[COVID-19 associated sino-orbital mucormycosis]. / COVID-19-assotsiirovannyi sinoorbital'nyi mukormikoz.

OBJECTIVE: To analyze the dynamics of symptoms in patients with COVID-19 associated sino-orbital mucormycosis. MATERIAL AND METHODS: We describe a series of 13 patients with COVID-19 associated sino-orbital mucormycosis aged 43 to 80 years diagnosed from August to October 2021. All of the patients had a severe disease and required noninvasive ventilation or intubation and administration of dexamethasone. 12 out of 13 patients (92.3%) suffered from diabetes mellitus. Symptoms of fungal infections of the nose and paranasal sinuses appeared in the interval from 7 to 25 days of hospital stay, most often in the second week (from 8 to 12 days). According to clinical and CT features the patients were divided into three groups, combining similar phenotypes of the disease. Group 1 - 1 patient with sinonasal mucormycosis, destruction of the alveolar ridge and the hard palate. Group 2 - 12 patients with sino-orbital mucormycosis. We noted, that in cases of bilateral sinus lesions orbital complications were unilateral in all patients, on the side of more severe lesion. Group 2 was divided into 2 subgroups: subgroup 2a included 2 patients with the superior orbital fissure syndrome: ptosis, proptosis, ophthalmoplegia, periorbital pain, pain or hypoesthesia of half face; subgroup 2b included 10 patients with the orbital apex syndrome, who, in addition to the above symptoms, had loss of vision and conjunctival chemosis. Group 3 - rhino-sino-cerebral mucormycosis. 2 patients from subgroup 2b were transferred to this group due to the intracranial spread of the process and focal neurological symptoms. CONCLUSION: Clinical forms of mucormycosis reflect successive stages of invasive spread of fungi.

Multiple maxillary periodontal abscesses as a manifestation of post-coronavirus disease 2019 mucormycosis: a case report.

BACKGROUND: Coronavirus disease 2019 makes patients more susceptible to superinfection of fungal disease as a consequence of immunological system impairment. Mucormycosis is a fungal infection that is rare but has a high mortality rate and mostly affects patients with poorly controlled diabetes mellitus or those receiving corticosteroids. CASE PRESENTATION: Here, we present a case of post-coronavirus disease 2019 mucormycosis in a 37-year-old Persian male presenting with multiple periodontal abscess with purulent discharge and necrosis of maxillary bone (without oroantral communication). Surgical debridement following antifungal therapy was the treatment of choice. CONCLUSION: Early diagnosis and immediate referral are the cornerstone of comprehensive treatment.

The mucormycosis and stroke: The learning curve during the second COVID-19 pandemic.

BACKGROUND: The Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM. METHODS: We conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM. RESULTS: Stroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes. T CONCLUSION: Due to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech).

Rhizopus homothallicus rhino-orbital-cerebral mucormycosis: Six cases from a tertiary care Centre, North India.

OBJECTIVE: To report six cases of Rhizopus homothallicus rhino-orbital-cerebral mucormycosis in North India between April 2021 and July 2021. CASE DETAILS: All six patients had diabetes, concomitant SARS-CoV-2 infection, a history of oxygen requirement and steroid intake. Among these six cases 4 were female. All patients presented with sinus pain and peri-orbital swelling. COVID-19-associated mucormycosis (CAM) was diagnosed based on microbiological examination of the biopsied tissue, and its staging was determined radiologically by CT and MRI. Three patients were in stage III-C, the others were in stage II-C, II-D and IV-A. A multidisciplinary team treated the patients with extensive surgical debridement of the affected tissue, correction of predisposing comorbidities and administration of an antifungal agents. Patients were followed up for 6 months with routine direct nasal endoscopy to check the sinonasal cavity for any recurrence. All the six patients survived at 6 months of follow-up. CONCLUSION: A timely initiated multidisciplinary team-based approach can reduce the mortality in rhino-orbital-cerebral mucormycosis cases caused by R. homothallicus.

