Table 1.

Summary of COVID-19-associated mucormycosis cases from Pakistan

Case	Age	Sex	Risk factors/Underlying conditions	ICU procedures	Corticosteroids before mucormycosis/Days of therapy	Site of infection (mucormycosis)/Days post-COVID diagnosis	Classification	Radiology	Mycological evidence	Co-infection	Outcome	Cause of death
1	62	M	Critical COVID-19	Mechanical ventilation	Yes/10 (methylprednisolone)	Lungs/14	Probable	CXR: Increase in patchy airspace opacification in bilateral lung zones with new consolidation in right lower lung zone	Positive tracheal aspirate culture	Aspergillus fumigatus, Pseudomonas aeruginosa	Died	ARDS, Multi-organ dysfunction
2	77	M	DM, HTN, critical COVID-19	Mechanical ventilation	Yes/10 (dexamethasone, later switched to methylprednisolone)	Lungs/18	Probable	CXR: Increase in peripheral airspace shadowing in bilateral mid and lower lung zones	Positive tracheal aspirate culture	NA	Died	Septic shock
3	50	F	DM(HbA1c 11.4), CKD, metabolic acidosis	Haemodialysis	Yes/10 (dexamethasone)	Rhino-orbital cerebral/16	Proven	MRI Orbits with contrast: Bilateral exophthalmos with thickening of extraocular muscles. Significant facial soft-tissue swelling sub-periosteal abscess glabella	Positive nasal tissue culture Histopathology of extraocular tissue and bony trabeculae of sinuses	NA	Presumed to have died (LAMA in critical condition)
4	33	M	DLBCL, on chemotherapy, critical COVID-19	Mechanical ventilation	No (last chemotherapy 2 months ago)	Lungs/–10	Proven	CXR: New consolidation in the right upper lobe and infiltrates in the right lower lobe with right paratracheal lymphadenopathy	Positive bronchoalveolar lavage culture	Aspergillus niger, Aspergillus nidulans	Died	Septic shock, multi-organ dysfunction, lactic acidosis
5	86	F	DM, HTN, severe pulmonary hypertension, on LTOT, atrial flutter	Non-invasive ventilation	Yes/18 (methylprednisolone)	Lungs/20	Probable	CT Chest: Diffuse areas of ground-glass haze with multifocal consolidations involving bilateral lung fields associated with interlobular septal thickening. Few consolidations with cavitary changes	Positive tracheal aspirate culture	Carbapenem-resistant Klebsiella pneumoniae	Died	ARDS, Arrhythmias
6	35	M	AML on induction chemo (Day 23), febrile neutropenia, critical COVID-19, DIC, AKI	Non-invasive ventilation	Yes/14 (dexamethasone)	Lung/12	Probable	CXR: Patchy bilateral airspace shadowing in bilateral mid and lower lung zone, became better-defined and dense, suggesting progression	Positive tracheal aspirate culture	NA	Presumed to have died (LAMA in critical condition)
7	53	F	DM (HBA1c 10.5), HTN, IHD, COVID-19 with CVST	NA	Yes/duration and type unknown	Rhino-cerebral/146	Proven	CT head: Sinusitis involving bilateral sphenoid air cells with secondary periosteitis of the sphenoid bone. MRI with skull base osteomyelitis	Nasal tissue smear showed aseptate hyphae but failed to grow on culture	Ceftriaxone-resistant Klebsiella pneumoniae and Aspergillus fumigatus	Lost to follow up
8	67	M	DM (HbA1c 11.9), IHD, non-severe COVID-19	NA	No	Rhino-orbital cerebral/12	Proven	MRI brain: Abnormal T2 hyper-intense signals in the right infratemporal region involving the pterygoid muscles with right-sided facial extension and intracranial extension in right temporal lobe	Positive nasal tissue culture Histopathology of enucleated eye Histopathology of right nasal turbinates	NA	Under-treatment
9	69	M	DM (HbA1c 7.8), HTN, IHD, COPD, post-TB bronchiectasis, S/P left lung pneumonectomy,	Non-invasive ventilation	Yes/18 days (methylprednisolone)	Lung/20	Probable	CXR: New development of patchy opacity in the right mid-lung zone	Positive tracheal aspirate culture	Aspergillus niger/Pseudomonas aeruginosa	Died	ARDS, Septic shock
10	64	F	DM (HbA1c 8.3), HTN, CLD	NA	Yes/duration and type unknown	Rhino-orbital/12	Proven	CT orbits: overall appearances are likely secondary to left orbital and periorbital cellulitis without abscess formation	Positive nasal tissue culture Histopathology of left eye and left ethmoid sinus tissue	NA	Under-treatment

Abbreviations: AKI, acute kidney injury; AML, acute myeloid leukaemia; ARDS, acute respiratory distress syndrome; CAM, COVID-19-associated mucormycosis; CKD, chronic kidney disease; CLD, chronic liver disease; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease 2019; CT, computed tomography; CVST, cerebral venous sinus thrombosis; CXR, chest X-ray; DIC, disseminated intravascular coagulation; DLBCL, diffuse large B-cell lymphoma; DM, diabetes mellitus; F, female; HbA1c, glycated haemoglobin; HTN, hypertension; ICU, intensive care unit; IHD, ischaemic heart disease; LAMA, left against medical advice; LTOT, long-term oxygen therapy; M, male; MRI, magnetic resonance imaging; TB, tuberculosis.