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Novel Risk Factors for Coronavirus Disease-Associated Mucormycosis (CAM): a Case Control Study During the Outbreak in India

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Novel Risk Factors for Coronavirus Disease-Associated Mucormycosis (CAM): a Case Control Study During the Outbreak in India medRxiv preprint doi: https://doi.org/10.1101/2021.07.24.21261040; this version posted July 26, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Novel risk factors for Coronavirus disease-associated mucormycosis (CAM): a case control study during the outbreak in India Umang Arora1, Megha Priyadarshi1, Varidh Katiyar2, Manish Soneja1, Prerna Garg1, Ishan Gupta1,- Vishwesh Bharadiya1, Parul Berry1, Tamoghna Ghosh1, Lajjaben Patel1 , Radhika Sarda1, Shreya Garg3, Shubham Agarwal1, Veronica Arora4, Aishwarya Ramprasad1, Amit Kumar1, Rohit Kumar Garg1, Parul Kodan1, Neeraj Nischal1, Gagandeep Singh5, Pankaj Jorwal1, Arvind Kumar1, Upendra Baitha1, Ved Prakash Meena1, Animesh Ray1, Prayas Sethi1, , Immaculata Xess5, Naval Vikram1, Sanjeev Sinha1, Ashutosh Biswas1,Alok Thakar3, Sushma Bhatnagar6, Anjan Trikha7, Naveet Wig1 1Department of Medicine, AIIMS, Delhi, India 2Department of Neurosurgery, AIIMS, Delhi, India 3Department of Otolaryngology & Head-Neck Surgery, AIIMS, Delhi, India 4Department of Medical Genetics, Sir Ganga Ram Hospital, Delhi, India 5Department of Microbiology, AIIMS, Delhi, India 6Department of Onco-anaesthesia and Palliative Medicine, AIIMS, Delhi, India 7Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, Delhi, India 1. Umang Arora, MD (Medicine), Junior Resident, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 2. Megha Priyadarshi, DM (Infectious disease), Junior Resident, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 3. Varidh Katiyar, MCh (Neurosurgery), Chief Resident, Department of Neurosurgery AIIMS, Delhi, India. E-mail ID: [email protected] 4. Manish Soneja, MD (Medicine), Additional Professor, Department of Medicine, AIIMS, Delhi. Email ID: [email protected] 5. Prerna Garg, MD (Medicine), Junior Resident, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 6. Ishan Gupta, MBBS, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 7. Vishwesh Bharadiya, MBBS, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 8. Parul Berry, MBBS, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 9. Tamoghna Ghosh, MBBS, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 10. Lajjaben Patel, MBBS, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 11. Radhika Sarda, DM (Infectious diseases), Senior Resident, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 12. Shreya Garg, MS (ENT), Junior Resident, Department of Otolaryngology & Head-Neck Surgery, AIIMS, Delhi, India. E-mail ID: [email protected] 13. Shubham Agarwal, MD (Medicine), Senior Resident, AIIMS, Delhi, India. E-mail ID: [email protected] 14. Veronica Arora, DNB (Medical Genetics), Associate Consultant, Sir Ganga Ram Hospital, Delhi, India. E-mail ID: [email protected] NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. medRxiv preprint doi: https://doi.org/10.1101/2021.07.24.21261040; this version posted July 26, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 15. Aishwarya Ramprasad, DM (Infectious diseases), Senior Resident, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 16. Amit Kumar, MBBS, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 17. Rohit Kumar Garg, DM (Infectious diseases), Senior Resident, Department of Medicine, AIIMS, Delhi, India. E-mail ID: [email protected] 18. Parul Kodan, DM (Infectious diseases), Assistant Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 19. Neeraj Nischal, MD (Medicine), Associate Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 20. Gagandeep Singh, MD (Microbiology), Associate Professor, Department of Microbiology, AIIMS, Delhi, India. Email ID: [email protected] 21. Pankaj Jorwal, Associate Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 22. Arvind Kumar, MD (Medicine), Associate Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 23. Upendra Baitha, MD (Medicine), Assistant Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 24. Ved Prakash Meena, MD (Medicine), Assistant Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 25. Animesh Ray, DM (Pulmonary Medicine and Critical Care), Assistant Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 26. Prayas Sethi, MD (Medicine), Assistant Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 27. Immaculata Xess, MD (Microbiology), Professor, Department of Microbiology, AIIMS, Delhi, India. Email ID: [email protected] 28. Naval Kishore Vikram, MD (Medicine), Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 29. Sanjeev Sinha, MD (Medicine), Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 30. Ashutosh Biswas, MD (Medicine), Professor, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] 31. Alok Thakar, MS (ENT), Professor and Head, Department of Otolaryngology & Head-Neck Surgery, AIIMS, Delhi, India. Email ID: [email protected] 32. Sushma Bhatnagar, MD (Anaesthesiology), Professor and Head, Department of Onco- anaesthesia and palliative medicine, AIIMS, Delhi, India. Email ID: [email protected] 33. Anjan Trikha, MD (Anaesthesiology), Professor, Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, Delhi, India. Email ID: [email protected] 34. Naveet Wig, MD (Medicine), Professor and Head, Department of Medicine, AIIMS, Delhi, India. Email ID: [email protected] medRxiv preprint doi: https://doi.org/10.1101/2021.07.24.21261040; this version posted July 26, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Acknowledgements None Availability of data and materials The data would be made available by the authors on specific requests keeping patient confidentiality in view. IRB approval The study was approved by the Institute Ethics Committee of AIIMS, Ansari Nagar, Delhi, India on 28/05/2021. The reference number for the approval is IECPG-353/28.05.21. Competing interests The authors declare that they have no competing interests. Authors’ contributions All listed authors meet the ICMJE criteria. We attest that all authors contributed significantly to the creation of this manuscript, each having fulfilled the criteria as established by the ICMJE. medRxiv preprint doi: https://doi.org/10.1101/2021.07.24.21261040; this version posted July 26, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Abstract: Background: The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies. Methods: We performed a case-control study comparing cases diagnosed with CAM and those who had recovered from COVID-19 without developing mucormycosis (controls). Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Results: 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases carried conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95%CI 1.1-11), use of systemic steroids (aOR 7.7,95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6,95% CI 1.2-2.2). Zinc therapy, probably due to its utility in immune function, was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM. Conclusion: Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM. medRxiv preprint doi: https://doi.org/10.1101/2021.07.24.21261040; this version posted
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