The Rise of Fungal Infections in COVID-19 Patients

Justin H. Joe, PhD, CIH, CSP, CPE & Philip Koh, PharmD

The COVID-19 global pandemic has impacted almost every aspect of our society. Many of the secondary effects of this virus are still on the verge of being discovered. One identified risk of contracting COVID-19 is the subsequent manifestation of a co-infection. Research is now showing that patients diagnosed with COVID-19 have a greater risk of fungal infections. These fungal infections are caused by various types of mold that are present in the patient’s surrounding environment. With a proper mold inspection, you can ensure your home or commercial building does not put you at risk of this severe co-infection.

The Risk of Fungal Infections Among COVID-19 Patients

The range of symptoms caused by COVID-19 is wide, though severe cases are characterized by acute respiratory distress syndrome (ARDS) secondary to inflammation of the lungs. These symptoms are typically treated with mechanical ventilation or supplemental oxygen. However, 72% of COVID-19 patients also report undergoing antimicrobial therapy as medical professionals seek to remedy new-found risks of superimposed infections (1). Despite these advances in the handling of COVID-19 cases, another dangerous, yet under-studied, possibility of co-infection that has risen to light recently is that of fungus related diseases such as pulmonary aspergillosis. With the increasing evidence of these type of infections emerging among COVID-19 patients, there is a great need for mold inspections in healthcare facilities and individual homes.

What is a Co-Infection?

Co-Infection refers to a situation when two or more microbes infect a body at the same time, attacking the same systems and sometimes even infecting the same individual cells. According to Bio-Med Central, “Co-infection is of particular human health importance because pathogen species can interact within the host. Interactions within the host can have either positive or negative effects on each of the co-infecting parasite species” (2). In other words, two pathogens, such as viruses, bacteria, or mold can either counteract one another, diminishing the severity of the illness, or benefit one another, increasing the harm done to an organism. In the instance of coronavirus and other diseases, most cases are worsened by the presence of a co-infection.

How Fungal Infections Manifest as a Co-Infection to COVID-19

Most forms of invasive fungi enter our bodies through airborne spores, causing an infection to arise in the respiratory system. If a patient is experiencing symptoms from COVID-19, the immune system in the lungs is already in overdrive trying to combat the virus. With the additional infestation of a differing organism, the body has a difficult time fighting off both microbes at the same time. This hampers our ability to deal with the infection. With our immune system compromised, both the virus and mold can then spread. This can greatly hurt our capacity to breathe, leading to a potentially life-threatening condition. There are several types of mold that have been prevalent as a co-infection during the COVID-19 outbreak.

COVID-19 Associated Pulmonary Aspergillosis

According to the CDC “Aspergillosis is an infection caused by Aspergillus, a common mold (a type of fungus) that lives indoors and outdoors” (3). It is common to breathe in Aspergillus spores without becoming sick. Most of the time, our body has natural defenses to avoid these spore particles from causing infiltrating our lungs. However, those with lung disease or a weakened immune system are at a higher risk of contracting an infection or developing health issues after inhaling Aspergillus spores.

COVID-19 Associated Pulmonary Aspergillosis, or CAPA, is the infection of aspergillosis in a patient already sick with COVID-19. As stated by the Imperial College of London “COVID-19 associated pulmonary aspergillosis (CAPA), has been reported in up to an alarming 20-35% of mechanically ventilated patients, in European studies” (4). Knowing the significant risk of co-infection, precautions can be taken to avoid this type of further complication.

The manifestation of CAPA can often be attributed to the patient’s environment. Researchers in the European Respiratory Journal released a statement about this issue, “There is also an increased risk of Aspergillus exposure for patients who are treated in hospital wards or makeshift “hospital” facilities that do not meet ICU specifications for appropriate room ventilation and air changes” (5). The presence of this mold can largely be attributed to hospital buildings that do not comply with the proper standards.

Another factor that could influence the risk of contracting CAPA is the use of dexamethasone. This drug is a corticosteroid used primarily to reduce the mortality of COVID-19 patients on mechanical ventilation. Even though this pharmaceutical treatment can reduce the severity of COVID-19, it could also contribute to the co-infection of CAPA.

To remain proactive about the manifestation of this condition, researchers recommend that patients who are still suffering from COVID-19 symptoms be screened for CAPA. This usually involves a combination of CT, chest imaging (a type of X-ray test), antigen, and blood tests. Some even suggest a bronchoscopy, a procedure where a small camera is inserted through the throat to inspect the lungs. Although the screening procedure could lead to a further spread of COVID-19, there is a benefit to avoiding undiagnosed CAPA through awareness and preventative screening.

The Rise of Candida Auris During the COVID-19 Pandemic

Another fungal infection that has spread at an alarming rate during the COVID-19 pandemic is caused by Candida auris. There are three main concerns about the C. auris mold, as described below:

1. In many cases, C. auris is multi-drug resistant, meaning that many of the medications used to treat Candida infections are ineffective for this particular sub-species. Reports suggest that some types are even immune to all three classes of anti-fungal drugs.

