We analyzed mucormycosis data from the Zygomyco.net registry (2009-2022), encompassing cases from 16 countries. India, Russia and the Czech Republic provided the largest contributions. India reported the highest case number, consistent with its substantially higher incidence compared to that of high-income countries. Among the 382 patients with mucormycosis, 236 (61.8%) were male (male-to-female ratio 1.6). The median age was 48 years [interquartile range (IQR) 32-60]. There were 59 pediatric patients (median age ranging from < 1 month to 19 years). Diabetes mellitus type 2 was the most common underlying condition (39%), with significant geographic variation (> 70% of cases in India and Iran but only 6.9% in Europe). Hematologic malignancies (HM, 31.4%), the second most common underlying condition, were absent in India and Iran. The primary clinical presentations were rhino-orbito-cerebral mucormycosis (ROCM, 36.6%), pulmonary (33.2%) and cutaneous mucormycosis (17.5%). Patients with diabetes mellitus typically developed ROCM (55.9%), while pulmonary infections were more common in those with HM or hematopoietic cell transplantation (HCT) (47.5%, p < 0.001). Rhizopus was the leading fungal genus (58%), followed by Lichtheimia (13.7%) and Mucor (7%), with regional variations. Pulmonary infections in HM patients were linked to L. corymbifera and R. microsporus, while Apophysomyces spp. and Saksenaea spp. were more frequent in Indian healthcare-associated cutaneous cases. Concomitant infections were observed in 8.7% of patients with HM, complicating diagnosis and treatment. In most of them (57.1%), Aspergillus spp. was involved. Improved diagnostic practices, including direct microscopy and cultures, showed higher positivity rates, although PCR remained underutilized. Antifungal therapy, primarily with an amphotericin B formulation, combined with surgery, was the most common therapeutic approach. Overall mortality was high (47.8%), particularly in disseminated or advanced ROCM cases. Multivariable analysis identified older age, advanced ROCM, and HM/HCT as independent mortality risk factors (p < 0.05); whereas localized sinusitis and combined medical and surgical therapy were independently associated with improved outcomes (p < 0.006). This study underscores regional disparities in the mucormycosis epidemiology and species distribution. Improved early detection is needed, particularly in immunocompromised populations with HM. Enhanced surveillance and tailored public health strategies are crucial to address this ongoing global health threat.

1st Department of Internal Medicine Laiko Hospital National and Kapodistrian University of Athens Athens Greece

Athens Colorectal Laboratory Athens Greece

BioTechMed Graz Austria

Carol Davila University of Medicine and Pharmacy National Institute for Infectious Diseases Matei Bals Bucharest Romania

Center for Biomedical Research in Network in Infectious Diseases Instituto de Salud Carlos 3 Madrid Spain

Center for Innovative Therapeutics and Diagnostics Richmond VA USA

CETRAMOR Rosario Argentina

Clinic for Infectious and Tropical Diseases Faculty of Medicine University Clinical Center of Serbia University of Belgrade Belgrade Serbia

Department of Biology Hakim Sabzevari University Sabzevar Iran

Department of Clinical Mycology Allergology and Immunology North Western State Medical University Named After 1 I Mechnikov Santiago de Cuba Str Build 1 28 Saint Petersburg 194291 Russia

Department of Colorectal Surgery Royal Devon and Exeter NHS Foundation Trust Exeter UK

Department of Infectious Diseases University Hospital Inselspital CH 3010 Bern Switzerland

Department of Laboratory Medicine and National Reference Center for Mycosis University Hospitals Leuven Louvain Belgium

Department of Medical Microbiology and Infection Prevention Amsterdam University Medical Center Location VUmc Amsterdam The Netherlands

Department of Medical Microbiology Charles University 2nd Faculty of Medicine and Motol University Hospital Prague Czech Republic

Department of Microbiology Faculty of Medicine and Dentistry and University Hospital Olomouc Olomouc Czech Republic

