Rhino-orbito-cerebral Mucormycosis Research Articles

Utility of Itraconazole in Combination with Liposomal Amphotericin B in Rhizopus oryzae Associated Mucormycosis-An Exploratory Study.

During the COVID-19 pandemic-associated mucor epidemic, acute antifungal drug shortage necessitated the exploration of other antifungals based on culture sensitivity. Itraconazole is a cheap, safe, and effective antifungal in sensitive cases. We enrolled itraconazole-sensitive COVID-19-associated mucormycosis during the mucormycosis pandemic. After the intensive phase course of liposomal amphotericin B, Itraconazole was offered in susceptible cases during the maintenance phase along with standard of care. These patients were clinically and radiologically followed for 6 months. We enrolled 14 patients (Male: Female-11:3) of Rhino-orbito-cerebral mucormycosis (ROCM) which included 12 diabetics. All patients had facial swelling, orbital swelling, visual impairment, and headache. MRI showed involvement of bilateral sinus (10/14), orbital extension (13/14), cavernous sinus (5/14), cerebral part of the internal carotid artery (3/14), and brain infarcts (4/14). All 14 patients showed sensitivity to Itraconazole with 12 having minimum inhibitory concentration (MIC) ≤ 1 μg/ml and 2 having MIC ≤ 2μg/ml. Follow-up at 6 months showed clinical improvement in the majority (11/14) and radiological improvement in six out of seven scanned patients. Our study shows the potential therapeutic role of oral Itraconazole in ROCM.

Pott's puffy tumor: An unusual complication of rhino-orbito-cerebral mucormycosis

ObjectiveTo describe clinicoradiological features and surgical outcomes in a series of nine patients with rhino-orbito-cerebral mucormycosis (ROCM) who presented with Pott's puffy tumor (ROCM-PPT) MethodsThe records of nine patients with ROCM-PPT seen between March 2020 and December 2021 were analysed. Clinical features, radiology, histopathology, operative findings, management and outcome were noted. Frontal sinus pneumatisation and outflow tract configuration was compared between patients and controls with ROCM and no PPT. ResultsROCM-PPT was diagnosed in 9 of 284 (3.2 %) patients with ROCM seen during the study period. There were six (66.7 %) males and the median age was 54 (IQR 46–60) years. Eight (88.9 %) patients had diabetes mellitus and seven (77.8 %) had been COVID-19 positive. Radiological features of osteomyelitis, subperiosteal abscess formation and dural enhancement were seen in all patients. No significant differences in pneumatisation or frontal sinus outflow tract configuration were noted between patients and controls. All patients underwent a craniectomy with frontal bone debridement and frontal sinus exteriorisation. All patients were treated with anti-fungal agents for several months. All patients had symptomatic improvement at a median follow-up of 21 (IQR 18–23) months. Repeat CT/MRI scans showed disease regression/resolution in six out of eight (75 %) patients with follow-up imaging, and stable disease in two others. ConclusionsROCM-PPT is a rare, delayed complication of mucormycosis that was seen in larger numbers during the recent COVID-19 pandemic. Aggressive debridement of osteomyelitic bone and antifungal therapy results in a good outcome.

Anesthesia Management of COVID-19 associated Rhino-Orbito-Cerebral Mucormycosis: A Prospective Observational Study

Abstract Background: Fungal infections (mucormycosis) have been reported as co-infection as well as opportunistic infection during and after COVID-19 (Coronavirus disease), involving the paranasal air sinuses with a high risk of morbidity and mortality. Considering the ongoing situation of COVID-19 associated with mucormycosis, we presented our experience of 110 patients being, or having previously been COVID -19 positive. Methods: This study included 110 patients in which surgical resection was done for Rhino-orbito-cerebral mucormycosis (ROCM) under general anesthesia and observed for 30 days postoperatively. Results: This study included 79 male patients with the majority of 51-60 years of age group (31.81%). Most common comorbidities observed in study were diabetes mellitus (77.27 %) followed by hypertension (39.09 %) & ischemic Heart Disease (9.09 %). Majority patients had received steroids (80 %) as a part of covid-19 treatment. All patients were receiving Amphotericin B at the time of surgery. On operative table extubation was possible in 80 % of the cases while others required average ICU stay (9.83 ± 7.33 days). Inotropic support was required in 20 % of patients. Majority patients were discharged successfully (85.45 %), while 10.91 % had mortality. On 30 days follow-up frontal Sinus Abscess (6.36 %) & maggots in maxilla and sphenoid (0.91 %) were noted. Conclusion: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. Perioperative anesthesia care plays an important role towards management and outcome of ROC mucormycosis. Difficult intubation is anticipated due to fungal debris and supraglottic edema in the oropharynx of the patient.

