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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 84-88

Post-COVID-19 infection: Mucormycosis – A tertiary care hospital experience

Department of Pathology, Government Medical College, Patiala, Punjab, India

Date of Submission07-Mar-2022
Date of Decision08-Jun-2022
Date of Acceptance10-Jun-2022
Date of Web Publication18-Jul-2022

Correspondence Address:
Kanwardeep Kaur
Department of Pathology, GMC, Patiala, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajprhc.ajprhc_23_22

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Background: Mucormycosis is an opportunistic infection which has increased in the recent times of upsurge of cases of covid 19. Secondary infection by mucormycosis is noticed in individuals with low immune status, patients on steroid and oxygen therapy. Aims and Objectives:The aim was to analyse mucormycosis cases post covid19 as per age, gender, site of involvement, hospitalization status, site involvement and treatment outcome of patients. Materials and Methods: A retrospective study was conducted on specimens received in the Department of Pathology, over a period of 1 year in which 29 cases of mucormycosis were included. Specimens received in the laboratory were fixed in 10% formalin and submitted to detailed gross examination. Proper orientation in eye exenteration specimens and meticulous examination of the debridement specimens was done along with submission of representative sections in all the cases. Sections were then stained with H and E stain and special stain i.e., PAS and examined microscopically. Results: In this study, 29 patients over a period of 1 year are presented from a tertiary care center out of which 19 are males and 10 females, 82.75% patients with mucormycosis are covid 19 positive. Nasal cavity and maxillary sinus are most common sites involved. Survival rate in these patients is high due to early diagnosis and treatment. Conclusion: Hence, the present study emphasizes on the high incidence of mucormycosis in Covid 19 patients with predisposing factors mainly immunocompromised status, hospitalized patients. To prevent the occurrence of mucormycosis, early identification and further investigation of this fungus will significantly reduce the severity of the disease and mortality rate in Covid 19 affected patients.

Keywords: Covid-19, hospitalisation, mucormycosis

How to cite this article:
Singh H, Kaur K, Mittal S, Kaur I, Mittal M, Kundal RK. Post-COVID-19 infection: Mucormycosis – A tertiary care hospital experience. Asian J Pharm Res Health Care 2022;14:84-8

How to cite this URL:
Singh H, Kaur K, Mittal S, Kaur I, Mittal M, Kundal RK. Post-COVID-19 infection: Mucormycosis – A tertiary care hospital experience. Asian J Pharm Res Health Care [serial online] 2022 [cited 2022 Sep 27];14:84-8. Available from: http://www.ajprhc.com/text.asp?2022/14/2/84/351316

  Introduction Top

COVID-19 is an illness caused by the severe acute respiratory syndrome coronavirus 2 coronavirus.[1] It is a global public health crisis associated with substantial morbidity and mortality worldwide.[2] COVID-19 complications are becoming more of a worry as new mutant strains emerge. In the COVID-19 era, new opportunistic infections are on the rise in patients. Fungal infections such as mucormycosis, aspergillosis, and candidiasis are the most frequent of these opportunistic diseases.[3],[4] Multiple cases of mucormycosis in people with COVID-19 are increasingly being reported around the world.[5] Mucormycosis is an opportunistic fungal infection that typically affects patients with lowered immune status such as diabetes mellitus, patients on mechanical ventilation (invasive and noninvasive) with supplemental oxygen administration, systemic steroid therapy, and patients on immunosuppressive therapy.[6],[7] This could be due to the increase in COVID -19 infection as well as the institution of aggressive supportive treatment such as systemic steroids, oxygen therapy, and immunosuppressive therapy to combat the cytokine storm.[7],[8] This is a fatal infection resulting in angioinvasion, mycotic thrombosis, and ischemic necrosis of tissues.[7] Clinically, black eschar, crusting, and necrotic tissue are seen over the turbinates, septum, and palate.[9] Rhino-orbito-cerebral region is reported in increased frequency as a result of post-COVID 19 infections and is the most common site of involvement by mucormycosis.[10]

