Rhino-orbital-cerebral Mucormycosis Research Articles

Imaging spectrum in rhino-orbito-cerebral mucormycosis: a cross-sectional study.

Rhino-orbital-cerebral mucormycosis (ROCM) is a life-threatening condition caused by a saprophytic fungus that predominately affecting immune-compromised patients. Early diagnosis of ROCM is of utmost importance to start the treatment as early as possible to prevent early and horrible complications of the disease. This retrospective study evaluated the imaging findings of 21 patients with biopsy and KOH mount-based evidence of invasive ROCM. The imaging was obtained from a Siemens Magnetom Amira 1.5T system with a strength of 1.5T or more. The spectrum of findings was evaluated for the sites of involvement, signal intensity, contrast characteristics, necrotic component as well as orbital, infratemporal, and intracranial extensions, especially cavernous sinuses, Meckel's cave, and the brain parenchyma. The mean age of the patients was 55.8±10.9 years and included 71% male. All the patients were positive for COVID-19 and the majority were diabetic. MRI showed predominant involvement of the maxillary sinus (17, 81%) and the ethmoidal sinus (15, 71.4%). The orbital extension was present in 18 cases (86%). T1-weighted imaging showed iso to low signal intensity in involved sinuses in the majority of the patients (9, 42.9%). Heterogeneously high signal intensity was observed in T2-weighted and short tau inversion recovery images in all the patients. Heterogenous contrast enhancement was present in 20 (95.2%) patients. The imaging spectrum of ROCM is variable. Multiplanar MRI with postcontrast images is a very useful complementary tool to the clinical evaluation to assess the extent of disease and its complications, which has a high mortality. Clinicians and radiologists should be aware of the imaging spectrums of ROCM.

Spectrum of neurological involvement in mucormycosis following COVID 19: A single tertiary centre study

Background: This study aims to describe the clinical and imaging spectrum of neurological involvement in rhino-orbital cerebral mucormycosis (ROCM) following COVID. In this observational study, all patients with confirmed COVID associated mucormycosis were recruited. Consecutive patients with neurological signs and symptoms or patients with evidence of neurological involvement based on imaging were evaluated. MRI of brain and paranasal sinuses were done in 3T MRI scanner and evaluated by a radiologist. Results: A total of 182 patients were recruited into the study out of which 72 (39.56%) patients had neurological involvement. The mean age of the patients was 50.31±11.06 (Range: 33-83) years. A male preponderance was noted with 56 (74.67%) patients being male. The commonest symptom reported was unilateral vision impairment and periorbital swelling. Patients were noted to have both fulminant and indolent course of illness. Clinical evidence of neurological and orbital involvement was observed in 33 and 55 patients, respectively. Meningeal involvement (50%) was the commonest imaging finding noted in our study. Other common findings noted were skull- based osteomyelitis (44.44%), cavernous sinus thrombosis (29.17%), intracranial abscess (27.78%), cerebritis (22.22%), infarcts (33.33%), neuritis and intracranial haemorrhage (2.78%). Conclusion: This study reports one of the largest single centre cohorts with neurological findings in COVID associated mucormycosis. COVID associated mucormycosis can present with plethora of neurological manifestations in imaging, such as infarct, intracranial and extracranial abscess, neuritis and nerve abscess, sinus thrombosis that may or may not be accompanied by focal neurological deficit corresponding to the anatomical involvement.

Rhino-orbito-cerebral mucormycosis during Covid-19 pandemic- a prospective observational study

