[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.

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.

Central Retinal Artery Occlusion in Rhino-Orbital-Cerebral Mucormycosis: An Inflammatory-Prothrombotic State.

PURPOSE: The aim was to evaluate patient profiles of rhino-orbital-cerebral mucormycosis (ROCM) cases with central retinal artery occlusion (CRAO) postcoronavirus disease 2019. DESIGN: A nonrandomized retrospective case-control study. METHODS: The ROCM cases presenting with CRAO were compared with a control ROCM group without CRAO at a tertiary care center. Demography, systemic status, clinical features, histopathology, imaging, and blood profile were assessed for any specific risk factors. RESULTS: A total of 12 patients were seen in the CRAO group and 16 in the non-CRAO group. The male-to-female ratio was 3:1 with a mean age of 49.5 years. In the CRAO group, 75% had diabetes mellitus with mean hemoglobin A1c of 9.03%, and 66.7% had received steroid treatment. All cases were histopathologically confirmed positive for mucor. There was a significant difference in mean D-dimer and serum ferritin between the 2 groups, with higher level in the CRAO group. All patients with CRAO had light perception-negative vision, with total ophthalmoplegia and proptosis seen in 66.7% of cases. Four patients had orbital apex involvement, 5 had cavernous sinus involvement, and 8 had intracranial involvement in the CRAO group. CONCLUSIONS: Inflammatory markers D-dimer and serum ferritin were significantly associated with CRAO, suggestive of hyperinflammatory and hypercoagulable state. A high index of suspicion should be maintained in cases with elevated markers and prophylactic anticoagulants can be started to prevent CRAO in a subset of patients.

A retrospective clinicopathological analysis of rhino-orbital mucormycosis in second wave of COVID-19.

Background: During the present surge of COVID-19 positive cases, concurrent multifold increase in the incidence of mucormycosis cases has resulted into significant morbidity and mortality. We retrospectively evaluated the clinicopathological features along with microbiological examination findings in histologically diagnosed cases of rhino-orbital mucormycosis. Material and Methods: All the H and E and special stained slides of included mucormycosis cases were retrieved from the records and were evaluated with microbiological findings including screening KOH mount examination and culture results. Results: Out of 16 cases with available details, 10 cases had the previous history of diabetes mellitus. The most frequent single site of involvement was maxillary sinus (7/25) followed by nasal cavity, orbit, ethmoid and sphenoid sinuses. While comparing the histological diagnosis with KOH mount findings and culture results, 15 cases revealed consistent results. Conclusion: A high clinical suspicion, monitoring, early diagnosis, and timely management can improve the morbidity and mortality of this life-threatening complication.

Long-term outcomes of transcutaneous retrobulbar amphotericin B in COVID-19-associated mucormycosis.

Purpose: To describe the long-term outcomes of transcutaneous retrobulbar amphotericin B (TRAMB) in COVID-19-associated mucormycosis. Methods: In total, 18 cases of COVID-19-associated mucormycosis were reviewed. In addition to the recommended treatment protocol, all patients were to be given 3.5 mg/ml/day of TRAMB for five days. Results: Of the 18 patients, 2 presented with stage 3a disease, 13 had stage 3c disease, and 3 patients had central nervous system (CNS) involvement (stage 4a and 4c). In addition to planned retrobulbar doses, five patients were given more while two patients received fewer injections (i.e., <5). At the last mean follow-up of 34.67 (±8.88) weeks, 11 patients were in radiological regression and 4 had stable disease while 2 patients had to undergo exenteration; one mortality was observed because of disease progression. Clinical regression in terms of visual and ptosis improvement was seen in seven and nine patients, respectively. Conclusion: Rhino-orbito-cerebral mucormycosis is a serious condition which warrants an aggressive treatment strategy. In unprecedented situations witnessed recently, TRAMB turned out to be an effective and economical alternative. Though large randomized studies are needed to establish its efficacy, TRAMB still manages to halt progression and salvage the globe in significant number of patients, and hence its use should be encouraged on a case-to-case basis especially in developing countries with limited resources.

Mortality and its determinants after an outbreak of post COVID-19 associated rhino-orbito-cerebral mucormycosis in Central India.

