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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 72-76

Mucormycosis in patients with COVID-19: A descriptive study at a tertiary care hospital in North Maharashtra


Department of Community Medicine, Government Medical College, Jalgaon, Maharashtra, India

Date of Submission28-Aug-2021
Date of Acceptance17-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Jitendra Bhaskar Surwade
Department of Community Medicine, Government Medical College, Jalgaon 425001, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_65_21

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  Abstract 

Introduction: 2019 novel coronavirus (2019-nCoV) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first reported in Wuhan, in China, rapidly spread to other parts of the world forming a global pandemic. Secondary fungal or bacterial infections or coinfections are important challenges increasing the patients’ morbidity and mortality in COVID infection patients. The coronavirus disease-2019 (COVID-19) pandemic has led to increases in the cases of mucormycosis in India; rhino-orbito-cerebral mucormycosis is considered the most common type of mucormycosis, which is acquired by inhaling fungal spores in the paranasal sinuses. Objectives: The aims of this study were to assess the clinical and demographic profile of the patient with mucormycosis admitted to Government Medical College, Jalgaon and to identify the risk factors observed in the admitted patient with mucormycosis. Materials and Methods: The cross-sectional descriptive study was conducted among the patients admitted for the treatment of mucormycosis in Government Medical College and Hospital, Jalgaon, Maharashtra. A total of 91 patients admitted from April 15, 2021 to June 15, 2021 were enrolled as study participants. Result: More than half of the study participants were having complaints of swelling and pain over the cheek and face at the time of admission, whereas 20% were having pain in the nose, growth/swelling, and discharge from nose followed by toothache and loss of teeth in 13% of the study participants. More than 50% of patients were diabetic and 91% have a history of steroid use for the treatment of COVID-19. 57% of the study participants were having a history of diabetes. Conclusion: The physician should be more attentive for mucormycosis among the post-COVID-19 patients with diabetes patients and/or presenting with pain in the facial or orbital region or blackish or bloody nasal discharge.

Keywords: Diabetes mellitus, mucormycosis, post-COVID, steroid


How to cite this article:
Lokhande GS, Bavaskar YG, Malkar VR, Ramanand J, Surwade JB, Saji DA, Suryawanshi S. Mucormycosis in patients with COVID-19: A descriptive study at a tertiary care hospital in North Maharashtra. MGM J Med Sci 2022;9:72-6

How to cite this URL:
Lokhande GS, Bavaskar YG, Malkar VR, Ramanand J, Surwade JB, Saji DA, Suryawanshi S. Mucormycosis in patients with COVID-19: A descriptive study at a tertiary care hospital in North Maharashtra. MGM J Med Sci [serial online] 2022 [cited 2022 May 17];9:72-6. Available from: http://www.mgmjms.com/text.asp?2022/9/1/72/340589




  Introduction Top


2019 novel coronavirus (2019-nCoV) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first reported first in Wuhan, China, rapidly spread to other countries of the world forming pandemic.[1] The disease pattern of coronavirus disease-2019 (COVID-19) ranges from mild pneumonia to life-threatening pneumonia associated with coinfection by bacteria and fungi.[2] The presence of associated comorbidities like chronic obstructive pulmonary disease (COPD), diabetes, and immunodeficient conditions made these patients more prone to develop opportunities for infection. Due to the associated co-morbidities (e.g., diabetes mellitus, COPD) and immunocompromised conditions (e.g., corticosteroid therapy, ventilation, and intensive care unit [ICU] stay), these patients are prone to develop severe opportunistic infections.

Secondary fungal or bacterial infections or coinfections are important challenges increasing the patients’ morbidity and mortality.[3] The COVID-19 pandemic has led to increases in the cases of mucormycosis in India. Mucormycosis, candidiasis, and pulmonary aspergillosis have been common fungal infections that were reported as superinfections in patients with COVID-19.[4] Rhino-orbito-cerebral mucormycosis is observed to be the most common form of mucormycosis which is acquired by inhaling spores of fungal into the paranasal sinuses. On the contrary, the use of corticosteroids for modulating immune-related lung injury and reducing the mortality rate in patients with COVID-19, that need respiratory supports and supplementary oxygen,[3] may predispose the patients to secondary infections that increase the risk of mortality.[5] COVID-19 has the potential to cause severe lung disease and subsequent damage to alveolar interstitial tissue. This may predispose patients to opportunistic fungal infection of the airways including sinuses. COVID-19-associated immune dysregulation leads to alteration in innate immunity characterized by a decrease in the number of T cells including both CD4 and CD8 cells.[6]

Objectives

  1. To assess the clinical and demographic profile of the patient with mucormycosis admitted to Government Medical College, Jalgaon.