ObjectiveAn unprecedented rise in mucormycosis cases; apparently called ‘an epidemic within a pandemic’ was seen worldwide. Therefore, the following study was conducted to know the epidemiology, underlying risk factors, diagnostic approach, and possible outcome of mucormycosis during the Covid-19 pandemic. MethodsA prospective observational study was conducted on patients with a high index of clinical suspicion of mucormycosis Data about demographics, co-morbidities, laboratory investigations, radiology, management, and outcomes were collected. ResultsWe got 45 cases of proven Rhino-orbital-cerebral-mucormycosis (ROCM) from clinically suspected cases. Covid-19 was the most common underlying risk factor (n ​= ​41, 91.11%) followed by Diabetes mellitus (DM) (n ​= ​39; 86.67%). Steroids and oxygen usage were noted in 53.66% (n ​= ​22) and 41.46% (n ​= ​17) respectively. Among the 51 suspected cases of mucormycosis, 47 were supported by radiodiagnosis. Histopathology diagnosed the highest number of mucormycosis cases (n ​= ​44; 97.78%), followed by KOH examination (n ​= ​36; 80%) and Culture (n ​= ​28; 62.22%). The most common species isolated from the tissue samples was Rhizopus species (n ​= ​17; 60.71%), followed by Mucor species (n ​= ​7; 25%). The mortality rate was 17.14%. ConclusionDM, Covid-19, and corticosteroids are the chief underlying risk factor for ROCM. Rhizopus spp. was the most dominant etiological agent. Early diagnosis and management with combined medical & surgical intervention have a better survival rate.

Mucormycosis: A 14-Year Retrospective Study from a Tertiary Care Center in Lebanon.

Mucormycosis (MCM) is a serious invasive fungal disease (IFD) that is associated with high mortality, particularly in immunocompromised patients. A global surge in MCM cases was reported with the COVID-19 pandemic. We analyzed all recorded cases of MCM at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon, over 14 years. We aimed to identify the incidence, seasonal variation, clinical characteristics of the patients, and predictors of mortality. We conducted a retrospective chart review between 1 January 2008 and 1 January 2023. All patients with proven or probable MCM were included in the study. Proven or probable MCM was defined by positive histopathology and/or positive cultures. A total of 43 patients were identified as having MCM. Their median age was 53 years, and the majority were males (58.1%). Most of the cases were diagnosed in the autumn season. In total, 67.4% of the patients had hematological malignancies (HMs), and 34.9% had uncontrolled diabetes mellitus (DM). The most common site of involvement was rhino-orbital-cerebral MCM (ROCM) (74%). The annual cases of MCM per 100,000 patient days increased markedly during the years of the COVID-19 pandemic (from 0 to 4.4 cases/100,000 patient days to 7.5 cases/100,000 during 2020 and 2021). Liposomal amphotericin (Ampho) B was used as a first-line agent in most of the patients (86%). The median duration of total in-hospital antifungal therapy was 21 days and 51.2% of the patients received step-down therapy with azoles. Surgical debridement and isolated ROCM were significantly associated with survival (p-value: 0.02 and <0.001, respectively). All-cause mortality was 46.7%, with chronic renal disease being significantly associated with mortality (p-value < 0.05). The incidence of MCM has been increasing at our institution, particularly since the COVID-19 pandemic. Early diagnosis, treatment, and surgical debridement improve patient outcomes and overall survival.

Influence of Prosthodontic Rehabilitation Using Zygomatic Implants in Covid 19 Related Mucormycosis (Rhino-Orbital-Cerebral) Maxillectomy Patients Upon Post-Operative Stress, Anxiety and Functional Impairment: A Prospective Cohort Study.

To determine the influence of prosthodontic rehabilitation using zygomatic implants in partial maxillectomy upon post-operative stress, anxiety and functional impairment, due to covid 19 associated rhino-orbital-cerebral mucormycosis (ROCM). Twenty maxillectomy patients fulfilling study criterion, received zygomatic implants (ZI) (quad zygoma) (ZDI Simpladent, Switzerland) retained/supported complete maxillary denture. Assessment of stress, anxiety, masticatory performance and speech were determined using diurnal salivary cortisol level, Appearance Anxiety Inventory, multiple sieve technique and auditory perception analysis, respectively. Data were recorded at 6 different stages of rehabilitation (after maxillectomy, implant placement, and after prosthesis delivery (1 week, 1 month, 6 months and 1 year)). Demographic data were expressed as frequency distribution, while mean values were used to find differences between various rehabilitation stages using Friedman and chi-square test with statistical significance value at p < 0.05. Average daily salivary cortisol levels declined from post maxillectomy (22.80 ± 0.902) to 1 year after prosthesis wearing (8.65 ± 0.985), indicating stress reduction after ZI rehabilitation. Mean scores for appearance anxiety reduced from pre-prosthetic rehabilitation (27.350 ± 3.030) to 1 year (8.950 ± 0.887) following prosthesis wearing. Functional parameters for mastication and speech also improved significantly during the course of rehabilitation. All differences between pre-prosthetic to 1-year stage after prosthesis wearing were found to be statistically significant at p < 0.05. Post ROCM maxillectomy cases after prosthetic rehabilitation using zygomatic implants showed significant improvement in the psychological (stress and anxiety) as well as function (mastication and speech) characteristics. Rehabilitation post ROCM maxillectomy with the present approach of fixed prosthesis using zygomatic implants mitigates deficient mastication and speech. It also impacts positively on patient psychology by decreasing stress and anxiety.

