Outbreak of Mucormycosis in Coronavirus Disease Patients, Pune, India

Abstract

We provide an overview of the epidemiology and clinical course of mucormycosis in the coronavirus disease (COVID-19) pandemic era. We conducted a retrospective chart review of 178 patients with clinical or diagnostic, endoscopically or histopathologically confirmed rhino-sino-orbital or cerebral mucormycosis after COVID-19 treatment during the second wave of COVID-19 in Pune, India. Median time to symptom onset from COVID-19 detection was 28 days. Moderate or severe COVID-19 was seen in 73% of patients and diabetes in 74.2%. A total of 52.8% received steroids. Eschar over or inside the nose was seen in 75%, but baseline clinical and laboratory parameters were mostly unremarkable. Bone penetration was present in ≈90% of cases, 30% had soft-tissue swelling of the pterygopalatine fossa and 7% had cavernous sinus thrombosis, and 60% had multifocal mucormycosis. Of the 178 study cases, 151 (85%) underwent surgical debridement. Twenty-six (15%) died, and 16 (62%) of those had multifocal mucormycosis.

Keywords: COVID-19; India; SARS-CoV-2; coronavirus disease 2019; fungal infections; fungi; invasive mucormycosis; respiratory infections; rhino-sino-orbital mucormycosis; severe acute respiratory syndrome coronavirus 2; viruses; zoonoses.

Figure 1

Frequency of rhino-sino-orbital and cerebral mucormycosis cases evaluated and treated at Sassoon General Hospital, Pune, India, before and during coronavirus disease pandemic. A) January 1, 2016–June 14, 2021; B) September 1, 2020–June 14, 2021.

Figure 2

Diagnostic endoscopic examinations of the nasal cavities of 2 patients with mucormycosis after coronavirus disease, Pune, India. A) Right nasal cavity shows crusting in the region of the middle meatus, blackish eschar with fungal elements between the middle turbinate and the nasal septum. Necrosis has begun setting in the part of the nasal septum below the region of the eschar. Mucopurulent discharge is seen trickling from the middle meatus to the nasopharynx because of underlying sinusitis. The inferior turbinate has undergone hypertrophy because of the underlying disease. B) Left nasal cavity shows extradural abscess being drained transnasally. Multiple polyps are noted in the region of the ethmoidal fovea. The crista ethmoidalis, left middle turbinate, and the right orbital roof are destroyed because of the underlying invasion by mucor. CE, crista ethmoidalis; EDA, extradural abscess; FP, ethmoidal fovea; IT, inferior turbinate; MM, middle meatus; MT, middle turbinate; NP, nasopharynx; OR, orbital roof; S, septum.

Figure 3

T2-weighted magnetic resonance imaging of the maxillary sinuses of a patient with mucormycosis after coronavirus disease, Pune, India, shows hypointense mucosal thickening bilaterally, more on the left side than the right. Near-complete occlusion of the sinus cavities and obliteration of left osteomeatal unit are seen. There is a mild deviation of the nasal septum with convexity toward the right side. There is mild soft tissue edema with altered signal abnormality involving the left pterygopalatine fossa extending to the left masticator space. L, left; R, right.

Figure 4

Histopathologic findings for necrotic tissue samples from patients with mucormycosis after coronavirus disease, Pune, India. A) Hematoxylin and eosin stain shows nonpigmented, wide, thin-walled ribbonlike pleomorphic broad aseptate hyphae of mucormycosis (original magnification ×40). B) Periodic acid–Schiff stain shows pleomorphic broad aseptate hyphae of mucormycosis (original magnification ×40). C) Methenamine silver stain shows nonpigmented (hyaline), pauciseptate, ribbonlike hyphae with right-angled branching consistent with Mucorales genera (original magnification ×40).