Rhino-orbito-cerebral Mucormycosis Research Articles

Our children are at risk of COVID-19- associated rhino-orbito-cerebral mucormycosis (ROCM)

Our children are at risk of COVID-19- associated rhino-orbito-cerebral mucormycosis (ROCM)

A Proposed Grading System and Experience of COVID-19 Associated Rhino Orbito Cerebral Mucormycosis from an Indian Tertiary Care Center

Mucormycosis is an opportunistic fungal infection. India faced an unprecedented increase in patients with post coronavirus disease 2019 (COVID-19) associated rhino-orbito-cerebral mucormycosis (ROCM). This study proposes a grading system which correlates the extent of the disease with the management plan. An observational study was conducted January 2021–June 2021. We identified 65 patients. Eleven patients had mild disease, 27 patients had moderate, 16 patients were severe and 11 patients were graded as very severe. The management was planned based on this grading system. Early diagnosis, aggressive surgical debridement and antifungal drug therapy is the key to improve survival in ROCM. Procedures such as endoscopic orbital clearance, sublabial maxillectomy, and modified endoscopic Denkers (MED) approach facilitate access and surgical debridement. The new grading system proposed assists in planning the approach and extent of surgical debridement.

EFFICACY OF KOH AND LACTO PHENOL BLUE STAIN FOR EARLY DIAGNOSIS OF RHINOORBITOCEREBRAL MUCORMYCOSIS

BACKGROUND: Rhino orbito cerebral mucormycosis has emerged as a complication after covid infection and in immunocompromised nd patients after 2 wave of covid infection in April to July 2021. This complication needs to be diagnose as early as possible to halt its spread to important nasal and orbital strucures. AIMS: This study aim to detect the sensitivity of different primary microbiological stain like KOH and lacto phenol blue. OBJECTIVE: Objective of study is to compare the efcacy of different microbiological stain to detect mucormycosis METHODOLOGY: Retrospective observational study CONCLUSION:Lactophenol blue should be the rst laboratory investigations to detect mucormycosis with higher efcacy than KOH stain

English

BACKGROUND Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating fungal infection with very high rates of mortality. Many patients post corona virus disease (COVID) infection are increasingly being diagnosed with mucormycosis (black fungus). Imaging being central to the early diagnosis of the infection, the study aims to characterize the major radiological patterns of involvement of mucormycosis. Computed tomography (CT) & magnetic resonance imaging (MRI) findings of 10 patients who were subsequently conformed to have mucormycosis were analyzed and 7 major patterns of involvement were detected. Imaging plays a vital role in the early diagnosis of ROCM. Knowledge about the common patterns of spread helps in picking the subtle signs of infection. KEYWORDS Mucormycosis, Post COVID, Fungal Sinusitis, ROCM

Comprehensive study on manifestation, management and outcome of post COVID rhino orbito cerebral mucormycosis in our institution

<p class="abstract">Rhino orbital mucor mycosis in covid infected patients presented a challenge in management. We tried analysing comprehensively the manifestations and management and prognosis of post COVID rhino orbito cerebral mucormycosis (ROCM) patients in our institution. Patients with symptoms of ROCM were managed according to the guidelines issued by the directorate of medical education, Tamil Nadu, India. 30 possible ROCM patients were treated so far from May 2021. Patients underwent radiological, microbiological and pathological investigation. In stage 1, nasal cavity alone was involved in 11 patients. In stage 2, paranasal sinus extension was seen in 8 patients. In stage 3, orbital extension was seen in 10 patients. In stage 4, intra cranial extension was seen in 1 patient. 10 patients were probable ROCM without microbiological or pathological evidence. 20 patients had proven ROCM. They were treated with endoscopic debridement. Out of them 10 patients had to undergo orbital decompression and 5 of them had improvement in vision. All proven ROCM patients were treated with 3 weeks of injection liposomal amphotericin B along with oral posaconazole 300 mg for 3-6 weeks. Post-operative histopathology noted fungal invasion of blood vessels in 19 cases and thrombus in 10 cases of orbital involvement. No mortality was reported in the study group. COVID variant associated thrombosis may be the reason for increased incidence of mucor mycosis in post COVID patients. Team work, appropriate guidelines and adequate supply of medications helped in achieving desired outcome.</p>

A multicentric observational study of imaging findings in COVID-19-related rhino-orbito-cerebral mucormycosis: a new Pandora\u2019s box