Pott’s Puffy Tumour in Mucormycosis: New Presentation of an Old Disease

Introduction: Pott’s puffy tumour (PPT) is a rare but grave complication of frontal sinusitis. During the second wave of Covid-19, there was rise in rhino-orbito-cerebral mucormycosis (ROCM) cases in India. There is a paucity of literature reporting association of frontal osteomyelitis with rhino-orbital cerebral mucormycosis. This study elucidates the clinico-epidemiological profile and clinical outcomes of management of frontal osteomyelitis in patients with ROCM. Materials &amp; Methods: A retrospective, observational study was conducted at a tertiary hospital from May 2021 to May 2022. 350 patients with covid-19 associated ROCM had reported to the hospital. 12 patients presenting either pre- or post-operatively with doughy swelling over the forehead, with/without oedema of the upper eyelid were clinically diagnosed to have frontal osteomyelitis. Minimal localised defects in the frontal bone were subjected to local excision of granulation tissue, evacuation of pus and biopsy. Cases involving extensive erosions of anterior table of frontal sinus underwent osteoplastic flap with obliteration. Results: 12 patients presented with frontal osteomyelitis. All received systemic antifungals and broad-spectrum antibiotics. It sufficed in only 1 case. 2 required additional local debridement. In 4, endoscopic sinus surgery achieved adequate disease control. 5 with extensive disease required osteoplastic flap with obliteration via either eyebrow or bicoronal incision. Conclusion: A high index of suspicion is warranted in patients with covid-19 associated mucormycosis who present with a forehead swelling because even though PPT is a rare clinical entity it is associated with potentially life-threatening complications.

Insulin and early debridement keys to survival in-COVID 19 associated mucormycosis patients(CAM)- An experience from tertiary care hospital In India.

Amid the second wave of COVID 19 India witnessed a surge of mucormycosis cases. This worsened the already existing health emergency. India a diabetic capital had all the favourable factors to support the growth of black fungus. This study was conducted with objectives of ascertaining patient characteristics, clinical type of mucormycosis, predisposing factors, predictors of survival and long term outcome of survivors. An ambispective study of COVID 19 associated mucormycosis patients admitted in mucor ward of tertiary care hospital between May 2021- August 2021 was done. Study was approved by Institute Ethical Committee. Demographic characteristics, presence of risk factors, clinical sign and symptoms, mode of diagnosis, treatment given, final outcome and long term follow up for a period of 1year from discharge was done. 367 CAM patients were included in the study. 72.5%(n = 266) were men and 27.5% (n = 101) were females. Mean age group was 51.3years (SD 12.4years). Most important comorbidity was diabetes( n = 320,87.2%), followed by cardiovascular disease (n = 68, 18.5%) and hypertension (n = 58,15.8%). Other predisposing factors were use of oxygen (n = 367,100%), antibiotics( n = 213,58%) and steroids (n = 272, 74.1%). Dexamethasone was the most commonly used steroid (n = 218,59.4%). Rhino orbital cerebral mucormycosis was the most common type. 83.7% patients (n = 307) survived and 16.3% (n = 60) succumbed to illness. Kaplan Meir survival analysis curve showed use of insulin (p = 0.025), early debridement ( p < 0.05) significantly increased survival rate. Similarly patients with lesions involving, face (p < 0.05) and nose (p = 0.014) had much better outcome as compared to disseminated forms. Only 96 patients remained in follow up. Of these patients no significant alteration in metabolic profile was noted and they remained euglycemic on oral hypoglycaemics. Early debridement and insulin use are keys to improved survival. Oxygen, Steroids and antibiotics are the risk factors for mucormycosis. Diabetes is the most important comorbidity.

