High Mortality Co-Infections of COVID-19 Patients: Mucormycosis and Other Fungal Infections

DISCOVERIES 2021, Jan-Mar, 9(1): e126 10.15190/d.2021.5 Fungal co-infections in COVID-19 patients DOI:

Focused REVIEW

High mortality co-infections of COVID-19 patients: mucormycosis and other fungal infections

Kinal Bhatt1,*, Arjola Agolli1, Mehrie H. Patel1, Radhika Garimella1, Madhuri Devi2, Efrain Garcia3, Harshad Amin3, Carlos Domingue3, Roberto Guerra Del Castillo3, Marcos Sanchez- Gonzalez1

1Division of Clinical and Translational Research, Larkin Health System, South Miami, FL, USA 2Pakistan Ziauddin Medical College, Karachi, Pakistan 3Larkin Community Hospital, Hialeah, FL, USA

*Corresponding authors: Kinal Bhatt, MD, MPH, Division of Clinical and Translational Research, Larkin Health System, South Miami, FL, USA, 7031 SW 62nd Ave, South Miami, FL; Phone: (928) 225 0273; Email: [email protected]

Submitted: February 6, 2021; Revised: Martch 30, 2021; Accepted: March 31, 2021; Published: March 31, 2021; Citation: Bhatt K, Musta A, Patel MH, Garimella R, Devi M, Garcia E et al. High mortality co-infections of COVID-19 patients: mucormycosis and other fungal infections. Discoveries 2021, 9(1): e126. DOI: 10.15190/d.2021.5

ABSTRACT infections. This report is intended to raise awareness Severe COVID-19 disease is associated with an of the importance of early detection and treatment of increase in pro-inflammatory markers, such as IL-1, mucormycosis and other fungal diseases, such as IL-6, and tumor necrosis alpha, less CD4 interferon- candidiasis, SARS-CoV-2-associated pulmonary gamma expression, and fewer CD4 and CD8 cells, aspergillosis, pneumocystis pneumonia and which increase the susceptibility to bacterial and cryptococcal disease, in COVID-19 patients, to fungal infections. One such opportunistic fungal reduce the risk of mortality. infection is mucormycosis. Initially, it was debated whether a person taking immunosuppressants, such SUMMARY as corticosteroids, and monoclonal antibodies will be 1. Introduction at higher risk for COVID-19 or whether the 2. COVID-19 and immunosuppression immunosuppresive state would cause a more severe 3. Fungal co-infections in COVID19 COVID-19 disease. However, immunosuppressants 3.1 Mucormycosis are currently continued unless the patients are at 3.2 Candidiasis (Candida auris) greater risk of severe COVID-19 infection or are on 3.3 SARS-CoV-2–assoc. pulmonary aspergillosis high-dose corticosteroids therapy. As understood so 3.4 Pneumocystis pneumonia far, COVID-19 infection may induce significant and 3.5 Cryptococcal disease (C. neoformans) persistent lymphopenia, which in turn increases the 4. Current treatment options for fungal infections in risk of opportunistic infections. It is also noted that COVID-19 patients 85% of the COVID-19 patients’ laboratory findings 4.1 Mucormycosis showed lymphopenia. This means that patients with 4.2 Candidiasis (Candida auris) severe COVID-19 have markedly lower absolute 4.3 SARS-CoV-2–assoc. pulmonary aspergillosis number of T lymphocytes, CD4+T and CD8+ T cells 4.4 Pneumocystis pneumonia and, since the lymphocytes play a major role in 4.5 Cryptococcal disease (C. neoformans) maintaining the immune homeostasis, the patients 5. Discussion with COVID-19 are highly susceptible to fungal co- 6. Conclusion www.discoveriesjournals.org/discoveries 1 Fungal co-infections in COVID-19 patients

Keywords various parts of the world has demonstrated that the SARS-CoV-2, COVID-19, mucormycosis, fungal SARS-CoV-2 virus follows an exponential growth, infection, candida auris, aspergillosis, pneumocystis and the mean basic reproduction number, which pneumonia, cryptococcus neoformans, coinfection. indicates the number of new infections that can arise from a single case of COVID-19 infection, is 1 Abbreviations estimated to be 1.4-4 . Angiotensin-converting enzyme 2 (ACE 2); Allergic The COVID-19 disease is associated with a range bronchopulmonary aspergillosis (ABPA); Acquired of clinical manifestations, particularly due to SARS- immune deficiency syndrome (AIDS); Acute myeloid CoV-2’s high human-to-human transmission rate via leukemia (AML); Acute respiratory distress syndrome respiratory droplets1. However, the presence of the (ARDS); Candida Auris (C. Auris); COVID-19 associated binding receptors in different tissues determines the pulmonary aspergillosis (CAPA) Cluster of differentiation range of clinical manifestations. The clinical (CD); Centers for Disease Control and Prevention (CDC); manifestations range from a self-limiting illness with Chronic obstructive pulmonary diseases (COPD); general symptoms, such as fever, cough, and Coronavirus disease of 2019 (COVID-19); Chronic headache, to more severe complications, including pulmonary aspergillosis (CPA); Cryptococcus acute respiratory distress syndrome, sudden cardiac Neoformans (C. Neoformans); Deciliter (dL); Human immunodeficiency virus (HIV); ICU (Intensive care unit); death, liver dysfunction, and multi-organ failure. An Interferon gamma (IFN-γ); Interleukin (IL); Interquartile analysis of 13 studies on laboratory-confirmed range (IQR); Milligram (mg); Pneumocystis jirovecii (P. COVID-19 cases conducted in China demonstrated jirovecii); Reverse transcription polymerase chain the prevalence of COVID-19-associated co- reaction (RT-PCR); Severe acute respiratory syndrome infections with bacteria, viruses, and fungi3. Severe coronavirus 2 (SARS-CoV-2); Sequential organ failure COVID-19 disease is associated with an increase in assessment (SOFA); World Health Organization (WHO). pro-inflammatory markers, such as IL-1, IL-6, IL-6, and tumor necrosis alpha, less CD4 interferon- 1. Introduction gamma expression, and fewer CD4 and CD8 cells; this, therefore, increases the susceptibility to Towards the end of 2019, an outbreak of a bacterial and fungal infections4. One such pneumonia-like infection occurred in Wuhan, China, opportunistic fungal infection involved is and rapidly spread across the globe. With the mucormycosis. Mucormycosis is an opportunistic utilization of genome sequencing technology, the fungal infection that belongs to the zygomycete disease was identified as coronavirus disease or family and are ubiquitous in the environment. The more commonly known as coronavirus disease 2019 major route of infection is via inhalations of spores, (COVID-19), and the etiological agent was which then spread to the paranasal sinuses and identified as severe acute respiratory syndrome lungs. Mucormycosis is non-pathologic in coronavirus 2 (SARS-CoV-2)1. As of March 2021, immunocompetent individuals as a result of the there are 93.3 million infected cases, with 2 million presence of an intact immunity via neutrophils confirmed deaths reported worldwide. This which hence permit the elimination of these spores5. respiratory illness has significantly impacted all However, in immunocompromised patients such as sectors of life, primarily healthcare and the those with uncontrolled diabetes mellitus, diabetic economy, and as a result, on March 11, 2020, the ketoacidosis, presence of an open wound, HIV/ WHO officially recognized COVID-19 disease as a AIDS, cancer, and organ transplant, mucormycosis pandemic. The coronaviruses are enveloped, can result in a severe invasive fungal infection6. positive-sense single-stranded viruses that utilize the Infection with mucormycosis is associated with human angiotensin-converting enzyme 2 (ACE2) high mortality primarily due to complications such receptors located on cells in many organs/tissues, as cavernous sinus thrombosis, disseminated including the lung, heart, kidney, bladder, eyes, infection, osteomyelitis, and death. Diagnosis is nasal and oral cavities, brain, thyroid, liver, made via routine blood work, biopsy, and gallbladder, stomach, pancreas, intestine, radiological imaging. The standard protocol for the reproductive system of males and females, and skin, management is primarily reversal of risk factors, to gain entry and trigger a range of clinical surgical debridement as well as intravenous manifestations2. Evaluating the data available from antifungal medication such as Amphotericin B6. www.discoveriesjournals.org/discoveries 2 Fungal co-infections in COVID-19 patients

