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      COVID-19 and mucormycosis superinfection: the perfect storm

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          Abstract

          Background

          The recent emergence of the Coronavirus Disease (COVID-19) disease had been associated with reports of fungal infections such as aspergillosis and mucormycosis especially among critically ill patients treated with steroids. The recent surge in cases of COVID-19 in India during the second wave of the pandemic had been associated with increased reporting of invasive mucormycosis post COVID-19. There are multiple case reports and case series describing mucormycosis in COVID-19.

          Purpose

          In this review, we included most recent reported case reports and case-series of mucormycosis among patients with COVID-19 and describe the clinical features and outcome.

          Results

          Many  of the mucormycosis reports were eported from India, especially in COVID-19 patients who were treated and recovered patients. The most commonly reported infection sites were rhino-orbital/rhino-cerebral mucormycosis. Those patients  were diabetic and had corticosteroids therapy for controlling the severity of COVID-19, leading to a higher fatality in such cases and complicating the pandemic scenario. The triad of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), corticosteroid use and uncontrolled diabetes mellitus have been evident for significant increase in the incidence of angioinvasive maxillofacial mucormycosis.  In addition, the presence of spores and other factors might play a role as well.

          Conclusion

          With the ongoing COVID-19 pandemic and increasing number of critically ill patients infected with SARS-CoV-2, it is important to develop a risk-based approach for patients at risk of mucormycosis based on the epidemiological burden of mucormycosis, prevalence of diabetes mellitus, COVID-19 disease severity and use of immune modulating agents including the combined use of corticosteroids and immunosuppressive agents in patients with cancer and transplants.

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          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Fei Zhou, Ting Yu, Ronghui Du … (2020)
          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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            Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study

            Nanshan Chen, Min Zhou, Xuan Dong … (2022)
            Summary Background In December, 2019, a pneumonia associated with the 2019 novel coronavirus (2019-nCoV) emerged in Wuhan, China. We aimed to further clarify the epidemiological and clinical characteristics of 2019-nCoV pneumonia. Methods In this retrospective, single-centre study, we included all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data. Outcomes were followed up until Jan 25, 2020. Findings Of the 99 patients with 2019-nCoV pneumonia, 49 (49%) had a history of exposure to the Huanan seafood market. The average age of the patients was 55·5 years (SD 13·1), including 67 men and 32 women. 2019-nCoV was detected in all patients by real-time RT-PCR. 50 (51%) patients had chronic diseases. Patients had clinical manifestations of fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). According to imaging examination, 74 (75%) patients showed bilateral pneumonia, 14 (14%) patients showed multiple mottling and ground-glass opacity, and one (1%) patient had pneumothorax. 17 (17%) patients developed acute respiratory distress syndrome and, among them, 11 (11%) patients worsened in a short period of time and died of multiple organ failure. Interpretation The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection. Funding National Key R&D Program of China.
            Article 0 comments Cited 9362 times – based on 0 reviews     Review now
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              Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report

              Mark Peters (2020)
              Abstract Background Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death. Methods In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the preliminary results of this comparison. Results A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55). Conclusions In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. (Funded by the Medical Research Council and National Institute for Health Research and others; RECOVERY ClinicalTrials.gov number, NCT04381936; ISRCTN number, 50189673.)
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                Author and article information

