Spike in Rhino-Orbital-Cerebral Mucormycosis Cases Presenting to a Tertiary Care Center During the COVID-19 Pandemic

Abstract

Objective: To determine if there was an increase in the rate of cases presenting with rhino-orbital-cerebral mucormycosis (ROCM) to a tertiary care center during the first wave of the coronavirus disease 2019 (COVID-19) pandemic and the characteristics of the presenting cases. Methods: Retrospective observational study reviewing ROCM cases presenting from March 25 until September 25, 2020. Cases fulfilling the clinical, radiological, and pathological/microbiological criteria for diagnosis with ROCM were included. The number of cases presenting during the designated interval, their COVID-19 status, comorbidities, and clinical presentation were analyzed. The number of cases during the corresponding interval in the previous 3 years was used as reference to detect if there was a recent spike. Results: Of the 12 ROCM cases identified, 5 had a concurrent positive reverse transcription PCR (RT-PCR) test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 1 had a prior positive result, and 6 did not have concurrent nor prior positive test results. Nine of the 12 cases had poorly controlled diabetes mellitus, and 2 cases had a hematological malignancy. All cases had orbital invasion, and eight cases had cerebral invasion. The number of cases identified during the interval is much higher than the numbers presenting in the prior 3 years during equivalent intervals (range, one to two cases) than those reported in the literature in different settings in the pre-pandemic era. Conclusions: There is an increased rate of ROCM cases presenting to our center during the first wave of the COVID-19 pandemic. This is a preliminary report, and further studies are needed to corroborate the findings and explain possible underlying links.

Keywords: COVID-19; SARS-CoV-2; invasive fungal infection; mucormycosis; rhino-orbital-cerebral mucormycosis.

Figure 1

Presenting signs in one of the cases. Moderate conjunctival chemosis in the right eye and severe conjunctival chemosis with lid swelling in the left eye in a 54-year-old male patient, diabetic, with chronic kidney disease, on mechanical ventilation in the intensive care unit for severe COVID-19.

Figure 2

Advanced rhino-orbital-cerebral mucormycosis (ROCM) in two patients. (A) Endoscopic view (0° lens) demonstrating black necrotic tissue filling the right nasal cavity (arrow), mucopurulent secretions (circle), and a perforation in the bony septum (arrowhead) through which the left inferior turbinate (Inf.T) can be seen. (B) Progressed disease despite surgical debridement in a 55-year-old diabetic male patient who had tested positive for COVID-19.

Figure 3

Radiological findings in our rhino-orbital-cerebral mucormycosis (ROCM) cases. Axial postcontrast T1WI showing (A) orbital infiltration with optic nerve sheath inflammatory changes (white arrow), the extra ocular muscles are hypoenhancing (black arrow) secondary to ischemic changes, and (B) cavernous sinus infiltration with lack of expected enhancement (solid white arrow). Perineural spread of the fungus is seen along the trigeminal nerve (dashed white arrow). (C) Axial non-contrast CT reveals destructive sinonasal soft tissue mass with fragmented bone and air loculi secondary to osteonecrosis (arrowhead).