Infection with SARS-CoV-2 drastically impacts the 3. Fungal co-infections in COVID19 immune system via induction of an inflammatory storm, an increase in neutrophil count as well a 3.1 Mucormycosis decrease in lymphocyte count, specifically CD4+ Mucormycosis, previously known as zygomycosis, and CD8+ T cells. Neutrophils ensure the is a severe fungal infection caused by a group of immunocompetence of individuals, so one would molds called mucoromycetes. It can affect the expect an even more increased immune response sinuses, brain or lungs and therefore can be quite against mucormycosis fungi when reading that common in people suffering or recovering from neutrophil numbers are rising during SARS-CoV-2. COVID-19. The common symptoms linked to Consequently, these patients are at increased mucormycosis are swelling in one side of the face, susceptibility of developing opportunistic infections fever, headache, nasal or sinus congestion, black such as mucormycosis, due to decreasing lesions on nasal bridge or upper inside of mouth12. lymphocyte cells5. CD4+ and CD8+ T cells serve a Fungi that most commonly cause mucormycosis are: prominent role against infection with mucormycosis Rhizopus species, Mucor species, Rhizomucor via recruiting cytokines, such as IL-4, IL-10, IL-17, species, Syncephalastrum species, Cunninghamella and IFN-γ5. Bertholletia, Apophysomyces species, and Lichtheimia species. Mucormycosis can present in 2. COVID-19 and immunosuppression many forms such as, gastrointestinal mucormycosis (more common in young children), rhinocerebral Initially it was debated whether a person taking mucormycosis (more common in people with immunosuppresants be at higher risk of getting uncontrolled diabetes and in people who had a COVID-19 or whether the immunosuppresive state kidney transplant), disseminated mucormycosis, would cause more severe COVID-19 infection7. pulmonary mucormycosis (more common in people However, currently the immunosuppressants are with cancer and in people who have had an organ continued unless the patients are at greater risk of transplant or a stem cell transplant) and cutaneous severe COVID-19 infection or are on high-dose mucormycosis13. corticosteroids therapy8. As understood so far, Symptoms of some fungal diseases can be similar COVID-19 infection may induce significant and to those of COVID-19, including fever, cough, and persistent lymphopenia which in turn increases the shortness of breath. Laboratory testing is necessary risk of opportunistic infections9. It is also noted that to determine if a person has a fungal infection or 85% of the COVID-19 patients’ laboratory findings COVID-19. Some patients can have COVID-19 and showed lymphopenia10. This means patients with a fungal infection at the same time. People with severe COVID-19 have markedley lower absolute severe COVID-19, such as those in an intensive care number of T lymphocytes, CD4+T and CD8+ T unit (ICU), are particularly vulnerable to bacterial cells11. And since the lymphocytes play a major role and fungal infections. Mucormycosis and orbital in maintaining the immune homeostasis10, the compartment syndrome in addition to COVID-19, patients with COVID-19 are highly susceptible to has been diagnosed in a previously healthy young fungal co-infections8. Moreover, the aggressive female14. Other authors have reported cases of acute disease course of the SARS-CoV-2 virus damages invasive fungal rhino-orbital mucormycosis15 and the lung tissues and alveolo-interstitial lesions which cavitary pulmonary mucormycosis16, 17 in patients puts the COVID-19 infected person prone to getting with COVID-19. Patients hospitalized for COVID- invasive fungal infections, specifically those that are 19 are at risk for healthcare-associated infections, airborne or with primarily pulmonary entry. These including candidemia, or bloodstream infections include infections like pneumocystis and caused by Candida and other fungal diseases. mucormycosis11. Mucormycosis is a rare fungal infection which is often life-threatening8. It is 3.2 Candidiasis (Candida auris) characterized by vascular invasion by the fungal Candida auris (C. auris) is an emerging fungus that hyphae which leads to thrombosis and necrosis8. can cause outbreaks of severe infections in There has been a surge of mucormycosis co- healthcare facilities and invasive candidiasis are infection in COVID-19 patients, many cases being some of the common presentations in COVID 19 reported worldwide. patients. Clinicians should consider fungal www.discoveriesjournals.org/discoveries 3 Fungal co-infections in COVID-19 patients pneumonias as a possible cause of respiratory from Aspergillus, is associated with high mortality illness, particularly if COVID-19 testing is negative. rates and is a prominent complication among those A total of 1,518 confirmed cases and 30 probable C. with profound immunosuppression, such as those Auris cases, were reported by U.S. States as of undergoing hematopoietic transplantation, as well as October 202018. A fungal infection commonly seen those with structural lung damage who receive during COVID-19 is C. Auris. The main concern systemic corticosteroids for their underlying regarding this fungal infection is related to C. auris condition, such as patients with chronic obstructive being a multi-drug resistant, being extremely hard to pulmonary diseases (COPD). Once they occur, these identify with standard laboratory methods and, C. super infections are associated with high mortality auris having caused various outbreaks in healthcare rates and may prolong the acute phase of COVID- settings. Some studies have suggested an increased 1925. Among fungal co-infections in France, the risk for Candida species in COVID-19 patients incidence of putative invasive pulmonary resulting in poor outcomes19, 20. The C. auris fungal aspergillosis was high (30%)26. To date, >100 cases infection is known to spread quickly in long-term of CAPA have been reported from many countries in care facilities. However, during the pandemic there Europe, Asia, Australia, and South America27, 28, 29, have been an increasing number of reports of C. often occurring in patients with no other risk factor auris in COVID-19 acute care units. Researchers than COVID-19–associated ARDS27, and multiple of suspect that these outbreaks may be related to them proven by autopsy 28, 29, 30. According to changes in routine infection control practices due to Hoenigl’s study, fungal diseases, and particularly the health crisis. For example, there is a limited CAPA, add insult to injury in a significant availability of gloves and gowns and there is a proportion of critically ill COVID-19 patients and possibility of faulty cleaning and disinfection are associated with high mortality rates, which may practices21, 22. According to this the US Center for be reduced by early diagnosis and initiation of Disease Control (CDC) report, among 67 patients appropriate antifungal therapy. In the absence of admitted to the COVID-19 unit and screened during antifungal prophylaxis, screening of COVID-19 point prevalence surveys, 35 (52%) received positive ARDS patients for CAPA and other fungal diseases test results. Mean age of colonized patients was 69 is essential31. CAPA should be suspected in severe years (range = 38–101 years) and 60% were male. COVID-19 patients who have worsening respiratory Six (17%) colonized patients later had clinical function or sepsis18. cultures that grew C. auris. Among patients screened When looking at incidences of CAPA in critically who had available medical records (17), two (10%) ill patients (e.g., patients on ICUs), rates vary were admitted directly from a long-term care facility substantially from 4% to as high as 35%. The and eight (40%) died within 30 days of screening, challenges in diagnosing fungal infections, and but whether C. auris contributed to death is particularly CAPA, are thought to explain this unknown23. A recent study showed that mortality variety in incidence rates. Clinical symptoms and among patients with COVID-19 and C. auris abnormalities on chest imaging are non-specific, candidemia was of 83.3% even with the use of positive sputum samples or tracheal aspirates do not appropriate antifungal therapy. All the isolates differentiate between colonization and infection, and studied were resistant to amphotericin B24. to perform invasive diagnostic procedures (e.g. bronchoscopy and bronchoalveolar lavage or lung 3.3.SARS-CoV-2–associated pulmonary asper- biopsy) is often not feasible due to the clinical gillosis (CAPA) condition of the patients. In addition, those Aspergillus genera, most frequently Aspergillus procedures are risky due to the possible transmission fumigatus, are ubiquitous in the environment and of Sars-CoV-2 as a result of aerosol formation32. cause a wide range of infections in humans, Emerging reports suggest that as many as one including invasive pulmonary aspergillosis (IPA), third of the patients with severe COVID-19 infection chronic pulmonary aspergillosis (CAPA), allergic requiring intensive care may also be battling another bronchopulmonary aspergillosis (ABPA), chronic life-threatening infection: invasive aspergillosis, a rhinosinusitis, fungal asthma, and aspergillus deadly fungal superinfection caused by Aspergillus bronchitis. Invasive pulmonary aspergillosis, the mold33. During the retrospective observational study most severe manifestation of disease of COVID-19 patients, bacterial and fungal co- www.discoveriesjournals.org/discoveries 4 Fungal co-infections in COVID-19 patients

