A Proposed Grading System and Experience of COVID-19 Associated Rhino Orbito Cerebral Mucormycosis from an Indian Tertiary Care Center

Diagnosis of Mucormycosis Using Frozen Section, Histopathology, Culture, and Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) Techniques: A Comparative Study

Mucormycosis usually occurs in immunocompromised patients or those with uncontrolled diabetes. Along the third wave of SARS-CoV-2, an associated angioinvasive opportunistic infection with Mucor, a life-threatening fungal infection, was rampant and emerging. With an increase in the usage of steroids in the COVID scenario, the rate of mucormycosis did take a rapid and alarming increase in King Edward Memorial Hospital, Pune, India. Any delay in the diagnosis and management of the disease was life-threatening. The most conventional methods to diagnose mucormycosis are microbiological culture and histopathology of the tissue. The microbiological culture method plays an important role in the diagnosis of mucormycosis. However, the technique is labour-intensive, taking seven to eight days. Histopathology leads to false-negative reports if the tissue is not biopsied from representative sites. On the other hand, molecular methods are rapid, reliable, and applicable to different body samples, such as tissue, paraffin-embedded tissue blocks, plasma, and urine. We aimed to use a reverse transcriptase polymerase chain reaction (RT-PCR) method to detect Mucor in plasma samples. Due to a lack of availability of fresh samples, nucleic acid was extracted from the tissue sections of 69 cases diagnosed as Mucor by histopathology. These samples were subjected to RT-PCR using the MucorGenius kit (Pathonostics, Maastricht, Netherlands). A total of 57 tissue samples were sent for culture, and 49% of our cases were positive by culture and equally by RT-PCR. There was 80% sensitivity and 76% specificity between culture and PCR techniques. However, the use of blood/plasma for RT-PCR for early diagnosis of mucormycosis will be the method of choice.

Outcome of Total Surgical Debridement of Covid Associated Rhino-Orbito-Cerebral Mucormycosis Based on a New Surgical Staging System: A Cohort Study

To propose a surgical staging system with management protocol for post-covid Rhino-orbito-cerebral mucormycosis (ROCM) with central skull base osteomyelitis. A prospective cohort study of a total of 193 post-covid ROCM patients was conducted between May 2021 and January 2022 at a tertiary care centre. Patients were assessed radiologically and staged from I to V. Follow up period was 16 months and the surgical outcome in terms of recurrent disease was assessed. A total of 193 patients (129 primary and 64 revision) were studied. Maxilla was found to be the epicenter of anterior disease (69.3%) and pterygoid wedge was noted to be the epicenter of posterior disease (85.6%). More than 65% of our patients, at the time of presentation, presented with involvement of the central skull base. Intracranial disease was noted in 13.9% of patients and the mortality rate was 6.2%. This staging system provides a systematic step-by-step protocol for the management of ROCM, with emphasis on meticulous disease clearance at the central skull base.

A Novel Classification System for Oral Cavity Mucormycosis: a Hospital Based Cross-Sectional Study

Background

Rhino-oculo-cerebral Mucormycosis (ROCM) is a well-known complication post-COVID-19 infection. The extension of this disease into the oral cavity is a grey area with no proper protocol for management of the same in the existing literature. Based on our experience in the management of oral extension, this study aims to propose a protocol to treat these cases.

Aim

To derive a classification for the surgeon from retrospectively collected data of 53 operated cases of oral Mucormycosis.

Settings and Design

Hospital record-based cross-sectional study; evaluation of the previously treated 53 cases of oral extension of post-COVID-19 Rhino-oculo-cerebral Mucormycosis in the duration between May 2021 to August 2021. Follow-up for a period of 1 year.

Methods and Material

Based on the preoperative data, 4 parameters were taken -Tooth tenderness, Tooth mobility, Palatal perforation, and Radiological findings. A clinical-radiological classification system was derived based on the intraoperative data from the OT notes and the preoperative findings corresponding to the 4 parameters.

Statistical Analysis

The statistical analysis was done using SPSS for windows version 20 software (SPSS Inc., Chicago, IL, USA).

Results

Totally 220 cases of ROCM were recorded in our institute. Of this, 53 patients were treated for ROCM extending into the oral cavity. In 27 patients, we were able to achieve primary closure. In 26 patients, there was oro-antral communication after removal of the palate. Based on this data, we derived a protocol that may be used by the treating surgeon to manage oral cavity cases of ROCM, so that aggressive tissue resection may be avoided unnecessarily.

Conclusion

This protocol will help the treating surgeon to have a clearer outlook on treating this disease.

