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Objectives: Diabetes mellitus (DM) seems the most common predisposing factor for rhino-orbito-cerebral mucormycosis (ROCM). This study aimed to study the impact of DM on the severity of COVID-19-associated ROCM (CAM). Methods:?This was a retrospective analytical study performed over a period of 3 months to assess the impact of DM on the severity of CAM in 100 patients and association of clinical correlates of DM with severity of CAM. Statistical analysis:?The data collected using the study tools were converted into a computer-based spreadsheet and analyzed. The statistical analysis comprised a descriptive analysis that involved calculating means, standard deviations, and proportions. For calculating the significance of the difference of mean between two groups, Student's t-test was applied. In addition, chi-square test (or Fisher's t-test if applicable) was applied to study the significance of association of clinical correlates of DM with severity of CAM for categorical variables and t-test for continuous variables. Results:?The prevalence of DM was 67%. The average presenting blood sugar level was 245.9?±?99.86?mg%. Glycated hemoglobin level between 4.5 and 6.5% was observed in 57 patients and over 6.5% in 43 subjects. A high body mass index (BMI) of 25 and above was noted in 52 patients. A significantly higher level of presenting blood sugar and a longer duration of hospital stay was noted in patients having stage 3b or higher (p?<?0.05) when compared with those having stage 3a or below. No significant correlation was observed in patients in stage 3a or below and those presenting with stage 3b or higher in terms of BMI, waist to hip ratio, or total cholesterol levels. There was a strong correlation between blood sugar level at presentation, severity of DM with the severity of ROCM, and a strong inverse correlation noted between HDL level and severity of ROCM. Conclusion:?A poor metabolic control is associated with a higher risk of a severe disease with intracranial involvement.
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Objectives?Individuals affected with rhino-orbito-cerebral mucormycosis (ROCM) associated with coronavirus disease 2019 (COVID-19) increased enormously in northern India during the second wave of the novel coronavirus disease. This study determined the demographic and clinical profile including the risk factors in patients presenting to a tertiary care hospital in northern India. Materials and Methods?This is a descriptive study involving patients admitted with COVID-19-associated ROCM and were managed from May 2021 to 20th July 2021. Statistical Analysis?The data was analyzed using SPSS (IBM SPSS Statistics 20, SPSS Inc., Chicago, Illinois, United States) software and Microsoft Excel (Version 16.49). The chi-squared and Fisher's exact tests were used to compare various outcomes. A p-value of less than or equal to 0.05 was considered to be statistically significant. Results?One hundred and seventeen (117) patients (males: 70 [59.8%], females:47 [40.2%]) with the average age of 51.85?±?12.80 years presented with orbital involvement. Diabetes mellitus was noted in 100 (86.2%) patients. Of the available data from the records, oxygen supplementation for the management of COVID-19 was received by 37/108 (34.3%) patients for a median average duration of 11 days. Forty-eight patients of one-hundred-seventeen (60%) patients were treated with corticosteroids with a median duration of steroid administration being 10 days. The duration between onset of symptoms related to mucormycosis and diagnosis of COVID-19 was 0 to 75 days for 48 patients. Intravenous amphotericin B was administered in all cases. External sinonasal debridement was performed in 90 of 114 (78.9%) patients, retrobulbar amphotericin B injection was administered in 56 of 117 (47.9%), and orbital exenteration was performed in 17 of 117 (14.5%) of cases. Conclusion?Administration of corticosteroids and diabetes mellitus seem to be the major underlying causes for the development of COVID-19-associated ROCM. Prompt diagnosis and multidisciplinary management approach are essential for a reduction in mortality.
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Most documented cases of mucormycosishave been reported in patients with uncontrolled diabetes mellitus, neutropenia, or treatment with corticosteroids. Recently, with the second wave of COVID-19, the Indian subcontinent has witnessed a dramatic rise in mucormycosisinfection in patients recovered from COVID-19. This association has been documented in various case reports/case series and institutional studies, and the mortality associated with this fungal infection is emerging as a cause of concern.Pulmonary mucormycosis is the second most common form after rhino-orbito-cerebral mucormycosis(ROCM),but most cases are diagnosed in autopsy specimens. Cutaneous, Gastro-intestinal and disseminated forms are relatively rare. This cases series comprises of 4 cases of mucormycosis in post-COVIDpatients with interesting presentations.We report two cases of combined pulmonary aspergillosis and pulmonary mucormycosis, one case of rhino-orbital-mucormycosis with lymph nodal involvement and one case of rhino-orbital mucormycosis with acute inflammatory demyelinating polyneuropathy(AIDP).
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Purpose: An unprecedented surge has been noted in rhino?orbital?Cerebral mucormycosis (ROCM) in times of current COVID?19 pandemic. The present prospective study aims to evaluate clinico?epidemiological profile, risk factors, management, and outcome of the cases of ROCM that presented to our tertiary care center during the study period from April to June 2021. Methods: All patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were staged and were treated with intravenous liposomal amphotericin B (AMB) and sino?nasal debridement of local necrotic tissue. Transcutaneous retrobulbar AMB (TRAMB), orbital decompression, and exenteration were instituted as indicated. All patients were followed up for a minimum of 6 months before arriving at the final outcome. Statistical analysis was performed. Results: A total of 49 patients presented during the study period, with a mean age of 42.2 years. The major risk factors included uncontrolled diabetes (89.8%), COVID?19 positivity (51.02%), and concurrent steroid use (38.77%). The most common presenting symptom was facial pain/swelling (43.65%), while the most common presenting sign was deterioration in vision (75.51%). Intravenous liposomal AMB was given to all patients along with sino?nasal debridement (85.71%), TRAMB (57.14%), orbital decompression (14.28%), and exenteration (12.24%). Overall, mortality at 6 months was 22.45% (11 patients). Age more than 60 years, intracranial extension, and HbA1c of more than 8.0% were observed to be statistically significant indicators of mortality. Conclusion: Early suspicion and timely diagnosis of mucormycosis at rhino?orbital stage is warranted in order to salvage life as well as visual function. TRAMB may prove as potentially favorable treatment modality in cases with limited orbital involvement.
