Rhino-orbital-cerebral Mucormycosis Research Articles

Outcomes of Transcutaneous Retrobulbar Amphotericin B in Rhino-Orbital-Cerebral Mucormycosis Among Patients Recovering From COVID-19: A Preliminary Experience.

BackgroundIn this study, we aimed to assess the outcomes of transcutaneous retrobulbar injection of amphotericin B (TRAMB) in rhino-orbital-cerebral mucormycosis (ROCM) among patients recovering from coronavirus disease 2019 (COVID-19).MethodologyThis retrospective study was conducted at a tertiary care center in eastern India from May 29th to July 31st, 2021, and included post-COVID-19 patients admitted with stage 3 and 4a ROCM who underwent TRAMB. The details of the ophthalmic examination, laboratory investigations, and radiological examination were retrieved from patients records. Patients were given TRAMB (3.5 mg/mL) on alternate days till they underwent debulking surgery and resumed from the second postoperative day alternatively till the patients showed clinical stabilization or improvement.ResultsIn total, 45 eyes of 41 patients were included in the study. The median number of injections given was six (minimum = 3; maximum = 10). Following was the distribution of number of injection needed in each eye: eight eyes (three injections), six eyes (four injections), seven eyes (five injections), three eyes (six injections), eight eyes (seven injections), 11 eyes (eight injections), and one eye had received nine and ten injections each. Overall, 21/32 (65.62%) eyes had improvement in proptosis whereas 9/32 (28.12%) had improvement in ptosis. Six patients had improvement in extraocular movement. In total, 25 eyes had no improvement whereas seven eyes had improvement in vision. Four eyes underwent exenteration. All nine patients with limited orbital disease had good improvement with fewer injections (median = 4). None of the patients undergoing TRAMB had an intracranial extension of disease. Moreover, 8.88% (4/45) of the eyes had post-TRAMB transient inflammation which resolved without any intervention. Finally, 3/41 of the patients died.ConclusionsTRAMB can be considered as an useful therapeutic adjunct in managing ROCM. Further, it can halt the progression of the disease while awaiting definitive surgical intervention.

COVID-19 Associated Mucormycosis with Newly Diagnosed Diabetes Mellitus in Young Males - A Tertiary Care Experience.

Introduction Patients with a history of or active COVID-19 infection are predisposed to the development of opportunist bacterial and fungal infections. A rising incidence of a rare occurring fungal infection earlier, called mucormycosis, has been reported in abundance across the globe since March 2021, especially in India just as the second wave of COVID-19 began, caused by the trifecta of hyperglycemia (new-onset or exacerbation of pre-existing diabetes), oxygen therapy (invasive or noninvasive ventilation), and prolonged intake of steroids. Objective The present study aimed at assessing the prevalence of post-COVID mucormycosis in males of younger age group and spread of rhino-orbital-cerebral mucormycosis (ROCM). Methods A case-control study was performed over a period of 3 months among 60 male patients with confirmed diagnosis of mucormycosis. Individuals < 40 years old were included in the case group ( n = 30), while those > 40 years old were included as controls ( n = 30). Disease spread was assessed in three types of ROCM, that is, rhinomaxillary, rhino-orbital, and rhino-orbito-cerebral mucormycosis. Results In the control group, the mean age was 48.47 years old, the mean HbA1c was 10.62 ± 1.88%, with most of them suffering from rhino-orbital mucormycosis. In the case group, the mean age was 31.57 years old, with a mean HbA1c of 10.11 ± 2.46%, and most patients had rhinomaxillary mucormycosis. The duration of steroid intake and mode of oxygen therapy were found to be significant in the severity of ROCM. Conclusion Rising cases of post-COVID mucormycosis have brought to light the fatal consequences of prolonged use of steroids and oxygen therapy towards the development and spread of ROCM among young and middle-aged males.

Alternating pattern of rhino-orbital-cerebral mucormycosis with COVID-19 in diabetic patients.

