Rhino-orbital Mucormycosis Research Articles

Microbiology Profile of COVID-19-Associated Rhino-Orbital Mucormycosis Pathogens in South India.

This study describes the microbiological and histopathological features of patients with COVID-19-associated rhino-orbital mucormycosis (ROM) seen at the L V Prasad Eye Institute between May and August 2021. Diagnosed clinically and radiologically, 24 patients with ROM were included in the study. Deep nasal swabs or endoscopically collected nasal swabs or orbital tissues were submitted for microbiological evaluation and invitro susceptibility testing by microbroth dilution for natamycin, amphotericin B, caspofungin, posaconazole, ketoconazole, and voriconazole. Cultures were processed by 28S ribosomal DNA polymerase chain reaction and molecular sequencing. A portion of orbital tissues was also sent for histopathological evaluation. The age of the patients ranged from 27 to 75 (mean 48.58 ± 14.09) years and the majority (79%) were male. Nineteen patients were known to be diabetic prior to developing ROM and 18 patients had recovered from active COVID-19 infection. Thirteen patients had a history of hospitalization during COVID-19 infection and eight received steroids. Of the 24 samples, microbiological evaluation identified Rhizopus arrhizus in 12, Rhizopus microsporus in 9, Lichtheimia ramosa in 2, and Rhizopus delemar in 1. Twelve isolates were tested for antifungal susceptibility and all were susceptible to natamycin and amphotericin B. The susceptibility to posaconazole was high, with minimum inhibitory concentration (MIC) < 2 µg/mL for 10/12 (84%) isolates, whereas the MIC of other drugs varied. Histopathological examination of tissues showed acute fulminant disease, granuloma formation, and vascular invasion by the fungal pathogens in these specimens. Rhizopus arrhizus was predominantly associated with ROM and most isolates were susceptible to amphotericin B and posaconazole. Further studies are needed to corroborate the findings and explain possible underlying links.

A Rare Case of Rhino-orbital Mucormycosis with Intracranial Tuberculosis in Latent Post Coronavirus Disease 2019 Diabetic Patient

A Rare Case of Rhino-orbital Mucormycosis with Intracranial Tuberculosis in Latent Post Coronavirus Disease 2019 Diabetic Patient

Isolated Lower Motor Neuron Facial Nerve Palsy as a Presenting Sign in COVID-19 Associated Orbital Mucormycosis Patients: A Retrospective Observational Study

Purpose: The main purpose of this study is to emphasize that isolated facial nerve involvement can be the first presenting symptom in patients suspected of COVID-associated Mucormycosis (CAM). Methods: This study is a retrospective observational study conducted at a tertiary care referral center which included patients with a history of CAM, who presented with isolated facial nerve palsy as initial presentation between March 2021 to March 2022 along with their follow-up. All the patients were managed with combined modality treatment with antifungal therapy and debridement of the necrotic tissue and fungal debris. Results: There were 184 eyes of 148 patients diagnosed with CAM. All patients developed rhino-orbital mucormycosis (ROM) following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36±23 days. 42(28%) patients presented with isolated Facial Nerve Palsy (FNP) as the initial presentation. The mean age was 48.5 years (range 38 to 67years) with a male predominance of 29 (69%). All were unilateral cases and were of Lower motor neuron type presentation. All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. At a mean follow-up of 13.1 months, 19 (45%) of the patients had improvement in Facial Nerve function and 23 (55%) had static functioning. None of them had worsened. With medical intervention and tarsorrhaphy, the corneal condition was improved in all patients. Conclusion: Isolated FNP is an unusual but important sign in the presentation of mucormycosis which can be misdiagnosed with a cerebrovascular accident leading to delay in the management. This is a large case series with isolated FNP in CAM cases. A high index of suspicion for mucormycosis in diabetic patients presenting with isolated facial palsy can save the life and salvage the eye.

