Concomitant Presence of Mandibular Mucormycosis in a COVID Positive Patient: Report of A Rare Case

Reports of COVID-19 associated mucormycosis has exponentially increased in recent times, especially in patients with uncontrolled diabetes. It is reported to be associated with high mortality and morbidity rates and hence has emerged as a public health crisis. Covid-19 associated mucormycosis poses a diagnostic challenge for the Dentists as the clinical and radiological featuresare largely non-specific. The most common variant of mucormycosis in general is rhino-orbital and involvement of mandible is a rather uncommon presentation. Here we document a rare case of mucormycosis affecting the mandible with the concomitant presence of COVID19 infection in a diabetic patient.

Microbiological assessment of COVID-19 associated acute invasive fungal rhinosinusitis: a tertiary hospital based study

Background: Acute invasive fungal rhinosinusitis (AIFRS) is an emerging disease on top of SARS CoV-2 virus infection and associated with severe and fatal prognosis especially in the presence of other immunosuppressive conditions. Aim of study: Identification of the causative agents of AIFRS in COVID-19 patients and its impact on the survival outcome. Methods: This retrospective study was carried out on 70 clinically and radiologically diagnosed AIFRS patients either in concomitant with COVID-19 infection or following recovery. Exudates from the lesions were collected during surgical debridement. Both microbiological and pathological examinations were done to identify the type of the causative fungi followed by assessment of the relation between different type of fungi and the outcome in the affected patients. Results: Positive fungal cultures were detected in 54 cases out of 70 where Mucor species were the most common isolates (42 patients) and only 12 cases were proven to be Aspergillus species. All patients were diabetic and under steroid therapy. Mortality rate was 42.9% and 25% in mucormycosis and aspergillosis respectively. High dose of steroid together with Mucor species infection were the most important risk factors in determining the prognosis and the outcome of the infection. Conclusion: Microbiological diagnosis together with other methods plays an important role in accurate and rapid diagnosis of AIFRS in association with COVID-19 for proper management and improving the outcome. © 2020 The author (s).

Fungal infection: An unrecognized threat

The fungi are eukaryotes and of great interest to microbiologist. Fungi are heterotrophic organism that require organic compounds for nutrition. According to Hawksworth, only around 100 fungi cause diseases in humans and animals out of around 1.5 million existing in the universe. Fungal pathogenic infection may cause allergies, superficial infection, as well as invasive mycosis in severe cases. Public health can be significantly affected by zoonotic fungi that transmit naturally between animals and humans. Prevention of fungal infection arising out of zoonotes has received insufficient attention as it lacks mass awareness. A number of different fungal infections, their signs and symptoms, preventive measures, and treatment protocol are demonstrated in this chapter. Regarding the treatment of various fungal infections, azoles, fluoropyrimidines, polyenes, and echinocandins are the only four molecular classes of drugs available as on date to target fungal metabolic pathways despite years of drug discovery research. Few other promising molecules like morpholines and allylamines are useful antifungal but with poor efficacy and severe side effects when administered systematically. Development of resistance against most common antifungal drugs further aggravates the situation. Fungal infection like mucormycosis is observed in some parts of the world after a patient gets infected with COVID-19 as there is impairment in the immunity system. There is an urgent need to control this fungal infection as it poses serious threat silently. We can limit the spread of fungal infection by protecting susceptible population from being exposed. More efforts are needed from a global health perspective to aware the people regarding neglected fungal infection and its problem so that socioeconomic consequences and mortality can be better explained. An integrated platform of prevention and control strategies for the spread of fungal infection is the need of the hour. © 2023 Elsevier Inc. All rights reserved.

Diagnosis of rhinocerebral mucormycosis as complication of COVID-19, features of patient's treatment

