Original Research Article Study on a deadly uninvited guest during the historical second wave at a tertiary health care center in south India Sunil Kumar Katari1, Suneetha Sunkari2, Bhargavi3*, T Khadeeja4, C Aparna5, G Baleswari6 1Assistant Professor, 2Assistant Professor, 3,4PG, 5Professor, 6Professor and HOD, Department of Pathology, Kurnool Medical College, Kurnool 518002. Andhra Pradesh, INDIA. Email: [email protected] Abstract Background: Mucormycotina are widely distributed fungal elements in nature and cause no harm to immunocompetent individuals, but they infect immunosuppressed people causing mucormycosis. Mucormycosis in Severe coronavirus disease (COVID-19) during the first wave escaped unnoticed in many healthcare centers while only a few cases were reported during 2020 in India. As mucormycosis is an invasive fungal infection, accurate identification and diagnosis of Mucormycotina on histopathological examination assists the clinician in further treatment. Aim of the study: To know the incidence of Mucormycosis in the histological specimens received. To know the Age, Sex and Site wise distribution of the same. To compare the present study with other global studies regarding incidence, age and gender wise distribution and suspect: histopatholocally confirmed ratio. Material and Methods: This is a prospective study done in the department of Pathology, Kurnool Medical College, Kurnool, on 162 biopsy specimens sent from patients of Severe coronavirus disease (COVID-19) suspected with mucormycosis of the Rhino-orbito-cerebral regions who underwent surgery in Government General Hospital, Kurnool, from 25st April 2021 to 20th June 2021 (56 days). The biopsy specimens were processed and studied. Results: Within a span of 56 days, out of 162 specimens received, 116 were histopathologically confirmed positive for mucormycosis. Conclusion: Severe coronavirus disease (COVID-19) is changing its course through unexpected life-threatening manifestations of which mucormycosis is one such entity in this second wave. As per the literature mucormycotina is a frequent contaminant in culture media, so histopathological examination always stands as a gold standard. Being invasive fungus with high mortality rate, any hint of mucormycosis in patients of Severe coronavirus disease (COVID-19) should be promptly treated medically and also surgically wherever required in order to contain the morbidity and mortality by this deadly black fungus. Keywords: Mucormycosis, Covid 19, Black fungus, diabetes, Histopathology, angioinvasion, immunosuppressed. *Address for Correspondence: Dr Bhargavi, Department of Pathology, Kurnool Medical College, Kurnool 518002. Andhra Pradesh, INDIA Email: [email protected] Received Date: 22/06/2021 Revised Date: 01/07/2021 Accepted Date: 25/07/2021 DOI: https://doi.org/10.26611/1052011 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. and Cunninghamella spp., which belong to the subphylum Access this article online Mucormycotina. Mucormycotina cause no harm to immunocompetent individuals but infect Quick Response Code: Website: immunosuppressed people resulting in mucormycosis. www.medpulse.in Major predisposing factors are neutropenia, use of corticosteroids, Diabetes mellitus, iron overload and breakdown of cutaneous barrier as a result of burns, 1 Accessed Date: surgical wounds and trauma . Severe coronavirus disease (COVID-19) in itself alters the innate immunity due to 04 October 2021 COVID-19-associated immune dysregulation characterized by decreased T cells, including CD4 and 2,3 CD8 cells. Mucormycosis in Severe coronavirus disease INTRODUCTION (COVID-19) during the first wave escaped unnoticed in Mucormycosis is an opportunistic infection caused by many health care centers while only a few cases were environmental fungi including mucor spp., Rhizopus spp., reported.3 Initially while COVID-19 associated pulmonary How to cite this article: Sunil Kumar Katari et al. Study on a deadly uninvited guest during the historical second wave at a tertiary health care center in south India. MedPulse International Journal of Pathology. October 2021; 20(1): 01-05. https://www.medpulse.in/Pathology/ MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 20, Issue 1, October 2021 pp 01-05 aspergillosis was increasingly recognized, mucormycosis be sparse or fragmented6. In lesions exposed to air, thick- which was rare previously has now become the deadly walled spherical structures can form at the ends of the addition to this Covid 19 spectrum. All physicians hyphae9. Routine HandE stains may show only the cell including ophthalmologists should, therefore, be aware of wall with no structure inside. In immunosuppressed hosts, the