Rhino-orbito-cerebral Mucormycosis Research Articles

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).
 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.
 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.
 Conclusion: Serial measurements of inflammatory markers (ESR, CRP) levels helps in the diagnosis and prognostication of ROCM along with clinical evaluation and imaging.

Comparative Study of Clinical Severity and Biochemical Markers in Pre COVID-19 and COVID-19 Rhino-Orbito Cerebral Mucormycosis

In view of high surge of sinonasal mucormycosis cases after the second wave of covid 19, present study was planned to know and compare the clinical severity of the disease and also to better understand the difference in the biochemical markers during precovid and post covid period. This retrospective observational study included all cases of sinonasal mucormycosis which were treated in our institute from August 2012 to August 2021. Details of these cases were collected from hospital database system. Biochemical parameters included FBS, HbA1C, urine ketone bodies, blood pH and creatinine. Clinical severity score was measured using self-structured severity scoring system. We found that out of 74 cases treated in our hospital 28 cases were in pre covid period while 46 cases belonged to covid 19 period. Higher male predominance was seen during post covid period (76% vs. 60%). Urine ketone bodies were positive in 7% patients in precovid period compared to 26% in post-covid period. FBS and HbA1C were high approximately 80 and 90% patients respectively in both groups. Clinical severity was significantly high in post covid patients. The present study showed that in spite of similar biochemical profile. The severity of mucormycosis was high in covid positive patients. This study shows that Covid-19 is an independent high risk factor in mucormycosis patients.

Various Treatment Modalities in COVID-19 Associated Facial Mucormycosis and the Need for its Surgical Management: A Systematic Review.

Mucormycosis emerged as a wildfire in post-covid-19 infected patients. Most frequently involved sites of mucormycosis are rhino-orbital, rhino-sinusal and rhino-orbito-cerebral. The hallmark sign of mucormycosis is tissue necrosis, which is often a late sign. The fatality rate of mucormycosis is 46% globally. Despite early aggressive combined surgical and medical therapy, the prognosis of mucormycosis is poor. We searched the electronic database of PubMed, web of science, Embase, Scopus and Google Scholar from Jan 2020 until December 2021 using keywords. We retrieved all the granular details of original research articles, case reports/series of patients with rhino-orbito-cerebral mucormycosis (ROCM), and COVID-19 reported worldwide. Subsequently, we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, treatment given and its outcome in people with COVID-19. (Prospero registration-CRD42021256830, June 4, 2021). Overall, 544 rhino-orbito-cerebral mucormycosis patients were included in our review with a history of Covid-19 infection. Out of which 410 patients had diabetes mellitus which has proven to be major contributing immunocompromised disease. Other diseases like hypertension, chronic kidney diseases, hypothyroidism, etc., were also attributed as an immunocompromised disease causing increased number of covid associated mucormycosis cases. We found out that total number of patients alive after taking only antifungal drug treatment were 25 in number, whereas total number of patients alive when antifungal drugs were combined with surgical intervention were 428 which was significantly higher. Our systematic review concluded that surgical debridement should be performed whenever feasible in parallel to antifungal treatment in order to reduce the mortality rate of COVID-19 associated rhino-orbito-cerebral mucormycosis patients.

Rhino-Orbito-Cerebral Mucormycosis (ROCM): An Observational Case Report of Covid-19 Positive Patients Admitted in Intensive Care Unit of Community Hospital in South India

Background: Rhino-orbito-cerebral mucormycosis (ROCM) increasing incidence in the setting of COVID-19 in India and elsewhere has become a matter of immediate concern. In this observational case report we have observed the signs and symptoms of ROCM among coronavirus positive patients with reference to “Mucor code “as reported by Honavar SG 2021, we have reported cases been admitted to ICU for <2weeks in a community hospital in South India. Method: Patient informed consent was taken, Patient’s data (Medical record, medication charts, daily report) were collected using a designed data collection form, observed warning signs and symptoms, and predisposed factors was noted and ROCM is characterized with reference to the “Mucor code”.Results: Nasal stuffiness, Foul smell and Facial pain and among others were the most coherent warning signs and symptoms observed among the patients in <2weeks of admission in ICU. Other observed predisposing risk factors were regular administration of corticosteroids, antibiotics, Diabetes Mellitus, Hypertension, and Kidney Stone.Conclusion: All the cases on preliminary examination on the basis of observed warning signs and symptoms were “Possible” ROCM a sub-type of Covid-19 associated mucormycosis (CAM), as this was the first reported case of the hospital. Our study gave basis for further diagnosis and monitoring of Covid-19 positive patient admitted in the intensive care units.