FREQUENCY AND OUTCOMES OF RHINO-ORBITAL MUCORMYCOSIS DURING COVID-19 INFECTION: EXPERIENCE FROM A TERTIARY CARE CENTER OF KPK

Aim: To study frequency and outcomes of rhino-orbital mucormycosis during COVID-19 infection in a tertiary care setup of KPK.&#x0D; Study Design: Retrospective cross-sectional study&#x0D; Settings and Duration: At Rehman Medical Institute, Peshawar from 1st September 2020 to 30th April 2021 (8 months).&#x0D; Materials and Methods: After taking informed consent and relevant approvals, all patients fulfilling the inclusion criteria underwent history taking to identify risk factors, clinical examination to find extent of infection and laboratory and radiological investigations to diagnose and find management plan. Data readings were save on Excel sheets and analyzed using SPSS v.25.0. &#x0D; Results: Among 59 patients, 37 (62.71%) were male and 22 (37.29%) female. Most of the patients (42.37%) fell between age category of 61-75 years. Overall 42 (71.18%) patients survived. Orbital involvement was present in 40 (67.80%) patients and 20 (33.89%) had to underwent exenteration. Among comorbidities, diabetes was most prevalent in 38 (64.40%) followed by hypertension in 11 (18.64%) while 7 (11.86%) patients had no co-morbid state.&#x0D; Conclusion: Rhino-orbital mucormycosis is very common superadded infection in patients suffering from COVID-19 and involves males more than the females. Most of the mucormycosis patients are either diabetics or on corticosteroids therapy for COVID-19. Orbital involvement in mucormycosis eventually happens in majority of patients and up to one third patients may need exenteration. However, strict diabetes control, judicious use of steroids and early diagnosis and treatment of mucormycosis may increase overall survival rate.

Review on mucormycosis – A gloom epoch

Mucormycosis recently known with the term as black fungus belongs to the Zygomycetes family. It is a filamentous non-septate fungus. Mucormycosis is not a novel disease, although it is becoming more well-known as a result of the extensive transmission of COVID-19-associated mucormycosis. COVID-19 is currently undergoing a catastrophic phase, which is being exacerbated by the devastating spread of mucormycosis. Mucormycosis identifies the target site by exploiting conditions such as immunocompromised health, steroid therapy, and diabetes that predispose patients to infection. Mucormycosis is more prevalent in India due to the relatively high percentage of diabetics in the population causing cutaneous mucormycosis, pulmonary mucormycosis, rhino-orbital cerebral mucormycosis, and gastrointestinal mucormycosis. It is a potentially fatal condition, and this review will provide an overview of the causative organism and its effects on human lives.

Clinical features, diagnosis, and treatment outcome of Rhino-orbito-cerebral mucormycosis: A 2-year experience at a tertiary care center

ABSTRACT Context: The incidence of the fungal disease, mucormycosis, is showing a steady increase among the Indian population in recent past years. Considered as a form of acute invasive fungal rhinosinusitis, the disease is characterized by high morbidity and mortality rates. Aims: The aim of this study was to study the clinical presentations, species distribution, and treatment outcomes in patients of rhinomucormycosis. Settings and Design: This was a tertiary care hospital-based case series. Subjects and Methods: The study was carried out between June 2018 and February 2020. All laboratory-confirmed cases of rhinomucormycosis were included in the study population. Results: Sixteen cases of histopathologically and microbiologically confirmed cases of rhinomucormycosis were included in the study. The study population included ten females and six males. Diabetes mellitus was found to be the most common comorbid condition in the study group (81.25%). Among the study group, swelling of cheek and thick blood-stained discharge were the most common presenting symptoms (9 cases out of 16). The most common clinical type was rhino-orbital mucormycosis. Rhizopus was the most common species encountered (87.5%). In spite of utmost care, treatment outcome was not favorable in most of the cases. Conclusion: An early diagnosis of mucormycosis in the background of immunocompromised status can help in initiating appropriate treatment, thereby reducing the morbidity and mortality associated with this disease condition.

Vitamin A Deficiency, COVID-19, and Rhino-Orbital Mucormycosis (Black Fungus): An Analytical Perspective.