PurposeOur aim was to analyze the patients with diabetic rhino-orbital–cerebral mucormycosis that we have treated in our clinic in the last 5 years, and to reveal the altering conditions with COVID-19.Materials and methodsA retrospective study was conducted on 39 rhino-orbital–cerebral mucormycosis (ROCM) patients with diabetes mellitus between 2017 and 2022. The patients were divided into two groups as those associated with and not associated with COVID-19 and compared.ResultsThirty-nine diabetic patients were included in the study, with 15 (38.5%) of them being COVID-19 associated mucormycosis (CAM) group. CAM patients showed higher orbital involvement and cavernous sinus involvement (p = 0.002 and p = 0.013, respectively). The mortality rate in the non-COVID-19 associated mucormycosis (non-CAM) group was statistically higher in patients with intracranial and cavernous sinus involvement (p = 0.015 and p = 0.033, respectively). The difference between the overall survival of the CAM patients and non-CAM patients was not statistically significant (p = 0.741).ConclusionsWith COVID-19, progressive mucormycosis accompanied by orbital and intracranial involvement is observed more frequently. However, on the contrary, the mortality rate in COVID-19-associated mucormycosis is considerably lower than expected. The fact that temporary immune suppression can be ameliorated with adequate supportive treatment and liposomal amphotericin-B which can be given to patients in high doses may explain this situation. It has been attained hints that the essential factor in the treatment of COVID-19-associated ROCM is the control of the underlying disease and to be cautious in the decision of early aggressive surgery.

Analysis of COVID-19-associated rhino-orbital-cerebral mucormycosis patients in a tertiary care center in Northern India.

Purpose:An unprecedented surge has been noted in rhino-orbital-Cerebral mucormycosis (ROCM) in times of current COVID-19 pandemic. The present prospective study aims to evaluate clinico-epidemiological profile, risk factors, management, and outcome of the cases of ROCM that presented to our tertiary care center during the study period from April to June 2021.Methods:All patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were staged and were treated with intravenous liposomal amphotericin B (AMB) and sino-nasal debridement of local necrotic tissue. Transcutaneous retrobulbar AMB (TRAMB), orbital decompression, and exenteration were instituted as indicated. All patients were followed up for a minimum of 6 months before arriving at the final outcome. Statistical analysis was performed.Results:A total of 49 patients presented during the study period, with a mean age of 42.2 years. The major risk factors included uncontrolled diabetes (89.8%), COVID-19 positivity (51.02%), and concurrent steroid use (38.77%). The most common presenting symptom was facial pain/swelling (43.65%), while the most common presenting sign was deterioration in vision (75.51%). Intravenous liposomal AMB was given to all patients along with sino-nasal debridement (85.71%), TRAMB (57.14%), orbital decompression (14.28%), and exenteration (12.24%). Overall, mortality at 6 months was 22.45% (11 patients). Age more than 60 years, intracranial extension, and HbA1c of more than 8.0% were observed to be statistically significant indicators of mortality.Conclusion:Early suspicion and timely diagnosis of mucormycosis at rhino-orbital stage is warranted in order to salvage life as well as visual function. TRAMB may prove as potentially favorable treatment modality in cases with limited orbital involvement.

A study on clinico-radiological profile, risk factors, and management of mucormycosis during COVID pandemic in Rewa, (M.P.)

