Risk Factors of COVID-19 Associated Mucormycosis (CAM) in Iranian Patients: A Single-Center Retrospective Study

Abstract

Background: COVID-19 associated mucormycosis (CAM) has been known as one of the most severe post-COVID morbidities.

Objectives: To describe CAM cases, identify possible risk factors, and report outcomes of patients.

Methods: This retrospective study was performed in Amir-Alam Hospital, Tehran, Iran between February 2020 and September 2021. Patients with mucormycosis who had an active or previous diagnosis of COVID-19 have been included.

Results: Of 94 patients with mucormycosis, 52 (33 men and 19 women; mean age: 57.0 ± 11.82 years) were identified with an active or history of COVID-19. Rhino-orbital, rhino maxillary, rhino-orbito cerebral subtypes of mucormycosis were detected in 6 (11.5%), 18(34.6%), and 28(53.8%) patients. As a control group, 130 (69 men and 61 women; mean age: 53.10 ± 14.49 years) random RT-PCR-confirmed COVID-19 patients without mucormycosis have been included. The mean interval between COVID-19 diagnosis and initial mucormycosis symptoms was 16.63 ± 8.4 days (range 0-51). Those in the CAM group had a significantly more severe course of COVID-19 (OR = 3.60, P-value < 0.01). Known history of previous diabetes mellitus (OR = 7.37, P-value < 0.01), smoking (OR = 4.55, P-value < 0.01), and history of receiving high-dose corticosteroid pulse therapy because of more severe COVID-19 (P-value = 0.022) were found as risk factors. New-onset post-COVID hyperglycemia was lower in the CAM group (46.2% vs. 63.8%; OR = 0.485, P-value = 0.028). After treatment of the CAM group, 41(78.8%) of patients recovered from mucormycosis. The mean ages of the expired patients in the CAM group were significantly higher than those who recovered from mucormycosis (66.18 ± 9.56 vs. 54.56 ± 11.22 years; P < 0.01); and COVID-19 disease was more severe (P = 0.046).

Conclusion: Either active or history of COVID-19 can cause an increase in the risk of mucormycosis development. Some of the most important risk factors are the medical history of diabetes mellitus, smoking, and high-dose corticosteroid therapy. CAM is important possible comorbidity related to COVID-19, which could make the post-COVID conditions more complicated. More research and studies with greater sample sizes among different ethnicities are needed to explore the association between COVID-19 and mucormycosis.

Keywords: CAM; COVID-19; Mucormycosis; SARS-CoV-2.

Fig. 1

A Axial Short tau inversion recovery (STIR) of a 47-year-old shows right maxillary sinus mucosal thickening with preantral (red arrow) and infratemporal (blue arrow) fat stranding suggestive of acute invasive sinusitis. B Axial fat sat T1 C + of the same patient shows trigeminal maxillary branch (V2) perineural spread of infection to the right cavernous sinus (green arrow). V2 pathway involvement in the infraorbital canal and groove (blue arrow) and inferior orbital fissure (red arrow) are visible

Fig. 2

Pathologic figures of the patients with CAM. A 56 -year-old man with a history of diabetes mellitus type 2 who presented with acute visual loss of right eye following covid-19 disease. Histologic evaluation of the periorbital adipose tissue showed broad branching nonseptate hyphae of mucormycosis in the background of necrotic adipose tissue. (B and C) 71- year-old man with a history of covid-19 was referred to our center due to the necrosis of the palate. Microscopic examination of the necrotic tissue showed that the arterioles wall was invaded by broad aseptate fungal hyphae