COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

Abstract

Background: Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

Aim: Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

Design: This was a retrospective, single-centre, observational study.

Methods: We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

Results: Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

Conclusion: COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Figure 1.

(A–E) Signs and symptoms of mucormycosis. (A) Black eschar lesion over face. (B) Periorbital oedema along with facial palsy. (C) Palatine ulcer with white base over right posterior region. (D) Congestion and small ulcer in right nares. (E) Chemosis and proptosis of right eye and restriction of eye movement on lateral gaze (left eye normal movement).

Figure 2.

Diagnosis of mucormycosis—radiology (A–E axial section, contrast-enhanced computed tomography images) and microbiology (F and G). (A) Left ethmoidal sinusitis with bony erosion (yellow arrow). (B) Right ethmoidal and sphenoid sinusitis (yellow arrow) with involvement of orbit and orbital apex, extension into cavernous sinus (yellow arrowhead). (C) Right maxillary sinusitis (yellow arrow) with deviated nasal septum (yellow arrowhead). (D) Left maxillary sinus showing thickened mucoperiosteal lining (yellow arrow). (E) Same patient from (D) showed increase in thickening and involvement of maxillary sinus after 1 week (yellow arrow). (F) Mucorales with aseptate hyphae seen on potassium hydroxide mount with calcofluor white stain. (G) Mucorales growth as greyish white colonies on Sabouraud dextrose agar medium.