Figure 1: Diagnostic and therapeutic pathway for invasive fungal co-infections in COVID-19 patients. Reproduced with permission from reference40.

infections occurred in <5% of all cases. However, jirovecii (10/108 patients; 9.3%). COVID-19 this is of significant concern due to their occurrence patients mostly exhibited marked lymphopenia and in the most vulnerable patients34. alterations in lymphocyte functions, likely explaining the high-rate of P. jirovecii detection36. 3.4 Pneumocystis pneumonia This association has been reported even in young Pneumocystis pneumonia also shares similar severely ill patients37. Differentiating COVID-19 symptoms of COVID-19 such as fever, cough, from pneumocystis jirovecii pneumonia is not difficulty breathing, chest pain, chills, fatigue, and usually possible from signs and symptoms. Sputum coinfection with Pneumocystis jirovecii may not be culture, RT-PCR, CT chest are recommended to appreciated in patients with severe SARS-CoV-2 diagnose on time and do a differential between infection. There have been reported cases of these COVID-19 and P. jirovecii38. two co-infections35. In another study, which included almost exclusively immunocompromised patients 3.5 Cryptococcal disease (C. neoformans) has reported an unexpectedly high proportion of Disseminated Cryptococcus neoformans (C. critically ill COVID-19 patients detected with P. neoformans) infection is a serious infection that can www.discoveriesjournals.org/discoveries 5 Fungal co-infections in COVID-19 patients occur in immunocompromised patients. There have some strains may be resistant to all antifungals. A been reported cases of C. neoformans and COVID - fungus highly likely to cause hospital setting 19 patients. The case reported by Mohamad Y and outbreaks, requires urgent identification and colleges, highlights the importance of early treatment initiation with contact precautions in suspicion of C. neoformans infection and other place40, 42. opportunistic infections in immunocompromised patients, putting in mind that patients with 4.3 SARS-CoV-2–associated pulmonary asper- Cryptococci have a high risk of mortality within gillosis (CAPA) 30 days, which warrants the use of corticosteroid Drugs recommended for the treatment of CAPA are and immunomodulatory drugs in a critically ill divided in two categories. For allergic aspergillosis patient with COVID‐19. In the current scenario, the and prevention, CDC recommends triazoles use of immunosuppressive therapy should be (itraconazole, voriconazole, posiconzaole, justified and to be alert for opportunistic infection esaconzaole) with corticosteroids. However, for like C. neoformans infection, which can lead to invasive aspergillosis, like the one seen in COVID- sepsis and mortality39. 19, CDC recommends voriconazole, lipid amphotericin B formulations, posaconazole, 4. Current treatment options for fungal infections isavuconazole, itraconazole, and echinococcus in COVID-19 (micafungin or caspofungin). Triazoles can be a safe choice for patients, but therapeutic drug monitoring 4.1 Mucormycosis (TDM) is highly recommended, and the interaction Global guidelines have demonstrated detailed and between azoles drugs should be observed diligently different approaches for the diagnosis and to observe for side effects. If the patient develops management of mucormycosis in 2019 by the aspergilloma, surgery may be required40, 43. European Confederation of Medical Mycology (ECMM) and Mycoses Study Group Education and 4.4 Pneumocystis pneumonia Research Consortium40. It states an immediate and The standard treatment for the pneumocystis complete surgical intervention should be taken in the pneumonia is a combination of trimethoprim and first place. In addition to it, systemic antifungals sulfamethoxazole. Corticosteroids can also be used should be added to first-line management. There is a for the moderate to severe pneumonia with low strong recommendation of high dose liposomal oxygen levels35-38. amphotericin B along with the adequate dosage of intravenous isavuconazole and posaconazole. Both 4.5 Cryptococcal disease (C. neoformans) triazoles can be given as salvage treatment as well. For asymptomatic patients and patients with mild-to- In high-risk patients such as neutropenic patients moderate pulmonary infections, CDC recommends who have graft versus host disease, prophylaxis with fluconazole. For people with severe lung infections posaconazole can be given. There is not enough data or infections in the central nervous system (brain and on the usage of combinations of other antifungal spinal cord), CDC recommended initial treatment drugs. Limited choice of therapy is creating with Amphotericin B in combination with significant pressure on patients with low incomes. flucytosine. Patient is then switched to fluconazole There is an excellent margin for uncertainty, and so for an extended period of time until infection is much research work can be on it40. clear. Dose and duration of the antifungal treatment may differ for pregnant women, children, and people 4.2 Candidiasis (Candia Auris) with limited resources. Some patients may require Patients suspected or confirmed with C. auris should surgery for removal of fungal growth, known as be treated with echinocandins (caspofungin, cryptococcomas40, 44. micafunging, and anidulafungin), azoles (fluconazole, voriconazaole, itraconazole), and 5. Discussion Amophotericin B and its liposomes. Therapeutic drug monitoring for optimizing efficacy and limiting Mucormycosis is associated with invasion of blood toxicity of azoles should be considered40, 41. As this vessels, which results in ischemic necrosis. is often a multidrug-resistant candida infection, Mucormycosis has the potential to invade various www.discoveriesjournals.org/discoveries 6 Fungal co-infections in COVID-19 patients systems in the body resulting in a myriad of clinical swab on a sabourauds dextrose agar culture. Since symptoms that progress rapidly. Based on the diabetes is one of the most common comorbidities of anatomic site involved, mucormycosis can be mucormycosis, it is possible that the patient either classified into the following forms: rhino-cerebral, had a previous undiagnosed mucor infection or it pulmonary, gastrointestinal, cutaneous, and may have been aggravated with further disseminated8. As a result of the harmful dysregulation of immunity secondary to COVID-19. complications associated with opportunistic co- Use of steroids and monoclonal antibodies to treat infections such as invasive fungal infections in COVID-19 may lead to exacerbation of COVID-19 disease, it is essential that health care opportunistic infections like mucormycosis as well45. workers, mainly physicians, are vigilant and aware Pasero et al. (2020) discussed a case of a 66-year- of the possibility of infection and take the necessary old male patient with a past medical history of precautions45. arterial hypertension, admitted to ICU in Italy with Monte Junior et al. (2020) reported a case of an COVID-19. The patient was intubated due to 86-year-old male patient with history of arterial COVID-19 complications. Over the course of 2 hypertension, admitted to the emergency room with week, the patient had multiple organ dysfunction symptoms of acute diarrhea, cough, dyspnea, and with sequential organ failure assessment (SOFA) fever that started 5 days ago with a confirmed score of 14, and his respiratory parameters continued COVID-19 diagnosis. Within 5 days of admission, worsening. Patient was started on empiric antibiotics patient’s hemoglobin level of 14.3 mg/dL dropped to therapy. After 2 weeks of empirical therapy a level of 5.6 mg/dL, which required infusion of three bronchial aspirate was repeated to confirm SARS- units of red blood cells. Esophago- CoV-2 and to detect other coinfections. The gastroduodenoscopy to rule out cause of internal bronchial aspirate confirmed coinfection of Rhizopus bleeding revealed two giant gastric ulcers with spp. and treated appropriately, yet the patient did not necrotic debris, confirmed to be mucormycosis upon survive and died at day 62 of refractory shock and biopsy. This patient did not have any other typical liver failure. The researchers here also suggested comorbidities to suggest suspicion of mucormycosis, altered and impaired immune system were the cause such as diabetes. A rare disease of gastrointestinal of higher risk of opportunistic infection and negative mucormycosis was contributed to immune outcome46. dysregulation caused by COVID-19. Despite Gago and Ibrahim (2021) represented a case of intensive care, this patient died within 36 hours of 53-year-old male patient with past medical history of the procedure. When the anticipated gastrointestinal obesity and depression was diagnosed with (GI) mucormycosis symptoms such as fever, nausea, secondary acute myeloid leukemia (AML) in abdominal pain, GI bleeding and perforation are January 2020 and transferred to the hospital for missing, establishing a correct diagnosis early on is further treatment. After five weeks of treatment the challenging. Since the GI mucormycosis is known to patient developed sore throat, paraguesia, dysosmia have up to 85% fatality rate, early diagnosis and and fever and was diagnosed with SARS-CoV-2 treatment becomes imperative in patient’s survival8. confirmed with nasal RT-PCR at day 54 after Mehta et al. (2020) presented a case of a 60-year- induction of chemotherapy. On day 8 after SARS- old male patient with a past medical history of >10 CoV-2 diagnosis, patient required intubation, and years of diabetes with a three-day history of severe was extubated on day 18 as he stabilized. However, breathlessness, pyrexia, tachypnea and generalized shortly after he developed fever up to 39.5 °C with malaise. While admitted for COVID-19 negative blood culture, acridine-orange leukocyte management, on day 10, patient developed bilateral cytospin test, viral PCRs, and fungal biomarkers. lid edema with right eye prominence. MRI of the Due to rapid respiratory deterioration patient brain showed soft tissue swelling of orbits