Infectious Disease

Mucormycosis is a rare but increasing fungal infection in post-COVID-19 patients

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Natarajan does not report any relevant financial information.

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Mucormycosis, a potentially life-threatening fungal infection, is increasing the death toll associated with COVID-19 in India.

It typically affects patients who are recovering from COVID-19 and who are immunocompromised due to COVID or from the use of steroids and / or concomitant diabetes.

“In its most common form, it colonizes the nose, sinuses and eyes and from there reaches the brain.” Sundaram Natarajan, MD, said in an interview with Healio / OSN.

Mucor is a mold that is common in humid areas, including soil, damp walls of old buildings, manure, and rotting fruits and vegetables. Because of its high affinity for blood vessels, a mucosal infection blocks blood flow and causes ischemia, tissue infarction, and necrosis. A healthy immune system can fight it off, but it spreads quickly in immunocompromised people and is fatal in a high percentage of cases. When it spreads to the eye, it quickly causes vision loss and blindness, and an enucleation must be performed to prevent fatal invasion of the brain.

Mucormycosis is a rare infection, but sporadic cases and small outbreaks have been reported around the world. Coupled with the dramatic rise in COVID-19 in India, the number of mucormycosis cases has risen accordingly.

“The officially reported cases in Maharashtra, a state in India, are over 4,000, but this is certainly an underestimation and, more likely, thousands. We are currently starting a survey in collaboration with the Indian ENT surgeons and dentists, ”said Natarajan.

The perfect storm

The combination of COVID-19, corticosteroid therapy, and diabetes creates the perfect storm in which mucormycosis takes root and thrives. Corticosteroids are a life-saving treatment used to reduce the dysregulated immune response seen in patients with COVID-19. However, they raise blood sugar levels and mushrooms enjoy the sugar, Natarajan said. Hyperglycemia in patients with diabetes creates an even more favorable environment.

“Diabetes affects many people in India and due to the weakened immune system, it is predisposed to more severe COVID-19 infection, which is usually treated with corticosteroids. With this combination of a disrupted immune system – that is, a common denominator of COVID-19 and diabetes – and the use of corticosteroids, the risk of mucormycosis increases exponentially, ”said Natarajan.

In addition, COVID-19 damages and weakens the upper respiratory tract and the eye, and increases susceptibility to fungal infections. Another factor is the use of antibiotics, which are also commonly prescribed to fight secondary infections in patients with COVID-19.

Rapid diagnosis, aggressive treatment

Common symptoms of mucormycosis that an ophthalmologist can easily spot include eyelid edema, orbital pain, eyelid ptosis, protruding eyes, impaired eye motility, double vision, and sudden loss of vision. They may precede or be related to other symptoms, such as toothache, nasal congestion, bad smell, nasal discharge and bleeding, facial paresthesia, and paralysis.

“It is extremely important to diagnose and treat the infection immediately because it develops very quickly. Post-COVID-19 patients need to be aware that they should watch out for any suspicious symptoms and contact the doctor immediately, ”said Natarajan.

Imaging, microscopy, and histopathological analysis of biopsies are used to confirm the clinical diagnosis. A contrast MRI scan can help identify the affected areas and guide surgery to remove the necrotic tissue. Repeated debridement may be required, and in more severe cases, exenteration of the eye socket and removal of the sinuses may be necessary. At the same time, aggressive antifungal therapy should be started immediately.

“We have to make people, doctors and ophthalmologists aware of this devastating threat,” said Natarajan.

He said there was a need to educate patients about precautions such as hand and environmental hygiene, avoiding contact with dirty surfaces, and wearing masks to avoid breathing in mucus spores. Post-COVID patients treated with steroids and patients with diabetes should be even more careful. Doctors, on the other hand, should avoid prescribing corticosteroids, tocilizumab, and antibiotics unless absolutely necessary.

“Since mucormycosis affects the eye, ophthalmologists can be the first to spot the signs of mucormycosis. It is important that you are aware of this potential infection, consider it in any differential diagnosis, and act promptly with medical and surgical treatments. That is why our ophthalmologist association organizes CME for ophthalmologists, ENT surgeons and doctors / diabetologists. Delays can be fatal to vision and life, ”said Natarajan.

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