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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 56-57

Musculoskeletal mucormycosis and COVID-19 pandemic – caution in the crisis

1 Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
2 Department of Pathology, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission30-Jun-2021
Date of Decision16-Jul-2021
Date of Acceptance20-Jul-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Dr. Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_10_21

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How to cite this article:
Dharmshaktu GS, Ansari TA, Pangtey T. Musculoskeletal mucormycosis and COVID-19 pandemic – caution in the crisis. J Orthop Dis Traumatol 2021;4:56-7

How to cite this URL:
Dharmshaktu GS, Ansari TA, Pangtey T. Musculoskeletal mucormycosis and COVID-19 pandemic – caution in the crisis. J Orthop Dis Traumatol [serial online] 2021 [cited 2023 Jun 6];4:56-7. Available from: https://jodt.org/text.asp?2021/4/2/56/324595

Dear Editor,

Mucormycosis has been on rampage in the COVID-19 pandemic times and has since achieved much notoriety, due to associated higher fatality rate and long-term complications. The emergence of coronavirus disease-associated mucormycosis has drawn national attention on otherwise uncommon pathogens affecting human population.[1] The disease is not new to patients with various comorbidities and also to musculoskeletal medicine. It is caused by fungi of Mucorales orders which are uncommon but potentially devastating and limb-threatening. The infection is characterized by angioinvasive growth and localized destruction, thus threatening the survival of life and limb. It presents as an aggressive and invasive infection with high mortality rate of about 40%.[2] Common predisposing factors are immunocompromised status, uncontrolled diabetes mellitus, or hematological malignancies.

A systematic review of the cases in PubMed and EMBASE databases from 1978 to 2014 for epidemiology, clinical, diagnostic, and therapeutic aspects of musculoskeletal mucormycosis was reported by Taj-Aldeen et al.[3] Middle age (median age 41, range 0.5–73 years) and men (71%) were common factors, direct inoculation was the chief cause, and hematogenous spread is common in immunocompromised cases. Diabetes, hematological malignancies, corticosteroid therapy, and transplantation were found to be associated conditions.

There are higher chances of cross-infection in COVID-10–positive cases in the setting of any extremity trauma or concomitant presence of wound the risk of which multiplies with preexisting diabetes or steroid use. The orthopedic fraternity may witness increased encounter with mucormycosis (which is relatively uncommon diagnosis in normal times) during pandemic times due to overall surge of cases and thus should tread cautiously. Vigilant approach and well-placed prevention strategy should be the mainstay; however, if an unfortunate incidence is noted, standard approach should be followed to deal with it by sticking to basics of wound care management.

Serial debridement, vacuum-assisted negative pressure therapy, and systemic antifungal regimen are standard treatments. This approach has successfully worked even in very complex cases. Palliative management in a case of mucormycosis of hand following a minor trauma, in a therapeutically resistant elderly patient with preexisting acute myeloid leukemia (AML), was cured by just sticking to these basics.[4] Local delivery of the drug in severe cases has been attempted in cases with mucormycosis similar to what is sometimes done for recalcitrant chronic bacterial osteomyelitis cases with promising results. An interesting case has been reported in a diabetic patient with AML disease who presented with right thigh and groin region swelling 4 months after bone marrow transplantation.[5] Later investigations revealed upper metadaiphyseal lesion in magnetic resonance imaging (MRI) and increased radiotracer uptake on bone scan. Biopsy showed black discoloration of the bone and fungal culture of the discharge displayed aseptate fungal hyphae, suggestive of mucormycosis. The case later developed pathological fracture and was treated with radical debridement, blade plate stabilization, and amphotericin mixed with polymethyl methacrylate or PMMA (300 mg amphotericin B in 40 mg simplex bone cement) in bead form over a steel wire along with course of systemic liposomal amphotericin B injection. Bead removal after 12 weeks was followed by bone grafting. Another report in an immunocompetent patient with controlled diabetes and history of traumatic leg injury with wound showed periosteal reaction on radiographs.[6] The wound was debrided well to healing; however, few months later, ankle pain and abscess, not responding to broad-spectrum antibiotics, were noted. Repeat biopsy revealed nonspecific inflammatory infiltrate and aseptate hyphae in Grocott staining, thus finally isolating Saksenae species in culture. Debridement and bead were done with successful outcome; however, the patient succumbed to a metastatic tumor.

