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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 99-100

Treatment of florid COVID-19-associated mucosal candidiasis and the diagnostic dilemma of suspected mucormycosis


1 Department of Dermatology, Maharashtra Medical Foundation’s Joshi Hospital, Pune, Maharashtra, India
2 Department of Dermatology, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India

Date of Submission19-Jul-2021
Date of Decision01-Sep-2021
Date of Acceptance28-Sep-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Sharad D Mutalik
Department of Dermatology, Maharashtra Medical Foundation’s Joshi Hospital, 778 Deccan Gymkhana, Pune 411004. Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_34_21

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How to cite this article:
Mutalik SD, Kulkarni VV, Rasal YD, Salunke TS. Treatment of florid COVID-19-associated mucosal candidiasis and the diagnostic dilemma of suspected mucormycosis. Indian J Drugs Dermatol 2021;7:99-100

How to cite this URL:
Mutalik SD, Kulkarni VV, Rasal YD, Salunke TS. Treatment of florid COVID-19-associated mucosal candidiasis and the diagnostic dilemma of suspected mucormycosis. Indian J Drugs Dermatol [serial online] 2021 [cited 2022 Aug 8];7:99-100. Available from: https://www.ijdd.in/text.asp?2021/7/2/99/332421



Sir,

The summative interplay of immune dysregulation and systemic deterioration caused by coronavirus disease 2019 (COVID-19) infection and its therapy, with classical risk factors, results in a plethora of oropharyngeal mucosal manifestations.[1],[2]

A 54-year-old woman, non-tobacco chewer with mild COVID-19 infection of 2 weeks, presented with white coating over lips and oral cavity. She had soreness, dysphagia, facial pain, and loosening of teeth. Diagnosed with diabetes mellitus at admission at the primary COVID care facility, she received metformin, favipiravir, colchicine, ivermectin, and oral corticosteroid (prednisolone 30 mg for 3 days, 20 mg for 3 days, and 10 mg for 3 days). She received no antibiotics.

She was afebrile with an extensive white plaque carpeting the labial and buccal mucosa, tongue, palate, oropharynx with facial swelling and tender maxillary sinuses. Non-necrotic dark brown pigmentation was seen over palatal, interpapillary gingival mucosa, and teeth [Figure 1]a, b. Vaginal mucosa was uninvolved.
Figure 1: (a) and (b) shows COVID-19-associated Candida-associated lesions involving lips and oral cavity with dark brown discoloration of mucosa and teeth; (c) and (d) shows complete resolution of Candida-associated lesions with 3 weeks fluconazole therapy

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Post-prandial blood sugar levels (180 mg/dl) and glycohemoglobin (6.6) were raised. Other baseline parameters were normal. Serology was nonreactive for the human immune deficiency virus. Potassium hydroxide mount from the oral lesion showed pseudohyphae, confirming the clinical diagnosis of candidiasis. Esophagogastroduodenoscopy ruled out esophageal candidiasis.

Intravenous fluconazole 200 mg (twice a day on admission and 200 mg intravenously daily for 7 days) was initiated along with clotrimazole (1%) mouth paint, and alcohol-free chlorhexidine gluconate (0.2%) oral rinses. The patient showed rapid clinical improvement, so fungal culture for species identification and sensitivity testing was not done. The patient remained afebrile without signs of candidemia.

The oral hyperpigmentation was post-inflammatory. MRI scan of the brain, orbit, and paranasal sinuses showed heterogeneous mucosal enhancement post-contrast in the nasal cavities, possibly early fungal sinusitis. A functional endoscopic sinus surgical biopsy showed inflamed sinonasal tissue. Calcofluor staining failed to yield fungal elements. MRI findings were concluded to be inspissated secretions with the patient showing steady clinical improvement. A dental evaluation confirmed the teeth were loosening in a pattern, consistent with periodontitis.

Oropharyngeal COVID-19-associated mucosal candidiasis (CAC) lesions resolved completely after 8 days of intravenous fluconazole followed by oral fluconazole 200 mg/day continued for 2 weeks more [Figure 1c, d].

CAC is reported throughout the spectrum of asymptomatic to critically ill patients.[3 Early diagnosis and monitoring are vital given the high mortality with systemic dissemination. Presently one-quarter of candidemia patients have COVID-19,[ linked to risks of COVID care and immunosuppressive medications.[4]

Fluconazole remains the principal azole drug used as monotherapy for susceptible Candida isolates in uncomplicated mucosal candidiasis in CAC. A collation of 63 cases of oral CAC from eight studies reported treatment with systemic fluconazole for 2 weeks in most cases. Candidemia-resistant or fluconazole-resistant strains needed echinocandins or liposomal amphotericin B therapy.[5] An epidemiologic study comparing candidemia in COVID and non-COVID patients concluded that the length of intensive care unit stays before the development of candidemia was significantly longer in the former; while the burden of sequential organ dysfunction more in the latter with no significant difference in the crude hospital mortality between the two.[6]

There is insufficient evidence in the literature reporting intra-oral finding of mucormycosis associated with COVID-19 disease. Facial/sinus pain, black pigmentation, nasal discharge are signs to be flagged. Post-inflammatory oral pigmentation and necrotizing periodontal disease are reported in COVID-19 infection.[1] Candidiasis itself can cause subgingival colonization and acute severe periodontitis.[7] Both factors could be responsible for acute teeth loosening in our case.

This letter reports the treatment of florid CAC and highlights the diagnostic challenges amidst an explosion of rare fungal co-infections in patients with COVID-19.

Acknowledgement

None

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Iranmanesh B, Khalili M, Amiri R, Zartab H, Aflatoonian M. Oral manifestations of COVID-19 disease: A review article. Dermatol Ther 2021;34:e14578.  Back to cited text no. 1
    
2.
Arastehfar A, Carvalho A, Nguyen MH, Hedayati MT, Netea MG, Perlin DS, et al. COVID-19-associated candidiasis (CAC): An underestimated complication in the absence of immunological predispositions? J Fungi (Basel) 2020;6:211. http://doi:10.3390/jof6040211. PMID:33050019;PMCID:PMC7712987  Back to cited text no. 2
    
3.
Corchuelo J, Ulloa FC. Oral manifestations in a patient with a history of asymptomatic COVID-19: Case report. Int J Infect Dis 2020;100:154-7.  Back to cited text no. 3
    
4.
Seagle EE, Jackson BR, Lockhart SR, Georgacopoulos O, Nunnally NS, Roland J, et al. The landscape of candidemia during the COVID-19 pandemic. Clin Infect Dis2021:ciab562. Doi:10.1093/cid/ciab562 [Epub ahead of print]. PMID:34145450.  Back to cited text no. 4
    
5.
Riad A, Gomaa E, Hockova B, Klugar M. Oral candidiasis of COVID-19 patients: Case report and review of evidence. J Cosmet Dermatol 2021;20:1580-4.  Back to cited text no. 5
    
6.
Macauley P, Epelbaum O. Epidemiology and mycology of candidaemia in non-oncological medical intensive care unit patients in a tertiary center in the united states: Overall analysis and comparison between non-COVID-19 and COVID-19 cases. Mycoses 2021;64:634-40.  Back to cited text no. 6
    
7.
Jabri B, Iken M, Achmit M, Rida S, Ennibi OK. Occurrence of Candida albicans in periodontitis. Int J Dent 2021;2021:5589664.  Back to cited text no. 7
    


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