Retrospective Analysis of Clinico-Epidemiological Profile of COVID 19 Associated Mucormycosis Patients: A Single Centre Experience in Southern Haryana

Background: A number of factors were supposed to be involved in very high rate of mucormycosis infectionin COVID 19 patients like the reduced immunity because of COVID infection itself along with use of steroids,administration of supplemental oxygen, worsening glycemic control. This retrospective study has been undertaken to analyse the clinical and demographic profile of patients and various other factors that were involved in development of mucormycosis.Material and Methods: This was retrospective observational study in which all patients admitted were eithersuspected but came out to be negative or which were culture or histopathological proven mucormycosis cases.The data was analysed for demographic as well as clinical profile of the patients and various risk factors involved.Results: Total 52 patients were included in the study. All of these were rhinoorbitocerebral mucormycosis patients.The mean age of mucor positive patients was 47.3 years with male to female ratio as 5:1. The comparison of risk factors among mucor positive and mucor negative patients showed that out of 30 mucor positive patients there were 18 (60%) patients with confirmed report of COVID 19 infection, 22 (73.3%) diabetic patients, 17 (56.7%)patients with recent history of steroid treatment and 11 (36.7%) patients with history of recent oxygen therapy.Conclusion: In this study there was no statistically significant association between specific risk factors and mucorpositivity, emphasizing the multifactorial nature of mucormycosis. Further research is necessary to evaluate the complex relationship between COVID-19 infection and other factors in the development of mucormycosis.

Management of rhino-orbito-cerebral mucormycosis: a clinico-radiological study—an institutional experience

BackgroundMucormycosis in the setting of COVID-19 has given rise to the concept of “epidemic within a pandemic.” Once known to be a rare fungal disease, mucormycosis has now been regrouped under emerging pathogens. It has got special affinity for the immunocompromised, which is one of the main reasons for the flare up of the fungus during the second wave of COVID. The burden of the disease was felt globally, and India is facing the major brunt owing to our population and healthcare services ratio.ObjectiveIn our study, we have made an attempt to evaluate the clinical and radiological findings in patients of rhino-orbito-cerebral mucormycosis (ROCM) and to formulate a management protocol which will benefit such patients in forthcoming years.MethodsThis is a retrospective single-center study in Northern India. A total of 350 patients, affected by ROCM, were included in the study. Medical records of these patients were reviewed. Their clinical manifestations, nasal endoscopic findings, microbiological and radiological records, extent of disease, treatment profile, surgical interventions, and outcomes were analyzed. Nasal swab which was sent for KOH mount/fungal culture revealed broad aseptate filamentous fungi branching at right angles. All patients received intravenous amphotericin B and had undergone extensive surgical debridement endoscopically. The maxillary sinus was the commonest paranasal sinus involved followed by the ethmoid sinuses. Tissue sent for histopathological examination confirmed mucormycosis, except for 3 cases.ResultsThe commonest presenting symptoms were cheek swelling with ophthalmoplegia, diminution of vision, and headache. The mean duration of follow-up was 8 months.The maxillary sinus was found to be involved in around 71% of the cases followed by the ethmoids and sphenoid. Thirty percent of the cases had visual complaints including diplopia and vision loss, whereas the palate was involved in around 35%. Nine patients had no perception of light in one eye on presentation, whereas 21 patients had perception of light only; 24 patients could count fingers close to face, and the rest had ambulatory vision. Three patients presented with facial palsy. All patients had favorable outcome except six who succumbed due to cerebral involvement and uncontrolled blood glucose levels.ConclusionA definite management protocol was formulated for ROCM which requires a multidisciplinary approach.

