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 Table of Contents  
LETTER TO EDITOR
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 87-88

Cerebral mucormycosis as a new phenotype of post-COVD-19 neurological syndrome


1 Department of Medicine, School of Medicine, Universidad Libre, Barranquilla, Colombia
2 Department of Medicine, School of Medicine, Universidad Libre, Cali, Colombia
3 Department of Medicine, Medical and Surgical Research Center, University of Cartagena; Department of Medicine, Clinical Research Group in Neurocritical Care, University of Cartagena, Cartagena, Colombia

Date of Submission17-Aug-2021
Date of Decision24-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication28-Apr-2022

Correspondence Address:
Dr. Ivan David Lozada-Martinez
Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_63_21

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How to cite this article:
Sanjuanelo-Fontalvo AJ, Serna-Trejos JS, Prado-Molina DG, Lozada-Martinez ID. Cerebral mucormycosis as a new phenotype of post-COVD-19 neurological syndrome. J Curr Res Sci Med 2022;8:87-8

How to cite this URL:
Sanjuanelo-Fontalvo AJ, Serna-Trejos JS, Prado-Molina DG, Lozada-Martinez ID. Cerebral mucormycosis as a new phenotype of post-COVD-19 neurological syndrome. J Curr Res Sci Med [serial online] 2022 [cited 2022 Aug 19];8:87-8. Available from: https://www.jcrsmed.org/text.asp?2022/8/1/0/344196



Sir,

We read with great interest the article published by Kanungo[1] entitled “Mucormycosis: New actor in the saga of COVID-19,” where the author presents evidence related to post-COVID-19 mucormycosis, mentioning some risk factors that may facilitate the infection and dissemination of the Mucorales agent, which are abundant in low- and middle-income countries due to the presence of marginalized areas and poor environmental sanitation. Likewise, the author proposes the design of studies to identify causal relationships and outcomes.[1] However, we consider it necessary to address the issue of cerebral mucormycosis as a new phenotype of the post-COVID-19 neurological syndrome, and the need for rapid and thorough research on this.

Although there is currently no precise definition of the post-COVID-19 syndrome, due to the lack of studies that have defined cutoff scores, it is presumed that it constitutes the time after 12 weeks after the onset of acute-phase symptoms of COVID-19.[2] Specifically, the post-COVID-19 neurological syndrome is defined as the persistence of neurological signs and/or symptoms following the acute phase of COVID-19, in those who may or may not have had neurological manifestations during this phase, and in those who may or may not have had a history of neurological disorders.[3],[4] This concept has gained great relevance due to the fact that it has been observed that it entails high health costs, morbidity, mortality, and disability.[3],[4] Even during this time period, it is presumed that there are still remnants of neuroinflammation during the acute phase of COVID-19, which may trigger cerebrovascular, neurometabolic, or neuroimmune disorders for the first time, or worsen a chronic neurological disease, adversely modifying the functional prognosis, and quality of life of the affected person.[3],[4] However, considering that this is a risk period for developing any type of neurological disorder, it is also viable to take into account any external infectious agent that takes advantage of the immunosuppression process that occurs in some patients due to the treatment or pathophysiological process of COVID-19, to invade and disseminate in the organism.

Although at present only the post-COVID-19 neurological syndrome and the presence of the neuropsychiatric phenotype (which consists of the presence of psychiatric symptoms after the acute phase) have been described in general terms,[3],[4] it would be pertinent to consider the presence of the cerebral mucormycosis-type infectious phenotype, based on the time period and the pathophysiological mechanism in which this infection is established in COVID-19 patients, and that its management cannot be the same due to the systemic affectation produced by COVID-19 and the limitations in the pharmacological or therapeutic approach, depending on the target organ lesion, especially in patients with risk factors that produce immunosuppression, hospitalized in intensive care units, or those with corticosteroid treatment plan.

Although mucormycosis is prevalent in selected regions, it is a fact that a particular phenotype must be established to ensure its rapid identification, staging (based on systemic compromise), and specific approach. Prakash and Chakrabarti[5] state that mucormycosis is 70 times more prevalent in India than in the rest of the world, making this country the critical and highest risk base for cerebral mucormycosis.[5] The same authors state that Type II diabetes mellitus, cancer, solid-organ transplantation, chronic kidney disease, tuberculosis, and trauma are potential risk factors for the development of mucormycosis; and evidencing that the prevalence of these diseases is very high,[5] one can perceive the potential risk of a high incidence of mucormycosis and specifically, cerebral mucormycosis.