AIM: To report cumulative mortality rates using survival analysis from an outbreak of 211 patients with post COVID-19 rhino-orbito-cerebral mucormycosis (ROCM) in central India. METHODS: Case files of eligible patients were evaluated and mucor was identified from deep nasal swabs using freshly prepared KOH mount. All patients underwent contrast enhanced MRI and disease staging was done based on the extent of anatomical involvement. All patients received intravenous Amphotericin B and sinus debridement was done when possible. Orbital exenteration was reserved for patients with advanced orbital disease. RESULTS: The mean age was 50.7 ± 10.2 of which 147 (70%) were men. At presentation, ROCM was limited to sinuses in 72 (34%), orbital extension was seen in 102 (48%) and 31 (15%) had CNS extension. Sinus debridement was possible in 82% cases (n = 173). Thirty-five (16.6%) patients died due to ROCM. The mean follow-up of patients who survived was 126.6 ± 16.4 days. The cumulative mortality rate at day 10 was 4.8% (95%CI = 2.6-8.8%) and increased 13.1% (95%CI = 9.1-18.7%) at day 30 and to 18.4% (95%CI = 13.6-24.8%) at day 60. Majority of deaths (n = 26, 75%) occurred within 1-month of ROCM presentation. Multivariable hazards analysis showed that patients with CNS involvement had a 6.5 times higher risk of death (Hazard Ratio = 6.71, 95% CI = 2.9-15.5, p < 0.001). CONCLUSION: We report significantly lower mortality rates compared to recent literature that varies from 30 to 80% at 1-month follow-up. Timely sinus debridement and systemic Amphotericin B can help reduce mortality. Presence of CNS extension significantly increased the mortality risk with patients with ROCM.

Corneal manifestations and treatment among patients with COVID-19-associated rhino-orbito-cerebral mucormycosis.

Purpose: TO report the corneal manifestations in patients with COVID-19-associated rhino-orbito-cerebral mucormycosis (ROCM). Methods: This study was a retrospective, observational, and record-based analysis of patients of ROCM with corneal involvement. Results: A total of 220 patients were diagnosed with ROCM over a period of 3 months. Thirty-two patients had developed corneal manifestations. The mean age at diagnosis was 52.84 ± 12.8 years. The associated risk factors were systemic mucormycosis, uncontrolled diabetes, recent COVID-19 infection, and injudicious use of systemic steroids. Twenty-nine patients were known diabetics, 32 had recent COVID-19 infection, and 13 gave a history of injudicious use of steroids. The right eye (RE) was affected in nine patients, the left eye (LE) in 20 patients, and both eyes in three patients. Nine patients had a round-oval corneal ulcer. One patient each had a perforated corneal ulcer with uveal prolapse, sealed perforated corneal ulcer, spontaneously healed limbal perforation, diffuse corneal haze with hyphemia, panophthalmitis, diffuse corneal stromal abscess, limbal ischemia, anterior uveitis with posterior synechiae, inferior corneal facet, and filamentary keratitis. Three patients each had a corneal melt and inferior conjunctival xerosis with chemosis. Orbital exenteration was performed in six patients. Five patients with corneal ulcers healed. Topical eye drops of amphotericin (0.5 mg/ml) cycloplegic, antiglaucoma medications, and lubricant eye drops were started along with systemic antifungals. Conclusion: Central corneal ulcer was the most common manifestation of mucormycosis. A concentration as low as 0.5 mg/ml of amphotericin eye drops was effective in the treatment.

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.

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.

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.

Retrobulbar Injection of Amphotericin B in Patients With COVID-19 Associated Orbital Mucormycosis: A Systematic Review.

PURPOSE: Following COVID-19 infection a rising count of rhino-orbito-cerebral mucormycosis is observed, requiring orbital exenteration, a disabling lifetime affecting surgery. One of the potential interventions for globe salvage in these patients is retrobulbar injections of amphotericin B. This study was conducted to review protocols, outcomes, and side effects of retrobulbar injection of amphotericin B in patients with COVID-19 associated rhino-orbito-cerebral mucormycosis (CAM). METHODS: The PubMed, Scopus, Web of Science, and Embase databases were searched using a comprehensive string of relevant keywords. All English studies with the confirmed diagnosis of CAM infection were included. We excluded all studies in which retrobulbar injection of amphotericin B was not implemented in any of the patients or there was a lack of clarified and detailed data about this procedure among participants. RESULTS: A total of 647 cases had a history of retrobulbar injection(s) of amphotericin B in 13 reviewed studies with 3,132 subjects of CAM. The most common protocol was the retrobulbar injection of 1 ml of 3.5 mg/ml liposomal amphotericin B for 3 doses daily or on alternate days. We discerned that the globe salvage rate was 95.0% in eyes with a history of retrobulbar injection(s). The total rate of orbital exenteration was 14.9%, regardless of the history of retrobulbar injection of the drug. Other outcomes of this intervention were vision salvage and reduced major ophthalmic complaints, including pain, swelling, chemosis, ptosis, and ophthalmoplegia. The side effects of this intervention were not serious, and most of them were transient. They included swelling at the injection site, restriction of ocular motilities, exacerbation of orbital inflammation, and even intensification of visual impairment in a few cases. CONCLUSIONS: Retrobulbar injection of amphotericin B should be considered a nearly safe and protective intervention against orbital exenteration in patients with CAM. It may also be effective in saving vision. Since the effectiveness of orbital exenteration in the survival of patients is not ascertained, retrobulbar injections can be considered an alternative intervention.