Mucormycosis in patients after coronavirus pneumonia has become increasingly common. It is known that this disease has predominantly rhinocerebral form, is characterized by aggressiveness, rapid spread of the process to the brain tissue, and high mortality rate. Nevertheless, this pathology is insufficiently studied and described in the current scientific literature. Diagnosis of rhinocerebral mucormycosis is made at late stages, and serious complications cannot be avoided, and sometimes even save the patient. The aim was to study the possibilities of early diagnosis and prevention of rhinocerebral mucormycosis as a complication of COVID-19 and to consider the peculiarities of treatment of patients. Materials and methods. The article presents the examination and treatment data of 7 patients with rhinocerebral mucormycosis after coronavirus pneumonia. Radiation methods included orthopantomography, multispiral computed tomography (MSCT), magnetic resonance imaging. The diagnosis of mucormycosis was confirmed by pathohistological examination. The treatment of the patients was complex. Surgical methods included removal of foci of soft and bone tissue lesions. In the postoperative period we performed dynamic observation, daily dressings. As conservative treatment systemic antifungal therapy (amphotericin B and posaconazole), symptomatic treatment were used. Results. As a result of clinical, radiological, histological, laboratory investigation the picture of rhinocerebral mucormycosis after coronavirus pneumonia at different stages of the disease was described in detail and the results of treatment were estimated. Conclusion. Early diagnosis of rhinocerebral mucormycosis is based on the detection of symptoms of maxillary sinusitis developed after coronavirus pneumonia. Risk factors may include type 2 diabetes mellitus, cardiovascular pathology, and prior long-term therapy with high-dose glucocorticosteroids. MSCT should be considered as a method of choice for early diagnosis of the disease, to determine the extent of the process. Histological examination of biopsy and surgical material can be used for diagnosis. Treatment of patients should be comprehensive and include early radical surgical removal of the affected tissues against the background of systemic antimycotic therapy. Timely diagnosis of the disease and comprehensive treatment can reduce mortality and increase the life expectancy of patients. © 2022 Clinical Dentistry LLC. All Rights Reserved.

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

Physicians of different specialties accumulate the clinical material about the atypical course of different diseases during the pandem-ics of the new coronavirus infection (COVID-19). Mucormycosis is one of such diseases, which was earlier observed in immunocom-promised patients with the uncontrollable diabetes mellitus, transplant recipients, patients with hematological diseases, neoplasias (especially after chemotherapy), or the HIV-infection. Aim of the study. Advancing the treatment tactics in patients with necrotic fungal rhinoorbital lesions in the COVID-19 infection based on the analysis of clinical and pathomorphological disease features. Material and methods. A prospective analysis of 13 clinical cases was conducted along with the pathomorphological study of the biopsy material. Results. Vascular and perineural changes were detected in affected tissues, which may confirm the specific pathogenesis of fungal lesions of the rhinofacial region in the post-COVID syndrome. © 2023, Media Sphera Publishing Group. All rights reserved.

Prevalence of COVID Associated Mucormycosis with Antifungal Susceptibility Profiles of Isolates in a Tertiary Care Hospital

Mucormycosis is an angioinvasive opportunistic fungal infection, but these have become emerging pathogens, especially in conditions with underlying predisposing risk factors in a favourable setting. With the exponential rise in COVID-19 cases, there was an increase in the number of mucormycosis cases among them. The global prevalence rate of mucormycosis in COVID-19 globally varies from 0.005 to 1.7 per million population and in India, it is approximately 0.14 cases/1000. The objective of this study is to detect the prevalence of mucormycosis with the antifungal susceptibility pattern among COVID-19 patients admitted in our hospital. A total of 347 COVID-19 and post-COVID-19 patients with symptoms suggestive of mucormycosis were included in this study. Nasal scrapings, debrided necrotic tissue, unhealthy tissue bits and biopsy tissues taken through FESS were processed for mycological examination under sterile conditions. Among the total 347 samples processed, 87(25%) were positive for fungal culture. Among the culture positves 7.8% (25) belong to mucorales. Among the total 87 fungal isolates, the majority of organism isolated was Aspergillus sp(68%), followed by Rhizopus sp (18%). Rhizopus/Aspergillus sp (5%), Mucor species (5%), Rhizomucor sp (2%), Mucor/Aspergillus sp(1%), Curvularia sp (1%) were the other fungi isolated. All the strains of Mucorales were sensitive to Posaconazole and one strain showed resistance to amphotericin B with MIC 8 microg/ml by microbroth dilution method based on CLSI M27 guidelines for Amphotericin B, and Posaconazole.Copyright © The Author(s) 2023.

Rhino-orbital mucormycosis in COVID-19 patients—a new threat?

BackgroundCoronavirus disease 2019 (COVID-19) is known to be associated with a myriad of viral, fungal, and bacterial co-infections. Rhino-orbital mucormycosis is a rare angio-invasive fungal infection which has shown a rising trend in the setting of COVID-19.Case presentationWe describe the imaging findings in 3 cases of rhino-orbital mucormycosis in patients with history of COVID-19. All cases had varying involvement of paranasal sinuses extending into the orbital compartment while case 3 had intracranial extension of infection.ConclusionsRhino-orbital mucormycosis can have aggressive necrosis of the involved paranasal sinuses and orbits with or without cerebral extension. Hence, the correct diagnosis is imperative as prompt antifungal drugs and surgical debridement can significantly reduce mortality and morbidity.