BackgroundThere is a sudden rise of fungal infection with corona virus disease. This is attributed to the immunomodulation by the disease and the drugs used, diabetes mellitus, steroid use, oxygen inhalation using dirty water, use of zinc and iron supplements, etc. Early diagnosis and prompt medical and surgical intervention is the mainstay of treatment. This can greatly reduce the high morbidity and mortality associated with this disease. The objective of the study is to describe the imaging findings of acute invasive rhino-orbito-cerebral mucormycosis (ROCM) in 25 patients with severe acute respiratory syndrome corona virus 2, from three different centers with proven mucormycosis. Special emphasis is placed on the signal enhancement patterns of sinonasal mucosa, the earliest and most common findings. Statistical analysis was performed using descriptive statistics.ResultsComputed tomography (CT) and magnetic resonance imaging (MRI) of 25 patients showed most commonly involved sinuses as maxillary and ethmoid sinuses (19, 76%) together. Sino-nasal mucosal thickening was the most common finding (24, 96%). Periantral infiltration (18, 72%) preceded before orbital (15, 60%), cerebral (5, 20%) and vascular (2, 8%) complications, with grossly intact bones. Sinus wall erosions were seen in only 2 patients (8%). Palatal (22%) and maxillary alveolar arch erosion (39%) were frequent findings. CT showed minimally enhancing hypodense soft tissue thickening as the predominant finding in involved areas, while MRI showed T1 and T2 iso- to hypointense mucosal thickening (62%) and intense (43%) and no (33%) contrast enhancement as the main finding.ConclusionsContrast enhanced MRI is better at demonstrating early mucosal abnormalities, turbinate necrosis, non-enhancing devitalized tissues, orbital apex involvement and intra-cerebral extension. Imaging findings of inflammatory tissue infiltration adjacent to the paranasal sinuses in premaxillary, retroantral fat, facial muscles, pterygopalatine fossa, temporal, infratemporal fossa and extraconal orbital fat along with typical patterns of sinonasal mucosal enhancement should raise the suspicion of acute invasive fungal etiology given the short duration of history and immunocompromised status. High incidence of periantral and orbital extension of the disease is suggestive of acute invasive form of fungal infection. Also the rapidly progressive inflammatory changes without much bone involvement should suggest the suspicion of ROCM. Bony, cerebral and vascular involvements are relatively late complications.

CT and MRI Findings of Invasive Mucormycosis in the Setting of COVID-19: Experience From a Single Center in India.

An increasing incidence of rhinoorbitocerebral mucormycosis (ROCM) among patients with COVID-19 has recently been reported in India. We report the imaging findings for 25 patients with COVID-19 and invasive ROCM at a single hospital in India. Findings included sinus wall erosions (n = 20), air within bony sinus structures (n = 11), and focal mucosal nonenhancement (n = 8). Orbital, vascular, and intracranial complications were also observed. Radiologists should recognize the increasing incidence of ROCM among patients with COVID-19 to facilitate early diagnosis.

Spectrum of intracranial complications of rhino-orbito-cerebral mucormycosis - resurgence in the era of COVID-19 pandemic: a pictorial essay.

Rhino-orbito-cerebral mucormycosis (ROCM) has regained significance following its resurgence in the second wave of the COVID-19 pandemic in India. Rapid and progressive intracranial spread occurs either by direct extension across the neural foraminae, cribriform plate/ethmoid, walls of sinuses, or angioinvasion. Having known to have a high mortality rate, especially with intracranial extension of disease, it becomes imperative to familiarise oneself with its imaging features. MRI is the imaging modality of choice. This pictorial essay aims to depict and detail the various intracranial complications of mucormycosis and to serve as a broad checklist of structures and pathologies that must be looked for in a known or suspected case of ROCM.

English

BACKGROUND Rhino-orbito-cerebral mucormycosis (ROCM) is a life-threatening infection caused by saprophytic fungi. The purpose of this study was to describe common radiographic patterns that may be useful in predicting the diagnosis and assessing the extent of involvement of rhino-orbito-cerebral mucormycosis in Covid and post Covid patients. METHODS The case records of patients with rhino-orbito-cerebral mucormycosis were reviewed. This included 200 patients of which 122 were males and 78 females, with a minimum age of 22 to a maximum of 80 years old. Computed tomography (CT) and / or magnetic resonance imaging (MRI) images were retrieved from the picture archiving and communication system (PACS) and analysed. Statistical analysis was performed using descriptive statistics. RESULTS All the patients showed sinusitis and ophthalmological symptoms. CT and MR imaging showed predominant involvement of the maxillary (196, 98 %) and ethmoid (194, 97 %) sinuses. Involvement of the orbit (186, 93 %) and face (114, 57 %) preceded involvement of the pterygopalatine fossa (90, 45 %) and brain (52, 26 %). CT showed minimally enhancing hypodense soft tissue thickening as the predominant finding in involved areas, while MRI showed T2 isointense to mildly hypointense soft tissue thickening and heterogeneous post-contrast enhancement as the main finding. In patients with extra sinus extension, bone erosion was seen in 80 patients (40 %) but few (20, 10 %) of the patients showed extension across grossly intact appearing bones. CONCLUSIONS In the context of Covid-19 with immunosuppression, a pattern of the nasal cavity, maxillary sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormycosis. Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents can occur. Multiplanar magnetic resonance imaging and computed tomography show anatomic involvement, helping in surgery planning. KEY WORDS Rhino-Orbito-Cerebral mucormycosis, Imaging Findings, MRI, Neuroradiology