Background: Second wave of coronavirus disease 2019 (Covid-19) pandemic has been particularly devastating in India. COVID-19 and mucormycosis (also known as black fungus) are causing comorbid conditions to worsen the extent of infection and mortality rates especially in India. Mucormycosis can involve nose, sinuses, orbit, central nervous system, lung (pulmonary), gastrointestinal tract any many other organs, but rhino orbital cerebral mucormycosis is the most common variety seen. Rapidity of dissemination of mucormycosis is an extraordinary phenomenon and a delay in the diagnosis could be fatal. Aims and Objectives: The objective of this study is to document the clinical features, radiological extent, risk factors, management,and outcome of mucormycosis. Materials and Methods: The study was retrospective observational study. Eighty-two mucormycosis patients admitted in SGMH Rewa were selected as study subjects. Data regarding clinical features, radiological extent, associated risk factors, comorbidities, management during hospital stay, and outcome of mucormycosis patients were collected on excel sheet and analyzed using appropriate statistical tests. Results: In our study, majority of the patients were unvaccinated (88%). Most common presenting complaint was nasal congestion with or without discharge in 78% patients followed by Facial swelling, visual disturbances, facial weakness, dental pain, etc. On CT or magnetic resonance imaging examination, all cases of mucormycosis had maxillary sinus (100%) involvement, followed by ethmoid (82%) and sphenoid (78%) sinuses. Diabetes mellitus was most common comorbidity seen in 52% cases. About 83% cases had history of receiving high dose steroid intravenously during management of COVID illness. Among study cases 72% patients have taken oxygen supplementation for more than 72 h, for COVID-19 pneumonia before hospitalization for mucormycosis. Therapy of Liposomal Amphotericin B and Oral Triazole (predominantly oral Posaconazole) was the most common medical treatment offered to all patients with COVID associated mucorpatient. Functional endoscopic sinus surgery was done on 93% cases followed by Modified Denker’s procedure was done in 12% cases. Conclusion: In our study, mucormycosis appears to be associated with COVID-19, diabetes, and use of corticosteroids. Full vaccination with COVID-19 vaccines, judicious use of corticosteroids in patients with COVID-19 and strict control of blood glucose level along with timely and proper management is highly recommended to reduce the incidence of fatal mucormycosis.

A review of COVID-19-associated mucormycosis in India

The resurgence of COVID-19 with the delta variant has accompanied a doubling in the prevalence of COVID-19-associated mucormycosis (CAM) in India. The prevalence grew to 80 times that of the global average. In this review, we describe the epidemiology, the clinical presentation, and treatment of CAM. We conducted a literature search on the PubMed, Google Scholar, Embase, and Harvard Library databases. The cytokine storm with high interleukin-6 (IL-6), hyperglycemia, ketoacidosis culminates into impaired endothelial and immune response, causing improved survival of the fungus. The most common presentation is rhinoorbital cerebral mucormycosis followed by pulmonary mucormycosis in patients with COVID-19. CAM patients have active or prior pulmonary tuberculosis, hyperglycemia, or a prolonged stay in the intensive care unit (ICU). A recent history of steroid medications and a high prevalence of tuberculosis (TB) may have contributed to an increased prevalence of CAM infections. Hypoxemic COVID-19 patients have a substantial improvement with steroid treatment but increases the risk of opportunistic infections. Although radiological signs have been described but the most common presentation is a subtle sign of eye, nasal, oral cavity, or pulmonary symptoms which requires high index of suspicion. Hence, one should not rely on radiological signs alone. Amphotericin B or isavuconazole along with surgical debridement is the treatment of choice for CAM. Early admission, diagnosis, and treatment lead to favorable outcomes.

Significance of laboratory diagnosis in coronavirus disease associated invasive fungal sinusitis from an otolaryngologist perspective: A retrospective study at a tertiary care nodal centre

Objective: Rhino-orbital cerebral mucormycosis is an angioinvasive life threatening fungal infection that presents acutely in patients with diabetic ketoacidosis and immunosuppression. The main objective of this study is to evaluate the sensitivity and specificity of various laboratory investigation required for confirmation of coronavirus disease associated invasive fungal sinusitis (CAIFS).

Adjunctive use of saturated solution of potassium iodide (SSKI) with liposomal amphotericin B (L-AMB) in mucormycosis achieves favorable response, shortened dose and duration of amphotericin: A retrospective study from a COVID-19 tertiary care center

PurposeSecond wave of COVID-19 pandemic was associated with an unprecedented rise in cases of mucormycosis, treatment of which has been challenging owing to the availability and side effects associated with amphotericin. MethodsAll patients presenting with rhino-orbital cerebral mucormycosis (ROCM) following COVID-19 infection between April 2021 to June 2021 were included in this retrospective interventional study. Primary objective was to assess the clinical response with combination of intravenous liposomal amphotericin B (4–5 mg/kg/day) and saturated solution of potassium iodide (SSKI) given orally along with surgical debridement. ResultsTwenty-five patients of ROCM were treated with the regimen. Mean age and fasting blood sugar levels were 53.48 years and 239.64 mg/dL respectively. All patients had history of intake of steroids with a mean daily dose of 86.39 mg of prednisolone equivalent. 88% of patients had a “proven” diagnosis of mucormycosis. Cultures were positive in 52% of patients with Rhizopus arrhizus as the predominant species. The mean daily dose of amphotericin received was 268 mg/day with a mean duration of 9.52 days. Mean daily dose of SSKI was 2.57 g. 21 patients (84%) had stabilization of disease at week 8 and achieved cure at the end of treatment whereas the mortality rate was 16%. Factors that significantly affected outcome were eye and central nervous system (CNS) involvement on presentation. ConclusionSSKI, with its remarkably low cost and safety profile, makes it a potential adjuvant drug that may help achieve the twin benefits of shortened duration and dose of LAMB.

