Mucormycosis: Covid’s Deadly Companion

The pandemic Covid-19 is continuing to spread around the world, with more than 200 million confirmed cases and four million deaths across nearly 200 countries. The SARS-CoV-2 was first identified in Wuhan, Hubei Province, China, in December 2019. The virus is primarily transmitted by inhalation or contact with infected droplets. The Second wave of COVID-19 is affecting most of the world but the scenario is very grim in India. The healthcare system collapsed in India during the second wave due to a surge in COVID cases leading to rise in opportunistic infections. Unfortunately, some Covid-19-treated patients develop Mucormycosis, also known as Black Fungus, which is a deadly infection. The mucormycosis epidemic in India has brought into sharp focus the seriousness of fungal infections and the relatively poor state of the science on their prevention, diagnosis, and management. Some of the variables responsible for the rise in mucormycosis cases in India include the inappropriate use of steroids and other immunomodulators, contaminated oxygen supplies, and poor glycemic management in a population with a preexisting risk of diabetes. Diabetes was discovered to be the most significant risk factor of them all. The current review mainly focuses on all the possible aspects for the rise in mucormycosis in covid patients in India along with its severity, diagnosis and treatment. Aishwarya Kashelkar1, Minakshi Nehete1* 1C. U. Shah College of Pharmacy, S.N. D.T. Women’s University, Sir Vithaldas Vidya Vihar, Juhu Campus, Santacruz (W), Mumbai-400049, Maharashtra, India. Submitted: 23 September 2021 Accepted: 29 September 2021 Published: 30 October 2021 www.ijppr. humanjournals.com Citation: Minakshi Nehete et al. Ijppr.Human, 2021; Vol. 22 (3): 387-402. 388 INTRODUCTION: Coronaviruses are a diverse group of viruses infecting many different animals, and they can cause mild to severe respiratory infections in humans being highly transmissible, this novel coronavirus disease 2019 (COVID-19), has spread fast all over the world [1]. WHO declared coronavirus disease 2019 (COVID-19), as a global pandemic in March 2020. Till now more than 200 million cases of covid-19 are being reported worldwide. India is rated second in the number of covid cases. In terms of infectiousness, severity, and symptoms, the lethal second wave of the COVID-19 pandemic that attacked India in April-May was substantially different from the first wave that struck in 2020. The upsurge in the cases in India during the second wave was mainly driven by the delta variant which was first detected in the South Asian nation and has now spread to over 80 countries. At the height of its second wave in May, India was seeing more than 400,000 confirmed daily infections far higher than the 97,000 per day peak it experienced last September. This escalation in the covid cases had made a way for the rise in opportunistic infections. Secondary infections are widespread in hospitalized, critically ill Covid-19 patients, accounting for 10 to 30 percent of cases, with fungal infections being 10 times more likely. One such opportunistic infection is Mucormycosis which although has a low incidence rate, varying from 0.005 to 1.7 per million populations globally [2]. In the aftermath of the continuing coronavirus pandemic, many instances have been seen recently, indicating a major increase in its incidence. It's the third most prevalent invasive fungal infection, and it's associated with a high rate of morbidity and mortality [3]. Mucormycosis has a 46 percent fatality rate worldwide [4]. It was reported that a large majority of the mucormycosis patients, constituting 84.4 percent, had a history of coronavirus disease. Mucormycosis or Zygomycosis is a rare, angioinvasive, rapidly progressive, and lifethreatening fungal infection caused by ubiquitous fungus that belong to class Zygomycetes and order Mucorales [5]. Mucormycosis is defined by tissue infarction and necrosis in the host tissues as a result of hyphae invading the vasculature [6]. The most frequently reported pathogens in mucormycosis are Rhizopus spp, Mucor spp, and Lichtheimia spp, followed by Rhizomucor spp, Cunninghamella spp, Apophysomyces spp, and Saksenaea spp [7]. Rhizopus arrhizus been the most common agent causing mucormycosis in India and globally [8] followed by Apophysomyces variabilis. Rhizopus arrhizusis is responsible for nearly 60% of mucormycosis cases in humans and also accounts for 90% of the Rhino-orbital-cerebral (ROCM) form [2,9]. www.ijppr. humanjournals.com Citation: Minakshi Nehete et al. Ijppr.Human, 2021; Vol. 22 (3): 387-402. 389 While several treatment options for COVID-19 have been evaluated, none except systemic glucocorticoids have been shown to improve survival in COVID-19. Use of systemic glucocorticoids to improve survival in COVID-19 has triggered mucormycosis to a greater extent. Major factors such as Diabetes mellitus, COVID-19, the widespread use of steroids, broad-spectrum antibiotics, antiparasitics, antivirals as a part of cocktail therapy used against COVID-19 even in mild cases with no strict prescription checks in India and most drugs including glucocorticoids readily available over the counter had led to surge in Mucormycosis cases in India [10]. Mucormycosis is difficult to diagnose. As a result, early diagnosis and treatment are critical, as even a 6-day delay doubles 30-day mortality from 35 percent to 66 percent [5]. Despite early diagnosis and aggressive combined surgical and medical therapy, the prognosis for recovery from mucormycosis is poor [11]. Four general principles are critical for managing mucormycosis: rapid diagnosis, reversal of underlying predisposing factors, surgical debridement of infected tissue and appropriate antifungal therapy [12]. Liposomal Amphotericin B has been the drug of choice for its treatment.