P163 Successful management of COVID-19-associated mucormycosis in state of pernambuco, northestearn brazil: 2 case reports
Authors: Batista Filipe , Araújo Eduardo , Takano Daniela , Ferraz Claudia , Guerra Carolina , Ferraz Tiago , Batista Renata , Batista Camila , Neto Reginaldo Lima 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Objectives
During the COVID-19 pandemic, several cases of mucormycosis related to SARS-CoV-2 were reported. This association is still poorly studied due to its recent emergence and makes diagnosis and treatment challenging. Usually, patients who are affected by this infection are immunocompromised by corticosteroid treatment and uncontrolled diabetes mellitus, being mucormycosis a life-threatening opportunistic invasive fungal infection caused by mucoromycetes, which reaches a mortality rate of about 50%, even with treatment. Thus, this association requires as much information as possible about the pathogenesis and treatment.

Methods
Here, we report two cases with conclusive diagnosis and positive evolution to mucormycosis associated with COVID-19 after corticosteroid therapy.

Results
The first case was a 68-year-old woman, hypertensive and diabetic, who was affected by SARS-CoV-2, with intense ocular pain and paralysis of extrinsic ocular muscles of the right eye and eyelid. The patient underwent CT scan of the sinuses with contrast, which showed signs on maxillary. The patient was submitted to sinusectomy with orbital decompression and the material from the surgery was sent for fungal investigation, which 20% KOH direct exam showed hyaline, sparsely-septate, broad, ribbon-like hyphae with irregular right-angle branching. Rhizopus oryzae was isolated on Sabouraud agar. Mucormycosis was diagnosed in the facial sinuses, and resolution of infection was obtained with liposomal amphotericin B. The second case was a 59-year-old woman, obesity degree 3, asthmatic and history of COVID-19, with history of abscesses in oral mucosa and palate, with drainage of brown secretion after 30 days of COVID-19 resolution. After medical discharge, the patient was evaluated by an oral and maxillofacial surgeon to solve an esthetic problem, when the material was collected for biopsy of the mucosal lesions. Histopathological exam showed aseptic thick mycelial filaments presenting right angle bifurcation, suggestive of Mucorales (mucormycosis). The patient was readmitted to the hospital for mucormycosis treatment based on isavuconazole (200 mg, q8 as attack dose on Day 1 and 2, and 3 toward q24), and treatment evolved positively with no need for surgical intervention. We conclude that the extensive use of steroids associated with diabetes is the main factor for the appearance of mucormycosis after COVID-19, but with a conclusive diagnosis and correct treatment, this infection can have a good evolution, resulting in an improvement in the patient's clinical condition, reducing the risk of death for this infection.

Conclusion
Isavuconazole appears to be a drug with a safe profile and with curative potential for mucormycosis. The possibility of oral use from the third day at its maintenance dose (200 mg/day) with intravenous use in the first 48 h at a dose of 200 mg every 8 h. Diabetic patients are more prone to infection, but patients infected with SARS CoV 2 using corticosteroids have shown to be a risk group for this fungus.