how they survive and spread in ticks,” said Kaylee Vosbigian, a doctoral student and lead author on the study. “What we have found could open the door to targeting these pathogens in ticks, before they are ever a threat to people.”

Vosbigian and her advisor, Dana Shaw, the corresponding author of the study and an associate professor in the Department of Veterinary Microbiology and Pathology, focused their research on Ixodes scapularis, also known as the blacklegged tick, which is responsible for spreading both Anaplasma phagocytophilum and Borrelia burgdorferi, the causative agents of anaplasmosis and Lyme disease. Both diseases are becoming increasingly common and can cause serious illness in humans and animals.

The team discovered that when ATF6 is activated in tick cells, it triggers the production of stomatin, a protein that helps move cholesterol through cells as part of a normal cellular processes. The bacteria exploit this process against their tick hosts, using the cholesterol -which they need to grow and build their own cell membranes but cannot produce themselves – to support their own survival and success.

“Stomatin plays a variety of roles in the cell, but one of its key functions is helping shuttle cholesterol to different areas,” Vosbigian said. “The bacteria take advantage of this, essentially stealing the cholesterol they need to survive.”

When the researchers blocked the production of stomatin, restricting the availability of cholesterol, bacterial growth is significantly reduced. The researchers believe this shows targeting the ATF6-stomatin pathway could lead to new methods for interrupting the disease cycle in ticks before transmission occurs.

As part of the study, Vosbigian also developed a new research tool called ArthroQuest, a free, web-based platform hosted by WSU that allows scientists to search the genomes of ticks, mosquitoes, lice, sand flies, mites, fleas and other arthropod vectors for transcription factor binding sites – genetic switches like ATF6 that control gene activity.

“There aren’t many tools out there for studying gene regulation in arthropods,” Vosbigian said. “Most are built for humans or model species like fruit flies, which are genetically very different from ticks.”

Using ArthroQuest, the team found that ATF6-regulated control of stomatin appears to be prevalent in blood-feeding arthropods. Since the hijacking of cholesterol and other lipids is common among arthropod-borne pathogens, the researchers suspect many may also exploit ATF6.

“We know many other vector-borne pathogens, like Borrelia burgdorferi and the malaria-causing parasite Plasmodium, rely on cholesterol and other lipids from their hosts,” Shaw said. “So, the fact that this ATF6-stomatin pathway exists in other arthropods could be relevant to a wide range of disease systems.”

The research was supported in part by a National Institutes of Health R01 grant and a College of Veterinary Medicine intramural seed grant.

Specialty

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Of these, 19% are children under 1 year of age, according to the prospective coverage plan.

‎This year, EIW in Kyrgyzstan was marked by the launch of a large-scale catch-up immunization campaign. During EIW 2025, 15,521 people were vaccinated as part of this campaign.

The goal of the 2025 EIW was to raise public awareness of the importance of vaccination and ensure wide access to vaccines for every resident of the country, including remote and hard-to-reach areas. Vaccinations were carried out against diseases such as: viral hepatitis B, tuberculosis (BCG), poliomyelitis, diphtheria, tetanus, Haemophilus influenzae and pneumococcal infections, rotavirus, measles, rubella, mumps, and human papillomavirus. 

‎To ensure access to vaccination throughout the country, 76 mobile teams were involved, including in mountainous and rural settlements.

Sports and mass events were held in seven regional centers, the Ak-Ordo residential complex and the Bishkek Park shopping center, bringing together more than 800 people. More than 20 round tables were also organized with the participation of doctors, representatives of local authorities and opinion leaders.

Earlier it was reported that Kazakhstan is to vaccinate boys against HPV starting from 2026. 

Pittcon’s professional quality online Short Courses are an affordable opportunity for continuing education. All courses count towards building your Professional Hours. Courses take place on Wednesdays, 1:00-3:00 PM EST. 

Course level: Intermediate

This hands-on course teaches step-by-step techniques for interpreting mass spectrometric data to identify molecular structures. Participants will learn elemental composition analysis, tandem MS interpretation, database use, and confidence level reporting, with a focus on manual (“pencil and paper”) methods. Real-world problems from CASMI and the Lockdown Challenge will highlight common pitfalls and effective strategies. Emphasis is on soft ionization and low-mass compounds (<400 Da), with examples from both natural and synthetic molecules. A take-home problem set will be provided for continued practice. Bring a pencil—let’s solve some spectra!