Role of histopathology in severity assessments of post-COVID-19 rhino-orbital cerebral mucormycosis - A case-control study

BackgroundThere was an upsurge in rhino-orbital-cerebral mucormycosis (ROCM) during the second wave of the COVID-19 pandemic in India. Histopathological examination of the biopsies witnessed greater tissue invasion in these cases. The present study aimed to evaluate the histopathological scoring system in the severity assessment and to compare the scores between ROCM that required orbital exenteration (cases) and those that were treated conservatively (controls). Material and methodsA retrospective study was conducted to analyze the histopathological features using a scoring system in patients diagnosed with mucormycosis on sino nasal biopsies. The scoring was based on the following parameters: the extent of necrosis (score 1 <50% and score 2 >50%), degree of angioinvasion (score 1 <3 vessels in 10 fields and score 2 > 3 vessels in 10 fields), degree of inflammation (mild, moderate or severe), and fungal load(score 1 to 4), based on which three grades (I to III) were given. The scores were compared between the case group and the control group. The data obtained were analyzed statistically. ResultsThe study included 40 controls and 10 cases. The median age of patients in the control group was 52 with 82.5%males (n = 43) and 17.5 % females (n = 7) while in the case group, the median age was 51 years, and all were males. The predominant inflammatory response was of mixed suppurative type (70 %, n = 28). The degree of necrosis was scored 2 in 57.5 % (n = 23) of controls and 70 %(n = 7) in the case group. All the samples in the case group showed scores of 2 for angioinvasion and scores of 3 and 4 for fungal load. There was a statistically significant difference in the degree of necrosis, angioinvasion, the severity of neutrophilic infiltrates, and fungal load between the cases and controls (p-value <0.05). ConclusionThe present study analyses the predictive role of histopathology in invasive mucormycosis. Higher fungal load, degree of angioinvasion, and the absence of granulomas are associated with advanced disease in sinonasal mucormycosis. The study findings recommend incorporating the histopathological scoring criteria in evaluating patients with sinonasal mucormycosis.

Turbinates involvment in rhino orbital cerebral mucormycosis in covid positive cases - A study on 100 cases

Mucormycosis also called as zygomycosis previously refers to several different diseases caused by infection with fungi belonging to the order Mucorales. Rizopus species are the most common causative organism. The infections are life threatening. Risk factors such as Diabetic Ketoacidosis and Neutropenia are present in most cases. During the pandemic period of COVID-19 2 wave rhino orbital mucormycosis was commonly effected with probable reasons are due to over dosage of steroid usage and o2 therapy, Uncontroled diabetes etc. To know the percentage of involvement of turbinates (MT,IT)in Rhino orbito cerebral mucormycosis cases in covid positive patients by doing endoscopic sinus surgery. A total of 100 covid positive patients with ROMM were selected and taken for radiological evaluation and selected for ESS during intraoperatively turbinates involvement with mucor (eschar/pus/crusting) was noted diagnosis of ROMM was based on CECT findings and symptoms in covid positive cases. Patients who are attending to Gandhi hospital during the pandemic of 2 wave of covid 19 were selected in study. Common age group with ROMM are 36to 55 years, with male predominance, commonest symptoms are unilateral facial pain &amp; swelling, nasal crusting and dental complaints, commonest sinus to be involved is maxillary sinus, comorbid condition is Diabetes mellitus and moderate percentage of involvement of turbinates(common is middle turbinate) were noted. On microbiological and pathological examination of specimen showed positive KOH mount and mucorales order fungi are common followed by rizopus species. Main conclusions in this study are turbinates involvement with mucor in covid positive cases (eschar/necrosis/pus discharge) is more common in 43 patients (43%), most common mucor pathology seen in maxillary sinus in 58 patients(58%),followed by ethmoid sinus and sphenoid and orbit, teeth.

Orbital Mucormycosis: Understanding the Deadly Fungus Sweeping the Globe.