Mucormycosis is a rare but serious opportunistic fungal disease characterized by rhino-orbito-cerebral and pulmonary involvement. It is mainly seen in people with secondary immunosuppression, isolated vitamin A deficiency, measles, and AIDS patients. It showed a rise during the second wave of the COVID-19 epidemic in the spring of 2021 in India, especially in diabetic COVID-19 patients. Vitamin A deficiency is known to cause nutritional immunodeficiency and hence leading the way to increased opportunistic fungal, bacterial, and viral infections. In the eye, it causes keratitis, night blindness, xerophthalmia, conjunctivitis, Bitot spots, keratomalacia, and retinopathy. It also causes decreased tear secretion and deterioration of the anatomical/physiological defense barrier of the eye. The negative impact of vitamin A deficiency has been previously demonstrated in measles, AIDS, and COVID-19. We think that mucormycosis in COVID-19 might be rendered by vitamin A deficiency and that vitamin A supplementation may have preventive and therapeutic values against mucormycosis and other ocular symptoms associated with COVID-19. However, any vitamin A treatment regimen needs to be based on laboratory and clinical data and supervised by medical professionals.

Transcaruncular medial orbitotomy: A globe sparing intervention in management of COVID associated mucormycosis [CAM

To describe a novel method of transcaruncular medial orbitotomy, local debridement and amphotericin B irrigation into orbit for COVID-19-associated rhino-orbital mucormycosis. Also to evaluate its its outcome in controlling the disease, increasing the survival rate and as a globe-sparing intervention in them. A total of ten COVID-19-associated mucormycosis patients with clinical and radiological evidence of orbital involvement with necrotic tissue localized in medial orbit were considered for our study. A transcaruncular modified medial orbitotomy with medial and inferomedial orbit debridement was done along with placement of scalp vein catheter by a single surgeon. Postoperatively 3.5 mg/ml liposomal amphotericin B irrigation through the catheter was done for 5 sittings. Correction of underlying systemic conditions and intravenous antifungals were given. Clinical response to the procedure was noted on postoperative week 1, week 4, and 3rd month (week 12). The mean age group was noted to be 49.9 years with a male: female ratio of 2.3:1. All patients were diabetics with 5 being newly detected diabetes after COVID infection. All the ten patients showed significant clinical improvement at the first follow-up (week 1). Five patients at 1st month showed clinical and radiological improvement, while one patient had worsening of orbital disease for which exenteration was done. Three patients succumbed to the disease due to altered cardiopulmonary status and 1 patient was lost to follow-up. All 6 survived patients were stable till the last follow-up. Hence, mortality rate accounted to 30% and globe survival of 40% in the current study. Transcaruncular approach to orbit for adequate debridement combined with amphotericin irrigation is a novel technique that can be considered for compartmental involvement of orbit in mucormycosis. Debridement removes the necrotic tissue, while local amphotericin irrigation directly reaches the target tissues that effectively halts the disease progression and hence can be considered an effective globe-sparing intervention without affecting the disease outcome.

Rhinoorbital mucormycosis in patients with the post-COVID syndrome. Clinical and morphological features

Rhinoorbital mucormycosis in patients with the post-COVID syndrome. Clinical and morphological features

Adding insult to injury: Fatal rhino-orbital mucormycosis eventuating in cutaneous involvement post-SARS-COV2 infection in a young female

Adding insult to injury: Fatal rhino-orbital mucormycosis eventuating in cutaneous involvement post-SARS-COV2 infection in a young female

Recurrent rhino-orbital mucormycosis in post-COVID-19 patients – A case series

Recurrent rhino-orbital mucormycosis in post-COVID-19 patients – A case series

Clinical study and outcome of rhino-orbital mucormycosis patients

Clinical study and outcome of rhino-orbital mucormycosis patients

An Unconventional Presentation of Mucormycosis in a 10-Year-Old Child: A Case Report

