Spectrum of Fungal Infections in a Tertiary Care Centre of North India: Pre-COVID and COVID Scenario and Implications.

Background Rhino orbital mucormycosis is a rare and very aggressive entity. A sudden rise of this entity has been noticed with the insurgence of the COVID-19 pandemic both among immunocompromised and immuno-competent patients. This study was done to determine any possible correlation between these two deadly diseases. Materials and Methods This was a retrospective observational study done in the pathology department of a tertiary care center in North India over a three-year period (January 2019 - December 2021). Patient details along with relevant clinical data were retrieved from the patient's record file. Hematoxylin and eosin-stained slides of diagnosed cases were taken from the department records. Results A total of 45 patients (34 males, 11 females) were included in the study, seven of which were ophthalmic exenteration specimens. The mean age of the patients was 52.68 years. Fifteen cases showed COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) positivity. Histopathology revealed the presence of mucormycosis in all the cases. There were six cases showing granuloma formation and 14 cases revealed mixed fungal infection. Optic nerve involvement was seen in six cases of exenteration specimens. Conclusions The present study showed a sudden resurgence of secondary fungal infections, especially during the second wave of the COVID-19 pandemic. Associated co-morbid conditions and injudicious use of steroids and antibiotics have been the cause of depressed immunity leading to the infections. One must be aware of such co-infections to facilitate timely medical management to reduce morbidity and mortality.

Cross-sectional study to describe the severity, bio-chemical associations, and final outcomes of COVID-19-associated rhino-orbital-cerebral mucormycosis in a tertiary hospital of East India.

Purpose: The second wave of coronavirus disease 2019 (COVID-19) pandemic triggered a mucormycosis epidemic in India. Diabetes mellitus and dysregulated immune response were contributors, and rhino-orbital-cerebral mucormycosis (ROCM) was the most common presentation. It is however not known whether bio-chemical parameters at presentation correlate with stage of ROCM or final outcome in terms of vision or mortality. Methods: This retrospective, hospital-based study included all in-patients of mucormycosis with ophthalmic manifestations at presentation admitted during June 1, 2021 to August 31, 2021. It aimed to evaluate the association between severity of infection, serum levels of HbA1c, ferritin, interleukin-6 (IL-6), C-reactive protein (CRP), and D-dimer levels at presentation and outcome. Results: There were altogether 47 eligible cases having a mean age of 48.8 ± 10.9 years with a male:female ratio of 2.6:1; forty-two (89.4%) had pre-existing diabetes, and five (10.6%) had steroid-induced hyperglycemia. The mean HbA1c among diabetics was 9.7 ± 2.1. HbA1c and serum CRP showed an increase over subsequent stages, which was not statistically significant (P = 0.31). IL-6 values for all stages were similar (P = 0.97). Only serum ferritin levels showed a statistically significant increase over stages (P = 0.04). IL-6 was significantly lower (P = 0.03) in patients who survived, whereas CRP levels were significantly lower in patients who had final visual acuity (VA) better than only perception of light (P = 0.03). Conclusion: Uncontrolled diabetes mellitus is a significant association of ROCM. Serum ferritin levels at presentation best correlate with extent of the disease. CRP levels are best to prognosticate cases that will have sufficient VA to carry on activities of daily living, whereas IL-6 levels are best associated with survival.

Risk Factors for Procurence of Mucormycosis and its Manifestations Post Covid-19: a Single Arm Retrospective Unicentric Clinical Study.

To assess the risk factors causative of ROCM post COVID-19. To determine the clinical manifestations, causative factors leading to surge in ROCM & factors contributing to poor prognosis in ROCM cases occurring in Western Rajasthan post COVID-19. In a Retrospective observational study, 56 post COVID-19 ROCM patients were analyzed from 'May-June 2021' at M.D.M. Hospital, Jodhpur. All patients after onset of disease were assessed as per selection criteria, included patients were examined for risk factors and clinical manifestations & then were statistically evaluated. Median age was 53 years with male to female ratio 2.7:1. Uncontrolled diabetes was noted in at least 85% patients. Steroid use was seen in 66%. Other major contributing factor to ROCM was the occupation; Out of 56 patients 69% were FARMERS.72% had no history of COVID-19 vaccination. Only 3% had no underlying disease. Overall mortality rate was 16% .2 determinants were associated with poor prognosis: higher HbA1c-Out of 7 cases of orbital exenteration, 6 (85%) had HbA1c > 12. 36% took immoderate amounts of Steam inhalation. Maxillary sinuses were the most involved sites (94%). Orbital involvement was seen in 33 and 12% were PL negative. Palatal involvement & intracranial involvement were seen in 14% and 7% respectively. Bilateral disease was seen in 28%. Uncontrolled DM & Humid working conditions came out to be the main predisposing factors for ROCM. Facial pain is considered to be the most common presenting complain. Maxillary sinus is the most involved site.