Prosthetic Rehabilitation of Post Covid Rhino-orbito Cerebral Mucormycosis

Covid 19 infection leads to reduced ciliary function, cytokine storm, thrombo-inflammation, microvascular coagulation and immune exhaustion. Hence, opportunistic infections such as mucormycosis are increasing in Covid affected patients. Covid infection has a tendency to worsen comorbid conditions like diabetes, hypertension, and cardiac disorders or even cause these life-threatening conditions in previously normal individuals. Corticosteroids used for the treatment of Covid puts the patients at risk of developing infections like mucormycosis since corticosteroids act as immune suppressors. At this juncture it is important to understand the pathophysiology, surgical/medical treatment as well the prosthetic rehabilitation of post covid rhino-orbito cerebral mucormycosis.

Clinical Anatomical Characteristics of Patients with Rhino-Orbit-Cerebral Mucormycosis

Background. Postponed coronavirus infection (COVID-19), accompanied by an immunosuppressive state and associated with the risk of secondary diseases such as mucormycosis. Diabetes mellitus is an independent risk factor for both severe COVID-19 and mucormycosis.
 Aims our aim was to experience the diagnosis and treatment of rhino-orbitocerebral mucormycosis in post-COVID-19 patients.
 Materials. A single-center, observational, non-randomized, cohort comparative study was conducted. We assessed the clinical features, risk factors, diagnosis and outcomes of mucormycosis among recovered COVID-19 patients with hospitalisation in the otorhinolaryngology department of the Samara State Medical University Clinics, Samara, from SeptemberDecember 2021. CT examinations were performed on Revolution EVO CT scanner (GE, Russia) and MRI on Aera MR scanner 1.5 T (Siemens, Germany). Materials for microbiological and histopathological examination were taken from all examined patients intraoperatively.
 Results. The experience of diagnosing and treating rhinoorbitocerebral mucormycosis in patients after a new coronavirus infection was analyzed, the influence of the complex use of radiation diagnostic methods, histopathological and microbiological methods on the development and effectiveness of mucormycosis treatment was determined.
 Conclusions. The effectiveness of disease management directly depends on the early initiation of etiotropic treatment, while the role of complex radiological diagnostics, histopathological and microbiological methods is important for early confirmation of the fungal etiology of the disease.

A STUDY ON THE OCULAR MANIFESTATIONS IN PATIENTS FOLLOWING COVID-19 INFECTION

Background And Objective: The objective of this study was to evaluate ocular manifestations in Post COVID-19 patients. Materials And Methods: This study was conducted at the Department of Ophthalmology, Chalmeda Ananda Rao Institute of Medical Sciences from October 2020 to April 2021. 200 patients with the history of COVID-19 infection were included in the study. Detailed history was taken, slit lamp examination and fundoscopy was done for all patients, relevant investigations like Optical coherence Tomography, Fundus Fluorescein Angiography were done. Results: 23 out of 200 (122 male and 78 female) patients had ocular manifestations, 15 patients had viral conjunctivitis, 3 patients had episcleritis, 2 patients had central serous chorioretinopathy (CSCR), 1 patient had Central retinal artery occlusion (CRAO), 2 patients were Rhino-Orbito-Cerebral Mucormycosis (ROCM) suspects. Conclusion: Study emphasises on ocular manifestations associated with COVID 19 infection and its sequelae. As these patients presented with an association with COVID 19 infection (either during or recovery) ophthalmologists should be watchful and screen for such entities

Mortality and its determinants after an outbreak of post COVID-19 associated rhino-orbito-cerebral mucormycosis in Central India.

