COVID-19-associated mucormycosis, diabetes and steroid therapy: Experience in a single centre in Western Mexico

Abstract

Background: COVID-19-associated mucormycosis (CAM) has emerged as a challenging complication as the current pandemic has increased the population requiring treatment with corticosteroids. CAM has caused a massive outbreak in India, reported to be causing cases in Iran, Egypt and The Netherlands.

Objectives: To describe CAM cases occurring in a single centre in Western Mexico.

Methods: Our group carried out a retrospective study from May 2020 to May 2021 to identify CAM cases in patients with previous COVID-19 diagnosis.

Results: Six CAM cases occurred in a single centre in Western Mexico during the study period, most of them with diabetes (n = 5/6) and all received corticosteroid therapy even when only three had severe COVID-19. After analysing local COVID-19 burden, it was estimated that in this region, CAM was 300 times more frequent among COVID individuals than the estimates for general population.

Conclusion: Similar to large reports in India and other countries, CAM cases reported in this study were diagnosed in individuals with diabetes, hyperglycaemic status and with history of previous use of corticosteroids. Identifying these individuals at risk can help the early identification of CAM. In addition, strict glycaemic control and avoidance of unnecessary corticosteroid in non-severe COVID-19 cases could help in preventing this complicated fungal infection.

Keywords: CAM; COVID-19; ROCM; SARS-CoV-2; corticosteroids; diabetes; infection; mucormycosis.

FIGURE 1

KOH and culture from CAM cases. Four cases were initially diagnosed by direct microscopy. Case 1 was diagnosed only by KOH cytology. Four cases had positive culture, cases 2, 4, 5, 6

FIGURE 2

Clinical characteristics of patients with COVID‐19–associated rhino‐orbital‐cerebral mucormycosis. Case 1: Male 65 YO, diabetes. Clinical features: oedema, necrosis in left orbit and an ulcer in palate but rapidly progressed over the next 2 days to subcutaneous emphysema, proptosis, and endophthalmitis. Case 2:62 YO male, Diabetes and recently diagnosed with hepatic cirrhosis. Clinical manifestations were headache, left‐side facial pain, proptosis, orbital and palate oedema. Palate also showed a necrotic ulcer. Case 4:56 YO male, diabetes. Clinically, headache, and left eye pain and oedema. Left eye with blindness, ptosis, and proptosis. A necrotic palate ulcer was also seen. Case 6: Male, 48 YO with 15‐year diabetes. After 5 days in hospital due to severe SARS‐CoV‐2 and ketoacidosis, patient showed bilateral orbit oedema, ecchymosis, and purulent secretion

FIGURE 3

Findings in imaging in patients with CAM. Case 1. CT scan showing pansinusitis, maxillar bone erosion, subcutaneous and intramuscular dissecting gas (white circle), Case 2. CT scan with mucosal thickening at in maxillary and ethmoid sinuses with communication between sinuses and cranial cavity. Case 3. CT scan showing pansinusitis, bone erosion, periorbital and hemi‐facial oedema (white arrow), subcutaneous gas, hypodensity in frontal lobes. Case 4. MRI showing left eye proptosis (white circle), postgadolinium enhancing of pre‐ and periorbital muscles and soft tissues. Sinus thickening and soft tissue dissection. Case 5. Wide bilateral consolidations, air bronchogram, image compatible with reversed halo sign (black circle)