Neuro-mucormycosis: Lessons from COVID-19-associated cases.

Background: Scarce data are available on the neurological presentations of coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) and COVID-19-unrelated rhino-orbito-cerebral mucormycosis (ROCM). This study aimed to compare the neurological presentations and their associated outcomes in patients with CAM and COVID-19-unrelated ROCM. Methods: In December 2021, a case-control analysis was conducted on the CAM (case group) and COVID-19-unrelated ROCM (control group) referrals of one center in Isfahan, Iran. Confirmed CAM patients from January 2020 to December 2021 constituted the case group, and patients with COVID-19-unrelated ROCM from 2016-2019 constituted the control group. Their data were then analyzed using proper (non) parametric tests and generalized linear models (GLM), therein P-value below 0.05 was considered as the criterion of statistical significance, and the SPSS software was used. Results: After retrieving data on 177 patients with mucormycosis, 78 patients with CAM were included as the case group and 72 patients with COVID-19-unrelated ROCM were included as the control group. Neurological presentations suggestive of second, third, and eighth cranial nerve involvement were more prevalent in the CAM group (all with P < 0.05). The mortality rate in the CAM group was 1.9 times that of the controls (P = 0.01), being explained by higher extent of corticosteroid administration among them. Higher age and presentation with gait ataxia, ptosis, and mydriasis were considered to be predictive of poor prognosis in patients with CAM (all with P < 0.05). Conclusion: The neurological manifestations of CAM differ from COVID-19-unrelated ROCM based on the presented results, some of which are associated with poor prognosis. Further replication is warranted to confirm our retrospective analyses.

A case study of rhino orbito cerebral Mucormycosis (ROCM) in a diabetic patient reported from a multispeciality hospital in Tamil Nadu

ROCM is the most common type of Mucormycosis and it can rapidly spread from the paranasal sinuses to orbit and brain which can be fatal in most patients. Diabetes mellitus is the most common risk factor in India. As invasive fungal diseases present with nonspecific clinical features, increasing awareness and education among clinicians about this deadly enemy is very crucial for early diagnosis and prompt initiation of appropriate therapy. We are reporting a case study on ROCM in a Diabetic patient caused by species along with a short review on the taxonomy, risk factors, pathogenesis, clinical forms, diagnosis and management of mucormycosis. We hope that this will help in expanding awareness among medical community about mucormycosis which is a lethal opponent of patients with Diabetes Mellitus.

Outcome of Total Surgical Debridement of Covid Associated Rhino-Orbito-Cerebral Mucormycosis Based on a New Surgical Staging System: A Cohort Study.

To propose a surgical staging system with management protocol for post-covid Rhino-orbito-cerebral mucormycosis (ROCM) with central skull base osteomyelitis. A prospective cohort study of a total of 193 post-covid ROCM patients was conducted between May 2021 and January 2022 at a tertiary care centre. Patients were assessed radiologically and staged from I to V. Follow up period was 16months and the surgical outcome in terms of recurrent disease was assessed. A total of 193 patients (129 primary and 64 revision) were studied. Maxilla was found to be the epicenter of anterior disease (69.3%) and pterygoid wedge was noted to be the epicenter of posterior disease (85.6%). More than 65% of our patients, at the time of presentation, presented with involvement of the central skull base. Intracranial disease was noted in 13.9% of patients and the mortality rate was 6.2%. This staging system provides a systematic step-by-step protocol for the management of ROCM, with emphasis on meticulous disease clearance at the central skull base.

