Survival factors in rhino-orbital-cerebral mucormycosis

Radiological differentiation between bacterial orbital cellulitis and invasive fungal sino-orbital infections

PURPOSE

Invasive fungal orbital infections (IFOI) may be difficult to differentiate from sinogenic bacterial orbital cellulitis (OC). This study investigates the features differentiating OC from IFOI on magnetic resonance imaging (MRI).

METHODS

Retrospective study of adult patients with sinogenic OC and IFOI with pre-intervention MRI. Patients without post-septal involvement, non-sinogenic OC (e.g.: secondary to trauma) and poor-quality scans were excluded. Independent Sample's t test and Fisher's exact test were conducted with p < 0.05 deemed statistically significant.

RESULTS

Eleven cases each of OC (Mean age: 41.6 ± 18.4 years-old, Male: 10) and IFOI (Mean age: 65.0 ± 16.6 years-old, Male: 9) between 2006 and 2023. IFOI patients were older, more likely immunocompromised and had a lower mean white-cell count (p value = 0.005, 0.035 and 0.017, respectively). The ethmoid and maxillary sinuses were most commonly involved in both entities. Pre-septal and lacrimal gland involvement were more common in OC (p = 0.001 and 0.008, respectively). Infiltrative OC orbital lesions were poorly demarcated, whilst those in IFOI were expansile/mass-like invading the orbit from the adjacent paranasal sinuses. Specific IFOI features included loss-of-contrast-enhancement (LoCE) of paranasal sinus tissues with orbital extension. Extra-orbital and -sinonasal extension indicative of IFOI included contiguous skull base or pterygopalatine fossa involvement, retro-antral and masticator space stranding and vasculitis.

CONCLUSION

This study describes the key MRI features of IFOI including differentiating markers from OC. These specific features, such as LoCE of the paranasal and orbital soft tissues, the location and pattern of contiguous soft-tissue involvement, provide expedient identification of IFOI which necessitate early surgical intervention for microbiological confirmation of an invasive fungal pathology.

Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study

PURPOSE

To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM).

METHODS

In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality.

RESULTS

Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality.

CONCLUSIONS

Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

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.

Identifying the Risk Factors for Orbital Complications in Isolated Sphenoid Rhinosinusitis

Background and Objectives: Isolated sphenoid rhinosinusitis may have devastating consequences such as orbital complications due to its anatomical contiguity with vital structures. This study aimed to identify patients with isolated sphenoid inflammatory diseases at high risk for developing orbital complications and requiring aggressive management through investigation of the clinical and computed tomography (CT) characteristics of patients with isolated sphenoid rhinosinusitis. Materials and Methods: The medical records of patients who underwent endoscopic sinus surgery between 2005 and 2022 were retrospectively reviewed. Patients with isolated sphenoid rhinosinusitis were identified based on a manual review of the clinical and histopathological findings. Participants' clinical and CT features were reviewed. Results: Among the 118 patients with isolated sphenoid rhinosinusitis, 15 (12.7%) developed orbital complications, including diplopia, extraocular motility limitation, ptosis, and visual impairment. Headaches and facial pain occurred significantly more frequently in patients with orbital complications than in those without orbital complications (p < 0.001). Patients with diabetes mellitus or malignant neoplasms were more likely to develop orbital complications than those without these comorbidities (p < 0.05). Bony dehiscence on CT images was significantly more common in patients with orbital complications than in those without. In the regression analysis, diabetes mellitus (OR, 4.62), malignant neoplasm (OR, 4.32), and bony dehiscence (OR, 4.87) were significant predictors of orbital complications (p < 0.05). Conclusions: Headaches and facial pain are the most common symptoms of isolated sphenoid rhinosinusitis. Orbital complications of isolated sphenoid rhinosinusitis are more common in patients with comorbidities such as diabetes mellitus or malignancy or in those with bony dehiscence on CT images.

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.

Factors affecting clinical outcome in COVID-associated rhino-orbito-cerebral mucormycosis (CAROM) patients-An ambispective, single-arm, observational study

BACKGROUND

COVID-associated Rhino-Orbito-Cerebral Mucormycosis (CAROM) appeared as an epidemic in India during the second wave of the COVID-19 pandemic during the months of March to May 2021. Though many reports have highlighted cross sectional and short-term attributes related to CAROM, long term follow up data is sparse.

OBJECTIVE

This report aims to analyze the follow-up outcomes in consecutive patients presenting to us during the epidemic.

PATIENTS AND METHODS

This was an ambispective observational analytical study, recruiting the consecutive patients admitted to our tertiary care centre during the period of the CAROM epidemic. The mortality rate during the follow-up and various factors affecting survival were studied using univariable and multivariable statistics with the Stata 14.0 software.

RESULTS

Of the 189 patients studied, eight were lost to follow-up. The outcome analysis was performed for the 181 patients. 93.6 % (162/173) of the patients had diabetes. The All-cause mortality was 45 % (81/181), while the ROCM-specific mortality was found to be 24 % (46/181) at a median follow-up of 176 days (IQR: 21-217 days). With univariable analysis, increasing age, higher serum IL-6 levels, presence of additional comorbidities (in addition to Diabetes and hypertension), bilateral disease, skin necrosis, palatal involvement, infratemporal fossa involvement, and impaired vision/ocular movements were found to be associated with increased mortality. However, on multivariable analysis, only 1) increasing age, 2) raised serum IL-6 levels, and 3) bilateral disease were predictive of increased mortality. Surgical debridement (endoscopic, palatal removal, orbital exenteration, neurosurgical intervention) was associated with significantly reduced mortality on both univariable and multivariable analysis.

CONCLUSION

Our intermediate-term follow-up data showed advanced age at presentation, raised IL-6 levels, and bilateral sinonasal involvement to be predictive of increased mortality, while surgical debridement is significantly protective from mortality in CAROM patients.

