Rhinocerebral mucormycosis: A deadly disease on the rise

Study of rhino-orbital-cerebral mucormycosis and its correlates during COVID-19 pandemic in a tertiary eye care institute of central India

PURPOSE

To evaluate factors associated with the occurrence of ROCM in COVID-19 patients and to compare its related parameters and outcomes between active and recovered COVID-19 groups.

METHODS

A total of 35 patients of ROCM associated with COVID-19 (active and post-COVID-19) were included. This is an ambispective study with retrospective medical records review for COVID-19 analysis and prospective assessments of ROCM-associated COVID-19 during the second wave of the COVID-19 pandemic. The demographic data, clinical parameters, and outcome were recorded on MS excel sheet, and various parameters were compared between active and recovered COVID-19 groups.

RESULTS

ROCM in recovered COVID-19 group was higher (57.1%) as compared to active COVID-19 (42.9%) (P = 1.00). High occurrence of ROCM was seen in those who had a history of hospitalization due to severity of COVID-19 (n 33, 94.28%), oxygen support (77.14), and received systemic steroids (82.9%). The most common comorbidity was diabetes mellitus (82.9%), and new-onset hyperglycemia was noticed in 17.1% of patients. Exenteration (28.6%) was performed in severe cases who had stage IV ROCM, bilateral, and CNS involvement (RR = 7.2, 95% CI: 2.91 to 18.00). The risk of globe exenteration was 1.35 (0.7-2.29) times higher in recovered COVID-19 group, and mortality was 1.76 (0.72-3.36) times higher in active COVID-19 group.

CONCLUSION

Monitored use of systemic steroids and the prompt management of hyperglycemia in COVID-19 patients are important factors for favorable outcomes with reference to globe salvage and life-saving in ROCM associated with COVID-19. Even recovered COVID-19 patients should be observed for persistent hyperglycemia and occurrence of ROCM.

Isolated Frontal Sinus Mucormycosis Post Covid 19-external Approaches Revisited!

Background

Isolated frontal sinus involvement in mucormycosis is seen very infrequently. Recent technological advances including image guided navigation and angled endoscopes have shifted paradigm towards minimally invasive surgeries. Open approaches are still relevant for the disease of frontal sinus with lateral extension where effective clearance cannot be obtained if approached endoscopically.

Objectives

The objective of this study was to describe the presentation and management of patients of mucormycosis with isolated frontal sinus involvement with help of external approaches.

Materials and methods

The available records of the patients were retrieved and analysed. The literature, the associated contributory clinical features and management techniques were reviewed.

Results

4 patients presented with isolated frontal sinus mucor involvement. 3 out of 4 patients had history of diabetes mellitus (75%). All patients had history of covid-19 infection (100%). 3 out of 4 patients had unilateral frontal sinus involvement and were operated by Lynch Howarth approach. Mean age of presentation was 46 years with male predominance. Bicoronal approach was used in one case with bilateral involvement.

Conclusion

Although conservative endoscopic surgeries are preferred nowadays for frontal sinus clearance but the extensive bony destruction with lateral extension in our series of patients with isolated frontal sinus mucormycosis warranted the need for open procedures.

Intraoperative Scoring Assessment as a Prognostic Tool in Covid-19 Associated Mucormycosis: A Short-Term Observational Study

To introduce an intraoperative scoring system for covid-19 associatedmucormycosis An observational study conducted among 43 cases of confirmed CAM whichincluded 35 males and 8 females, with an average age of 56 years. The surgicalapproach adopted in our cases included endoscopic surgical debridement withDenker’s approach including mandatory pterygopalatine and infratemporal fossaexploration. All cases were intraoperatively scored using our designed intraoperativescoring assessment tool for mucormycosis. Postoperatively patient recovery wasassessed using C reactive protein levels and weekly imaging. Although an early observation in the post op period we observed highermortality among cases reporting with high scores as per our intraoperative reportingsystem. At the end of 2 months of completed treatment we report 6 cases of mortalityamong whom 5 cases were found to have scores (> 25) and one reported with a scoreof 18. This assessment helped us in grading the disease severity and also gaveus an insight about the postoperative prognosis too. Global scientific collaboration andreporting of a validated tool for CAM is of paramount importance to increase theknowledge with regard to this emerging disease.

Facial Nerve Palsy: An Unusual Presentation in Patients with Rhino Cerebral Mucormycosis

The aim of this study is to highlight involvement of facial nerve as a presenting symptom in rhino cerebral mucormycosis. A retrospective longitudinal study was carried out for a period of 1 year from May 2017 to May 2018 in Department of Otorhinolaryngology of Dr. D. Y. Patil Medical College and Hospital, Kolhapur. The usual presentation include nasal stuffiness, headache, eye pain and orbital swelling, ophthalmoplegia and visual loss. However we had four patients who presented to our OPD with facial nerve palsy and rhino cerebral mucormycosis. All four patients were diabetic. The available clinical and laboratory data was retrospectively collected and analyzed. Facial nerve palsy is an unusual but significant sign in presentation of mucormycosis. It could be misdiagnosed as CVA with subsequent delay in the treatment. A high index of suspicion for mucormycosis in diabetic patients presenting with facial palsy will be helpful in achieving early and accurate diagnosis with prompt management and better outcome.