and required reintubation on day 22 with a positive paranasal sinuses with mucosal thickening. Patient SARS-CoV-2 nasopharyngeal swab and negative was initially diagnosed with orbital cellulitis and bronchoalveolar lavage. Due to worsening ophthalmic consultation was obtained the next day. hemodynamic situation, the patient died on day 24. Upon examination, the ophthalmologist suspected a A full autopsy was performed and revealed invasive diagnosis of invasive fungal infection like Rhizopus microspores from lung tissue. Researchers mucormycosis, which was confirmed with a nasal suggested chemotherapy combined with www.discoveriesjournals.org/discoveries 7 Fungal co-infections in COVID-19 patients corticosteroids resulted in a prolonged neutropenic after discharge with generalized fatigue, shortness of phase leading to opportunistic infection like breath and hemoptysis. Patient was started on mucormycosis. Due to negative testing of fungal empiric antibiotics therapy (IV vancomycin and infections the patient was not treated with any other piperacillin-tazobactam) for suspected healthcare- azoles except voriconazole, an antifungal used a associated pneumonia. His chest x-ray showed prophylaxis in such patients. This report was also increasing airspace density in both lungs with intended to raise awareness for early detection and pleural effusion. On Day 3, a repeat sputum revealed treatment of mucormycosis47. filamentous fungus and empiric treatment of Hanley et al. (2020) reported a post-mortem case liposomal amphotericin B was started. Despite series of nine patients with confirmed COVID-19 at persistent drainage of pleural effusion with pigtail premortem between March 1 and April 30, 2020. catheter over the next few days, repeat chest CT was The median age at death of this cohort was 73 years unchanged. On repeated sample analysis, Rhizopus (IQR 52-79). At least one major organ, azygosporous was also diagnosed, and patient was predominantly the lung showed thrombotic features put on appropriate treatment. Despite all efforts at full autopsies and diffuse alveolar damage was the patient developed cardiac arrest and died on most consistent lung finding in all ten patients. The hospitalization day 17. Researchers recommended series supported several novel autopsy findings, severe COVID-19 should be considered as a risk including secondary disseminated mucormycosis, factor for invasive fungal infections, particularly requiring additional investigation to understand the those who receive immunosuppressive medications role of this opportunistic infection in COVID-19 like steroids and IL-6 inhibitors (tocilizumab). patients48. Because there are no non-invasive tests available for Sen et al. (2021) conducted a retrospective, invasive fungal infections, researchers believe cases interventional study on 6 COVID-19 patients who of mucormycosis cases may be higher in numbers developed rhino-orbital mucormycosis and were than what is reported50. managed at a tertiary ophthalmic center in India Moorthy et al. (2021) completed multi-centric between August 1 and December 15, 2020. All retrospective study in Bangalore, India in 18 patients patients were men with mean age of 60.5 ± 12 with with diabetes mellitus (DM) with positive SARS- type 2 diabetes. All except one patient received CoV-2 infections. 15 of 18 patients had confirmed systemic corticosteroids treatment for COVID-19. uncontrolled DM and all received corticosteroid for The researchers reported mean duration of 15.6 ± 9.6 COVID-19 treatment. Surprisingly, 12 of 18 patients days between diagnosis of COVID-19 and had complained of vision loss, 7 of whom then development of symptoms of mucor. All patients underwent orbital exenteration. The results showed had undergone endoscopic sinus debridement and 16 cases of mucormycosis, 1 of aspergillosis and 1 only two required orbital exenteration, however all case of mixed fungal infection. Six of these patients six patients were alive at the last follow up. The died, 11 survived and 1 was lost to follow up. researchers put much emphasis on high index of Researchers confirmed significantly higher suspicion, early diagnosis, and appropriate incidence of fungal infections (p = 0.03) amongst management for patient survival49. diabetic patients and suspect strong association with Kanwar et al. (2021) also reported a fatal case of immunosuppression related to corticosteroid 56-year-old man who was hospitalized for COVID- administration51. 19. This patient had pre-existing end-stage renal Karimi-Galougahi et al. (2021) reported a case of disease on hemodialysis and ultimately developed 61-year-old woman with no past medical history and mucormycosis during his hospitalization. Patient has was hospitalized for COVID-19 infection for 2 a positive SARS-CoV-2 RT-PCR while weeks. During her admission, she received asymptomatic, until four days later, he was remdesivir, interferon-alpha, and systemic hospitalized for fatigue and shortness of breath, at corticosteroid. Patient did not require intubation and which time he received methylprednisolone, mechanical ventilation. Patient developed right tocilizumab and single dose of convalescent plasma. hemifacial pain with no other sinonasal symptoms, Upon admission, blood cultures were negative for hemifacial numbness, decreased visual acuity, and bacterial and fungal microorganisms. Patient was chemosis one week after her discharge, which discharged home 7 days later, readmitted five days prompted her second hospitalization. The non- www.discoveriesjournals.org/discoveries 8 Fungal co-infections in COVID-19 patients contrast CT of paranasal sinuses, MRI, and particularly high mortality mucormycosis, in diagnostic sinonasal endoscopy suggested and COVID-19 patients to reduce the risk of mortality. confirmed invasive fungal infection of Due to association with a very high mortality rate, mucormycosis. In this case, although the patient was the researchers put much emphasis on high index of healthy, researchers indicated that the corticosteroid suspicion, early diagnosis, and appropriate treatment induced diabetes and immunosuppression management for patient survival. It is essential to in addition to immune dysregulation caused by assess the risk factors, the types of invasive mycosis COVID-19 caused invasive mucormycosis, to provide appropriate individualized treatment. encouraging prompt diagnosis by physicians52. Additional investigation is needed to understand the Several other Rhino-orbital mucormycosis cases role of opportunistic infections in COVID-19 have been reported. Waizel-Haiat et al. (2021) patients. Finally, we provide a flow diagram (Figure reported a case of a 24-year-old female in Mexico 1) to assist the clinicians and laboratory experts in City, with past medical history of obesity, who the management of aspergillosis, candidiasis, tested positive for COVID-19. She was brought to mucormycosis, or cryptococcosis, as comorbidities the emergency room, where she complained of left in COVID-19 patients. midface pain at least six days prior to admission, and within two days showed signs of left lid swelling Acknowledgements and maxillary hypoesthesia. When oral amoxicillin- The author thank to their host institutions for clavulanate did not provide relief, rhinoscopy was support. completed with contrast-enhanced CT of head and chest, revealing invasive fungal infection. This Conflict of Interest patient developed multiple other complications of COVID-19, including metabolic acidosis combined The authors declare no conflicts of interest. with pulmonary insult and acute kidney injury due to disseminated intravascular coagulopathy, leading to References death due to multi-organic failure due to septic 1. Khan M, Adil SF, Alkhathlan HZ, Tahir MN, Saif S, shock. The researchers concluded this patient had Khan M, Khan ST. COVID-19: A Global Challenge immunosuppressive state secondary to diabetic with Old History, Epidemiology and Progress So Far. ketoacidosis, making her susceptible to COVID-19 Molecules. 2020 Dec 23;26(1):39. doi: and mucormycosis coinfections. Her late diagnosis 10.3390/molecules26010039. PMID: 33374759; and delay in treatment further contributed to this PMCID: PMC7795815. unfortunate outcome53. 2. Jin Y, Yang H, Ji W, Wu W, Chen S, Zhang W, Duan Currently, there is only one ongoing clinical trial G. Virology, Epidemiology, Pathogenesis, and [NCT04368221] at Rennes University Hospital in Control of COVID-19. Viruses. 2020 Mar France to assess prevalence of opportunistic fungal 27;12(4):372. doi: 10.3390/v12040372. PMID: co-infections in COVID-19 infected and 32230900; PMCID: PMC7232198. mechanically ventilated patients in ICU. Researchers 3. Lai CC, Wang CY, Hsueh PR. Co-infections among feel ICU patients with ARDS are not systematically patients with COVID-19: The need for combination screened for the respiratory fungal infections. The therapy with non-anti-SARS-CoV-2 agents? J study will allow to determine median time between Microbiol Immunol Infect. 2020 Aug;53(4):505-512. doi: 10.1016/j.jmii.2020.05.013. PMID: 32482366; entry in ICU and beginning of ARDS and PMCID: PMC7245213. colonization of fungal infections such as Aspergillus, Pneumocystis jirovecii and mucoromycetes. The 4. Pemán J, Ruiz-Gaitán A, García-Vidal C, et al. Fungal study will also evaluate time between diagnosis and co-infection in COVID-19 patients: Should we be targeted treatment at ICU discharge, up to 1 month concerned?. Rev Iberoam Micol. 2020;37(2):41-46. doi:10.1016/j.riam.2020.07.001 and further help develop preventive strategies54. 5. Pasero, D., Sanna, S., Liperi, C. et al. A challenging 6. Conclusion complication following SARS-CoV-2 infection: a case of pulmonary mucormycosis. Infection (2020). https://doi.org/10.1007/s15010-020-01561-x This report is intended to raise awareness for early detection and treatment of various fungal infections, 6. Hernández JL, Buckley CJ. Mucormycosis. [Updated 2020 Jun 26]. In: StatPearls. Treasure Island (FL): www.discoveriesjournals.org/discoveries 9 Fungal co-infections in COVID-19 patients

