A Clustered Case Series of Mucorales Detection in Respiratory Samples from COVID-19 Patients in Intensive Care, France, August to September 2021

Abstract

While COVID-19-associated pulmonary aspergillosis is now well described in developed countries, COVID-19-associated mucormycosis (CAM) has seemed to remain quite rare in Europe. A retrospective study was performed between March 2020 to September 2021 among COVID-19 adult patients in the intensive care unit (ICU) at Toulouse Hospital (Southern France). PCR screening on respiratory samples, which target Aspergillus or Mucorales DNA, were performed, and the number of fungal detections was evaluated monthly during the study period. During the 19 months of the study, 44 (20.3%) COVID-19 ICU patients had a positive PCR for Aspergillus, an overall rate in keeping with the incidence of ICU COVID-19 patients. Ten patients (7.1%) had a positive Mucorales PCR over the same period. Surprisingly, 9/10 had a positive Mucor/Rhizopus PCR in August-September 2021, during the fourth Delta SARS-CoV-2 variant wave. Epidemic investigations have identified a probable environmental cause linked to construction works in the vicinity of the ICU (high levels of airborne spores due to the mistaken interruption of preventive humidification and summer temperature). Even if CAM are apparently rare in Europe, a cluster can also develop in industrialised countries when environmental conditions (especially during construction work) are associated with a high number of COVID-19 patients in the ICU.

Mucormycosis in a Patient with Severe COVID-19 Disease—The First Case Report in Romania and a Literature Review

“…In a study conducted by Guemas et al, a probable cause of CAM onset was described as being the construction site near the hospital, stating that the level of spores was higher due to the construction site and due to the high temperatures and humidity associated with the summer [ 22 ]. The area nearby the hospital site was investigated for construction sites, but no active construction sites were found.…”

Clinical Phenotypes of COVID-19 Associated Mucormycosis (CAM): A Comprehensive Review

“…Analogously, in another German study, among 100 COVID-19 ICU patients whose respiratory specimens were checked routinely for Mucorales via culture and PCR, only one PCR in the bronchoalveolar lavage (BAL) came out positive for Mucorales (1%) [ 120 ]. However, a cluster of cases was detected in a French ICU, during a two month period, which was possibly linked to construction work that was undertaken near the ICU [ 62 ].…”

“…In the French study [ 57 ], PCR was positive in 15/17 (88%) patients with CAM in serum (n = 14), BAL (n = 7), tissues (n = 3) and peritoneal fluid (n = 1) [ 57 ]. It is of interest that, in another French study [ 62 ], Mucorales was detected with PCR in respiratory samples of 10 COVID-19 patients, of which 80% simultaneously tested positive for Aspergillus. This cluster of cases was possibly attributed to environmental exposure, due to construction work near the hospital [ 62 ].…”

“…It is of interest that, in another French study [ 62 ], Mucorales was detected with PCR in respiratory samples of 10 COVID-19 patients, of which 80% simultaneously tested positive for Aspergillus. This cluster of cases was possibly attributed to environmental exposure, due to construction work near the hospital [ 62 ].…”

“…All patients had pulmonary involvement, 3/8 were treated with L-Amphotericin B, 4/8 with a combination of L-Amphotericin B and Posaconazole and/or isavuconazole and 1/8 with isavuconazole. Four out of eight (50%) patients died [ 62 ]. Aspergillus fumigatus, Aspergillus niger and Aspergillus nidulans have been isolated [ 70 ], while mixed mold infections with Candida are also described in the literature [ 66 , 67 ].…”