  2. To identify the risk factors observed in the admitted patient with mucormycosis.



  Materials and methods Top


A cross-sectional descriptive study was conducted among the patients admitted for the treatment of mucormycosis in a government tertiary care hospital in Northern Maharashtra. A total of 91 patients admitted from April 15, 2021 to June 15, 2021 were enrolled as study participants. Data were collected in two parts; information regarding COVID-19 history, treatment of COVID-19, duration of treatment, the need for oxygen, ICU admission and need for a ventilator, and vaccination status were collected by using pretested and predesigned questionnaires.

The following information was extracted from the available record of the patient: demographic characteristics; associated comorbidity, such as diabetes, leukemia, organ transplantation and others; period since diagnosis of COVID-19, site of lesion, method used for diagnosis of mucormycosis, treatment received including antifungal medicines and surgical procedure. Patients with confirmed diagnoses by microscopy or histopathology were included in the study.

The purpose of the study was explained to the study participants. Only after their written consent patients were enrolled in the study. Institutional ethics committee permission was taken before the beginning of the study. Confidentiality of the information was ensured.

Definitions of study parameter

A confirmed case of mucormycosis was identified after observing fungi in the sterile body fluids or tissue of a patient by microscopic visualization of broad ribbon-like aseptate hyphae.

Sample processing

Tissue biopsies from the affected site were used for conventional microscopy and histopathology. Potassium hydroxide was used for processing the tissue before microscopic examination. The tissue from the affected site was inoculated on 2 sets of Sabouraud Dextrose Agar and incubated at 25°C and 37°C. Based on macroscopic characteristics positive cultures were identified. Hematoxylin or Gomori methenamine silver stain was used for histopathological examination of the tissue sample.

Statistical methods

Data were entered in MS Excel. Percentages and mean were calculated for the parameters studied.


  Results Top


During the study period, a total of 1577 patients with COVID-19 and 91 patients with mucormycosis were admitted, diagnosed, and treated at the tertiary care Hospital. The mean age of the patient was 52.47 years (standard deviation [SD] 12.84 years), with a minimum age of 26 and maximum age of 83 years. [Table 1] shows more than 80% of the study participants were in the age group of 31–70 years. Of the total study participants, 56 (61.34%) were males and 35 (38.46%) were female participants. Among the patients admitted for the treatment of mucormycosis, 84 (92.30%) were having a history of COVID-19 infection. More than half of the study participants were having complaints of swelling and pain over check and face at the time of admission, whereas 20% were having pain in the nose, some growth/swelling and discharge from nose followed by toothache and loss of teeth in 13% of the study participants.
Table 1: Distribution of patients as per clinicodemographic parameters

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Of the total study participants with mucormycosis, more than 50% were diabetic. Seventy-three (80.22%) of the study participants admitted with mucormycosis had received O2 therapy for the treatment of COVID-19. It was observed that 38(52.05%) of the study participants received O2 therapy for less than 7 days and 33 (45.21%) of the study participants received treatment for 7–14 days. Of the total study participants with mucormycosis, only 9.89% needed ICU admission. More than 90% of the study participants had a history of steroid use for the treatment of COVID-19. It was observed that 64 (77.11%) study participants used steroids for COVID-19 treatment for 7–14 days, whereas 17 (20.48%) study participants used steroids for less than 7 days.

