COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum

Abstract

Aims: 1: Describe the epidemiology and determine risk factors for COVID-19 associated mucormycosis. 2: Elaborate the clinical spectrum of Rhino-Orbital-Cerebral Mucormycosis (ROCM), pattern of neuroaxis involvement and it's radiological correlates.

Methods: Observational study. Consecutive, confirmed cases of mucormycosis (N = 55) were included. A case of mucormycosis was defined as one who had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological examination (HPE). Data pertaining to epidemiology, risk factors, clinico-radiological features were analysed using percentage of total cases.

Results: Middle aged, diabetic males with recent COVID-19 infection were most affected. New onset upper jaw toothache was a striking observation in several cases. Among neurological manifestations headache, proptosis, vision loss, extraocular movement restriction; cavernous sinus, meningeal and parenchymal involvement were common. Stroke in ROCM followed a definitive pattern with watershed infarction.

Conclusions: New onset upper jaw toothache and loosening of teeth should prompt an immediate search for mucormycosis in backdrop of diabetic patients with recent COVID-19 disease, aiding earlier diagnosis and treatment initiation. Neuroaxis involvement was characterized by a multitude of features pertaining to involvement of optic nerve, extraocular muscles, meninges, brain parenchyma and internal carotid artery.

Keywords: CAM; COVID19; Diabetes; Neuroaxis; ROCM; Steroid.

Fig. 1

Steps of methodology.

Fig. 2

Salient clinical and radiological manifestations of mucormycosis at a glance. A: Right eye proptosis with malar edema, erythema and flattening of right nasolabial fold. B. Blackish discoloration, ulceration and perforation of hard palate. C. MRI brain, T2, coronal image showing right orbital soft tissue and extraocular muscle infiltration and sinusitis. D. MRI brain, T1 fat suppression, coronal showing edematous and bulky extraocular muscles. E. MRI brain, T2 fat suppression, coronal showing sinusitis, orbital soft tissue, extraocular muscle, optic nerve and facial muscle infiltration. F. MRI brain, T2 axial showing hyperintensity in right basi-frontal region suggestive of cerebritis. G. MRI brain, axial, DWI showing hemodynamic stroke involving superficial and deep watershed zones. H. MR angiography brain vessels showing no flow in right Internal carotid artery petrous and cavernous segments onwards, in the same patient. I. MRI brain, axial, contrast image showing meningeal enhancement in right temporal region. J. MRI brain,axial, contrast showing enhancement in right orbital apex and cavernous sinus.