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Fungal Infections

Cumulative Mortality and Factors Associated With Outcomes of Mucormycosis After COVID-19 at a Multispecialty Tertiary Care Center in India

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Ophthalmology

Published Online: December 9, 2021

Original Investigation

Article Information and Disclosures

Twinkle Choksi, MD¹;

Anamika Agrawal, DNB¹;

Purva Date, DNB¹;

Darshana Rathod, MS¹;

Anuja Gharat, DNB¹;

Avinash Ingole, MS¹;

Bhushan Chaudhari, DNB¹;

Nitin Pawar, MS¹

Author Affiliations

¹Department of Ophthalmology, Topiwala National Medical College, BYL Nair Charitable Hospital, Mumbai Central, Mumbai, India

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Key Points

Question What is the mortality rate among patients with COVID-19–associated rhino-orbitocerebral mucormycosis at 1 month?

Findings In this case-control study of 73 patients, 26 (36%) died within 10 days after admission. The cumulative probability of death was 53% at day 21, and assisted ventilation during prior COVID-19 treatment or visual acuity of no light perception were associated with a higher risk of death.

Meaning These findings suggest that the mortality rate after rhino-orbitocerebral mucormycosis is high and that a subgroup of patients who have severe COVID-19 or present with severe orbital disease are more likely to die within 10 days of admission.

Abstract

Importance An outbreak of COVID-19–associated rhino-orbitocerebral mucormycosis (CAM) has occurred in many parts of the world. Although the clinical profile and risk factors for CAM have been studied, cumulative mortality and its risk factors have not.

Objective To report the cumulative mortality rates at different times in cases with CAM and identify risk factors for CAM-associated mortality.

Design, Setting, and Participants This retrospective case-control study was conducted from March 1 to May 30, 2021, in a tertiary care multispecialty hospital in western India. All patients diagnosed with CAM and with a minimum follow-up of 30 days or those who died before 30 days due to CAM were included.

Main Outcomes and Measure Cumulative mortality in CAM using survival analysis.

Results A total of 73 consecutive patients with CAM with a mean (SD) age of 53.5 (12.5) years were included in the analysis, of whom 48 (66%) were men. CAM developed at a median of 28 (IQR, 15-45; range, 4-90) days after recovery from COVID-19. Of the 73 patients with CAM, 26 (36%) died; the cumulative probability of death was 26% (95% CI, 16%-41%) at day 7 and doubled to 53% (95% CI, 39%-69%) at day 21. Sinus debridement was performed in 18 of 51 patients (35%), and 5 of 52 (10%) underwent exenteration, whereas intravenous lyophilized amphotericin B was administered to 48 patients (66%). A multivariate Cox proportional hazards regression analysis showed that receiving mechanical ventilation in the past was associated with a nearly 9-fold increased risk of death (hazard ratio [HR], 8.98; 95% CI, 2.13-38.65; P = .003), and patients who had visual acuity of light perception or better had a 46% lower risk of death (HR, 0.56; 95% CI, 0.32-0.98; P = .04). Intravenous amphotericin B administration was associated with a reduced rate of exenteration (0 vs 5 of 25 [20%]; P < .001). On multivariate analysis, those who received intravenous amphotericin B had a 69% reduced risk of death (HR, 0.31; 95% CI, 0.06-1.43; P = .13).

Conclusions and Relevance These findings suggest that the mortality rate after rhino-orbitocerebral mucormycosis is high and that a subgroup of patients with severe COVID-19 or presenting with severe orbital disease are more likely to die within 10 days of admission.

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Article Information

Accepted for Publication: October 19, 2021.

Published Online: December 9, 2021. doi:10.1001/jamaophthalmol.2021.5201

Corresponding Author: Avinash Ingole, MS, Department of Ophthalmology, Topiwala National Medical College, BYL Nair Charitable Hospital, Mumbai Central, OPD Building, 2nd Floor, Mumbai, Maharashtra 400 008, India (dr.avinshingole@yahoo.com).

Author Contributions: Mr Ingole had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Choksi, Agrawal, Date, Rathod, Ingole.

Acquisition, analysis, or interpretation of data: Choksi, Date, Gharat, Ingole, Chaudhari, Pawar.

Drafting of the manuscript: Choksi, Date, Ingole, Chaudhari.

Critical revision of the manuscript for important intellectual content: Choksi, Agrawal, Date, Rathod, Gharat, Ingole, Pawar.

Statistical analysis: Choksi, Date, Rathod, Ingole, Pawar.

Administrative, technical, or material support: Choksi, Date, Gharat, Chaudhari, Pawar.

Supervision: Choksi, Agrawal, Rathod, Gharat, Ingole.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Dilip Asgaonkar, MD, Girish Rajadhyaksha, MD, Rosemarie DeSouza, MD, Vrinda Kulkarn, MD, Mala Kaneria, MD, and Santosh Gosavi, MD, Department of Internal Medicine, Topiwala National Medical College, BYL Nair Charitable Hospital, Mumbai Central, India, contributed clinical management of patient and systemic complications during the course of admission. Bachi Hatiram, MS, Sanjay Chhabria, MS, and Vicky Khattar, MS, Department of Otorhinolaryngology, Topiwala National Medical College, BYL Nair Charitable Hospital, managed the otorhinolaryngology aspect of patient treatment during the course of admission. Sabyasachi Sengupta, DO, DNB, Sengupta’s Research Academy, Mumbai, India, assisted with statistical analysis and manuscript writing. No compensation was received by any of these individuals except Dr Sengupta for their services.

Additional Information: We thank the wife of the deceased patient in the promotional image for consenting to publish the photograph.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.