Introduction Mucormycosis (black fungus) is a rare opportunistic fungal infection commonly affecting immunocompromised individuals. There has been a surge in the number of these cases during the second wave of the coronavirus disease 2019 (COVID-19) in India. Mucormycosis has been reported to occur within a week or a few weeks post-recovery from COVID-19. The most common clinical manifestation of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). At our tertiary care center, we initiated a prospective study to identify risk factors, study ocular manifestations, and explore medical and surgical management of orbital mucormycosis patients in the post-COVID-19 era. Material and methods This is a detailed description of a prospective observational hospital-based study. The study included 148 patients who presented with ROCM. A detailed history was taken regarding the complaint, duration, and associated risk factors. Systemic, local, and complete ophthalmic examinations were done that included assessment of extraocular movements, visual acuity, slit-lamp examination, and fundus examination. All data were recorded separately for each patient in a pre-decided proforma. Result The study group consisted of 148 patients. In our study, the highest association was with COVID-19-positive status (68.24%), out of which 57 (56.43%) were on oxygen support. Diabetes mellitus contributed next to COVID-19 with 86 (58.10%) patients with a positive history of diabetes. Seventy-one (47.97%) patients were on steroids, out of which 68 (67.32%) were COVID-19-positive and the rest (23%) were on steroids due to various systemic reasons. Rhinomaxillary involvement was present (51%). Out of 63 patients with orbital involvement, 16 (25.39%) presented bilaterally and 47 showed unilateral orbital involvement more on the right side (42.85%). The predominant location of orbital involvement was the orbital apex. The most common symptom seen in our study was nasal discharge (86.5%), and ophthalmoplegia was the most common sign. Conclusion Corticosteroids should be used with caution to prevent negative impact and potential ROCM. Good glycemic and metabolic control is crucial for treatment.Management of mucormycosis involves surgical debridement, antifungal agents, and retrobulbar amphotericin B injections. Early diagnosis and aggressive treatment are essential for success. Orbital exenteration may be necessary for advanced stages, while conservative approaches may work for earlier stages. Patient counseling is needed for cosmetic rehabilitation. A multidisciplinary approach involving various specialists is necessary.

A study on epidemiology, clinical profile, management, and outcome of Covid-19-associated rhino-orbital-cerebral mucormycosis in a tertiary hospital in Tamil Nadu

: The main objective of the study is to estimate determine the patient demographics, comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management of COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM).: A descriptive cross-sectional study was conducted among 50 patients admitted and suspected with Mucormycosis in 3 months duration from May 21 to July 21 Covid pandemic at a tertiary hospital in Villupuram. Written informed consentwas taken from patients or nearest of kin. This study was approved by Institutional Ethical Committee of Villupuram.: 84% patients among suspected mucormycosis were found to be diabetic, with 70% being males and 61.9% had covid history either covid positive or post covid status. About 60% of suspected mucor cases had h/o oxygen treatment and almost 44% had h/o steroid treatment for their covid treatment. Clinically 40% had extraocular muscle involvement in the form of restricted eye movement to total ophthalmoplegia and mortality was ranging from 37.5-57.14%. Those with proper glycemic control and initiation of treatment at appropriate time with endoscopic sinus debridement and antifungal therapy showed better recovery.: The study reveals that COVID-19 associated Mucormycosis has risen dramatically due to interplay of uncontrolled diabetes and in-appropriate corticosteroid use leading to pathogenic invasion and adverse outcomes. The infection has caused high morbidity and mortality among covid positive than post covid patients. It could be minimized by strict diabetic control under appropriate insulin dosage, wise use of steroids/oxygen and timely intervention based on clinical evaluation rather than waiting for investigations could minimize the complications from the infection and shorten the hospital stay.

Optimization of Oral Posaconazole Step Down Therapy in Management of Rhino-Orbital-Cerebral Mucormycosis (ROCM): Outcome of an Institutional Protocol.

All cases of ROCM received antifungal for a prolong period in step down phase. There is no definite guidelines regarding duration. We have formulated and followed an institutional protocol with good results. To determine the outcome of an institutional protocol and required optimum duration of oral posaconazole therapy to cure ROCM in step down phase, 30 ROCM patientswere followed up in step down phase. Oral posaconazole tablet was given for minimum 3, 4 & 1/2 and 6months to stage-II, III & IV cases respectively, with a provision of extension for another 6weeks in suspected active diseases. Nasal endoscopy, MRI, histopathology /culture of suspected tissue and hematologic investigations were done routinely to identify the residual active disease or recurrences at earliest. Outcome of this protocol proved excellent as all cases of ROCM were cured. Oral posaconazole step down therapy for a duration according to the stages of disease cured 18 cases (60%) of ROCM. Fourteen patients required extended duration of therapy as per provision of our treatment protocol. Only one patient needed re-debridement. The cases with deformities needed extended period of posaconazole therapy. No one needed posaconazole therapy for more than 7and1/2months.

