COVID associated mucormycosis: A preliminary study from a dedicated COVID Hospital in Delhi

Abstract

Background: It is an incontrovertible fact that the Rhino Orbital Cerebral Mucormycosis (ROCM) upsurge is being seen in the context of COVID-19 in India. Briefly presented is evidence that in patients with uncontrolled diabetes, a dysfunctional immune system due to SARS-COV-2 and injudicious use of corticosteroids may be largely responsible for this malady.

Objective: To find the possible impact of COVID 19 infection and various co-morbidities on occurrence of ROCM and demonstrate the outcome based on medical and surgical interventions.

Methodology: Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID-19 infection. Diagnostic nasal endoscopy (DNE) was performed on each patient and swabs were taken and sent for fungal KOH staining and microscopy. Medical management included Injection Liposomal Amphotericin B, Posaconazole and Voriconazole. Surgical treatment was restricted to patients with RT PCR negative results for COVID-19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow-up for survived patients was maintained regularly for the first postoperative month.

Results: Out of total 131 patients, 111 patients had prior history of SARS COVID 19 infection, confirmed with a positive RT-PCR report and the rest 20 patients had no such history. Steroids were received as a part of treatment in 67 patients infected with COVID 19. Among 131 patients, 124 recovered, 1 worsened and 6 died. Out of 101 known diabetics, 98 recovered and 3 had fatal outcomes. 7 patients with previous history of COVID infection did not have any evidence of Diabetes mellitus, steroid intake or any other comorbidity.

Conclusion: It can be concluded that ROCM upsurge seen in the context of COVID-19 in India was mainly seen in patients with uncontrolled diabetes, a dysfunctional immune system due to SARS-COV-2 infection and injudicious use of corticosteroids.

Keywords: Acute invasive fungal sinusitis; COVID-19; Diabetes mellitus; Mucormycosis.

Fig. 1

a) Broad aseptate/pauci septate hyphae on KOH mount suggestive of mucormycosis. b) and c) mucorals on lactophenol cotton blue mount.

Fig. 2

(a)Contrast enhanced axial CT scan in soft tissue window in a 61 year old male with mucormycosis shows soft tissue contents in right retro antral region (white arrow) with fat stranding and soft tissue contents in right preantral region (black star) (b)Contrast enhanced axial CT in soft tissue window in in a 33-year-old post COVID male patient with left sided CAM shows soft tissue contents in right sphenopalatine foramen extending to pterygopalatine fossa (curved arrow) (c)Contrast enhanced coronal CT in soft tissue window in a 28-year-old male with rhino ocular mucormycosis shows involvement of left orbit in form of soft tissue contents in superomedial part of extraconal space abutting the superior oblique and medial rectus muscle (black star) and fat stranding in intraconal compartment (white arrow).

Fig. 3

Post contrast T1 fat saturated coronal(a) and axial image(b) in a 47-year-old male with right rhino-orbito-cerebral mucormycosis shows phlegmonous soft tissue content in right orbital apex (white arrow) encasing the optic nerve and extending into cavernous sinus which shows lack of enhancement and convex lateral margin (black arrow) The right optic nerve appears bulky and shows diffusion restriction suggestive of ischemia (c) (white arrowhead).

Fig. 4

An irregular area of altered signal intensity is seen in right occipital lobe in the same patient as in Fig. 2. appearing hypointense on axial post contrast T1 fat saturated image (a) (white star) hyperintense on T2 weighted image(b) and showing peripheral diffusion restriction(c) suggestive of subacute infarct.

Fig. 5

a) Intracranial spread of fungus; b) retrobulbar fungal abscess.

Fig. 6

Clinical presentation of COVID associated and non-COVID Invasive Fungal Sinusitis.

Fig. 7

Clinical presentation a) palatal ulceration; b) gingival lesions; c) maxillectomy specimen; d) ptosis; e) orbital abscess; f) orbital exenteration specimen.

Fig. 8

DNE a) Black crust middle turbinate; b) mucopus middle meatus; c) black crust, lateral nasal wall.

Fig. 9

A): Histopathology image showing hyphae of mucor. Stain Hematoxylin and eosin, power 400×; B): Cytology image showing hyphae of mucor along with neutrophilic infiltrate. Stain MayGraunwald Giemsa, power 1000×; C): Histopathology image showing hyphae of mucor in Silver methenamine stain, power 400×; D): Histopathology image showing hyphae of mucor in PAS stain. Power 400×; E): Histopathology image showing vascular invasion. Stain SM power 400×; F): Cytology image showing dual infection; orange arrow mucor, blue arrow Aspergillus. Stain Papanicolaou; power 1000×. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)