To the editor,
Background
With the current pandemic of coronavirus disease 2019 (COVID-19) raging, there has been a frantic search for treatment options. Out of the several treatment options that have been tried with varying degrees of success, systemic glucocorticoids have been shown to improve survival in COVID-19. Unfortunately, the widespread use of glucocorticoids has also led to an increase in the side effects of these drugs especially an increase in secondary bacterial or fungal infections. COVID-19-associated pulmonary aspergillosis (CAPA) complicating the course of COVID-19 has widely been reported; there are only a few reports on mucormycosis [1, 2], probably due to the lack of clinical suspicion and difficulty in isolation of causative fungi.
Main text
Mucormycosis is an acute or subacute rapidly progressing infections caused by the angioinvasive fungi in the order of Mucorales [3]. It most commonly affects patients with poorly controlled diabetes mellitus and immunocompromised patients, leading to significant morbidity and mortality. The most common region affected is the nose, paranasal sinus, and brain leading to rhino-orbital and rhino-cerebral mucormycosis; this is also seen in the present pandemic and most of the case reports are of rhino-orbito-cerebral mucormycosis [4]; however, there are reports of pulmonary [1] and gastrointestinal mucormycosis too [5]. The cause for increased mucor infection in patients is complex and includes an interplay of factors, like pre-existing diseases, such as diabetes mellitus; use of immunosuppressive therapy like glucocorticoids and tocilizumab; pre-existing lung conditions; and systemic immune alterations by the virus itself like reduced number of T lymphocytes, CD4+T, and CD8+T cells [4].
Many challenges have also emerged in the management of mucormycosis during this pandemic. Early detection, control of hyperglycemia, liposomal amphotericin B, and surgical debridement are the cornerstones in the successful management of mucormycosis. However, in the current scenario, it is difficult to control the hyperglycemia due to the extensive use of steroids, most operation theaters remain shut due to diversion of manpower and other resources to other departments; therefore, delaying surgical debridement and the presence of coexisting multi-organ dysfunction in these patients makes it difficult to shift them for imaging studies.
Conclusion
In this scenario, it is imperative that clinicians should be sensitized to the increased risk of development of this fatal infection, especially while treating diabetic coronavirus-affected patients with systemic steroids. In addition, judicious use of glucocorticoids must be advocated in all patients.
Acknowledgements
None
Abbreviations
- COVID-19
Corona virus 2019
- CAPA
COVID-19-associated pulmonary aspergillosis
Authors’ contributions
SSB and VKK contributed to the manuscript concept, design, acquisition of the data, and writing and revising of the original draft. All authors have read and approved the final manuscript.
Funding
No funding was obtained.
Availability of data and materials
Not applicable
Declarations
Ethics approval and consent to participate
Not applicable
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Satvinder Singh Bakshi, Email: saty.bakshi@gmail.com.
Vinoth Kumar Kalidoss, Email: vinob4u@gmail.com.
References
- 1.Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, et al. Coronavirus disease (Covid-19) associated mucormycosis (CAM): case report and systematic review of literature. Mycopathologia. 2021;5:1–10. doi: 10.1007/s11046-021-00528-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Veisi A, Bagheri A, Eshaghi M, Rikhtehgar MH, Rezaei Kanavi M, Farjad R. Rhino-orbital mucormycosis during steroid therapy in COVID-19 patients: a case report. Eur J Ophthalmol. 2021;10:11206721211009450. doi: 10.1177/11206721211009450. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Bakshi SS. Rhino-orbital mucormycosis. Bull Emerg Trauma. 2019;7(1):88–89. doi: 10.29252/beat-0701015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.John TM, Jacob CN, Kontoyiannis DP (2021) When uncontrolled diabetes mellitus and severe COVID-19 converge: the perfect storm for mucormycosis. J Fungi Basel Switz 7(4):298 [DOI] [PMC free article] [PubMed]
- 5.do Monte Junior ES, Santos MELD, Ribeiro IB, Luz G d O, Baba ER, Hirsch BS, et al. Rare and fatal gastrointestinal mucormycosis (zygomycosis) in a COVID-19 patient: a case report. Clin Endosc. 2020;53(6):746–749. doi: 10.5946/ce.2020.180. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Not applicable