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 Table of Contents  
TEACHING IMAGES
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 173-174

Rhino-Orbito-Cerebral Mucormycosis in COVID-19


Department of Otorhinolaryngology, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangalore, Karnataka, India

Date of Submission24-May-2021
Date of Decision28-May-2021
Date of Acceptance30-May-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Harsh Suri
Department of Otorhinolaryngology-Head and Neck Surgery, Yenepoya Medical College, Yenepoya(Deemed to be University), Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_126_21

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  Abstract 


COVID-19 is associated with a wide range of opportunistic bacterial and fungal infections Mucormycosis is a fatal fungal infection mainly involving the nose, paranasal sinuses, orbit and brain with a high mortality rate.

Keywords: COVID-19, Diabetes mellitus, Mucormycosis


How to cite this article:
Suri H, Rajmohan D, Subramaniam V. Rhino-Orbito-Cerebral Mucormycosis in COVID-19. Arch Med Health Sci 2021;9:173-4

How to cite this URL:
Suri H, Rajmohan D, Subramaniam V. Rhino-Orbito-Cerebral Mucormycosis in COVID-19. Arch Med Health Sci [serial online] 2021 [cited 2021 Aug 1];9:173-4. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/173/319378



A 53-year-old lady with no prior co-morbidities presented with a history of right sided cheek and eye swelling of 5 days duration associated with severe pain which was sudden in onset and gradually progressive. She also complained of right nasal obstruction of 10 days duration. She was incidentally diagnosed with COVID Pneumonia (CORADS V score) on May 8, 2021 but reverse transcription polymerase chain reaction RT-PCR was negative and had been treated with intravenous dexamethasone 8 mg twice a day for 5 days elsewhere, details of which are unknown.

On initial examination, diffuse swelling was seen over the right side of the face and right eye and patient was unable to open her eye completely [Figure 1]a. Endoscopic examination revealed black necrotic debris filling the right nasal cavity with erosion of the inferior and middle turbinates and meati along with purulent discharge [Figure 1]b. Fundoscopic examination was done which showed orbital cellulitis with no signs of papilledema. Initial investigations showed elevated Serum Ferritin (563 ng/mL), D-Dimer (707.9 ng/ml) and C-reactive protein (90 mg/L). Her Glycosylated Hemoglobin was14.8% and blood sugar was 511 mg/dl. This could be attributed to undetected Diabetes mellitus. She tested positive for SARS-COV2 by RT-PCR on May 8, 2021.
Figure 1: (a) Clinical photograph showing involvement of the cheek and orbital cellulitis. (b) Endoscopic image showing black necrotic debris in the right nasal cavity. (c) Magnetic resonance imaging showing soft tissue in the sphenoid sinus and extending into right parasellar region and into right temporal lobe with involvement of orbital muscles and orbital apex. (d) potassium hydroxide mount showing fungal hyphae

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A culture swab was collected from the right nasal cavity and sent for potassium hydroxide mount which demonstrated Rhizopus species [Figure 1]d. Contrast-enhanced computed tomography of nose, paranasal sinuses, and orbit showed diffuse mucosal thickening with heterogeneous enhancement involving the right ethmoid and sphenoid sinuses. There was diffuse edema in the right temporalis, lateral pterygoid muscle, and infratemporal fossa with involvement of the medial, lateral, and inferior recti along with diffuse preseptal and premaxillary soft-tissue edema suggestive of rhino-orbital mucormycosis.

The patient was subsequently posted for endoscopic debridement under general anesthesia and necrotic tissue was cleared from the sinuses and other involved areas. Simultaneously, liposomal amphotericin B was started at 3 mg/kg/day and the dose was gradually increased up to 7 mg/kg/day with careful monitoring of blood sugar and renal parameters.

Magnetic resonance imaging brain done subsequently showed localized temporal lobe abscess [Figure 1]c, although the patient did not present with any neurological deficits. The patient is currently under treatment for the same with conventional amphotericin B at 1.5 mg/kg/day due to the unavailability of liposomal Amphotericin B along with intravenous broad-spectrum antibiotics. The patient has been responding well to the treatment.


  Discussion Top


Mucormycosis, a term coined by an American pathologist Baker in 1957 is an acute and often lethal fungal infection. It is typically an angio invasive condition caused by mold fungi such as rhizopus, mucor, rhizomucor, and absidia. It spreads through the inhalation of fungal spores and usually affects those with decreased immunity.[1]

Recently, several cases have been detected in people who are either infected or recovering from COVID-19 infection worldwide, with a huge surge of cases in India. Uncontrolled diabetes mellitus with or without diabetic ketoacidosis, increased corticosteroid usage, increased ferritin levels and prolonged use of mechanical ventilators facilitate the fungal spores to germinate in people with COVID-19 infection.[2]

Mucormycosis can involve the nose, sinuses, orbit, and brain (rhino-orbital-cerebral mucormycosis) and can spread to pulmonary and gastrointestinal organs (invasive type).

The peculiar features of this condition include black necrotic turbinates with blood-tinged nasal discharge associated with facial pain. There may be periorbital and perinasal swelling and discoloration along with ptosis leading to complete ophthalmoplegia. It spreads rapidly to involve the brain with mortality rate of about 90%.[3]

The condition has to be aggressively treated at the earliest. Effective control of blood sugar levels is the key to preventing further spread. Endoscopic surgical debridement of the devitalized tissues from all the affected areas constitutes the first line of treatment. Liposomal amphotericin B is the drug of choice and should be administered at a dose of 5–10 mg/kg/day with careful monitoring of renal function. Amphotericin B nasal washes are also reported to be useful.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent forms. In the forms patient has given her consent and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eucker J, Sezer O, Graf B, Possinger K. Mucormycoses. Mycoses 2001;44:253-60.  Back to cited text no. 1
    
2.
Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India [published online ahead of print, 2021 May 21]. Diabetes Metab Syndr 2021;doi:10.1016/j.dsx.2021.05.019.  Back to cited text no. 2
    
3.
Deutsch PG, Whittaker J, Prasad S. Invasive and Non-Invasive Fungal Rhinosinusitis-A Review and Update of the Evidence. Medicina (Kaunas) 2019;55:319.  Back to cited text no. 3
    


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