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Background:There is a sudden rise of fungal infection with coronavirus 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 retrospective study is to describe the imaging findings of acute invasive rhino-orbito-cerebral mucormycosis (ROCM) in 58 patients with severe acute respiratory syndrome coronavirus 2, from SVP hospital with proven mucormycosis. Special emphasis is placed on the signal patterns of sinonasal mucosa, the earliest and most common findings.Material And Methods:We report the sinonasal, orbital and neuroimaging findings in patients of suspected acute invasive ROCM. A total of 58 patient’s scans were analyzed. The study comprises cases performed at two different imaging modalities and a tertiary care hospital from March 23,2021 to September 1, 2021. All the patients had positive reverse transcriptase polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 and were hospitalized with clinically severe disease as per the guideline s laid down during the second wave in India. They were on intravenous steroids and oxygen. Thirty patients (52%) had diabetes mellitus. All of them presented with headache, facialand/or orbital pain,periorbital puffiness with decreased vision, during the course of treatment. CT or MRI examination of the paranasal sinuses, orbits and brain was done, with intravenous contrast wherever possible. The presence of mucormycosis was confirmed by histological diagnosis in all of them following clinico-radiological diagnosis of acute invasive ROCM. Result:Computed tomography (CT) and magnetic resonance imaging (MRI) of 58 patients showed most commonly involved sinuse s as maxillary and ethmoid sinuses together. Sino-nasal mucosal thickening was the most common finding. Periantral infiltration preceded orbital, cerebral complications, with grossly intact bones. Sinus wall erosions were seen in only patients and maxillary alveolar arch erosionwere frequent findings. CT showed hypodense soft tissue thickening or fat stranding as the predominant finding in involved areas, while MRI showed T2 iso-to hyperintense mucosal thickening with T2 hypointense component as the main finding. Conclusion:MRI is better at demonstrating early mucosal abnormalities, turbinate necrosis, 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 thickening 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.
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Purpose: Known predisposing factors for mucormycosis are neutropenia and diabetes. Though COVID?19 is associated with hyperinflammatory response, a high surge in rhino?orbital?cerebral mucormycosis (ROCM) cases was observed during the second wave. The histopathological features reflect the background pathogenesis. This study analyzes the histopathological features and clinical presentation of COVID?19?associated ROCM. Methods: In this retrospective observational study, the clinical details of 89 proven ROCM patients treated during May–July 2021 were collected from the case records. Histopathological features were correlated with clinical staging groups and outcomes. The mean neutrophil?to?lymphocyte ratio (NLR) of clinical and outcome groups were compared. Results: The mean age was 54.71 ± 11.03 years, with male patients constituting a majority (78.7%). Uncontrolled diabetes mellitus was noted in 70.8% of patients, and 3.4% had normal range of blood sugar. The mean blood sugar was 298.08 ± 99.51 mg/dL. The mean duration of onset of symptoms of mucormycosis from the diagnosis of COVID?19 was 17.36 ± 7.392 (3–45) days. Poor outcome with disease progression or death occurred in 21.3% of patients. Clinical group II patients (44.9%) with ROCM stages 3c and above had poor outcomes (P = 0.005). Histopathological analysis showed minimal inflammation in 25.8%, neutrophil extracellular trap (NET) in 75.3%, and angio?invasion in 28.1% of patients. Minimal inflammation was associated with clinical group II (P = 0.004) and poor outcome (P = 0.001). Angio?invasion correlated with poor outcome (P = 0.007). Patients with severe clinical group and poor outcome had higher mean NLR with P = 0.017 and P = 0.007, respectively. Conclusion: Vision loss and cerebral involvement had poor outcomes. The histopathologic features such as inflammation and angio?invasion along with NLR aid as prognostic indicators in the management of ROCM. The role of NET in the pathogenesis of COVID?19?associated ROCM needs further studies
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Purpose: To study the clinical profile and magnetic resonance imaging (MRI) features in patients of COVID?19?associated rhino?orbital?cerebral mucormycosis (CA?ROCM) with orbital involvement and perform a clinicoradiological correlation. Methods: A cross?sectional study was performed at a tertiary care center in north India from May 2021 to June 2021. Consecutive patients with clinical, nasal endoscopic, and/or microbiological evidence of CA?ROCM underwent MRI of paranasal sinuses, orbit, and brain as per the study protocol. Orbital MRI findings were studied in detail and were correlated with clinical signs. Results: Two hundred and seventy patients were studied. The mean age was 48.4 (± 16.82) years. A male predilection was noted (male:female = 1.77). Orbital involvement was seen in 146 (54%) patients on clinical evaluation and in 184 (68%) patients on MRI. Unilateral orbital involvement was more common (134; 92%). The most common presenting symptom was periorbital and/or facial pain (141; 52.2%) and the most common clinical sign was periorbital edema (116; 43%). The most common MRI finding was suggestive of orbital cellulitis (160; 59%). Orbital compartment syndrome was found in 17 (6.3%) patients. The inter?rater agreement between clinical and radiological assessments to detect the involvement of infraorbital nerve and frontal nerve was found to be 85.56%, (? 0.621) and 93.70% (? 0.776), respectively. The diagnostic accuracy, sensitivity, and specificity of MRI to detect medial orbital wall defect were found to be 87.9%, 65%, and 97%, respectively. Conclusion: Orbital imaging features of a cohort of ROCM patients have been presented with clinicoradiological correlation.