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| CONCEPT AND ISSUE |
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| Year : 2021 | Volume
: 22
| Issue : 2 | Page : 123-126 |
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Mucormycosis in COVID-19 patients: A review
Khina Sharma1, Jyoti2, Ramandeep Kaur1
1 Tutor, College of nursing Government Medical College and Hospital, Chandigarh, India
2 Principal, College of nursing Government Medical College and Hospital, Chandigarh, India
| Date of Submission | 31-Aug-2021 |
| Date of Decision | 05-Jan-2022 |
| Date of Acceptance | 06-Jan-2022 |
| Date of Web Publication | 31-Jan-2022 |
Correspondence Address:
Mrs. Khina Sharma
Government Medical College and Hospital, Chandigarh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijcn.ijcn_87_21
Mucormycosis is a rare but invasive, fungal infection mainly found in immunocompromised patients, which occurs due to the fungi mucormycetes. It is a rapidly occurring fungal infection with a high mortality rate. Although rare, the cases of mucormycosis have been raised abnormally in COVID-19 patients in India during second wave, in which a severe rise in COVID-19 cases was reported. Many states of India have already declared it as an epidemic, and the sad part is that the medication to treat it is running low. Mucormycosis has been reported in COVID-19-positive patients at any time after COVID-19 infection, either during hospitalisation or several days to weeks after discharge.
Keywords: COVID-19, fungal infection, mucormycosis
How to cite this article:
Sharma K, Jyoti, Kaur R. Mucormycosis in COVID-19 patients: A review. Indian J Cont Nsg Edn 2021;22:123-6 |
| Introduction | |  |
COVID-19 is a highly infectious respiratory infection which has caused health concerns all over the world, and it hence declared as pandemic by the World Health Organisation in March 11, 2020.[1] Globally, as of 6 June 2021, there have been 172,630,637 confirmed cases of COVID-19, including 3,718,683 deaths, reported to World Health Organisation.[2] Alone in India, 28,909,975 total cases have been reported till 7 June 2021, of these patients, 1,401,609 patients are still having active disease and 349186 deaths are reported, which accounts for 1.21% mortality due to COVID-19. Various types of COVID-19 vaccines are being administered to people all over the world, which is able to reduce the number of infected individuals as well as severity of the disease. In India, 232,786,482 individuals have received vaccination as of 7 June 2021.[3] This large number indicates that slowly India is going to win the battle against deadly coronavirus disease. However, a new danger has been emerged amongst COVID-19 patients in India, mucormycosis, popularly known as “black fungus.” COVID-19 has led to a surge in cases of this potentially fatal fungal infection. Mucormycosis or black fungus is now an epidemic within the larger pandemic.[4]
The term mucormycosis was first given by the American pathologist R. D. Baker. It is also called zygomycosis. Mucormycosis is defined as an insidious fungal infection caused by members of Mucorales and zygomycotic species.[5]
| Current Outbreak of Mucormycosis during COVID-19 Pandemic in India | | |
Mucormycosis is a rare but potentially serious fungal infection caused by mold called mucormycetes. Although India is the mucormycosis capital of the world, more than 10,000 cases in <2 months have shocked the health community. Till 25 May, India had registered over 11,700 black fungus cases, with the maximum cases being reported in Gujarat and Maharashtra.[6]
The spike of mucormycosis patients at present appears to be the fallout of inappropriate COVID-19 treatment or overuse of steroids, a life-saving treatment for severely ill COVID-19 patients. Steroids such as dexamethasone and methylprednisolone used to reduce the exaggerated inflammatory response to the coronavirus appear to be the primary trigger, with a high prevalence of diabetes making it worse.[7] According to the ICMR, the fungus thrives on high blood glucose, making COVID-19 patients with uncontrolled diabetes vulnerable to fungal infection. It is also reported that inadequate infection control in hospitals also risks exposing COVID patients to secondary bacterial and fungal infections.[8]
| Prevalence | | |