Diabetic post-covid mucormycosis: A dermatoglyphic prediction.

Aim: To identify the characteristic pattern/parameter among diabetic post-covid mucormycosis patients which may further help in identifying such susceptible patients in a much earlier course of the disease. Materials and Methods: The study was done with 30 diabetic patients (21 males and 9 females) admitted in RIMS Ranchi during the second wave of Covid-19 for post-covid complications. Palm and fingerprint pattern was taken by ink and pad method to measure the qualitative and quantitative parameters. Result: Diabetic post-covid mucormycosis patients were found to have predominantly whorl pattern in males, loop in females, and C-line pattern absent in 36.6%. Proximal axial triradii with ulnar deviation was 76.6%. All the ridge counts (except ab ridge count of right hand) when compared with hypothesized value were found to be significant with P value (<0.005). None of the three angles measured were found to be significant. Conclusion: All the ridge counts (except ab ridge count of right hand) were found to be a reliable parameter for the diagnosis of diabetic post-covid mucormycosis. ATD angle known to be the most reliable parameter for diagnosis of diabetes mellitus in dermatoglyphics is found to be nonreliable with respect to diabetes post-covid mucormycosis.

Another Addition To The Covid-19 Associated Complications-Mucormycosis.

New manifestations of coronavirus disease are appearing over time. The association between coronavirus and mucormycosis must be given serious consideration. Without early diagnosis and treatment, there may be rapid progression of the disease, with high mortality from complications. We present a case of a 40-year-old male who presented with rhino-orbital-cerebral mucormycosis and COVID-19 infection. With this case, we highlight the importance of considering mycotic coinfection in COVID-19 patients with diabetes and the significance of its early diagnosis and treatment.

Anti-fungal therapy: An overview for maxillofacial surgeons in post-covid-19 fungal infections.

India is well known as the diabetes "capital" of the world but now it is also becoming the mucormycosis "capital" of the world. Indian Council of Medical Research has formed an "Evidence-Based Advisory in The Time of COVID-19 on Screening, Diagnosis, and Management of Mucormycosis." As per this advisory, an oral and maxillofacial surgeon forms an integral part of the team dedicated to fight this epidemic of mucormycosis. Also, there are other fungal infections such as aspergillosis which are getting reported in these patients affecting the paranasal sinuses and the jaws. Aggressive surgical debridement and a thorough knowledge of anti-fungal therapy are must in treating these fungal infections. The aim of this article is to give an overview on the available anti-fungal therapy required to manage the ever-increasing rise in fungal infections faced by maxillofacial surgeons in post-COVID-19 patients.

Impact of Oral Rehabilitation on Patients with Post-COVID-19 Mucormycosis Using Liverpool Oral Rehabilitation Questionnaire in Central India: Qualitative Study

Aim: This study aimed at qualitatively assessing post-COVID-19 mucormycosis prosthetically rehabilitated patients using Liverpool Oral Rehabilitation Questionnaire (LORQ) in Central India. Materials and methods: Forty-eight subjects were included in the study who were prosthetically treated post-COVID-19 mucormycosis and who were willing to participate in the study. The LORQ with certain modifications was given to the targeted population 1 week after the delivery of the prosthesis. Wilcoxon paired test was used to analyze the results and p-value ≤0.05 will be considered to be significant. Results: For all the individual questions, LORQ showed a significant decrease following the treatment (p < 0.05) except for Q3 (did you have mouth dryness?) where there was no significant difference between pre and postscores. Conclusion: On comparing the databases, it could be concluded that prosthetic rehabilitation of post-COVID-19 mucormycosis patients significantly improved the quality of life (QOL). Clinical significance: Since there is a lack of data regarding the impact of prosthodontic intervention on the life of people suffering from post-COVID-19 mucormycosis, this study was planned out. The result of this article will help clinicians to plan out future treatment strategies and modalities and have a better communication with the patient regarding the prosthetic outcome beforehand and endeavor the need of the patient. © The Author(s). 2022.

Complete and incomplete lower motor neuron facial palsy in post-COVID-19 mucormycosis.

