Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 2715  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
E-IJD® - SHORT COMMUNICATION
Year : 2022  |  Volume : 67  |  Issue : 2  |  Page : 206
Secondary cutaneous mucormycosis post-COVID-19: Case series from a tertiary center


1 Department of Dermatology, Venereology, Leprosy, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 Department of Microbiology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

Date of Web Publication13-Jul-2022

Correspondence Address:
B Abhirami
Room No: 162, New PG Girls Hostel (Ghaghari Hostel), Rajendra Institute of Medical Sciences (RIMS), Bariatu, Ranchi - 834009, Jharkhand
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_781_21

Rights and Permissions

   Abstract 


Background: Mucormycosis is an angioinvasive mucorales fungal infection. Cutaneous type formed 10.5% of cases in India in precovid-19 era. Glucocorticoid-induced immunosuppression and hyperglycemia, reusable oxygen humidifiers in COVID-19 therapy, and preexisting uncontrolled diabetes mellitus contribute to post-COVID-19 mucormycosis. However, for post-COVID-19 cutaneous mucormycosis, sufficient data is not available. Aim: To study factors related to post-COVID-19 cutaneous mucormycosis. Methodology: Clinical and investigation details of six patients admitted in tertiary center with post-COVID-19 cutaneous mucormycosis. Results: Among six patients, three were males and three females; all in 45–60 years age group from districts under tertiary center. Site of eschar was face (four) and lips (two). All six were positive for COVID-19 10–12 days prior to admission for mucormycosis. All had intravenous steroids and supportive humidified oxygen therapy for minimum 1 week under COVID-19 treatment. They presented to emergency with ophthalmic/ENT complaints; subsequently, they developed cutaneous manifestations within 2–3 days. All six had diabetes mellitus, with above 400 mg/dL sugar levels at admission. Conclusion: This study's findings correlated with various studies across the country and elsewhere. Preexisting diabetes mellitus and steroid therapy for COVID-19 increase the risk of mucormycosis. Caution for early diagnosis, maintaining blood glucose levels, and judicious use of steroids for treatment of COVID-19 are indicated.


Keywords: Cutaneous mucormycosis, diabetes mellitus, eschar, post-COVID-19, steroid induced


How to cite this article:
Abhirami B, Kumar P, Mishra DK, Yadav SP. Secondary cutaneous mucormycosis post-COVID-19: Case series from a tertiary center. Indian J Dermatol 2022;67:206

How to cite this URL:
Abhirami B, Kumar P, Mishra DK, Yadav SP. Secondary cutaneous mucormycosis post-COVID-19: Case series from a tertiary center. Indian J Dermatol [serial online] 2022 [cited 2022 Aug 17];67:206. Available from: https://www.e-ijd.org/text.asp?2022/67/2/206/350849





   Introduction Top


Mucormycosis among COVID-19 and post-COVID-19 patients is reported in second wave from March 2021.[1] Seven thousand mucormycosis were reported so far in India. However, there are very few reports on post-COVID-19 cutaneous mucormycosis. This paper reports occurrence and possible factors related to post-COVID-19 cutaneous mucormycosis in a tertiary hospital.

Aims and objectives

To study factors related to post-COVID-19 cutaneous mucormycosis.


   Materials and Methods Top


A case series of six patients with post-COVID-19 cutaneous mucormycosis admitted in a tertiary center (31/05/2021 to 06/06/2021 – posting time of the first investigator in COVID duty) is described with microbiological confirmation for one patient.


   Results Top


Informant was either the patient or attendant.

Summary of clinical details of all six patients [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] is in [Table 1].
Figure 1: Fifty-five-year-old female with eschar on the face

Click here to view
Figure 2: Fifty-six-year-old male with eschar on the lower lip

Click here to view
Figure 3: Fifty-four-year-old male with eschar on the lower lip

Click here to view
Figure 4: Fifty-eight-year-old female with eschar on the face

Click here to view
Figure 5: Forty-eight-year-old male with eschar on the face

Click here to view
Figure 6: Forty-six-year-old female with eschar on the face

Click here to view
Table 1: Details of the six patients with post-COVID-19 cutaneous mucormycosis

Click here to view


In all cases, face was site of cutaneous manifestation. Four patients developed eschar over skin adjacent to upper half of nose and below affected eye. Two had eschar on lower lip. Though mucormycosis was rapidly progressive, cutaneous mucormycosis was asymptomatic and slowly progressive in size, as per history by the patient's attender.

