Mucocutaneous manifestations of COVID-19-associated mucormycosis: A retrospective cross-sectional study

Background: Cutaneous mucormycosis has shown a significant upsurge during the COVID-19 pandemic. Due to the rapid progression and high mortality of cutaneous mucormycosis in this context, it is important to identify it early. However, very few studies report detailed clinical descriptions of cutaneous mucormycosis in COVID-19 patients. Objectives: To describe mucocutaneous lesions of COVID-19-associated mucormycosis based on clinical morphology and attempt to correlate them with radiological changes. Methods: A retrospective cross-sectional study was conducted at a tertiary care centre from 1st April to 31st July 2021. Eligibility criteria included hospitalised adult patients of COVID-19-associated mucormycosis with mucocutaneous lesions. Results: All subjects were recently recovering COVID-19 patients diagnosed with cutaneous mucormycosis. One of fifty-three (2%) patients had primary cutaneous mucormycosis, and all of the rest had secondary cutaneous mucormycosis. Secondary cutaneous mucormycosis lesions presented as cutaneous-abscess in 25/52 (48%), nodulo-pustular lesions in 1/52 (2%), necrotic eschar in 1/52 (2%) and ulcero-necrotic in 1/52 (2%). Mucosal lesions were of three broad sub-types: ulcero-necrotic in 1/52 (2%), pustular in 2/52 (4%) and plaques in 1/52 (2%). Twenty out of fifty-two patients (38%) presented with simultaneous mucosal and cutaneous lesions belonging to the above categories. Magnetic resonance imaging of the face showed variable features of cutaneous and subcutaneous tissue involvement, viz. peripherally enhancing collection in the abscess group, “dot in circle sign” and heterogeneous contrast enhancement in the nodulo-pustular group; and fat stranding with infiltration of subcutaneous tissue in cases with necrotic eschar and ulcero-necrotic lesions. Limitations: The morphological variety of cutaneous mucormycosis patients in a single-centre study like ours might not be very precise. Thus, there is a need to conduct multi-centric prospective studies with larger sample sizes in the future to substantiate our morphological and radiological findings. Conclusions: COVID-19-associated mucormycosis patients in our study presented with a few specific types of mucocutaneous manifestations, with distinct magnetic resonance imaging findings. If corroborated by larger studies, these observations would be helpful in the early diagnosis of this serious illness.

Extensive meningoencephalitis, retrobulbar neuritis and pulmonary involvement in a patient of neurobrucellosis.

We report an unusual case of neurobrucellosis who presented with headache, vision loss, confusional state, retrobulbar neuritis and left hemiparesis. Neuroimaging studies showed features of ischemic infarct and white matter abnormalities. Pulmonary involvement in form of lobar pneumonia of left basal lobe was another unusual manifestation. Diagnosis was based on the rising titers of antibrucella antibody. Patient showed remarkable improvement on triple drug therapy in form of doxycycline, rifampicin and streptomycin.

Diagnostic criteria for neurocysticercosis: some modifications are needed for Indian patients.

In India and other less developed countries the diagnosis of neurocysticercosis is frequently difficult because several other prevalent neurological disorders can present with a similar clinical and neuroimaging picture. Currently available international criteria seem to be helpful for the diagnosis of neurocysticercosis, however, these criteria have been criticized for not being effective in differentiating several other infective and neoplastic diseases of central nervous system (CNS), like CNS tuberculosis, from neurocysticercosis. In this article, modifications in the recent diagnostic criteria given by Del Brutto et al (2001) are being suggested, so, it can become more suitable for Indian patients. In India the overwhelming majority of patients with neurocysticercosis have either single enhancing or less frequently multiple enhancing CT lesions. Imaging and clinical features of various infective conditions, like tuberculoma, fungal granuloma, and parasitic granuloma, and of neoplastic conditions like cerebral metastasis, are remarkably similar. Keeping this in mind, the modification suggested in this article is to replace epidemiological criteria with the section diagnosis of neurocysticercosis with caution in certain situations. These situations are middle or old age, evidence of pre-existing tuberculosis or malignancy, pre-existing HIV infection and in patients with grossly abnormal neurological examination. In these situations, in the absence of one of the absolute criteria, it should be essential to consider and exclude all other likely possibilities before making a diagnosis of neurocysticercosis. However, because of the high prevalence of several disorders with similar features it is difficult to make reliable diagnostic criteria for neurocysticercosis, which are easy to use, and have a high specificity and sensitivity.

Refractory epilepsy: diagnosis and management.

Persistence of seizures despite appropriate medical treatment is called refractory epilepsy. Persistent seizures have enormous psychosocial, behavioural and cognitive effects in addition to effects on mortality. Almost 2,40,000 to 3,20,000 patients of refractory epilepsy in India are potential candidates for epilepsy surgery. Causes of refractory or intractable epilepsy are inadequate anti-epileptic treatment, difficulty in treating some epileptic syndromes and difficulty in controlling seizures due to structural brain diseases. Careful evaluation of historical details, especially based on an eyewitness account is the most important aspect in establishing the diagnosis of epilepsy. Raised serum prolactin level helps in differentiating convulsive seizures from non-epileptic convulsions. Video electroencephalographic monitoring is proved effective and efficient mean to establish the rightful diagnosis. Recent developments in neuro-imaging have revolutionised the diagnosis of underlying pathology in patients with refractory epilepsies. Patients with refractory epilepsy should be referred to a specialised epilepsy centre where facilities for epilepsy surgery are available. When medical therapy fails, other options are helpful like use of newer anti-epileptic drugs, vagus nerve stimulation or consideration of epilepsy surgery.