Role of orbital exenteration in rhino-orbital-cerebral mucormycosis

Purpose–Mucormycosis is an uncommon, rapidly progressive, commonly fatal, opportunistic serious fungal infection.The high mortality rate highlights the importance of early detection and treatment. The purpose of this study to determine theoutcome of orbital exenteration in Rhino-orbital-cerebral mucormycosis(ROCM) patients. Methods and materials–This study includesall proven ROCM patients who had underwent orbital exenteration based on SION Scoring system from 1st may 2021 to 30 june 2021 in MYH hospital, Indore.Those patients were reviewedand the outcome of orbital exenterationwas analysed. Results- Total 29ROCM patients were underwent for orbital exenteration based on SION Scoring system. 19(65.5 %)out of 29 patients had intracranial extension and 10 (34.480%) did not have intracranial extension.&#x0D; Out of 29, 6 (20.68%) patients hadsuccumbed to death within 10 days of orbital exenteration was having bilateral orbital involvement with intracranial extension.23(79.34%) patientshave favorable outcome with regular follow up. Conclusion- Survival of mucormycosis patients depends on the their good glycemic control,immune status, laterality of the orbital involvement and early detection of intracranial extensionof the disease.With prompt medical (high dose intravenous amphotericin B) and early aggressive surgical intervention involving FESS and orbital exenteration can preventintracranial extension and may improve survival rate .Intracranial extension of the disease has invariably been associated with high mortality.

Rhino-orbital-cerebral mucormycosis: An epidemiological study from a tertiary care referral center in Western India.

Purpose:Rhino-orbital-cerebral mucormycosis (ROCM) is a rare opportunistic fungal infection with a fulminant course and an often fatal outcome. It can occur in immune-compromised patients such as those having uncontrolled diabetes, on long-term corticosteroid or immunosuppressive therapy, with COVID-19 infection, renal failure, AIDS, malignancy, or organ transplant. The aim of our study was to study the epidemiology of mucormycosis in COVID-19 patients and identify its risk factors.Methods:Ours was an epidemiological study wherein we gathered the demographic, clinical, histopathological, and radiological data of 458 patients of mucormycosis who presented to us between August 2020 and May 2021. Mucormycosis was defined through clinical and radiological findings or positive culture reports.Results:Out of all, 20.74% of patients did not have any past or concurrent history of COVID-19. The most common symptom of mucormycosis was orbital/facial pain (38.64%) and the most common sign was periocular/facial edema (50.74%). Mucormycosis involving the nose and sinuses (94.54%) was most common followed by rhino-orbital (45.41%) and brain involvement (10.04%). The most common risk factor for mucormycosis was diabetes [81.92%], followed by corticosteroid use [79.69%] and supplemental oxygen [48.90%]. Most of the patients received similar treatment with IV amphotericin B [88.64%] and local debridement [80.74%]Conclusion:With the third wave of COVID-19 still lurking, a fatal fungal infection should be kept in mind in COVID-19 active as well as recovered patients, especially those who have co-morbid medical conditions such as uncontrolled diabetes and who are treated with large doses of corticosteroids.

COVID-19 associated pulmonary mucormycosis: A systematic review of published cases with review of literature.

