key: cord-0855929-l454wp18
authors: Dulski, Theresa M.; DeLong, Megan; Garner, Kelley; Patil, Naveen; Cima, Michael J.; Rothfeldt, Laura; Gulley, Trent; Porter, Austin; Vyas, Keyur S.; Liverett, Hazel K.; Toda, Mitsuru; Gold, Jeremy A.W.; Kothari, Atul
title: Notes from the Field: COVID-19–Associated Mucormycosis — Arkansas, July–September 2021
date: 2021-12-17
journal: MMWR Morb Mortal Wkly Rep
DOI: 10.15585/mmwr.mm7050a3
sha: 8eb3d4242f2e29ce64b2af6a004bf18d2c262142
doc_id: 855929
cord_uid: l454wp18

nan

Research Electronic Data Capture software (version 10.6.18; Vanderbilt University) (6) and linked to state vital records and state immunization and COVID-19 registries. Patient demographic characteristics, underlying conditions, clinical course, treatment, and clinical outcomes were examined. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. § Ten COVID-19-associated mucormycosis cases that occurred during July 12-September 28, 2021, were reported to ADH by six hospitals. ¶ Nine patients lived in Arkansas, with patients representing each of the state's five public health unit regions; one patient lived in a bordering state. Among all 10 patients, the median age was 57 years (range = 17-78 years), all patients were non-Hispanic White persons, seven were male, one had a history of solid organ transplantation, and one had a history of recent traumatic injury at the body site where mucormycosis later developed. Eight patients had diabetes; among these, the median hemoglobin A1c was 8.6% (range = 6.0%-14.3% [normal <5.7%]).** During hospitalization, three patients with diabetes experienced diabetic ketoacidosis. Mucormycosis clinical signs and symptoms included those that were rhino-orbital (four patients, including three with cerebral involvement), pulmonary (three), disseminated (two), and gastrointestinal (one).

The median interval from COVID-19 diagnosis to the first positive test result for mucormycosis was 18.5 days (range = 6-52 days). None of the patients had been vaccinated against COVID-19. COVID-19 treatment included supplemental oxygen therapy (eight patients), invasive mechanical ventilation (five), corticosteroids (nine), tocilizumab (two), and baricitinib (two). Five patients received surgical treatment to excise mucormycosis-affected tissue. Six of the 10 patients died during hospitalization or within 1 week of discharge.

The findings in this report are subject to at least two limitations. First, cases were identified using passive reporting, which could have missed some mucormycosis cases. Second, the definition of COVID-19-associated cases was limited to positive tests within 60 days preceding mucormycosis diagnosis, which could have missed some cases occurring outside this period. § 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq. ¶ Three additional potential cases were reported to ADH but were excluded from this report, two because the patients lacked clinical evidence of invasive mucormycosis and the other because the interval from COVID-19 diagnosis and mucormycosis diagnosis exceeded 60 days. ** One patient did not have a recent hemoglobin A1c result available. https:// www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html

The 10 reported COVID-19-associated mucormycosis cases occurred during a 79-day period (July 12-September 28, 2021) coinciding with a statewide surge in COVID-19 cases caused by the highly transmissible SARS-CoV-2 B.1.617.2 (Delta) variant. † † By comparison, nine mucormycosis cases per year might be expected in Arkansas (population approximately 3,000,000) § § based on the estimated U.S. incidence of mucormycosis hospitalizations (approximately three per 1,000,000 persons annually) (7) . The reported COVID-19associated mucormycosis cases might have occurred because of COVID-19-induced immune dysregulation or medical treatments (5) .

Because of the severity of mucormycosis, it is important that clinicians maintain a high index of suspicion for COVID-19associated mucormycosis, including in patients without severe immunocompromising conditions. Mucormycosis treatment guidelines recommend prompt antifungal therapy ¶ ¶ and surgical intervention to improve outcomes (8) . Maintenance of glycemic control in patients with diabetes, guideline-based use of corticosteroids for COVID-19 treatment,*** and vaccination against COVID-19 should be encouraged. As a result of these reported cases, ADH sent an update on the statewide Health Alert Network (October 21, 2021) and nationwide Epi-X listserv (October 22, 2021) to improve mucormycosis prevention, diagnosis, and treatment. COVID-19-associated mucormycosis surveillance and case investigations are ongoing.

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All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Keyur S. Vyas reports consulting fees from the American Association of Hip and Knee Surgeons. Theresa M. Dulski reports that her spouse receives restricted stock units as part of his compensation at a cancer diagnostics company that also does COVID-19 testing. No other potential conflicts of interest were disclosed.