Rare cases of systemic phaeohyphomycoses caused by Bipolaris species as a Post SARS-COV 2 sequelae

PURPOSE: The deadly second wave of COVID-19 brought an unprecedented rise of cases of associated invasive fungal infections. In this study we present two rare cases of systemic phaeohyphomycoses by Bipolaris species as a Post SARS-COV 2 sequelae, which may usually be neglected as contaminants. METHODS & MATERIALS: Retrospective study of 1150 specimens received from patients with a high index of clinical suspicion of invasive fungal infections from April 2021 to June 2021 to identify cases of invasive phaehyphomycoses among post COVID patients. Diagnosis of phaeohyphomycoses was established on microbiological evidence including microscopy and culture, and radiological evidence along with supporting clinical features. The diagnosis of phaeohyphomycoses was confirmed when dark pigmented thin septate hyphae with or without spores were demonstrated in aseptically aspirated fluid or tissue specimen with pure culture isolate of velvety dark, brownish black flat colonies on Sabouraud dextrose agar at 25°C. RESULTS: During the study period, two cases were confirmed as invasive phaeohyphomycoses caused by Bipolaris spicifera phenotypically. The first case was of invasive fungal sinusitis and second of invasive pulmonary phaeohyphomycoses. Overall incidence rate was 0.55% (2/364). Both cases were post COVID, with history of COVID 2-3 weeks before current presentation and hospitalisation with oxygen support for the same, uncontrolled diabetes mellitus (HbA1C: 11 & 8 respectively), and hypothyroidism. First case was initially treated as of mucormycosis, considering her clinical presentation and high index of suspicion with several similar cases reported in our area. He was managed with Amphotericin B along with surgical debridement. Second case was suspected as case of invasive pulmonary aspergillosis and was managed with voriconazole initially and later started on itraconazole after laboratory confirmation. Due to initial false diagnosis in our cases, patients were subjected to long course of amphotericin B and voriconazole respectively, whereas it could have been managed with itraconazole which has far lesser side effects. CONCLUSION: High index of suspicion is required to confirm invasive phaeohyphomycoses as dematiaceous fungi are often contaminants or commensals. Correct and timely diagnosis is necessary for adequate management of invasive phaeohyphomycoses cases.