Who Should Attend This Course?

Students and professionals working in the fields that require compound identification using mass spectrometry, across fields such as natural products, environmental and forensic sciences. 

Learning Objectives:

At the end of the course, students will be able to:
1. Confidently determine elemental composition from MS data
2. Propose a reasonable structure from tandem mass spectral data
3. Understand origins of major fragment ions in tandem mass spectra
4. Assign confidence in the structure proposal and understand limitations of MS for structure elucidation

About the Course Instructor

Dejan Nikolic is a Research Associate Professor in the Department of Pharmaceutical Sciences, College of Pharmacy, UIC. His research interests include structure elucidation of natural products using mass spectrometry, determination of ADME properties of plant ingredients and development of new assays for drug discovery from plant sources. For the past several years he has been actively involved in the Critical Assessment of Small Molecules Identification (CASMI) initiative aimed at unbiased assessment of different approaches used in structure elucidation by mass spectrometry. He has authored and co-authored more than 100 publications and trained numerous undergraduate and graduate students both through classroom and hands-on training.

Seasonal affective disorder (SAD) is commonly associated with autumn and winter months, but it can also emerge during the summer season, causing significant psychological difficulties.

Summer is generally regarded as a time of happiness and vitality, characterized by warm weather, vacations and outdoor activities. However, for some individuals, summer can trigger symptoms such as low energy, restlessness, sleep disturbances, appetite changes and a general sense of inner unease.

Experts note that summer seasonal depression is often triggered by extreme heat, high humidity, disruptions in sleep patterns and the atypical effects of prolonged or intense sunlight exposure.

Expert insights

Özlem Balaban, a specialist in Mental Health and Psychiatric Disorders at Bakırköy Mazhar Osman Research and Training Hospital, explained to Anadolu Agency (AA) that depression is a common condition, and seasonal depression is considered a subtype of this illness.

Balaban emphasized that seasonal depression is characterized by recurrent depressive episodes in specific seasons. “We generally expect individuals to recover during spring and summer. However, in some patients, depression recurs during these seasons rather than in autumn and winter, which is a less common pattern. This relates to factors causing depression, one of which is disruption in the biological rhythm of the body,” she stated.

Balaban explained that the human body operates on a 24-hour circadian rhythm, and disruption of this rhythm increases the risk of depression. She described depression as a state where a person feels significantly down, unhappy and lethargic compared to their usual self.

Symptoms of depression include loss of pleasure in life (anhedonia), lack of interest in previously enjoyed activities, low energy, impaired attention and concentration, changes in sleep and appetite, slowed movements, and intense feelings of guilt or worthlessness.

In seasonal depression, similar symptoms are expected, including a pervasive sense of unhappiness and mood decline. Specifically in summer depression, patients often experience reduced sleep or insomnia, which can lead to excessive daytime sleepiness, increased appetite, weight gain and cravings for carbohydrate-rich foods.

Importance of treatment

Balaban underlined that depression is a significant public health issue but is treatable. She stressed the importance of consulting a psychiatrist, as diagnosis and treatment require professional medical expertise.

“This is not something a person can overcome alone through casual conversation or home remedies. Treatment should be based on scientific medical knowledge,” she said.

The treatment of depression varies depending on the severity of symptoms. In mild to moderate cases, psychotherapy is usually the first step. For moderate to severe depression, medication is often necessary.

Balaban noted that depression treatments are consistent worldwide. “We are fortunate in our health care system; we have access to all treatments available internationally. Recently, bright light therapy has become more common, especially for seasonal depression. It is widely used in northern countries such as Norway and Sweden, where winters are longer and darker compared to our sun-rich, four-season climate. Bright light therapy has proven effective for treating seasonal depression,” she said.

Highlighting psychiatry as a successful medical field with many treatment options, Balaban encouraged individuals experiencing any mental health issues to seek professional help.

“In psychiatry, we have many treatment options tailored to fit the unique needs of each person. Therefore, anyone feeling psychological distress should definitely consult a psychiatrist,” she concluded.