Presentation of mucormycosis in post Covid-19 infected patients and an approach to its management in a tertiary care centre of central India

Background: This is a case study of 70 cases admitted in our hospital post covid-19 infection with different complaints and signs and symptoms indicating Rhino-Orbital-Cerebral-mucormycosis (ROCM). Materials and Methods: All the cases were again screened for COVID infections and comorbidities like Diabetes mellitus, Hypertension or any other immunocompromised state. The level of involvement like nasal cavity, septum, turbinates, sinuses, pterygopalatine fossa, palate, orbit or any cerebral involvement was noted and the protocol of medical and surgical management was decided in accordance to that. Post surgery KOH mount and HPE report, CT and MRI findings were the major pillars in this regard. Results: In 100% of cases we did middle meatus antrostomy with partial middle turbinectomy and in 57% cases we did medial maxillectomy with Modified Denker’s.Rest middle meatus mega antrostomy with ethmoidectomy with partial middle turbinectomy &amp; full house FESS was done in 21% of cases. Conclusion: The first step in the management of mucormycosis is to have a high index of clinical suspicion especially in those with COVID- 19 who have diabetes mellitus, and who have received systemic corticosteroids while on treatment.

Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies

The incidence rate of invasive mucormycosis (IM) in patients with hematological malignancies (HMs) is increasing year by year, ranging from 0.07% to 4.29%, and the mortality rate is mostly higher than 50%. With the ongoing pandemic of COVID-19, COVID-19-associated mucormycosis (CAM) also became a global health threat. Patients with high risk factors such as active HMs, relapsed/refractory leukemia, prolonged neutropenia may still develop breakthrough mucormycosis (BT-MCR) even under the prophylaxis of Mucorales-active antifungals, and such patients often have higher mortality. Rhizopus spp. is the most common genus associated with IM, followed by Mucor spp. and Lichtheimia spp. Pulmonary mucormycosis (PM) is the most common form of IM in patients with HMs, followed by rhino-orbital-cerebral mucormycosis (ROCM) and disseminated mucormycosis. The prognosis of IM patients with neutrophil recovery, localized IM and receiving early combined medical-surgical therapy is usually better. As for management of the disease, risk factors should be eliminated firstly. Liposome amphotericin B (L-AmB) combined with surgery is the initial treatment scheme of IM. Those who are intolerant to L-AmB can choose intravenous formulations or tablets of isavuconazole or posaconazole. Patients who are refractory to monotherapy can turn to combined antifungals therapy.

Cross-sectional study to describe the severity, bio-chemical associations, and final outcomes of COVID-19-associated rhino-orbital-cerebral mucormycosis in a tertiary hospital of East India

The second wave of coronavirus disease 2019 (COVID-19) pandemic triggered a mucormycosis epidemic in India. Diabetes mellitus and dysregulated immune response were contributors, and rhino-orbital-cerebral mucormycosis (ROCM) was the most common presentation. It is however not known whether bio-chemical parameters at presentation correlate with stage of ROCM or final outcome in terms of vision or mortality.This retrospective, hospital-based study included all in-patients of mucormycosis with ophthalmic manifestations at presentation admitted during June 1, 2021 to August 31, 2021. It aimed to evaluate the association between severity of infection, serum levels of HbA1c, ferritin, interleukin-6 (IL-6), C-reactive protein (CRP), and D-dimer levels at presentation and outcome.There were altogether 47 eligible cases having a mean age of 48.8 ± 10.9 years with a male:female ratio of 2.6:1; forty-two (89.4%) had pre-existing diabetes, and five (10.6%) had steroid-induced hyperglycemia. The mean HbA1c among diabetics was 9.7 ± 2.1. HbA1c and serum CRP showed an increase over subsequent stages, which was not statistically significant (P = 0.31). IL-6 values for all stages were similar (P = 0.97). Only serum ferritin levels showed a statistically significant increase over stages (P = 0.04). IL-6 was significantly lower (P = 0.03) in patients who survived, whereas CRP levels were significantly lower in patients who had final visual acuity (VA) better than only perception of light (P = 0.03).Uncontrolled diabetes mellitus is a significant association of ROCM. Serum ferritin levels at presentation best correlate with extent of the disease. CRP levels are best to prognosticate cases that will have sufficient VA to carry on activities of daily living, whereas IL-6 levels are best associated with survival.