Retrobulbar Amphotericin B Injection in Curbing the Progression of COVID Associated Rhino-orbital Cerebral Mucormycosis: A Retrospective Case Series.

Purpose To assess whether transcutaneous retrobulbar Amphotericin B (TRAMB) injection can halt disease progression and reduce the requirement of exenteration in post-COVID 19 Rhino-orbital cerebral Mucormycosis (ROCM)) with limited orbital disease. Methods Retrospective series from a single center included 22 patients with KOH proved post-COVID 19 ROCM with radiographic evidence of limited orbital involvement were evaluated from May 2021 to October 2021. TRAMB was given along with systemic intravenous Amphotericin B injection and sinus debridement. Demographic profile, clinical data, operative notes, blood and radiological investigations were evaluated. The primary outcome was to assess the halt in the progression of orbital disease. The primary outcome measure was to assess the halt of the disease progression and the secondary outcome was improvement in the clinical signs and symptoms. Results The mean age was 50.36 ± 9.72 years and 77.3% were men. The Stagewise distribution was twelve (54.5%) patients in stage 3a, four (18.2%) patients in stage 3b, four (18.2%) in stage 3c, one (4.5%) patient in stage 3d and one (4.5%) had stage 4 disease. Improvement in lid edema and conjunctival chemosis were noticed and it was statistically significant (p value < 0.01), similarly visual acuity and ocular motility showed significant improvements (p value 0.04 and < 0.01 respectively). 1 patient died and 1 patient required exenteration later. Twenty patients showed halting of orbital disease after TRAMB injection. Conclusion TRAMB can be an alternative adjuvant therapeutic option to preserve the globe in patients with limited orbital disease but not at all replacement for exenteration.

Post COVID-19 recurrent rhino ocular cerebral mucormycosis: A curse like no other

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has been linked to a number of opportunistic bacterial and fungal infections. Aspergillus and Candida have been identified as the primary fungal pathogens for COVID-19 co-infection. Recently, several cases of mucormycosis in COVID-19 patients have been reported worldwide, particularly in India. Now, remember that mucormycosis can be of different types like rhino-ocular-cerebral (ROCM), pulmonary, gastrointestinal, etc., here we are dealing with a case of rhino-ocular cerebral mucormycosis which not only occurred once but twice post covid-19 infection. As we recover from the epidemic and the pandemic, it is essential to look back and understand what led to the insane surge of mucormycosis in post-covid-19 patients, especially in our country, India. Mucor is ubiquitous and present constantly around us, so no single factor but an array of elements is responsible predominantly being the incorrect use of corticosteroids in uncontrolled diabetics, which led to severe immunosuppression, injury to the beta cells of the pancreas by the SARS-COV-2 in newly diagnosed diabetics. In such cases, it is important to evaluate the patient thoroughly and orbital exenteration is done depending upon the doctor's judgment and MRI findings. Following is a case report of one such patient with recurrent post COVID mucormycosis predisposed by uncontrolled diabetes mellitus and managed by orbital exenteration.

Critical Review of Covid-19 Associated Mucormycosis of Nose and Paranasal Sinuses in A Tertiary Care Hospital in Ongole, Andhra Pradesh