  Materials and Methods Top

Over the course of a year, a retrospective research was undertaken on specimens obtained in the Department of Pathology, which comprised of 29 cases of mucormycosis. The inclusion criteria were all cases of suspected mucormycosis. The exclusion criteria were previously diagnosed or known cases of fungal infection were not included in this study. Clinical details such as age, gender, COVID -19 status, oxygen therapy/hospitalization status, site involvement, and patient outcome following treatment were gathered from hospital records, while histological data were obtained from original pathology reports.

Specimens were fixed in 10% formalin and subjected to a thorough physical examination after they arrived at the laboratory. Proper orientation in eye exenteration specimens and meticulous examination of the debridement specimens was done along with the submission of representative sections in all the cases. The sections were then stained with H and E stain as well as a special stain, PAS, and microscopically analyzed.

The consent of patients was taken in their vernacular language.

Statistical analysis

The Chi-square test was used to examine the relationship between the different variables in mucormycosis patients, and the P value was calculated. P < 0.001 was considered statistically significant.

  Results Top

During the 4-month period, a total of 29 cases of mucormycosis were reported in the histopathology laboratory.

The patients ranged in age from 13 to 75 years old. There were 19 males and 10 females with M:F ratio of 1.9:1. P value was 0.865 which was found not significant [Table 1].
Table 1: Gender distribution in different age groups

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Twenty-four patients with mucormycosis are COVID -19 positive and five patients are COVID -19 negative. The ratio between COVID-19 positive and COVID-19 negative in our study came out to be 4.8:1. As the P < 0.001, there is a strong association between mucormycosis with COVID-19 positive patients [Table 2]. There was a gender distribution in different age groups.
Table 2: COVID status in mucormycosis patients

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During treatment of patients with mucormycosis, 16 (55.17%) patients had a history of administration of supplemental oxygen and hospitalization status [Table 3].
Table 3: Hospitalization status in mucormycosis patients

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Specimens were resected from different sites. There were a total of 20 cases of the nasal cavity and maxillary sinus combined. A total of 05 cases of eye exenteration were studied. Two cases of lung biopsy were also noted. The least affected sites were buccal mucosa and gut. P value calculated is <0.001, which shows the high significance of mucormycosis in the nasal cavity and maxillary sinus [Table 4].
Table 4: Site involvement in mucormycosis patients

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A total number of patients who died due to mucormycosis in COVID-19 patients is two (6.89%) out of 29 patients. The outcome of patients after the treatment has high significance and survival rate is high [Table 5]
Table 5: Outcome of patients

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  Discussion Top

There are many common invasive-fungal infections (aspergillosis, candidiasis, cryptococcosis, and mucormycosis) that can be seen arising in a setting of immunosuppressive state or chronic pulmonary disease.[11] However, recently, there has been a sudden and significant increase in the incidence of mucormycosis in the background of the ongoing COVID-19 pandemic.[12] Mucormycosis, also known as zygomycosis, is a rare and dangerous fungal infection that mainly affects people who have a weakened immune system.[13] The present study observed a male predominance in cases of COVID-associated mucormycosis, as observed by Singh AK et al.,[5] The disease incidence was high in patients falling between 41 and 60 years of age (n = 20, 68.96%). Mucor mainly occurs between the age group of 40–60 years, ICU admission is also one of the predisposing factors, as observed by Selarka et al. and Singh et al.[5],[14] Most of the 29 cases of mucormycosis in the present study had rhino-orbital region involvement. The maxillary sinus and nasal cavity are the most common sites, similarly, Patel et al. have also shown the rhino-orbital region as the most common site of involvement in the patients of mucormycosis but without a background of COVID-19 infection.[15] Five patients with orbital mucormycosis cases are included in the study, in one of the orbital cases, mucormycosis was seen touching to the retina and in some cases even extending to extraocular regions [Figure 1] and [Figure 2]. Two cases of mucormycosis in the lung were also diagnosed [Figure 3]. Gastric mucormycosis is an uncommon but deadly fungal illness caused by Mucorales (a filamentous fungus) invading the gastric mucosa, which can cause substantial mortality (up to 54%) in immunocompromised patients.[16] The stomach is the most prevalent location of the infection in the gastrointestinal tract, followed by the colon, ileum, duodenum, and jejunum.[17] In this study, we have received only one case of gut diagnosed with mucormycosis in which the outcome of the patient was fatal [Figure 4] and [Figure 5].
Figure 1: Photomicrograph showing mucormycosis touching to the retina (HPE - H and E, ×100)