Department of Microbiology Immunology and Transplantation KU Leuven Louvain Belgium

Department of Microbiology Sheffield Teaching Hospitals NHSFT Florey Institute for Host Pathogen Interaction University of Sheffield Sheffield UK

Department of Microbiology University Hospital of Patras 26504 Patras Greece

Department of Nursing University of West Attica Athens Greece

Department of Pediatrics Federal University of São Paulo UNIFESP São Paulo Brazil

Departments of Medicine and Microbiology and Immunology University of Maryland School of Medicine Baltimore MD USA

Division of Infectious Diseases Department of Internal Medicine and Center for Infectious Diseases Research American University of Beirut Medical Center Beirut Lebanon

Division of Infectious Diseases Department of Internal Medicine Medical University of Graz Graz Austria

Doodhadhari Burfani Hospital and Research Institute Bhupatwala Haridwar India

Fungal Clinic Panchkula Former Professor and Head Department of Microbiology Government Medical College Hospital Sector 32 Chandigarh India

Hennepin Healthcare Division of Infectious Diseases University of Minnesota Medical School 701 Park Ave Minneapolis MN 55415 1623 USA

Infectious and Tropical Diseases Research Center Health Research Institute Ahvaz Jundishapur University of Medical Sciences Ahvaz 61357 15794 Iran

Infectious Diseases Research Laboratory 4th Department of Internal Medicine Attikon General University Hospital School of Medicine National and Kapodistrian University of Athens Athens Greece

Infectious Diseases Unit 3rd Department of Pediatrics Aristotle University School of Medicine Hippokration Hospital Thessaloniki Greece

Institute of Hygiene and Medical Microbiology European Excellence Center of Medical Mycology Medical University of Innsbruck Schöpfstraße 41 6020 Innsbruck Austria

Institute of Microbiology and Immunology Medical Mycology Reference Laboratory University of Belgrade Faculty of Medicine Dr Subotića 1 11000 Belgrade Serbia

Intensive Care Unit Laiko Hospital Athens Greece

Ion Ionescu de La Brad Iasi University of Life Sciences Iași Romania

Mycology Reference Laboratory National Centre for Microbiology Instituto de Salud Carlos 3 Majadahonda Spain

Pediatric Ambulatory Care 1 Health Authority Attica NHS Athens Greece

Pediatric Oncology Institute Federal University of São Paulo UNIFESP São Paulo Brazil

School of Medicine European University Cyprus Nicosia Cyprus

School of Medicine National and Kapodistrian University of Athens Athens Greece

See more in PubMed

Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis. 2012;54(Suppl 1):S23-34. https://doi.org/10.1093/cid/cir866 . (PMID: 22247442). PubMed DOI

Walsh TJ, Hospenthal DR, Petraitis V, Kontoyiannis DP. Necrotizing mucormycosis of wounds following combat injuries, natural disasters, burns, and other trauma. J Fungi. 2019;5:57. https://doi.org/10.3390/jof5030057 . DOI

Skiada A, Pagano L, Groll A, Zimmerli S, Dupont B, Lagrou K, et al. Zygomycosis in Europe: analysis of 230 cases accrued by the registry of the European Confederation of Medical Mycology (ECMM) Working Group on Zygomycosis between 2005 and 2007. Clin Microbiol Infect. 2011. https://doi.org/10.1111/j.1469-0691.2010.03456.x . PubMed DOI

De Pauw B, Walsh TJ, Donnelly JP, Stevens DA, Edwards JE, Calandra T, et al. European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group; National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis. 2008. https://doi.org/10.1086/588660 . PubMed DOI

Donnelly JP, Chen SC, Kauffman CA, Steinbach WJ, Baddley JW, Verweij PE, et al. Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clin Infect Dis. 2020. https://doi.org/10.1093/cid/ciz1008 . PubMed DOI PMC