StatPearls Publishing; 2020 Jan. Available from: With COVID-19-Associated Acute Respiratory https://www.ncbi.nlm.nih.gov/books/NBK544364/ Distress Syndrome, Ophthalmic Plastic and 7. Thng, Z. X., De Smet, M. D., Lee, C. S., Gupta, V., Reconstructive Surgery, 2020, doi: Smith, J. R., McCluskey, P. J., Thorne, J. E., Kempen, 10.1097/IOP.0000000000001889 J. H., Zierhut, M., Nguyen, Q. D., Pavesio, C., & 16. Pasero D. Sanna S. Liperi C. et al. A challenging Agrawal, R. (2020). COVID-19 and complication following SARS-CoV-2 infection: a case immunosuppression: a review of current clinical of pulmonary mucormycosis. Infection (2020). experiences and implications for ophthalmology https://doi.org/10.1007/s15010-020-01561-x patients taking immunosuppressive drugs. The British 17. Nariman K. Christina G. David M. A case report of journal of ophthalmology, bjophthalmol-2020- COVID-19 associated pulmonary mucormycosis, 316586. Advance online publication. Arch Clin Cases 2020; 7(3):46-51, DOI: https://doi.org/10.1136/bjophthalmol-2020-316586 10.22551/2020.28.0703.10172 8. Monte Junior, E., Santos, M., Ribeiro, I. B., Luz, G. 18. Fungal Diseases and COVID-19 | CDC, O., Baba, E. R., Hirsch, B. S., Funari, M. P., & de https://www.cdc.gov/fungal/diseases/candidiasis/invas Moura, E. (2020). Rare and Fatal Gastrointestinal ive/index.html Mucormycosis (Zygomycosis) in a COVID-19 Patient: A Case Report. Clinical endoscopy, 53(6), 19. Al-Hatmi AM, Mohsin J, Al-Huraizi A. Et Al, Covid- 746–749. https://doi.org/10.5946/ce.2020.180 19 associated invasive candidiasis. The Journal of Infection. 2020. 9. Pasero, D., Sanna, S., Liperi, C., Piredda, D., Branca, G. P., Casadio, L., Simeo, R., Buselli, A., Rizzo, D., 20. Lone SA, Ahmad A. Candida auris—the growing Bussu, F., Rubino, S., & Terragni, P. (2020). A menace to global health, Mycoses. 2019;62:620-37. challenging complication following SARS-CoV-2 21. Justin H, Philip K, The Rise of Fungal Infections in infection: a case of pulmonary mucormycosis. COVID-19 Patients, BNF, 2021 Infection, 1–6. Advance online publication. https://doi.org/10.1007/s15010-020-01561-x 22. Prestel C, Anderson E, Forsberg K, Et Al, Candida auris Outbreak in a COVID-19 Specialty Care Unit- 10. Salehi, M., Ahmadikia, K., Badali, H. et al. Florida, July-August 2020. MMWR Morb Mortal Opportunistic Fungal Infections in the Epidemic Area Wkly Rep 2021;70:56-57. DOI: http://dx.doi.org/ of COVID-19: A Clinical and Diagnostic Perspective 10.15585/mmwr.mm7002e3externalicon from Iran. Mycopathologia 185, 607–611 (2020). https://doi.org/10.1007/s11046-020-00472-7 23. Hiram V. Rogelio J. Gloria M, Outbreak of Candida auris infection in a COVID-19 hospital in Mexico, 11. Gangneux, J. P., Bougnoux, M. E., Dannaoui, E., Journal Pre-proof, 2021, DOI: https://doi.org/ Cornet, M., & Zahar, J. R. (2020). Invasive fungal 10.1016/j.cmi.2020.12.030 diseases during COVID-19: We should be prepared.