Background: Mucormycosis is a fungal infection caused by filaments of Mucoraceae which invades blood vessels culminating in a lethal opportunistic infection. During the second wave of COVID-19, all over India a spurt of increased reporting of Mucoraecea infection was experienced. Compromised individual immunity system was suspected. Its early diagnosis and suitable surgical intervention were essential to decrease morbidity and mortality. Aim of the Study: To study the demography, clinical features, risk factors, laboratory investigations, and radiological findings of patients with mucormycosis and to evaluate the clinical outcomes in each case. Materials: A cross sectional study from the Department of ENT of Government Medical College Hospital, Ongole;350 COVID-19 RT-PCR positive patients presented with clinical symptoms and signs of Mucormycosis between February 2021 and February 2022 were analyzed. All age groups and genders were included. Mucormycosis proved on microscopic examination of the aspirate or histopathologies of tissue specimens were included. Clinical findings, risk factors, comorbidities, outcome of the disease, biochemical and hematological investigations, radiological signs, nature of fungal elements isolated, treatment instituted were noted. Surgical procedures included were Functional Endoscopic sinus surgery, extended Endoscopic sinus surgery, Medial maxillectomy, ethmoidectomy, Sphenoid exploration, frontal sinusotomy, Orbital exenteration and Skull base surgeries. Antifungal treatment consisted of administration of liposomal Amphotericin B and posaconazole. Result(s): 350 patients included in this study;268/350 (76.57%) males and 82/350 (23.42%) females with a male to female ratio of 3.26:1. 211 (60.28%) patients living in rural areas and 139 (39.71%) living in the urban areas. 324 (92.57%) patients were positive for COVID-19 (RT-PCR) test and 26 patients were negative. There were 233 (66.57%) patients who were obese with more than 30 BMI index and 117 (33.42%) who were with less than 30 BMI index. 299 (85.42%) patients were diabetic and 51 (14.57%) patients were non diabetic. Vaccination was taken 188 (53.71%) of the patients and not taken by 162 (46.28%) of the patients. Mortality rate was 09/350 (02.57%). It was observed that the variables such as Living area, COVID-19 (RT-OCR) test positivity, obesity, Diabetes mellitus and usage of steroids were significantly associated with Mucormycosis in this study. Conclusion(s): Mucormycosis was found to be common in males, from the rural areas. Other significant risk factors for Mucormycosis were COVID-19 (RT-OCR) test positivity, obesity, Diabetes mellitus and usage of steroids. The most common clinical symptoms and signs among were nasal obstruction with noisy breathing, blood stained nasal discharge, headache, periorbital swelling, reduced vision, Ptosis, external ophthalmoplegia, and facial pains were common. Surgical management reduced the morbidity and mortality of Mucormycosis in this study.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Alternating pattern of rhino-orbital-cerebral mucormycosis with COVID-19 in diabetic patients.

PURPOSE: Our aim was to analyze the patients with diabetic rhino-orbital-cerebral mucormycosis that we have treated in our clinic in the last 5 years, and to reveal the altering conditions with COVID-19. MATERIALS AND METHODS: A retrospective study was conducted on 39 rhino-orbital-cerebral mucormycosis (ROCM) patients with diabetes mellitus between 2017 and 2022. The patients were divided into two groups as those associated with and not associated with COVID-19 and compared. RESULTS: Thirty-nine diabetic patients were included in the study, with 15 (38.5%) of them being COVID-19 associated mucormycosis (CAM) group. CAM patients showed higher orbital involvement and cavernous sinus involvement (p = 0.002 and p = 0.013, respectively). The mortality rate in the non-COVID-19 associated mucormycosis (non-CAM) group was statistically higher in patients with intracranial and cavernous sinus involvement (p = 0.015 and p = 0.033, respectively). The difference between the overall survival of the CAM patients and non-CAM patients was not statistically significant (p = 0.741). CONCLUSIONS: With COVID-19, progressive mucormycosis accompanied by orbital and intracranial involvement is observed more frequently. However, on the contrary, the mortality rate in COVID-19-associated mucormycosis is considerably lower than expected. The fact that temporary immune suppression can be ameliorated with adequate supportive treatment and liposomal amphotericin-B which can be given to patients in high doses may explain this situation. It has been attained hints that the essential factor in the treatment of COVID-19-associated ROCM is the control of the underlying disease and to be cautious in the decision of early aggressive surgery.

Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital-cerebral mucormycosis: preserving the salvageable.

BACKGROUND: Rhino-orbital-cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible. METHODS: The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up. RESULTS: There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement. CONCLUSIONS: Systemic and protocol-based management can save the life and salvage the eyes.