Rhino-orbito-cerebral mucormycosis and its resurgence during COVID-19 pandemic: A review.

This study aimed to review the current literature for epidemiology, pathogenesis, clinical spectrum and management of rhino-orbito-cerebral-mucormycosis (ROCM), especially highlighting the association between ROCM and COVID-19 disease and factors resulting in its resurgence during the pandemic. Mucormycosis is a rare, but an important emerging opportunistic fungal infection, often associated with high morbidity and mortality. ROCM is the commonest and also the most aggressive clinical form occurring in debilitated patients in conjunction with sinus or para-sinus involvement due to the propensity for contiguous spread. Recently ROCM has shown an unprecedented resurgence during the current pandemic. Reports from different parts of the world indicated an increased risk and incidence of ROCM in patients who had required hospital admission and have recovered from moderate-to-severe COVID-19 disease. A majority of mucormycosis cases have been reported from India. The presence of diabetes mellitus (DM) and use of corticosteroids for COVID-19 pneumonia were found to be the key risk factors, resulting in higher mortality. Amidst the ongoing pandemic, with the third wave already having affected most of the world, it becomes imperative to adopt a risk-based approach toward COVID-19 patients predisposed to developing ROCM. This could be based on the most recently published literature and emerging data from centers across the world. The present review intended to elucidate the causes that brought about the current spike in ROCM and the importance of its early detection and management to reduce mortality, loss of eye, and the need for mutilating debridement.

COVID-19 associated mucormycosis: A case report in Pakistan and a review of 144 cases.

Mucormycosis is the third most common mycosis in order of its importance as a human pathogen, occurrence of which has become more frequent around the world. Although not proven as a causal association, the increased number of cases has been attributed to Covid-19, the rampant use of corticosteroids, and diabetes. We report the case of a 53-year-old male with mucormycosis related to a Covid-19 infection as the novel case from Pakistan and discuss its epidemiology, diagnostic principles, and management. In our literature review, this is the 145th case being reported with most cases occurring in India, mostly in males, of rhino-orbital form and about a third of them leading to the death of the patient.

Diabetic ketoacidosis and coronavirus disease 2019-associated mucormycosis: a case report.

BACKGROUND: Mucormycosis is a rare, life-threatening fungal infection that affects immunocompromised hosts. Diabetes mellitus is a common predisposing condition and most often presents with rhino-orbital-cerebral infection. Association with coronavirus disease 2019 infection was revealed following a resurgence in cases of mucormycosis during the second wave of the pandemic wherein poorly controlled diabetes mellitus was the most significant risk factor in the affected population. Rhino-orbital-cerebral mucormycosis has a high mortality rate, and cerebral involvement is a poor prognostic factor. Herein, we report a case of newly diagnosed diabetes mellitus with concurrent coronavirus disease 2019 infection complicated by diabetic ketoacidosis and rhinocerebral mucormycosis at presentation, describe the diagnostic and therapeutic challenges, and discuss the interventions that ultimately resulted in a favorable clinical response. CASE PRESENTATION: We describe the case of a previously healthy 13-year-old African American female patient with newly diagnosed diabetes mellitus and concurrent severe acute respiratory syndrome coronavirus 2 infection whose disease course was complicated by rhinocerebral mucormycosis. She presented with fever, altered mental status, and Kussmaul respirations and was diagnosed with diabetic ketoacidosis with concern for cerebral edema. Concern for infectious cerebritis arose due to recurring fevers and persistently altered mental status despite correction of her metabolic derangements. This raised concern for infectious cerebritis and prompted evaluation with serial head imaging, lumbar puncture, and initiation of broad empiric antimicrobial regimen. Head imaging revealed an evolving cerebral abscess, and fungal deoxyribonucleic acid was identified on blood metagenomics testing, which ultimately confirmed the diagnosis of rhinocerebral mucormycosis. Treatment was challenging as she required surgical debridement of the frontal lobe and aggressive antifungal therapy complicated by electrolyte derangements and electrocardiogram changes that necessitated modification of the antimicrobial regimen. Despite these challenges and high mortality rate, the patient was discharged from the hospital in stable condition to inpatient rehabilitation service for reconditioning after prolonged hospitalization. CONCLUSION: Rhinocerebral mucormycosis mortality is associated with delays in therapeutic interventions, thus a high index of suspicion and early recognition were essential for timely initiation of antifungal therapy and surgical debridement.