To report cumulative mortality rates using survival analysis from an outbreak of 211 patients with post COVID-19 rhino-orbito-cerebral mucormycosis (ROCM) in central India. Case files of eligible patients were evaluated and mucor was identified from deep nasal swabs using freshly prepared KOH mount. All patients underwent contrast enhanced MRI and disease staging was done based on the extent of anatomical involvement. All patients received intravenous Amphotericin B and sinus debridement was done when possible. Orbital exenteration was reserved for patients with advanced orbital disease. The mean age was 50.7 ± 10.2 of which 147 (70%) were men. At presentation, ROCM was limited to sinuses in 72 (34%), orbital extension was seen in 102 (48%) and 31 (15%) had CNS extension. Sinus debridement was possible in 82% cases (n = 173). Thirty-five (16.6%) patients died due to ROCM. The mean follow-up of patients who survived was 126.6 ± 16.4days. The cumulative mortality rate at day 10 was 4.8% (95%CI = 2.6-8.8%) and increased 13.1% (95%CI = 9.1-18.7%) at day 30 and to 18.4% (95%CI = 13.6-24.8%) at day 60. Majority of deaths (n = 26, 75%) occurred within 1-month of ROCM presentation. Multivariable hazards analysis showed that patients with CNS involvement had a 6.5 times higher risk of death (Hazard Ratio = 6.71, 95% CI = 2.9-15.5, p < 0.001). We report significantly lower mortality rates compared to recent literature that varies from 30 to 80% at 1-month follow-up. Timely sinus debridement and systemic Amphotericin B can help reduce mortality. Presence of CNS extension significantly increased the mortality risk with patients with ROCM.

Rhino-orbito-cerebral mucormycosis in a pregnant woman

Mucormycosis is an uncommon, rapidly progressive, angioinvasive fungal infection characterized by large areas of tissue necrosis. We report a case of a 25-year-old primigravida of gestational age 25 weeks with clinically and radiologically proven COVID-19-related rhino-orbito-cerebral mucormycosis (ROCM) stage 3c with gestational diabetes. She was treated with injection liposomal amphotericin B, but her condition rapidly progressed with impending intracranial extension. She was subjected to total exenteration of the left eye with extensive endoscopic sinus surgery and continued on systemic antifungals along with supportive therapy for four weeks after surgery.

COVID-19 associated Mucormycosis (CAM): Implications for perioperative physicians - A narrative review.

Mucormycosis once considered a rare disease with an incidence of 0.005 to 1.7 per million, has become one of the greatest menaces during the coronavirus disease (COVID-19) pandemic. India alone has contributed to nearly 70% of the global caseload of COVID-associated mucormycosis (CAM) and it had even been declared as a notifiable disease. Second wave of COVID-19 pandemic saw a steep rise in the incidence of mucormycosis and these patients have been presenting to anesthesiologists for various surgical procedures due to its primary or secondary sequelae. Rhino-orbito-cerebral mucormycosis (ROCM) is the commonest manifestation and is caused by Rhizopus arrhizus. Injudicious use of corticosteroids in vulnerable patients could have been a major contributing factor to the sudden rise in ROCM during the pandemic. Concerns related to anesthetic management include COVID-19 infection and post COVID sequalae, common presence of uncontrolled diabetes mellitus, possibility of difficult mask-ventilation and/or intubation, various drug therapy-associated adverse effects, and interaction of these drugs with anesthetic agents. Thorough preoperative optimization, multidisciplinary involvement, perioperative care, and vigilance go a long way in improving overall outcomes in these patients.

The baneful alliance of COVID-19 and mucormycosis: Histopathological concerns.

Mucormycosis, once a rare fungal disease, has now shown a surge in cases, and its epidemiology in India is intriguing. Rising incidence confers the necessity of defining the demography of the population at risk, early diagnosis, and recommendations for the management of mucormycosis in patients with coronavirus disease (COVID-19) infection. To study the clinico-epidemological profile, risk factors, and histopathological features of COVID-19-associated Mucormycosis (CAM). This is a retrospective observational study. Fifty-six biopsy specimens taken from patients of COVID-19 with clinical suspicion of mucormycosis were included. Diabetes mellitus, corticosteroids, and oxygen therapy were the most common risk factors associated with CAM. The mean duration between the onset of symptoms of COVID-19 and onset of CAM was 25.2 ± 15.3 days. Rhino-orbito-cerebral mucormycosis (ROCM) was present in 24.5% of the cases, with a survival rate of 58.3%. Histopathology showed tissue invasion by branching broad-based, pale, fungal hyphae consistent with mucor in 49 (87.5%) cases. Inflammation was acute neutrophilic type in 61.2% of the patients with a survival rate of 63.33%. The survival rate with chronic non-granulomatous and chronic granulomatous was 100% and 81.8%, respectively. Keeping a high index of suspicion for mucormycosis in COVID-19 by all medical fraternities of the health community in the existence of risk factors is the need of the hour for prompt diagnosis. Biopsy of antral necrotic tissue should be performed immediately after suspicion for histopathological study to confirm the diagnosis of mucormycosis and predict prognosis depending on the type of inflammation incited, fungal morphology, load, and necrosis.