Establishing Minimally Invasive Colorectal Unit at a Tertiary Care Indian Centre in Covid-19 Second Wave

Aim: Minimally invasive cancer surgery is the becoming the standard of care in colorectal oncology. With the growing interest in the use of tailored approach to improve the outcomes, colorectal oncology demands sub-specialised care. Method(s): This is a description of establishment of a dedicated colo-rectal oncology unit at a newly built tertiary care centre in the country, Tata Memorial Centre (Varanasi) with special emphasis on the introduction of laparoscopy for standard and extended colo-rectal surgery. Result(s): Over a period of 4 months, from February 2021 to May 2021, 35 colo-rectal surgeries have been done with 5 emergency cases and the remaining in elective setting. Operative procedures included -10 colectomies, 5 stoma/ostomy creations, 7 rectal resections in standard TME plane, 2 total pelvic exenterations, 11 extended rectal resections. 22 of these 35 surgeries (62.8%) were done using laparoscopic approach. Laparoscopy has been used across all procedures, specifically 5 colectomies, 7 standard TME rectal surgeries, 5 extended rectal resections and 1 total pelvic exenteration. Clavein dindo Grade 3 or higher morbidity was seen in 5.7% cases. Joint clinic session dedicated to colorectal oncology is conducted to provide a tailor-made individualized care to appropriate patients. Conclusion(s): Use of minimally invasive approach in colorectal oncology along with a sub specialized unit is the need of the hour to improve the outcomes in this cohort of patients.

A Real-World Study of Covid-19 Associated Rhino-Orbital-Cerebral Mucormycosis (Rocm)

Background: Mucormycosis is an invasive fungal illness associated strongly with COVID-19 and found lethal in many cases. Rhino-orbital-cerebral mucormycosis (ROCM) is the most common mucormycosis infection. The worldwide disease concern for ROCM has grown recently following the spike in incidence during the COVID-19 pandemic. This study shows the clinical characteristics and therapeutic outcomes of patients with ROCM. Material(s) and Method(s): A retrospective observational study on 77 patients with ROCM was performed between March 2021 and June 2021 at a tertiary care hospital. This study only included patients who were microbiologically tested and conformed for ROCM. Numerous clinal diagnosis tests were performed to examine vision, paralysis of the eye muscles, eyeball protrusion, orbital swelling, extra-ocular movements, fundus examination, and extent of orbital involvement on MRI. Result(s): This study of 77 patients, showed a higher ratio of male patients (74.04%) for ROCM cases. The average age of all patients was 49.14 years, and 62 (80.52%) were detected for COVID in the past. These patients were hospitalised for a minimum of 1 day to a maximum of 127 days, with an average of 40.48 days. Type 2 diabetes was found in 40 (52%) cases, while hypertension was the second most common comorbid condition observed in 21 (27.27%) cases. Amphotericin B injection was the preferred therapeutic drug shown in this study for 44 patients out of 56 who used any medication. Exenteration was also shown as a possible therapy that was performed on 53.25% of patients. Conclusion(s): ROCM is more prevalent in diabetic male patients of 50 years of age infected by SARS-CoV2 who have had a later bacterial or fungal illness exacerbated by SARS-CoV2. Amphotericin B injection and exenteration could be the best possible therapeutic solution for treating ROCM. Copyright © 2022 Authors. All rights reserved.

A study of orbital mucormycosis cases at a tertiary hospital

Aims: The aims of this study was to identify demographic data risk factors for the disease, clinical presentation and treatment outcome of patients having COVID-19 related mucormycosis. Materials and Methods: This was a prospective, interventional study done in a tertiary hospital carried out from May 2021 to July 2021. Results: With 40 patients under study, the mean age of patients was 52.4 years. The incidence was more in males (80%) than in females. 95% patient had history of COVID-19. In these patient, the treatment of COVID-19 received were either Steroids (92%), O2 therapy (57.5%) or had an ICU stay (37.5%). T2DM was present in 62.5% while T1DM in 2.5%. These patients mainly received intravenous amphotericin-b (92.5%) along with syrup posaconazole as medical management. functional endoscopic sinus surgery (FESS) was done in all the patients while maxillary debridement or maxillectomy was done in 42.5% patients. In ophthalmic conservative line of management 37.5% received transcutaneous retrobulbar amphotericin B (TRAMB). 10% patients underwent exenteration who presented in later stages of the disease. Inspite of all the interventions, 22.5% succumbed due to low health conditions. Conclusion: Corticosteroids followed by DM were the commonest pre-disposing factor for COVID-19 related mucormycosis. Early FESS and timely TRAMB reduced the spread of the disease and conserved vision respectively. © 2022 Innovative Publication,.