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Introduction

Mucormycosis is a severe fungal infection caused by species in the order Mucorales, particularly those within the Mucoraceae family, encompassing the genera Rhizopus, Mucor, and Lichtheimia.¹ It is the third most common cause of invasive fungal infections (IFIs) globally, accounting for 8% of such infections, following aspergillosis and candidiasis.^2,3 Previous studies have highlighted geographic variation in the annual incidence of mucormycosis, with rates reported as 3.3 cases per 100,000 hospital admissions in Italy,⁴ 1.76 per 10,000 hospitalizations in Iran,⁵ and 0.12 per 10,000 discharges in the United States.⁶ The most frequent clinical manifestations of mucormycosis include rhino-cerebral, maxillofacial, and pulmonary infections. The infection may also affect multiple organs, including the brain, kidneys, liver, and gastrointestinal tract.⁷ The incidence of pulmonary mucormycosis has increased with advancements in immunosuppressive medicine. For example, a study from western China reported that pulmonary mucormycosis accounted for 78% of the 59 reported cases.⁸ Several predisposing clinical factors have been identified, including diabetic ketoacidosis, uncontrolled diabetes mellitus, immunosuppressive therapies, and hematological malignancies (such as lymphoma and leukemia). Diabetes mellitus and hematological malignancies were the most common underlying conditions in cases of mucormycosis, reported in 17 to 88% and 38 to 62% of cases, respectively.³ Studies stated that in poorly controlled diabetes mellitus, especially during diabetes ketoacidosis (DKA), neutrophil functions such as phagocytosis and chemotaxis are significantly impaired.⁹ Moreover, the acidosis due to KDA leads to elevated serum iron levels, which promotes Mucorales species’ growth. This immune and metabolic disturbance creates a conducive environment for IFIs.¹⁰

Chronic lymphocytic leukemia (CLL) is a hematological malignancy characterized by the abnormal proliferation of CD5+ B lymphocytes in most cases, which leads to immune dysregulation.¹¹ CLL cells express immune-suppressing cytokines, and T-lymphocytes often exhibit immune exhaustion, which contributes to the frequent infections observed in these patients.¹² Bruton’s tyrosine kinase (BTK) inhibitors, such as zanubrutinib, are the targeted therapies used to treat CLL; however, they disrupt B-cell receptor signaling and may impair immune function, thereby heightening susceptibility to IFIs.¹³ Specifically, BTK inhibitors can compromise innate and adaptive immunity, particularly by affecting T-lymphocyte function, reducing antibody production, and decreasing immune surveillance against pathogens.¹⁴ Given the increasing use of BTK inhibitors, healthcare professionals must be vigilant regarding the potential life-threatening IFIs associated with their administration.

The spleen plays a vital role in humoral immunity by producing IgM antibodies and clearing pathogenic microorganisms and cellular debris through phagocytosis. However, in critical care settings such as abscesses and infarction, splenectomy is often performed, which compromises host immunity.¹⁵ This immunocompromised state significantly increases the risk of overwhelming post-splenectomy infection (OPSI) syndrome and IFIs.^15,16 Moreover, the delayed diagnosis of IFIs, particularly mucormycosis, remains challenging in acute clinical scenarios. Conventional culture methods are often slow and may yield false negative results due to the poor growth characteristics of Mucorales species.¹⁷ Advanced diagnostic techniques, such as metagenomic next-generation sequencing (mNGS), offer greater sensitivity and faster detection. However, their limited availability in routine microbiology laboratories and high cost restricts widespread clinical use.¹⁸ Early findings on chest computed tomography (CT) scans, such as the reversed halo sign (RHS), nodules within the halo, and a thick rim of peripheral consolidation, have been associated with pulmonary mucormycosis in immunocompromised individuals.¹⁹ This sign is considered an early but transient sign of pulmonary mucormycosis, which disappears after 15 days of infection. However, despite the diagnostic relevance of RHS, it is frequently overlooked in clinical settings.²⁰ These limitations often contribute to delayed management of mucormycosis and poor patient outcomes.¹⁸ This case study presents a fatal mucormycosis infection in a zanubrutinib-treated CLL patient, accompanied by a review of relevant literature underscoring the importance of early intervention in these high-risk situations.

