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.

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.

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.

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.

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.

Clinical Features and Mortality of COVID-19-Associated Mucormycosis: A Systematic Review and Meta-Analysis

Rationale. Invasive fungal infection secondary to the coronavirus disease 2019 (COVID-19) has been increasing. Whereas COVID-19-associated pulmonary aspergillosis has been shown to be associated with high mortality, less is known about COVID- 19-associated mucormycosis (CAM). The overall mortality of non-COVID-19 mucormycosis ranges from 20% to 100%, depending on the infection site. Delayed diagnosis, neurological symptoms, and pre-existing malignancies are associated with worse outcomes. Herein, our study aimed to elucidate the characteristics, risk factors, and outcomes of CAM. Methods. We searched all observational studies reporting CAM through PubMed and EMBASE on September 13th, 2021. Case reports, case series, and observational studies without clearly documented diagnostic criteria for COVID-19 or mucormycosis were excluded. We collected data on the comorbidities, initial symptoms, site of infection, treatment for COVID-19, frequency of orbital exenteration, and mortality. One-group meta-analyses were performed for the potential risk factors, orbital exenteration, and mortality. Results. Our systematic review identified 32 eligible observational studies. The largest number of studies were conducted in India, followed by Egypt, Iran, and Turkey. A total of 4,463 patients were included in the analysis. The most common initial presentation was ocular symptoms: 78%, followed by facial: 48%, nasal: 21%, constitutional: 12%, oral: 4.4%, neurological: 1.1%, and others: 0.4%. Diabetes mellitus (DM) and glucocorticoid therapy were present in 81% (95% CI, 76-86;I2=96%) and 79% (95% CI, 75-84;I2=91%), respectively. Among those with DM, the percentage of newly-diagnosed DM was 30% (216/711). Diabetic ketoacidosis, malignancy, and immunosuppression were found in 4.9% (165/3353), 0.7% (25/3471), and 0.6% (18/2921), respectively. Regarding the outcomes, orbital exenteration was performed in 17% (95% CI, 13-21;I2=83%) of the patients. Pooled estimate of mortality of CAM was 29% (95% CI, 22-36;I2=94%). Conclusion. The most prevalent type of CAM was rhino-orbital-cerebral mucormycosis. In addition to DM, severe hyperglycemia and immune dysregulation provoked by excessive corticosteroid therapy may have played a critical role in the recent rise of mucormycosis cases among COVID-19 patients. This systematic review and meta-analysis revealed a high frequency of orbital exenteration and mortality. The development of CAM can be associated with poorer prognoses in COVID-19 patients. Keeping the possible risk factors in mind and paying attention to the usual clinical presentation will be crucial to suspect CAM as early as possible.

Management of Post COVID Mucormycosis -Maxillectomy

Background:Mucormycosis has been increasingly described in patients with covid 19 2nd wave (delta variant) which is a highly contagious disease caused by SARS-COV-2 is the leading cause of global pandemic. AIM AND OBJECTIVES: To evaluate etiology, indications, management options and complications in patients managed with endoscopic and external maxillectomy after mucormycosis, to evaluate the incidence and distribution of cases who had extensive mucormycosis and to evaluate the outcome of the management options. Materials and Methods: This is a prospective study done in 30 cases at a tertiary care centre.All the patients were subjected to detailed history taking, clinical examination, endoscopic, radiological, pathological, microbiological investigations after taking informed consent. Patients with age group(30yrs -70yrs) who presented with ROM with extensive maxillary sinus involvement and destruction of different walls of the maxillary sinus were managed with different types of maxillectomies. Results: In this study, 30 cases of post covid rhinoorbital mucormycosis who presented to our hospital were studied, among male 24(80%) & females6 (20%).12 patients (40%) were in 5th to 6th decade and 9 patients (30%) in 4th to 5th decade.Main presenting features were unilateral cheek pain, cheek swelling, nasal obstruction, loosening of teeth, tooth ache, cheek numbness, headache, periorbital edema, visual disturbances being present in 95% of the patients.5% presented with epistaxis, ptosis, diplopia alone.90% patients were known case of diabetes milletus,10% are denovo diabetes.All the patients were subjected to routine blood investigations, microbiological, radiologicalinvestigations.(CT, MRI contrast- PNS, Orbit & Brain).Most commonly seen in males 80%. 1 patient had to undergo orbital exenteration,3 patients underwent palatal resection. Conclusion: Debridement of sinuses is necessary in all cases of mucormycosis so that the fungal reservoir could be removed and the antifungal therapy can reach the viable areas. Therefore the management of mucormycosis is individualised to each patient based on the extension of the disease and overall general conditon of the patient.

Clinical outcome of orbital apex syndrome in COVID associated mucormycosis patients in a tertiary care hospital.

