| Abstract|| |
Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been associated with a wide range of opportunistic bacterial and fungal infections. Recently, several cases of mucormycosis in people with COVID-19 have been increasingly reported worldwide, in particular in India. 1. To study the total prevalence of mucormycosis and other fungal species in patients' samples. 2. To elaborate on the associated underlying risk factors and their presentations with COVID-19. The study was conducted at the Department of Microbiology, Kalpana Chawla Government Medical College from April 2021 to July 2021 during the COVID-19 pandemic. Both outpatient and admitted cases were included in the study suspected of mucormycosis with underlying COVID-19 infection or post-recovery phase. In total, 906 nasal swab samples were collected at the time of the visit from suspected patients and were sent to the microbiology laboratory of our institute for processing. Both microscopic examinations by preparing a wet mount with KOH and lactophenol cotton blue stain and culture using Sabouraud's dextrose agar (SDA) were done. Subsequently, we analyzed the patient's clinical presentations at a hospital, associated comorbidities, site of mucormycosis infection, past history for use of steroids or oxygen therapy, admissions required, and its outcome in patients with COVID-19. In total, 906 nasal swabs from suspected cases of mucormycosis in people with COVID-19 were processed. In all, 451 (49.7%) fungal positivity was seen, out of which 239 (26.37%) were mucormycosis. Other fungi such as Candida (175, 19.3%), Aspergillus 28 (3.1%), Trichosporon (6, 0.66%) and Curvularia (0.11%) were also identified. Out of the total, 52 were mixed infections. The total percentage of patients having underlying active COVID-19 infection or in the post-recovery phase was 62%. Most cases (80%) were of rhino-orbital origin, 12% were Pulmonary and the rest 8% where no primary site of infection was confirmed. Among risk factors, pre-existing diabetes mellitus (DM), or acute hyperglycemia was present in 71% of cases. Corticosteroid intake was recorded in 68% of cases, chronic hepatitis infection in 4%, two cases of chronic kidney disease, and only one case with triple infection of COVID-19, underlying HIV, and pulmonary tuberculosis. Death from fungal infection was reported in 28.7% of the cases. Even with rapid diagnosis, treatment of underlying disease, and aggressive medical and surgical intervention, the management is often not effective, leading to an extension of the infection and ultimately death. So, early diagnosis and prompt management of this suspected new emerging fungal infection with COVID-19 should be considered.
Keywords: Black fungus, COVID-19, diabetes, mucormycosis, rhino-orbital-cerebral
|How to cite this article:|
Chillana S, Mohit Chilana KA. COVID-19 and mucormycosis: A black fungus disaster?. Indian J Dermatol 2022;67:535-8
| Introduction|| |
Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been associated with a wide range of opportunistic bacterial and fungal infections. Both Aspergillus and Candida have been reported as the main fungal pathogens for co-infection in people with COVID-19. Recently, several cases of mucormycosis in people with COVID-19 have been increasingly reported worldwide, in particular in India.
Mucormycosis is an uncommon but fatal fungal infection that usually affects patients with altered immunity. Mucormycosis is an angioinvasive disease caused by mold fungi of the genera Rhizopus, Mucor, Rhizomucor, Cunninghamella, and Absidia of the order Mucorales, class Zygomycetes. Rhizopus oryzae is the most common type and responsible for nearly 60% of mucormycosis cases in humans and also accounts for 90% of the rhino-orbital-cerebral (ROCM) form. The mode of contamination occurs through the inhalation of fungal spores.
Globally, the prevalence of mucormycosis varies from 0.005 to 1.7 per million population, while its prevalence is nearly 80 times higher (0.14 per 1000) in India compared to developed countries, in a recent estimate for 2019–2020. In other words, India has the highest number of cases of mucormycosis in the world.
Importantly, Diabetes mellitus (DM) has been the most common risk factor linked with mucormycosis in India, although hematological malignancies and organ transplants take the lead in Europe and the USA. Nevertheless, DM remains the leading risk factor associated with mucormycosis globally, with an overall mortality of 46%.
| Methods|| |
The study was conducted from April 2021 to July 2021 in a tertiary care hospital at Kalpana Chawla Government Medical College. Both outpatient and admitted cases suspected of mucormycosis with underlying COVID-19 infection or post-recovery phase were included in the study. In total, 906 nasal swabs samples were collected at the time of the visit from suspected patients and were sent to the microbiology laboratory of our institute for processing. Both microscopic examinations by preparing a wet mount with KOH and lactophenol cotton blue stain and culture using Sabouraud's dextrose agar (SDA) were done.
Subsequently, we analyzed the patient's clinical characteristics, associated comorbidities, use of steroids, and its outcome in patients with COVID-19.
- COVID-19 active infection or post-recovery case.
- Suspected case of rhino-orbital mucormycosis, i.e., sudden onset of severe headache, decrease in vision, recent unilateral or bilateral blindness, and nasal blackish discharge/sputum production.