2. This particular fungal infection is extremely hard to identify with standard laboratory methods, making it very common to misidentify without specific technology. As may be expected, this misidentification often leads to inadequate management of the infection.

3. C. auris has caused various outbreaks in healthcare settings. Swift identification of this fungal infection in a hospitalized patient is necessary to promptly carry out the proper precautions that will stop the spread.

The Candida auris fungal infection is known to spread quickly in long-term care facilities. However, during the pandemic there has been an increasing number of reports of C. auris in COVID-19 acute care units. Researchers suspect that these outbreaks may be related to changes in routine infection control practices due to the health crisis. For example, there is a limited availability of gloves and gowns and there is a possibility of faulty cleaning and disinfection practices.

There have been multiple reports of new C. auris infections that were not associated with previously identified cases. This suggests an increase in undetected infections. The exact percentage of infection caused by C. auris is unknown, however, many patients are instead diagnosed with unidentified antifungal-resistant lung and blood infections (6).

Fungal Infections Can Be Prevented

One of the best ways to avoid a fungal infection superimposed on COVID-19 is to ensure your environment is free of these molds. Many homes, office buildings, and healthcare facilities contain dangerous molds that have never been detected. Molds thrive in moist environments; therefore, it is commonly found where a leak has occurred.

If indoor mold is discovered, it is recommended to hire a professional to perform mold inspection and remove the infestation. Attempting to remove mold on your own can sometimes lead to further damage.

BNF Consulting, Inc. is a licensed mold inspection company in New York that is qualified to inspect your home, office building, or healthcare facility. In an initial mold inspection, we conduct a visual analysis, moisture survey, and mold sampling. If mold is detected, we are also licensed to perform a safe and effective remediation of the mold according to US EPA regulations. Call us today at 914-297-8335 for a free consultation!

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About Authors:

Justin H. Joe, PhD, CIH, CSP, CPE, is a Certified Industrial Hygienist and

a principal consultant of BNF Consulting, Inc. Dr. Joe graduated from the University of Illinois at Urbana-Champaign with PhD and MS degrees in nuclear engineering. Dr. Joe has provided industrial hygiene consulting as a core function with his diverse background of experience and education.

Philip Koh, Pharm.D. graduated from the Massachusetts College of Pharmacy and

Health Science with a doctorate in pharmacy. He has since been working as a consultant pharmacist in the community setting and serving as an subject matter expert in BNF Consulting, Inc.

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References :

1 Timothy M Rawson, Luke S P Moore, Nina Zhu, Nishanthy Ranganathan, Keira Skolimowska, Mark Gilchrist, Giovanni Satta, Graham Cooke, Alison Holmes, Bacterial and Fungal Coinfection in Individuals With Coronavirus: A Rapid Review To Support COVID-19 Antimicrobial Prescribing, Clinical Infectious Diseases, Volume 71, Issue 9, 1 November 2020, Pages 2459–2468, https://doi.org/10.1093/cid/ciaa530.

2 Allotey, P. and Zhou, X., 2021. Co-Infection And Syndemics. [online] Biomedcentral.com. Available at: <https://www.biomedcentral.com/collections/cis> [Accessed 14 January 2021].

3 Cdc.gov. 2021. Aspergillosis | Types Of Fungal Diseases | Fungal Diseases | CDC. [online] Available at: <https://www.cdc.gov/fungal/diseases/aspergillosis/index.html> [Accessed 14 January 2021].

4 Johns, S. and Campus, S., 2021. COVID-19 Patients Could Be At Greater Risk Of Fungal Infections, Researchers Say | Imperial News | Imperial College London. [online] Imperial News. Available at: <https://www.imperial.ac.uk/news/200933/covid-19-patients-could-greater-risk-fungal/> [Accessed 14 January 2021].

5 Darius Armstrong-James, Jonathan Youngs, Tihana Bicanic, Alireza Abdolrasouli, David W. Denning, Elizabeth Johnson, Varun Mehra, Tony Pagliuca, Brijesh Patel, Johanna Rhodes, Silke Schelenz, AnandShah, Frank L. van de Veerdonk, Paul E. Verweij, P. Lewis White, Matthew C. Fisher. Confronting and mitigating the risk of COVID-19 Associated Pulmonary Aspergillosis (CAPA). European Respiratory Journal. Jan 2020, 2002554; DOI: 10.1183/13993003.02554-202.

6 Posteraro B, Torelli R, Vella A, Leone PM, De Angelis G, De Carolis E, Ventura G, Sanguinetti M, Fantoni M. Pan-Echinocandin-Resistant Candida glabrata Bloodstream Infection Complicating COVID-19: A Fatal Case Report. J Fungi (Basel). 2020 Sep 6;6(3):163. doi: 10.3390/jof6030163. PMID: 32899996; PMCID: PMC7559523.