Case series such as the one reported by Roushdy and Hamid,[6] where it is observed that this infection is also prevalent in Egypt, show how deadly this condition is, and the need for rapid progress in its control. Dave et al.[7] conducted a multicenter study characterizing the clinical presentation, management, and outcomes of rhino-orbito-cerebral mucormycosis, where they found that the duration between the diagnosis of COVID-19 and the presentation of this complication was on average 16 days (±21).[7] Of 36 patients, 62% had compromised vision, 100% had sinus involvement, 30% had cavernous sinus involvement, and 33% had central nervous system involvement.[7] All patients were treated with systemic liposomal amphotericin B and at 5-month follow-up, it was observed that 60% of patients had a favorable outcome. However, it was evidenced that having central nervous system compromise is a predictor of unfavorable outcome (P < 0.04) and mortality (P < 0.03).[7]

Considering the causal relationship between the pathophysiological process and factors associated with the management of COVID-19, and the post-COVID-19 time period where cerebral mucormycosis may develop, we propose to define cerebral mucormycosis as a new phenotype of post-COVID-19 neurological syndrome. Likewise, to reinforce strategies aimed at neurological or neurosurgical management in necessary cases, neurorehabilitation,[8] neuro-nutrition,[9] and research to characterize the sensitivity and microbial resistance, to improve outcomes, and ensure the survival of those with cerebral mucormycosis. Regarding screening and early identification of this problem, we suggest the creation of centers and teams specialized in the follow-up of patients with risk factors clearly associated with the development of mucormycosis, but above all, those who pass to the post-COVID-19 phase. These teams should be multidisciplinary, and students of health sciences can be included to establish a massive program in the community. In addition, the population should be widely educated about any warning sign or symptom that suggests the presence of mucormycosis to avoid progression to advanced stages that could compromise the life of the person.

Financial support and sponsorship

The research was totally funded by the researchers.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kanungo R. Mucormycosis: New actor in the saga of COVID-19. J Curr Res Sci Med 2021;7:1-2.  Back to cited text no. 1
  [Full text]  
2.
Rodríguez-Hernández YA, Villamizar-Gómez FJ, Mantilla-Pardo JC, Robledo-Arias JS, Rahman S, Lozada-Martinez ID, et al. Post-COVID 19 neurological syndrome: The need to define a cut-off score between the acute and post-COVID 19 phases. Ann Med Surg (Lond) 2021;71:102983.  Back to cited text no. 2
    
3.
González-Herazo MA, Silva-Muñoz DC, Guevara-Martínez PA, Lozada-Martinez ID. Post-COVID 19 neurological syndrome: A fresh challenge in neurological management. Neurol Neurochir Pol 2021;55:413-4.  Back to cited text no. 3
    
4.
Camargo-Martínez W, Lozada-Martínez I, Escobar-Collazos A, Navarro-Coronado A, Moscote-Salazar L, Pacheco-Hernández A, et al. Post-COVID 19 neurological syndrome: Implications for sequelae's treatment. J Clin Neurosci 2021;88:219-25.  Back to cited text no. 4
    
5.
Prakash H, Chakrabarti A. Epidemiology of mucormycosis in India. Microorganisms 2021;9:523.  Back to cited text no. 5
    
6.
Roushdy T, Hamid E. A case series of post COVID-19 mucormycosis – A neurological prospective. Egypt J Neurol Psychiatr Neurosurg 2021;57:100.  Back to cited text no. 6
    
7.
Dave TV, Gopinathan Nair A, Hegde R, Vithalani N, Desai S, Adulkar N, et al. Clinical presentations, management and outcomes of Rhino-Orbital-Cerebral Mucormycosis (ROCM) following COVID-19: A multi-centric study. Ophthalmic Plast Reconstr Surg 2021;37:488-95.  Back to cited text no. 7
    
8.
Ortega-Sierra MG, Durán-Daza RM, Carrera-Patiño SA, Rojas-Nuñez AX, Charry-Caicedo JI, Lozada-Martínez ID. Neuroeducation and neurorehabilitation in the neurosurgical patient: Programs to be developed in Latin America and the Caribbean. J Neurosurg Sci 2021. doi: 10.23736/S0390-5616.21.05439-4.  Back to cited text no. 8
    
9.
Mila-Grande JC, Granadillo-Daza RL, Agudelo-Rios DA, Lozada-Martínez ID. Regarding: Management of unfavorable outcome after mild traumatic brain injury: Review of physical and cognitive rehabilitation and of psychological care in post-concussive syndrome. Neurochirurgie. 2022;68:243-44.  Back to cited text no. 9
    




 

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