Case Presentation

A 47-year-old male with CLL for the past 3 years, classified as Rai stage IV, presented to Jiangxi Cancer Hospital, Nanchang, China, on November 7, 2021, with a one-week history of abdominal pain and fever. The patient had been undergoing treatment for CLL with zanubrutinib at a dose of 160 mg twice daily. His medical history was complicated by uncontrolled diabetes, with an admission glucose level of 17.9 mmol/L, indicating hyperglycemia. On physical examination, he was febrile and exhibited clinical features suggestive of a systemic infection.

Imaging revealed significant findings: chest CT showed patchy shadows in the upper lobe of the left lung and a nodule in the lower lobe of the right lung, with a reversed halo sign, suggesting an infection (Figure 1a). Abdominal CT with contrast demonstrated splenic artery embolism and splenic infarction, leading to a diagnosis of splenic infarction (Figure 1b). Laboratory investigations showed leukocytosis (11.36 × 10⁹/L) with neutrophilia (10.43×10⁹/L) and lymphopenia (2.14×10⁹/L), suggesting a possible underlying infection. The patient also presented with anemia (hemoglobin: 130 g/L) and thrombocytopenia (56 × 10⁹/L), with elevated inflammatory markers, including C-reactive protein (154.55 mg/L) and procalcitonin (2.78 ng/mL). Coagulation tests showed prolonged prothrombin time (15.9 seconds), hyperfibrinogenemia (7.15 g/L), and elevated D-dimer (9.66 mg/L), indicating disseminated intravascular coagulation (DIC).

Figure 1 (a) Chest computed tomography (CT) scan demonstrating a nodule in the lower lobe of the right lung with a reversed halo sign (arrow), indicative of possible invasive fungal infection. (b) Contrast-enhanced abdominal CT revealing splenic artery embolism (lower arrow) and splenic infarction (upper arrow).

The patient was started on empirical broad-spectrum antibiotics, including intravenous cefoperazone-sulbactam (administered every 8 hours, 1 gram per vial, 3 vials per day) and moxifloxacin hydrochloride (50 mL per vial, administered once daily), along with platelet support. However, due to worsening splenic infarction and signs of progressive organ dysfunction, an emergency splenectomy was performed on November 10, 2021. Postoperatively, the patient’s condition worsened, necessitating mechanical ventilation for respiratory failure, and was subsequently transferred to the intensive care unit (ICU). Liver enzymes (alanine aminotransferase: 170 U/L; aspartate aminotransferase: 8020 U/L) and renal function markers (urea: 11.4 mmol/L; creatinine: 110 μmol/L) worsened, hyperglycemia persisted despite insulin therapy, and the highest recorded body temperature was 39.5 °C.

Given the patient’s declining condition and persistent infection, the antimicrobial regimen was escalated to include intravenous biapenem (0.6 grams every 12 hours), imipenem/cilastatin (1 gram per vial, administered every 8 hours), and fluconazole (100 mL containing 0.2 g per pouch, administered once daily). On November 12, 2021, a bronchial alveolar lavage (BAL) sample was obtained from the patient and sent for metagenomic next-generation sequencing (mNGS) to investigate the exact etiology of the infection. By the third postoperative day, the patient developed signs of myocardial injury, as evidenced by significant ST-segment elevation on electrocardiogram (leads I, II, AVF, V4, V5, and V6), with creatine kinase-myocardial band (CK-MB) levels rising to 82 U/L and troponin I at 0.11 ng/mL. He then developed metabolic acidosis, shock, and multiorgan failure. Despite intensive resuscitation and continued mechanical ventilation, the patient’s condition rapidly deteriorated and passed away shortly thereafter on November 13, 2021. The mNGS report, received after the patient’s death, identified Rhizomucor pusillus as the primary pathogen, with co-infection by Enterococcus faecium and Human betaherpesvirus 7 (HHV-7). A summary of the key laboratory findings is presented in Table S1.

Discussion

Mucormycosis, although rare, is a severe and often fatal complication in immunocompromised individuals, especially those with chronic lymphoproliferative disorders on immunosuppressive therapy like BTK inhibitors.²¹ In our case, a 47-year-old male with CLL on zanubrutinib presented with rapid progression of mucormycosis. The patient’s disease course from admission to death in a week highlights the aggressive nature of mucormycosis in immunocompromised patients compared to slow and insidious presentations in some other cases. For example, a previously reported case of a 74-year-old female with CLL on zanubrutinib had a slower onset of mucormycosis with cutaneous lesions developing over an extended period prior to diagnosis.²² Our case emphasizes the rapid progression of mucormycosis in high-risk individuals when diagnosis and treatment are delayed.