Background:There is sharp rise in cases of Coronavirus disease 2019 (COVID-19)-associated mucormycosis worldwide and specially during second wave of COVID-19 pandemic. This systemic review was conducted to characterize pulmonary mucormycosis associated with COVID-19 infection.Materials and Methods:A systematic literature search was conducted in the electronic database of PubMed and Google Scholar from 1st January 2020 to June 5, 2021 using keywords. Details of all the cases that reported pulmonary mucormycosis in people with COVID-19 so far, were retrieved and analyzed.Result:Total 9 articles of pulmonary mucormycosis with COVID-19 infection were reported in the database of PubMed and Google Scholar. Only one case till date was reported from India, others are from USA (n-3), Italy (n-2), France (n-1), UK (n-1), and Arizona (n-1). Pooled data from this study showed mucormycosis was predominantly seen in males (8 male, 1 female). The most common comorbidities associated were diabetes (n-3), hematological malignancy, (n-2) and end-stage renal disease (n-2), while 2 cases did not show any associated comorbidity. All the cases were having severe COVID-19 infection and 7 out of 9 patients were in ICU and on mechanical ventilation at the time of diagnosis. None of the cases associated with rhino-orbital-cerebral mucormycosis (ROCM) except 1 patient with sinus involvement. Mortality was found in 7 out of 9 patients.Conclusion:There is a need to keep a high index of suspicion in patients with severe COVID-19 infections, diabetic, and received treatment in ICU with ventilator support for early diagnosis and treatment. Although Mucor is less common than Aspergillus infection, it is associated with higher mortality.

A RETROSPECTIVE STUDY OF INVASIVE MUCORMYCOSIS IN COVID-19 PATIENTS FROM A TERTIARY CARE HOSPITAL, UT OF J&amp;K, INDIA.

Mucormycosis is an angioinvasive disease caused by saprophytic fungi of the order Mucorales. There are growing reports of rhino-orbital mucormycosis in people with SARS COV-2, especially those from India. Diabetes mellitus (DM) is a very dangerous factor in COVID-19 and mucormycosis. We aim to conduct a retrospective study to determine patient characteristics of mucormycosis and COVID-19 from December 2020 to December 2021 at our tertiary care hospital, North India. During our study time, we have come across 7 such patients. Diabetes mellitus was a major risk factor for all patients with rhino-orbital cerebral mucormycosis. There was a high prevalence among males and the average age of presentation was 51years. All patients received the same treatment with steroids and amphotericin B as well as local anesthetics. Deaths were 42.8%. Our study concludes that patients infected with COVID 19 are easily infected with mucormycetes due to immunosuppression, dysfunction of phagocytes and lymphocytes, and the use of antibodies and steroids.

A clinico-pathological study of COVID-19 associated rhino-orbital-cerebral mucormycosis.

Purpose:Known predisposing factors for mucormycosis are neutropenia and diabetes. Though COVID-19 is associated with hyperinflammatory response, a high surge in rhino-orbital-cerebral mucormycosis (ROCM) cases was observed during the second wave. The histopathological features reflect the background pathogenesis. This study analyzes the histopathological features and clinical presentation of COVID-19-associated ROCM.Methods:In this retrospective observational study, the clinical details of 89 proven ROCM patients treated during May–July 2021 were collected from the case records. Histopathological features were correlated with clinical staging groups and outcomes. The mean neutrophil-to-lymphocyte ratio (NLR) of clinical and outcome groups were compared.Results:The mean age was 54.71 ± 11.03 years, with male patients constituting a majority (78.7%). Uncontrolled diabetes mellitus was noted in 70.8% of patients, and 3.4% had normal range of blood sugar. The mean blood sugar was 298.08 ± 99.51 mg/dL. The mean duration of onset of symptoms of mucormycosis from the diagnosis of COVID-19 was 17.36 ± 7.392 (3–45) days. Poor outcome with disease progression or death occurred in 21.3% of patients. Clinical group II patients (44.9%) with ROCM stages 3c and above had poor outcomes (P = 0.005). Histopathological analysis showed minimal inflammation in 25.8%, neutrophil extracellular trap (NET) in 75.3%, and angio-invasion in 28.1% of patients. Minimal inflammation was associated with clinical group II (P = 0.004) and poor outcome (P = 0.001). Angio-invasion correlated with poor outcome (P = 0.007). Patients with severe clinical group and poor outcome had higher mean NLR with P = 0.017 and P = 0.007, respectively.Conclusion:Vision loss and cerebral involvement had poor outcomes. The histopathologic features such as inflammation and angio-invasion along with NLR aid as prognostic indicators in the management of ROCM. The role of NET in the pathogenesis of COVID-19-associated ROCM needs further studies.