Post COVID-19 rhinocerebral mucormycosis: a case report and literature review.

The pandemic of coronavirus disease 2019 (COVID-19) still remains on an upsurge trend. The second and the waves of this disease have led to panic in many countries, and some parts of the world suffering from the fourth wave. In the midst of this pandemic, COVID-19 patients are acquiring secondary infections such as mucormycosis also known as "black fungus disease". Mucormycosis is a serious, but rare opportunistic fungal infection that spreads rapidly, and hence prompt diagnosis and treatment are necessary to avoid mortality and morbidity rate. We report in this paper, a case of a diabetic patient who presented with bilateral nasal obstruction, anosmia, and frontal headache diagnosed with rhinocerebral mucormycosis developing after COVID-19 infection with a favorable outcome after a medico-surgical treatment. Through this case, we aim to aware patricians of this possible association and the importance of early diagnosis to optimize treatment outcomes.

[COVID-19-associated mucormycosis in ophthalmological practice in the Volgograd region]. / COVID-19-assotsiirovannyi mukormikoz v oftal'mologicheskoi praktike Volgogradskogo regiona.

The problem of fungal infections in the era of COVID-19 has acquired special significance. This infection, directly or indirectly, through the use of glucocorticoids and antibiotics in its treatment, as well as poorer self-management of chronic diseases, has led to a wide spread of risk factors for fungal diseases among people who have had a novel coronavirus infection. The article presents two cases of COVID-19-associated mycosis, more related to mucormycosis, which were diagnosed by ophthalmologists in the Volgograd region. In the first case, the severe course of rhino-orbito-cerebral form of mucormycosis required a number of surgical interventions and prolonged treatment in the intensive care unit. In the second case, the patient asked for help without signs of aggravation of the general condition, but with irreversible local manifestations. In both cases, the eyeball was removed. Morphological examination revealed aseptal ribbon hyphae of different diameters, branching mainly at right angles, more typical for fungi of the Mucorales family. Due to the severe consequences of the disease, clinicians, including ophthalmologists, need to be especially alertness in patients with the described symptoms and risk factors in the post-COVID period.

Rhino-orbital mucormycosis.

PURPOSE OF REVIEW: The current article will update and review the clinical and radiological manifestations and management of rhino-orbital mucormycosis (ROM). RECENT FINDINGS: There has been an increase in cases of ROM worldwide, especially in India. Immunosuppression (especially diabetes mellitus) is a known predisposing risk factor for ROM. Delayed diagnosis and treatment of ROM can be vision or life-threatening. This article reviews the clinical and radiologic features, treatment, and prognosis of ROM with special emphasis on new and emerging therapies. SUMMARY: ROM is an angioinvasive fungal infection that affects the sinuses and orbits and may present to ophthalmologists. Clinicians should have a high index of suspicion for ROM, especially in patients with poorly controlled diabetes mellitus or other immunosuppression. Corticosteroid treatment (including the recent COVID-19 pandemic) may be a predisposing risk factor for ROM.

Risks of mucormycosis in the current Covid-19 pandemic: a clinical challenge in both immunocompromised and immunocompetent patients.

