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• W4223518424 abstract "COVID-19-associated pulmonary mucormycosis (CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus (≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B (5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4–6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but under-reported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required. COVID-19-associated pulmonary mucormycosis (CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus (≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B (5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4–6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but under-reported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required. The COVID-19 pandemic precipitated an epidemic of mucormycosis worldwide, especially in India.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Crossref PubMed Scopus (39) Google Scholar Traditionally, the site of involvement of mucormycosis is related to the underlying predisposing factors. Rhino-orbital mucormycosis occurs in uncontrolled diabetes, whereas pulmonary mucormycosis is seen in patients with haematological malignancy and transplant recipients.2Prakash H Chakrabarti A Global epidemiology of mucormycosis.J Fungi (Basel). 2019; 5: 26Crossref PubMed Scopus (265) Google Scholar During the COVID-19-associated mucormycosis (CAM) outbreak, rhino-orbital mucormycosis was the most common manifestation, followed by pulmonary mucormycosis.3Patel A Kaur H Xess I Michael JS Savio J Rudramurthy S et al.A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.Clin Microbiol Infect. 2020; 26: e9-15Summary Full Text Full Text PDF Scopus (102) Google Scholar, 4Hussain S Riad A Singh A et al.Global prevalence of COVID-19-associated mucormycosis (CAM): living systematic review and meta-analysis.J Fungi (Basel). 2021; 7: 985Crossref PubMed Scopus (8) Google Scholar, 5Hussain S Baxi H Riad A et al.COVID-19-associated mucormycosis (CAM): an updated evidence mapping.Int J Environ Res Public Health. 2021; 1810340Crossref Scopus (14) Google Scholar Among the various risk factors for rhino-orbital mucormycosis and pulmonary mucormycosis, uncontrolled diabetes overshadowed all others.3Patel A Kaur H Xess I Michael JS Savio J Rudramurthy S et al.A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.Clin Microbiol Infect. 2020; 26: e9-15Summary Full Text Full Text PDF Scopus (102) Google Scholar In two large multicentre cohort studies from India, pulmonary mucormycosis accounted for 13·3% of the total patients with mucormycosis before the COVID-19 pandemic, and 8·6% of the total patients with mucormycosis during the COVID-19 pandemic.3Patel A Kaur H Xess I Michael JS Savio J Rudramurthy S et al.A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.Clin Microbiol Infect. 2020; 26: e9-15Summary Full Text Full Text PDF Scopus (102) Google Scholar, 6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Crossref PubMed Scopus (126) Google Scholar The lower proportion of patients with pulmonary mucormycosis during the CAM outbreak could be due to the difficulty in diagnosis of and little awareness of pulmonary mucormycosis.7Muthu V Agarwal R Dhooria S et al.Has the mortality from pulmonary mucormycosis changed over time? A systematic review and meta-analysis.Clin Microbiol Infect. 2021; 27: 538-549Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar Often, pulmonary mucormycosis is either not suspected or remains undiagnosed (due to inadequate infrastructure), despite clinical suspicion. The disruption of diagnostic and clinical services during the COVID-19 pandemic further compounded the difficulties in diagnosing COVID-19-associated pulmonary mucormycosis (CAPM).8Garg D Muthu V Sehgal IS et al.Coronavirus disease (Covid-19) associated mucormycosis (CAM): case report and systematic review of literature.Mycopathologia. 2021; 186: 289-298Crossref PubMed Scopus (196) Google Scholar, 9Pandey N Kaushal V Puri GD et al.Transforming a general hospital to an infectious disease hospital for COVID-19 over 2 weeks.Front Public Health. 2020; 8: 382Crossref PubMed Scopus (21) Google Scholar Although there are global guidelines for the management of mucormycosis,10Rudramurthy SM Hoenigl M Meis JF et al.ECMM/ISHAM recommendations for clinical management of COVID-19 associated mucormycosis in low- and middle-income countries.Mycoses. 