Zanubrutinib is an effective treatment for CLL. However, its impact on the impairment of innate immune responses, particularly neutrophil and macrophage functions, and the increased susceptibility to invasive infections should not be overlooked.²³ In our case, the extended administration of zanubrutinib impaired the immune system’s ability to effectively combat the fungal pathogen, even with normal neutrophil counts. The patient’s diabetic condition, characterized by hyperglycemia, creates a conducive environment for the development of mucormycosis.²⁴ Elevated glucose levels in the body create a nutrient-rich environment conducive to the growth and proliferation of Mucorales species.²⁵ The splenectomy compromised the patient’s capacity to filter pathogens effectively. Splenectomy increases the patient’s vulnerability to systemic infections due to the spleen’s critical role in the innate immune system.^26,27 The patient demonstrated neutrophilia; however, neutrophil-mediated phagocytosis was compromised, which may contribute to the dissemination of the fungal infection.²⁸

The clinical presentation of mucormycosis presents considerable challenges, especially in differentiating it from other common infections in immunocompromised individuals.²⁵ For example, pulmonary mucormycosis exhibits characteristics similar to pneumonia, whereas rhino-cerebral mucormycosis resembles bacterial sinusitis.^29,30 The chest CT of our case revealed a reversed halo sign, which serves as a radiological indicator of IFIs.¹⁹ The reversed halo sign, despite its association with severe infection, was initially not subjected to additional investigation. The clinicians concentrated on other acute issues, such as splenic infarction and respiratory failure, delaying the diagnosis.³¹ In suspected mucormycosis, it is important to promptly initiate diagnostic methods such as direct microscopy, histopathology, fungal culture, and molecular assays to confirm the etiological agent.³² Direct microscopy can provide rapid initial evidence of fungal elements in biological specimens. Fungal culture helps determine the etiology of infection, enables species identification, and allows for subsequent antifungal susceptibility testing.³³ To accelerate the diagnosis of mucormycosis in similar higher-risk patients, clinicians should prioritize early molecular diagnostics such as polymerase chain reaction (PCR) or NGS. These techniques allow for the quick and reliable detection of fungal DNA, particularly in situations when it is difficult to acquire tissue samples or when fungal cultures produce negative results.³⁴ Unfortunately, in the present case, the NGS results from the patient’s alveolar lavage fluid were unavailable before the patient’s demise. This underscores the need for rapid diagnostics, particularly in critically ill patients, where clinical deterioration can outpace the availability of test results. New methods are being developed, such as the enzyme-linked immunosorbent assay (ELISA), to detect the highly purified fucomannan wall carbohydrates of Mucor species. These methods may be considered upon their availability.^35,36 Emerging tools such as point-of-care antigen detection assays and artificial intelligence-assisted imaging techniques may enable the early identification of mucormycosis.^37,38 When feasible, tissue sampling via bronchoscopy or biopsy remains essential for definitive diagnosis.³⁹ The suspicion of IFIs in higher-risk groups, such as patients with diabetes, neutrophil dysfunction, or those receiving BTK inhibitors, is essential. Integrating these clinical risk variables into standardized diagnostic algorithms might facilitate timely testing and empirical treatment.¹⁷

The patient was initially treated with broad-spectrum antibiotics due to his septic presentation, which was appropriate. However, antifungal coverage was not included in the empirical treatment. This was a critical oversight as immunocompromised patients, especially those on BTK inhibitors, are at high risk of IFIs.⁴⁰ The exclusion of antifungal agents from initial empirical therapy might be due to the rarity of mucormycosis and its non-specific clinical presentation, often leading clinicians to prioritize bacterial pathogens in septic cases. Later, as the patient’s condition worsened postoperatively, fluconazole was added to the treatment plan. However, fluconazole lacks activity against Mucorales and is not recommended for mucormycosis due to intrinsic resistance.⁴¹ This might have contributed to the lack of clinical improvement, emphasizing the necessity of pathogen-specific antifungal selection in high-risk patients.

