Pooja S Nagare¹, Ravi Sasank Sai²* and Ishita Wadhwa²

¹Associate Professor, Department of Otorhinolaryngology, Therna Medical College, India
²Junior Resident, Department of Otorhinolaryngology, Dr.B.V.P Pravara Institute of Medical Sciences, Ahmednagar, India

*Corresponding Author: Ravi Sasank Sai, Junior Resident, Department of Otorhinolaryngology, Dr.B.V.P Pravara Institute of Medical Sciences, Ahmednagar, India.

Received: February 06, 2023; Published: February 27, 2023

Abstract

Mucormycosis, also known as black fungus, is a rare but serious fungal infection that has been increasingly reported in patients with COVID-19. This infection typically affects the sinuses, but can also spread to the brain, lungs, and other parts of the body.

Risk factors for mucormycosis include uncontrolled diabetes, immunosuppression, and prolonged use of steroids. Patients with COVID-19 who have been hospitalized and on mechanical ventilation, as well as those who have received high doses of steroids, are particularly vulnerable to this infection.

Symptoms of mucormycosis include severe headache, facial pain or swelling, black discharge from the nose, and difficulty breathing. If left untreated, the infection can lead to blindness, brain damage, and even death.

Early diagnosis and prompt treatment are crucial for managing mucormycosis in patients with COVID-19. Treatment typically involves a combination of antifungal medications and surgical debridement of infected tissue.

It is important for healthcare providers to be aware of the potential for mucormycosis in patients with COVID-19, particularly those who have risk factors or are experiencing severe symptoms. Maintaining good glycemic control and avoiding unnecessary use of steroids in COVID-19 patients may also help to reduce the risk of mucormycosis.

Aim and Objective: 1. To provide a comprehensive overview of the clinical presentation, symptomatology, pathological, and radiological findings in cases of mucormycosis. 2. To examine the role of various risk factors in the development and progression of Post-COVID-19 mucormycosis and to use these findings to design a customized treatment strategy.

Methods: A prospective longitudinal study was conducted at our tertiary healthcare center in Maharashtra. Participants were selected based on the presence of clinical symptoms of mucormycosis and COVID-19 recovery. A comprehensive medical examination was performed, including otorhinolaryngologic (DNE, KOH, Fungal Culture), medical, and ophthalmological evaluations, as well as laboratory tests, biopsy, and imaging studies. The treatment strategy included administration of IV antifungals (Liposomal-Amphotericin B) and surgical procedures such as Modified Denker's approach, open maxillectomy, and orbital exenteration if needed. The patients were followed up for six months to monitor for recurrence.

Results: An initial diagnosis was made based on KOH mount and CT and MRI studies followed by fungal culture. All the patients were surgically treated. Out of 25 patients 12 patients underwent Endoscopic sinus surgery with modified Denker's approach, 4 patients underwent Total Maxillectomy with external facial degloving approach. One patient underwent surgical exenteration of the involved eye. All the patients were administered with Liposomal-Amphotericin-B 4 mg/Kg/body weight for a period of 14-21 days Patients were discharged after 21 days with Posaconazole and followed up after 3-weeks, 3-months and 6-months post-operatively and routine diagnostic nasal endoscopy is performed during all OPD visits and all the patients had significant improvement.

Conclusion: In India, particularly among the diabetic patients with steroid therapies for COVID-19 recovery during the second wave there was an exponential increase in invasive fungal diseases like Mucormycosis. Early diagnosis and prompt initiation of appropriate antifungal therapy is crucial in the management of post-COVID mucormycosis.

