Mucormycosis and COVID-19: An epidemic within a pandemic in India

Abstract

Importance: Coronavirus disease (COVID-19) causes an immunosuppressed state and increases risk of secondary infections like mucormycosis. We evaluated clinical features, predisposing factors, diagnosis and outcomes for mucormycosis among patients with COVID-19 infection.

Methods: This prospective, observational, multi-centre study included 47 consecutive patients with mucormycosis, diagnosed during their course of COVID-19 illness, between January 3 and March 27, 2021. Data regarding demography, underlying medical conditions, COVID-19 illness and treatment were collected. Clinical presentations of mucormycosis, imaging and biochemical characteristics and outcome were recorded.

Results: Of the 2567 COVID-19 patients admitted to 3 tertiary centres, 47 (1.8%) were diagnosed with mucormycosis. Mean age was 55 ± 12.8years, and majority suffered from diabetes mellitus (n = 36, 76.6%). Most were not COVID-19 vaccinated (n = 31, 66.0%) and majority (n = 43, 91.5%) had developed moderate-to-severe pneumonia, while 20 (42.6%) required invasive ventilation. All patients had received corticosteroids and broad-spectrum antibiotics while most (n = 37, 78.7%) received at least one anti-viral medication. Mean time elapsed from COVID-19 diagnosis to mucormycosis was 12.1 ± 4.6days. Eleven (23.4%) subjects succumbed to their disease, mostly (n = 8, 72.7%) within 7 days of diagnosis. Among the patients who died, 10 (90.9%) had pre-existing diabetes mellitus, only 2 (18.2%) had received just one vaccine dose and all developed moderate-to-severe pneumonia, requiring oxygen supplementation and mechanical ventilation.

Conclusions: Mucormycosis can occur among COVID-19 patients, especially with poor glycaemic control, widespread and injudicious use of corticosteroids and broad-spectrum antibiotics, and invasive ventilation. Owing to the high mortality, high index of suspicion is required to ensure timely diagnosis and appropriate treatment in high-risk populations.

Keywords: COVID-19; Mucormycosis; coronavirus disease 2019; diabetes mellitus; systemic corticosteroids.

FIGURE 1

Clinical and radiological features of a 61‐year‐old female patient with poorly controlled diabetes mellitus (type 2) who was diagnosed with moderate‐severity COVID‐19 and invasive rhino‐orbital‐cerebral mucormycosis. The patient had received systemic corticosteroids and broad‐spectrum antibiotics for the management of severe COVID‐19 pneumonia. She eventually succumbed to the disease. On presentation, she had complete right‐sided ptosis, proptosis and complex ophthalmoplegia suggestive of orbital apex syndrome. There was also right peri‐orbital and hemifacial swelling and tenderness. The patient had dysphagia which necessitated the insertion of a nasogastric tube. (A) Examination of the oral cavity revealed the presence of black necrotic tissue involving the palate with pharyngeal extension consistent with an eschar. (B) Coronal CT scan of paranasal sinuses showing bilateral right more than left‐sided opacification of the maxillary sinuses with poor aeration. Gadolinium‐enhanced T1‐weighted axial magnetic resonance imaging demonstrates the presence of a heterogeneously enhancing intra‐orbital lesion with contiguous involvement of the right cavernous sinus. (C) Gadolinium‐enhanced T1‐weighted coronal magnetic resonance imaging of the brain demonstrates the presence of a right‐sided ring‐enhancing lesion suggestive of a fungal abscess

FIGURE 2

Diagnostic and treatment algorithm of mucormycosis in patients with COVID‐19. Abbreviations: allo‐HSCT = Allogenic hematopoietic stem cell transplant, GMS = Gomori's methenamine silver, HM = Hematopoietic malignancies, PAS = Periodic acid‐Schiff stain and SOT = Solid organ transplant (Adapted and modified from Song et al and Sen et al ¹⁴ )