First report of rhino-orbital-cerebral mucormycosis after COVID-19 infection in Bulgaria.

Mucormycosis is a relatively rare infection but with a high mortality rate due to the difficult and time-consuming diagnostic and therapeutic process. The authors present the first case of rhino-orbital-cerebral mucormycosis, histologically and microbiologically proven, in a patient after COVID-19 infection in Bulgaria.

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.

Bilateral blindness in a young male of rhino-orbital-cerebral mucormycosis: A case report.

The storm of COVID-19-associated mucormycosis (CAM) has not yet settled, and it has proven itself a disfiguring and potentially life-threatening disease, complicating the course of COVID-19 infection. Mucormycosis is a rare but devastating fungal infection caused by filamentous fungi of the family Mucoraceae. We report a rare case of a 37-year-old diabetic male with bilateral rhino-orbital-cerebral mucormycosis (ROCM) where it leads to bilateral central retinal artery occlusion (CRAO) as manifestation of the disease. Bilateral CRAO secondary to ROCM is extremely rare. A strong suspicion of CAM in uncontrolled diabetics can result in early diagnosis and management.

Orbital magnetic resonance imaging profile and clinicoradiological correlation in COVID-19-associated rhino-orbital-cerebral mucormycosis: A single-center study of 270 patients from North India.

PURPOSE: To study the clinical profile and magnetic resonance imaging (MRI) features in patients of COVID-19-associated rhino-orbital-cerebral mucormycosis (CA-ROCM) with orbital involvement and perform a clinicoradiological correlation. METHODS: A cross-sectional study was performed at a tertiary care center in north India from May 2021 to June 2021. Consecutive patients with clinical, nasal endoscopic, and/or microbiological evidence of CA-ROCM underwent MRI of paranasal sinuses, orbit, and brain as per the study protocol. Orbital MRI findings were studied in detail and were correlated with clinical signs. RESULTS: Two hundred and seventy patients were studied. The mean age was 48.4 (± 16.82) years. A male predilection was noted (male:female = 1.77). Orbital involvement was seen in 146 (54%) patients on clinical evaluation and in 184 (68%) patients on MRI. Unilateral orbital involvement was more common (134; 92%). The most common presenting symptom was periorbital and/or facial pain (141; 52.2%) and the most common clinical sign was periorbital edema (116; 43%). The most common MRI finding was suggestive of orbital cellulitis (160; 59%). Orbital compartment syndrome was found in 17 (6.3%) patients. The inter-rater agreement between clinical and radiological assessments to detect the involvement of infraorbital nerve and frontal nerve was found to be 85.56%, (κ 0.621) and 93.70% (κ 0.776), respectively. The diagnostic accuracy, sensitivity, and specificity of MRI to detect medial orbital wall defect were found to be 87.9%, 65%, and 97%, respectively. CONCLUSION: Orbital imaging features of a cohort of ROCM patients have been presented with clinicoradiological correlation.

Localized surgical debridement for the management of orbital mucormycosis.

PURPOSE: To describe the role of localized debridement and instillation of amphotericin B for the management of orbital mucormycosis post COVID-19 infection with a view to avoid exenteration. METHODS: The records of all patients with orbital mucormycosis post COVID-19 infection in the last 6 months from December 2020 to June 2021 were evaluated, and ten patients were identified who were successfully managed with localized debridement, that is, removing the fungal tissue and necrotic material and amphotericin B gel instillation locally. MRI scan was used to identify the area of fungal infiltration and presence of necrotic material. Early surgery in the form of transconjunctival orbitotomy was performed for disease in the infraorbital fissure area, and superior transcutaneous lid crease approach was employed for disease in the superomedial orbit or medial orbit. Most patients had lid edema, ptosis, and proptosis; this resolved with the medication. Systemic antifungals were given and the follow-up ranged from 1 to 5 months. RESULTS: The ptosis, proptosis, and lid edema subsided in all, except in one patient who had residual ptosis and in one who had residual ophthalmoplegia. Vision deficit did not occur in any patient. All patients were successfully discharged on oral antifungal medication. CONCLUSION: Localized clearance of the fungal tissue and the necrotic material is a good option to avoid exenteration in cases of orbital mucormycosis, avoiding disfigurement and mental trauma to the patient.