Clinical, Radiological, and Histopathological Findings of Post-Exenterated Mucormycosis Specimens

Introduction: A sharp upsurge in the number of coronavirus disease-associated mucormycosis cases was noted during the second wave of coronavirus disease in India. The fungal hyphae spread from the nasal mucosa, orbit to the brain, hence otherwise called rhino-orbito-cerebral mucormycosis (ROCM). Prompt diagnosis and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome. This study is done to enumerate the clinical, radiological, and histopathological findings of post-exenterated specimens of ROCM. Methods: This is a non-randomized cross-sectional study conducted at a tertiary care center. Ten post-exenterated specimens were examined histopathologically for the involvement of the central retinal artery, superior ophthalmic vein (SOV), optic nerve, muscle, and orbital fat showing necrosis. Clinical findings of these 10 patients were studied retrospectively for visual loss, proptosis, extraocular movements for muscle involvement, scleral necrosis, and fundus findings for artery or vein occlusions. Preoperative magnetic resonance imaging (MRI) findings like the number of orbital quadrants showing soft tissue thickening or tissue enhancement, diffusion restriction in the optic nerve, soft tissue enhancement seen at the orbital apex or superior orbital fissure, loss of flow void in the left internal carotid artery, enlargement of the SOV containing filling defect on post-contrast images were noted. Results: Optic nerve involvement was seen in 100% patients clinically, 70% on MRI, and 50% on histopathological examination (HPE). Muscle involvement was seen in 100% patients clinically, 90% on MRI, and 80% on HPE. None of the patients had scleral necrosis clinically. Scleral tenting was seen in 20% patients on MRI and 20% on HPE. Clinically, central retinal artery involvement was seen in 40%, and cilioretinal artery involvement was seen in 10%. MRI could not give much information on artery involvement. Clinically, none of them had central retinal vein occlusion. 20% had an enlarged SOV seen on MRI. HPE showed vascular involvement in 90% of the specimens. Conclusion: Clinical, radiological, and histopathological findings play a major role in the diagnosis, staging, and follow-up of ROCM.

COVID-19-associated mucormycosis in India: Why such an outbreak?

An unprecedented mucormycosis outbreak occurred in India during the second COVID-19 wave in spring 2021. COVID-19-associated mucormycosis (CAM) was observed, mainly rhino-orbito-cerebral mucormycosis (ROCM), in patients with poorly controlled diabetes and treated with inappropriate doses of glucocorticoids. The aim of this mini-review was to compare the characteristics of the CAM epidemic in India with (i) mucormycosis cases before the COVID-19 pandemic and (ii) CAM in the rest of the world (particularly in France) in order to identify the reasons for this outbreak. In India, the major mucormycosis epidemiologic change during the COVID-19 pandemic was an increase in the percentage of patients treated with corticosteroids who developed CAM. Compared with the rest of the world, India reported a higher mucormycosis incidence even before the COVID-19 pandemic. Moreover, in India, patients with CAM were more likely to have diabetes mellitus and ROCM; conversely, mortality rates were lower. The reasons for such a localized epidemic in India have remained unclear, but some hypotheses can be put forward, particularly the combination of high prevalence of uncontrolled diabetes mellitus and frequent indiscriminate corticosteroid utilization in a country that already had a high mucormycosis burden before the COVID-19 pandemic.

Sinonasal and Orbital Imaging Findings in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis During the Second Wave of COVID-19: A Retrospective Cohort Study in a Tertiary Hospital in Central India.