Imaging findings in invasive rhino-orbito-cerebral mucormycosis in post–COVID-19 patients

Rhino-orbito-cerebral mucormycosis (ROCM) is a life-threatening addition to the COVID-19 disease spectrum and is caused by an angioinvasive saprophytic opportunistic fungus. Early diagnosis is important to avoid disease spread and mortality. Contrast-enhanced magnetic resonance imaging plays a major role in detection of intraorbital and intracranial extension. We present imaging findings of 15 patients with post-COVID-19 rhino-orbito-cerebral mucormycosis who were diagnosed with invasive sinus mucormycosis at our institution and are currently undergoing treatment. All patients were diabetics, and 80% had a history of steroid intake during the course of COVID-19 treatment. There was a male preponderance (73.3%). The maxillary sinus was most commonly involved (86.7%). Orbital and intracranial invasion was seen in 73.3% and 60% of patients, respectively. The presence of retroantral, facial, infratemporal, and orbital fat stranding was an early sign of extrasinus spread. Other common sites of extrasinus involvement were the orbit and face, followed by the orbital apex, masticator space, pterygopalatine fossa, bone, skull base, cavernous sinus, brain, and internal carotid artery. In conclusion, early detection of extrasinus spread of mucormycosis by imaging is important so that aggressive treatment can be given and mortality can be reduced.

Post-COVID-19 rhino-orbito-cerebral mucormycosis: a new addition to challenges in pandemic control.

ObjectiveTo document and analyse demographic data, clinical presentation, possible interventions for early clinical detection and management of post-COVID-19 rhino-orbito-cerebral mucormycosis (ROCM).Method32 patients having history of SARS-CoV-2 infection with features of ROCM were observed in terms of their history, presenting features, clinical, microbiological examination, type of surgical intervention, surgical sites of involvement which were subsequently analyzed.ResultsThe mean (± S.D.) age of patients was 57 ± 13 years. All patients were diabetic. Mean (± S.D.) time of onset of ROCM symptoms, since onset of COVID-19 symptoms was 18 (± 4) days. 12.5% patients were fully vaccinated. 78.1% patients received steroid therapy; 28.1% received high flow nasal oxygen. 87.5% patients had blurring of vision, 65.62% headache, 59.37% cheek and eyelid swelling, 50% proptosis, 46.87% ophthalmoplegia, 40.62% ptosis, 40.62% loss of sensation over cheek, 25% orbital pain. Examination of specimen with KOH mount revealed Mucor spp. in all patients. 87.5% patients underwent endoscopic sinus surgery with debridement with/without orbital clearance; 56.25% maxillectomy; 25% orbital exenteration. 87.5% patients had paranasal sinus involvement, 43.75% orbit sparing orbital apex, 68.75% orbit with orbital apex. 81.25% patients had involvement of pterygopalatine fossa±infratemporal fossa. 50% patients had disease in Vidian canal and pterygoid wedge. 25% of patients had involvement of palate and 56.25% cheek and eyelid soft tissues.ConclusionA judicious COVID treatment protocol, high index of suspicion, close monitoring of high-risk patients and early institution of treatment can prevent case severity and reduce mortality.

