Mucormycosis in Rural Central Valley California

Author:

Almira Opardija (US)

Abstract:

Background:
Mucormycosis (MCM), an opportunistic fungal disease affecting hosts with compromised immune systems and uncontrolled diabetes mellitus (DM), is relatively rare in the United States (U.S). According to CDC, Central California has counties with some of the highest burden of DM in the entire country. We aim to characterize the clinical presentation and outcomes of mucormycosis in the Central California region given the high burden of DM in the area.

Methods:
We conducted a retrospective review of MCM cases at a major referral teaching hospital in Fresno, California between 2010-2023. Cases were identified using International Classification of Diseases, Ninth or Tenth Revision codes. Data including demographics, predisposing factors, SARS-CoV-2 positivity, clinical features, microbiological data, management, and outcomes were collected. Descriptive statistics were used to analyze the sample characteristics based on outcome measures. Measures of association were tested using the χ2 or Fisher exact test for categorical measures and the Wilcoxon-Rank sum test for continuous measures.

Results:
We identified forty-five patients with MCM. We noted a surge of nine cases in 2017 and seventeen cases between 2021-2022 (Figure 1). Since the Sars-CoV-2 pandemic started, there were 21 cases. However, only 8 of these cases had known prior Sars-CoV-2. The median age of patients was 53 (table 1) and 89 % of the patients had DM with 18 % presenting in diabetic ketoacidosis (DKA). Twenty-four of 39 patients (62%) with DM had Hemoglobin A1c above 7.5 gm/dl, while 15 patients (38%) had values above 10 gm/dl.
Rhino-orbital-cerebral mucormycosis (ROCM) was the most common manifestation (60%), followed by pulmonary (22%) and other organs including bowel, muscle, and skin (<10%) (table 2). Diagnosis was made by either a positive fungal culture, and/or by the specific histopathological evidence associated with MCM (Fig.2 and 3). The mainstay of initial therapy in all patients was intravenous amphotericin followed by surgical management. On average patients were on amphotericin for about 24 days (ranging 1-90 days) and 91% of patients had on average three surgeries (ranging 1-12). Forty-two % of patients died due to MCM. All patients with DKA (100%) died compared with 31% of those without DKA (p=0.001). The mortality rate was significantly higher in patients with histopathological evidence of angioinvasion (69% vs 28%, p= 0.015). Risk of death was higher in patients with higher median hemoglobin A1C levels (9.5 gm/dl versus 6.4 gm/dl, p=.004). The highest mortality rate occurred with patients with ROCM (70%). Conclusions: Despite medical and pharmaceutical advancements in the management of DM, the burden of uncontrolled type 2 DM in the U.S continues to rise and further impacts the incidence of devastating fungal diseases such as Mucormycosis. This is particularly concerning in the rural areas affected by heath care disparities among other barriers. Our study indicates that hemoglobin A1C could be used as a potential predictor of mortality in those affected by Mucormycosis. Research efforts identifying barriers to care and promoting better diabetes management in vulnerable populations is of paramount importance to prevent the upsurge of invasive fungal diseases in the rural Unites States.

Abstract Number: 17

Conference Year: 2024

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