Rhino-orbito-cerebral mucormycosis and its resurgence during COVID-19 pandemic: A review.

This study aimed to review the current literature for epidemiology, pathogenesis, clinical spectrum and management of rhino-orbito-cerebral-mucormycosis (ROCM), especially highlighting the association between ROCM and COVID-19 disease and factors resulting in its resurgence during the pandemic. Mucormycosis is a rare, but an important emerging opportunistic fungal infection, often associated with high morbidity and mortality. ROCM is the commonest and also the most aggressive clinical form occurring in debilitated patients in conjunction with sinus or para-sinus involvement due to the propensity for contiguous spread. Recently ROCM has shown an unprecedented resurgence during the current pandemic. Reports from different parts of the world indicated an increased risk and incidence of ROCM in patients who had required hospital admission and have recovered from moderate-to-severe COVID-19 disease. A majority of mucormycosis cases have been reported from India. The presence of diabetes mellitus (DM) and use of corticosteroids for COVID-19 pneumonia were found to be the key risk factors, resulting in higher mortality. Amidst the ongoing pandemic, with the third wave already having affected most of the world, it becomes imperative to adopt a risk-based approach toward COVID-19 patients predisposed to developing ROCM. This could be based on the most recently published literature and emerging data from centers across the world. The present review intended to elucidate the causes that brought about the current spike in ROCM and the importance of its early detection and management to reduce mortality, loss of eye, and the need for mutilating debridement.

A cross-sectional study to describe the spectrum of ocular manifestations and risk factors of mucormycosis presenting to a tertiary hospital of East India.

To report the clinico-demographic profile of rhino-orbito-cerebral mucormycosis (ROCM) in patients during the "second wave" of the COVID-19 pandemic in eastern India, and their ophthalmic manifestations at presentation to our tertiary institute. Cross-sectional study amongst patients presenting to our center based on their hospital records. Demographic information, history related to COVID-19, records of detailed ocular examination, and microbiological, radiological, and histopathological investigation were entered into an online worksheet and analyzed using SPSS 26.0. A total of 219 patients with ROCM were treated from May to September 2021, and 110 of these had ocular manifestations at presentation (50.2%). The age of patients ranged from 22 to 83 years and the mean ± standard deviation (SD) age was 49.9 ± 12.9 years. Ninety (81.8%) patients had been diagnosed with diabetes mellitus, 31 (34%) had hypertension, and 10 had other comorbidities. The duration between the onset of COVID-19 and mucormycosis symptoms was 0 to 60 days with a mean ± SD interval of 20.9 ± 12.6 days. Fifty-six (50.9%) patients had a history of steroid use. Unrelenting ocular or facial pain was the most common presenting symptom, ptosis was the most common anterior segment manifestation, and ophthalmic artery occlusion was the most common posterior segment manifestation. Our data from eastern India reinforces the relationship between COVID-19, diabetes, corticosteroid use, and ROCM. Knowledge of various presenting anterior and posterior segment manifestations of the disease as described in the present study will guide clinicians to recognize the disease early and make every effort to prevent complications.

Glycemic Control Variations In Covid-19 Associated Mucormycosis”

Background: Mucormycosis is opportunistic invasive fungal infection characterised by angioivasion, thrombosis and necrosis of the tissues. Diabetes mellitus being the commonest immunocompromised state predisposing to mucormycosis in India, a study about glycemic control in CAM (covid-19 associated mucormycosis) patients and the severity of mucormycosis was necessary so as to reduce the morbidity and mortality in CAM patients. Methods: A retrospective descriptive study was conducted between May 2021 and July 2021 at Bowring &amp; Lady Curzon hospital. 315 patients with post-covid ROCM (rhino-orbito-cerebral mucormycosis) were included in the study. Glycemic control of the patients was monitored with FBS, PPBS, HBA1C values.The extent and severity of CAM was studied in patients with good and poor glycemic control.. Results: 243 (77.14%) patients were male and 72 (22.86%) were female. 296 (93.97% )patients had prior history of diabetes mellitus and 19 (6.03%) patients had newly detected diabetes mellitus. 275(87.30%) patients had poor glycemic control. 17 (6.18%) patients out of 275 presented with diabetic ketoacidosis (DKA). 40 (12.70%) patients had good glycemic control. Conclusions: Diabetes mellitus has emerged as important risk factor associated with development of mucormycosis. In covid-19, poorly controlled diabetes, steroid induced hyperglycemia, covid induced insulin resistance act as fertile land for the development of mucormycosis. Hence monitoring glycemic status, judicious use of steroids, control of sugars may help in reducing the severity or occurance of mucormycosis. Keywords: Mucormycosis, Diabetes mellitus, Covid-19 associated mucormycosis, Hyperglycemia.