2021; 64: 1028-1037Crossref PubMed Scopus (54) Google Scholar, 11Cornely OA Alastruey-Izquierdo A Arenz D et al.Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.Lancet Infect Dis. 2019; 19: e405-e421Summary Full Text Full Text PDF PubMed Scopus (471) Google Scholar there is no clear guidance on the diagnosis and treatment of pulmonary mucormycosis, including CAPM. We framed the current consensus statement to address the diagnosis and management of CAPM and to identify the knowledge gaps in this area. We formed a CAPM clinical practice guideline group (CAPM-GG), including experts from the Fungal Infection Study Forum and the Academy of Pulmonary Sciences in India. We selected experts, with specific interest in mucormycosis who were actively involved in managing CAPM and pulmonary mucormycosis, from various disciplines, including pulmonary medicine, infectious diseases, clinical mycology, pathology, radiodiagnosis, and thoracic surgery to be part of CAPM-GG. At the outset, the experts were briefed on the objectives of the CAPM-GG and the Delphi process (appendix p 5). For the systematic review, two authors (RA and VM) searched PubMed and Embase databases (from inception to Sept 25, 2021) using the search terms: (“COVID” OR “SARS-CoV” OR “coronavirus”) AND (mucor* OR “zygomycosis”). The references obtained from the search were imported into a reference manager software. Our search retrieved 306 articles. We excluded abstracts, articles in a language other than English, and animal studies. After excluding duplicate citations, we reviewed 236 articles in detail (appendix pp 9–25). We reviewed the articles reporting cases of CAPM, relevant review articles, large series of CAM, and our personal files to identify the questions to be addressed (appendix pp 26–30). On the basis of the literature review, three authors (VM, RA, and AC) formulated the initial questions. The questions were circulated by e-mail, and additional questions were invited from the CAPM-GG. Subsequently, we followed a modified Delphi method (appendix p 5). We used the commercially available, web-based Delphi platform for circulating the questions and receiving anonymous responses from the participants. The Delphi process was continued until the predefined criteria of consensus (≥70% agreement or disagreement on a statement) was achieved, or for a maximum of three rounds. After each round of Delphi, we held virtual meetings to discuss the unresolved issues. The comments received during the two rounds and the virtual discussions were incorporated into the final round of Delphi. We recorded the responses to statements using a five-point Likert scale: strongly agree, somewhat agree, neutral, somewhat disagree, and strongly disagree. For the statements for which a response was recorded using the Likert sale, the categories strongly agree and somewhat agree, or strongly disagree and somewhat disagree, were considered together. We recommend a course of action for statements for which consensus of 70% or more was reached and suggest a course of actions for those with a consensus of less than 70%, and provided the consensus level for important summary statements. Statements failing to achieve the predefined consensus criteria even after the final meeting were recorded as dissensus. The online surveys and meetings were conducted between Oct 1 and Nov 1, 2021. 26 of the 28 invited experts participated in the survey. The CAPM-GG comprised experts from pulmonary medicine (13 [50%]), infectious diseases (six [23%]), clinical mycology (three [12%]), radiodiagnosis (two [8%]), pathology (one [4%]), and thoracic surgery (one [4%]), belonging to either public sector (14 [54%]) or private sector (12 [46%]) institutes across the country. The results of the Delphi process are presented in table 1. We achieved a consensus for 84 of the 89 statements, based on which we provide various clinical practice statements for different questions on CAPM.Table 1Results of the Delphi process for the various statements on different questions concerning CAPMSurvey responseConsensus level (%)Definition of CAPMProven CAPMYes100%Probable CAPMYes100%Possible CAPMYes75%Risk factorsUncontrolled diabetesYes100%Inappropriate steroid therapyYes100%Severe COVID-19Yes78%ImmunosuppressionYes95%Immunomodulators for COVID-19 (eg, tocilizumab)Yes28%Altered iron metabolismYes78%ICU admission for COVID-19No85%Use of industrial oxygen, contaminated humidifier water, or