key: cord-0701529-8j5sdn5b authors: Kumar, Rabish; Singh, Meeta; Sagar, Tanu; Bharanidharan,; Khurana, Nita; Kumar, Vikas; Meher, Ravi; Malhotra, Vikas; Goel, Ruchi; Saxena, Sonal; Kumar, Jyoti title: Sensitivity of liquid‐based cytology in the diagnosis of mucormycosis in COVID‐19 treated patients date: 2022-05-02 journal: Cytopathology DOI: 10.1111/cyt.13131 sha: e94145d454b40695c640e9d46438e8f73331678a doc_id: 701529 cord_uid: 8j5sdn5b BACKGROUND: The coronavirus disease 2019 (COVID‐19) infection caused by the novel severe acute respiratory syndrome corona virus 2 (SARS‐CoV‐2) is associated with a wide range of disease patterns, ranging from mild to life‐threatening pneumonia. COVID‐19 can be associated with a suppressed immune response and/or hyperinflammatory state due to a cytokine storm. Reduced immunity, combined with steroid usage to prevent a cytokine storm along with various pre‐existing comorbidities can prove to be fertile ground for various secondary bacterial and fungal infection, including mucormycosis. Diagnosis of Mucor is a challenging task given the high negativity rate of various detection methods. While histopathology is considered the gold standard, the acquisition of necessary tissue biopsy specimens requires invasive procedures and is time consuming. METHOD: In this study five different methods of Mucor detection, namely conventional cytopathology, liquid‐based cytology (LBC, BD SurePath™), potassium hydroxide (KOH) preparation, culture, and histopathology were analysed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all five methods. RESULTS: LBC had values for sensitivity, specificity, PPV, and NPV of 72.4%, 100%, 100%, and 38.4%, respectively, closely matching histopathology in sensitivity (75.9%). The sensitivity of culture, conventional cytopathology, and KOH were very low compared to histopathology and LBC. CONCLUSION: This study showed that LBC, can be a rapid and effective alternative to histopathology in Mucor diagnosis. Diagnosis of mucormycosis is based on clinical suspicion, direct smear, histopathology, and culture. Newer methods of diagnosis include various polymerase chain reaction-based techniques. Direct microscopy can be used for a rapid presumptive diagnosis of mucormycosis. Culture of specimens is essential for the diagnosis of mucormycosis since it allows identification of the genus and species, and eventually antifungal susceptibility testing. Nevertheless, there are challenges in establishing a clinical diagnosis of mucormycosis due to the difficulty in obtaining a positive culture in some cases and the fact that tissue biopsy for histopathology is an invasive procedure not suitable for some cases. Cytopathology is receiving increased attention in the examination of fungal diseases because of its rapidity, accuracy, and minimal invasiveness. 15 However, conventional cytology has poor sensitivity owing to various artefacts caused by air drying, and the presence of proteins, mucous, inflammation, haemorrhage, and necrosis. 16 Liquid-based cytology (LBC), developed in 1991, improves the quality of samples and effectiveness of cytopathological tests. 17 With the advantages of standardised and automated preparation, it has reduced the unsatisfactory rate and improved specimen adequacy and the ability to perform ancillary tests with residual specimen. 18 Accordingly, it is more sensitive, specific, and cost-effective as compared to conventional cytopathology. 19 Recently, LBC has been utilised for the diagnosis of pulmonary aspergillosis. 20 The present study attempts to evaluate the applicability of LBC to the quick and accurate diagnosis of mucormycosis as compared to other direct microscopy methods such as potassium hydroxide (KOH) examination, conventional smears, and histopathology ( Table 1) . The objective of this study was to evaluate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various available diagnostic modalities for mucormycosis detection. A prospective study was conducted in the pathology and microbiology department of a COVID-dedicated tertiary centre between April 2021 to July 2021. Without compromising on safety protocols in place during the COVID crisis, the sample was taken to include as many cases as possible for which results were available for all five diagnostic modalities examined in the study (ie, histopathology, conventional cytopathology, LBC, KOH preparation, and culture). Patients who had received antifungal therapy were excluded from the study. A total of 34 COVID-19 treated patients suspected of having mucormycosis, whose samples were sent to the pathology and microbiology departments during April to July 2021, were included in the study. Detailed histories were taken, and physical examinations were noted ( Table 1) . Out of 34 patients, 31 (91.2%) had received steroid therapy for moderate to severe disease. In the present study, a special cytobrush (BD SurePath™) was used to collect samples from the hard/soft palate, lateral nasal wall, middle/inferior turbinate, and orbital apex (post exenteration). Smears were prepared on two glass slides for each patient, which were allowed to air dry and wet fix, respectively. All of the samples Eighty-two of these cases were reported from India 1,6,23-31 (Table 4) . Mucormycosis was seen mainly in males (78.9%). The most common risk factor was DM, seen in 80% of cases. Corticosteroid therapy was used in 76.3% of cases. Nose and sinuses (88.9%) were the most common site followed by rhino-orbital (56.7%). 21 Mucormycosis was first described by Fürbinger in a patient who died of cancer and in whom the right lung showed a haemorrhagic infarct with fungal hyphae and a few sporangia. In 1885, Arnold Paltauf published the first case of disseminated mucormycosis, which he named "Mycosis mucorina." 32 The gold standard for mucormycosis diagnosis is histopathology followed by culturing, both of which are time-consuming, and culture has a high false negativity rate, and thus these methods are not suitable for rapid diagnosis of mucormycosis. Histological examination of biopsied tissue is the preferred diagnostic method but is variably invasive. Patients with mucormycosis require early and accurate diagnosis to receive timely and optimal antifungal treatment. 33 If treatment is not initiated promptly, Mucorales species may cause acute and highly invasive disease in predisposed patients and prove to be fatal. 34 Cytology plays an important role, including conventional and LBC preparation, but detecting Mucorales in conventional cytopathology smears is challenging due to overpowering background features. 35 In the present study, conventional cytology, KOH preparation, LBC, culture, and biopsy of 34 patients admitted to our hospital for Two out of these three cases were positive on culture. These findings were similar to the present study. The limitations of this study were the relatively small sample size, and the reliability of operators who were overworked during the pandemic conditions, and not all sites were amenable to sampling for LBC. The present study shows that LBC with its sensitivity of 72.4% can be a good alternative to histopathology, which had a sensitivity of 75.9%, for diagnosis of Mucor infection, with the added advantage of a shorter turnaround time and being less invasive. I would like to thank our seniors, juniors and technical staff for their continuous support and work during these difficult times, without which this paper wouldn't be possible. The authors have no conflicts of interest to declare. Proper informed consent was taken. Not needed. Not needed. The data that support the findings of this study are available on request from the corresponding author. 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