AIM: To share clinical pattern of presentation, the modalities of surgical intervention and the one month post-surgical outcome of rhino-orbito-mucormycosis (ROCM) cases. METHODS: All COVID associated mucormycosis (CAM) patients underwent comprehensive multidisciplinary examination by ophthalmologist, otorhinolaryngologist and physician. Patients with clinical and radiological evidence of orbital apex involvement were included in the study. Appropriate medical and surgical intervention were done to each patient. Patients were followed up one-month post intervention. RESULTS: Out of 89 CAM patients, 31 (34.8%) had orbital apex syndrome. Sixty-six (74.2%) of such patients had pre-existing diabetes mellitus, 18 (58%) patients had prior documented use of steroid use, and 55 (61.8%) had no light perception (LP) presenting vision. Blepharoptosis, proptosis, complete ophthalmoplegia were common clinical findings. Seventeen (19.1%) of such patients had variable amount of cavernous sinus involvement. Endoscopic debridement of paranasal sinuses and orbit with or without eyelid sparing limited orbital exenteration was done in most cases, 34 (38.2%) patients could retain vision in the affected eye. CONCLUSION: Orbital apex involvement in CAM patients occur very fast. It not only leads to loss of vision but also sacrifice of the eyeball, orbital contents and eyelids. Early diagnosis and prompt intervention can preserve life, vision and spare mutilating surgeries.

COVID-19 associated rhino-orbital-cerebral mucormycosis-an institutional series.

Mucormycosis is almost always confined to the patients with altered host defenses amongst which diabetes is considered as the strongest risk factor. COVID-19 only been seen in severe cases but also in mild and moderate cases of SARS-CoV-2 infections. After preliminary clinical and radiological diagnosis, surgical management in the form of endoscopic sinus surgery, debridement, and orbital exenteration (8) was performed. Medical management in the form of antifungal therapy (amphotericin-B, posaconazole, and isavuconazole) was initiated. In this case series, 79 proven cases of COVID-19 associated rhino-orbital-cerebral mucormycosis were analyzed retrospectively from mid-April 2021 to mid-September 2021. 67 patients were known diabetics, whereas rest 12 had new onset diabetes mellitus. Of these 79 cases, 27 cases had the disease limited to sinuses (rhino-mucormycosis), 43 had orbital involvement also (rhino-orbital mucormycosis), and 9 had cerebral involvement as well (rhino-orbital-cerebral mucormycosis). During this time-period, a total of 14 mortalities occurred. Most of the patients were discharged after completion of amphotericin-B therapy and rest stayed little longer till their general condition improved. COVID-19 causes dysregulation and alteration of immune response in the body which predispose to invasive fungal infections. In addition, uncontrolled diabetes mellitus and corticosteroid treatment increase the risk of mucormycosis by many folds.

Post COVID-19 mucormycosis: A case series

Objective: To evaluate the associated factors between COVID-19 and mucormycosis. Methods: Twenty-two patients of COVID-19 associated mucormycosis (including 3 asymptomatic patients who were cured of COVID-19) from a single medical unit of our institute were included. A detailed history was noted, with special emphasis on the time of onset of mucormycosis symptoms, presence of comorbidities, including new onset diabetes, severity of COVID-19, oxygen requirement, details of receipt of steroids and immunomodulators such as tocilizumab, imaging findings, including the number of sinuses involved, bony erosions, orbital and cerebral involvement, microscopy, culture and histopathology reports and antifungals given. Surgical interventions including number of debridements, orbital exenteration, maxillectomy, and the vaccination status were noted. Results: All 22 patients had rhino-orbital cerebral mucormycosis, 27.27% in the first wave and 72.73% during the second wave. Diabetes was the commonest comorbidity, and 40.91% patients were newly detected diabetics. The time of presentation in relation to their COVID-19 symptoms was 8-15 days (average 12.5 days). Ten out of 22 (45.45%) had asymptomatic or mild COVID-19 and 40.91% did not require supplemental oxygen. Five out of 22 (22.73%) did not receive steroids. Twelve out of 22 (54.55%) had orbital involvement, 3 (13.64%) had palatal ulcer and 4 (18.18%) had cerebral involvement and all these had progressed in spite of treatment with appropriate antifungals. Conclusions: COVID-19 associated mucormycosis is a frequent, lethal, post COVID-19 complication, occurring even in mild and asymptomatic cases who have not received steroids or oxygen.

Correlates of depression, anxiety, self-esteem, and suicidal ideas in COVID-associated mucormycosis patients and the effects of treatment.

AIM: The aim was to study the correlates of depression, anxiety, self-esteem, and suicidal ideas in patients of COVID-associated mucormycosis (CAM) and effects of treatment. MATERIALS AND METHODS: A cross-sectional, analytical study was performed in a tertiary care center in Western Maharashtra. By purposive sampling, 34 patients of CAM were included in the study with their informed consent and after obtaining ethical clearance. A self-made questionnaire to include demographic and clinical details was filled. Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-Esteem Scale (RSES), and Suicidal Ideation Attributes Scale (SIDAS) were applied after initial diagnosis. The HADS, RSES, and SIDAS were reapplied after their operative treatment. RESULTS: A significant reduction in anxiety and depression scores postoperatively was seen. No significant difference was found in self-esteem or suicidal ideas postoperatively in the study population. However, patients who underwent orbital exenteration showed a significant reduction in level of self-esteem with anxiety and depression postoperatively. No specific correlation was found between the computed tomography score, family history, intensive care unit admission, or orbital exenteration with anxiety, depression, self-esteem, and suicidal ideas. CONCLUSION: Levels of anxiety and depression in patients of CAM reduced significantly after treatment, but self-esteem worsened in males more than females owing to disfigurement. There is a need of psychological counseling in patients of mucormycosis undergoing a debilitating surgery both pre- and postoperatively for a better outcome and recovery.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1.

Purpose: COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management. Methods: This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021. Results: Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05). Conclusion: : Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.