Mixed invasive fungal infections among COVID-19 patients

  1. Vanya Singh
  2. Amber Prasad
  3. Prasan Kumar Panda
  4. Manjunath Totaganti
  5. Amit Kumar Tyagi
  6. Abhinav Thaduri
  7. Shalinee Rao
  8. Mukesh Bairwa
  9. Ashok Kumar Singh

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Abstract

Background and Purpose: The healthcare system in India collapsed during the second wave of the COVID-19 pandemic. A fungal epidemic was announced amid the pandemic with several cases of COVID-associated mucormycosis and pulmonary aspergillosis being reported. However, there is limited data regarding mixed fungal infections in COVID-19 patients. Therefore, we present a series of ten consecutive COVID-19 patients with mixed invasive fungal infections (MIFIs). Materials and Methods: Among COVID-19 patients hospitalized in May 2021 at a tertiary care center in North India, 10 cases of microbiologically confirmed COVID-19- associated mucormycosis-aspergillosis (CAMA) were evaluated. Results: All patients had diabetes and the majority of them were infected with severe COVID-19 pneumonia (6/10, 60%) either on admission or in the past month while two were each of moderate (20%) and mild (20%) categories of COVID-19; and were treated with steroid and cocktail therapy. The patients were managed with amphotericin-B along with surgical intervention. In total, 70% of all CAMA patients (Rhizopus arrhizus with Aspergillus flavus in seven and Aspergillus fumigatus complex in three patients) survived. Conclusion: The study findings reflected the critical importance of a high index of clinical suspicion and accurate microbiological diagnosis in managing invasive dual molds and better understanding of the risk and progression of MIFIs among COVID-19 patients. Careful scrutiny and identification of MIFIs play a key role in theimplementation of effective management strategies.

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  1. Version published to 10.18502/cmm.7.4.8407
  2. ScreenIT

    SciScore for 10.1101/2021.08.09.21261555: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIACUC: Study Design and patients: This case series is part of a project titled disease profile of COVID-l9 including their follow-up in patients at a tertiary institute in India, approved by the Institutional Ethical Committee, All India Institute of Medical Sciences (AIIMS), Rishikesh, India (CTRI/2020/08/027169).
    Field Sample Permit: Scraping or exudate from the nasal cavity and/or paranasal sinuses, hard palatal lesions, sinus material, a biopsy from extracted tooth socket area, endoscopic collection of debrided tissue/biopsy, etc were sampled [6].
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This study has its own limitations with lack of serum GM test which could have helped identifying the cases as of proven invasive aspergillosis. In the study, despite an early diagnosis of fungal infection post-admission, most participants could not be started on antifungal immediately with an average gap of 4-5 days in diagnosis and start of antifungal due to limited supply of amphotericin-B (Figure 1). Similar observations were made in a multicentric study conducted in other parts of India [30]. A delay of a week in diagnosis may double the 30-day mortality from 35% to 66% [3]. Treating CAMA is more worrisome since one (aspergillosis is a metastatic invasive infection) focuses majorly on medical treatment while the other focuses equally on surgical and medical management (mucor is a locally invasive infection). Patient 1 was diagnosed about 10 days after admission and couldn’t be saved, reflecting on the need for timely diagnosis and treatment. In conclusion, mixed fungal infections i.e. CAMA as COVID sequelae may be an emerging disease. This outbreak was seen particularly in COVID (or post-) patients with uncontrolled diabetes, on steroids, or cocktail therapy, or living in unhygienic environments. So judicious and relevant use of various medicines (drug stewardship) along with strict maintenance of personal and environmental hygiene is the key to prevent CAMA in COVID era. Patients should be advised to keep a check on their glycaemic index and seek medical advice at the e...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  3. Version published to 10.1101/2021.08.09.21261555v1 on medRxiv