Bialek R, Konrad F, Kern J, Aepinus C, Cecenas L, Gonzalez GM, et al. PCR based identification and discrimination of agents of mucormycosis and aspergillosis in paraffin wax embedded tissue. J Clin Pathol. 2005. https://doi.org/10.1136/jcp.2004.024703 . PubMed DOI PMC

Chakrabarti A, Singh R. Mucormycosis in India: unique features. Mycoses. 2014. https://doi.org/10.1111/myc.12243 . PubMed DOI

Drogari-Apiranthitou M, Skiada A, Panayiotides I, Vyzantiadis TA, Poulopoulou A, Christofidou M, et al. Epidemiology of mucormycosis in Greece: results from a nationwide prospective survey and published case reports. J Fungi. 2023. https://doi.org/10.3390/jof9040425 . DOI

Parra Farinas R, Alonso-Sardon M, Velasco-Tirado V, Gallindo Perez I, Carbonell C, Alvarez Artero E, et al. Increasing incidence of mucormycosis in Spanish inpatients from 1997 to 2018. Mycoses. 2022. https://doi.org/10.1111/myc.13418 . PubMed DOI

Patel A, Kaur H, Xess I, Michael JS, Savio J, Rudramurthy S, et al. A multicenter observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India. Clin Microbiol Infect. 2020. https://doi.org/10.1016/j.cmi.2019.11.021 . PubMed DOI PMC

Dolatabadi S, Ahmadi B, Rezaei-Matehkolaei A, Zarrinfar H, Skiada A, Mirhendi H, et al. Mucormycosis in Iran: a six-year retrospective experience. J Mycol Med. 2018. https://doi.org/10.1016/j.mycmed.2018.02.014 . PubMed DOI

Gouzien L, Che D, Cassaing S, Lortholary O, LetscherBru V, Paccoud O, et al. Epidemiology and prognostic factors of mucormycosis in France (2012–2022): a cross-sectional study nested in a prospective surveillance programme. Lancet Reg Health Eur. 2024. https://doi.org/10.1016/j.lanepe.2024.101010 . PubMed DOI PMC

Jeong W, Keighley C, Wolfe R, Lee WL, Slavin MA, Kong DCM, et al. The epidemiology and clinical manifestations of mucormycosis: a systematic review and meta-analysis of case reports. Clin Microbiol Infect. 2019. https://doi.org/10.1016/j.cmi.2018.07.011 . PubMed DOI

Makrilakis K, Kalpourtzi N, Ioannidis I, Iraklianou S, Raptis A, Sotiropoulos A, et al. Prevalence of diabetes and pre-diabetes in Greece. Results of the First National Survey of Morbidity and Risk Factors (EMENO) study. Diabetes Res Clin Pract. 2021;172:108646. https://doi.org/10.1016/j.diabres.2020.108646 . PubMed DOI

Chevreul K, Berg Brigham K, Bouché C. The burden and treatment of diabetes in France. Global Health. 2014. https://doi.org/10.1186/1744-8603-10-6 . PubMed DOI PMC

Giampaoli S, Palmieri L, Donfrancesco C, Lo Noce C, Pilotto L, Vanuzzo D. Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey Research Group. Cardiovascular health in Italy. Ten-year surveillance of car-diovascular diseases and risk factors: Osservatorio Epidemiologico Cardio-vascolare/Health Examination Survey 1998–2012. Eur J Prev Cardiol. 2015. https://doi.org/10.1177/2047487315589011 . PubMed DOI

Heidemann C, Scheidt-Nave C. Prevalence, incidence and mortality of diabetes mellitus in adults in Germany - A review in the framework of the Diabetes Surveillance. J Health Monit. 2017. https://doi.org/10.17886/rki-gbe-2017-062 . PubMed DOI PMC

Soriguer F, Goday A, Bosch-Comas A, Bordiú E, Calle-Pascual A, Carmena R, et al. Prevalence of diabetes mellitus and impaired glucose regulation in Spain: The Di@bet.es study. Diabetologia. 2012. https://doi.org/10.1007/s00125-011-2336-9 . PubMed DOI