[Table 2] shows only 7 (7.69%) of the study participants had received both doses of the vaccine, 14 (15.38%) participants received only a single dose, while 70 (76.92%) participants not received even a single dose of vaccine. Positive KOH report was observed in 52 (57.14%) of the patients who participated in the study. Out of 91 patients admitted to the hospital, 35 (38.46%) were discharged, 22 (24.18%) referred to a higher center for further management, 2 (2.19%) died due to mucormycosis and 16 (17.58%) patients died due to post-COVID-19 complications and remaining 16 (17.58%) were under treatment at the time of the study. Liposomal amphotericin B was the most used antifungal agent. Twenty-two patients needed major resection of affected site and rest of the cases underwent functional endoscopic sinus surgery (FESS).
Table 2: Distribution of study participants as per studied parameters

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Thus, underlying risk factors observed in patients with mucormycosis were history of diabetes mellitus (57.14%), use of steroids (91.21%), oxygen therapy in (80.22%), and longer duration of steroid use, that is, 714 days in (77.11%).


  Discussion Top


This study was conducted to assess the clinical and demographic profile of the patient and to identify underlining risk factors in the patients admitted with mucormycosis at tertiary care hospitals. Management of patients with mucormycosis requires a multimodal approach, which includes discontinuation of factors resulting in the immunocompromised state, reversal of predisposing factors, and early treatment with active antifungal agents and surgical procedures to remove all infected tissues.[7]

In this study, more than 80% of the patients were in the age group of 31–70 years. Male predominance was observed in this study. Of the total patients, 56 (61.34%) were males and 35 (38.46%) were females. The mean age of patients involved in this study was 52.47 ± 12.84 years. The minimum and maximum age of the study participants was 26 and 83 years, respectively. A study conducted by Patel et al.[8] observed that the median age of the study participants was 48 years and 69.5% of participants affected by mucormycosis were men. A multicentric study conducted by Sen et al.[9] observed that the mean age of the study participants was 51.9 years and 71% of the male with mucormycosis participated in the study. A study conducted by Gupta[10] revealed that the mean age of the study participants was 50 years and sex-wise distribution shows slight male preponderance with the ratio of male–female 2.5:1.

The most common complaint among the study participants was swelling and pain over check and face at the time of admission, whereas 20% were having pain in the nose, some growth/swelling, and discharge from the nose followed by toothache and loss of teeth in 13% of the study participants. Ludhar and Nilakhe[7] observed that 62.5% of patients presented with nasal discharge, whereas all the patients were having nasal crusting in their study.

Among the patients admitted for the treatment of mucormycosis, 84 (92.30%) were having a history of COVID-19 infection, and the remaining 7 (7.70%) may be having a subclinical infection. Among 91 patients admitted for treatment of mucormycosis 52 (57%) were diabetic. In contrast to the findings in this study, John et al.[11] observed that 94% of the participants with mucormycosis were diabetic. In 73.5% of cases with mucormycosis, diabetes was observed as a risk factor in India.[7] A multicentric study conducted by Sen et al.[9] observed that 78% of the participants with mucormycosis were having diabetes. 77% of the study participants with mucormycosis were diabetic in the study conducted by Priya et al.[12] COVID-19 cases with a history of diabetes are at increased risk of developing the severe disease and these cases are also at higher risk of fungal infections.[13] Globally diabetes mellitus is identified as the leading underlying comorbidity in cases diagnosed with mucormycosis.[14] In addition, to a decrease in the immune response to microorganisms phagocytic activity of immune cells is decreased in patients with diabetes which favors fungal proliferation.73 (80.22%) of the study participants admitted with mucormycosis had received O2 therapy for the treatment of COVID-19.[15] A multicentric study conducted by Sen et al.[9] observed that 79% of the patients with mucormycosis received O2 therapy for the treatment of COVID-19. In this study, 38(52.05%) of the study participants received O2 therapy for less than 7 days and 33 (45.21%) of the study participants received treatment for 7–14 days.

Of the total study participants with mucormycosis, only 9.89% needed ICU admission. In contrast to our study ICU admission was required in 68% of the patients in the study conducted by John et al.[11]

More than 90% of the study participants had a history of steroid use for the treatment of COVID-19. A study conducted by Sen et al.[9] revealed a history of use of steroids in 87% of patients admitted with mucormycosis. Use of corticosteroids was observed in 88% of the study participants with mucormycosis in the study conducted by John et al.[11] There are reports of mucormycosis related to short courses of corticosteroids.[16] Patients receiving systemic steroids are at increased risk of fungal rhinosinusitis.[17] Sixty-four (77.11%) study participants used steroids for COVID-19 treatment for 7–14 days, whereas 17 (20.48%) study participants used steroids for less than 7 days.