reused masksNo65%No or irregular use of a mask during COVID-19 or post-COVID-19 periodNo79%Zinc supplement for COVID-19No75%Clinical featuresFeverSuggestive83%Worsening or productive coughSuggestive87%Brownish or black sputumHighly suggestive74%Chest painSuggestive71%HaemoptysisHighly suggestive70%Worsening respiratory symptoms patients with COVID-19Suggestive83%Worsening chest imagingSuggestive70%Evaluation of CAPMCharacteristic imaging on CT with intravenous contrastYes100%Routine imaging of paranasal sinuses or brainNo89%Respiratory sample positive for Mucorales by conventional diagnostic techniquesYes100%Bronchoalveolar lavage sample positive for Mucorales by molecular diagnostic techniquesYes74%SerologyNo83%Molecular test of blood, urine, or body fluidNo58%Imaging findingsReversed halo signHighly suggestive100%Thick-walled cavityHighly suggestive94%Large consolidation or necrotising pneumoniaHighly suggestive81%Mycotic aneurysmHighly suggestive100%Bird's nest signHighly suggestive95%Multiple large nodulesHighly suggestive72%Serial imaging showing air-fluid levelsSuggestive80%Pleural effusion associated with other findingsSuggestive74%PneumothoraxNon-specific100%Mediastinal lymphadenopathyNot suggestive89%Centrilobular nodules or tree in bud appearanceNot suggestive100%Differential diagnosisSevere COVID-19Yes82%COVID-19-associated pulmonary aspergillosisYes100%TuberculosisYes96%Other cavitary pneumoniasYes75%Bacterial pneumonia (community and hospital acquired)Yes86%Diagnostic proceduresOpen-lung biopsy for diagnosisNo73%Diagnostic bronchoscopy should be performed as early as possible for the evaluation of suspected CAPMYes95%Flexible bronchoscopy can be safely performed in all patients with COVID-19 (intubated and non-intubated), following standard precautionsYes78%CT-guided trucut biopsy (or fine-needle aspiration with on-site evaluation)Yes91%Laboratory processing of samplesUse of high-volume samplesYes85%Rapid transport to the laboratoryYes90%Use of Calcofluor microscopical examinationYes72%Semiquantitative estimation of fungusNot recommended85%Mincing (instead of grinding) the tissue sampleYes87%PCR from surgical or biopsy specimens for bronchoalveolar lavage fluidYes74%The histopathology of CAPM is not different from non-CAPMYes90%Immunohistochemistry is useful in differentiating mucormycosis from aspergillosis in tissuesYes61%Species identification and antifungal susceptibilityDoes species identification help in the management?Yes74%Is an antifungal susceptibility test essential for optimal therapy?Yes71%Choice of drug and doseLiposomal amphotericin B is the treatment of choice for CAPMYes100%If liposomal formulation is unavailable, any lipid formulation can be usedYes100%If no lipid formulation is available, amphotericin B deoxycholate should be used as the primary therapy over posaconazole or isavuconazoleYes94%Initial dose of intravenous liposomal amphotericin B5 mg/kg80%Should the amphotericin B dose be escalated in bilateral or non-operable disease?No85%Should the amphotericin B dose be escalated in the presence of uncontrolled risk factors for CAPM?No90%Should the amphotericin B dose be escalated in the presence of extrapulmonary mucormycosis (disseminated or ROCM)?No52%After complete or partial response is achieved, maintenance treatment with isavuconazole or posaconazole should be givenYes100%Preferred formulation of posaconazole is a tabletYes80%Therapeutic drug monitoring of posaconazoleYes74%Combination of antifungalsThe combination of antifungals (posaconazole or isavuconazole with amphotericin) is not evidence based and should not be recommendedYes89%Echinocandins in combination with amphotericin B can be given in CAPMNo83%Salvage therapy with posaconazole or isavuconazole might be considered in refractory patientsYes100%Nebulised amphotericin B for CAPMNo95%Response monitoring and duration of therapyDuration of therapy should be based on response assessment (instead of a fixed duration)Yes81%Monitoring with a weekly chest radiography (along with antifungals as and when required)Yes95%Preferred timing of CT scan for response assessment4–6 weeks70%Surgery For CAPMAll patients with potentially resectable disease of the lung (unilateral) should undergo surgeryYes95%Preoperative multidisciplinary team evaluationYes100%Timing of surgery after diagnosis*After stabilising the metabolic derangements.As early as possible (< 1 week); <2 weeks34%; 40%Spirometry