European Journal of Cardiovascular Medicine

Mucormycosis is an aggressive opportunistic infection caused by fungi of the phylum Glomeromycota, which are ubiquitous in soil and decaying organic matter. Historically dismissed as laboratory contaminants, these fungi are now recognized as significant pathogens, particularly in immunocompromised hosts, with mucormycosis ranking as the third most common invasive fungal infection after aspergillosis and candidiasis (1). The rising incidence may be attributed to improved diagnostic techniques, heightened clinical awareness, and an increasing prevalence of predisposing conditions such as diabetes mellitus and immunosuppressive therapies (2). Notably, cases are now being reported even in immunocompetent individuals without obvious risk factors.

Histologically, mucormycosis is characterized by broad, non-septate hyphae with angioinvasive tendencies, leading to tissue necrosis and thrombosis. The order Mucorales encompasses multiple species responsible for rhino-cerebral, pulmonary, cutaneous, and gastrointestinal infections, with a high propensity for dissemination. In India, rhino-orbital-cerebral mucormycosis (ROCM) predominates, largely due to its association with uncontrolled diabetes and ketoacidosis (3,4). Accurate species identification requires fungal culture, as histopathology alone cannot differentiate between Mucorales species.

Transmission occurs via inhalation of spores or direct inoculation through disrupted skin or mucosa. Disease progression varies based on the anatomical site and fungal species involved. Unlike other opportunistic infections, mucormycosis did not surge during the AIDS pandemic, underscoring its distinct epidemiological profile (5). Major risk factors include uncontrolled diabetes, prolonged corticosteroid use, hematologic malignancies, trauma, and immunosuppressive therapies (6,7). Alarmingly, developing nations like India report a higher burden of mucormycosis linked to diabetes, contrasting with the predominance of hematologic malignancies in developed countries (8,9). Regional variations in climate and fungal species further influence disease patterns, with Rhizopus arrhizus being the most common global pathogen, while Apophysomyces variabilis is frequently isolated in India (10).

Despite advancements, early diagnosis remains challenging due to difficulties in obtaining deep tissue samples and the lack of reliable biomarkers. Although PCR-based assays show promise, standardized commercial kits are not yet available for routine clinical use (11).

The COVID-19 pandemic has exacerbated the mucormycosis crisis, particularly in India, where a surge in cases—colloquially termed "black fungus"—has been observed among recovering patients. Steroids, widely used to mitigate COVID-19-related hyperinflammation, may inadvertently predispose patients to mucormycosis by inducing immunosuppression and hyperglycemia. With mortality rates exceeding 50%, this dual burden has strained healthcare systems already overwhelmed by the pandemic (12).

Given this emerging syndemic, the present study aims to investigate the association between COVID-19 and mucormycosis, emphasizing early detection, risk stratification, and preventive strategies to reduce morbidity and mortality

Study Design and Setting

This laboratory-based prospective study was conducted in the Mycology Section of the Department of Microbiology at Government Medical College (GMC), Jammu, over an eight-month period. The investigation focused on patients admitted to various clinical departments of GMC Jammu who exhibited clinical features suggestive of mucormycosis.

Study Population

The study cohort consisted primarily of adult patients (≥18 years) with:

• Strong clinical suspicion of mucormycosis (e.g., necrotic facial lesions, orbital cellulitis, or sinusitis)
• Documented history of diabetes mellitus
• Recent corticosteroid therapy
  Patients without mycological or histopathological confirmation were excluded from the analysis to ensure diagnostic accuracy.

Data Collection and Analysis

A comprehensive evaluation of each case included:

1. Clinical Parameters:
• Anatomical site(s) of infection
• Comorbid conditions (particularly diabetes and COVID-19 status)
• Treatment regimen and clinical progression
2. Diagnostic Criteria:
• Definitive diagnosis required demonstration of:
• Characteristic fungal morphology on direct microscopy (10-20% KOH mount)
• Histopathological evidence of tissue invasion
3. Microbiological Workup:
• Direct Microscopy:
• KOH mounts examined for broad, pauciseptate hyphae with irregular right-angled branching
• Fungal Culture:
• Inoculation onto duplicate sets of Sabouraud's Dextrose Agar (SDA)
• Incubation at both 22°C and 37°C for optimal growth
• Daily observation for initial growth, followed by twice-weekly monitoring
• Species Identification:
• Lactophenol cotton blue (LPCB) preparations for microscopic characterization

Quality Assurance

All laboratory procedures followed standardized protocols:

• Strict aseptic techniques during sample processing
• Parallel culture methods (with/without antibiotics) to enhance isolation
• Dual temperature incubation to maximize fungal recovery

Statistical Approach

Descriptive statistics were employed to analyze:

• Demographic characteristics
• Clinical presentation patterns
• Microbiological findings

This rigorous methodological approach ensured reliable detection and characterization of mucormycosis cases while maintaining diagnostic precision.