Biopsy from eschar of the first patient showed fungal hyphae on KOH mount [Figure 7] and black colonies of Rhizopus oryzae on Sabouraud agar [Figure 8] confirming cutaneous mucormycosis.
Figure 7: KOH mount showing fungal hyphae

Click here to view
Figure 8: Black colonies of Rhizopus oryzae in Sabouraud agar

Click here to view


All six patients were above 45 years (range 45–60 years), three males and three females from referral area of this tertiary center. They had tested positive for COVID-19 previously (hospital records) and recovered from illness from various nongovernment hospitals in the state. Their COVID-19 illness occurred –10–12 days prior to symptoms of mucormycosis.

Initial symptoms involved ophthalmic/ENT complaints which started 1/2 days after the patient tested negative for COVID-19. Skin manifestations occurred –2–3 days after initial symptoms among all six patients.

All received injectable dexamethasone 8 mg twice daily for at least 1 week followed by oral tapering steroids for another week and humidified oxygen for minimum 1 week during hospitalization for COVID-19. They had coexisting diabetes mellitus with fasting sugar between 250 and 300 mg/dL and post prandial sugar between 350 and 500 mg/dL following steroid administration during COVID-19. Their RBS at admission were above 350 mg/dL.

Of the six patients, one had received both doses of covishield vaccine.


   Discussion Top


All six patients developed cutaneous mucormycosis as necrotic eschar with surrounding erythema and induration.[2],[3] Face, the classically affected site,[3],[4] was site of cutaneous mucormycosis in all cases. Cutaneous lesions developed either after rhino-cerebral or rhino-orbital mucormycosis without preexisting history of trauma; hence, they classified as secondary cutaneous mucormycosis.[3],[4],[5]

Punch skin biopsy for KOH mount and Sabouraud dextrose agar culture for fungal elements are approved methods for confirming diagnosis.[3],[6]

All six patients were in 45–-60 years age group as also reported by KR Kumar et al.[7] There were three males and three females. However, Singh AK et al.[1] and Nurettin Bayram et al.[8] reported post-COVID-19 mucormycosis predominantly among males.

All of them tested positive and received treatment under COVID-19 protocol. They developed mucormycosis 10–12 days after COVID-19, which agrees with Nurettin Bayram et al.[8] and Deepak Garg et al.[9]

Patients in this study received injectable steroids twice daily for minimum 1 week; then oral tapering steroids for another week for COVID-19 and subsequently developed mucormycosis as comparable to reports by Singh AK et al.,[1] Asri S et al.,[5] Bayram et al.,[8] Garg et al.,[9] Khatri et al.,[10] S Sharma et al.,[11] and Mainak Banerjee et al.[12] RECOVERY trial[13] observed injectable dexamethasone 6 mg once daily for 10 days as optimum dose for COVID-19. They had received humidified oxygen during COVID-19 treatment and developed cutaneous mucormycosis thereafter. La Fauci V et al.[14] reported reusable oxygen humidifiers play a role in transmission of nosocomial pathogens through aerosol. Asri S et al.[5] reported increase in mucormycosis infection following use of low-quality industrial-grade oxygen cylinders and tap water in humidifiers.

They had diabetes mellitus and uncontrolled sugar profile at admission and developed clinical manifestations of mucormycosis subsequently as with Singh et al.,[1] Bonifaz A,[4] Bayram et al.,[8] Garg et al.,[9] Akshay Khatri et al.,[10] S Sharma et al.,[11] and Mainak Banerjee et al.[12]

One had received both doses of covishield vaccine. Shah KM et al.[15] reported cutaneous mucormycosis at injection site following COVID-19 vaccination (Moderna).