Journal de mycologie medicale, 30(2), 100971. 24. Amir A, Agostinho C, Frank L. Et Al, COVID-19 https://doi.org/10.1016/j.mycmed.2020.100971 Associated Pulmonary Aspergillosis (CAPA)—From Immunology to Treatment, J. Fungi 2020, 6(2), 12. What is Mucormycosis? Severe fungal infection cases 91; https://doi.org/10.3390/jof6020091 linked to COVID-19? https://timesofindia.indiatimes.com/life-style/health- 25. Alanio A, Dellière S, Fodil S, Et Al, Prevalence of fitness/health-news/coronavirus-severe-fungal- putative invasive pulmonary aspergillosis in critically infection-cases-linked-to-covid-19-heres-what-we- ill patients with COVID-19. Lancet Respir know/photostory/79836584.cms?picid=79836589 Med. 2020;8:e48–9. 13. Shikha G, Mucormycosis, a rare Fungal Infection 26. Arastehfar A, Carvalho A, Van de Veerdonk FL, et linked to COVID-19: Causes, Symptoms, Types, al. COVID-19 associated pulmonary aspergillosis Prevention, and Treatment, 2020, (CAPA)—from immunology to treatment. J Fungi https://www.jagranjosh.com/general- (Basel) 2020; 6:91. knowledge/mucormycosis-a-rare-fungal-infection- 27. Helleberg M, Steensen M, Arendrup MC. Invasive 1608646233-1 aspergillosis in patients with severe COVID-19 14. Amanda W, Mucormycosis with orbital compartment pneumonia [manuscript published online ahead of syndrome in a patient with COVID-19, The American print 5 August 2020]. Clin Microbiol Infect 2020. Journal of Emergency Medicine, 2020, ISSN 0735- doi:10.1016/j.cmi.2020.07.047. 6757, https://doi.org/10.1016/j.ajem.2020.09.032 28. Santana MF, Pivoto G, Alexandre MAA, et al. 15. Mekonnen Z, Ashraf D. Jankowski T, Et Al, Acute Confirmed invasive pulmonary aspergillosis and Invasive Rhino-Orbital Mucormycosis in a Patient COVID-19: the value of postmortem findings to www.discoveriesjournals.org/discoveries 10 Fungal co-infections in COVID-19 patients