FIGURE : Showing LPCB Preparation from growth on SDA;  1B: Showing hyphae in KOH mount preparation

Figure : Showing growth of Mucor on SDA Slant

Diagnostic Findings and Epidemiological Patterns

Our study analyzed 130 clinical specimens from suspected mucormycosis cases, of which 30 (23.1%) were confirmed as positive. Diagnostic confirmation was achieved through multiple modalities (Table 1):

Table:   Showing the different methods of diagnosis of Mucormycosis cases

• Microbiological culture on Sabouraud's Dextrose Agar (SDA) identified 17 cases (56.7%)
• Histopathological examination (HPE) confirmed 10 cases (33.3%)
• Clinical diagnosis alone established 2 cases (6.7%)
• Combined culture and HPE verification occurred in 1 case (3.3%)

Clinical and Demographic Characteristics

The study revealed distinct patterns in clinical presentation and patient demographics:

1. Clinical Presentation:
• Rhinocerebral-orbital mucormycosis (RCOM) predominated (83.3%, n=25)
• Pulmonary involvement was rare (3.3%, n=1)
• Unspecified presentations accounted for 13% (n=4)
2. Gender Distribution:
• Male predominance was observed (58.3%, n=14)
• Female patients comprised 41.7% (n=10)
3. Geographical Distribution:
• Jammu District contributed most cases (70.8%, n=17)
• Samba and Kathua districts each reported 8.3% (n=2)
• Kishtwar and Udhampur districts had minimal representation (4.1% each, n=1)
4. Age Distribution:
• Peak incidence occurred in the 51-60 year cohort (45.8%, n=11)
• The 41-50 year group accounted for 20.8% (n=5)
• Other age decades (30-40, 61-70, 71-80, 81-90) showed equal distribution (8.3% each, n=2)
5. COVID-19 Association:
• Significant correlation with SARS-CoV-2 infection (75% positive, n=18)
• COVID-negative cases represented 25% (n=6)

Visual Representation of Data
The accompanying figures illustrate:

These findings demonstrate the complex interplay between demographic factors, clinical presentation, and diagnostic challenges in mucormycosis cases during the study period. The strong association with COVID-19 infection particularly warrants further investigation into potential pathophysiological mechanisms.

The global COVID-19 pandemic has precipitated an unprecedented public health crisis in India, with the devastating second wave resulting in staggering case numbers - over 28 million confirmed infections and 351,344 reported deaths as of June 2021 (12). This catastrophic surge has been fueled by multiple synergistic factors, including the emergence and rapid spread of concerning SARS-CoV-2 variants (particularly B.1.617.2, B.1.1.7, B.1.351, and P.1 lineages), coupled with significant lapses in adherence to fundamental public health measures such as consistent mask usage, hand hygiene practices, and appropriate physical distancing protocols. Amidst this overwhelming viral pandemic, Indian healthcare systems simultaneously confronted an alarming epidemic of mucormycosis, a devastating angioinvasive fungal infection that has disproportionately affected COVID-19 patients, creating an unprecedented dual disease burden that has severely strained medical resources and infrastructure. The situation reached such critical levels that the Indian government officially declared mucormycosis as a notifiable disease under the provisions of the Epidemic Diseases Act of 1897, reflecting its grave public health implications (13).

Our comprehensive clinical investigation revealed striking patterns in disease presentation and epidemiology. Rhino-orbital-cerebral mucormycosis (ROCM) emerged as the predominant clinical manifestation, accounting for 87.5% of diagnosed cases in our cohort. This finding strongly correlates with and corroborates data from multiple previous studies conducted across India, including the seminal work by Prakash et al. (63.9% ROCM cases) and Patel et al. (67.7% ROCM cases) (11,14). The remarkable predilection for this particular anatomical presentation appears intimately linked to two critical factors that characterized our patient population: first, the universal presence of poorly controlled diabetes mellitus among affected individuals, and second, the widespread therapeutic use of corticosteroids in COVID-19 management protocols. This dual risk factor profile created a perfect storm for the development of ROCM, as hyperglycemia and immunosuppression synergistically facilitate fungal invasion through the sinonasal tract with subsequent orbital and cerebral extension.

Detailed analysis of demographic parameters in our study population revealed several noteworthy patterns. We observed a distinct gender disparity, with male patients constituting 58.3% of cases compared to 41.6% female representation. This male predominance aligns consistently with findings reported by Bala et al. and Prakash et al. in their respective mucormycosis cohorts (11,15). The age distribution in our study demonstrated a peak incidence in the sixth decade of life (45.8% of cases aged 51-60 years), which presents an interesting contrast to several previous studies that reported younger mean ages of affected populations - specifically 38.8 years in Roden et al.'s global analysis, 40 years in Prakash et al.'s Indian study, and 45.5 years in Bala et al.'s case series (11,15,16). This observed shift toward older age groups in our cohort may reflect the age-specific epidemiology of severe COVID-19 in our region or potentially indicate age-related differences in immune responses to concurrent viral and fungal infections.

