COVID-19-associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic's second wave in India.

Jesil Mathew Aranjani,Habeeb Ibrahim Abdul Razack,Atulya Manuel,Sam T Mathew,Susanna Kar Pui Lau

doi:10.1371/journal.pntd.0009921

Abstract

Coronavirus Disease 2019 (COVID-19), during the second wave in early 2021, has caused devastating chaos in India. As daily infection rates rise alarmingly, the number of severe cases has increased dramatically. The country has encountered health infrastructure inadequacy and excessive demand for hospital beds, drugs, vaccines, and oxygen. Adding more burden to such a challenging situation, mucormycosis, an invasive fungal infection, has seen a sudden surge in patients with COVID-19. The rhino-orbital-cerebral form is the most common type observed. In particular, approximately three-fourths of them had diabetes as predisposing comorbidity and received corticosteroids to treat COVID-19. Possible mechanisms may involve immune and inflammatory processes. Diabetes, when coupled with COVID-19–induced systemic immune change, tends to cause decreased immunity and an increased risk of secondary infections. Since comprehensive data on this fatal opportunistic infection are evolving against the backdrop of a major pandemic, prevention strategies primarily involve managing comorbid conditions in high-risk groups. The recommended treatment strategies primarily included surgical debridement and antifungal therapy using Amphotericin B and selected azoles. Several India-centric clinical guidelines have emerged to rightly diagnose the infection, characterise the clinical presentation, understand the pathogenesis involved, and track the disease course. Code Mucor is the most comprehensive one, which proposes a simple but reliable staging system for the rhino-orbital-cerebral form. A staging system has recently been proposed, and a dedicated registry has been started. In this critical review, we extensively analyse recent evidence and guidance on COVID-19–associated mucormycosis in India.

Highlights

India reported 31 million cases of Coronavirus Disease 2019 (COVID-19) as of July 17, 2021, trailing only behind the United States (US) with about 3 million cases [1]
We reviewed the official websites of professional societies like the “Indian Medical Association” and governmental portals like the “Directorate General of Health Services–India” before the said date for any essential treatment and management guidelines
There are 3 possible theories for COVID-19–associated mucormycosis (CAM) related to immune and inflammatory processes: (1) COVID-19 causes significant lymphopenia, resulting in a dramatic reduction in the availability of T cells (CD4+ and CD8+) and opening the entry gate for opportunistic fungal infections; (2) increased pro-inflammatory markers in patients with severe disease; and (3) pronounced damage of pulmonary tissues by COVID-19 aids the invasive fungi, especially the airborne ones or those that attack through the respiratory system [47,48]

Summary

Introduction

India reported 31 million cases of Coronavirus Disease 2019 (COVID-19) as of July 17, 2021, trailing only behind the United States (US) with about 3 million cases [1]. The common COVID-19 manifestations, as observed in a study of over 136,000 cases during the initial months of infection spread in India, included high fever (88%), dry cough (67.7%), fatigue (38.1%), dyspnoea (18.6%), and muscle pain (14.8%), while 7.1% patients were asymptomatic [9].

Results

Conclusion