Background Mucormycosis is a consequence of the angioinvasive disease caused by filamentous fungi that belong to the order Mucorales, particularly Mucor, Rhizopus, and Rhizomucor. Rhizopus oryzae is the most prevalent form. The invading hyphae lead to damage of blood vessels leading to thrombosis and consequent tissue necrosis. The incidence of this disease entity witnessed a significant rise during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. Timely diagnosis and prompt treatment are crucial to diminish both the mortality and morbidity associated with this disease. Imaging plays a pivotal role in diagnosing the ailment, evaluating its extent, identifying complications such as thrombosis, and facilitating surgical planning. It demonstrates exceptional sensitivity in detecting the disease at its early stages, often before symptoms manifest. Due to the angioinvasive nature of Mucor, early detection assumes utmost importance as it necessitates intensive antifungal therapy and the removal of devitalized tissue through debridement. Methodology We conducted a retrospective cohort study to analyze computed tomography (CT) imaging findings in patients with COVID-associated rhino-orbito-cerebral mucormycosis (ROCM) confirmed by histopathological examination. We compared these findings with CT findings of the nose and paranasal sinuses in patients without mucor following COVID-19 sinusitis (non-ROCM). Results All 16 cases in the non-ROCM group were in stage 1 disease. In contrast, in the ROCM group, three patients had stage 1 disease, five patients had stage 2 disease, and 10 patients had stage 3 disease (p = 0.0001). The pterygopalatine fossa was significantly affected in 10 of 18 ROCM patients and in none of the non-ROCM patients. Conclusions Imaging plays a crucial role in the early detection of mucormycosis. It assists treating physicians in initiating prompt and aggressive treatment, thereby improving the prognosis of this frequently fatal disease.

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.

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.

Post-COVID-19 rhino-orbito-cerebral mucormycosis-A clinico-mycological study from North India.

The second wave of coronavirus disease 2019 (COVID-19), during the early 2021, lead to a devastating outbreak of mucormycosis in India. This study aimed to determine the aetiology, clinical features, comorbidities, and risk factors of rhino-orbito-cerebral mucormycosis (ROCM) and antifungal susceptibility pattern for the isolates. The study included all suspected cases of ROCM in post-COVID-19 patients attending the hospital from May to December 2021. A total of 70 patients were diagnosed with mucormycosis during the study period. The commonest presentations were rhino-orbital and rhino-orbito-cerebral in 35.7% of cases each. Diabetes mellitus was the commonest associated risk factor in 95.7% of all patients, while 78.5% of the patients were treated with corticosteroids in the recent past, and 25.7% presented with active COVID-19 pneumonia. The commonest isolate was Rhizopus arrhizus n = 14, followed by Aspergillus flavus n = 16, A. fumigatus n = 4, A. niger n = 3, Fusarium oxysporumn = 1, and Apophysomyces variabilisn = 1. Fungal species identification was done by phenotypic methods for all the isolates and DNA sequence analysis of 18 isolates, and antifungal susceptibility testing of 30 isolates was performed by commercially prepared HiMIC plate (HiMedia, Mumbai, India) using broth microdilution for amphotericin B, isavuconazole, itraconazole, voriconazole, and posaconazole. The MIC50 and MIC90 of amphotericin B for R. arrhizus strains were 0.25 and 4 μg/ml, respectively; and the MIC50 and MIC90 results for itraconazole, posaconazole, and isavuconazole were 8 and 8, 2 and 2, and 2 and 8 μg/ml, respectively. In vitro data showed that amphotericin B was the most effective antifungal against most species. The commercially available ready-to-use minimum inhibitory concentration plates are user-friendly for performing antifungal susceptibility, which may be useful in choosing appropriate regimens and monitoring emerging resistance.

POST-COVID ROCM (RHINO ORBITAL CEREBRAL MUCORMYCOSIS) INVOLVING SKULL BASE – A RARE CASE REPORT

INTRODUCTION Mucormycosis in the setting of COVID-19 has given rise to the concept of 'epidemic within a pandemic'. It is a life-threatening fungal infection caused by fungi belonging to class Zygomycetes. It has got special affinity for the immunocompromised which is one of the main reasons for the flare up of the disease during COVID. Rhino-orbito-cerebral Mucormycosis (ROCM) is by far known to be the most common form of this disease. This usually presents with nasal dryness and blockage, swelling and numbness of cheek, blackish discoloration of nose, cheek and palate. It has been seen that in late stages of mu c o rmy c o s i s , p a t i e n t s p r e s e n t e d w i t h ophthalmoplegia, diminuition of vision, loss of vision, altered sensorium or even facial palsy. MATERIAL AND METHOD We here-in report a rare case of a 67-year-old diabetic male who was diagnosed with post- COVID Mucormycosis involving skull base with right abducens nerve and right hypoglossal nerve palsies. Management comprised of endoscopic debridement of the disease followed by administration of liposomal amphotericin. Patient was followed for 6 months with repeated nasal endoscopies and follow-up MRI. CONCLUSION There was visible recovery of the sixth and twelfth nerves. No recurrence has been observed. K e y w o r d s – R h i n o - o r b i t o - c e r e b r a l m u c o r m y c o s i s , a b d u c e n s n e r v e p a l s y, h y p o g l o s s a l n e r v e p a l s y, e n d o s c o p i c debridement, dolleros canal

