Mucormycosis in COVID-19: A systematic review of literature

Mucormycosis, the Black Fungus in the Post-COVID-19 Pandemic: A Case Report with Review of Literature

Mucormycosis, a concerning and often fatal fungal infection, has shown a significant rise in cases following the COVID-19 pandemic in India, particularly affecting patients with uncontrolled comorbidities such as diabetes mellitus and other immunocompromised individuals. Our case series examines five instances of mucormycosis, supported by appropriate radiographic and histopathological evidence correlating with clinical observations. Our review indicated that patients were experiencing ailments or undergoing treatments that compromised their immune systems. We analyzed additional epidemiological data, including common infection sites, gender predispositions, and mortality rates. Treatments were tailored based on symptom severity, encompassing both surgical and medical approaches. The primary reason for the rise in cases was linked to elevated glycaemic levels and weakened immunity among post-COVID-19 patients. The report provides a detailed explanation of the factors contributing to this correlation. Our findings underscore the critical importance of timely surgical intervention and advocate for further investigation into treatment efficacy and symptom monitoring specific to mucormycosis in post-COVID-19 patients in India.

COVID-19-Associated Rhinocerebral Mucormycosis, an Incidental Finding or a Matter of Concern - Mixed-Method Systematic Review

With the advent of COVID-19, the number of patients diagnosed with mucormycosis has increased, especially in developing countries. The reason behind this increase is that COVID-19 causes hypoxia that promotes the growth of fungus. To identify the association between mucormycosis and COVID-19, in critically ill or immunocompromised COVID-19 patients. The literature included in the review was researched from October 1, 2021, to November 1, 2022, by using the Google Scholar database as the search engine. Of the 20 articles included, there were 4 case reports, 2 case series, 10 narrative reviews, and 4 quantitative studies. Mucormycetes growth is caused by several factors, including hyperglycemia owing to previously existing diabetes or excessive use of steroids, increased ferritin levels owing to the inflammatory cascade initiated by COVID-19, and immunosuppression caused by the use of steroids or other immunosuppressive therapy. Reduced white-cell count and activity in COVID-19 leads to increased germination of fungal spores hence developing a catastrophic picture of rhinocerebral mucormycosis. Considering that the hematological patient is frequently treated with cortisone, immunosuppressed due to the underlying condition, but also through the administered therapy, the association with a possible diabetes makes this patient susceptible to developing rhinocerebral mucormycosis during COVID-19 infection. Despite being severe, the association between mucormycosis and COVID-19 is specific and treatable. Development of mucormycosis in hematological patients suffering from severe COVID-19 disease is dangerous, yet not compulsory and can be prevented. Using a common steroid-dose protocol with hyperbaric oxygen and necessary preventive measure reveals the disease as a superadded infection. Hypoxia, poor glycemic control and overuse of steroids or immunosuppressive drugs cause it.

Mucormycosis: A Case Series

Mucormycosis is a potentially life-threatening invasive fungal infection caused by diverse fungal organisms in the order Mucorales. Traditional risk factors of mucormycosis include poorly controlled diabetes, hematological malignancies such as leukemia and lymphoma, and post-transplant patients, with rhino-orbito-cerebral and pulmonary mucormycosis as common manifestations. We report four cases of mucormycosis precipitated by classical as well as atypical risk factors, with common sites of infection such as pulmonary and rhino-orbital to rare manifestations such as peritoneal mucormycosis. Diagnoses were confirmed by either a histopathological sample or a positive culture. Only one patient had concomitant positive culture and histopathology results. Low culture positivity rate has delayed the diagnosis of two cases. First-line antifungal therapy was limited to amphotericin B deoxycholate in three cases due to financial cost, but all patients responded to the treatment. There were two mortalities, but both were unrelated to disease progression. All cases had source control done, except for the patient with pulmonary mucormycosis, due to poor lung reserve which refrained him from surgery. With emerging evidence of local therapies for endobronchial lesions, they potentially serve as an alternative for patients who are not suitable for operation. This case series also aims to contribute to the local epidemiology of mucormycosis, highlights the importance of early diagnosis, and draws attention from stakeholders to the challenges faced in managing this life-threatening infection.

