Study of Profile of Mucormycosis During the Second Wave of COVID-19 in a Tertiary Care Hospital

Abstract

Introduction and aimMucormycosis is a lethal opportunistic infection caused by filamentous fungi of the family Mucoraceae (black fungus). There has been a sudden increase in the incidence of these cases during the second wave of the COVID-19 pandemic due to the immunocompromised state caused by the disease and its treatment. Early diagnosis and appropriate medical management are essential to reduce disease morbidity and mortality. Through this study, we aim to study the clinical features, risk factors, laboratory investigations, and radiological findings of patients with mucormycosis as well as evaluate the clinical outcomes in each case. Methods and materialsThis was a prospective study that included only confirmed mucormycosis cases admitted in Tata Main Hospital (TMH) from April 2021 to July 2021. A case of mucormycosis was defined as the one in which clinical and radiological features were consistent with mucormycosis and fungus was demonstrated in the tissue by potassium hydroxide (KOH) mount/culture/histopathological examination (HPE). Data relating to epidemiology, risk factors, clinico-radiological features, and outcomes were analyzed and expressed as a percentage of total cases. ResultsOf the total 15 cases, three patients (33.3%) had active COVID-19 infection, eight (53.3%) were in the post-COVID-19 state, two (13.4%) had COVID-19 like illness and two (13.4%) patients did not have COVID-19 in the recent past. There was male predominance with the male to female ratio being 2.75:1. The commonest associated co-morbid condition was diabetes mellitus (13 patients, 86.7%). Amongst the myriad manifestations, periorbital swelling was the commonest symptom (11 patients, 73.3%). Among neurological manifestations, involvement of cranial nerves was found in nine (60%) patients with the third cranial nerve being the most commonly affected nerve (eight patients, 53.3%). Cavernous sinus thrombosis (CST) was found in one (6.7%) patient. Diagnostic nasal endoscopy (DNE) revealed eschar at various sites in 13 patients (86.7%). Central retinal artery occlusion (CRAO) was found bilaterally in one patient (6.7%) while two patients (13.3%) had CRAO on the left. Radiologically, the most commonly involved sinuses were maxillary and ethmoidal (eight patients, 53.3%). Bilateral sinus involvement was more common (46.7%) than unilateral sinus involvement. The average length of stay (LOS) was 17.5±7.8 days. The overall mortality was 40%. Five (33.3%) patients developed secondary bacterial infections. All patients received medical therapy with intravenous amphotericin B. In addition, seven (46.7%) patients underwent functional endoscopic sinus surgery (FESS) with debridement of which, five (71.4%) patients survived and made a good recovery. One patient (6.7%) with pulmonary mucormycosis underwent lobectomy. ConclusionNew-onset headache, black nasal discharge, periorbital swelling, retro-orbital pain, visual diminution, restriction of eye movements should prompt an immediate search for mucormycosis especially in the background of his...

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“…According to the available post-COVID literature, [9][10][11][12][13][14][15][16] India is the epicenter of black fungus, primarily mucormycosis, as compared to more prevalence of aspergillosis in the Western world. Reasons include rampant usage of steroids and associated risk factors like diabetes mellitus and environmental conditions.…”

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“…Infection may develop by inhaled fungal spores that are ubiquitously present in the air or by inoculation of the spores into disrupted mucosa or wounds. The hyphal growth cause invasion of blood vessels, resulting in thrombosis and progressive necrosis that leads to soft tissue and bone destruction irrespective of the route of invasion ( Pasternak and Olszanecki, 2021 ; Kamath et al, 2022 ). In susceptible hosts, six distinctive clinical manifestation could be observed including rhino-orbital-cerebral, pulmonary, gastrointestinal, cutaneous, disseminated, and uncommon infection.…”

“…being the most prevalent causative pathogen ( Pasternak and Olszanecki, 2021 ; Hoenigl et al, 2022 ). The major predisposing factors for the development of mucormycosis are uncontrolled diabetes mellitus with ketoacidosis, neutropenia, hematological malignancy, stem cell and solid organ transplantations, iron chelation therapy with deferoxamine, and corticosteroid usage ( Hussain et al, 2021 ; Hoenigl et al, 2022 ; Kamath et al, 2022 ). Hyperglycemic state, low oxygen level, high iron levels, an acidic medium, and a decreased phagocytic activity occurred in most COVID-19 patients favor the growth of fungi, particularly Mucorales that use free iron levels in the serum for their pathogenesis ( Morales-Franco et al, 2021 ; Darwish et al, 2022 ).…”

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“…In India, the prevalence of COVID-19-associated mucormycosis was 80 times higher as compared to other developed nations worldwide. Around 71% of global cases of mucormycosis have been reported from India alone, Maharashtra being the second most common state to do so [3]. This could be attributed partly to the immunocompromised status caused by the disease, partly to associated patient comorbidities, and the rest to the hot and humid tropical climate.…”

“…A case of mucormycosis is defined as one in which clinical and radiological features were consistent with mucormycosis and fungus was demonstrated in the sample by KOH mount or culture or histopathological examination. There are various forms of presentation of mucormycosis such as rhinonasal, rhino-orbital, rhino-orbital-cerebral, pulmonary, cutaneous, gastrointestinal, and disseminated [3].…”