Since the Coronavirus Disease (COVID-19) pandemic, there have been several unusual presentations of mucormycosis in India, especially amongst immune-competent adults. COVID-19 infection has been found to have profound effects on the patient’s immunity and some patients, though asymptomatic for COVID-19, can be infected by mucormycosis and develops dangerous complications. Skin involvement of the orbital, zygomatic and maxillary areas is a common occurrence in extensive cases of rhinoorbital mucormycosis, however, isolated involvement of the alar skin is an extremely rare occurrence in such patients. Paediatric cutaneous mucormycosis is by itself a rare entity, seen majorly in children with history of allogeneic hematopoietic stem cell transplantations, chemotherapeutic treatment, or patients with human immunodeficiency virus infections, herpes and other lifethreatening viral infections. Patients receiving long-term steroid therapy are also predisposed to invasive fungal infections. This case was about a 10-year-old boy presented with a black crusted lesion over the nose to the otolaryngology outpatient department. The patient had history of contact with a COVID-19 positive individual. Examination revealed a necrotic patch over the palate and Non Contrast CT Scan of (NCCT) the paranasal sinuses showed pansinusitis. A KOH mount showed fungal elements and the patient underwent emergency debridement of nasal skin with endoscopic sinus and palatal debridement. Injectable liposomal Amphotericin-B was started. Over a period of one month, the patient showed significant clinical improvement. Though rare, sinonasal mucormycosis can present in the form of a cutaneous lesion which is an unconventional symptom. A general awareness amongst healthcare professionals, with a multidisciplinary approach, timely diagnosis and specialist intervention can improve outcomes in this sinister disease.

Rehabilitation of patient using a patient-specific implant with bar-retained maxillary obturator and orbital prosthesis postoperated rhino-orbital mucormycosis

ABSTRACT The “black fungus” or Mucor mycosis affected a significant number of COVID patients during the pandemic. Aggressive surgical intervention of these cases resulted in large palatal &amp; orbital defects that required prosthetic rehabilitation. This is a painstaking process due to compromised retention and minimum residual bone. In this dental centre, two case was rehabilitated with 3D printed titanium patient specific implants (PSI) followed by prosthetic rehabilitation.A 36-year-old male diabetic COVID patient was diagnosed with mucormycosis and underwent right orbital exenteration &amp; maxillectomy. Upon recovery, a PSI was designed and 3D printed to provide support for orbital and maxillary prosthesis. PSI was fixed to the orbital rims and remaining zygomatic bone for supporting the prostheses and Bar-clip retained prostheses were fabricated using the conventional method.During COVID-19 pandemic, patients who contracted Mucormycosis had a poor prognosis with conventional prostheses since all the supporting structures had been affected by the infection. Conventional prostheses for maxillofacial defects do not have adequate supporting hard &amp; soft tissues to provide retention and support. The PSI with Bar retained protheses have been selected as a treatment option for such types of defects.PSIs can be valuable aids in rehabilitating patients with large maxillofacial defects.

A retrospective clinicopathological analysis of rhino-orbital mucormycosis in second wave of COVID-19.

During the present surge of COVID-19 positive cases, concurrent multifold increase in the incidence of mucormycosis cases has resulted into significant morbidity and mortality. We retrospectively evaluated the clinicopathological features along with microbiological examination findings in histologically diagnosed cases of rhino-orbital mucormycosis. All the H and E and special stained slides of included mucormycosis cases were retrieved from the records and were evaluated with microbiological findings including screening KOH mount examination and culture results. Out of 16 cases with available details, 10 cases had the previous history of diabetes mellitus. The most frequent single site of involvement was maxillary sinus (7/25) followed by nasal cavity, orbit, ethmoid and sphenoid sinuses. While comparing the histological diagnosis with KOH mount findings and culture results, 15 cases revealed consistent results. A high clinical suspicion, monitoring, early diagnosis, and timely management can improve the morbidity and mortality of this life-threatening complication.