Even before the pandemic, the prevalence of mucormycosis may have been about 70 times higher in India than the overall figure for the rest of the world. There was an increasing trend of mucormycosis from a single centre at successive periods, with an annual incidence of 12.9 cases per year during 1990–1999, 35.6 cases per year during 2000–2004 and 50 cases per year during 2006–2007. The overall numbers increased from 25 cases/year (1990–2007) to 89 cases/year (2013–2015). A multicentre study across India reported 465 cases from 12 centres over 21 months; the study reported an annual incidence of 22 cases/year and an average of 38.8 cases for each participating centre.[9]
| Risk Factors for Mucormycosis amongst COVID-19 Patients | | |
Mucormycosis is an invasive fungal infection, occurs by mucormycetes fungus. It is rarely seen in healthy individuals. Human body is not the usual habitat of this fungus; however, it can enter the body through inhalation or skin injuries and can present in the nose and mucus of healthy individuals. These organisms are found in abundance in a country such as India and particularly in soil and decaying organic matter such as fruits and vegetables. A normally functioning immune system typically fights it off. It is frequently seen in events where the immune system is suppressed such as uncontrolled diabetes, haematological malignancy, immunosuppressive and corticosteroid therapy.[4],[7],[10]
| Possible Routes of Transmission of Mucormycosis during Hospitalisation | | |
Published evidence points to several potential sources of the infection in hospitals, but it does not mention oxygen tanks, humidifiers or face masks. Two studies published in 2014 and 2016 implicate hospital linens from poorly managed laundries as a source. In 2009, a review of research into hospital outbreaks identified ventilation systems, adhesive bandages, wooden tongue depressors and ostomy bags as other possible sources of this fungal infection. Pathologists also report that another possible transmission route is the inhalation of spores in dust from nearby building works, or contaminated air-conditioning filters. They also focused on the importance of infection through the skin, for example, through burns, needle-stick injuries, catheter insertion sites, insect bites and stings.[11]
| Pathogenesis and Clinical Symptoms | | |
Mucormycosis can affect various body organs. Currently, it is manifesting as an invasive rhino-orbito-cerebral disease in COVID patients, affecting nose, eye, throat, ear, mouth, lungs and brain. The infection is commonly known as a black fungus because it obstructs blood flow to affecting tissue, which kills infected tissue and this necrotic tissue that causes the characteristic black discoloration of the patient's tissue, rather than the fungus itself.[7],[10],[11]
The most common clinical manifestations are rhinocerebral, pulmonary and cutaneous involvement. The area of involvement can be affected by the underlying condition. While rhinocerebral involvement is reported in diabetic patients, rhinocerebral and pulmonary involvement is seen in patients with neutropenia due to bone marrow transplantation and leukaemia. Contamination follows the inhalation route. The phagocytic cells of a healthy individual can destroy the spores of the inhaled fungus, but in patients with low immunity such as patients on immunosuppressants, patients having tumour, diabetic patients or patients who are prolonged hospitalised, the spores can infect the vascular endothelium by invasion. Warning signs of the mucormycosis in COVID patients include pain and redness around the face and particular around eyes or nose, with headache, fever, coughing, shortness of breath, haematemesis and altered mental status.[10],[11],[12]
According to the experts, infection with mucormycetes should be suspected when there is sinusitis; local pain on the cheek bone, one-sided facial pain, numbness or swelling; blackish discoloration over bridge of nose/palate; teeth loosening and blurred/double vision with pain; thrombosis, necrosis and skin lesion and chest pain, pleural effusion and worsening of respiratory symptoms. Experts advise that one should not count all cases of blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators. Experts emphasise not to hesitate to seek aggressive investigations for detecting fungal infection, they advise.[8]
| Treatment Modalities for Mucormycosis | | |