Purpose: To study facial nerve palsy (FNP) in post-COVID-19-mucormycosis patients and its ocular complications, report different presentations of FNP in such patients, and propose its etiopathogenesis based on presentation and clinico-radiologic localization. Methods: A prospective cohort study was carried out in patients of post-COVID-19-mucormycosis who presented at our tertiary center, over a period of 3 months. Motor and sensory examination of the facial nerve was done to diagnose FNP and localize the lesion clinically. Slit-lamp examination was done for grading corneal involvement. MRI brain, orbit, and paranasal sinuses (PNS) with contrast were studied to find involvement along the facial nerve. It was assessed whether this site of lesion corresponded with clinical localization. Data were analyzed using the percentage of total cases and Fisher's test. Results: A total of 300 patients with post-COVID-19 mucormycosis were examined, of which 30 (10%) patients were found to have FNP. All were lower motor neuron (LMN) type and were associated with corneal complications. The most common site clinically was distal to the chorda tympani (66.66%) and radiologically was infratemporal (IT) fossa (63.4%). The clinical localization significantly correlated with the radiological findings (P = 0.012). Twenty percent of patients showed incomplete involvement of facial muscles. Conclusion: FNP was found to be of LMN type. The most common site of insult was IT fossa. There was a good clinico-radiological correspondence of lesions. Isolated lesions were also found along the peripheral nerve course, presenting as incomplete facial palsy. Recognition of FNP in post-COVID-19 mucormycosis, in all its variable forms, is important to manage corneal complications.

Rhino-Orbital Mucormycosis After COVID-19 Infection in a Patient With Non-Hodgkin's Lymphoma.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may be succeeded by a spectrum of complications, including invasive fungal infections (IFIs). Here, we describe a case of rhino-orbital mucormycosis in a recovered coronavirus disease-19 (COVID-19) patient with underlying non-Hodgkin's lymphoma (NHL). Our patient was normotensive, non-diabetic, presenting with multiple non-healing ulcers on different parts of the body. She received high-dose glucocorticoids and antibiotics during her severe COVID-19 illness. Three weeks following COVID-19 detection, she developed progressive rhino-orbital lesion with profuse pus formation, along with pain and redness of the left eye. Histopathology from the lesion revealed mucormycosis. She was treated with Amphotericin B. Unfortunately, the patient died after the first cycle of chemotherapy for NHL. Due to the high chance of mortality, timely clinical suspicion along with microbiological diagnosis is necessary for the early detection of infection. Strong policymaking should also be implicated to revisit the cost effectiveness of available treatments to reduce case fatality.

Outcome of transcutaneous retrobulbar injection of liposomal amphotericin B in post-COVID-19 rhino-orbito-cerebral mucormycosis: Our experience.

Purpose: To assess the outcome and response of transcutaneous retrobulbar injection of amphotericin B (TRAMB) in post-coronavirus disease of 2019 (COVID-19) rhino-orbito-cerebral mucormycosis (ROCM) and to establish a scoring system in guiding treatment modalities. Methods: An interventional, prospective study was done on 82 eyes of post-COVID-19 ROCM from May 2021 to July 2021. A comprehensive multi-departmental evaluation along with detailed ophthalmic examination, laboratory investigations, and radiological examination was done. Scoring points were given to each symptom, sign, and radiological features of orbit and the total score was taken. Based on these scores, severity of disease was grouped into A, B, and C corresponding to mild, moderate, and severe orbital ROCM. One milliliter of reconstituted liposomal amphotericin B was given to all patients every alternate day as three doses. Efficacy of these injections was assessed in all groups, even though other treatment modalities like orbital debridement and exenteration were considered for moderate and severe cases. Patients were followed up for a period of 8 weeks. Results: Out of 82 eyes, symptomatic improvement was seen in a major proportion (72%) of patients. A statistically significant improvement in scores was noted in group A (93% improved) with a P value of 0.002, while 68.4% showed improvement in group B (P-value- 0.0001). Group C with severe disease showed minimal improvement in post-injection scores of 41% (P-value 0.086), necessitating surgical intervention. No serious adverse effect of the drug or procedure was noted. Conclusion: Significant improvement in scores of groups A and B highlights TRAMB as an effective and safe treatment modality in mild to moderate ROCM. It is an effective adjunct in severe cases, along with other interventions. Also, the scoring system helps in assessing the severity and guiding in management strategies.