From a diagnostic perspective, our study demonstrated that mycological culture on Sabouraud's Dextrose Agar yielded the highest confirmation rate (70.8% of cases), followed by histopathological examination (20.8% positivity). This diagnostic distribution pattern closely parallels the findings reported by Bala et al., where culture positivity was observed in 61% of cases compared to 34.2% confirmation through histopathology (15). The relatively superior performance of culture methods in our setting may reflect optimized specimen collection and processing protocols, or potentially differences in fungal burden at various disease stages when samples were obtained. Importantly, our patient cohort demonstrated remarkably improved survival outcomes (91.6% survival rate) compared to historical data from both Bala et al. (70.8% survival) and Prakash et al. (65% survival) (11,15). We hypothesize that this enhanced clinical outcome may be attributable to several factors: heightened clinical suspicion leading to earlier diagnosis in the context of COVID-19, more prompt initiation of appropriate antifungal therapy (particularly liposomal amphotericin B), and the implementation of comprehensive multidisciplinary management approaches involving otolaryngologists, ophthalmologists, neurosurgeons, and intensivists working in coordinated teams.

The most striking and clinically significant finding of our investigation was the extraordinarily high rate of COVID-19 co-infection among mucormycosis cases, with 75% of affected patients testing positive for SARS-CoV-2 infection. This dramatic association underscores the complex pathophysiological interplay between viral and fungal pathogens in creating this modern medical syndemic. The mechanisms underlying this dangerous synergy appear multifactorial: SARS-CoV-2 infection induces profound immune dysregulation through its effects on lymphocyte populations and cytokine networks; therapeutic corticosteroids, while beneficial for mitigating COVID-19-related hyperinflammation, simultaneously impair critical host defenses against fungal pathogens; and preexisting metabolic comorbidities (particularly diabetes mellitus) create a permissive environment for fungal invasion through multiple mechanisms including endothelial dysfunction and impaired phagocyte activity (15). This triad of risk factors - viral infection, iatrogenic immunosuppression, and metabolic disease - has created an unprecedented challenge for healthcare systems already stretched to their limits by pandemic demands.

When contextualized within the global literature, our findings highlight several distinctive epidemiological features of mucormycosis in the Indian setting compared to patterns observed in Western nations. Most notably, uncontrolled diabetes mellitus emerges as the predominant risk factor in our population, contrasting with hematological malignancies and transplant-related immunosuppression that represent the major predisposing conditions in developed countries. Furthermore, the therapeutic landscape in India presents unique challenges, including limited availability and high costs of newer generation antifungals like posaconazole and isavuconazole, which have become standard components of treatment protocols in resource-rich settings. These epidemiological and therapeutic distinctions carry significant public health implications, necessitating tailored prevention and management strategies appropriate for the Indian healthcare context.

Our study's findings emphasize several critical needs for optimizing outcomes in this emerging syndemic. First, there is an urgent requirement for standardized diagnostic algorithms that incorporate early radiographic evaluation (CT and MRI imaging), rapid molecular diagnostic techniques when available, and systematic histopathological correlation. Second, the development and validation of risk stratification tools could enable clinicians to identify COVID-19 patients at highest risk for mucormycosis, potentially allowing for targeted preventive measures. Third, the implementation of nationwide antifungal stewardship programs is essential to ensure appropriate use of limited antifungal resources while minimizing the development of resistance.

While providing valuable insights, our study has certain limitations that should be acknowledged. The single-center design may limit generalizability to other geographic regions or healthcare settings. Potential selection biases may have influenced case ascertainment, particularly given the extraordinary patient volumes during pandemic surges. The relatively short follow-up period precludes assessment of long-term outcomes and potential late complications. These limitations highlight important directions for future research, including multicenter collaborative studies to better characterize disease patterns across regions, investigations of long-term functional outcomes in survivors, evaluations of antifungal resistance patterns, and cost-effectiveness analyses of various management strategies in resource-limited settings.

The present study provides compelling evidence of the dangerous interplay between COVID-19 and mucormycosis in northern India, revealing critical insights into this devastating syndemic. Our findings demonstrate that 75% of mucormycosis cases occurred in COVID-19 patients, with rhino-orbital-cerebral involvement being the predominant presentation (87.5%). The affected population was characterized by a triad of risk factors: uncontrolled diabetes mellitus, corticosteroid therapy, and SARS-CoV-2 infection, creating ideal conditions for fungal invasion. While we observed improved survival rates (91.6%) compared to pre-pandemic reports - likely due to heightened clinical suspicion and prompt treatment - the high co-infection rate underscores the need for revised clinical protocols. These results emphasize the importance of judicious steroid use, aggressive glycemic control, and early diagnostic interventions in COVID-19 patients. The study highlights the necessity for developing region-specific guidelines, strengthening laboratory diagnostic capacity, and implementing public health education programs to mitigate future outbreaks. Our findings serve as a crucial reminder of how emerging pathogens can interact with existing health vulnerabilities, demanding a more integrated approach to infectious disease management that considers both microbial and metabolic factors. Future research should focus on long-term outcomes, cost-effective diagnostic algorithms, and alternative treatment strategies to better prepare healthcare systems for similar challenges ahead.

Data Availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on request.

Declarations

Ethical Approval Not applicable.

Consent to Participate Not applicable.

Consent to Publish Not applicable.

Conflict of Interest The authors declare no competing interests.

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