Mucormycosis, also called "Black Fungus", is a new cause for worry in the current Coronavirus disease 2019 (covid-19) pandemic. Mucormycosis is devasting due to its high rate of morbidity and mortality which is a great cause of concern. Mucormycosis, in general, affects immunocompromised patients including diabetic, people with malignancies, organ and stem cell transplants and people affected with pandemic diseases like covid-19. Diagnosis of Mucormycosis is often delayed either due to clinical complications or misdiagnosed as symptoms of other diseases, especially covid-19. This could delay the treatment protocol which results in the failure of treatment. Mortality rate due to secondary infections in covid-19 patients with uncontrolled diabetics and who are on steroid therapy can soon reach 100% if diagnosis and treatment doesn't happen on timely basis. Risk of Mucormycosis is not just in immunosuppressed patients, but immunocompetent people with late diagnosis are also prone to infection. In view of this, we present a comprehensive review on risks of Mucormycosis in immunocompromised and immunocompetent patients highlighting the epidemiology, forms of Mucormycosis, immune response against Mucorales, difficulties in diagnosis and challenges in treatment of Mucormycosis, with emphasis on covid-19 associated Mucormycosis. Importantly, we have discussed the precautions and care to effectively manage Mucormycosis in immunocompromised and immunocompetent patients. Thus, current review helps clinicians in understanding various risk factors in both immunocompromised (especially covid-19 patients) and immunocompetent patients which is critical in managing Mucormycosis in current covid-19 pandemic.

A case series of mucormycosis after covid infection in two hospitals.

This paper aims to discuss clinical aspects of mucormycosis. This case series was conducted in two services, comprising six mucormycosis cases during COVID-19 pandemic. About gender, there are 4 (66.7%) males and 2 (33.3%) females with mean age (48.7 ± 9.4) years. All cases presented complaints of pain and swelling in oral cavity and had an aggressive clinical presentation. Five patients had diabetes and one had a nasal non-Hodgkin lymphoma. Histologically, large, branched, hyphae associated with necrotic areas were observed, confirming microscopically such as mucormycosis through PAS and GMS stains. In four cases, treatment consisted in surgical debridement associated with antifungal therapy. All patients were submitted to debridement and received antifungal treatment (amphotericin B). Five patients were followed up without clinical recurrence, but unfortunately one patient died. Diagnosis of mucormycosis should be early because it is related to high mortality. The treatment consists of surgical debridement associated with antifungal therapy.

Analysis of COVID-19-associated rhino-orbital-cerebral mucormycosis patients in a tertiary care center in Northern India.

Purpose: An unprecedented surge has been noted in rhino-orbital-Cerebral mucormycosis (ROCM) in times of current COVID-19 pandemic. The present prospective study aims to evaluate clinico-epidemiological profile, risk factors, management, and outcome of the cases of ROCM that presented to our tertiary care center during the study period from April to June 2021. Methods: All patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were staged and were treated with intravenous liposomal amphotericin B (AMB) and sino-nasal debridement of local necrotic tissue. Transcutaneous retrobulbar AMB (TRAMB), orbital decompression, and exenteration were instituted as indicated. All patients were followed up for a minimum of 6 months before arriving at the final outcome. Statistical analysis was performed. Results: A total of 49 patients presented during the study period, with a mean age of 42.2 years. The major risk factors included uncontrolled diabetes (89.8%), COVID-19 positivity (51.02%), and concurrent steroid use (38.77%). The most common presenting symptom was facial pain/swelling (43.65%), while the most common presenting sign was deterioration in vision (75.51%). Intravenous liposomal AMB was given to all patients along with sino-nasal debridement (85.71%), TRAMB (57.14%), orbital decompression (14.28%), and exenteration (12.24%). Overall, mortality at 6 months was 22.45% (11 patients). Age more than 60 years, intracranial extension, and HbA1c of more than 8.0% were observed to be statistically significant indicators of mortality. Conclusion: Early suspicion and timely diagnosis of mucormycosis at rhino-orbital stage is warranted in order to salvage life as well as visual function. TRAMB may prove as potentially favorable treatment modality in cases with limited orbital involvement.