Retrospective analysis of the role of retrobulbar amphotericin-B injection in the management of COVID-19 associated rhino-orbito-cerebral-mucormycosis.

Introduction: Rhino-orbito-cerebral-mucormycosis (ROCM) is the most common form of mucormycosis observed during the second wave of COVID-19 where a steep rise in the number of cases was seen. The orbital form is almost always associated with fungal sinusitis. Among the various treatment modalities available, the role of retrobulbar Amphotericin-B injections is under-reported. This study is conducted to determine the role of transcutaneous retrobulbar amphotericin-B (TRAMB) in the management of COVID-19 associated ROCM. Methods: a retrospective analysis of 61 patients of COVID-19 associated ROCM was done, who met the inclusion criteria and presented to a tertiary care center, between May to August 2021. These patients were administered TRAMB (deoxycholate/emulsion form) along-with systemic amphotericin B. All the patients were evaluated for clinical improvement. Results: out of 61 patients, 58 (95.08%) showed overall improvement. 40 patients (65.57%) stabilized or improved clinically and 3 patients succumbed to the illness due to advanced systemic mucormycosis and acute kidney failure. Sixteen out of 58 patients underwent orbital exenteration. Out of remaining 43 patients, 35 showed complete recovery of orbital and ocular disease and the disease stabilized in eight patients. Seven patients demonstrated TRAMB associated ocular complications which however completely resolved in six patients. Conclusion: to the best of the author´s knowledge, regression of orbital mucormycosis with improvement in ptosis, proptosis, ocular motility and stabilization of visual acuity are scarcely reported in literature. Further TRAMB as a globe non-deforming treatment modality is an option available for ROCM.

Diagnostic Tools in COVID-19-Associated Mucormycosis: Do We Need 3-dimensional Computed Tomography

Introduction: Early detection of COVID-19-associated mucormycosis (CAM) is critical for accurate staging and optimal treatment. Three-dimensional computed tomography (3D CT) reconstruction of the face has recently come up as a newer diagnostic tool in CAM. Method(s): This clinical study was done to evaluate the efficacy of 3D CT in diagnosing and managing CAM. We compared 3D CT reconstruction with conventional 2D CT. One hundred twenty-three confirmed cases of mucor were subjected to 3D CT reconstruction in addition to contrastenhanced magnetic resonance imaging after comprehensive clinical workup. The involvement of maxillary walls, alveolus, palate, orbital floor, zygomatic process, and other facial skeleton were noted. The plan of management was decided after assessing the extent in 3D CT. Result(s): Anterior maxillary wall was found to be the commonly involved (9.7%). Involvement of the lateral maxillary wall was noted in 8.1% of subjects. Sixty-seven subjects underwent endoscopic endonasal debridement, 19 underwent total maxillectomy, 3 had infrastructure maxillectomy, 8 had orbital exenteration, and 12 had combined endoscopic and open surgeries. In 21 patients (17%), open surgery was done based on additional 3D CT findings at the first instance and revision surgeries were avoided. Conclusion(s): 3D CT face was found to be superior to conventional CT in diagnosing the extent of disease and plays an important role in preoperative surgical planning of CAM. Minor cortex erosions are not picked up by conventional CT;it also does not show finer details and leaves the surgeon imagining the disease extent. 3D CT decreases delay in diagnosis, facilitates the surgical plan, and reduces the need for multiple surgeries. It is a valuable tool in the assessment of revision cases and follow-up.

CT-Scan Guided Intra-orbital Amphotericin Injection in COVID-19-associated Mucormycosis, a pilot study