Liposomal amphotericin B was the most used antifungal agent for medical management. Surgical resection of the affected site was done in twenty-two cases and FESS was done in 11 cases.


  Conclusion Top


Mucormycosis is one of the complications observed in patients with COVID-19 in the later stage of the disease. History of diabetes, use of corticosteroid, duration of use of corticosteroid, and oxygen therapy during the treatment of COVID-19 were risk factors observed in the patients with mucormycosis. Physicians should be more attentive for mucormycosis among the post-COVID-19 patients with diabetes and/or presenting with pain in the facial or orbital region or blackish or bloody nasal discharge.

Limitations

No comparison group was included, and the study was conducted in a single institute.

Ethical policy and institutional review board statement

The study protocol was reviewed and approved by the Institutional Ethics Committee of Government Medical College, Jalgaon, Maharashtra, India vide approval letter no. GMC/IFC Approval/51/2021 dated June 2, 2021.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Mehta S, Pandey A Rhino-orbital mucormycosis associated with COVID-19. Cureus 2020;12:e10726.  Back to cited text no. 2
    
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Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 3
    
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Hughes S, Troise O, Donaldson H, Mughal N, Moore LSP Bacterial and fungal coinfection among hospitalized patients with COVID-19: A retrospective cohort study in a UK secondary-care setting. Clin Microbiol Infect 2020;26:1395-9.  Back to cited text no. 4
    
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Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, et al; RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med 2021;384:693-704.  Back to cited text no. 5
    
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Sarkar S, Gokhale T, Choudhury SS, Deb AK COVID-19 and orbital mucormycosis. Indian J Ophthalmol 2021;69:1002-4.  Back to cited text no. 6
    
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Ludhar A, Nilakhe SS Study of mucormycosis patients attending tertiary care hospital: A retrospective study. Int J Res Med Sci 2019;7:1622-5.  Back to cited text no. 7
    
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Patel A, Kaur H, Xess I, Michael JS, Savio J, Rudramurthy S, et al. Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India. Clin Microbiol Infect 2020;26:944.e9-944.e15.  Back to cited text no. 8
    
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Sen M, Honavar SG, Bansal R, Sengupta S, Rao R, Kim U, et al; Members of the Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC) Study Group. Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India: Collaborative OPAI-IJO study on mucormycosis in COVID-19 (COSMIC), report 1. Indian J Ophthalmol 2021;69:1670-92.  Back to cited text no. 9
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Gupta SK Clinical profile of mucormycosis: A descriptive analysis. Int J Sci Stud 2017;5:160-3.  Back to cited text no. 10
    
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John TM, Jacob CN, Kontoyiannis DP When uncontrolled diabetes mellitus and severe COVID-19 converge: The perfect storm for mucormycosis. J Fungi (Basel) 2021;7:298.  Back to cited text no. 11
    
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Priya P, Ganesan V, Rajendran T, Geni VG Mucormycosis in a tertiary care center in south India: A 4-year experience. Indian J Crit Care Med 2020;24:168-71.  Back to cited text no. 12
    
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Huang I, Lim MA, Pranata R Diabetes mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis, and meta-regression. Diabetes Metab Syndr 2020;14:395-403.  Back to cited text no. 13
    
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Jeong W, Keighley C, Wolfe R, Lee WL, Slavin MA, Kong DCM, et al. The epidemiology and clinical manifestations of mucormycosis: A systematic review and meta-analysis of case reports. Clin Microbiol Infect 2019;25:26-34.  Back to cited text no. 14
    
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Hoang K, Abdo T, Reinersman JM, Lu R, Higuita NIA A case of invasive pulmonary mucormycosis resulting from short courses of corticosteroids in a well-controlled diabetic patient. Med Mycol Case Rep 2020;29:22-4.  Back to cited text no. 16
    
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Donnelly JP, Chen SC, Kauffman CA, Steinbach WJ, Baddley JW, Verweij PE, et al. Revision and update of the consensus definitions of invasive fungal disease from the European organization for research and treatment of cancer and the mycoses study group education and research consortium. Clin Infect Dis 2020;71:1367-76.  Back to cited text no. 17
    



 
 
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