probability of development of opportunistic fungal the hyphal elements will be found with abundant necrosis, infections such as mucormycosis in patients with COVID- hemorrhage, and blood vessel thrombosis10. Important 19 illness, especially in those with comorbidities and on diagnostic features include identification of fungal immunosuppressive agents in the coming future4. elements invading the blood vessel wall or inside their Mucormycotina are ubiquitous in the environment and can lumen6. Sparse neutrophilic inflammation can be found in be found in soil and decomposing matter5. Their spores are the periphery of the lesion. easily airborne, which can cause contamination of Pitfalls in morphological diagnosis: The major microbiological culture media6. So not all culture results morphological differentiation should be done among are reliable. As mucormycosis is an invasive fungal Mucorales genera, Aspergillus spp., and Candida spp5. infection, accurate identification and diagnosis of The presence of abundant septation and acute-angle Mucormycotina on histopathological examination assists branching should suggest the diagnosis of Aspergillus the clinician in further treatment. spp., while yeasts with pseudo-hyphae should suggest Aim of the study: To know the incidence of Candida spp. Poor staining of hyphae with GMS Mucormycosis in the histological specimens received. To (Grocott’s methenamine silver stain) should suggest know the Age, Sex and Site wise distribution of the same. mucormycosis. In order to specifically identify Mucorales To compare the present study with other global studies in tissues or to detect dual infections by Mucorales genera regarding incidence, age and gender wise distribution and and other fungi, it is important to use suspect : histopatholocally confirmed ratio. immunohistochemistry, in situ hybridization, or PCR15,16. RESULTS MATERIAL AND METHODS With the approval of the ethics committee, this prospective Total no. of histopathological specimens received during 486 study was done in the department of Pathology, Kurnool the present study Medical College, Kurnool, on 162 biopsy specimens sent Total no. of specimens suspecting Mucormycosis 162 from patients of Severe coronavirus disease (COVID-19) Total no. of specimens histopathologically positive for 116 suspected with mucormycosis of the Rhino-orbito-cerebral Mucormycetes regions who underwent surgery in Government General Out of 486 biopsy specimens received in the Hospital, Kurnool, from 25th April 2021 to 20th June 2021. histopathology department during the period of present (56 Days) study, 162 were from patients of Severe coronavirus Inclusion criteria: All resected tissues of Rhino-orbito- disease (COVID-19) treated in GGH Kurnool, who were cerebral regions of Severe coronavirus disease (COVID- suspected to have developed Mucormycosis. These 19) patients suspected of mucormycosis were included in patients underwent surgical resection of affected tissues from the paranasal sinuses and orbital regions. the present study. Exclusion criteria: All resected tissues from non-covid patients were excluded from the present study. All the specimens were fixed in 10% neutral buffered formalin, processed in Automatic tissue processor into paraffin embedded sections and stained with routine Hematoxylin and Eosin stain, examined under light microscopy and correlated with clinical and radiological findings. The histopathological reports were analyzed with respect to age, sex and site wise distribution Graph 1: Proportion of Mucormycosis suspected specimens mucormycosis. The data was properly tabulated and analyzed. Results and Conclusion were derived from such Of the 162 biopsy specimens received, 116 were analysis. The data shown in charts was prepared using histopathologically confirmed positive for mucormycosis. Microsoft Excel Software. Identifying Mucormycosis on histopathology: Mucormycetes form non-septate hyphae of variable width (6-50µm) with frequent right-angle branching1. The hyphae may vary in width, appear folded or crinkled, and MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 20, Issue 1, October 2021 Page 2 Sunil Kumar Katari et al. Graph 2: Percentage of Mucormycosis positive confirmed cases Table 1: Site wise and Sex wise Distribution of Mucormycosis Graph 4: Age wise and Sex wise Distribution of Mucormycosis Site Males Females Cerebral 2 - Gender Distribution Occular 6 - In the present study out of 116 positive cases, males were Paranasal sinuses 87 21 95 were males and 21 were females. Total 95 21 Graph 5: Gender distribution in Mucormycosis cases Graph 3: Site wise and sex wise distribution Table 2: Age and Sex wise Distribution of Mucormycosis