desirable in all patients preoperatively, especially before pneumonectomy or in those with pre-existing lung diseaseYes100%Surrogate tests such as 6-MWT or other methods are sufficient to assess exercise capacity (if spirometry not possible)Yes90%Preoperative assessment of frailtyYes82%Delay surgery or continue medical management and reassess in frail patientsYes89%Surgery for CAPM in the presence of COVID-19-related lung disease†Except in patients with emergent indications such as massive haemoptysis.After stabilistion80%Extensive invasion of mediastinal structures and hilar vessels seen on thoracic imaging is associated with technical difficulties during surgery and poor outcome; hence, initial medical management followed by reassessment is suggestedAgreed81%Prevention of CAPMProphylactic antifungals or nebulised amphotericin B to prevent CAPM in patients with COVID-19 admitted to hospital or the ICUNo91%Universal maskingYes95%Avoidance of construction siteYes90%Control of blood sugars in diabetesYes100%Immunosuppression for COVID-19, optimal dose, and durationYes95%Severe COVID-19 and development of CAPM before 10 days of therapy with glucocorticoidsStop therapy71%No glucocorticoid use for non-severe (non-hypoxaemic) COVID-19Yes100%Judicious use of corticosteroids for post-COVID-19 lung disease (at the lowest possible dose for the shortest possible duration)Yes78%CAPM=COVID-19-associated pulmonary mucormycosis. 6-MWT=6 min walk test. CAPA=COVID-19-associated pulmonary aspergillosis. ICU=intensive care unit. ROCM=rhinoorbitocerebral mucormycosis.* After stabilising the metabolic derangements.† Except in patients with emergent indications such as massive haemoptysis. Open table in a new tab CAPM=COVID-19-associated pulmonary mucormycosis. 6-MWT=6 min walk test. CAPA=COVID-19-associated pulmonary aspergillosis. ICU=intensive care unit. ROCM=rhinoorbitocerebral mucormycosis. Pulmonary mucormycosis diagnosed either at the same time as, or within 3 months of, confirmed COVID-19 was agreed upon as the entry criterion for diagnosing CAPM.6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Crossref PubMed Scopus (126) Google Scholar We further classified CAPM as proven, probable, and possible (panel 1). The consensus for the proven and probable CAPM categories was obtained following the first round of surveys. For the possible CAPM category, we could only reach a consensus in the third round. The experts were divided in their opinions on possible CAPM, given the potential for over-diagnosis and unnecessary empirical treatment, which is both long lasting and expensive. However, we retained the possible CAPM category, recognising the need for an epidemiological definition for facilitating research and adopting a judicious treatment approach. Furthermore, the group emphasised that an extensive evaluation of possible CAPM should be undertaken by performing bronchoscopy or other suitable diagnostic procedures to confirm or exclude the diagnosis.Panel 1Definitions of COVID-19 associated pulmonary mucormycosisCOVID-19-associated pulmonary mucormycosis (CAPM) is diagnosed either simultaneously with or within 3 months of virologically confirmed COVID-19.Proven CAPMHistopathology or cytology showing aseptate hyphae or culture obtained by a sterile procedure from a usually sterile site (pleural fluid or lung) showing growth of Mucorales.Probable CAPMPresence of all the following: compatible clinical features, risk factors, and suggestive imaging (thick-walled cavity, large consolidation, reversed halo sign, or multiple large nodules) and demonstration of aseptate hyphae (with or without growth of Mucorales) in a sample representative of the lower respiratory tract (including bronchoalveolar lavage, non-bronchoscopic bronchial lavage, bronchial washings, bronchial brushing, endotracheal aspirates, and sputum).Possible CAPMPresence of all the following: compatible clinical features; uncontrolled diabetes, prolonged or inappropriate glucocorticoid therapy (dose, duration, or indication deviating from the current evidence-based practice for glucocorticoids in COVID-19); and highly suggestive radiology (reversed halo sign, mycotic aneurysm, or thick-walled cavity), in the absence of a definite alternative diagnosis. COVID-19-associated pulmonary mucormycosis (CAPM) is diagnosed either simultaneously with or within 3 months of virologically confirmed COVID-19. Proven CAPM Histopathology or