Clinical Profile of Central Nervous System Involvement in Patients with Rhino Orbital Cerebral Mucormycosis.

Mucormycosis is life threatening fungal infection that occurs in immunocompromised patients. Patients at risk are those with poorly controlled diabetes mellitus, immunosuppressed patients such as those undergoing treatment for hematological cancer or recipients of solid organ and hematopoietic stem cell transplantation. COVID 19 infection is known to produce a state of hyper inflammation with release of various cytokines this state of immune dysfunction is associated with development of opportunistic infections, of which Mucormycosis is on the rise currently. The widespread use of corticosteroids can cause secondary infections including mucormycosis. CNS penetration typically starts with nasal involvement followed by the paranasal sinuses and palate, ultimately invading the orbit and brain or by direct hematological spread which is called as Rhino-orbito-cerebral Mucormycosis (ROCM) . MATERIAL: This is a cross sectional study conducted on 50 patients diagnosed with COVID 19 associated mucormycosis admitted to the hospitals attached to BMCRI from May2021 to August 2021.All the ROCM cases with CNS manifestation were included The relevant demographic data, clinical presentation, neurologic manifestations, underlying co morbidity, medical treatments, and surgical interventions done were recorded and analyzed. OBSERVATION: A total of 50 patients were included mean age 49.3 year with 38 males and 12 females .Most common comorbidity was diabetes (94%)followed by hypertension (26%) .Most common symptom was headache (86%) followed by facial swelling (68%), facial pain (66%).40% Patients had CNS symptom among which most common was hemiparesis. EOM restriction(70%) and abnormal vision(70%) being most common examination finding. Most common sinus being involved was maxillary 94% followed by ethmoid sinus 92%. Neurological manifestation included acute infarct (56%), Cavernous sinus thrombosis (28%),ICA occlusion (10%) abscess (34%), 3 patients had dual fungal infection. 26% patient underwent craniotomy, 6%carniotomy with Denkers procedure, 30% underwent maxillectomy. Among the mortality group, average duration of diabetes was 11.5 years, average steroid use of 9.53 days, CRP was 104mg/l, D Dimer 755ng/dl, as compared to 5.89 years, 5.3 days, 58.9mg/l, 419ng/dl, respectively among recovered patients. Most patient were left with morbidity like vision loss and facial disfigurement (40%) being most common while hemiparesis in (14%) patients . CONCLUSION: Diabetes mellitus being the main predisposing factor for ROCM. Delayed diagnosis or inappropriate treatment may result in massive tissue destruction and possible extension into the cranial base and/or vault and orbit. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability.

Study Correlating Neutrophil-Lymphocyte Ratio with Clinical Staging in Mucormycosis Patients.

Rhino-orbital mucormycosis is an aggressive fungal opportunistic infection of the immune-compromised, debilitated patients. The presence of neutrophilia and lymphocytopenia in patients affected with mucormycosis have been reported. Not much study has been done to establish the ratio of neutrophil to lymphocyte as a possible indicator for the severity of Rhino-orbital mucormycosis which is clinical staged. As such, this study aims to find out the relationship of the neutrophil-lymphocyte ratio with the clinical staging of Rhino-orbital mucormycosis in COVID19 recovered patient and if such a ratio can help to identify the severity of the opportunistic fungal infection. MATERIAL: This is a Cross-sectional study done on 100 patients who were diagnosed with Mucormycosis based on radiological findings, post-COVID19 recovery. The neutrophil-lymphocyte ratio was estimated after obtaining the complete blood count of the patient and calculating the ratio by the division of differential Neutrophil by the differential Lymphocyte count. The clinical staging of Mucormycosis was done based on radiological findings. OBSERVATION: The median value of Neutrophil Lymphocyte ratio was found to be elevated in all the clinical stages of Mucormycosis (from stage 2 to 4) at the time of admission as well as discharge considering the normal value of N/L ratio in a healthy individual to be 3. The median N/L ratio was also found to be in decreasing trend as compared from the time of admission to discharge in all the stages 2 to 4 of mucormycosis and was statistically significant (p=0.00) in stage 3 of mucormycosis. CONCLUSION: The Neutrophil-Lymphocyte ratio can be used as a viable marker of severity of mucormycosis and is a good prognostic indicator for resolution of disease especially in stage 3 of mucormycosis. This study helps to reiterate the importance of N/L ratio in the treatment protocol of mucormycosis.