COVID-19 associated mucormycosis: Staging and management recommendations (Report of a multi-disciplinary expert committee)

Abstract

Even before the onslaught of COVID-19 pandemic could settle, the unprecedented rise in cases with COVID-19 associated mucormycosis has pushed the medical health to the fringe. Hyperglycaemia and corticosteroids appear to be the most consistent associations leading to the commonest manifestation of mucormycosis, Rhino-Orbito-Cerebral Mucormycosis. To address challenges right from categorisation and staging of the disease to the management of relentless progression, a multi-disciplinary expert committee was formed to handle the task in an evidence-based format to enforce best practices. The report of the committee on one hand attempts to succinctly present the currently available evidence while at the other also attempts to bridge the evidence-deficient gaps with the specialty-specific virtuosity of experts.

Invasive Fungal Infections Complicating COVID-19: A Narrative Review

“…The characteristics of the candidemia cases (disease localisation, etiologic agents, diagnostic methods, treatment, and outcomes) were similar to those with other IFI [211]. The observational studies indicate a low rate of histopathological diagnoses (43.8%) and positive cultures (23.6%), even though these are required for a proven diagnosis [213]. This is probably due to technical difficulties in obtaining diagnostic samples from COVID-19 patients because of safety concerns or clinical instability secondary to respiratory failure.…”

“…This is probably due to technical difficulties in obtaining diagnostic samples from COVID-19 patients because of safety concerns or clinical instability secondary to respiratory failure. Furthermore, Mucorales are fragile and, if the material taken from biopsies or other specimen is not managed carefully, a culture may become negative [213]. The treatment of mucormycosis is challenging and requires the prompt administration of anti-fungal agents and debulking surgery but, even after treatment, the average mortality rate associated with the disease is 40% [213].…”

“…Furthermore, Mucorales are fragile and, if the material taken from biopsies or other specimen is not managed carefully, a culture may become negative [213]. The treatment of mucormycosis is challenging and requires the prompt administration of anti-fungal agents and debulking surgery but, even after treatment, the average mortality rate associated with the disease is 40% [213]. Among the case reports/case series, maxillofacial surgery was reported in 35 cases (59.3%); however, the outcome was not always favourable probably because of highly invasive disease [140,145,[147][148][149][150][151]157,159,161,163].…”

“…In the largest study of COVID-19-associated mucormycosis, a disease stage of <3b (orbital involvement without vision loss) was associated with a better outcome and, regardless of stage, surgery (paranasal sinus debridement and/or orbital exenteration) was associated with stable residual or regressive disease [177]. Together with infection control, the key elements of successful mucormycosis management suggested in the clinical guidelines are an early diagnosis, species identification, a combination of anti-fungal therapy and aggressive surgical resection/debridement, the optimisation of blood glucose levels, and the correct use of glucocorticoids for COVID-19 treatment (administration to hypoxic patients, and not exceeding the dose and treatment duration established by the guidelines) [213][214][215][216].…”

COVID-19-associated mucormycosis: Looking for the culprit!

“…The case reported by Jadaun et al [6] also points the poor outcome of an invasive fungal infection in an immunocompromised critically ill with COVID-19 with special issues in diagnosis and management [1] . Of note, multi-disciplinary expert committees were formed to handle the task in an evidence-based format to enforce best practices of CAM management [ 14 , 15 ].…”