Perineural spread of rhino-orbito-cerebral mucormycosis in post-Covid-19 patients-Description of this rare pathwayin the rural population of southern Rajasthan

Various opportunistic infections were found to be more common in patients with a history of Covid-19 infection after the second wave of pandemic. The rural and tribal population was severly hit due to quack practices, lack of health care, and knowledge. Clinical features range from non-invasive sinusitis to aggressive invasive form in immunocompetent hosts. Rhino-orbito-cerebral mucormycosis (RCOM) is a very infrequent but lethal fungal infection, usually affecting diabetic patients (Ketoacidosis state). It has characteristic patterns of spread, i.e., continuous, direct spread or via vascular invasion, while perineural spread being the least common pathway of invasion. We report nine cases of invasive fungal infection with an symptomatic perineural spread in this study.

Clinical Phenotypes of COVID-19 Associated Mucormycosis (CAM): A Comprehensive Review.

A mucormycosis surge was reported during the COVID-19 pandemic in India. A literature search until 14 July 2022, with the aim of updating COVID-19-associated mucormycosis (CAM), identified 663 studies and 88 met inclusion criteria (8727 patients). India reported 8388 patients, Egypt 208 and Europe 40. Rhino-orbito-cerebral mucormycosis (ROCM) was identified among 8082 (98.3%) patients, followed by 98 (1.2%) with pulmonary. In India, 82.6% of patients had diabetes mellitus, with 82% receiving corticosteroids. In Europe, 75% presented pulmonary CAM, 32.5% had diabetes and 40% were immunocompromised. CAM was identified at a median of 17.4 days (IQR 7.5 days) post COVID-19 diagnosis, and PCR was performed in five studies. Rhino-orbital invasion is clinically obvious, while cerebral involvement presents with cavernous sinus thrombosis, meningitis and cerebrovascular disease. Symptoms of pulmonary CAM usually overlap with severe COVID-19 pneumonia. High-dose liposomal Amphotericin B (and early surgical debridement in ROCM) are the mainstay of therapy. The median mortality rate was estimated to be 21.4% (IQR 31.9%), increased by the presence of pulmonary (80% (IQR 50%) or cerebral involvement (50% (IQR 63.9%). In summary, different CAM clinical phenotypes need to be distinguished, influenced by geographical presentation. Opportunities exist for diagnosis and therapy optimization, based on earlier high-dose antifungal therapy, early source control, strict glycemic control and restriction of steroids to COVID-19 patients with oxygen requirements.

Clinicoradiological profile and outcome of cavernous sinus syndrome with coronavirus disease-2019-associated rhino-orbito-cerebral mucormycosis.

With coronavirus disease 2019 (COVID-19) pandemic across the world, there had been an exponential increase in rhino-orbito-cerebral mucormycosis (ROCM). Extension of infection to cavernous sinus leads to cavernous sinus syndrome (CSS). This study aims to describe incidence, clinicoradiological profile, and outcome of CSS positive along with comparative analysis of CSS negative COVID-19-associated ROCM. This was a prospective and observational study conducted from May 1, 2021, to July 31, 2021. Subjects included ROCM with active or recovered COVID-19 (past 6 weeks) and were categorized and staged. CSS was defined as involvement of two or more of third, fourth, fifth, or sixth cranial nerve with one each direct and indirect qualitative neuroradiological features. Clinicoradiological features of CSS-positive and negative COVID-19-associated ROCM groups were compared. Incidence of CSS with COVID-19-associated ROCM was 28%. Mean age of subjects was 44 ± 15 years with 60% being males and 73% were proven ROCM. Significant differences seen across the CSS-positive and negative groups were ocular, nasal, and cerebral findings including eyelid and periocular discoloration, ptosis, proptosis, ophthalmoplegia, nasal discharge, mucosal inflammation, and fever. Oculomotor, trochlear, and abducens nerves were significantly involved more in CSS-positive group. Significant radiological findings across two groups included indirect features in orbit, nose, and paranasal sinuses along with direct features in cavernous sinus. Surgical intervention was more common in CSS-positive group. Mortality in CSS-positive group at 8-24 weeks was 13 and 27%, respectively. Extension of ROCM to CSS was more common in young males in advanced stages of proven ROCM with concurrent COVID-19. CSS-positive group had significant difference in clinicoradiological features involving orbit, nose, paranasal sinuses, and central nervous system as compared to CSS-negative group. This study highlights the need to develop an objective scoring system considering clinical and radiological features for diagnosis of CSS with COVID-19-associated ROCM.