It is essential to control blood glucose level as well as diabetic ketoacidosis in vulnerable patients. One should use steroids and immunomodulators judiciously; correct dose, correct timing and duration are essential. First line of treatment of mucormycosis includes antifungals. However, some patients may eventually require surgery. Experts have said that it is of prime importance to control diabetes, reduce steroid use and discontinue immunomodulators. To maintain adequate systemic hydration, the treatment includes infusion of intravenous normal saline before infusion of amphotericin B and antifungal therapy, for at least 4–6 weeks. Experts stressed the need to control hyperglycaemia, and monitor blood glucose level after discharge following COVID-19 treatment, and also in diabetics. If the infection is severe, extensive debridement with removal of the affected tissue is done. Patients need to be monitored clinically and with radio imaging for response and to detect disease progression. Management of COVID-19 patients with mucormycosis is a team effort involving internal medicine specialists, microbiologists, intensivist, neurologist, ENT specialists, ophthalmologists, dentists, surgeons (maxillofacial/plastic), specialised nurses and others.[8],[9],[10],[11],[12],[13]
| Prevention of Mucormycosis | | |
According to the ICMR, the preventive guidelines to be considered in COVID-19 patients include controlling hyperglycaemia, monitoring blood glucose levels in active and post-COVID-19 patients and in diabetics, using steroids judiciously. It is also advised by the experts to use clean and sterile water for humidifiers during oxygen therapy. Healthcare providers and patients are instructed to not miss the sign and symptoms of the disease. All the cases with blocked nose should not be considered as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators. It is advised to not hesitate to seek aggressive investigations, as appropriate (KOH staining and microscopy, culture, MALDI-TOF), for detecting fungal aetiology. Crucial time to initiate treatment for mucormycosis should not be lost. Precautions to be follow by the general population include: use masks, wear shoes and gloves while handling soil (gardening), moss or manure and maintain personal hygiene.[4],[8],[9],[10],[11],[12],[13],[14]
| Prognosis of Mucormycosis | | |
The prognosis largely depends on the disease progression and subsequent treatment given in response to the diseases. Early stage of mucormycosis can be treated completed with antifungal drugs as well as supportive treatment. In extensive cases, surgery can lead to loss of the upper jaw and sometimes even the eye. Patients may experience difficulties such as difficulty with chewing, swallowing, blindness, facial aesthetics and loss of self-esteem. Be it the eye or upper jaw, these can be replaced with appropriate artificial substitutes or prostheses. While prosthetic replacement of the missing facial structures can commence once the patient stabilises after surgery, it is necessary to reassure the patient about the availability of such inventions instead of leaving the patient to panic with the sudden unforeseen loss, augmenting a post-COVID stress disorder which is already a reality. Prosthetic reconstruction can be achieved after surgery, but provisional solutions should be planned even before surgery for better long-term outcomes. Prosthetic reconstruction can ensure a patient that the cure is not more dreadful than the disease itself.[5],[15]
| Mortality Due to Mucormycosis | | |
Mucormycosis has an overall mortality rate of 50%. According to the literature, survival rate varies with foci of the fungal infection: Sinusitis without cerebral involvement –87%, rhino cerebral mucormycosis –45%, focal cerebral mucormycosis – 33%, pulmonary forms –36%, cutaneous isolated –90%, disseminated disease –16% and involvement of gastrointestinal form–10%. Better survival rate can be seen in patients with low baseline serum concentration of iron/ferritin, neutropenia, control of blood glucose and malignant cases which is not associated with infection.[16]
| Conclusion | | |
During current COVID-19 pandemic situation, mucormycosis has emerged as a life-threatening fungal infection amongst these patients. Although the mucormycosis is a rare infection, the cases of superinfection in COVID-19 patients are reported from many health centres all over India. Its manifestation can be very aggressive and having an alarming mortality rate if not treated in adequate time. Therefore, keeping its high mortality rate in consideration, it is necessary to follow appropriate COVID-19 treatment guidelines including appropriate use of steroids, control of blood glucose levels and early diagnosis and prompt treatment including use of antifungals, once diagnosed, along with surgical management, if required. With preventive guidelines, early intervention with surgical debridement and therapeutic use of antifungal drugs, mortality associated with this deadly disease can also be improved.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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