The ROC Staging System for COVID-related Rhino-Orbital-Cerebral Mucormycosis

ABSTRACT Purpose To report and validate an objective staging system for COVID-related Rhino-Orbito-Cerebral mucormycosis (ROCM). Methods Proof of concept of a new ROC staging system was devised for COVID-related ROCM. The staging system was based on data points drawn from a comprehensive ophthalmic examination, diagnostic endoscopy, and appropriate imaging of orbit, paranasal sinuses and brain in post-COVID ROCM patients to formulate the final staging expressed as R0−3O0−3C0−3. Each stage in the sinus, orbit and brain was graded into three levels of severity of disease. Progressive stages necessitated more active and urgent intervention and poorer prognosis. Finally, ten consecutive ROCM patients were independently staged by two blinded clinicians by examining clinical photographs and radiological images and the results matched for concordance. Results Each component of the staging: Rhino, Orbital, and Cerebral were graded 0–3 based on severity. Each stage was matched with a recommended management plan. The final ROC grading by two independent clinicians showed a high degree of concordance – maximum for orbit grade (100%) followed by brain (90%) and sinuses (80%). Overall R0−3O0−3C0−3 staging had 70% concordance. Extrapolation of final ROC staging of two clinicians showed 60% match. When we allowed for one-point difference in the ROC staging system the concordance between two clinicians improved to 100% and the management plan matched in 90%. Conclusion The proposed ROC staging system based on objectively defined clinico-radiological criteria of the three components of COVID-related ROCM is simple-to-use and has high concordance when validated by independent clinicians. The staging helps devise a management plan and has prognostic value.

Rhino Orbito-Cerebral Mucormycosis Prevention and Treatment guidelines in Covid-19 Pandemic- an E.N.T. Perspective

Mucormycosis (sometimes called zygomycosis) is a serious fungal infection caused by a group of moulds called mucormycetes. These fungi live throughout the environment, particularly in soil and in decaying organic matter, such as leaves, compost piles, or rotten wood. People get mucormycosis by coming in contact with the fungal spores in the environment. For example, the lung or sinus forms of the infection can occur after someone breathes in spores.

Managing mucormycosis in diabetic patients: A case report with critical review of the literature

Rhino-orbito-cerebral mucormycosis (ROCM) is a rare and potentially fatal invasive fungal infection which usually occurs in diabetic and other immunocompromised patients. This infection is associated with high morbidity and mortality rates. Prompt diagnosis and rapid aggressive surgical debridement and antimycotic therapy are essential for the patient's survival. Herein, we reviewed the localization and treatment strategies in patients with ROCM and diabetes as an underlying condition. Furthermore, we report one case of ROCM in our department. From 117 identified studies published in PubMed, 14 publications-containing data from 54 patients-were included. All patients were diagnosed clinically and by histopathological and/or bacteriological analysis for ROCM caused by the order Mucorales. Uncontrolled diabetes mellitus is one of the main risk factors for ROCM. A successful management of ROCM requires an early diagnosis, a prompt systemic antifungal therapy, and a rapid aggressive surgical debridement including exploration of the pterygopalatine fossa. An orbital exenteration may be necessary.

Diabetes and rhino-orbito-cerebral mucormycosis - A deadly duo.

Rhino-orbito-cerebral mucormycosis(ROCM) is an uncommon yet potentially fatal fungal infection predominantly seen in immunocompromised individuals. However, there is very limited data available from India regarding outcome of patients with ROCM and diabetes mellitus. To ascertain clinical parameters and factors in the final outcome of patients with diabetes mellitus and ROCM. This series included retrospective analysis of medical records of 91 patients with diabetes mellitus who were diagnosed with ROCM from january 2007 to june 2019at a tertiary care hospital in Punjab. The mean age of patients was 52.6years (range 18-82years), with men constituting the majority (71.4 %). Ophthalmoplegia was the most frequent presenting feature seen in 77 % of patients followed by proptosis (71 %). Intracranial involvement was seen in 20 % of the patients and cavernous sinus thrombosis was diagnosed in 9(10 %) patients. Out of 91 patients, 81 patients were subjected to appropriate surgical procedure depending upon site and extent of involvement by mucorales. A total of 53 (58.2 %) patients survived while 38(41.8 %) patients succumbed. Delay in presentation to hospital, intracranial extension and loss of vision at presentation adversely affected the outcome (p < 0.05). Aggressive surgical management in the form of multiple debridements was superior to single debridement (p < 0.05). Diabetic ketoacidosis did not significantly affect the outcome (p = 0.359). ROCM in patients with diabetes mellitus, is a rapidly progressive disease with a high fatality rate and grave outcome unless diagnosed early and managed aggressively.

A Rare Case of Rhino Orbito Cerebral Mucor Mycosis Associated with COVID 19 Infection

A Rare Case of Rhino Orbito Cerebral Mucor Mycosis Associated with COVID 19 Infection

Rhino-Orbito-Cerebral Mucormycosis: An Audit.

