Mucormycosis has emerged as major fungal infection with COVID-19, thereby leading to increased mortality and morbidity. Mucormycosis in India ranges from 0.02-9.5 cases per 100,000 people. Mortality observed among COVID associated mucormycosis infections during the second wave was 31-50% [1]. Mucormycosis is an angio-invasive infection, caused by environmental fungal species of the order Mucorales including Rhizopus, Lichtheimia, Mucor, and Rhizomucor species [2]. The clinical presentation of mucormycosis varies according to the site of involvement including rhino-orbital-cerebral, pulmonary, cutaneous, gastrointestinal and disseminated forms. Attributes and risk factors observed in the pathogenesis of mucormycosis during COVID-19 were uncontrolled diabetes/diabetic ketoacidosis, corticosteroids, iron chelators and hematological malignancies.

A study was done at Indira Gandhi medical college, Shimla over a period of 8 months (May 2021 to December 2021). All hospitalized patients diagnosed with COVID-19 and with suspected mucormycosis were included in the study. Biopsy/scrapings of affected area were received at Microbiology department. Samples were subjected to direct microscopy using 10%/20% KOH for fungal elements and cultured on Sabouraud’s dextrose agar (SDA) with antibacterial and antifungal agents and incubated at 250 and 370C. Macroscopic identification was done by observing colony morphology. Microscopic identification was done by LCB mount [3].              

A total of 913 cases of covid-19 were admitted in the isolation unit during this period out of which 62(6.8%) were suspected of mucormycosis. Patients affected were mainly in the 5^th (15%) and 6^th (38%) decade of life Most common comorbid condition was diabetes10 (76%) followed by corticosteroids 4 (30%), hypertension 2 (15%) and hepatitis C virus 2 (15%) infection. Patients presented with fever, facial swelling, facial pain, nasal discharge, epistaxis, altered sensorium, visual deterioration, proptosis, ptosis, ophthalmoplegia and loss of vision. Involved sites in COVID-associated mucormycosis were rhino-sinusal 9 (69%), rhino-orbital 2 (15%), maxilo-facial 2 (15%) and rhino-cerebral 1 (7%). Initiation of antifungal therapy improved outcome in CAM. Overall mortality observed in COVID-associated mucormycosis was 32%. Broad, aseptate, thick-walled and ribbon-like hyaline hyphae with wide-angle branching was seen in KOH findings. Upon culture, in SDA, Rapidly growing mycelial colonies are floccose, dense and hairy in appearance. Initially it was white in color but later greyish in color. Of the 62 samples KOH and culture positive were 9(14%) and 11(18%). Among culture positive Rhizopus species was observed in 10(77%) and Lichtheimia species in 1(7%) (Figure 1-10).

Figure 1: Age-Wise Distribution of CAM (n = 13)

Figure 2: Comorbidity Conditions in CAM (n=13)

Figure 3: Distribution of Rhino-Cerebral Presentation

Figure 4: Distribution of Rhino-Orbital Presentation

Figure 5: Showing Results of Site of Involvement in Mucormycosis (N =13)

Figure 6: Head Computed Tomography – Showing Soft Tissue Density Content in Left Maxillary Sinus Extending into Intra-Orbital Region (Arrow)

Figure 7: Head Computed Tomography – Showing Cavernous Sinus Involvement along with Bilateral Optic Nerve. (Arrow)

Figure 8: KOH Mount: Hyphae Seen Under 40X

Figure 9: Rhizopus on SDA

Figure 10: LB Mount of Lichthemia as Seen under 40X

Patients affected were between the age group of 30 to 70 years. Most common comorbid condition was uncontrolled diabetes, followed by corticosteroids, hypertension and hepatitis C virus infection. Patients presented with fever, facial swelling, facial pain, nasal discharge, epistaxis, altered sensorium, visual deterioration, proptosis, ptosis, ophthalmoplegia and loss of vision. Involved sites were rhino-sinusal, rhino-orbital, maxilo-facial and rhino-cerebral. Rhizopus species was the most common isolate, followed by Lichtheimia species. Overall mortality observed in COVID-associated mucormycosis was 32%.

In COVID 19 infection with a comorbid condition like uncontrolled diabetes, there is a need to have high degree of suspicion for mucormycosis coinfection. COVID-associated mucormycosis is an emerging problem necessitating increased vigilance in COVID-19 patients, even those who have recovered.

1. Singh, A.K. et al. “Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India.” Diabetes and Metabolic Syndrome: Clinical Research and Reviews, vol. 15, no. 4, 2021, pp. 102146.

2. Hussain, S. et al. “Global prevalence of COVID-19-associated mucormycosis (CAM): living systematic review and meta-analysis.” Journal of Fungi, vol. 7, no. 11, 2021, pp. 985.

3. Chander, J. Medical Mycology. 4th ed., Mehta Publishers, 2018.