Clinical profile, prognostic factors, and outcomes of rhino-orbital-cerebral mucormycosis in the setting of COVID-19: A retrospective study

PURPOSE

The purpose was to study the demographics, clinical and radiological presenting patterns, prognostic variables, and outcome of management of rhino-orbital-cerebral-mucormycosis (ROCM) in coronavirus disease (COVID-19) patients.

METHODS

We retrospectively analyzed COVID-19 patients with proven ROCM from April 2021 to November 2021. All included patients were given systemic antifungal therapy depending on clinical response and underwent functional endoscopic sinus surgery (FESS) with orbital wall decompression. Administration of transcutaneous retrobulbar amphotericin B (TRAMB) injection, exenteration, and maxillectomy was done when indicated as per a novel algorithm.

RESULTS

A total of 64 patients with ROCM were included in the study. The mean age of 54.5 (standard deviation [SD] - 10.6) years with a male predominance (male: female = 55:9) was observed. Pre-existing diabetes mellitus (DM) was the most common comorbid state, 47 (73.4%). The most common ophthalmic presentation was proptosis (n = 40) (62.5%). Bulky extraocular muscles (n = 64) (100%) and intraorbital fat stranding (n = 41) (64%) were the most common radiological findings. Twenty-eight patients received TRAMB, while 11 patients underwent exenteration with FESS. Our study had a mortality rate of 18.7% (n = 12). The mean glycated hemoglobin of 13.5% (SD - 1.1) and a higher serum ferritin value of 976.25 (SD - 592) were observed in the deceased group. Vision was preserved in 38 (73.7%) patients in the survived group.

CONCLUSION

ROCM has a wide array of presentations, with proptosis as the most common clinical finding. Bulky EOM and intraorbital fat stranding were the most common radiological findings. Thorough surgical debridement with systemic and local antifungal therapy results in reasonable outcomes for ROCM in COVID-19 patients. Older age, intensive care unit admissions, uncontrolled DM, central nervous system involvement, and shorter duration of antifungal treatment are poor prognostic factors associated with mortality.

Rise of mucormycosis during the COVID-19 pandemic and the challenges faced

Mucormycosis (previously called zygomycosis) is a diverse group of increasingly recognized and frequently fatal mycotic diseases caused by members of the class zygomycetes. Mucormycosis is around 80 times more common in India, compared to other developed countries, with a frequency of 0.14 cases per 1,000 population. The most frequent causative agent of mucormycosis is the following genera from the Order Mucorales Rhizopus, Mucor, Rhizomucor, Absidia, Apophysomyces, Cunninghamella, and Saksenaea. The major risk factors for the development of mucormycosis are diabetic ketoacidosis, deferoxamine treatment, cancer, solid organ or bone marrow transplantations, prolonged steroid use, extreme malnutrition, and neutropenia. The common clinical forms of mucormycosis are rhino-orbital-cerebral, pulmonary, cutaneous, and gastrointestinal. During the second wave of COVID-19, there was a rapid increase in mucormycosis with more severity than before. Amphotericin B is currently found to be an effective drug as it is found to have a broad-spectrum activity and posaconazole is used as a salvage therapy. Newer triazole isavuconazole is also found effective against mucormycosis. This study aimed to review various studies on the laboratory diagnosis and treatment of mucormycosis.

The Psychological Impact of Rhino-Orbital Mucormycosis During the Second Wave of COVID-19 Pandemic From South East Asian Country

AIM

The present study addressed overcoming the lacunae in the literature of psychiatric manifestations associated with rhino-orbital mucormycosis. The current study aimed to assess the symptoms of depression, anxiety, stress, coping measures, suicidal intent, and visual disability in patients of rhino-orbital mucormycosis (ROM) during the epidemic of the disease at the nodal tertiary care center in North India.

