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| CASE REPORT |
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| Year : 2022 | Volume
: 5
| Issue : 3 | Page : 113-115 |
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Post-COVID mixed fungal infection – A case report and review of literature
P Sivakumar, K Krishnamoorthy, T Joseph Pratheeban, E Mathan, OM Rahman, Shahul Hameed
Department of Respiratory Medicine, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India
| Date of Submission | 12-Jun-2022 |
| Date of Decision | 23-Jan-2023 |
| Date of Acceptance | 01-Feb-2023 |
| Date of Web Publication | 01-Mar-2023 |
Correspondence Address:
Dr. P Sivakumar
Department of Respiratory Medicine, Tirunelveli Medical College, Tirunelveli, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/japt.japt_17_22
In the COVID-19 pandemic era, an increasing number of cases of mucormycosis have been associated with COVID-19. Mucormycosis is an invasive fungal infection in the background of immunosuppression state. COVID-19 and its treatment cause immunosuppression in patients. Mucormycosis commonly causes necrosis in the nose, paranasal sinuses, and facial bones and may also spread into the brain and lungs. A 58-year-old male, who was a known case of diabetes mellitus, was admitted with COVID-19 reverse transcription–polymerase chain reaction positive and B/L GGO with 50% lung involvement in computed tomography (CT) chest, treated as per protocol, and discharged. After 2 weeks of discharge patient presented with hemoptysis, cough with expectoration and breathlessness. Patient was admitted and stabilized. CT chest taken showed right (Rt) upper lobe and lower lobe mucormycosis and left (Lt) upper lobe and lower lobe aspergilloma. Fiberoptic bronchoscopy was done and bronchial wash taken then sent for fungal KOH and culture.fungal culture report showed mixed fungal infection like mucormycosis and aspergilloma. Patient treated with tablet posaconazole and other supportive measures and discharged. Patient asked to review every month. Followup CT chest taken at 1 month and end of 5 months. CT chest revealed partial resolution of Rt upper and lower lobe mucormycosis and persistence of Lt upper and lower lobe aspergilloma lesions. The patient persistently had hemoptysis and hence was referred to cardiothoracic surgery for surgical management of aspergilloma. COVID-19 and treatment of COVID-19 cause underlying immunosuppression that leads to fungal infections such as mucormycosis and aspergilloma. Early identification and treatment of fungal infection reduce morbidity and mortality.
Keywords: Aspergilloma, COVID-19, mixed fungal infection, mucormycosis
How to cite this article:
Sivakumar P, Krishnamoorthy K, Pratheeban T J, Mathan E, Rahman O M, Hameed S. Post-COVID mixed fungal infection – A case report and review of literature. J Assoc Pulmonologist Tamilnadu 2022;5:113-5 |
How to cite this URL:
Sivakumar P, Krishnamoorthy K, Pratheeban T J, Mathan E, Rahman O M, Hameed S. Post-COVID mixed fungal infection – A case report and review of literature. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2023 Mar 21];5:113-5. Available from: https://www.japt.in//text.asp?2022/5/3/113/370806 |
| Introduction | |  |
COVID-19 pandemic and treatment of COVID-19 have been associated with the increasing trend of fungal infections such as mucormycosis and aspergilloma in COVID-recovered patients. Mucormycosis occurs in immunocompromised and diabetic ketoacidosis. It commonly affects the paranasal sinuses, orbit, facial bones, brain, and lungs.[1] It causes thrombosing vasculitis, infarction, and inflammation and is followed by tissue necrosis.[2] Pulmonary mucormycosis causes fatal morbidity and mortality; early identification and treatment will reduce the morbidity and mortality.