Mucormycosis has been reported in spine also and presents more diagnostic challenge as the presentation may be vague and nonspecific in most cases. Affliction of isolated lumbar spine was reported in a male patient presenting with low back pain with known history of diabetes, hypertension, chronic kidney disease, and regular hemodialysis.[7] Hypointense MRI signals in L4 and 5 vertebra (abnormal signal in contrast with an enhancing soft tissue anterior to these vertebrae) and mild anterolisthesis of L5 over S1 were sole radiological features. Computed tomography (CT)-guided biopsy finally revealed mucormycosis growth on microscopy. The patient, however, succumbed to comorbidities despite initiation of lipid formulation of amphotericin B. Suspicion in a case with history of COVID-19 positivity in the past with unexplained low back pain may be investigated appropriately to exclude fungal etiology. A large series of consecutive cases treated with arthroscopic anterior cruciate ligament reconstruction were reported with fungal osteomyelitis over 10-year period out of which few cases belonged to mucormycosis affliction.[8] Oncological debridement was done with a median of four sessions in all cases. Five of those cases with large cavity were later managed by hemicylindrical intercalary grafting, eight and six needed allograft prosthetic composite or tumor type prosthesis, and one required a mix of both. Amputation was an eight unfortunate incident in one case. These reports underline grave nature of musculoskeletal mucormycosis and highlight importance of suspicion of fungal infection and their exclusion by culture in required cases. Many a times only bacteriological or mycobacterial cultures are sent by our colleagues and fungal cultures are not given importance. Frequent reporting of various fungal organisms in osteoarticular infection suggests adoption of uniform policy of mandatory fungal cultures or mounting examinations in every musculoskeletal infection case. These recommendations and their benefits shall be beneficial even beyond the pandemic is over and normalcy is back.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, et al. Coronavirus disease (COVID-19) associated mucormycosis (CAM): Case report and systematic review of literature. Mycopathologia 2021;186:289-98.  Back to cited text no. 1
Bouza E, Munoz P, Guinea J. Mucorpycosis: An emerging diasease? Clin Microbiol Infect 2006;12:7-23.  Back to cited text no. 2
Taj-Aldeen SJ, Gamaletsou MN, Rammaert B, Sipsas NV, Zeller V, Roilides E, et al. Bone and joint infections caused by mucormycetes: A challenging osteoarticular mycosis of the twenty-first century. Med Mycol 2017;55:691-704.  Back to cited text no. 3
Maleitzke T, Stahnke K, Trampuz A, Märdian S. A case report of cutaneous mucormycosis of the hand after minor trauma in a patient with acute myeloid leukaemia. Trauma Case Rep 2019;23:100221.  Back to cited text no. 4
Arockiaraj J, Balaji G, Ashok A, Kokil G. Amphotericin B cement beads: A good adjunctive treatment for musculoskeletal mucormycosis. Indian J Orthop 2012;46:369-72.  Back to cited text no. 5
[PUBMED]  [Full text]  
Parize P, Mamez AC, Garcia-Hermoso D, Dumaine V, Poirée S, Kauffmann-Lacroix C, et al. Successful treatment of Saksenaea sp. osteomyelitis by conservative surgery and intradiaphyseal incorporation of amphotericin B cement beads. Antimicrob Agents Chemother 2019;63:e0100618.  Back to cited text no. 6
Hadgaonkar S, Shah K, Bhojraj S, Nene A, Shyam A. Isolated mucormycotic spondylodiscitis of lumbar spine – A rare case report. J Orthop Case Rep 2015;5:55-7.  Back to cited text no. 7
Costa-Paz M, Muscolo DL, Ayerza MA, Sanchez M, Astoul Bonorino J, Yacuzzi C, et al. Mucormycosis osteomyelitis after anterior cruciate ligament reconstruction: Treatment and outcomes of 21 reported cases. Bone Jt Open 2021;2:3-8.  Back to cited text no. 8


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