Management of rhino-orbital-cerebral mucormycosis: our experience

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Mucormycosis is a rapidly progressive, angio-invasive fungal infection caused by the fungus belonging to mucoraceae family that has predilection for the paranasal sinuses and adjacent mucosa. Of all the forms of mucormycosis, rhino orbital cerebral (ROCM) is the most commonand most aggressive. Our aim is to study the diagnosis, investigation, medical and surgical management of ROCM.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A retrospective study of 273 patients was conducted at the department of ENT, government medical college and hospital, Nagpur between March 2021 to August 2021. Data was collected and analysed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Total 273 patients of mucormycosis were included in this study. There was total 197 (73%) males and 76 (27%) females, patient belonged to age group between 16 to 74 years. Diagnosis was made on the basis of clinical presentation and typical radiological and histopathological findings. On radiography, disease may be limited to a single sinus or involve multiple sinuses. In our study maxillary sinus was most commonly involved sinus 265 (97.06%) followed by ethmoid sinus 258 (94.50%), sphenoid sinus 209 (76.55%), frontal sinus 88 (32.23%). Extension to pterygomaxillary and infratemporal fossa was seen in 160 (58.60% patients), frontal bone involvement in 7 (2.56%), intra-orbital extension 67 (24.54%), intracranial extension 43 (15.75%), mandibular erosion 4 (1.46%).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Rhino orbital cerebral mucormycosis is a life-threatening fungal infection, with very high mortality. Interprofessional management typically consists of intervention from an infectious disease specialist, otorhinolaryngologist, microbiologist, ophthalmologist, and paramedical staff, all working hand in hand for better achievement of results. Early diagnosis and intervention surely achieve better prognosis.&lt;/p&gt;

A fungal epidemic amidst a viral pandemic: Risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis in India

ABSTRACT Purpose To study the risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis (ROCM) during the COVID-19 pandemic in India. Methods Multi-centric retrospective case-control study conducted from October 2020 to May 2021. Cases comprised of consecutive patients of COVID-19-associated ROCM (CA-ROCM) presenting at the participating ophthalmic institutes. Controls comprised of COVID-19-positive or COVID-19-recovered patients who did not develop ROCM. Comparative analysis of demographic, COVID-19 infection, treatment parameters and vaccination status between cases and controls performed. Clinical and imaging features of CA-ROCM analyzed. Results There were 179 cases and 361 controls. Mean age of presentation in cases was 52.06 years (p = .001) with male predominance (69.83%, p = .000011). Active COVID-19 infection at the time of presentation of ROCM (57.54%, p < .0001), moderate to severe COVID-19 (p < .0001), steroid administration (OR 3.63, p < .00001), uncontrolled diabetes (OR 32.83, p < .00001), random blood sugar >178 mg/dl were associated with development of CA-ROCM. Vaccination showed a protective effect (p = .0049). In cases with intracranial or cavernous sinus extension there was history of steroid administration (OR 2.89, p = .024) and orbital apex involvement on imaging (OR 6.202, p = .000037) compared to those with only rhino-orbital disease. Conclusion Male gender, active COVID-19 infection, moderate or severe COVID-19, uncontrolled diabetes, steroid administration during COVID-19 treatment are risk factors for developing rhino-orbital-cerebral mucormycosis. Vaccination is protective. Random blood sugar of >178 mg/dl in COVID-19 positive or recovered patients should warrant close observation and early detection of ROCM. Presence of ophthalmoplegia, blepharoptosis at first clinical presentation and orbital apex involvement on imaging are associated with intracranial extension in ROCM.

Risk factors and outcomes of COVID associated mucormycosis in kidney transplant recipients.