Knowledge, attitude, and practice toward mucormycosis among patients presenting to six tertiary eye care hospitals in South India - A multicentric online questionnaire-based survey.

Purpose: To study the awareness on mucormycosis among outpatients who visited six tertiary eye care hospitals at Madurai, Pondicherry, Coimbatore, Tirunelveli, Chennai, and Tirupati. Methods: This was a telephone-based survey conducted using questionnaires consisting of 38 questions in five sections from July 5 to 25, 2021. Patients visiting the eye hospitals for an examination were contacted over their phones and responses were directly entered onto the Google forms platform. Results: A total of 4573 participants were included in the study. Among all participants, a cumulative 83% of participants had some knowledge of mucormycosis. More than 80% of them reported that their prime source of information was through mass communication like television or radio. Around 34.8% of the respondents were aware that it can occur after treatment for coronavirus disease 2019 (COVID-19) infection, only half of them (54.3%) knew that systemic steroids were the main risk factor. The knowledge scores were higher for participants who were diabetics (n = 1235) or had been affected by COVID-19 earlier (n = 456) or whose friends had mucormycosis earlier (n = 312). Knowledge, attitude, and practice (KAP) scores of nonprofessional health-care workers (n = 103) were much better compared to patients. Conclusion: Such KAP studies give us an idea of the impact of the measures taken for educating the public. In this study, a cumulative 83% of participants had some knowledge of mucormycosis and 86% knew that this was an emergency. More than 50% of the participants were not aware that diabetes is a risk factor for mucormycosis.

The Past, Present and Future of COVID-19 Associated Mucormycosis: A Rapid Review.

Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2, which is known for the multiple mutations and forms that have rapidly spread across the world. With the imminent challenges faced by low- and middle-income countries in curbing the public health fallbacks due to limited resources, mucormycosis emerged as a fungal infection associated with high mortality. In this rapid review, we explored MEDLINE, Cochrane, Web of Science, WHO Global Database, and the search engine-Google Scholar for articles listed until July 2021 and presented a narrative synthesis of findings from 39 articles. The epidemiology, causative factors, incidence parameters, pharmacological treatment, and recommendations for low- and middle-income countries are enlisted. This study concludes that a majority of the globally reported COVID-19 associated mucormycosis cases stemmed from India. Individuals receiving systemic corticosteroids or who have a history of diabetes mellitus are more prone to contracting the disease. Public health authorities in LMIC are recommended to strengthen antifungal therapies for COVID-19 associated mucormycosis and to strategize reduction in diabetes mellitus prevalence.

Coronavirus disease-associated mucormycosis (CAM): A case control study during the outbreak in India.

The recent second wave of COVID-19 cases in India has been marked by an unexpected increase in cases of mucormycosis reported in the context of COVID illness. Herein we aim to identify risk factors that may explain the sudden surge of cases and help develop preventive strategies. MATERIAL: We performed a case-control study comparing cases diagnosed with CAM and those who had recovered from COVID-19 without developing mucormycosis (controls). Information on comorbidities, glycemic control, and practices related to COVID-19 treatment was recorded. OBSERVATION: 100 patients of CAM (cases) and 150 patients of COVID-19 without mucormycosis (controls) were included in the study. The spectrum of involvement of CAM cases included rhino-sinus (n=98, 98%), rhino orbital (n=58, 58%), rhino-orbito-cerebral (n=29, 29%). In CAM group symptoms of mucormycosis began a mean of 13.46 days after onset of COVID-19. The mean age of the CAM study group was 51.16 years with 69 males (69%) and 31 females (31.0). The most frequent comorbidities seen in our study population was diabetes (n=113, 45.2%) and hypertension (n=54, 21.6%). Diabetes was significantly more frequent among cases than controls (89% vs 24%, p <0.001). 31% of patients in CAM case group showed a common practise of steam inhalation during covid illness. Most common symptom reported in CAM was related to the eye which included eye pain (58%), lid swelling (54%), eye swelling (47%). Sino-nasal symptoms were nasal discharge (25%), nasal stuffiness (21%), and epistaxis (4%). Other common symptoms were headache (51%) and facial pain (36%). On examination of nasal cavity, crusting and ulceration were present in 83% patients. Eye involvement was present in 60% of cases, of which 27% of cases had vision loss. For definitive diagnosis of CAM, Potassium hydroxide (KOH) mount was positive for aseptate hyphae in 31 patients (31%). Use of systemic steroids for the management of COVID-19, was more frequent in CAM case group than control group (n=70, 70%). The CAM case group showed mean Hba1c of 10.7 ± 2.45, mean Serum Iron levels was 49.01 ± 18.69, mean ferritin was 913.37, mean CRP was 131.56 and mean LDH was 428.70. CONCLUSION: Overzealous use of steroids, uncontrolled sugars and repeated steam inhalation provided a favourable environment for the growth of mucormycosis. Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis.

