Novel risk factors for Coronavirus disease-associated mucormycosis (CAM): a case control study during the outbreak in India

Arora, U.; Priyadarshi, M.; Katiyar, V.; Soneja, M.; Garg, P.; Gupta, I.; Bharadiya, V.; Berry, P.; Ghosh, T.; Patel, L.; Sarda, R.; Garg, S.; Agarwal, S.; Arora, V.; Ramprasad, A.; Kumar, A.; Garg, R. K.; Kodan, P.; Nischal, N.; Singh, G.; Jorwal, P.; Baitha, U.; Meena, V. P.; Ray, A.; Sethi, P.; Xess, I.; Vikram, N. K.; Sinha, S.; Biswas, A.; Thakar, A.; Bhatnagar, S.; Trikha, A.; Wig, N.

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.