Clinical profile of COVID-19-associated mucormycosis patients and the clinical suspects: a descriptive audit

BackgroundIndia witnessed a massive surge of rhino orbital cerebral mucormycosis (ROCM) cases during the second wave of COVID-19, recording the highest number of cases in the world, indeed, an epidemic within the pandemic.ObjectivesTo describe the clinical profile of patients with COVID-19-associated mucormycosis (CAM) and the clinical suspects for mucormycosis.MethodsThis single-center descriptive, observational study/audit was done at Indira Gandhi Medical College, Pondicherry, South India. This study is about the clinical profile of 7 CAM patients and 14 COVID-19 patients who were suspects of CAM, based on their risk factors and clinical symptoms, and were referred to the ENT department.Statistical analysisAll the descriptive variables were summarized as mean, frequency, and percentages for qualitative data.ResultsAll 7 CAM patients were COVID-19 positive and were not vaccinated against COVID-19, All 7 were known diabetic, all 7 had steroid therapy for their COVID status, and 5 out of 7 (71%) had uncontrolled diabetes mellitus at the time of diagnosis. Facial pain, nasal discharge, and eye swelling were the presenting symptoms of CAM. Maxillary and ethmoid sinuses were the most commonly involved para nasal sinuses. Four out of seven (57.1%) CAM patients survived after 16 months of follow-up, after surgical and medical treatment for CAM. Of the 14 clinical suspects who were negative for CAM, 2 were negative for COVID-19, their risk factors were brought under control, 3 expired due to COVID complications, and 9 patients are alive till date.ConclusionUncontrolled diabetes is a risk factor for ROCM/CAM, another possible risk factor is steroid therapy, and we hypothesize that COVID infection could also be a possible risk factor that needs to be studied more extensively in a larger sample. Early clinical suspicion, withdrawal of steroids, rapid control of diabetes mellitus, appropriate investigations, and early surgical intervention combined with medical treatment offers better outcome.

Intracranial extension in COVID-19 associated mucormycosis cases (P4-10.001)

<h3>Objective:</h3> To describe COVID-19 associated rhino-orbital-cerebral mucormycosis (ROCM) patients. <h3>Background:</h3> During the rampantly spreading pandemic of COVID-19, India observed a surge in mucormycosis cases. The most common form of secondary infection noted in COVID-19 infected immunocompromised patients was mucormycosis. The infection mainly spread through the nasal passage and in few uncontrolled cases, it crossed the dura mater and presented itself as rhino-orbital-cerebral mucormycosis. <h3>Design/Methods:</h3> The study was conducted after Institute Ethics Committee approval. ROCM cases were studied in detail, their demographic, radiological data, treatment details and 90 days’ follow-up are described. <h3>Results:</h3> The most effective tool for diagnosis and confirmation of mucormycosis within time is magnetic resonance imaging (MRI) and histopathological techniques. The chief complaints of patients inflicted with COVID-19 associated mucormycosis were headache, fever, ophthamloplegia, ptosis, ulceration, diminution of vision, and general weakness. Infarcts were observed in 55.55% (15/27) of the cases, in right parietal lobe, right periventricular region, right cerebral infarcts, acute infarct in left frontal parietal lobe, bilateral frontal and left occipital lobe. Most common form of infarct was lacunar infarct. Haemorrhage was detected in only three patients 11.53% (3/26). Abscess formation was seen in 26.92% (7/26) patients in right temporal region, cavernous sinus and left temporal lobe. Three of the patients displayed meninges involvement and thrombosis was seen in 44% (11/25) of the total patients in internal carotid artery (ICA) in six patients, in cavernous sinus in two patients and in superior ophthalmic vein in one patient. <h3>Conclusions:</h3> Our case-series showed intracranial extension of mucormycosis in COVID-19 patients predominantly inform of thrombosis followed by intracranial abscess and haemorrhage. Appropriate care, anti-fungal medication and surgical procedures should be performed in conjunction to manage the spread of disease. <b>Disclosure:</b> Ms. Tangri has nothing to disclose. Awadh K. Pandit has nothing to disclose. Mr. Misra has nothing to disclose. Dr. Srivastava has nothing to disclose. Vishnu VY has nothing to disclose. Rajesh Kumar Singh has nothing to disclose. Divya MR has nothing to disclose.