Dual Fungal Infections (Aspergillosis and Mucormycosis) in a Diabetic Mellitus Patient Leading to Maxillary Sinusitis as a Post-COVID Manifestation: First Case Report.

Coronavirus infectious disease-19 caused by Severe acute respiratory distress syndrome-coronavirus-2 has emerged to be an emergency global health crisis for more than a year. And, as the disease has spread, a number of new clinical features have been observed in these patients. Immunosuppression caused by this disease results in an exacerbation of pre-existing infections. While corticosteroids are considered a life-saving therapeutic intervention for this pandemic, they have proved to be a double-edged sword and their indiscriminate use has produced some deleterious results. Recently, in the backdrop of this expression, a notable rise in invasive fungal infections has been identified even in the post-remission phase. Mucormycosis, Aspergillosis, and Candidiasis are the three most common opportunistic fungal infections among those observed. COVID-19 patients with diabetes mellitus are already at a higher risk of developing such secondary infections due to impaired immunity. Here we present a rare case report of a 50-year old male diabetic mellitus patient diagnosed with dual fungal infections (Aspergillosis along with Mucormycosis) leading to maxillary sinusitis as a post-COVID manifestation. To our knowledge, this is the first such case reported till date.

Mucormycosis in COVID-19 pandemic: study at tertiary hospital in India.

AIM: During the second wave of COVID-19, cases of mucormycosis were increased suddenly over a period of 3 months in Maharashtra, India. An attempt was made to study the clinical profile and risk factors associated with mucormycosis. MATERIALS AND METHODS: A retrospective descriptive study was carried out at a tertiary hospital during May 2021-July 2021. After obtaining informed written consent from the participants, various details of all participants, such as diabetes mellitus, use of steroids in COVID-19 treatment, use of immunosuppressant drugs, oxygen therapy, use of ventilators, complications that occurred during treatment, etc., were noted. All mucormycosis patients were treated with amphotericin B and aggressive surgical treatment. RESULTS: In the present study, 74.7% of mucormycosis patients were male. 77.4% of mucormycosis patients were above 40 years of age. 6.7% of mucormycosis patients were partially vaccinated. Among risk factors, 86.6% had diabetes mellitus, 84% had COVID-19 infection, 44% had received steroids, and 54.7% had received oxygen. 80% of patients were present during and within 1 month of COVID-19 infection. 52% of patients were presented in stage III and 41.3% were presented in stage II. Despite aggressive surgical debridement along with amphotericin B, mortality was 25.33%. 5.3% of patients had brain abscesses, 8% of patients had cavernous sinus thrombosis, 4% of patients had facial nerve palsy and 1.3% of patients had meningitis. CONCLUSION: Mucormycosis was predominantly seen in male above the age of 40 years COVID-19 infection and diabetes mellitus was common risk factor for mucormycosis.