Rhino-orbital mucormycosis during steroid therapy in COVID-19 patients: A case report

Abstract

Purpose: To report two cases of COVID-19 under treatment with a corticosteroid; in one case rhino-orbitocerebral mucormycosis and in another one rhino-orbital mucormycosis developed.

Case presentation: A 40-year old woman and a 54-year old man with severe COVID-19 underwent corticosteroid therapy for immune-related lung injuries. The first case presented with a bilateral visual loss and complete ophthalmoplegia of the right eye. The second case presented with vision loss, proptosis, orbital inflammation, and complete ophthalmoplegia on the left side. Histopathologic, nasal endoscopic examinations, and radiologic findings confirmed mucormycosis in both patients. The patients denied orbital exenteration and were managed with systemic amphotericin B and daily endoscopic sinus debridement and irrigation with diluted amphotericin B. Because of the intracranial space involvement, the first case died. The second case was successfully managed surgically and medically.

Conclusion: Rhino-orbital/cerebral mucormycosis may be developed in COVID-19 patients under treatment with corticosteroid, and requires prompt diagnosis and management.

Keywords: COVID-19; Rhino-orbitocerebral; corticosteroid; mucormycosis; rhino-orbital.

Figure 1.

A 40-year old COVID-19-affected woman presented with rhino-orbitocerebral mucormycosis. Complete blepharoptosis and ophthalmoplegia are seen on the right side without significant inflammatory signs (a). Note the blackish necrotic tissues in her hard palate (b). The chest CT scan shows ground-glass opacities in both lungs, particularly in peripheral regions (c). Note the presence of bilateral opacifications of the ethmoidal and sphenoidal sinuses (d and e) that were propagated into the intracranial space through the cribriform plate (f).

Figure 2.

Representative histopathological microphotographs of debrided tissues from the patients’ paranasal sinuses. Note the presence of granulomatous inflammation (a) with marked necrosis (asterisk), prominent vasculitis (a and b), and large numbers of irregular non-septate branching mucor hyphae (c) (hematoxylin and eosin) (a–c: case 1). The mucor hyphae show reactivity on Periodic acid-Schiff (d and e, case 2) and the eosinophilic irregular filaments are markedly angioinvasive (f–h, case 1) (hematoxylin and eosin).

Figure 3.

A 54-year old COVID-19 affected man with diabetes mellitus and presented with rhino-orbital mucormycosis. Periorbital inflammation, complete blepharoptosis, and ophthalmoplegia are seen on the left side (a). The chest CT scan discloses multiple mostly peripheral ground-glass opacities with the crazy paving appearance in the lungs and compatible with COVID-19 (b). CT scan shows opacifications in the left maxillary, sphenoidal, and ethmoidal sinuses together with orbital tissue involvement (c and d).