Multicenter Epidemiologic Study of Coronavirus Disease–Associated Mucormycosis, India

Abstract

S econdary infections are known to complicate the clinical course of coronavirus disease . Bacterial infections are the most common secondary infections, but increasing reports of systemic fungal infections are causing concern. In the early part of the COVID-19 pandemic, <1% of secondary infections reported in COVID-19 patients were fungal (1,2). Preexisting conditions, indiscriminate use of antimicrobial and glucocorticoid drugs, and lapses in infection control practices are putative factors contributing to the emergence of systemic fungal infections in severe COVID-19 cases (3). After incidence of candidemia and invasive aspergillosis in COVID-19 patients increased (4,5), awareness of possible fungal co-infections increased among clinicians and microbiologists. One study reported invasive fungal infections in ≈6% of hospitalized COVID-19 patients (6). Occasional reports of COVID-19-associated mucormycosis (CAM) from various centers (7,8) and a series of 18 cases from a city in South India increased our concerns about CAM (9). India has a high burden of mucormycosis among patients with uncontrolled diabetes mellitus, and many severe COVID-19 patients have diabetes (8,10). India also is one of the countries worst affected by the COVID-19 pandemic. Thus, we would expect India to have many CAM cases. We conducted a nationwide multicenter study to evaluate the epidemiology and outcomes of CAM and compare the results with cases of mucormycosis unrelated to COVID-19 (non-CAM). Methods Study Design and SettingWe conducted a retrospective observational study involving 16 healthcare centers across India (Figure 1).

Epidemiology and Pathophysiology of COVID-19-Associated Mucormycosis: India Versus the Rest of the World

“…Combination medical therapy (use of amphotericin followed by isavuconazole or posaconazole) was associated with better survival. The reported mortality obtained in our review of literature from India (36.5%) is much lower than the previous Indian data on non-COVID-19 mucormycosis (52%) [45] and a recently reported large study on CAM (45.7%) [3]. The predominance of ROM and timely treatment may partly explain the better survival reported from India.…”

“…While we have yet to completely understand the pathogenesis and consequences of SARS-CoV-2 on the human host, different disease complications continue to emerge. The recent surge of COVID-19-associated mucormycosis (CAM) in India is alarming due to its high mortality, the sheer number of cases, and the limited availability of antifungal drugs [2,3]. India has reported more than 47,000 cases of mucormycosis in three months (May to July 2021), and the actual figures are likely higher.…”

First report of COVID-19-associated rhino-orbito-cerebral mucormycosis in pediatric patients with type 1 diabetes mellitus

“…The second case had an interval of 10 days between COVID-19 diagnosis and the first evidence of mucormycosis. A multicenter epidemiologic study revealed that the median time to CAM diagnosis was 18 days, with majority of the patients developing late CAM (mucormycosis was diagnosed ≥8 days after COVID-19 diagnosis) [24] . Similar findings were reported by Pal et al .…”

Imaging of COVID-19-associated craniofacial mucormycosis: a black and white review of the “black fungus”

“…A subset of diabetic COVID-19 patients treated with steroids, oxygen, and/or prolonged intensive care admission develop rhino-orbito-cerebral mucormycosis. 25 Radiologists must have a high index of suspicion for early diagnosis. IFRS is a fulminant condition that can lead to devastating blindness, stroke, and death as early as 48 h after presentation.…”