Journal of Current Research in Scientific Medicine

EDITORIAL
Year
: 2021  |  Volume : 7  |  Issue : 1  |  Page : 1--2

Mucormycosis: New actor in the saga of COVID-19


Reba Kanungo 
 Department of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry, India

Correspondence Address:
Reba Kanungo
Department of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry
India




How to cite this article:
Kanungo R. Mucormycosis: New actor in the saga of COVID-19.J Curr Res Sci Med 2021;7:1-2


How to cite this URL:
Kanungo R. Mucormycosis: New actor in the saga of COVID-19. J Curr Res Sci Med [serial online] 2021 [cited 2021 Dec 4 ];7:1-2
Available from: https://www.jcrsmed.org/text.asp?2021/7/1/1/320511


Full Text



The second surge of COVID-19 has sparked several concerns in patients. Information on the coronavirus outbreak is continually evolving. Besides the disease due to SARS CoV2, COVID-19 as we have seen has been associated with several complications due to non-infectious as well as infectious causes. Among the infectious complications, bacterial and fungal opportunistic infections have been the mainstay. One such infection making the headlines in recent days is mucormycosis, wrongly labeled as “black fungus.” Several cases of this highly invasive infection have been reported from several parts of India. Questions are being raised regarding its sudden surge, why in India, and what are its triggers? Knowledge of the Coronavirus infection is evolving every day. The genetic makeup of the virus, its mutations, cell and virus interaction and host immune response are some of the areas of emerging information on the Coronavirus. Bacterial and fungal opportunistic infections in hospitalized patients, those in intensive care units (ICU) and under assisted respiration are problems associated with moribund COVID patients. Several factors including secondary infections have been documented in these patients. Multidrug resistant Klebsiella including carbapenem resistant Enterobacteriaceae Acinetobacterbaumanii and Pseudomonas aeruginosa as hospital acquired aetiology with multi drug resistance with focus on polymyxins, mainly colistin as treatment options. Reports of pulmonary aspergillosis have also been documented across the globe along with Candida auris from patients in the ICU. Mucormycosis has now been added on to the panel being reported mainly from India.

The surge of post-COVID mucormycosis is disconcerting. Increase in cases, associated with morbidity and mortality in some comes as the “last straw on the camel’s back” in the fight against COVID-19. This has led some states to declare post-COVID mucormycosis as a reportable disease. A query that comes to mind regarding the sudden occurrence of a large number of cases across the country. During the first wave of the pandemic, there were some reports across the globe of lung infections due to Aspergillus in post-COVID patients. Reports of Aspergillus in the second wave has not been as frequent as mucormycosis involving the rhino-orbital area, with some spreading to the cerebral cortex. There have been several speculations regarding this surge. Contaminated and reusing of masks, humidifiers to oxygen tubing of industrial oxygen and overuse of steroids have been some of the assumptions. To know the exact predisposing factors leading to post COVID mucormycosis, there has to be systematic analysis of contributing factors without bias.

One of the major factors that are possible is a combination of overuse of steroids compounded with underlying diabetes. There are 77 million diabetics in our country, 54%–76% of cases of reported diabetes mellitus and 47% unaware. Of these only a quarter achieve glycemic control.[1] The severity of COVID with increased morbidity has been established in diabetic patients globally. Severe COVID outcome with the deregulated immune system, massive tissue reaction, coagulopathies, cytokine storm, etc., along with invasive procedures, ventilations have been compounded to a system prone for secondary infection. Mucormycosis as an established secondary infection in uncontrolled diabetes with high mortality rates (40%–80%) has already been established.[2]

The Mucorales are a group of fungi found as environmental contaminants, spores found in moist humid areas.[3] The spores that are inhaled do not produce any infection in an individual with intact immune status. However, in a post COVID patient, whose immune status has been battered by the disease, presents an ideal state for the spores to establish and invasive infection. This infection is aided by steroid therapy which acts on the immune system suppressing it further, by decreased neutrophil migration, (the first line of defence), and followed by inhibition at several other steps. Mucor on the other hand finds a suitable environment to invade, being an angio-invasive fungus spreading rapidly causing massive tissue necrosis.[4] Hyperglycemia, compounded with ketoacidosis contribute further to the process. Another hypothesis is the availability of free iron in diabetic ketoacidosis. Iron acts as a growth factor for the Mucorales. With these associations based on anecdotal observations, we need to establish facts beyond conjectures to address the problem of overwhelming post-COVID mucormycosis. Scientifically designed clinical and epidemiological studies need to be done during the ongoing pandemic to unravel some of the speculations floating around causing panic and fear among the population. Studies to document the association of risk factors, immunological parameters, fungal characteristics, anti-fungal spectrum and management strategies need to be carried out. Above all the there is an urgent need to take a look at steroid therapy regarding its timing, duration and monitoring the course, keeping hyperglycaemia at bay. Educating the patients regarding infection prevention and control practices and lifestyle management. With the overwhelming number of cases, this appears daunting. But as they say “prevention is better than cure.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Soman R, Sunavala A. Post Covid-19 mucormycosis-From frying pan in to the fire. JAPI 2021;69. Available from: https://www.japi.org/x27464c4/. [Last accessed on 2021 May].
2Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr Clin Res Rev 2021. [doi: 10.1016/j.dsx. 2021.05.019].
3Mucormycosis. Available from: https://www.cdc.gov/fungal/diseases/mucormycosis/index.html. [Last accessed on 2021 May].
4Prakash H, Chakrabarti A. Epidemiology of mucormycosis in India. Microorganisms 2021;9:523.