Stress Events and Other Risk Factors for Mucormycosis Among Diabetic Individuals, Bathinda, Punjab: A Case-Control Study

Background & objectives : Mucormycosis is a rare fungal infection that contributes to the high mortality rate of 45–90% reported in India. In November 2023, India’s National Disease Surveillance Program identified a surge in mucormycetes fungal infection among reported cases at All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab. The descriptive analysis identified diabetes and acute stress events (hospitalizations, surgeries, dental procedures, or trauma in the past 6 weeks) among 70% and 50% of cases, respectively. A case-control study was conducted among individuals with diabetes to identify stress events and other risk factors for mucormycosis. Methods : A case was defined diabetic individual diagnosed with mucormycosis by both clinical presentation and microbiological confirmation (KOH/cacoflour white microscopy) and imaging (CT scan) in hospital X between January 2023 and June 2024. Sample size was assumed to be 50% exposure to stress events among cases and 25% among controls, with a 2:1 control-to-case ratio, 95% CI, and 80% power. Controls were diabetics attending a non-communicable disease clinic in the same hospital who did not have mucormycosis between January 2023 and June 2024. The participants were interviewed using a semi-structured questionnaire to collect information on their socio-demographics and potential exposures. The adjusted odds ratio (aOR) was calculated with a 95% confidence interval. Results : Among the 36 cases, the median age was 54 years (IQR: 45–61), with 81% being males; 102 controls had a median age of 52 years (IQR: 43–61), with 55% being males. Rural residence was reported in 75% of cases compared to 63% of controls, while other comorbidities, apart from diabetes, were observed in 36% of cases and 49% of controls. The sites primarily affected by mucormycosis were rhino-orbital-cerebral (78%) and pulmonary (10%) cases. In multivariate analysis, acute stress events (aOR=3.2; 95%CI= 1.1-9.3), cattle handling (aOR=4.9; 95%CI= 1.8-13.3), and using earthen pots for drinking water storage (aOR=3.7; 95%CI= 1.4-9.4) were identified as significantly increasing the odds of developing mucormycosis. Conclusions : It is recommended that individuals with diabetes and those with soft tissue injuries use personal protective equipment when handling cattle. Sensitise clinicians on the role of stress events in identifying high-risk individuals and raise awareness among people with diabetes about associated risks, including the use of earthen pots for water storage.