METHODS

Fifty-four inpatients of laboratory-proven rhino-orbital mucor-mycosis (ROM) were included for an observational, cross-sectional study at nodal, designated COVID-19, and mucormycosis treating tertiary care hospital. Patients with Hindi Mini-Mental State Examination score <24, prior psychiatric illness, and severely ill requiring ventilator support were excluded. The psychological variables were assessed using Depression, Anxiety, and Stress Scale 21 (DASS 21), Beck's Suicide intent Scale, Coping Scale Questionnaire, and Visual disability scale (IND-VFQ33). Their socioeconomic status was assessed using the Modified Kuppuswamy Scale.

RESULTS

Ninety percent of patients with ROM had diabetes mellitus. The majority (44%) of patients belonged to lower socioeconomic strata. Higher frequencies of severe depression (28%), extremely severe anxiety (26%), and mild stress (17%) were noted in the study participants. On the Tukey test, depression score was higher in patients of ROM compared to COVID (with ROM) (p-value= 0.016). On Tukey analysis, anxiety score was significantly higher in ROM patients compared to COVID (with ROM) patients (p-value = 0.018). Coping scores were significantly higher in COVID (with ROM) patients compared to ROM patients (p value = 0.035). Mild to moderate visual disability was noted in the study participants.  Conclusion: The current study reflects the association of higher depression and anxiety scores in cases with ROM that indicated higher mental health needs. Early assessment, early detection, and early intervention for psychological help, along with the multidisciplinary team, helped to improve the overall psychological outcome of the affected patients.

Vitamin A Deficiency, COVID-19, and Rhino-Orbital Mucormycosis (Black Fungus): An Analytical Perspective

Mucormycosis is a rare but serious opportunistic fungal disease characterized by rhino-orbito-cerebral and pulmonary involvement. It is mainly seen in people with secondary immunosuppression, isolated vitamin A deficiency, measles, and AIDS patients. It showed a rise during the second wave of the COVID-19 epidemic in the spring of 2021 in India, especially in diabetic COVID-19 patients. Vitamin A deficiency is known to cause nutritional immunodeficiency and hence leading the way to increased opportunistic fungal, bacterial, and viral infections. In the eye, it causes keratitis, night blindness, xerophthalmia, conjunctivitis, Bitot spots, keratomalacia, and retinopathy. It also causes decreased tear secretion and deterioration of the anatomical/physiological defense barrier of the eye. The negative impact of vitamin A deficiency has been previously demonstrated in measles, AIDS, and COVID-19. We think that mucormycosis in COVID-19 might be rendered by vitamin A deficiency and that vitamin A supplementation may have preventive and therapeutic values against mucormycosis and other ocular symptoms associated with COVID-19. However, any vitamin A treatment regimen needs to be based on laboratory and clinical data and supervised by medical professionals.

Cavernous Sinus Thrombosis Linked to COVID-19 Infection: a Case Report

The severity of SARS-CoV-2 virus infection is mainly related to its respiratory complications. However, it can also lead to a large variety of thromboembolic events. Symptoms may include headache, fever, and neurological disorders. Since 2020, the clinical presentation of COVID-19 infection has become increasingly varied, leading in some cases to complex symptom associations, including numerous neurological symptoms. SARS-CoV-2 may lead to neurotropism which could reach the central nervous system and all cranial nerves. Cavernous sinus thrombosis is a rare condition and may occur as a complication of ear, nose, and throat (ENT) or facial infections. A 73-year-old man without personal or family history of thrombosis was referred to the emergency room for a sudden appearance of diplopia and ptosis, 3 days after testing positive for COVID-19 infection. An initial head CT-scan found no signs of stroke. He underwent a cerebral MRI 7 days later, which revealed a thrombosis of his right cavernous sinus. A brain CT scan 7 days later showed regression of the thrombosis with complete recanalization of the cavernous sinus. This was accompanied by a complete regression of diplopia and fever. He was discharged from the hospital 10 days after hospital admission. In this case report, we describe a rare event of cavernous thrombophlebitis following a COVID-19 infection.

