Simplified screening and referral protocol for sinonasal mucormycosis in post COVID-19 patients

Abstract

Background

To study incidence of sinonasal mucormycosis in active and post COVID-19 patients in a district-level hospital in India and develop a simplified screening and referral protocol for use at peripheral centres to aid rapid diagnosis/treatment.

Methods

Study design: A prospective, interventional cohort study conducted from April 2021 to January 2022. Setting: Secondary level hospital in North India. Inclusion criteria: COVID-19 positive patients with diabetes mellitus as co-morbidity and with at least one of the following: received steroid therapy and/or on high flow oxygen therapy and/or had prolonged hospital stay (> 7 days). Exclusion criteria: Patients already immunocompromised/having malignancy/organ transplant recipients. Clinical workup: History, examination, imaging (CECT/MRI nose and paranasal sinuses if indicated), diagnostic nasal endoscopy + Nasal scrapings for KOH mount to detect fungal elements. STROBE guidelines were followed in the study.

Results

Fourteen out of 250 patients tested positive for mucormycosis (incidence 5.6%). Thirteen were symptomatic, one patient was asymptomatic and detected on screening. No significant difference was found in mucormycosis versus non-mucormycosis group with respect to HbA1c status, vaccination status or steroid + oxygen treatment (p > 0.05 in all scenarios). Patients were treated with intravenous liposomal amphotericin B and surgical debridement when indicated. Two succumbed to disease (survival 85.7%). A clinical screening protocol was thus developed which can be used as an effective tool even at far-flung and remote healthcare facilities for diagnosis and timely referral of patients.

Conclusions

Mucormycosis is a potentially lethal disease which needs rapid diagnosis and timely action to decrease morbidity and mortality.

Key points

COVID causes immunosuppression.

COVID and diabetes mellitus together cause synergistic immune dysregulation.

Such patients are very vulnerable to develop opportunistic infections like Mucormycosis.

Our proposed screening protocol is easy-to-use even by minimally-trained healthcare workers.

Asymptomatic patients diagnosed with mucormycosis are relatively rare. Therefore, clinicians need to be vigilant of symptoms of ROCM.