Mucormycosis - An Adamant Parasitic Fungal Infection Requiring Multiple Surgeries

Introduction - Mucormycosis is a life threatening invasive fungal infection that mostly occurs in immunocompromised patients. Aim of our study is to analyze the management of mucormycosis in rhinoorbital mucormycosis cases and dire requirement for more than one surgical intervention for their management. The limitations of first surgery, progressive nature of disease, and difficult anatomical regions were the areas to address in most of our patients in this series. Methodology - Our case series consists of 34 confirmed cases of mucormycosis using standard staining and histopathological confirmation on biopsy. The study group being subjected to complete modern diagnostic, CT, MRI scrutinization. Detailed follow up with serial endoscopies, post-surgery. Re confirmation of residual on progressive mucormycosis disease condition being subjected to repeat of these investigative tools and confirmation with PET scan. Results – Total of 34 patients were included in our study majority of them were diabetic. Only 3 patients underwent single stage debridement however 34 patients underwent debridement in two successive stage and two patients required third surgery for disease clearance. Conclusion – Repeated surgical debridement is must for complete disease eradication in case of rhinoorbitocerebral mucormycosis. Also, medical management can prolong the survival of patients with disease in areas which are inaccessible by surgical clearance. Serial radiography with CT, MRI and PET scan are not only contributary but mandatory.

Risk factors affecting outcome of rhino-orbital-cerebral mucormycosis in COVID-19 patients

BackgroundMucormycosis is a serious life-threatening fungal infection that recently made severe sudden and devastating surge during the second wave of the COVID-19 epidemic with a mortality rate of up to 50%.Although the causality link between COVID-19 and rhino-orbito-cerebral mucormycosis (ROCM) remains unclear, many factors including poor diabetes control, high doses of steroids, viral-induced lymphopenia, and cytokine storm have been attributed to ROCM in patients with COVID-19.Orienting to risk factors and early recognition of this potentially fatal opportunistic infection is the key to optimal management and improved outcomes. In these contexts, we conducted a prospective study for 33 patients admitted to our tertiary hospital to determine the risk factors for ROCM in patients with COVID-19 and the cumulative mortality rates.ResultsThis study found a statistically significant relation between the fate of death in COVID-MUCOR patients who had presented fever, ophthalmoplegia, facial skin necrosis, and visual loss with those who received dose of steroid to control their respiratory symptoms P < 0.001.Death from COVID-MUCOR was statistically significant related to the prolonged interval from the onset of the symptoms to start of treatment and intervention. Also, it was found that there was a significant decrease in duration between COVID-19 infection and the start of mucormycosis (days) with incidence of DKA on admission. Nineteen (57.6%) of the patients had uncontrolled diabetes mellitus (hemoglobin A1C (HbA1c) of > 7.0%).ConclusionMucormycosis epidemic was precipitated by a unique confluence of risk factors: diabetes mellitus, widespread use of steroids, and perhaps SARS-CoV-2 infection itself. Restricting steroid use in patients with severe COVID-19 requiring oxygen therapy, and screening for and optimally controlling hyperglycemia, can prevent COVID-MUCOR in a large majority.

