The diversity and outcome of post-covid mucormycosis: A case report

COVID-19 and Mucormycosis of Orofacial Region: A Scoping Review

During the second wave of coronavirus disease, or COVID-19, infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in the year 2021 around the globe, there is a surge in the number of cases of mucormycosis or "Black Fungus" that is directly/indirectly associated with COVID-19. In this review article, mucormycosis of the orofacial region has gained importance from the maximum published literature (45 articles) from various databases like PubMed, Google Scholar, Scopus, Web of Science, and Embase. Rhino-orbital cerebral mucormycosis (ROCM) is a fatal condition associated with COVID-19 among categories of mucormycosis such as pulmonary, oral, gastrointestinal, cutaneous, and disseminated. ROCM targets the maxillary sinus, also involving teeth of the maxilla, orbits, and ethmoidal sinus. These are of particular interest to dentists and oral pathologists for proper diagnosis and identification. Co-morbid conditions, especially diabetes mellitus type II, have to be monitored carefully in COVID-19 patients as they have a higher risk of developing mucormycosis. In this review article, various presentations of COVID-19-linked mucormycosis are mentioned having particular emphasis on pathogenesis, signs and symptoms, clinical presentation, various diagnostic modalities including histopathology, radiology like CT and MRI, serology, tissue culture, various laboratory investigations, treatment protocols, management with prognosis, and so on. Any suspected case of mucormycosis needs quick detection and treatment since it progresses quickly due to the destructive course of infection. Long-term follow-up along with proper care is a must to detect any kind of recurrence.

Various Treatment Modalities in COVID-19 Associated Facial Mucormycosis and the Need for its Surgical Management: A Systematic Review

Introduction

Mucormycosis emerged as a wildfire in post-covid-19 infected patients. Most frequently involved sites of mucormycosis are rhino-orbital, rhino-sinusal and rhino-orbito-cerebral. The hallmark sign of mucormycosis is tissue necrosis, which is often a late sign. The fatality rate of mucormycosis is 46% globally. Despite early aggressive combined surgical and medical therapy, the prognosis of mucormycosis is poor.

Methods

We searched the electronic database of PubMed, web of science, Embase, Scopus and Google Scholar from Jan 2020 until December 2021 using keywords. We retrieved all the granular details of original research articles, case reports/series of patients with rhino-orbito-cerebral mucormycosis (ROCM), and COVID-19 reported worldwide. Subsequently, we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, treatment given and its outcome in people with COVID-19. (Prospero registration-CRD42021256830, June 4, 2021).

Results

Overall, 544 rhino-orbito-cerebral mucormycosis patients were included in our review with a history of Covid-19 infection. Out of which 410 patients had diabetes mellitus which has proven to be major contributing immunocompromised disease. Other diseases like hypertension, chronic kidney diseases, hypothyroidism, etc., were also attributed as an immunocompromised disease causing increased number of covid associated mucormycosis cases. We found out that total number of patients alive after taking only antifungal drug treatment were 25 in number, whereas total number of patients alive when antifungal drugs were combined with surgical intervention were 428 which was significantly higher.

Conclusion

Our systematic review concluded that surgical debridement should be performed whenever feasible in parallel to antifungal treatment in order to reduce the mortality rate of COVID-19 associated rhino-orbito-cerebral mucormycosis patients.

Comparative risk assessment of COVID‐19 associated mucormycosis and aspergillosis: A systematic review

COVID‐19 is not only limited to a defined array but also has expanded with several secondary infections. Two uncommon opportunistic fungal infections, COVID‐19 associated mucormycosis (CAM) and aspergillosis (CAA), have recently been highly acquainted by many worldwide cases. Two immune response deteriorating factors are considered to be responsible for immunosuppression: comorbidities and medication. Due to unlike infection sites and patterns, CAM and CAA‐associated factors deflect a few degrees of proximity, and the present study is for its assessment. The study evaluated 351 CAM cases and 191 CAA cases retrieved from 65 and 53 articles based on inclusion criteria, respectively. Most of the CAM reported from India and CAA were from four South‐European and West‐European neighbor countries. The mean ages of CAM and CAA were 52.72 ± 13.74 and 64.81 ± 11.14, correspondingly. Mortality of CAA (56.28%) was two times greater than CAM (26.02%). Nevertheless, the count of diabetes cases was very high in CAM compared to CAA. The main comorbidities of CAM were diabetes (nearly 80%) and hypertension (more than 38%). All noticeable complications were higher in CAA except diabetes, and these were diabetes (34.55%), hypertension (45.03%), and obesity (18.32%). Moreover, pre‐existing respiratory complications like asthma and chronic obstructive pulmonary disease are visible in CAA. The uses of steroids in CAM and CAA were nearly 70% and 66%, respectively. Almost one‐fourth of CAA cases were reported using immunosuppressant monoclonal antibodies, whereas only 7.69% were for CAM. The overall finding highlights diabetes, hypertension, and steroids as the risk factors for CAM, whereas obesity, chronic pulmonary disease, and immunosuppressants for CAA.