Kaveeshwar SA, Cornwall J. The current state of diabetes mellitus in India. Australas Med J. 2014. https://doi.org/10.4066/amj.2013.1979 . PubMed DOI PMC

Arora U, Priyadarshi M, Katiyar V, Soneja M, Garg P, Gupta I. Risk factors for Coronavirus disease-associated mucormycosis. J Infect. 2022. https://doi.org/10.1016/j.jinf.2021.12.039 . PubMed DOI

Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005. https://doi.org/10.1086/432579 . PubMed DOI

Alqarihi A, Gebremariam T, Gu Y, Swidergall M, Alkhazraji S, Soliman SSM, et al. GRP78 and Integrins Play Different Roles in Host Cell Invasion during Mucormycosis. MBio. 2020. https://doi.org/10.1128/mBio.01087-20 . PubMed DOI PMC

Roilides E, Kontoyiannis DP, Walsh TJ. Host defenses against zygomycetes. Clin Infect Dis. 2012;54(Suppl 1):S61–6. https://doi.org/10.1093/cid/cir869 . PubMed DOI

Roberds A, Bobrov AG, Rautemaa-Richardson R, Walsh TJ. Invasive Fungal Diseases of Combat Wounds: Burden, Epidemiology, and Mycology. Mycopathologia. 2024;189(6):102. https://doi.org/10.1007/s11046-024-00908-4 . PubMed DOI PMC

Prakash H, Ghosh AK, Rudramurthy SM, Singh P, Xess I, Savio J, et al. A prospective multicenter study on mucormycosis in India: Epidemiology, diagnosis and treatment. Med Mycol. 2019. https://doi.org/10.1093/mmy/myy060 . PubMed DOI

Cornely OA, Alastruey-Izquierdo A, Arenz D, Chen SCA, Dannaoui E, Hochhegger B, et al. 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. Lancet Infect Dis. 2019. https://doi.org/10.1016/s1473-3099(19)30312-3 . PubMed DOI PMC

Millon L, Caillot D, Berceanu A, Bretagne S, Lanternier F, Morio F. Evaluation of Serum Mucorales Polymerase Chain Reaction (PCR) for the Diagnosis of Mucormycoses: The MODIMUCOR Prospective Trial. Clin Infect Dis. 2022;75(5):777–85. https://doi.org/10.1093/cid/ciab1066 . PubMed DOI

Pana ZD, Seidel D, Skiada A, Groll AH, Petrikkos G, Cornely OA, et al. Invasive mucormycosis in children: an epidemiologic study in European and non-European countries based on two registries. BMC Infect Dis. 2016. https://doi.org/10.1186/s12879-016-2005-1 . PubMed DOI PMC

Roilides E, Zaoutis TE, Walsh TJ. Invasive zygomycosis in neonates and children. Clin Microbiol Infect. 2009;15(Suppl 5):50–4. https://doi.org/10.1111/j.1469-0691.2009.02981.x . PubMed DOI

Pamidimukkala U, Sudhaharan S, Kancharla A, Vemu L, Challa S, Karanam SD, et al. Mucormycosis due to Apophysomyces species complex- 25 years’ experience at a tertiary care hospital in southern India. Med Mycol. 2020. https://doi.org/10.1093/mmy/myz081 . PubMed DOI

Jeong W, Keighley C, Wolfe R, Lee WL, Slavin MA, Chen SCA, et al. Contemporary management and clinical outcomes of mucormycosis: A systematic review and meta-analysis of case reports. Int J Antimicrob Agents. 2019. https://doi.org/10.1016/j.ijantimicag.2019.01.002 . PubMed DOI

El Eid R, Chowdhary A, El Zakhem A, Kanj SS. Invasive fungal infections in wars, following explosives and natural disasters: A narrative review. Mycoses. 2024. https://doi.org/10.1111/myc.13762 . PubMed DOI