- Suspected pulmonary mucormycosis suggestive by chest X-ray or CT scan.
- Confirmed case of neurological issues for blindness or decreased vision.
- Any other infectious/non-infectious etiology for rhino-orbital sinusitis.
| Results|| |
In total, 906 nasal swabs of suspected cases of mucormycosis in people with COVID-19 were processed in the Department of Microbiology. In total, 239 (26.37%) mucormycosis were detected [Figure 2] and other fungi such as Candida (175, 19.3%), Aspergillus (28, 3.1%), Trichosporon (6, 0.66%) and Curvularia (0.11%) were identified. Different species of Mucormycosis are depicted in [Figure 1]. Overall, 451 (49.7%) Total fungi positivity was seen, 443 (48%) and 52 out of the total were mixed infections.
Also, 53% were males and the rest 47% were female patients. The total percentage of patients having an underlying active COVID-19 infection or in post-recovery phase was 62%, and the rest did not have a history of COVID-19. Among risk factors, pre-existing DM or acute hyperglycemia was present in 71% of cases, corticosteroid intake was recorded in 68% of cases, chronic hepatitis infection was observed in 4%, and two cases of chronic kidney disease and one case with underlying HIV and pulmonary tuberculosis were present.
Most (80%) were of rhino-orbital origin, 12% were pulmonary, and the rest 8% were those where no primary site of infection was confirmed.
In 16% of cases, asymptomatic or mild symptomatic was present at the time of admission. The most common presentations at the time of the hospital visit were decreased vision or total blindness, rhinitis, blackish color sputum production, headache, and nausea. Also, 70% of cases required hospitalization at the time of the first presentation of fungal disease or for either COVID-19 treatment.
Overall, mortality was noted in 28.7% of the cases even after prompt rapid treatment.
| Discussion|| |
Fungal infections are not common in healthy individuals but several immunocompromised conditions predispose them. This includes uncontrolled DM with or without DKA, hematological and other malignancies, organ transplantation, COVID-19, and acquired immunodeficiency syndrome (AIDS). Mucormycosis can involve the nose, sinuses, orbit, central nervous system (CNS), lung (pulmonary), gastrointestinal tract (GIT), skin, jaw bones, joints, heart, kidney, and mediastinum (invasive type), but ROCM is the commonest variety seen in clinical practice worldwide.
Mucormycosis is characterized by the presence of hyphal invasion of the sinus tissue and a time course of fewer than 4 weeks. Clinically, rhinocerebral-mucormycosis can present with atypical signs and symptoms similar to complicated sinusitis, such as nasal blockage, crusting, proptosis, facial pain and edema, ptosis, chemosis, and even ophthalmoplegia, with headache and fever and various neurological signs and symptoms, if the intracranial extension is present. A black eschar is often seen in the nasal cavity or over the hard palate region but is not characteristic.
Without early diagnosis and treatment, there may be a rapid progression of the disease, with reported mortality rates from intra-orbital and intracranial complications of 50 to 80%. The predisposing factors associated with mucormycosis in Indians include diabetes (73.5%), malignancy (9.0%), and organ transplantation (7.7%). Because there are no studies that compared patients of mucormycosis in non-diabetic COVID-19 who did not receive steroids versus COVID-19 patients who received steroids and developed mucormycosis, it is difficult to establish a causal effect relationship between COVID-19 and mucormycosis in relation to corticosteroids. Nonetheless, there appears to be a number of triggers that may precipitate mucormycosis in people with COVID-19 in relation to corticosteroids.
It is highly likely that reported cases of mucormycosis maybe an underrepresentation of the real burden owing to difficulty in making a microbiological or histopathological diagnosis, especially in a raging pandemic setting. Defining active and recovered COVID-19 and its relation to the onset of mucormycosis could be difficult considering the lower sensitivity of confirmatory molecular methods like Reverse transcriptase polymerase chain reactions (PCR). Finally, evaluating the outcomes in people with mucormycosis and COVID-19 could be difficult at the moment because of the lack of follow-up for these patients during or after recovering while many of these patients are still under treatment.
Mucormycosis infection carries an immense public health importance, primarily because the fatality rate with mucormycosis is very high. Especially, the intracranial involvement of mucormycosis increases the fatality rate to as high as 90%. Moreover, the rapidity of dissemination of mucormycosis is an extraordinary phenomenon and even a delay of 12 h in the diagnosis could be fatal, the reason being that 50% of cases of mucormycosis have been historically diagnosed only in the post-mortem autopsy series.
| Conclusion|| |
Revised guidelines should be made for optimal hyperglycemia, and only judicious evidence-based use of corticosteroids in patients with COVID-19 is recommended to reduce the burden of fatal mucormycosis. More research is needed to know the overall impact of the reversal of risk factors with COVID-19 and mucormycosis.
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Conflicts of interest
There are no conflicts of interest.
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