This study aims at identifying the predisposing factors, clinical and radiological features that dictated the treatment outcome of Rhino-orbito-cerebral mucormycosis (ROCM). This is a retrospective observational study. Medical records of 39 patients with ROCM proven by fungal smear or histopathology (HPE), admitted in Sri Ramachandra Institute of Higher Education and Research from Jan 2015 to Dec 2019 were reviewed and audited. The mean age of the patients was 52.6years and they were predominantly men (76.9%). There is a statistically significant association between uncontrolled diabetes and increasing severity of the disease in this study and an important cause of mortality. Fungal smear and HPE plays a crucial role in diagnosis. Radiological evaluation helps in identifying the extent of spread and in this study 31% of patients had intraorbital and 20% had intracranial extension. In-hospital mortality was 13%. Our results showed better outcome when combined medical and surgical intervention was undertaken. Rhino-orbito-cerebral Mucormycosis is a rapidly spreading invasive fungal infection with significant mortality and morbidity. Early diagnosis and proactive surgical and medical intervention is crucial for better outcome. Hence the clinician should be highly alert to certain subtle clinical signs and radiological features in a diabetic patients for improving the treatment outcomes and avoiding potentially fatal complications.

Rhino-Orbito-Cerebral Mucormycosis in Diabetic Disease Mucormycosis in Diabetic Disease.

The authors present their experience about clinical evidences that include patients with an untreated diabetes who developed rhino-orbito-cerebral mucormycosis (ROCM). They were treated with endoscopic sinus surgery and medical treatment with intravenous, intradural therapy, and sinus washes with amphotericin B. The ROCM is a disease with a rapid evolution and an increase in mortality rate, especially if the fungus enters the cranial cavity. Therefore, it would be necessary in all diabetic patients with sinus symptoms, headaches, visual changes, suspect a mucormycosis, and perform a careful radiology assessment and a nasal endoscopy. Often, despite an early diagnosis and rapid treatment for ROCM, it is not possible to stem the disease, which ends with the patient's death.

Diabetic versus non‐diabetic rhino‐orbito‐cerebral mucormycosis

To compare the characteristics and outcomes of rhino-orbito-cerebral mucormycosis (ROCM) in diabetic versus non-diabetic patients. It is a retrospective comparative case series on consecutive patients with biopsy-proven ROCM. Systemic and ophthalmic manifestations, imaging, management and final outcomes were compared between diabetic versus non-diabetic ROCMs referred the eye clinic of a university-based hospital (2008-2016). Forty-three diabetics (55 eyes) with mean age of 54.6 (SD:12.5) years and 20 non-diabetics (24 eyes) with mean age of 57.5 (SD:13.8) years were enrolled. Patients' survival was observed in 51% of diabetics and 70% of non-diabetics (P=.1). The mortality rate was 7.4 times (CI95%: 1.85-29.96) higher in diabetic ROCM treated with non-liposomal amphotericin (P=.01). Exenteration did not significantly change the mortality rate in either group. Globe survival was 40% and 50% in diabetics and non-diabetics (P=1), respectively. Vision survival was observed in 20% of diabetics and 37% of non-diabetics (P=.2). Patients', globe and vision survivals were not different between diabetic and non-diabetic patients with ROCM. They were 51%, 40% and 20% in diabetic and 70%, 50% and 37% in non-diabetic ROCM.

Multi-disciplinary Approach in Management of Rhino-orbito-cerebral Mucormycosis in Resource-poor Setting in Sub-saharan Africa: A Case Report

Rhino-orbito-cerebral mucormycosis (ROCM) is an uncommon acute aggressive fungal infection occurring in several immunocompromised states including diabetes which is the most common predisposing factor. In this case report we present the clinical finding, therapeutic challenges and outcome in a 44 years old male type II diabetic patient. Patient first presented to the ortorhinolaryngologist with complaints of nasal discharge, postnasal drip, cough, hyposmia, facial pains, and intermittent nasal obstruction. He had bilateral intranasal antrostomy, upon X-ray confirmation of homogenious opacity of the left maxillary antrum and mucosal thickening of the right antrum. Fungal study of the specimen revealed mucormycosis. Six months later he presented with perception of light (PL) vision in the right eye and non-perception of light (NPL) in the left eye. There was mild lid edema in the right eye. There was marked proptosis associated with external ophthalmoplegia suggestive of orbital apex syndrome. The conjunctiva was keratinized and the cornea necrotic and opaque. The left eye enucleation and nasal exploration were done. The patient objected to taking amphotericn B, the drug of choice for this condition because of his previous adverse reaction experience to the drug. Posacornazole, the second line drug could not be assessed, posing a great therapeutic challenge in the effective management of this case. The patient was later referred for neurosurgical management but was reported to have died at a tertiary health facility in Abuja.