Machine learning based predictive model and systems-level network of host-microbe interactions in post-COVID-19 mucormycosis.

Mucormycosis, a rare infection is caused by fungi Mucorales. The affiliation of mucormycosis with Coronavirus disease (COVID-19) is a rising issue of concern in India. There have been numerous case reports of association of rhino-cerebral-orbital, angioinvasive, pulmonary, respiratory and gastrointestinal tract related mucormycosis in patients with history of COVID-19. The immune dysregulation, preposterous use of steroids, interleukin-6-directed therapies and mechanical ventilation in COVID-19 immunocompromised individuals hypothesizes and predisposes to advancement of mucormycosis. The gaps in mode of presentation, disease course, diagnosis and treatment of post-COVID-19 mucormycosis requires critical analysis in order to control its morbidity and incidence and for prevention and management of opportunistic infections in COVID-19 patients. Our study performs machine learning, systems biology and bioinformatics analysis of post-COVID-19 mucormycosis in India incorporating multitudinous techniques. Text mining identifies candidate characteristics of post-COVID-19 mucormycosis cases including city, gender, age, symptoms, clinical parameters, microorganisms and treatment. The characteristics are incorporated in a machine learning based disease model resulting in predictive potentiality of characteristics of post-COVID-19 mucormycosis. The characteristics are used to create a host-microbe interaction disease network comprising of interactions between microorganism, host-microbe proteins, non-specific markers, symptoms and drugs resulting in candidate molecules. R1A (Replicase polyprotein 1a) and RPS6 (Ribosomal Protein S6) are yielded as potential drug target and biomarker respectively via potentiality analysis and expression in patients. The potential risk factors, drug target and biomarker can serve as prognostic, early diagnostic and therapeutic molecules in post-COVID-19 mucormycosis requiring further experimental validation and analysis on post-COVID-19 mucormycosis cases.

Cerebrovascular Involvement in Mucormycosis in COVID-19 Pandemic.

BACKGROUND: Many countries have seen an unprecedented rise of cases of coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM). Cerebrovascular involvement in CAM has not been studied so far. We describe clinico-radiological manifestations of cerebrovascular complications observed in CAM. METHODS: In this multicentric retrospective observational study from India, patients with CAM who developed cerebrovascular involvement were studied. Their demographics, risk factors, clinical manifestations, imaging, laboratory profile and outcomes were noted. RESULTS: Out of 49 subjects with cerebrovascular involvement, 71.4% were males while average age was 52.9 years. Ischemic stroke was commonest (91.8%) followed by intracranial haemorrhage (6.1%) and subarachnoid haemorrhage (2%). The incidence of cerebrovascular complications in CAM was found to be 11.8% in one center. Cerebrovascular symptoms appeared a median of 8.3 days from the onset of mucormycosis. Commonest presentation of mucormycosis was rhino-orbito-cerebral syndrome in 98%. Diabetes mellitus was present in 81.7%. Forty percent developed stroke despite being on antiplatelet agent and/or heparin. Amongst subjects with ischemic strokes, location of stroke was unilateral anterior circulation (62.2%); bilateral anterior circulation (17.8%); posterior circulation (11.1%) and combined anterior and posterior circulation (8.9%). Vascular imaging revealed intracranial occlusion in 62.1%; extracranial occlusion in 3.4% and normal vessels in 34.5%. Mortality was 51% during hospital stay. CONCLUSIONS: Cerebrovascular involvement was seen in 11.8% patients of CAM. Angio-invasive nature of the fungus, prothrombotic state created by COVID-19, and diabetes were important causative factors. Subjects with CAM should be screened for involvement of the brain as well as its vessel. Antiplatelet agents/heparin did not seem to provide complete protection from this type of stroke.

Mucormycosis: An unanticipated progeny of COVID-19.

The rapid surge of COVID-19 cases in the second wave of the pandemic has crippled the healthcare delivery system in Nepal and neighboring countries. Unlike in the first wave of the pandemic, several cases of mucormycosis have been reported in patients with COVID-19 from Nepal and India. In this report, we briefly describe the clinical presentation, diagnosis, and risk factors for mucormycosis and explore why patients with COVID-19 are at an increased risk for developing the infection. As treatment of mucormycosis is challenging and consumes a lot of resources, prevention of mucormycosis is pivotal in low-income countries like Nepal. We also highlight some basic steps that are easy to perform and important to reduce the risk of infection.