The Rhizomucor pusillus was the primary pathogen in our case; however, the co-infection due to E. faecium and HHV-7 may have contributed to the rapid clinical deterioration. E. faecium is a known cause of severe bloodstream infections in immunocompromised patients and often exhibits multidrug resistance, complicating the empirical antibiotic selections.⁴² Similarly, HHV7 may occur in immunosuppressed patients and has been associated with encephalitis, rash, and persistent fever. While the pathogenic role of HHV-7 remains unknown, its existence could be a sign of underlying immunological malfunction.⁴³ For high-risk patients, early identification of these co-pathogens using blood cultures and molecular diagnostics is important for targeted antimicrobial therapy.

Liposomal amphotericin B is the standard of care for mucormycosis, with isavuconazole considered in certain cases. Liposomal amphotericin B is the first-line therapy for mucormycosis due to its broad-spectrum activity against fungal species and lower nephrotoxicity compared to conventional amphotericin B.⁴⁴ Isavuconazole is used as an alternative treatment when amphotericin B is unavailable or poorly tolerated, and some studies suggest it offers comparable efficacy.^45,46 Similarly, posaconazole can also be considered; however, due to its varying efficacy against different Mucorales species, it is not recommended as the primary treatment option.^41,47 The observation of respiratory symptoms and radiological findings suggestive of IFIs should prompt the initiation of early empirical antifungal therapy, even before diagnostic confirmation. Given the high mortality associated with mucormycosis in immunocompromised hosts, including those receiving BTK inhibitors, the early administration of liposomal amphotericin B as empirical therapy could be lifesaving.⁴⁸

The limitation of this study is that it is a single case and has a retrospective design, as the information was collected after the patient’s death. Moreover, the autopsy of patients was not conducted, which might provide answers to specific clinical questions of cases having no definitive diagnosis. Despite these limitations, this case report highlights the gaps in current clinical practices. It stresses the need for earlier suspicion, improved diagnostic methods, and appropriate empirical therapies to improve outcomes in similar scenarios. Future studies focusing on regional epidemiological surveillance and antifungal stewardship programs are essential to guide targeted empirical therapy in high-risk populations. Additionally, institutional protocols that account for immunosuppressive therapies, underlying comorbidities, and local fungal profiles should be developed to support timely intervention and potentially reduce mortality.

Conclusion

This case report underscores the importance of early recognition and prompt antifungal intervention in high-risk patients, particularly those with CLL receiving BTK inhibitors such as zanubrutinib. Radiological findings, especially the reversed halo sign, should not be overlooked, as they may indicate IFSs and warrant immediate fungal workup, including molecular diagnostics via PCR and NGS. Although diagnosis delays are often unavoidable in complicated cases, a multidisciplinary approach, including timely consultation with infectious disease specialists, may have enhanced the management of such cases.

This case study yields several important lessons. Clinicians must maintain high vigilance for fungal infections in immunocompromised patients, particularly those on BTK inhibitors. When radiological signs suggest IFIs, early initiation of targeted diagnostic and empirical antifungal therapy is crucial. In suspected cases of mucormycosis, liposomal amphotericin B or isavuconazole should be prioritized over fluconazole, which lacks activity against Mucorales.

Data Sharing Statement

This study did not involve the creation or analysis of new data, so data sharing does not apply.

Ethical Statement

The authors take full responsibility for the work, ensuring that any concerns about accuracy or integrity are properly addressed. All procedures followed ethical guidelines set by the institutional or national research committee(s) and complied with the Declaration of Helsinki (2013 revision). Institutional approval for publication was obtained from the Human Research Ethics Committee of the Jiangxi Cancer Hospital and Institute (Approval No. 2024ky078). Written informed consent was obtained from the patient’s relatives to publish this case report and related images.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This work was supported by Science and Technology Research Project of Jiangxi Provincial Department of Education (GJJ2403604) and (GJJ2203508); Research start-up fund of Jiangxi Cancer Hospital (BSQDJ2024001), and by 2023 Key Project for Science and Technology Innovation of Jiangxi Provincial Health Commission (2023ZD005). The funders have no role in article writing and publishing.

Disclosure

The authors declare no conflicts of interest in this work.

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