A STUDY OF FEQUENCIES OF CRAO CASES IN POST COVID 19 RHINO ORBITAL MUCOR MYCOSIS

Introduction: Mucormycosis is a life-threatening fungal infection that occurs in patients who are immune compromised because of diabetic ketoacidosis, neutropenia and/or organ transplantation. In pandemic of COVID 19 an unusual epidemic of rhino-orbital-cerebral mucormycosis was observed affecting post COVID patients mainly. Covid 19 causes endothelial dysfunction due to inflammatory induced homeostasis and a pro coagulant state with multi-organ involvement[1].All these inflammatory and hypercoaguble states are established risk factors for retinal artery occlusion. Direct invasion of vessels by fungal hyphae leading to widespread occlusive vasculitis and thrombosis can also lead to complications like Central Retinal Artery Occlusion in patients of mucormycosis. Aim: To report a series of CRAO cases in Post Covid Rhino-orbito cerebral mucormycosis patients and describe clinical profile and outcome. Methodology: In a cross sectional study all adult patients at SDU medical college from 1st April to 31st August 2021 diagnosed as Rhino-orbital-cerebral Mucormycosis were included. Epidemiological data of all cases and relevant history were noted. Detailed history regarding COVID hospitalization and treatment received were noted. Detailed ocular examination including fundus examination was done.Primary outcome measure was CRAO. Results: A total of 34 patients were included in study out of which 26.47% were females and 73.52% were males. CRAO was observed in a total of 10 patients (27.02) out of which 9(90%) were males and 1(10%) was female. Conclusion: Association of invasive mucormycosis with COVID-19 is dangerous and has serious consequences. Detailed ophthalmological surveillance in such patients is mandatory to avoid sight threatening complications.

Fatality Chooses Its Path Through the Orbit: A Study of Rhino-Orbito-Cerebral Mucormycosis as a Complication of COVID-19 Infection.

Introduction and aim Mucormycosis is a rare but serious angio-invasive infection caused by a group of fungi called mucormycetes and it mainly affects people who are immunocompromised, or patients already infected with other diseases.The dreaded mucormycosis infection has recently gained gross ill-repute for having claimed many lives in coronavirus disease (COVID-19) and/or post-COVID-19 patients. Hence a need was felt to study the development of mucormycosis in COVID-19 patients to better prevent and treat this fungal infection in anticipated future waves of the pandemic. This study also aims to establish an association between COVID-19 positivity, systemic comorbidities, and treatment modalities with the possibility of occurrence of vision and life-threatening mucor infection of the nose, paranasal sinuses, orbit, and brain. Methods This is a hospital-based, retrospective, case-control study. The study reviewed case files of all patients diagnosed with rhino-orbito-cerebral mucormycosis (ROCM) from April 1, 2021, to May 31, 2021. A set of age-matched COVID-19-positive patients hospitalized during the study period with moderate to severe disease were recruited as controls. We addressed factors that could be associated with the development of fungal infection and studied the period between COVID-19 positivity and the onset of ROCM. Results The age of patients in both groups ranged from 40-60 years with 13 females and 17 males. A statistically significant correlation (p-value = 0.032) was found between positive reverse transcription-polymerase chain reaction (RT-PCR) history and use of intravenous (IV) corticosteroids (11 [73.3%] cases and all controls). The mean duration from COVID-19 positivity to the presentation of mucormycosis was 12.10±7.27 days. Uncontrolled blood sugar was found to be themost significant correlation (p-value = 0.003). Mucormycosis is 13.678 times more likely in people with abnormal hemoglobin A1c (HbA1c). Co-morbidities like anemia, chronic kidney disease (CKD), coronary artery disease (CAD), and leukemia were found in controls, but none of these conditions were seen in patients who developed mucormycosis. Conclusion Judicious use of steroids and strict control of blood sugar levels should be emphasized in the management of COVID-19 patients.