Rhino-orbito-cerebral mucormycosis in an acute lymphoblastic leukemia pediatric patient. Case report and review of literature

Mucormycosis is a disease caused by opportunistic fungi of the order Mucorales that generally affects immunocompromised patients or those with underlying disease. It has a high mortality rate and is the third most common invasive fungal infection. The following is a case report of a 12-year-old pediatric patient diagnosed with B-cell acute lymphoblastic leukemia, who presented an aggressive infectious disease two months after beginning chemotherapy, which began in the right frontal and maxillary sinuses, with subsequent progression and extension, progressively deteriorating the patient's clinical status. Culture and biopsy of the affected areas were performed, confirming by histopathology and isolation a rhino-orbito-cerebral mucormycosis due to Actinomucor elegans. The patient was treated with specific antifungal therapy as an inpatient and left the service after obtaining negative cultures, continuing with outpatient antifungal treatment.

Gingival presentation of mucormycosis post infection with COVID-19: series of 3 cases

Through the evolution of this global pandemic, it became increasingly clear that patients with pre-existing conditions such as diabetes mellitus, chronic kidney diseases (CKD), chronic cardiovascular disease, underlying malignancies, organ transplant recipients, and chronic liver disease are at increased risk for developing severe post COVID-19 complications. One such complication seen after COVID-19 is mucormycosis. Oral mucormycosis is a rare but highly fatal disease. Early diagnosis and timely treatment of rhinomaxillary mucormycosis are necessary to limit the spread of infection, which otherwise can lead to high morbidity and mortality. Dental healthcare practitioners should be familiar with its initial presentation, which if left undiagnosed or ignored can rapidly spread to the orbital and cerebral region leading to death. The case series describes the gingival clinical presentation in its initial stage, relevant basic clinical investigations, treatment, and the importance of an inter-professional team approach in the early management of patients with mucormycosis after post covid-19 infection.

Risk factors and outcomes of fungal superinfections in patients with severe COVID-19: an observational study from Pisa academic hospital

Background

Superinfections acquired during the hospital course represent common complications in COVID-19 patients. Several studies reported an increasing incidence of COVID-19 associated pulmonary aspergillosis (CAPA) and candidaemia. The aim of this study is to describe fungal superinfections in a large cohort of hospitalized patients with COVID-19 and identify factors independently associated with the risk of fungal superinfections.

Methods

Observational study including patients with COVID-19 admitted to the tertiary-care, University Hospital of Pisa, Italy from April 2020 to May 2021. Patients with pneumonia and laboratory confirmed SARS-CoV-2 infection with a RT-PCR test on a nasopharyngeal swab, were eligible for the study. Patients who died within 24 hours from admission and those with missing data were excluded. Data about fungal superinfections were collected. To identify factors independently associated with the development of fungal superinfections, a multivariate regression analysis was performed.

Results

Among 983 patients with COVID-19, 52 (5.3%) fungal superinfections were detected. Fungal superinfections included: 24/52 (46%) CAPA, 27/52 (51.9%) episodes of candidaemia and 1 case of pulmonary pneumocystosis in a haematological patient. All patients with CAPA were cared for in intensive care unit (ICU). The majority of patients received liposomal amphotericin B as antifungal treatment (83.3%). In-hospital mortality was 41.7%. Among 27 episodes of candidaemia, 16 (59.3%) occurred in ICU while 11 (40.7%) in medical wards. In-hospital mortality was 14.8%. Overall, patients with fungal superinfections had a median age of 73 (IQRs 59-77) years and a median length of ICU stay of 40 (17-50) days. In-hospital mortality among all patients with superinfections was 28.8%. On multivariable analysis, ICU stay (OR 17.63, 95% CI 8.3-37.41, p<0.001), high-dose steroids (OR 13.48, 95% CI 6.68-27.26, p<0.001), and diabetes mellitus (OR 2.14, 95% CI 1.09-4.17, p=0.026) were factors independently associated with the risk of developing a fungal superinfection.

Conclusions

Fungal superinfections may complicate the hospital course of COVID-19 patients, especially of those admitted to ICU. Surveillance with detection of galactomannan on bronchoalveolar lavage in patients with clinical deterioration should be performed. A rational use of steroids is essential to avoid the risk of developing a fungal superinfection.