COVID-19-Associated Mucormycosis: A Matter of Concern Amid the SARS-CoV-2 Pandemic

Mucormycosis is an invasive fungal infection caused by fungi belonging to order Mucorales. Recently, with the increase in COVID-19 infections, mucormycosis infections have become a matter of concern globally, because of the high morbidity and mortality rates associated with them. Due to the association of mucormycosis with COVID-19 disease, it has been termed COVID-19-associated mucormycosis (CAM). In the present review, we focus on mucormycosis incidence, pathophysiology, risk factors, immune dysfunction, interactions of Mucorales with endothelial cells, and the possible role of iron in Mucorales growth. We review the limitations associated with current diagnostic procedures and the requirement for more specific, cost-effective, convenient, and sensitive assays, such as PCR-based assays and monoclonal antibody-based assays for the effective diagnosis of mucormycosis. We discuss the current treatment options involving antifungal drug therapies, adjunctive therapy, surgical treatment, and their limitations. We also review the importance of nutraceuticals-based therapy for the prevention as well as treatment of mucormycosis. Our review also highlights the need to explore the potential of novel immunotherapeutics, which include antibody-based therapy, cytokine-based therapy, and combination/synergistic antifungal therapy, as treatment options for mucormycosis. In summary, this review provides a complete overview of COVID-19-associated mucormycosis, addressing the current research gaps and future developments required in the field.

Case report: Nasopharyngeal mucormycosis, atypical presentation in a seventy-year-old diabetic lady

INTRODUCTION AND IMPORTANCE

Mucormycosis is rare type of infection yet, it is common in patient with Diabetes Mellitus and immune deficiencies. Mucormycosis mostly target the rhino-orbito-cerebral region, hence the common presenting symptoms are nasal symptoms followed by orbito-cerebral symptoms.

CASE PRESENTATION

Here, we present a diabetic lady with unusual presentation of mucormycosis. This old lady present with long history of left dull ear pain and decrease in hearing, nasopharyngeal exam revealed a mild bulging in the fossa of Rosenmuller region. The mild bulging reported as left nasopharyngeal heterogonous soft tissue mass extending to the left external auditory canal and skull base by CT scan. Excisional biopsy was taken and found to be nasopharyngeal mucormycosis CONCLUSION: Mucormycosis is a fatal infection which require early diagnosis and emergent intervention.

Global Cutaneous Mucormycosis: A Systematic Review

Cutaneous mucormycosis is the third most common clinical type of mucormycosis. The signs and symptoms vary widely, and it is important to make the diagnosis as early as possible in order to achieve a better outcome. We present a systematic review of its epidemiology, clinical presentation, diagnosis, and treatment, analyzing cases published from 1958 until 2021. The review was conducted according to the PRISMA guidelines and included 693 cases from 485 articles from 46 countries. Most publications were from North America (256 cases, 36.9%) and Asia (216 cases, 31.2%). The most common risk factors were diabetes mellitus (20%) and hematological malignancies (15.7%). However, a large proportion of published cases (275, 39.6%) had no identified underlying disease. The most common mode of transmission was trauma (54%), and 108 (15.6%) cases were healthcare-associated. In this review, 291 (42.5%) patients had localized infection, and 90 (13%) had disseminated mucormycosis. In Europe, N. America and S. America, the most common genus was Rhizopus spp., while in Asia it was Apophysomyces spp. (34.7%). Treatment was performed with antifungals, mainly amphotericin B, and/or surgery. Mortality was significantly lower when both antifungals and surgery were applied (29.6%).

RHINOSINUSITIS IN PATIENTS IN POST-COVID-19 PERIOD: ETIOLOGY, CLINICAL AND MORPHOLOGICAL CHARACTERISTICS

OBJECTIVE

The aim is to identify the etiology, clinical and morphological features of rhinosinusitis in patients in post-COVID-19 period.

PATIENTS AND METHODS

Materials and methods: In the present study, it was carried out the analysis of 11 cases of rhinosinusitis, which developed after COVID-19 infection. The diagnosis of rhi¬nosinusitis was established on the basis of anamnesis, clinical and laboratory examination, specialized instrumental examination (rhinoendoscopy, X-ray, magnetic resonance imaging, spiral and 3D computed tomography). All patients underwent endoscopic sanitation of the nasal cavity, expansion of the maxillary anastomosis, maxillary sinusotomy, sanitation of the maxillary sinuses and removal of pathologically altered tissues. Microbiological examination of the swab from the nasal cavity was carried out in all patients. Histological and morphometric research methods were used during the morphological study of surgical material. The nonparametric Mann-Whitney U test was used to compare the means in the groups.

RESULTS

Results: The conducted comprehensive study made it possible to identify chronic atrophic rhinosinusitis at the stage of exacerbation caused by associations of bacteria and fungi in patients in post-COVID-19 period. Among bacteria, the authors most often noted Staphylococcus aureus, Staphylococcus epidermidis, Klebsiella pneumonia, Streptococcus pneumonia and Enterococcus faecalis. Among fungi, there were Aspergillus, Candida, Mucor and Coccidioides. Fungal infection was characterized by invasion into the mucous membrane of the nose and paranasal sinuses. In patients in post-COVID-19 period the invasive bacterial-fungal chronic atrophic rhinosinusitis at the stage of exacerbation was predominantly bilateral, characterized by the involvement of several or all paranasal sinuses in the process. Patients with such pathology complained of periodic fever, headaches and malaise; nasal congestion and constant difficulty in nasal breathing; yellowish-greenish-reddish discharge from the nasal cavity, sometimes with a fetid odor; discomfort and pain in the area of paranasal sinuses; immobility of the eyeball, hyposmia or anosmia; reduction or complete loss of vision. Frequent risk factors for the development of invasive bacterial-fungal chronic atrophic rhinosinusitis at the stage of exacerbation in patients in post-COVID-19 period were the information about moderate or severe course of this infection in anamnesis; comorbidities (predominantly diabetes mellitus, hypertensive disease and ischemic heart disease).

CONCLUSION

Conclusions: The study conducted by the authors made it possible to identify the etiological, clinical and morphological features, as well as risk factors of rhinosinusitis in patients in post-COVID-19 period. This information will contribute to a better understanding of such pathology by the doctors and improve the diagnostic and treatment process.