Covid-19 associated mucormycosis

Abstract

: Corona virus disease-2019 (COVID-19) is associated with various opportunistic, bacterial, and fungal infections. High risk groups include people with diabetes especially diabetic ketoacidosis, solid organ transplantation, long-term systemic corticosteroid use, and iron overload. Many cases of mucormycosis were reported worldwide. Mucormycosis is an invasive fungal infection with high morbidity and mortality. Early diagnosis and treatment with appropriate anti-fungals lead to improved outcomes. The aim of this study is to establish the factors associated with mucormycosis in a COVID-19 setting, like comorbidities and treatment protocols for treatment of COVID-19. The histological patterns and tissue reactions to mucormycosis also were studied. In patients with ongoing COVID-19 infection and in a post COVID-19 scenario, we studied the biopsy findings of mucormycosis in various sites like rhino-orbital, lung, gastric and trachea. Material for this study is from a tertiary care hospital in South India. Patient age ranged from 30 years to 74 years. Mean age of the patients was 51 years. Male to female ratio was 1:1.1. Tissue from sino- nasal mucosa, peri orbital tissue, exenterated eyeball, lung tissue and tissue from rare sites like gastric and tracheal mucosal lesions were also included in this study. Tissue was fixed in 10% buffered formalin. Routine Haematoxylin and Eosin(H&E) stains were done. Gomori’s Methenamine silver (GMS) stains were done on all cases. Tissue was submitted for fungal cultures in all the cases.Total of twenty-three cases were diagnosed as mucormycosis based on the morphology and special stains in this analysis. Histology revealed areas of infarction in all cases with neutrophilic infiltration. Granulomatous reaction was seen in seven cases and melanin pigment was seen in two cases. 100% of patients were diabetics. There was neutrophilia in 100% of cases. Lymphopenia was seen in 85.7%, C-Reactive Protein (CRP) was elevated in 100% of cases.Ferritin was done in 14 patients and D-dimer was done in 17 patients and in all patients, these were elevated. All patients were treated with steroids according to the treatment protocol for COVID-19, Remdesivir was given in 72.7% of cases and second immunomodulator drugs like Tocilizumab in four cases and Baricitinib in one case.Mucormycosis is an emerging problem with COVID-19. It is important to carefully monitor blood glucose levels and take into account underlying medical conditions of patients before initiation of steroid therapy. Early recognition of symptoms and early diagnosis has a better outcome in patients with mucormycosis associated with COVID-19 infection.

COVID-19-Associated Mucormycosis

“…During the COVID-19 pandemic, the surge of CAM has become a serious concern, particularly in India. [ 3 7 ] Double- and triple-mutant variants of SARS-CoV-2 have emerged in India during the second wave of COVID-19, which are more dreadful and are doubted to play a mightier role in the CAM surge. Resultant immune system defects with COVID-19 need to be studied to understand its pathophysiology.…”

“…COVID-19-associated mucormycosis (CAM) is an emergent opportunistic infection that has commanded global attention, more so during the second wave of COVID-19. [ 1 2 3 ] While the correlation between the two is understandable, the underlying pathophysiological mechanisms of CAM are still elusive.…”

“…They include hypertension, chronic cardiovascular diseases, renal failure, liver failure, obesity, use of interleukin-6 blockers, high ferritin leading to iron overload, acidosis, intravenous drug abuse, and prolonged hospitalization. [ 1 2 3 11 15 ] In recent studies, it was observed that a heavy dose of zinc supplementation either as self-administration by the patients or as over-prescription by the treating clinicians can increase the risk for Mucor. [ 7 16 ]…”