Unravelling the Knots between Uncontrolled Diabetes, Corticosteroids and SARS-CoV-2 in the Rising Incidence of “Deadlier” Mucormycosis

Abstract

The second wave of COVID-19 in early 2021 has caused havoc across the globe and despite a bit flattening curve of SARS-CoV-2 cases in India, another fatal complication known as CAM created chaos in the whole country. An alarmingly high increase in the number of cases led to the healthcare infrastructure inadequacy due to excessive demand for hospital beds, drugs, oxygen, and vaccines. The rhino-orbital-cerebral form is the most common clinical presentation observed. A complex interplay between uncontrolled blood glucose, unjudicial use of corticosteroids and SARS-CoV-2 infection has to an upsurge in CAM cases. The majority of these cases had diabetes as predisposing comorbidity and corticosteroids were administered to treat COVID-19. Probable pathologic mechanisms may involve immunological and inflammatory processes. Diabetes, together with COVID-19 induces systemic immunological alterations, leading to decreased immunity and an augmented risk of secondary infections. Prolonged use of high-dose corticosteroids acts as another risk factor for CAM. The hypoxic conditions in COVID-19, uncontrolled diabetes, steroid-induced hyperglycemia, DKA, and increased ferritin levels due to SARS-CoV-2 mediated immunosuppression provide a perfect environment for the Mucorales spores germination in these patients. The recommended treatment strategies mainly include surgical debridement and antifungal therapy using Amphotericin B and selected azoles. Several clinical guidelines focusing on Indian patients have been proposed for accurate diagnosis of infection, identifying clinical presentation, understanding the pathogenesis mechanisms, and tracking the disease course for rapid management of the disease.