| Case Report | | |
We report a 58-year-old male, who was a known case of diabetes mellitus on drugs for the past 2 years. He was admitted with COVID-19 reverse transcription–polymerase chain reaction positive and Ground Glass Opacity (GGO) with 50% lung involvement in computed tomography (CT) chest [Figure 1]; treated with oxygen via nonrebreather mask, remdesivir, steroids, and heparin as per protocol; and discharged after 14 days with good improvement. After 2 weeks of discharge, the patient presented with hemoptysis, cough with expectoration, and breathlessness. On admission, the patient was conscious, afebrile, dyspneic, and tachypneic, and his saturation was 96% at room air, pulse rate - 90/min, respiratory rate - 22/min, blood pressure - 110/70 mmHg, auscultation of RS-Bilateral infrascapular crepts heard, chest X-ray showed right (Rt) middle and lower zone heterogeneous opacity with left (Lt) mid and lower zone homogeneous opacity. CT chest revealed Rt upper and lower lobe cavity with consolidation and Lt upper and lower lobe soft-tissue density within the cavity lesion suggestive of Rt side mucormycosis and Lt side aspergilloma [Figure 2]. After stabilization of the patient, fiberoptic bronchoscopy was done and bronchial wash taken sent for fungal KOH, culture and sensitivity revealed mixed fungal infection Mucorales and Aspergillus. Otorhinolaryngology, Ohthalmology, Neurology opinion was obtained, the patient was treated with tablet posaconazole 300 mg BD on day 1, followed by tablet posaconazole 300 mg OD on day 2 onward and other supportive measures, patient condition improved and then discharged. The patient was followed at 1 month [Figure 3], and after 5 months of posaconazole treatment, follow-up CT chest revealed complete resolution of Rt upper and lower lobe mucormycosis and persistence of Lt upper and lower lobe aspergilloma [Figure 4] manifesting as recurrent hemoptysis; hence, the patient was referred to cardiothoracic surgery for surgical management. Planned for surgery, in the meantime, the patient had massive hemoptysis and deterioration of general condition and dead. | Figure 1: CT chest - During COVID-19 RT-PCR positive. CT: Computed tomography, RT-PCR: Reverse transcription–polymerase chain reaction
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 | Figure 2: CT chest - During presenting with hemoptysis. CT: Computed tomography
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 | Figure 3: CT chest - After 1 month of posaconazole treatment. CT: Computed tomography
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 | Figure 4: CT chest - After 5 months of posaconazole treatment. CT: Computed tomography
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| Discussion | | |
Objective
The objective of this study was to discuss the pathophysiology and management of mucormycosis in COVID-19-recovered patients.
Pathophysiology
According to published literature of COVID-19 and its treatment also contribute to the development of mucormycosis.[3] Following factors such as COVID-19-induced lymphopenia resulting in reduced availability of T-cells and favorable for the entry of opportunistic fungal infection.[1] Hyperferritinemia and high serum iron induce a defect in innate and adaptive immunity and also favor for the growth of Mucorales.[1] Free radical-induced endothelial dysfunction, Hepcidin activation induces ferritin independent of the inflammatory reaction. Upregulation of glucose receptor protein is an essential receptor for vascular invasion of Mucorales through its spore coat protein.[4] Virus-induced pulmonary tissue damage favors opportunistic fungal infection.[5] High blood sugar and steroid use in the treatment of COVID19 also causes an immune defect, which impairs the phagocytes to eliminate the fungi. ketoacidosis also favors the growth of Mucorales.[6] Complicated pathophysiology favors for the development of mucormycosis and other fungal infections in COVID-19-recovered patients.[7]
Management
Treatment of mucormycosis involves the combination of antifungal and surgical debridement. Elimination of predisposing factors such as high blood sugar, ketoacidosis, immunosuppressive drugs, iron overload, and judicial use of steroid for the treatment will prevent the development of mucormycosis.
Antifungal drugs
Early initiation of antifungal in mucormycosis will improve the treatment outcome.Amphotericin B is the drug of choice .5 mg/kg dose daily. Nephrotoxicity less in liposomal preparation of amphotericin B, then step down the therapy with posaconazole 300 mg BD on day 1, followed by posaconazole 300 mg OD on day 2 onward for or isavuconazole orally.[2] Duration of treatment individualized depends on the improvement of symptoms and near resolution of radiological findings.
Surgery
Early lobectomy or pneumonectomy with antifungal therapy will improve the outcome of pulmonary mucormycosis.
| Conclusion | | |
Early detection of pulmonary mucormycosis and early medical and surgical treatment will reduce the mortality in pulmonary mucormycosis. Treat the underlying comorbid condition and avoidance of severe immunosuppression also important in the outcome of pulmonary 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 | | |
| 1. | |
| 2. | Gupta R, Kesavadev J, Krishnan G, Agarwal S, Saboo B, Shah M, et al. COVID-19 associated mucormycosis: A descriptive multisite study from India. Diabetes Metab Syndr 2021;15:102322.  |
| 3. | |
| 4. | Spellberg B, Edwards J Jr., Ibrahim A. Novel perspectives on mucormycosis: Pathophysiology, presentation, and management. Clin Microbiol Rev 2005;18:556-69. |
| 5. | Aranjani JM, Manuel A, Abdul Razack HI, Mathew ST. COVID-19-associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic's second wave in India. PLoS Negl Trop Dis 2021;15:e0009921. |
| 6. | Banerjee M, Pal R, Bhadada SK. Intercepting the deadly trinity of mucormycosis, diabetes and COVID-19 in India. Postgrad Med J 2022;98:e108-9. |
| 7. | Singh Y, Ganesh V, Kumar S, Patel N, Aggarwala R, Soni KD, et al. Coronavirus Disease-Associated Mucormycosis from a Tertiary Care Hospital in India: A Case Series. Cureus 2021;13:e16152. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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