Radiological findings of mucormycosis rhinosinusitis among Indian COVID-19 patients during the pandemic second wave

BackgroundSinonasal mucormycosis is a quickly progressing and lethal fungal disease which showed an increased incidence in COVID-19 patients in the Indian population during the second wave of the pandemic. The objective of this study was to study the various sinus areas affected and the imaging findings of the disease.MethodsThe imaging records of patients with sinonasal mucormycosis during the second wave of the COVID-19 pandemic were reviewed and analysed for whom computed tomography (CT) and/or magnetic resonance imaging (MRI) images had been performed.ResultsOf the 65 patients, 6.1% had single sinus involvement, and 93.9% had multiple sinus involvement, and out of latter, 91.8% had bilateral sinuses affected by the disease process. A total of 49.2% patients with sinus involvement had erosions of the sinus walls. A total of 35.4% patients had only sinonasal mucormycosis, 38.5% patients had rhino-orbital mucormycosis, 4.6% patients had rhino-cerebral mucormycosis and 16.9% patients had rhino-orbitocerebral mucormycosis. The pterygopalatine fossa was affected in 26.2% patients. A total of 9.2% patients had cavernous sinus thrombosis. A total of 12% of the cases had infarction in the cerebral hemispheres.ConclusionIn a setting of sinonasal mucormycosis, especially in the immuno-compromised and with those infected with COVID-19, cross-sectional imaging can assess the presence and extent of the disease and helps plan its medical and surgical management.

Magnetic Resonance Imaging Features of Rhino-Orbito-Cerebral Mucormycosis in Post-COVID-19 Patients: Radio-Pathological Correlation.

There has been a notable increase in rhino-orbito-cerebral mucormycosis (ROCM) post-coronavirus disease 2019 (COVID-19), which is an invasive fungal infection with a fatal outcome. Magnetic resonance imaging (MRI) is a valuable tool for early diagnosis of ROCM and assists in the proper management of these cases. This study aimed to describe the characteristic MRI findings of ROCM in post-COVID-19 patients to help in the early diagnosis and management of these patients. This retrospective descriptive study was conducted at a single hospital and included 52 patients with COVID-19 and a histopathologically proven ROCM infection who were referred for an MRI of the paranasal sinuses (PNS) due to sino-orbital manifestations. Two radiologists reviewed all the MR images in consensus. The diagnosis was confirmed by histopathological examination. The maxillary sinus was the most commonly affected PNS (96.2%). In most patients (57.7%), multiple sinuses were involved with the black turbinate sign on postcontrast images. Extrasinus was evident in 43 patients with orbital involvement. The pterygopalatine fossa was involved in four patients. Three patients had cavernous sinus extension, two had pachymeningeal enhancement, and one had epidural collection. The alveolar margin was affected in two patients, and five patients had an extension to the cheek. The awareness of radiologists by the characteristic MRI features of ROCM in post-COVID-19 patients helps in early detection, early proper management, and prevention of morbid complications.

Role of Inflammatory Markers as Prognostic Indicators in Treatment of Mucormycosis

Introduction: Mucormycosis is opportunistic fungal infection characterized by extensive inflammation, necrosis and infarction of the involved tissues. It is associated with rise in levels of inflammatory markers [Erythrocyte sedimentation rate (ESR) , C-reactive protein (CRP)]. This study was done to know the role of ESR, CRP as prognostic indicators in the treatment of covid-19 associated mucormycosis (CAM).&#x0D; Materials and Methods: : A retrospective descriptive study was conducted between May 2021 and December 2021 at a tertiary centre. 315 patients with post-covid ROCM (Rhino-orbito-cerebral mucormycosis) were included in study. ESR and CRP were sent for all patients at the time of admission. Postoperatively the same were repeated on post-op (POD) day 7, day 14, and day 30 during follow-up.&#x0D; Results: 243 (77.14%) patients were male and 72 (22.86%) were female. 6 patients with stage IV ROCM had recurrence of the disease in the postoperative period. Mean ESR values in these patients at the time of admission, POD-7, 14, 30 were 98.17, 68.17, 44.00, 80.33 respectively. Mean CRP values in these patients at the time of admission, POD-7, 14, 30 were 58.50, 48.17, 26.33,37.83 respectively.&#x0D; Conclusion: Serial measurements of inflammatory markers (ESR, CRP) levels helps in the diagnosis and prognostication of ROCM along with clinical evaluation and imaging.