Impact of Prosthodontic Treatment on the Oral Health-related Quality of Life in Mucormycosis Patient: A Case Report

Mucormycosis is a fulminant fungal infection that occurs most often in diabetic and immunocompromised patients, including those with hematologic malignancies. Patients with maxillary resections present a challenge situation for the maxillofacial prosthodontist. Prosthodontic rehabilitation of such patients presents a significant challenge in restoring speech, deglutition and mastication, and respiration. This report discusses the impact of post-surgical management of mucormycosis patient with prosthodontic treatment and evaluating the oral health-related quality of life using the Oral Health Impact Profile-14 (OHIP-14) questionnaire.

Clinical features, diagnosis, and outcomes of rhino-orbito-cerebral mucormycosis- A retrospective analysis

Background and Purpose:

Rhino-orbito-cerebral mucormycosis (ROCM) is a rare disease with acute and fulminant manifestation. This infection is associated with high morbidity and mortality rates. Herein, we reviewed the manifestations, underlying conditions, medical treatments, and surgical interventions in ROCM patients admitted to a tertiary referral center in northern Iran over a seven-year period.

Materials and Methods:

In a retrospective analysis, 15 cases of ROCM were identified from 2007 to 2013 in Bu Ali Sina Hospital, Sari, Iran. All the ROCM cases were clinically diagnosed and confirmed by histopathological and/or mycological examination. The relevant demographic data, clinical, ophthalmic, and neurologic manifestations, underlying conditions, medical treatments, and surgical interventions were recorded and analyzed.

Results:

The mean age of the patients was 54±11 years (age range: 28–70 years); 26.7% of the patients were male and 73.3% female (male: female ratio of 1: 2.7). Uncontrolled diabetes was noted in at least 86.7% (13/15) of the cases. The maxillary sinuses were the most frequently involved sites (66.7% of the cases) followed by the ethmoid sinus. Amphotericin B in combination with surgical debridement was used in the treatment of 80% of the cases. Furthermore, 73.3% of the patients who were diagnosed early and underwent medical and extensive surgical debridement of the infected tissues survived.

Conclusion:

Uncontrolled diabetes mellitus is considered to be the main predisposing factor for ROCM. To prevent and reduce mortality rate of this acute disease, early diagnosis based on clinical findings and biopsy is recommended.

Purification and characterization of a cytochrome c with novel caspase-3 activation activity from the pathogenic fungus Rhizopus arrhizus

BACKGROUND

Members of Rhizopus species are the most common cause of mucormycosis, a rare but often fatal fungal infection. Host induced pathogen apoptosis and pathogen induced host cell apoptosis are often involved in fungal infections. In many organisms, the release of mitochondrial cytochrome c can trigger apoptosis by activating caspase proteases, but the role of fungal cytochrome c in apoptosis remains unknown.

RESULTS

DNA sequence encoding Rhizopus arrhizus cytochrome c was cloned and expressed in E. coli. Both native and recombinant cytochrome c were purified using ion exchange followed by gel filtration chromatography. The identities of purified proteins were confirmed by MALDI-MS and UV-Visible spectroscopy. For the first time, we demonstrated that Rhizopus arrhizus cytochrome c could activate human capspase-3 in HeLa cell extracts. We also found that Rhizopus arrhizus cytochrome c has redox potential, peroxidase activity, and spectral properties similar to human and horse cytochrome c proteins.

CONCLUSIONS

Rhizopus arrhizus cytochrome c can activate human caspase-3 in HeLa cell extracts and it possesses similar physical and spectral properties as human and horse cytochrome c. This protein was found to have a previously unknown potential to activate human caspase-3, an important step in the apoptosis cascade.

Mucormycosis causing maxillary osteomyelitis

Mucormycosis is an opportunistic fungal infection, more commonly observed in immunocompromised patients. The mode of infection is via the inhalation route and infection begins initially in the nose and paranasal sinuses with subsequent invasion into the vascular tissue, eventually leading to thrombosis and necrosis of nearby hard and soft tissues. Here, we report a case of chronic osteomyelitis of the maxillary bone with fungal infection (mucormycosis) and extensive tissue necrosis in an uncontrolled diabetes mellitus patient.

Rhino-orbital mucourmycosis in a non-immunocompromised patient

Mucormycosis, also known as phycomycosis or zygomycosis, is caused by common Zygomycete fungi frequently found in soil and decaying vegetation. These mainly infect immunocompromised patients and cause an acute fulminating fungal disease; mucormycosis rarely affects otherwise healthy people. Mucormycosis is a fatal infection with a poor prognosis. Of the different types of mucormycosis, the rhinocerebral type is the most severe one, and its type 2 subtype, the rhino-orbital-cerebral form is the deadliest variety. Here, we report a case of mucormycosis presenting with extensive necrosis of the maxilla with extension into the retrobulbar and infrabulbar region in an otherwise healthy patient. He underwent extensive debriding surgery followed by amphotericin B first and then oral antifungal therapy, but unfortunately, even after extensive surgery and medical treatment, he did not survive.

Rhinocerebral Mucormycosis Presenting as Oroantral Fistula

Mucormycosis refers to a severe infection with fungi of order Mucorales, seen in diabetic and immunocompromised patients. Rhino-orbito-cerebral mucormycosis is known to exist in two forms, the well-known acute form and the less well-recognized chronic form. The most common presenting features of the chronic form are ophthalmologic, including ptosis, proptosis, visual loss and ophthalmoplegia. Here, we report a case of chronic rhinocerebral mucormycosis (RCM) presented with nonhealing oroantral fistula in a diabetic patient without any orbital symptoms. We are reporting this case for its unusual presentation.

How to cite this article

Mane RS, Patil BC, Mohite AA. Rhinocerebral Mucormycosis Presenting as Oroantral Fistula. Clin Rhinol An Int J 2012;5(3):135-137.