support antemortem management. Rev Soc Bras Med 40. Song G, Liang G, Liu W. Fungal Co-infections Trop 2020; 53:e20200401. Associated with Global COVID-19 Pandemic: A 29. Rutsaert L, Steinfort N, Van Hunsel T, et al. COVID- Clinical and Diagnostic Perspective from 19-associated invasive pulmonary aspergillosis. Ann China. Mycopathologia. 2020;185(4):599-606. Intensive Care 2020; 10:71. doi:10.1007/s11046-020-00462-9 30. Antinori S, Rech R, Galimberti L, et al. Invasive 41. Park JY, Bradley N, Brooks S, et al. Management of pulmonary aspergillosis complicating SARS-CoV-2 patietns with Candida auris fungemia at community pneumonia: a diagnostic challenge [manuscript hospital, Brooklyn, New York, USA, 2016-2018. published online ahead of print 26 May 2020]. Travel Emerg Infect Dis. 2019; 25(3):601-602. Med Infect Dis 2020. doi:10.1016/j. 42. CDC. How are C. neoformans infections treated? tmaid.2020.101752. Updated November 19, 2020. 31. Martin H, Invasive Fungal Disease Complicating https://www.cdc.gov/fungal/diseases/cryptococcosis- Coronavirus Disease 2019: When It Rains, It neoformans/treatment.html Accessed March 28, 2021 Spores, Clinical Infectious Diseases, , 43. CDC. Candida Auris. Updated March 3, 2021. ciaa1342, https://doi.org/10.1093/cid/ciaa1342 https://www.cdc.gov/fungal/candida-auris/index.html 32. Center for Medical Mycology. COVID-19 and Accessed March 28, 2021 Aspergillus Co-infections. Updated September 16, 44. CDC. Fungal Diseases. Updated January 8, 2021. 2020. https://www.cdc.gov/fungal/diseases/aspergillosis/trea https://www.exeter.ac.uk/medicalmycology/news/artic tment.html Accessed March 28, 2021. les/covid-19andaspergillusco-.html Accessed March 45. Mehta S, Pandey A. Rhino-Orbital Mucormycosis 29, 2021. Associated With COVID-19. Cureus. 33. Xconomy. COVID-19 and Fungal superinfections: 2020;12(9):e10726. Published 2020 Sep 30. The deadly, perfect storm. Updated May 5, 2020. doi:10.7759/cureus.10726 https://xconomy.com/san-diego/2020/05/05/covid-19- 46. Pasero D, Sanna S, Liperi C, et al. A challenging and-fungal-superinfections-the-deadly-perfect-storm/ complication following SARS-CoV-2 infection: a case Accessed March 29, 2021 of pulmonary mucormycosis [published online ahead 34. Nori P, Cowman K, Chen V, Et Al, Bacterial and of print, 2020 Dec 17]. Infection. 2020;1-6. fungal coinfections in COVID-19 patients hospitalized doi:10.1007/s15010-020-01561-x during the New York City pandemic surge. Infection 47. Zurl, C, Hoenigl, M, Schulz E, et al. Autopsy proven Control & Hospital Epidemiology, 2021; 42(1), 84-88. pulmonary mucormycosis due to Rhizopus Doi:10.1017/ice.2020.368 microspores in a critically ill COVID-19 patient with 35. Aravind A. David D. Elliot J. A Case of COVID-19 underlying hematological malignancy. Journal of and Pneumocystis jirovecii Coinfection, American Fungi 2021, 7(2), 88; Journal of Respiratory and Critical Care Medicine, https://doi.org/10.3390/jof7020088 2020;Vol 2, Issue 1, 48. Hanley, B, Naresh K, Roufosse C, et al. https://doi.org/10.1164/rccm.202003-0766LE Histopathological findings and viral tropism in UK 36. Alexandre A, Sarah D, Sebastian V, Et Al, The patients with severe fatal COVID-19: a post-mortem presence of Pneumocystis jirovecii in critically ill study. Lancet Microbe. 2020 Oct; 1(6):e245-e253. patients with COVID-19, Journal of Infection, 2020, 49. Sen M, Lahane S, Lahane T, et al. Mucor in a viral DOI:https://doi.org/10.1016/j.jinf.2020.10.034 land: A tale of two pathogens. Indian J Opthlamol. 37. Pavan B, Mandee N, James B, Concurrent COVID-19 2021 Feb; 69(20): 244-252. Doi:10.4103/ and Pneumocystis jirovecii pneumonia in a severely ijo.IJO_3774_20. immunocompromised 25-year-old patient, PubMed, 50. Kanwar A, Jordan A, Olewiler S, Wehberg K, Cortes 2020, DOI: 10.1016/j.ijid.2020.07.061 M, Jackson BR. A Fatal Case of Rhizopus 38. Mouren D, Goyard C, Catherinot E, et al. COVID-19 azygosporus Pneumonia Following COVID-19. J and Pneumocystis jirovecii pneumonia: Back to the Fungi (Basel). 2021;7(3):174. Published 2021 Feb 28. basics [published online ahead of print, 2021 Feb doi:10.3390/jof7030174 5]. Respir Med Res. 2021;79:100814. 51. Moorthy A, Gaikwad R, Krishna S, Hegde R, Tripathi doi:10.1016/j.resmer.2021.100814 KK, Kale PG, Rao PS, Haldipur D, Bonanthaya K. 39. Mohamad Y., Amna A. Said B., Cryptococcemia in a SARS-CoV-2, Uncontrolled Diabetes and patient with COVID‐19: A case report, Wiley Online Corticosteroids-An Unholy Trinity in Invasive Fungal Library, 2020, https://doi.org/10.1002/ccr3.3668 Infections of the Maxillofacial Region? A www.discoveriesjournals.org/discoveries 11 Fungal co-infections in COVID-19 patients