Purpose : A high incidence of sinu-orbital Mucormycosis as a fulminant and opportunistic fungal infection happened following the COVID-19 pandemic. Traditionally, patients with apical or extensive orbital involvement are candidates for exenteration. We designed and applied CT scan guided orbital amphotericin C delivery. In this study we aimed to report this novel technique and results of this method in control of orbital mucormycosis with apical involvement. Methods : A high incidence of sinu-orbital Mucormycosis as a fulminant and opportunistic fungal infection happened following the COVID-19 pandemic. Thus named as CAM. Traditionally, patients with orbital mucormycosis with apical or extensive involvement are considered hopeless for saving the eye. We designed and applied CT scan guided orbital amphotericin C delivery. Results : A total of thirty patients with mean age of 52±11.86 were enrolled in this study. Twenty-three (76.7%) patients were male;group A: 11 (73.3%) and B: 12 (80%). The majority of the patients in both group were diabetics (A: 10 (66.7%), B: 10 (76.9%)). Most patients in both groups had received corticosteroids and antiviral therapy for their recent COVID-19, 23 (82.1%) and 25 (89.3%), respectively. No patient in group A underwent exenteration. Eleven (78.6%) patients in group B underwent orbital exenteration. Of the 6 expired patients, 5 (83.3%) were in group B (P<0.0001). Peri-orbital ecchymosis and intracranial air extension were observed in 2 (13.3%) and 1 (6.7%) in group A patients, respectively. Conclusions : Intra-orbital amphotericin injection under CT-guidance can be considered as a highly effective method in patients with orbital mucormycosis. This method may decrease exenteration without increasing mortality of patients.

Exploring the globe salvaging treatment options in patients of COVID-19-associated mucormycosis with orbital involvement.

Purpose: To explore the various globe salvaging treatment strategies for patients with coronavirus disease 2019-associated mucormycosis (CAM). Methods: This was a prospective: interventional analytical study conducted at a Medical College in rural India. A total of 84 patients of CAM admitted between May 2021 and August 2021 were enrolled for the study. Patients with histologically proven CAM with clinical and/or radiological evidence of orbital involvement were divided into three treatment categories based on the site and extent of the lesion. Re-assessment was performed after 7 days. For patients who worsened with the primary approach, orbital exenteration was considered based on a Sion Hospital Scoring System. A novel approach to intra-orbital anti-fungal therapy, site-centered peri-bulbar injection of amphotericin B (SCPeriAmB), was also explored. All the patients were followed up for at least 3 months. Convenience sampling with descriptive statistics was used. Results: Six patients had to finally undergo exenteration by the end of the study period. The rest of the patients were reported to be stable or improved. No mortalities were reported on delaying the exenteration. No adverse events were noted in patients who were given SCPeriAmB. Conclusion: Globe salvaging treatment options should be advocated as a primary approach in patients with CAM. Site-centered peri-bulbar injections can be considered as an approach for delivering intra-orbital anti-fungal therapy in selected patients.

Rhino-orbital mucormycosis in a patient with no susceptibility following P.vivax malaria infection-a case report.

BACKGROUND: Mucormycosis is a potentially lethal, angioinvasive fungal infection caused by the Mucoracea family comprising Mucor, Rhizopus, and Absidia species. It is commonly associated with uncontrolled diabetes mellitus, the use of corticosteroids, immunosuppressive drugs, and Covid-19 infection. The occurrence of mucormycosis in an immunocompetent patient is rare. Also, only a few case reports have been published where patients developed mucormycosis with associated malarial infection. CASE PRESENTATION: A young female presented with a 3-weeks history of painful swelling and outward protrusion of the right eye with complete loss of vision. She had a history of P.vivax malaria two weeks before her ocular symptoms. On ocular examination, there was proptosis and total ophthalmoplegia with loss of corneal sensations in the right eye. Hematological examination revealed normocytic normochromic anemia and thrombocytopenia. MRI was suggestive of right-sided pansinusitis and orbital cellulitis with right superior ophthalmic vein thrombosis and bulky cavernous sinus. Nasal biopsy was negative for fungal culture. An emergency surgical debridement of all the sinuses was done with right orbital exenteration. Histopathology confirmed the diagnosis of mucormycosis and the patient improved post-operatively on systemic antifungals. CONCLUSION: Such an association of mucormycosis with malaria infection is rarely reported in the literature and is hypothesized to be a result of immunosuppression caused by malaria. Also, emphasis is laid upon having a high index of suspicion for fungal infection in the setting of pansinusitis even if the risk factors are absent. We hereby report a case of rhino-orbital mucormycosis following P.vivax malaria in a 20-year-old female with anemia and thrombocytopenia.

Pelvic Exenteration for Locally Advanced Rectal Cancer: an Initial Experience from North-east India.