Invasive mucormycosis (IM) is a life-threatening fungal infection occurring mostly in solid organ transplant (SOT) recipients, patients with hematological malignancies, and diabetes. A sudden spurt of mucormycosis has been reported in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic in India; however, there is little data about coronavirusdisease 2019 (COVID-19) associated mucormycosis (CAM) in kidney transplant recipients (KTRs). We describe the clinical presentations, risk factors, treatment and outcomes of 11 mucormycosis cases in KTRs post-COVID-19 infection from February 2020 to June 2021 at a single center in India. Mucormycosis was seen in 11/102 (10.7%) KTRs during the pandemic. Six patients had mild disease and rest five had moderate disease. Seven patients had pre-existing diabetes mellitus and four developed new onset hyperglycemia after receiving steroids for COVID-19 infection. All had poorly controlled sugars at the time of presentation. Most common presentation was rhino-orbital-cerebral mucormycosis (ROCM) in 10/11 (89%) patients and one has pulmonary mucormycosis. All patients received combination of amphotericin B and surgical debridement/excision of affected tissue followed by posaconazole prophylaxis. Nine patients recovered, however two patients succumbed to their illness after median of 14 (7-21) days from diagnosis. One patient developed acute T-cell-mediated rejection during the course of recovery. At last follow up, the mean serum creatinine was 2.05mg/dl as compared to 1.4mg/dl at presentation. IM is a common fungal infection in transplant recipients in India after COVID-19. Early diagnosis and prompt treatment with combination of surgical debridement and liposomal amphotericin B are key to better outcomes in CAM. Judicious use of steroids and control of hyperglycemia is key to avoid flaring up of the fungal infection.

A retrospective analysis of characteristics and perioperative outcomes of rhino-orbital-cerebral mucormycosis in COVID-19 patients posted for surgical debridement under general anaesthesia in a tertiary care hospital

Abstract Background: Rhino-orbital-cerebral mucormycosis (ROCM) has increasingly been reported in patients with severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) disease-2019 (COVID-19) from India. Methods: A retrospective study was done to analyse the demographic and clinical characteristics, treatment received for COVID-19 during the hospital stay, perioperative outcomes in ROCM patients posted for surgical debridement under general anaesthesia from May 2021 to July 2021 at our tertiary care teaching hospital in Tirupati, southern India. Results: Overall, 350 patients with ROCM and COVID-19 had undergone surgical debridement under general anaesthesia Mucormycosis was predominantly seen in males (65.7%). Majority of the cases (40%) were in the age group between 41-50 years. Common comorbidities were: pre-existing diabetes mellitus (DM) (70%), hypertension (32%), new-onset DM/hyperglycaemia (22%) and cardiac disease (8%). The most common sites involved in mucormycosis were the nose and paranasal sinuses (100%) followed by rhino-orbital (63.1%). A history of hospital admission for COVID-19 management was evident in 89.7%; 40.7% of the patients had received oxygen therapy during their hospital stay. The use of corticosteroids for the treatment of COVID-19 was noted in 73.2%. The types of surgical procedures done were: functional endoscopic sinus surgery (FESS) (98.5%) and neurosurgery procedures (3.4%). Revision surgery was performed in 18.5% of the cases. Perioperative complications observed were anticipated difficult intubation during pre-operative airway assessment 35.7%, intraoperative hypertension 8.5%. A patient had developed intraoperative cardiac arrest, post-operative-delayed recovery and needed ventilator requirement. Outcomes of ROCM patients associated with COVID-19 were: discharged 91.7%, death 8.3%. Conclusions: Diabetes mellitus, rampant use of corticosteroids in the treatment of COVID-19 appear to have contributed to the development of ROCM. Early diagnosis, a thorough pre-operative evaluation, surgical debridement are likely to result in better prognosis in COVID-19 patients with ROCM.