COVID-19 and Mucormycosis of Orofacial Region: A Scoping Review.

During the second wave of coronavirus disease, orCOVID-19, infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in the year 2021 around the globe, there is a surge in the number of cases of mucormycosis or "Black Fungus" that is directly/indirectly associated with COVID-19. In this review article, mucormycosis of the orofacial region has gained importance from the maximum published literature (45 articles) from various databases like PubMed, Google Scholar, Scopus, Web of Science, and Embase. Rhino-orbital cerebral mucormycosis (ROCM) is a fatal condition associated with COVID-19 among categories of mucormycosis such as pulmonary, oral, gastrointestinal, cutaneous, and disseminated. ROCM targets the maxillary sinus, also involving teeth of the maxilla, orbits, and ethmoidal sinus. These are of particular interest to dentists and oral pathologists for proper diagnosis and identification. Co-morbid conditions, especially diabetes mellitus type II, have to be monitored carefully in COVID-19 patients as they have a higher risk of developing mucormycosis. In this review article, various presentations of COVID-19-linked mucormycosis are mentioned having particular emphasis on pathogenesis, signs and symptoms, clinical presentation, various diagnostic modalities including histopathology, radiology like CT and MRI, serology, tissue culture, various laboratory investigations, treatment protocols, management with prognosis, and so on. Any suspected case of mucormycosis needs quick detection and treatment since it progresses quickly due to the destructive course of infection. Long-term follow-up along with proper care is a must to detect any kind of recurrence.

Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study

ABSTRACT Purpose To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM). Methods In this retrospective case–control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (−TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality. Results Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality. Conclusions Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

MANAGEMENT AND FUNCTIONAL OUTCOME OF SARS COVID-19 INDUCED RHINO ORBITAL CEREBRAL MUCORMYCOSIS

Background: Rhino-orbital cerebral mucormycosis(ROCM) is an uncommon infection caused by the angiotropic fungus belonging to the order Mucorales and has high morbidity and mortality despite treatment. Rhino-orbital cerebral mucormycosis almost always occurs in immunocompromised hosts, including patients with uncontrolled diabetes mellitus, hematologic cancers, and solid organ or hematopoietic stem cell transplants. The suspicion or diagnosis of rhino-orbital cerebral mucormycosis triggers a medical as well as surgical emergency with the delay in treatment, increasing morbidity and mortality. Aim: 1.outcome of medical management 2.functional outcome and evaluation after medical management 3.complications of mucormycosis 4.outcome after surgical management Methods: 62 SARS covid-19 cases were evaluated who were diagnosed with rhino orbital cerebral mucormycosis.most of the patients presented with ptosis.proptosis.orbital cellulitis,decreased visual acuity,sluggishly reacting pupils, restricted extraocularmovemets.some patients were known diabetics and some diagnosed with diabetes after COVID 19 reovery.Retrobulbar Liposomal Amphotercin –B(3.5mg) was given to all patients for 10 alternate days and simultaneously patients received IV LIPOSOMAL AMPHOTERCIN 300mg OD for 10days renal function tests were monitored. 54 of them improved on day 5 of injection most patient Results: s visual acuity improved from CF –CF to CF&gt;6mts, patients with perception of light didn't show any improvement in visual acuity but ptosis,proptosis,conjunctival congestion and chemosis was improved and 10 patients underwent exenteration. ROCM is seen Conclusion: in most SARS COVID 19 who were known diabetics or post covid -19 induced uncontrolled high sugars most patients received high dose of steroids during covid 19 treatment.most patient showed improvement of symptoms after retrobulbar IV Amphotericin 3.5mg and improvement is observed on MRI stages too and some patients underwent exenteration which prevented furthurer spread of infection