cytology showing aseptate hyphae or culture obtained by a sterile procedure from a usually sterile site (pleural fluid or lung) showing growth of Mucorales. Probable CAPM Presence of all the following: compatible clinical features, risk factors, and suggestive imaging (thick-walled cavity, large consolidation, reversed halo sign, or multiple large nodules) and demonstration of aseptate hyphae (with or without growth of Mucorales) in a sample representative of the lower respiratory tract (including bronchoalveolar lavage, non-bronchoscopic bronchial lavage, bronchial washings, bronchial brushing, endotracheal aspirates, and sputum). Possible CAPM Presence of all the following: compatible clinical features; uncontrolled diabetes, prolonged or inappropriate glucocorticoid therapy (dose, duration, or indication deviating from the current evidence-based practice for glucocorticoids in COVID-19); and highly suggestive radiology (reversed halo sign, mycotic aneurysm, or thick-walled cavity), in the absence of a definite alternative diagnosis. The prevalence of CAPM was reported to be 0·01% in patients with COVID-19 from the community (data from one centre in Mexico), 0·15% in patients admitted to hospital with COVID-19 (data from five tertiary-care centres in India), and 1·00% in patients with COVID-19 on mechanical ventilation (data from 59 micology laboratories in France).6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Crossref PubMed Scopus (126) Google Scholar, 12Guzman-Castro S Chora-Hernandez LD Trujillo-Alonso G et al.COVID-19-associated mucormycosis, diabetes and steroid therapy: experience in a single centre in western Mexico.Mycoses. 2021; 65: 65-70Crossref PubMed Scopus (5) Google Scholar, 13Gangneux JP Dannaoui E Fekkar A et al.Fungal infections in mechanically ventilated patients with COVID-19 during the first wave: the French multicentre MYCOVID study.Lancet Respir Med. 2021; 10: 180-190Summary Full Text Full Text PDF PubMed Google Scholar The burden of CAPM following the second wave of the COVID-19 pandemic in India and other countries remains largely unknown.14Ramaswami A Sahu AK Kumar A et al.COVID-19-associated mucormycosis presenting to the emergency department-an observational study of 70 patients.QJM. 2021; 114: 464-470Crossref PubMed Scopus (10) Google Scholar, 15Selarka L Sharma S Saini D et al.Mucormycosis and COVID-19: an epidemic within a pandemic in India.Mycoses. 2021; 64: 1253-1260Crossref PubMed Scopus (42) Google Scholar, 16Seidel D Simon M Sprute R et al.Results from a national survey on COVID-19-associated mucormycosis in Germany: 13 patients from six tertiary hospitals.Mycoses. 2021; 65: 103-109Crossref PubMed Scopus (14) Google Scholar, 17Bayram N Ozsaygılı C Sav H et al.Susceptibility of severe COVID-19 patients to rhino-orbital mucormycosis fungal infection in different clinical manifestations.Jpn J Ophthalmol. 2021; 65: 515-525Crossref PubMed Scopus (31) Google Scholar In a systematic review, CAPM accounted for 26 (9·5%) of 275 patients with CAM from across the world.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Crossref PubMed Scopus (39) Google Scholar 17 (7·3%) of 233 reported CAM cases from India and nine (21·4%) of 42 reported CAM cases from the rest of the world were due to CAPM.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Crossref PubMed Scopus (39) Google Scholar On the basis of the scarce data available from India,6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Crossref PubMed Scopus (126) Google Scholar France,18Danion F Letscher-Bru V Guitard J et al.COVID-19 associated mucormycosis in France: a rare but deadly complication.Open Forum Infect Dis. 2021; 9ofab566PubMed Google Scholar and Chile,19Rabagliati R Rodríguez N Núñez C Huete A Bravo S Garcia P COVID-19-associated mold infection in critically ill patients, Chile.Emerg Infect Dis. 2021; 27: 1454-1456Crossref PubMed Scopus (25) Google Scholar the pooled prevalence of CAPM was estimated to be 5 (95% CI <1 to 29) per 10 000 patients admitted to hospital with COVID-19 (appendix p 6). The prevalence of CAPM was higher in India and Chile than in France. After the second wave of COVID-19, India reported more than 40 000 patients with CAM. The experts estimated that the number of patients with CAPM in the recent CAM epidemic should have been around 4000. However, no more than 40 incidents of CAPM have been published globally.