A clinicoepidemiological study of orbital mucormycosis in COVID-19 pandemic at a tertiary healthcare hospital, North-West Rajasthan, India

Background Mucormycosis is an opportunistic fungal infection with high morbidity and mortality. Purpose The aim of this study was to determine the risk factors, clinical presentation, management, and outcome of management of orbital mucormycosis during the coronavirus disease 2019 (COVID-19) pandemic. Patients and methods This is a prospective hospital-based observational study that was conducted on cases of rhino-orbital cerebral mucormycosis (ROCM) presented to a tertiary health-care center in North-West Rajasthan, India, during the second wave of COVID-19 over a period of 1 month (May 26, 2021 to June 25, 2021). The patients were followed up for 3 months. A total of 40 cases fulfilling the clinical, radiological, and pathological or microbiological criteria for the diagnosis of ROCM were included in the study. Results Out of a total of 126 mucormycosis patients, 40 had ocular manifestations ranging from lid edema, chemosis, and ptosis to severe manifestations such s ophthalmoplegia, optic neuritis, and cavernous sinus thrombosis. Rare presentations of corneal eschar and corneal ulcer were also reported. Among the 40 patients of orbital mucormycosis, 57.5% were in the age group of 51–65 years, 65% were males, 62.5% were COVID positive, 37.5% had a history of oxygen therapy during the COVID-19 illness, and 85% were not vaccinated against COVID-19. All patients with orbital involvement had rhinitis at presentation. Intravenous Amphotericin B was given to all patients. Functional endoscopic sinus surgery was done in 92.5% of the cases and orbital exenteration was done in 35% of the patients to prevent the spread of mucor and to reduce mortality. In 32.5% of the patients, retrobulbar Amphotericin B was given. The mean length of hospital stay was 24.62±11.70 days and 70% of the patients were discharged from the hospital on oral antifungal therapy. A total of 30% of the patients with cerebral involvement passed away. During the follow-up of 3 months, three (7.5%) more patients who discontinued treatment progressed to advanced disease and died, while 62.5% (25 out of 40) patients were alive with stable/regressed disease. The survival rate with retrobulbar Amphotericin B was 92.30% and with exenteration was 92.85%, which was statistically significant compared with the 5% survival rate in the cases in whom no such intervention was done. Conclusion Early diagnosis and treatment of ROCM reduced morbidity and mortality in mucormycosis patients.

Imaging spectrum of rhino-orbital-cerebral mucormycosis secondary to COVID-19 infection: a reporting checklist.

In recent times, India has been in the midst of a notifiable epidemic of mucormycosis (a rare angio-invasive fungal infection), within the ongoing global coronavirus disease 2019 (COVID-19) pandemic. Epidemiological studies have reported the estimated prevalence of mucormycosis to be around 70 times higher in India as compared to the global data, even in the pre-COVID era. However, in the last 3 months, our city witnessed an unprecedented surge in cases of post-COVID-19-associated rhino-orbital-cerebral (ROC) mucormycosis.This pictorial review aims to illustrate the entire imaging spectrum of mucormycosis in the head-neck-face region. Along with the usual sites (nose, paranasal sinuses, orbits), this disease also involves the skull base, palate, temporal bone, and deep neck spaces. Many cases also demonstrated morbid and, at times, fatal intracranial and neurovascular complications.This review also aims to provide a structured reporting template that will prove useful to the radiologists interpreting imaging studies of ROC mucormycosis.

A Case of Bilateral Central Retinal Artery Occlusion in a Post-COVID Rhino-Orbital-Cerebral Mucormycosis Patient

Central retinal artery occlusion (CRAO) is a multifactorial disease, where inflammation and hypercoagulability are the major risk factors. It is a rare occurrence in this geographical area in patients diagnosed with sinus mucormycosis infection, which has emerged as one of the most fulminant, opportunistic secondary infection during post-COVID era. We report a case of a bilateral CRAO, in a 66-year-old, post-COVID, diabetic patient. A complete eye examination followed by radiological imaging of brain, orbit, and paranasal sinuses were done. Multidisciplinary approach was contemplated to reach a diagnosis of bilateral rhino-orbital-cerebral mucormycosis (ROCM). Intravenous liposomal amphotericin-B injection was started as a part of systemic management and an aggressive sinus debridement of both sides with amphotericin-B wash was also done. Despite an early diagnosis and intervention, the patient succumbed to her illness. All post-COVID patients presenting with the complaints of blurring of vision should be meticulously examined for the presence of any retinal abnormality in both the eyes as this may be a manifestation of an underlying secondary fungal infection. Early diagnosis of ROCM and management will help in reducing complications.