                Contributors
                Jaffar A. Al-Tawfiq:
                ORCID: http://orcid.org/0000-0002-5752-2235
                jaffar.tawfiq@jhah.com
                Journal
                Journal ID (nlm-ta): Infection
                Journal ID (iso-abbrev): Infection
                Title: Infection
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 0300-8126
                ISSN (Electronic): 1439-0973
                Publication date (Electronic): 24 July 2021
                Pages: 1-21
                Affiliations
                [1 ]GRID grid.415305.6, ISNI 0000 0000 9702 165X, Infectious Disease Unit, Specialty Internal Medicine, , Johns Hopkins Aramco Healthcare, ; Dhahran, Saudi Arabia
                [2 ]GRID grid.257413.6, ISNI 0000 0001 2287 3919, Infectious Diseases Division, Department of Medicine, , Indiana University School of Medicine, ; Indianapolis, IN USA
                [3 ]GRID grid.21107.35, ISNI 0000 0001 2171 9311, Infectious Diseases Division, Department of Medicine, , Johns Hopkins University School of Medicine, ; Baltimore, MD USA
                [4 ]GRID grid.415696.9, Administration of Pharmaceutical Care, , Alahsa Health Cluster, Ministry of Health, ; Alahsa, Saudi Arabia
                [5 ]GRID grid.415310.2, ISNI 0000 0001 2191 4301, Department of Medicine, , King Faisal Specialist Hospital and Research Center, ; Jeddah, Saudi Arabia
                [6 ]GRID grid.56302.32, ISNI 0000 0004 1773 5396, Pediatric Department, College of Medicine, , King Saud University, ; Riyadh, Saudi Arabia
                [7 ]GRID grid.56302.32, ISNI 0000 0004 1773 5396, Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, , King Saud University and King Saud University Medical City, ; Riyadh, Saudi Arabia
                [8 ]Research Center, Almoosa Specialist Hospital, Alahsa, Saudi Arabia
                [9 ]GRID grid.1007.6, ISNI 0000 0004 0486 528X, School of Nursing, , Wollongong University, ; Wollongong, Australia
                [10 ]College of Nursing, Princess Norah Bint Abdul Rahman University, Riyadh, Saudi Arabia
                [11 ]GRID grid.415305.6, ISNI 0000 0000 9702 165X, Molecular Diagnostics Laboratory, , Johns Hopkins Aramco Healthcare, ; Dhahran, Saudi Arabia
                [12 ]GRID grid.411335.1, ISNI 0000 0004 1758 7207, College of Medicine, , Alfaisal University, ; Riyadh, Saudi Arabia
                [13 ]Research Center, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
                [14 ]GRID grid.29857.31, ISNI 0000 0001 2097 4281, Department of Medicine Keystone Health, , Penn State University School of Medicine, ; Hershey, PA USA
                [15 ]National Taskforce for Combating the Corona Virus, Riffa, Bahrain
                [16 ]GRID grid.459866.0, ISNI 0000 0004 0398 3129, Royal College of Surgeons in Ireland-Bahrain, ; Muharraq, Bahrain
                [17 ]Internal Medicine, Infectious Diseases and Clinical Microbiology, Bahrain Defense Force Hospital, Riffa, Bahrain
                [18 ]GRID grid.415298.3, ISNI 0000 0004 0573 8549, King Fahad Military Medical Complex, ; Dhahran, Saudi Arabia
                [19 ]GRID grid.417990.2, ISNI 0000 0000 9070 5290, Division of Pathology, , ICAR-Indian Veterinary Research Institute, ; Izatnagar, Bareilly, Uttar Pradesh India
                [20 ]Department of Medicine, Wellspan Chambersburg and Waynesboro Hospitals, Chambersburg, PA USA
                [21 ]GRID grid.415305.6, ISNI 0000 0000 9702 165X, Dhahran Health Center, , Johns Hopkins Aramco Healthcare, ; Rm A-420, Building 61, P.O. Box 76, Dhahran, 31311 Saudi Arabia
                Author information
                http://orcid.org/0000-0002-5752-2235
                Article
                Publisher ID: 1670
                DOI: 10.1007/s15010-021-01670-1
                PMC ID: 8302461
                PubMed ID: 34302291
                SO-VID: c84296a8-4f19-461c-bef2-89b068d72976
                Copyright © © Springer-Verlag GmbH Germany, part of Springer Nature 2021
                License:

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                Date received : 3 June 2021
                Date accepted : 19 July 2021
                Categories
                Subject: Review

                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: sars-cov-2,covid-19,mucormycosis
                Data availability:
                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: sars-cov-2, covid-19, mucormycosis

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