Mucormycosis Associated with COVID-19 – Case Report and Review of Current Knowledge

Case Description

A 55-year-old patient was hospitalized for severe COVID-19 characterized by fever, dry cough, and progressive shortness of breath lasting 3 days. Significant in the patient's history was terminal chronic kidney failure (on hemodialysis for the past year), type 2 diabetes mellitus diagnosed 10 years ago and treated with oral antidiabetics, ischemic cardiomyopathy, and hypertension.

Initial assessment yielded the following results:

• Physical examination: BP 110/80 mmHg, HR 90/min, RR 26/min, oxygen saturation 84% (increased to 95% following oxygen therapy), BMI 24 kg/m²
• Laboratory tests: hemoglobin (Hb) 78 g/l, blood glucose 7.8 mmol/l, glycated Hb 53 mmol/mol.

Chest X-ray showed cardiomegaly and bilateral diffuse opacities in the lungs. Intravenous (i.v.) dexamethasone treatment was started at a dose of 6 mg/day for 14 days, along with remdesivir (day 1: 200 mg, days 2–5: 100 mg). The patient also continued oxygen therapy, thromboprophylaxis, and hemodialysis. During treatment, blood glucose rose to a maximum of 16.7 mmol/l. Clinical improvement was observed 14 days after hospitalization.

However, 3 days later, the afebrile patient began to complain of a cough with sputum expectoration and dysuria (despite not having a urinary catheter during hospitalization). Urine culture confirmed the presence of E. coli, and the infection was treated with i.v. meropenem at a dose of 1 g/day for 10 days. Chest X-ray and CT scan done 21 days after hospitalization revealed a cavity in the right upper lung field with a minimal pleural effusion on the right. Based on culture results showing Rhizopus microsporus, liposomal amphotericin B treatment was commenced at a dose of 3 mg/kg/day. The patient was discharged 54 days after hospitalization and continued on amphotericin B at the same dose for an additional 25 days as an outpatient. A right upper lobectomy was also scheduled.

What Does the Available Literature Say About COVID-19-Associated Mucormycosis?

A total of 8 case reports (including the one mentioned above) involving patients (7 men, average age 57.5 years) with COVID-19-associated mucormycosis were included in a systematic review available as of January 9, 2021, from the PubMed and Embase databases. The most common comorbidity was diabetes mellitus (n = 4), and 3 patients had no identified risk factors for mucormycosis. Acute respiratory distress syndrome (ARDS) developed in 7 patients, and elevated creatinine was noted in 5 of them. Clinical signs of mucormycosis were identified during hospitalization in 2 patients, while in the remaining patients, these signs appeared only after initiating COVID-19 treatment (on average 10–14 days after hospitalization). The mucormycosis types included rhino-orbito-cerebral (n = 3), pulmonary (n = 3), gastrointestinal (n = 1), and disseminated (n = 1). It was diagnosed post-mortem in 2 patients. All patients except for the one presented in the above case report died.

Discussion and Conclusion

Mucormycosis is another serious infection complicating the course of COVID-19, alongside aspergillosis. Patients with diabetes who use systemic corticosteroids with immunosuppressive and hyperglycemic effects may be at higher risk. Managing the infection requires correcting hyperglycemia, treatment with amphotericin B, and surgical intervention. Therefore, corticosteroids should be used judiciously only in patients with hypoxemia.

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Source: Garg D., Muthu V., Sehgal I. S. et al. Coronavirus disease (COVID-19) associated mucormycosis (CAM): case report and systematic review of literature. Mycopathologia 2021 May; 186 (2): 289−298, doi: 10.1007/s11046-021-00528-2.