COVID-19-associated mixed mold infection: A case report of aspergillosis and mucormycosis and a literature review

Abstract

COVID-19-associated mold infections have been increasingly reported, and the main entity is COVID-19-associated aspergillosis (CAPA). Similarly, COVID-19-associated mucormycosis has been reported in hematology, and its prevalence is high and has been increasing in the diabetic population in India during the third COVID-19 pandemic wave. Simultaneous infection with Mucorales and Aspergillus is rare and even rarer during COVID-19. Here, we report the case of a previously immunocompetent patient with severe SARS-CoV-2 infection complicated with probable CAPA and mucormycosis co-infection. Specific diagnostic tools for mucormycosis are lacking, and this case highlights the advantages of analyzing blood and respiratory samples using the quantitative polymerase chain reaction to detect these fungi. We further reviewed the literature on mixed Aspergillus/Mucorales invasive fungal diseases to provide an overview of patients presenting with both fungi and to identify characteristics of this rare infection.

Keywords: Aspergillosis; COVID-19; Corticosteroids; Invasive fungal disease; Mucormycosis; SARS-CoV-2.

Fig. 1

Time course of the patient with COVID-19-associated pulmonary aspergillosis and COVID-19-associated mucormycosis. AMb, liposomal amphotericin b; AN, amikacin; ATB, antibiotic; ATF, antifungal; AZT, azithromycin; BAL, bronchoalveolar lavage; CTC, corticosteroids; CTX, cefotaxime; DXM, dexamethasone; FEP, cefepime; GM Ag, galactomannan antigen; ICU, intensive care unit; MP, methylprednisolone; PCR, polymerase chain reaction; SXT, sulfamethoxazole–trimethoprim; VORI, voriconazole.

Fig. 2

(A) Chest CT on day 19 after symptom onset, which shows a right apical excavation with peripheral condensation. Direct examination of the bronchoalveolar lavage with calcofluor white showing (B) Aspergillus-type mycelium (original magnification × 200) and (C) Mucorales-type mycelium (original magnification × 400). Microscopic culture examination with cotton blue showing (D) Aspergillus niger and (E) Rhizopus delemar (original magnification × 200).