Retrospective, Multi-centric Analysis. J Maxillofac 54. Clinicaltrials.gov. Bethesda (MD): National Library of Oral Surg. 2021 Mar 6:1-8. doi: 10.1007/s12663-021- Medicine (US). 2020 April 29-2020 September 4. 01532-1. Epub ahead of print. PMID: 33716414; Identifier NCT04368221, Characterization of fungal PMCID: PMC7936599. infections in COVID-19 Infected and Mechanically 52. Karimi-Galougahi M, Arastou S, Haseli S, Fulimant Ventilated Patients in ICU (MY-CO-VID). Cited on mucormycosis complicating coronavirus disease 2019 2021 March 28. https://clinicaltrials.gov/ct2/ (COVID-19). Wiley Online Library. 2021 Mar 13. show/NCT04368221 https://doi.org/10.1002/alr.22785 This article is an Open Access article distributed under 53. Waizel-Haiat S, Guerrero-Paz JA, Sanchez-Hurtado L, the terms of the Creative Commons Attribution License, Calleja-Alarcon S, Romero-Gutierrez L. A Case of which permits unrestricted use, distribution, and Fatal Rhino-Orbital Mucormycosis Associated With reproduction in any medium, provided the original work New Onset Diabetic Ketoacidosis and COVID- is properly cited and it is not used for commercial 19. Cureus. 2021;13(2):e13163. Published 2021 Feb purposes; 2021, Bhatt K. et al., Applied Systems and 5. doi:10.7759/cureus.13163 Discoveries Journals.