When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis

Abstract

Mucormycosis (MCR) has been increasingly described in patients with coronavirus disease 2019 (COVID-19) but the epidemiological factors, presentation, diagnostic certainty, and outcome of such patients are not well described. We review the published COVID-19-associated mucormycosis (CAMCR) cases (total 41) to identify risk factors, clinical features, and outcomes. CAMCR was typically seen in patients with diabetes mellitus (DM) (94%) especially the ones with poorly controlled DM (67%) and severe or critical COVID-19 (95%). Its presentation was typical of MCR seen in diabetic patients (mostly rhino-orbital and rhino-orbital-cerebral presentation). In sharp contrast to reported COVID-associated aspergillosis (CAPA) cases, nearly all CAMCR infections were proven (93%). Treating physicians should have a high suspicion for CAMCR in patients with uncontrolled diabetes mellitus and severe COVID-19 presenting with rhino-orbital or rhino-cerebral syndromes. CAMR is the convergence of two storms, one of DM and the other of COVID-19.

Case series of four secondary mucormycosis infections in COVID-19 patients, the Netherlands, December 2020 to May 2021

“…CAPA was associated with a 50% mortality rate and is mainly caused by Aspergillus fumigatus [8]. Recently, secondary fungal infections caused by Mucorales in critically ill COVID-19 patients were reported from India, with mortality rates ranging between 24.3% and 81% depending on the clinical manifestation [9,10].…”

Mucormycosis in COVID-19- A burgeoning epidemic in the ongoing pandemic

“…15 This is supported by a recent nationwide multicenter study on MCR in India, where 57% of patients had uncontrolled DM and 18% had diabetic ketoacidosis. 15 The uncontrolled/unsupervised use of corticosteroids that compounded the glucose homeostasis, could have been a contributing factor exposing COVID-19 patients to MCR. Corticosteroid use is a key risk factor for opportunistic mycoses, including MCR.…”

“…14 Moreover, India has the second-largest number of adults aged 20-79 years with diabetes mellitus (DM). 15 In fact, DM is the single most common (i.e., seen in more than fifty percent cases of MCR) risk factor for MCR in India. 15 This is supported by a recent nationwide multicenter study on MCR in India, where 57% of patients had uncontrolled DM and 18% had diabetic ketoacidosis.…”

“…15 In fact, DM is the single most common (i.e., seen in more than fifty percent cases of MCR) risk factor for MCR in India. 15 This is supported by a recent nationwide multicenter study on MCR in India, where 57% of patients had uncontrolled DM and 18% had diabetic ketoacidosis. 15 The uncontrolled/unsupervised use of corticosteroids that compounded the glucose homeostasis, could have been a contributing factor exposing COVID-19 patients to MCR.…”

“…Corticosteroid use is a key risk factor for opportunistic mycoses, including MCR. 12,15 Not only the cases who have been treated or on the treatment of COVID-19 are affected but cases of MCR in non-COVID-19 patients are also reported from India. 16,17 In the current pandemic of COVID-19, a myriad of manifestations and complications have emerged due to MCR and are being reported every other day.…”