Comparative Study of Clinical Severity and Biochemical Markers in Pre COVID-19 and COVID-19 Rhino-Orbito Cerebral Mucormycosis

In view of high surge of sinonasal mucormycosis cases after the second wave of covid 19, present study was planned to know and compare the clinical severity of the disease and also to better understand the difference in the biochemical markers during precovid and post covid period. This retrospective observational study included all cases of sinonasal mucormycosis which were treated in our institute from August 2012 to August 2021. Details of these cases were collected from hospital database system. Biochemical parameters included FBS, HbA1C, urine ketone bodies, blood pH and creatinine. Clinical severity score was measured using self-structured severity scoring system. We found that out of 74 cases treated in our hospital 28 cases were in pre covid period while 46 cases belonged to covid 19 period. Higher male predominance was seen during post covid period (76% vs. 60%). Urine ketone bodies were positive in 7% patients in precovid period compared to 26% in post-covid period. FBS and HbA1C were high approximately 80 and 90% patients respectively in both groups. Clinical severity was significantly high in post covid patients. The present study showed that in spite of similar biochemical profile. The severity of mucormycosis was high in covid positive patients. This study shows that Covid-19 is an independent high risk factor in mucormycosis patients.

Clinical Phenotypes of COVID-19 Associated Mucormycosis (CAM): A Comprehensive Review

A mucormycosis surge was reported during the COVID-19 pandemic in India. A literature search until 14 July 2022, with the aim of updating COVID-19-associated mucormycosis (CAM), identified 663 studies and 88 met inclusion criteria (8727 patients). India reported 8388 patients, Egypt 208 and Europe 40. Rhino-orbito-cerebral mucormycosis (ROCM) was identified among 8082 (98.3%) patients, followed by 98 (1.2%) with pulmonary. In India, 82.6% of patients had diabetes mellitus, with 82% receiving corticosteroids. In Europe, 75% presented pulmonary CAM, 32.5% had diabetes and 40% were immunocompromised. CAM was identified at a median of 17.4 days (IQR 7.5 days) post COVID-19 diagnosis, and PCR was performed in five studies. Rhino-orbital invasion is clinically obvious, while cerebral involvement presents with cavernous sinus thrombosis, meningitis and cerebrovascular disease. Symptoms of pulmonary CAM usually overlap with severe COVID-19 pneumonia. High-dose liposomal Amphotericin B (and early surgical debridement in ROCM) are the mainstay of therapy. The median mortality rate was estimated to be 21.4% (IQR 31.9%), increased by the presence of pulmonary (80% (IQR 50%) or cerebral involvement (50% (IQR 63.9%). In summary, different CAM clinical phenotypes need to be distinguished, influenced by geographical presentation. Opportunities exist for diagnosis and therapy optimization, based on earlier high-dose antifungal therapy, early source control, strict glycemic control and restriction of steroids to COVID-19 patients with oxygen requirements.

Surgical management of post-COVID invasive rhino-orbito-cerebral mucormycosis and its outcomes: Role of neurosurgeons in a tertiary care center

Background:

Mucormycosis, which was previously considered to be rare, has emerged with a new challenge in patients infected with or recovering from COVID-19. Immunocompromised patients are particularly prone to developing this disease. The most common form of presentation is rhino-orbito-cerebral mucormycosis (ROCM). We present various neurosurgical approaches to an entire spectrum of its clinical manifestations.

Methods:

This is a retrospective study of patients who were admitted to the neurosurgery department with ROCM and a history of COVID-19 infection between November 1, 2020, and September 1, 2021. All cases of ROCM underwent contrast-enhanced computed tomography/magnetic resonance imaging of the brain, paranasal sinuses, and orbit. A tissue biopsy was sent for histopathological analysis. All confirmed cases received liposomal amphotericin B and surgical treatment was immediately undertaken.

Results:

Out of 200 patients with ROCM, 40 patients presented with neurological manifestations. Seven out of 40 patients had focal lesions in the brain and skull bone that needed neurosurgical intervention along with sinus debridement and antifungal treatment. These seven patients presented with different clinical manifestations: large-vessel stroke (one), medium-vessel stroke (one), frontal lobe abscess (one), frontal bone osteomyelitis (two), isolated central nervous system involvement (one), and mucor mimicking trigeminal schwannoma (one). The surgical intervention included decompressive craniectomy, frontal craniotomy, subtemporal craniotomy, and a minimally invasive supraorbital keyhole approach.

Conclusion:

In high-risk patients, a high level of clinical suspicion combined with appropriate investigations should be performed as soon as possible. Symptoms and early warning signs should not be overlooked, as treatment delays can be fatal. A minimally invasive surgical approach is possible in view of decreasing the morbidity of large craniotomy.