AN INSTITUTIONAL STUDY ON COVID-19 ASSOCIATED RHINO-ORBITAL-CEREBRAL MUCORMYCOSIS

Background: Prior to the COVID-19 pandemic, the prevalence of mucormycosis in India was approximately 0.14 cases per 1000 population. With the second wave of the COVID-19 pandemic, there has been a tremendous increase in the number of Rhino-Orbital mucormycosis cases with a high mortality of 30.7%.This paper discusses the institutional experience of 67 cases of rhino–orbital–cerebral mucormycosis related to COVID-19 infection. Methods: In this case series, 67 proven cases of COVID-19 associated rhino-orbital-cerebral mucormycosis were analyzed retrospectively from April 2021 to March 2022. Clinical profile of all the patients were studied for signs and symptoms at presentation, possible risk factors and comorbidities. Microbiological and imaging studies was done in all patients and taken up for surgical management which included open or endoscopic debridement, maxillectomy, orbital decompression, orbital exenteration etc. Postoperatively patients were started on parenteral antifungal and discharged on oral antifungal after repeat imaging and endoscopy to rule out residual or recurrent disease. Results: The mean age of presentation was 49.1 years. Diabetes and use of steroids during covid treatment was seen in 91% and 83.5% of cases respectively. Unilateral headache and nasal obstruction were the most common symptoms. Open debridement using Weber Ferguson incision and medial maxillectomy was the most common surgical approach followed in our institution with good recovery and less chances of need for revision surgery. Conclusion: Timely diagnosis and intervention in the form of thorough surgical debridement and antifungal therapy are critical aspects in improving clinical outcomes in such patients.

Risk Factors of Rhino Orbital Mucormycosis.

To determine the clinical presentation and risk factors associated with rhino orbital mucormycosis. Mucormycosis is a rapidly progressive fungal infection caused by filamentous fungi in the Mucoraceae family. In large numbers, they release spores into the air, and humans get exposed through inhalation. The spores inoculate in the paranasal sinuses and nasopharynx and subsequently spread to the orbit and intracranial cavity. The present COVID-19 pandemic has witnessed a resurgence of rhino-orbital mucormycosis cases, mainly seen in patients with immunocompromised status. Hence, our study evaluated the risk factors and clinical features of rhino orbital mucormycosis. This was a prospective, single-center, cross-sectional study. Patients attending tertiary care centers fulfilling the inclusion criteria were evaluated with a detailed history including sociodemographic profile, occupation, history of fever, COVID-19 infection, steroid or immunosuppressant use, organ transplants, diabetes mellitus and use of oxygen (O2). A complete ophthalmic evaluation was performed, including best-corrected visual acuity, anterior segment evaluation with slit lamp biomicroscopy, and posterior segment evaluation using indirect ophthalmoscopy. Computed Tomography (CT) scan of paranasal sinuses was done for all the patients, and Magnetic Resonance Imaging (MRI) for a few patients if indicated. Intraoperatively, samples were sent for Potassium Hydroxide (KOH) stain while debridement and patients with positive results were included in the study. Forty participants were included, out of which 34 (85%) were males and six (15%) were females. The mean age of the patients was 51.75 years. Out of 40 patients, 29 (72.5%) had h/o COVID-19 infection, 30 (75%) were known type 2 diabetes mellitus, 25 (62.5%) had a h/o steroid intake and 25 (62.5%) had a history of O2 use. 17 (42.5%) patients presented with low vision, out of which 15 had no light perception. 30 (75%) patients had ptosis, 22 (55%) patients presented with proptosis, 15 (37.5%) patients had limited ocular motility, 11 (27.5%) had complete ophthalmoplegia, and 11 (27.5%) patients had central retinal artery occlusion. Rhino orbital Mucormycosis is more prevalent in patients with COVID-19 infection, especially those who have used steroids and oxygen and with type 2 diabetes mellitus. Early presentation with treatment can prevent further ocular morbidity.

Manifestations of Mucormycosis and Its Complications in COVID-19 Patients: A Case Series Study.

Mucormycosis is an opportunistic fungal disease that affects immunocompromised patients. With the advent of SARS-CoV-2, this opportunistic disease has increased. A case series of 47 patients with COVID-19 associated mucormycosis have been analyzed. Demographic information, signs, symptoms, laboratory investigations, imaging studies, and their association with ICU admission and 30-day mortality were assessed. Total number of 47 consecutive rhino-orbital cerebral mucormycosis (ROCM) cases were analyzed. Periorbital swelling was the most common sign among patients. Majority of cases had diabetes. All patients received liposomal Amphotericin B. Debridement was performed for all cases. SARS-CoV-2 increases the susceptibility to mucormycosis infection in various ways. Uncontrolled level of HbA1c in all patients, even non-diabetic individuals, indicates hyperglycemia over the past three months. Diabetes, orbital exenteration, ptosis, periorbital swelling, DKA, LOC, brain involvement, and mechanical ventilation all correlated with a higher rate of ICU admission and 30-day mortality. In addition, a higher white blood cell count is related to the higher probability of ICU admission. While considering all of the inflammatory laboratory data and HbA1c could help predict 30-day mortality.

