How is mucormycosis involved in some cases of COVID-19?

Updated: Jul 06, 2021
  • Author: Avnish Sandhu, DO; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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The COVID-19 pandemic, caused by severe SARS-CoV-2, has affected 177 million people worldwide and accounts for 3.82 million deaths as of June 2021. COVID-19 disease can be complicated by secondary bacterial infection; however, reports of invasive fungal infection (COVID-19-associated pulmonary aspergillosis, Pneumocystosis, and mucormycosis) are rising. [47]  The incidence of COVID-19-associated mucormycosis (CAM) has increased in India, with more than 20,000 cases reported. [48, 49, 50, 51]

COVID-19 has a predisposition to cause extensive lung damage, which promotes colonization and infection of invasive fungi of airway, sinuses, and lung. [48, 52, 53, 54, 55]  Alteration in T cell immunity, use of steroids, and broad-spectrum antibiotics are additional risk factors for acquiring invasive fungal infection. [48, 52, 53, 54, 55]  COVID-19 disrupts iron metabolism, resulting in high ferritin state and increasing intracellular iron, which causes tissue damage. This causes more iron to be released into the circulation, and it is this increase in free iron that is a risk factor for mucormycosis. [47]  

Diabetes mellitus has been previously described in this chapter as a risk factor for mucormycosis. Patients with diabetes and infected with SARS-CoV2 are at increased risk for mucormycosis. High expression of ACE-2 receptors in pancreatic islets caused by SARS-CoV-2 results in insulin resistance leading to poorly controlled diabetes, further increasing the risk for mucormycosis.

A retrospective study conducted in India from September -December 2020, reported a 2.0 fold rise in 2020 compared to 2019 of COVID-19 mucormycosis, with prevalence of 0.27% among hospitalized COVID-19 patients; the most common clinical manifestation was rhino-orbital form. [56]  Case fatality at 12 weeks was 45.7% with no difference in mortality among COVID-19 and non-COVID-19 patients. [56]

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