Keywords: Mucormycosis; Modified Denker’s Approach; Rhino-Orbital-Cerebral Mucormycosis; Invasive Fungal Sinusitis; Post-Covid-19 Mucormycosis

References

1. Aggarwal SK., et al. “Case Report: Rhino-orbital Mucormycosis Related to COVID-19: A Case Series Exploring Risk Factors”. American Journal of Tropical Medicine and Hygiene 2 (2022): 566-570.
2. Gomes MZR., et al. “Mucormycosis Caused by Unusual Mucormycetes, Non-Rhizopus, -Mucor, and -Lichtheimia Species”. Clinical Microbiology Reviews2 (2011): 411-445.
3. Sharma R., et al. “Mucormycosis in the COVID-19 Environment: A Multifaceted Complication”. Frontiers in Cellular and Infection Microbiology 12 (2022): 937481.
4. Watkinson JC and Clarke RW. “Scott-Brown’s Otorhinolaryngology and Head and Neck Surgery”. Eighth Edition: 3 volume set. 8^th CRC Press (2018).
5. Flint PW., et al. “Cummings Otolaryngology - Head and Neck Surgery”. E-Book: Head and Neck Surgery, 3-Volume Set. Elsevier Health Sciences; (2010).
6. Sreenivas S. “Mucormycosis (Black Fungus): What to Know” (2023).
7. Sharma S., et al. “Post coronavirus disease mucormycosis: a deadly addition to the pandemic spectrum”. Journal of Laryngology and Otology (2023): 1-6.
8. Peñaloza HF., et al. “Neutrophils and lymphopenia, an unknown axis in severe COVID-19 disease”. PLoS Pathogen9 (2021): e1009850.
9. John TM., et al. “When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis”. Journal of Fungi4 (2021): 298.
10. Bhatia M. “The rise of mucormycosis in Covid-19 patients in India”. Expert Review of Anti-infective Therapy 2 (2022): 137-138.
11. Honavar SG. “Code Mucor: Guidelines for the Diagnosis, Staging and Management of Rhino-Orbito-Cerebral Mucormycosis in the Setting of COVID-19”. Indian Journal of Ophthalmology6 (2021): 1361.
12. Bhattacharyya A., et al. “Rhino-orbital-cerebral-mucormycosis in COVID-19: A systematic review”. Indian Journal of Pharmacology4 (2021): 317-327.
13. Kaur K and Gurnani B. “Rhino-orbital-cerebral mucormycosis in COVID-19 patients - Taming the black evil with pharmacological weapons”. Indian Journal of Pharmacology5 (2021): 417-419.
14. Chen N., et al. “Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study”. Lancet Lond Engl10223 (2020): 507-513.
15. Rawson TM., et al. “Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing”. Clinical Infectious Diseases (2020): ciaa530.
16. “Information on COVID-19 Treatment, Prevention and Research”. COVID-19 Treat. Guidel (2023).
17. “Dexamethasone in Hospitalized Patients with Covid-19 — Preliminary Report”. The New England Journal of Medicine (2020): NEJMoa2021436.
18. “Post covid mucormycosis: our experience”. International Journal of Recent Scientific Research (2023).
19. Gangneux JP., et al. “Invasive fungal diseases during COVID-19: We should be prepared”. Journal of Medical Mycology 2 (2023): 100971.
20. Pathak L., et al. “Management of post-COVID mucormycosis at a tertiary care center in Northern India”. Egypt Journal of Otolaryngology1 (2023): 19.
21. “Mucormycosis coinfection associated with global COVID-19: a case series from India”. International Journal of Otorhinolaryngology and Head and Neck Surgery (2023).
22. Saldanha M., et al. “Paranasal Mucormycosis in COVID-19 Patient”. Indian Journal of Otolaryngology and Head and Neck Surgery 2 (2023): 3407-3410.
23. Mehta S and Pandey A. “Rhino-Orbital Mucormycosis Associated With COVID-19”. Cureus 9 (2023): e10726.
24. “Mucor in a Viral Land: A Tale of Two Pathogens”. Indian Journal of Ophthalmology (2023).
25. White PL., et al. “A national strategy to diagnose COVID-19 associated invasive fungal disease in the ICU”. Clinical Infectious Diseases (2020): ciaa1298.

Citation

Citation: , Ravi Sasank Sai., et al. “COVID-19 Associated Rhino-Orbital Mucormycosis During the Pandemic: Our Experience on Diagnostic Challenges to Management".Acta Scientific Otolaryngology 5.3 (2023): 55-66.

Copyright

Copyright: © 2022 , Ravi Sasank Sai., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.