Invasive Fungal Infections in Dengue Recovered Patients: A New Phenomenon in the Covid-19 Era

Abstract

Invasive fungal rhinosinusitis was seen to rise to epidemic levels after the 2nd wave of ongoing Covid pandemic, especially in tropical countries, maximally in India. A similar trend is being observed for cases who have recently recovered from dengue virus infection. Post dengue invasive fungal infection is a new presentation and any associations between it and Covid pandemic need to be studied in detail to help prepare for any complications. 3 patients presented to the out-patient department of E.N.T at a tertiary level teaching hospital in East India with complains similar to rhinosinusitis. These patients were then evaluated and diagnosed to be infected from Mucormycosis and Aspergillosis fungal sinusitis after which they were managed with surgical debridement and systemic antifungal therapy. All had a recent history of recovery from Dengue virus infection and a possible association could be suspected. 3 patients presented with complains of pain over upper jaw with orbital swelling and loss of vision developing over a period of 24 days. Two of them had ulceration of hard palate. They were then subjected to Contrast MRI along with CT scan of the Paranasal sinuses which depicted pansinus involvement with intracranial extension in two patients. These were then planned for diagnostic nasal endoscopies along with biopsies which turned out to be Invasive fungal sinusitis in the form of Aspergillosis and Mucormycosis. All the 3 patients had recent history of recovery from Dengue virus infection and did not have any other co-morbidities. Covid Associated Mucormycosis (CAM) is a well-known entity now but no reports of Dengue associated Invasive fungal sinusitis are yet reported. Whether this new phenomenon has anything to do with the interactions between dengue virus and coronavirus is not known at present and needs to be studied in detail so appropriate management protocols can be formulated.

Keywords: COVID19; Mucormycosis; New phenomenon; Post dengue.

Fig. 1

A shows right side gum abscess. B and C T2w MRI shows mucosal thickening in bilateral nasal cavity, maxillary, ethmoid, sphenoid and frontal sinuses. There is evidence of left orbital cellulitis with extension of inflammation up to the orbital apex resulting in left eye ball proptosis

Fig. 2

A Severe proptosis and chemosis of left eye. On B T1w C and D T2w MRI there is evidence of mucosal thickening in left ethmoid, sphenoid, maxillary sinuses and bilateral nasal cavities. Extension of inflammation also seen in left infratemporal space, involving the left retroantral fat pad and masticator space. There is associated cellulitis in left orbit intraconal, conal and extraconal post septal parts with involvement of extraocular muscles. Focal peripheral enhancing lesion in left temporal lobe measuring 19 × 17x21mm (AP x TD x CC) likely represents abscess formation (D)

Fig. 3

Patient with gross periorbital swelling