Predictors of Mucormycosis in COVID-19

Abstract

Background and Aims: Mucormycosis, a serious angioinvasive infection caused by common filamentous fungi, that is,
mucormycetes, constitutes the third most common invasive fungal infection, following aspergillosis and candidiasis.
Although a rare infection, in recent times we witnessed a sudden surge of mucormycosis cases post-COVID-19 (coronavirus
disease 2019). The present study was carried out to understand its relation to COVID-19, inflammatory markers, steroid
use during COVID-19 treatment, clinical course and outcome of the disease. Material and methods: The present study was
conducted at RNT Medical College, Udaipur over a period of 1 month. Written and informed consent from patients were
taken. In this study, 15 patients admitted in COVID wards, medical wards, muormycosis ward and ICU were included if
fungal hyphae were found on potassium hydroxide (KOH) mount and there was a history of COVID-19 illness; negative
KOH mount patients were excluded. Results: In the present study, on admission, out of 15 patients, 7 (46.7%) were admitted
with mean neutrophil-to-lymphocyte ratio (NLR) >5.5, mean C-reactive protein (CRP) 126, mean interleukin (IL)-6 82.4,
mean lactate dehydrogenase (LDH) 528, mean ferritin 662, mean D-dimer 1760; 5 (33.3%) patients were admitted with mean
NLR 3.5-5.5, mean CRP 68, mean IL-6 39.6, mean LDH 336, mean ferritin 448, mean D-dimer 780; and 3 (20%) patients
were admitted with mean NLR <3.5, mean CRP 16, mean IL-6 12.8, mean LDH 172, mean ferritin 226, mean D-dimer 430.
Out of the 7 patients who were admitted with NLR >5.5, 3 (42.8%) were admitted with orbital cellulitis and 4 (57.2%) with
invasive sinusitis. Out of 5 patients admitted with NLR 3.5-5.5, 3 (60%) were admitted with orbital cellulitis and 2 (40%)
with invasive sinusitis. Out of 3 patients admitted with NLR <3.5, 1 (33.3%) patient had orbital cellulitis and 2 (66.7%) had
invasive sinusitis. Out of total 7 patients who were admitted with orbital cellulitis, in 71.4% patients, steroid was used
during COVID-19 treatment and out of 8 patients who were admitted with invasive sinusitis, in 62.5% patients, steroid was
used during COVID-19 treatment. In the present study, 68% patients were male and 32% were female. Around 78% patients
were from rural area and 22% patients were from urban area. Overall, 74% cases were treated with amphotericin B. Among
these, 36% cases were diagnosed with orbital cellulitis and 38% cases were diagnosed with invasive sinusitis. Around 26%
cases were treated with posaconazole, and among these 9% were orbital cellulitis cases and 17% were invasive sinusitis
cases. About 85.72% cases of orbital cellulitis and 75% cases of invasive sinusitis improved. Nearly 42.86% cases who were
admitted with NLR >5.5 did not improve with treatment. Conclusion: As per present study, inflammatory markers of
COVID-19, NLR and history of steroid use during treatment can be considered as predictors of mucormycosis occurrence and
their outcome