Pelvic exenteration is a surgery done to achieve margin negative resection in locally advanced rectal cancer infiltrating pelvic organs anterior to it. A retrospective observational study of patients undergoing pelvic exenteration for locally advanced rectal cancer was done at a single surgical unit of a tertiary care cancer centre. The period of study was from 1st January 2019 to 30th June 2021. A total of twelve patients underwent pelvic exenteration for locally advanced rectal cancer during the study period. The median duration of surgery was 310 min (range 250 to 380 min). The median duration of hospital stay was 14 days (range 12 to 30 days). Seven patients had documented postoperative complications, either major or minor, with a complication rate of 58.3%. Three patients required re-admission for complications. Two patients had COVID19 infection in the postoperative period but had uneventful recovery. Margin negative resection (R0) was achieved in eight patients (66.67%). Pelvic exenteration for locally advanced rectal cancer is a definitive surgery associated with a high morbidity rate. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01529-3.

Outcomes of Transcutaneous Retrobulbar Amphotericin B in Rhino-Orbital-Cerebral Mucormycosis Among Patients Recovering From COVID-19: A Preliminary Experience.

Background In this study, we aimed to assess the outcomes of transcutaneous retrobulbar injection of amphotericin B (TRAMB) in rhino-orbital-cerebral mucormycosis (ROCM) among patients recovering from coronavirus disease 2019 (COVID-19). Methodology This retrospective study was conducted at a tertiary care center in eastern India from May 29th to July 31st, 2021, and included post-COVID-19 patients admitted with stage 3 and 4a ROCM who underwent TRAMB. The details of the ophthalmic examination, laboratory investigations, and radiological examination were retrieved from patients records. Patients were given TRAMB (3.5 mg/mL) on alternate days till they underwent debulking surgery and resumed from the second postoperative day alternatively till the patients showed clinical stabilization or improvement. Results In total, 45 eyes of 41 patients were included in the study. The median number of injections given was six (minimum = 3; maximum = 10). Following was the distribution of number of injection needed in each eye: eight eyes (three injections), six eyes (four injections), seven eyes (five injections), three eyes (six injections), eight eyes (seven injections), 11 eyes (eight injections), and one eye had received nine and ten injections each. Overall, 21/32 (65.62%) eyes had improvement in proptosis whereas 9/32 (28.12%) had improvement in ptosis. Six patients had improvement in extraocular movement. In total, 25 eyes had no improvement whereas seven eyes had improvement in vision. Four eyes underwent exenteration. All nine patients with limited orbital disease had good improvement with fewer injections (median = 4). None of the patients undergoing TRAMB had an intracranial extension of disease. Moreover, 8.88% (4/45) of the eyes had post-TRAMB transient inflammation which resolved without any intervention. Finally, 3/41 of the patients died. Conclusions TRAMB can be considered as an useful therapeutic adjunct in managing ROCM. Further, it can halt the progression of the disease while awaiting definitive surgical intervention.

Post COVID-19 Rhino Orbito Cerebral Mucormycosis: Who is the Real Culprit

Aim and background: Coronavirus disease 2019 (COVID-19) pneumonia has been frequently associated with symptoms such as shortness of breath, cough, loss of sense of smell, fever, and fatigue. Patients with preexisting conditions such as hypertension, diabetes mellitus, or coronary artery disease are especially susceptible to compilations arising from COVID-19 pneumonia. Patients with poorly controlled diabetes mellitus or those that are immunocompromised are at an increased risk of developing mucormycosis. Objective: To study the possible association between invasive fungal sinusitis (mucormycosis) and COVID-19. Materials and methods: A retrospective observational study was conducted at a tertiary care centre over 4 months, involving all patients with rhino orbito cerebral mucormycosis suffering from or having a history of coronavirus disease infection. Results: Seventy patients presented with mucormycosis, 65 had an association with COVID-19. The maxillary sinus and the anterior ethmoidal sinuses were the most common sinuses affected. Intra-orbital extension was seen in 30% of cases, while intracranial extension was only seen in 6%. Diabetes mellitus was present in 65 cases and was uncontrolled in 45 cases. All patients had a history of steroid use during their coronavirus treatment and 10% had tocilizumab administration. All 70 patients underwent surgical debridement, of which 21 had undergone orbital exenteration. Overall mortality was 7.6%, but with significant morbidity in survivors. Conclusion: Multiple manifestations and complications of COVID-19 are emerging as the pandemic is progressing. Mucormycosis emerged as a major health care problem with lots of morbidity and mortality, especially in the Indian subcontinent. Overzealous use of immunosuppressants along with uncontrolled diabetes was the major causative factor. Early diagnosis and early surgical debridement was the key to survival.