S5.5d SARS-CoV-2 associated invasive fungal sinus infections; the Sri Lankan perspective
Authors: Thabrew H , Sigera Liyanage Shamithra Madhumali , Anand A P , Ramanayake R A D M , M V Munasinghe , Wickramasekara W L L N , Jayasekera P I 
Published: September 2022

Abstract

S5.5 Genomic epidemiology of fungal infections, September 22, 2022, 3:00 PM - 4:30 PM

Introduction
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to 663 426 reported cases and 16 506 deaths as of May 5, 2022, in Sri Lanka recording the worst pandemic of the modern era. Coronavirus 2019 (COVID-19) associated mucormycosis has caused an epidemic within the pandemic in the neighboring India leading to soaring case numbers estimated at 140 per million population recording 80 times higher prevalence in comparison to developed countries. On the contrary, Sri Lanka has not seen a rise in COVID-19-associated fungal infections on a similar scale, even though geophysical conditions are shared.

Objective
This study was done with the aim of exploring the epidemiology of COVID-19-associated invasive sinus infections in Sri Lanka.

Methods
A retrospective study was done on the sinus samples received from patients suspected of having COVID-19-associated invasive fungal sinusitis. The study was done during the third wave of the pandemic in Sri Lanka from May 1, 2021 to March 31, 2022. Multiple sinus samples from all SARS-CoV-2 PCR-positive patients received at the Mycology Reference Laboratory of the Medical Research Institute were included in the study. The presence of pauci septate broad fungal filaments with wide angle branching was considered suggestive of mucormycosis and the presence of mucormycetes fungi in the culture of the specimen was considered confirmatory for mucormycosis. Similarly, the presence of thin hyaline branching septate fungal filaments was considered suggestive of fungal infection, and the organism was confirmed by the presence of growth in the culture. Available details on the request forms were analyzed to identify demographic data and risk factors in COVID-19-associated invasive sinus infections.

Results
A total of 133 sinus samples were received from 102 SARS-CoV-2 PCR-positive patients during the third wave. All 45 patients (44%, 45/102) had positive findings indicating fungal sinusitis. The median age was 56 (IQR 48-61) years in the patients with fungal sinusitis. A majority (60%) of them were female patients. Microscopic and/or culture-positive mucormycosis was demonstrated in 35 (34%, 35/102) patients. Culture-proven mucormycosis was seen in 20 patients while direct microscopic evidence was seen in 28 patients. All mucormycosis patients isolated Rhizopus arrhizus which was identified by morphological methods. A total of 4 patients (4%, 4/102) had A. fumigatus growing in the culture, 2 patients with A. flavus and 1 with A. terreus sinus infection were seen. Mixed growth of A. flavus and Rhizopus arrhizus was seen in 1 patient. Risk factors were not mentioned in 23 patients. Diabetes mellitus was found in 31% (11/35) of patients with mucormycosis, while 2 patients had chronic kidney disease and 1 had hypertension.

Conclusion
This study demonstrates that fungal sinusitis is a significant entity in Sri Lanka with 34% proven mucormycosis infection in the samples received at the Mycology Reference Laboratory from SARS-CoV-2 PCR positive patients. Diabetes mellitus was seen in 31% of the COVID-19-associated mucormycosis cases. However, further studies are required to establish the effect of risk factors on mucormycosis.