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Figure 2: Photomicrograph showing mucormycosis in the eye (HPE - H and E, ×100)

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Figure 3: Photomicrograph showing mucormycosis in lung biopsy (HPE - H and E, ×400)

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Figure 4: Photomicrograph showing mucormycosis in gut (HPE - H & E, ×100)

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Figure 5: Photomicrograph showing mucormycosis in gut (HPE - H & E, ×400)

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In individuals with pulmonary mucormycosis, the presence of fungal hyphae typical of mucormycetes in biopsies of afflicted tissues or bronchoalveolar lavage is a basis for a conclusive diagnosis based on histology. It is a critical diagnostic technique because it identifies the presence of fungus as a pathogen in the collection from a culture contaminant and is required to determine whether blood vessel invasion has occurred. In contrast to Aspergillus species or other hyaline molds, which produce nonpigmented, wide (5–20 m), thin-walled, ribbon-like hyphae with broad, aseptate, and right angle branching, Mucorales genera produce nonpigmented, wide (5–20 m), thin-walled, ribbon-like hyphae with broad, aseptate, and right angle branching. In routine, hematoxylin and eosin (H and E) stains are used, which may show merely the cell wall with no structures inside, or highly degenerate hyphae on rare occasions. The stains Grocott methenamine silver (GMS) and periodic acid–Schiff (PAS) can aid to highlight the fungal wall, while PAS provides a better view of the surrounding tissue than GMS[18],[19] [Figure 6]. Angioinvasion aids in the spread of the fungus from the site of infection to distant locations. Mucormycosis infections are characterized by extensive angioinvasion, which leads to vascular thrombosis and tissue destruction[20],[21] [Figure 7].
Figure 6: Photomicrograph showing mucormycosis on PAS stain (HPE - PAS, ×400)

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Figure 7: Photomicrograph showing angioinvasion by mucormycosis (HPE - H and E, ×400)

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Due to immunosuppressive medication and systemic immunological changes caused by COVID-19 infection, the majority of COVID-19 patients develop mucormycosis. In addition to this, patients who had a longer duration of hospital stays, who were admitted to intensive care units, and those who required invasive or noninvasive ventilation due to acute respiratory distress syndrome were found to be more prone to develop a nosocomial fungal infection. In the present study, there are 82.75% of patients who are COVID-19 positive developed mucormycosis, as observed by Sharma et al.,[12] Patients in the middle and later stages of the infection have a greater chance of developing secondary fungal infection.[11],[22],[23] The mortality rate is higher in patients with secondary invasive fungal infection (53%) when compared to patients without mucormycosis (31%).[7],[11],[22],[23] An increased risk of mortality was associated with a delay in diagnosis of mucormycosis for more than 5 days.[24],[25] In this study, the mortality is less probably because the disease was diagnosed in the early stages and was rigorously managed both medically and surgically. Furthermore, the follow-up period was short.

  Conclusion Top

The present study emphasizes on the high incidence of mucormycosis in COVID-19 patients with predisposing factors mainly immunocompromised status, hospitalized patients. To prevent the occurrence of mucormycosis, early identification and further investigation of this fungus will significantly reduce the severity of the disease and mortality rate in COVID-19 affected patients.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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