India witnessed two-fold increase in mucormycosis cases: CDC study

Naina Mishra

Tribune News Service

Chandigarh, June 5

A twofold rise in mucormycosis has been found in the first evidence-based multicentre study on Covid-19 Associated Mucormycosis (CAM) held in India between September and December last year, as compared to the same period in 2019.

The study which took place in 16 centres of India, including PGIMER, Chandigarh, compared epidemiology and outcomes among cases of coronavirus disease (Covid-19)–associated mucormycosis (CAM).

Under the doctors at PGIMER, a study was conducted with the name of MucoCovi (Muco from mucormycosis, Covi from Covid-19) study at 16 centres across the country. The study results were published yesterday in the reputed Emerging Infectious Disease Journal (Journal of CDC, Atlanta, USA) as ‘Multicenter Epidemiologic Study of Coronavirus Disease associated Mucormycosis, India’. 

Among 287 mucormycosis patients, 187 (65.2%) had CAM; CAM prevalence was 0.27% among hospitalized COVID-19 patients. The researchers noted a 2.1-fold rise in mucormycosis during the study period compared with September–December 2019.

Uncontrolled diabetes mellitus was the most common underlying disease among CAM and non-CAM patients. The most common underlying disease among both CAM and non-CAM groups was uncontrolled diabetes mellitus (62.7%). COVID-19 was the only underlying disease in 32.6% of CAM patients.

It was seen that on an average CAM diagnosis was made 18 days after Covid-19 infection. The most common sites of infection were found to be nose with eye involvement (in 58% cases) followed by nose with eye and brain involvement (27% cases) and then lung infection (9% cases). It shows a considerable number of patients reported late to the hospital after the disease progression to the brain. Besides facial pain, nasal blockage and discharge; toothache and loosening of teeth were seen in a high number of cases for the first time.

On comparing the cases of CAM with mucormycosis without Covid-19 (i.e. Non-CAM) it was seen that uncontrolled diabetes mellitus was the most common underlying disease in both groups. In patients with CAM, newly detected diabetes mellitus was more frequent compared to non-CAM cases (20.9% versus 10%). This suggests the direct role of COVID-19 in causing or worsening diabetes, which may predispose these patients to mucormycosis.

In fact, patients with diabetic ketoacidosis developed CAM early, in less than eight days of Covid-19. On the other hand, those patients who developed CAM later had mostly received steroid treatment. It was seen that inappropriate use of steroids (63.3%) i.e. either in very high doses or use in patients who did not need it was associated with development of late CAM, i.e. more than eight day after Covid-19 diagnosis.

The overall death rate due to mucormycosis (both CAM and non-CAM) was 38.3% at six weeks and 45.7% after 12 weeks of illness. It was seen that patients >54 years of age, those with brain or lung involvement and those who had to undergo ICU admission had a higher risk for death.

According to the study, the COVID-19–related hypoxemia and improper glucocorticoid use independently were associated with CAM.

“The Covid-19 pandemic has led to increases in mucormycosis in India, partly from inappropriate glucocorticoid use. Age, rhino-orbital-cerebral involvement, and intensive care unit admission were associated with increased mortality rates; sequential antifungal drug treatment improved mucormycosis survival, the study concluded.

Dr. Arunaloke Chakrabarti, Professor & Head, Department of Medical Microbiology, PGIMER, said, “The rise in number of cases coincides with the country’s Covid-19 epidemic. Clinicians should be vigilant for mucormycosis in the patients recovering from Covid-19 illness, especially among patients with new or previously diagnosed diabetes mellitus and clinical manifestations of facial or orbital pain or black or blood-stained nasal discharge or loosening of teeth. In addition, improper glucocorticoid use for the Covid-19 treatment is an additional risk factor in CAM. Therefore, treating physicians should ensure they use appropriate drugs and doses in Covid-19 patient treatments.”