key: cord-1051827-8aakfczw
authors: Rastogi, Ashu; Khamesra, Anshu
title: Triple challenge of diabetes, COVID-19, and mucormycosis
date: 2021-08-13
journal: Int J Diabetes Dev Ctries
DOI: 10.1007/s13410-021-00991-z
sha: 326931822d8f4bfc9b069a1230a2cee05dc0919d
doc_id: 1051827
cord_uid: 8aakfczw

nan

India is witnessing a steep surge of COVID-19 along with increasing mortality from SARS-CoV-2 infection in the second wave propounded by an unprecedented outbreak of mucormycosis infections. Although mucormycosis is a rare disease, the prevalence of mucormycosis in India is about 80 times that of developed countries [1] . A systematic review identified 101 reported cases of mucormycosis in COVID-19 worldwide and majority (83%) from India [2] . This is likely the tip of the iceberg as no national surveillance exists for mucormycosis. Countrywide data suggest close to 8880 cases of mucormycosis during the COVID-19 pandemic in India as of 22 May 2021 [3] . This has forced the Indian government to declare mucormycosis a notifiable disease under the Epidemic Diseases Act, 1897, on May 20, 2021.

Has fungal infections come as a surprise in the COVID-19 pandemic? Looking back, the incidence of fungal infection during the SARS-CoV1 infection in 2003 was 14.8-27%, contributing to maximum mortality (25-73.7% of all deaths) [4] . A high probability of increased incidence of fungal infections in COVID-19 in affected or recovered patients is unlikely to be unprecedented considering biological similarities between SARS-CoV-1 and -2, both requiring prolonged hospitalization. Moreover, prolonged supraphysiological doses of glucocorticoids (GCs) predispose patients with compromised immunity (secondary to diabetes) for opportunistic fungal infections including mucormycosis. High-dose steroids are used for severe or critically ill COVID-19 patients that reduces mortality [5] . GCs are continued beyond the second week in patients requiring prolonged ICU stay increasing susceptibility for mucormycosis.

Why is that India is ravaged with mucormycosis in the COVID-19 pandemic, while the rest of the world has only isolated reports of mucormycosis? Is it secondary to swelling number of COVID-19 patients in the second wave in India with the potentially more virulent strain B1.617.2, when the rest of the world is observing a downtrend? Or is it due to healthcare delivery issues including hasty makeshift COVID care facilities with possible unsterilised hospital linen, non-sterile medical devices including humidifiers for inhaled oxygen, usage of industrial oxygen due to shortage of medical oxygen, tropical climate, and agrarian population? Uncontrolled hyperglycemia (mean HbA1c 8.48%)

[6] and increasing number of COVID-19 patients on supraphysiological and prolonged course of glucocorticoids (resulting in worsening glycemic control) also predispose to mucormycosis.

An early recognition of symptoms, equitable distribution of healthcare resources including diagnostic facilities (radiological and histopathology), adequate supplies of antifungal drugs, availability of operative facilities, and surgical expertise at peripheral centers are some measures that may ward off this triple challenge.

The authors declare no competing interests.

Global epidemiology of mucormycosis

Mucormycosis in COVID-19: a systematic review of cases reported worldwide and in India

covid-19-crisis-whichstates-in-india-have-repor ted-the-highe st-number-of-mucor mycos is-cases-988666

Clinical analysis of 146 patients with critical severe acute respiratory syndrome in Beijing areas

Dexamethasone in hospitalized patients with COVID-19