Risk Factors, Clinical Manifestations, and Outcomes of COVID-19-Associated Mucormycosis and Other Opportunistic Fungal Infections

Abstract

Introduction: An epidemic of opportunistic fungal infections during the second wave of the coronavirus disease 2019 (COVID-19) pandemic badly affected India in 2021. Several unknown, unique factors played a role in its causation and survival outcomes, including the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study was to analyse the probable underlying risk factors and to know immediate and late outcomes of opportunistic fungal infections in the unique setting of the SARS-CoV-2 pandemic. Methods: In this retrospective cohort study, clinical records of COVID-19-associated opportunistic fungal infections were reviewed for risk factors, clinical features, microbiological and pathological findings, and outcomes during a one-year follow-up at a tertiary care teaching hospital in Northern India. Results: A total of 390 patients were admitted with symptoms and clinical signs consistent with the criteria for the diagnosis of COVID-19-associated mucormycosis (CAM). Diabetes mellitus was the most common comorbidity (74%). During the management of SARS-CoV-2, 192 (49%) patients received corticosteroids, 151 (39%) were on oxygen support, and 143 (37%) used at-home steam inhalation. Masks of any type were used by 236 (60.5%) patients, of whom most used cloth masks (n=147, 37.6%). Microbiologically, fungal growth was positive in 138 (35.3%) samples; of these, 74 (19%) had non-Mucorales fungal colonies. The fungal infection invaded structures beyond the paranasal sinuses in 60% of the cases. The overall mortality in this cohort after one-year follow-up was 40.25%. Conclusions: An alignment of several predisposing conditions precipitated an epidemic of opportunistic fungal infections during the COVID-19 pandemic that resulted in high mortality in affected patients.

Determinants of Mortality in COVID-19–Associated Opportunistic Fungal Infections

“…The mean ± SD (range) age of the cohort was 54 ± 13 (14–88) years, which included 282 (72%) men and 109 (28%) women. Based on the level of evidence, patients were categorized as possible, probable, and proven cases of rhino-orbital-cerebral mucormycosis 11 . In 256 (66%) samples, fungi were cultured, isolated, and identified.…”

“…For this study, information about demographics, epidemiology, clinical features, laboratory investigations, and treatment was collected. The detailed methodology and descriptive information about the cohort are published elsewhere 11 . Patients were managed through a multidisciplinary approach that involved specialists depending on the clinical presentation.…”

“…A standard treatment regimen was followed, which was devised based on published guidelines 5 . In brief, this included initial surgical debridement, followed by systemic amphotericin B therapy for 2 weeks and oral posaconazole for 3 months while monitoring for any adverse effects 11 . Deaths that occurred during hospitalization or within 3 weeks of discharge from the hospital were labeled as early mortality, whereas those that occurred after 3 weeks of discharge but within a year were labeled as late mortality.…”