Novel risk factors for Coronavirus disease-associated mucormycosis (CAM): a case control study during the outbreak in India

Abstract

Background: The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies. Methods: We performed a case-control study comparing cases diagnosed with CAM and those who had recovered from COVID-19 without developing mucormycosis (controls). Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Results: 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases carried conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95%CI 1.1-11), use of systemic steroids (aOR 7.7,95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6,95% CI 1.2-2.2). Zinc therapy, probably due to its utility in immune function, was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM. Conclusion: Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.

Hyperglycemia and steroid use increase the risk of rhino-orbito-cerebral mucormycosis regardless of COVID-19 hospitalization: Case-control study, India

“…Diabetes mellitus as a risk factor for ROCM is well documented during the pre-COVID era [ 5 , 25 ]. In COVID-19 pandemic, pre-existing diabetes could worsen glycaemic control, thereby causing ketoacidosis and increasing the risk of mucormycosis [ 26 , 27 ]. Our finding is consistent with published studies reporting a higher risk of mucormycosis among people with diabetes and more so after COVID-19 [ 4 , 9 , 11 , 24 , 26 – 28 ].…”

A study on the morbid histopathological changes in COVID‐19 patients with or without comorbidities using minimally invasive tissue sampling

“…These changes did not differ significantly between patients with different underlying host factors 23 . Patients with severe COVID‐19 are at an increased risk to develop secondary fungal infections with aspergillus or mucor 24–27 . A review showed the prevalence of COVID‐19 associated pulmonary aspergillosis (CAPA) to be around 8.6%.…”

“… 23 Patients with severe COVID‐19 are at an increased risk to develop secondary fungal infections with aspergillus or mucor. 24 , 25 , 26 , 27 A review showed the prevalence of COVID‐19 associated pulmonary aspergillosis (CAPA) to be around 8.6%. Destruction of the bronchial mucosa and alveolar injury, COVID‐19 associated immune‐dysregulation, and immunosuppressive treatment is thought to create favorable conditions for fungal growth.…”

Case report: Nasopharyngeal mucormycosis, atypical presentation in a seventy-year-old diabetic lady

“…Diabetes Mellitus, neutropenia, lymphopenia, organ transplant and recently COVID-19 are the commonest predisposing factors in this type of infections [2] , [3] , [4] , [5] , [6] , [7] , [8] . Diabetes Meletus is a key factor of developing mucormycosis through three different hypotheses: 1- impaired neutrophil function, 2- decreased binding of transferrin to iron and 3- increased GRP-78.…”