Thus, factors related to post-COVID-19 cutaneous mucormycosis could be the same as post-COVID-19 mucormycosis; however, study on larger sample will help comment on the same.


   Limitations Top


Detailed comment on post-COVID-19 cutaneous mucormycosis in this tertiary center is not possible as study includes only patients seen during first investigator's COVID-19 posting.


   Conclusion Top


This study reports post-COVID-19 cutaneous mucormycosis during the second wave of COVID-19 from this tertiary center. Preexisting diabetes mellitus and uncontrolled sugar levels, excessive use of steroids, and use of humidified oxygen for COVID-19 are main factors in the development of rhino-orbital/rhino-cerebral mucormycosis and subsequently cutaneous mucormycosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr 2021;15:102146.  Back to cited text no. 1
    
2.
Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis 2012;54(Suppl 1):23-34.  Back to cited text no. 2
    
3.
Castrejón-Pérez AD, Welsh EC, Miranda I, Ocampo-Candiani J, Welsh O. Cutaneous mucormycosis. An Bras Dermatol 2017;92:304–11.  Back to cited text no. 3
    
4.
Bonifaz A, Tirado-Sánchez A, Hernández-Medel ML, Kassack JJ, Araiza J, González GM. Mucormycosis with cutaneous involvement. A retrospective study of 115 cases at a tertiary care hospital in Mexico. Australas J Dermatol 2021;62:162-7.  Back to cited text no. 4
    
5.
Asri S, Akram MR, Hasan MM, Asad Khan FM, Hashmi N, Wajid F, et al. The risk of cutaneous mucormycosis associated with COVID 19: A perspective from Pakistan. Int J Health Plann Manage 2022;37:1157-9.  Back to cited text no. 5
    
6.
Skiada A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and diagnosis of mucormycosis: An update. J Fungi 2020;6:265.  Back to cited text no. 6
    
7.
KR Kumar P. Mucormycosis: A black fungus- post covid complications. J Regan Biol Med 2021;3:1-8  Back to cited text no. 7
    
8.
Bayram N, Ozsaygili C, Sav H, Tekin Y, Gundogan M, Pangal E, et al. Susceptibility of severe COVID-19 patients to rhino-orbital mucormycosis fungal infection in different clinical manifestations. Jpn J Ophthalmol 2021;65:515-25.  Back to cited text no. 8
    
9.
Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, et al. Coronavirus disease (Covid-19) associated mucormycosis (CAM): Case report and systematic review of literature. Mycopathologia 2021;186:289-98.  Back to cited text no. 9
    
10.
Khatri A, Chang KM, Berlinrut I, Wallach F. Mucormycosis after coronavirus disease 2019 infection in a heart transplant recipient-Case report and review of literature. J Mycol Med 2021;31:101125.  Back to cited text no. 10
    
11.
Sharma S, Grover M, Bhargava S, Samdani S, Kataria T. Post coronavirus disease mucormycosis: A deadly addition to the pandemic spectrum. J Laryngol Otol 2021;135:442-7.  Back to cited text no. 11
    
12.
Banerjee M, Pal R, Bhadada SK. Intercepting the deadly trinity of mucormycosis, diabetes and COVID-19 in India. J Postgrad Med 2021;8:140537.  Back to cited text no. 12
    
13.
Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, et al. Dexamethasone in hospitalised patients with COVID-19. N Engl J Med 2021;384:693-704.  Back to cited text no. 13
    
14.
La Fauci V, Costa GB, Facciolà A, Conti A, Riso R, Squeri R. Humidifiers for oxygen therapy: What risk for reusable and disposable devices? J Prev Med Hyg 2017;58:E161-5.  Back to cited text no. 14
    
15.
Shah KM, West C, Simpson J, Rainwater YB. Cutaneous mucormycosis following COVID-19 vaccination in a patient with bullous pemphigoid. JAAD Case Rep 2021;15:80-1.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (1,877 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Limitations
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed202    
    Printed18    
    Emailed0    
    PDF Downloaded2    
    Comments [Add]    

Recommend this journal