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Crossref PubMed Scopus (39) Google Scholar, 20Alfishawy M Elbendary A Younes A et al.Diabetes mellitus and coronavirus disease (Covid-19) associated mucormycosis (CAM): a wake-up call from Egypt.Diabetes Metab Syndr. 2021; 15102195Crossref Scopus (3) Google Scholar, 21Chennamchetty VK Adimulapu S Kola BP et al.Post-COVID pulmonary mucormycosis—a case report.IP Indian J Immunol Respir Med. 2021; 6: 62-66Google Scholar, 22Dantis K Rathore V Kashyap NK Gupta N De S Singha SK SARS-CoV-2 sequel: pulmonary mucormycosis with a mycotic aneurysm in a transplant recipient.Tuberc Respir Dis (Seoul). 2021; 84: 335-337Crossref PubMed Google Scholar, 23Rabagliati R Rodríguez N Núñez C Huete A Bravo S Garcia P Covid-19-associated mold infection in critically ill patients, chile.Emerg Infect Dis. 2021; 27: 1454-1456Crossref PubMed Scopus (25) Google Scholar, 24Rana G Gautam S Mawari G Daga MK Kumar N Raghu RV Massive hemoptysis causing mortality in a post COVID-19 infected Asian male patient: presenting as pulmonary mucormycosis, pulmonary tuberculosis and later sino-nasal mucormycosis.Respir Med Case Rep. 2021; 34101511PubMed Google Scholar Thus, there is a possibility of gross under-reporting of the number of patients with CAPM. All participants considered uncontrolled diabetes (hyperglycaemia) and inappropriate (or excessive) glucocorticoid therapy as major risk factors for CAPM.25Cornely OA Duarte RF Haider S et al.Phase 3 pharmacokinetics and safety study of a posaconazole tablet formulation in patients at risk for invasive fungal disease.J Antimicrob Chemother. 2016; 71: 718-726Crossref PubMed Scopus (105) Google Scholar, 26Riad A Shabaan AA Issa J et al.COVID-19-associated mucormycosis (CAM): case-series and global analysis of mortality risk factors.J Fungi. 2021; 7: 837Crossref PubMed Scopus (12) Google Scholar COVID-19 per se, and the associated dysregulation of iron metabolism, were also considered to be contributing factors.27Kumar HM Sharma P Rudramurthy SM et al.Serum iron indices in COVID-19-associated mucormycosis: a case-control study.Mycoses. 2021; 65: 120-127Crossref PubMed Scopus (5) Google Scholar Although patients with COVID-19 requiring intensive care have been noted to develop CAPM,13Gangneux JP Dannaoui E Fekkar A et al.Fungal infections in mechanically ventilated patients with COVID-19 during the first wave: the French multicentre MYCOVID study.Lancet Respir Med. 2021; 10: 180-190Summary Full Text Full Text PDF PubMed Google Scholar, 16Seidel D Simon M Sprute R et al.Results from a national survey on COVID-19-associated mucormycosis in Germany: 13 patients from six tertiary hospitals.Mycoses. 2021; 65: 103-109Crossref PubMed Scopus (14) Google Scholar most experts believed that intensive care was not an independent risk factor. The CAPM-GG did not consider zinc supplementation, contaminated humidifiers, industrial oxygen, or reused masks as risk factors for CAPM.1Muthu V Rudramurthy SM Chakrabarti A Agarwal R Epidemiology and pathophysiology of COVID-19-associated mucormycosis: India versus the rest of the world.Mycopathologia. 2021; 186: 739-754Crossref PubMed Scopus (39) Google Scholar, 28Muthu V Kumar M Paul RA et al.Is there an association between zinc and COVID-19-associated mucormycosis? Results of an experimental and clinical study.Mycoses. 2021; 64: 1291-1297Crossref PubMed Scopus (14) Google Scholar The experts also found insufficient evidence to indicate tocilizumab or other immunomodulators as risk factors for CAPM.6Patel A Agarwal R Rudramurthy SM et al.Multicenter epidemiologic study of coronavirus disease-associated mucormycosis, India.Emerg Infect Dis. 2021; 27: 2349-2359Crossref PubMed Scopus (126) Google Scholar None of the clinical features were found to be specific to CAPM, and the presentation of CAPM is often indistinguishable from COVID-19 or any pneumonic illness.29Hoenigl M Seidel D Carvalho A et al.The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries.Lancet Microbe. 2022; (published online Jan 25.)https://doi.org/10.1016/S2666-5247(21)00237-8Summary Full Text Full Text PDF Scopus (28)" @default.
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• W4223518424 title "Definition, diagnosis, and management of COVID-19-associated pulmonary mucormycosis: Delphi consensus statement from the Fungal Infection Study Forum and Academy of Pulmonary Sciences, India" @default.
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