Successful Treatment of Acute Invasive Rhino-Orbito-Cerebral Mucormycosis Associated with COVID -19: Case Report and Literature Review

Background and Aim: Mortality associated with post-coronavirus disease 2019 (COVID-19) rhino-orbital cerebral mucormycosis (ROCM) is an evolving concern. Association of COVID-19, corticosteroid therapy, and uncontrolled diabetes mellitus (DM) are considered predisposing factors for ROCM. We present two cases of successful treatment leading to patient survival for post-COVID-19, stage 4c-ROCM. Case Presentation: Two middle-aged men with poorly controlled DM were referred to our hospital for post-COVID-19 ROCM. They had received intravenous antivirals and dexamethasone as treatment in a primary center. Both patients had unilateral oculofacial pain and swelling followed by acute visual loss, unilateral proptosis, facial palsy, and trigeminal hypoesthesia. A computed tomography scan revealed opacity and bony erosion of paranasal sinuses (PNS). Obtained specimens confirmed mucormycosis agent on histopathological examination. After the failure of conservative treatments, retrobulbar injections of liposomal-amphotericin B, PNS debridement, and orbital exenteration, both patients developed blurred consciousness owing to the extension of the infection into the intracranial cavity. Brain magnetic resonance imaging revealed a right frontal lobe abscess in case 1 and a left frontal sinus abscess and involvement in case 2. Both underwent transcranial debridement and resection of necrotic tissue and drainage of the abscess. At follow-up, the patients were in good condition, and the fungal cultures were negative for mucormycosis agents. Conclusion: ROCM may be a complication of COVID-19 in high-risk patients. Control of the patient’s underlying systemic condition and prompt treatment with antifungal agents, along with timely aggressive resection of cerebral abscess and necrotic paranasal tissues, are the mainstays of management for ROCM.

Effects of SARS-Cov-2 infection and rhino-orbital mucormycosis on concentrations of inflammatory biomarkers in Indian populations

Rhino-orbital mucormycosis is a rare life threatening invasive fungal infection that has recently shown a very high mortality rate in India during COVID-19 pandemic. We have designed the present study to find out associations between COVID-19 induced rhino-orbital mucormycosis and concentrations of inflammatory markers, i.e. D-dimer, Ferritin, IL-6, CRP and PCT, in blood serum of Indian population.There were four groups in the study, viz. control group with healthy subjects, treatment group-1 with patients suffering from SARS-COV-2 infection, treatment group-2 with patients suffering from both SARS-COV-2 infection and rhino-orbital mucormycosis, and treatment group-3 with patients suffering from rhino-orbital mucormycosis after SARS-COV-2 infection recovery. Inflammatory markers were quantified with standard protocols, and recorded data were subjected to statistical analyses.We found that patients suffering from SARS-COV-2 infection were more susceptible to rhino-orbital mucormycosis, as they had higher concentrations of inflammatory markers in their blood than the other subjects. Diabetes mellitus, hypertension, cardiovascular diseases and renal disorders were the associated comorbidities with the patients. We also found higher concentrations of inflammatory markers in males than the females, indicating towards their higher susceptibility in developing rhino-orbital mucormycosis than females. Present study therefore suggests that the frequent occurrence of rhino-orbital mucormycosis in India during second wave of COVID-19 was possibly due to indiscriminate use of corticosteroids by COVID-19 patients. Subjects with previous history of comorbidities like diabetes mellitus, hypertension, cardiovascular disorders and renal diseases are the most susceptible population groups for developing infection. Moreover, males are at higher risk of developing mucormycosis than the females.