A Comparison Between Potassium Hydroxide (KOH) Microscopy and Culture for the Detection of Post-COVID-19 Rhino-Orbital-Cerebral Mucormycosis

Background and objective Mucormycosis is an emerging and serious angioinvasive infection caused by filamentous fungi related to the order of Mucorales and the class of Mucormycetes. There was a marked increase in the number of cases of mucormycosis in India following the second wave of the coronavirus disease 2019 (COVID-19) pandemic in the year 2021. In this study, we aimed to compare potassium hydroxide (KOH) microscopy with culture for the detection of post-COVID-19 rhino-orbital-cerebral mucormycosis (ROCM). Materials and methods The KOH microscopy was performed with a 10% or 20% KOH-mounted slide with specimens collected from suspected cases of post-COVID-19 ROCM. Simultaneously, the culture was done on Sabouraud dextrose agar (SDA). These were incubated at 37 ℃ and 25 ℃ for 28 days. Diagnostic parameters were calculated by comparing KOH with gold standard culture. Results KOH mount was positive for broad aseptate fungal hyphae in 322 (54.1%) cases, while it was negative in 244 (41.0%) cases. KOH mount was positive for other fungi in 29 (4.8%) samples. The diagnostic accuracy of the KOH mount for Mucorales was 70.3%. KOH mount had a sensitivity of 84.9%, specificity of 61.5%, positive predictive value (PPV) of 56.9%, and negative predictive value (NPV) of 87.2%. Conclusions Based on our findings, the KOH microscopy positivity rate was higher in tissue samples compared to nasal swabs, with a sensitivity of 84.9%, specificity of 61.5%, PPV of 56.9%, and NPV of 87.2%. The overall diagnostic accuracy of the KOH mount for Mucorales was 70.3%.

Imaging spectrum in rhino-orbito-cerebral mucormycosis: a cross-sectional study

Background

Rhino-orbital-cerebral mucormycosis (ROCM) is a life-threatening condition caused by a saprophytic fungus that predominately affecting immune-compromised patients. Early diagnosis of ROCM is of utmost importance to start the treatment as early as possible to prevent early and horrible complications of the disease.

Materials and methods

This retrospective study evaluated the imaging findings of 21 patients with biopsy and KOH mount-based evidence of invasive ROCM. The imaging was obtained from a Siemens Magnetom Amira 1.5T system with a strength of 1.5T or more. The spectrum of findings was evaluated for the sites of involvement, signal intensity, contrast characteristics, necrotic component as well as orbital, infratemporal, and intracranial extensions, especially cavernous sinuses, Meckel's cave, and the brain parenchyma.

Results

The mean age of the patients was 55.8±10.9 years and included 71% male. All the patients were positive for COVID-19 and the majority were diabetic. MRI showed predominant involvement of the maxillary sinus (17, 81%) and the ethmoidal sinus (15, 71.4%). The orbital extension was present in 18 cases (86%). T1-weighted imaging showed iso to low signal intensity in involved sinuses in the majority of the patients (9, 42.9%). Heterogeneously high signal intensity was observed in T2-weighted and short tau inversion recovery images in all the patients. Heterogenous contrast enhancement was present in 20 (95.2%) patients.

Conclusion

The imaging spectrum of ROCM is variable. Multiplanar MRI with postcontrast images is a very useful complementary tool to the clinical evaluation to assess the extent of disease and its complications, which has a high mortality. Clinicians and radiologists should be aware of the imaging spectrums of ROCM.

Lack of surgical resection is associated with increased early mortality in hematological patients complicated with rhino-orbital-cerebral mucormycosis

Rhino-orbital-cerebral mucormycosis (ROCM), which is an acute fatal infectious disease with a high mortality rate, is increasingly being diagnosed in patients with hematological diseases worldwide. We aimed to investigate the clinical characteristics, treatment, and prognosis of hematological diseases complicated by ROCM. Our sample comprised a total of 60 ROCM patients with hematological diseases. The most common primary disease was acute lymphoblastic leukemia (ALL) (n=27, 45.0%), while 36 patients (60.0%) were diagnosed with a clear type of pathogen, all belonging to the Mucorales, most commonly Rhizopus (41.7%). Of the 32 patients (53.3%) who died, 19 (59.3%) died of mucormycosis, and 84.2% (n=16) of those died within 1 month. Forty-eight cases (80.0%) received antifungal treatment combined with surgical therapy, 12 of whom (25.0%) died of mucormycosis, amounting to a mortality rate that was significantly lower than in patients who received antifungal therapy alone (n=7, 58.3%) (P=0.012). The median neutrophil value of patients who underwent surgery was 0.58 (0.11-2.80) 103/μL, the median platelet value was 58.00 (17.00-93.00) 103/μL, and no surgery-related deaths were reported. Multivariate analysis showed that patient's advanced age (P=0.012, OR=1.035 (1.008-1.064)) and lack of surgical treatment (P=0.030, OR=4.971 (1.173-21.074)) were independent prognostic factors.In this study, hematological diseases associated with ROCM have a high mortality rate. Lack of surgical treatment is an independent prognostic factor for death from mucormycosis. Surgery may therefore be considered in patients with hematological disease even if their neutrophil and platelet values are lower than normal.

A Case of Post-COVID-19 Rhino-Cerebral Mucormycosis in an Immunocompromised Patient

Mucormycosis is a fulminant angioinvasive fungal infection that occurs in an immunocompromised condition, most commonly in diabetic patients. Rhino-cerebral and pulmonary infections are common but may also lead to disseminated disease associated with a high mortality rate (almost 100%). Here we report on an elderly diabetic lady presented with a headache and altered level of consciousness and peri-orbital swelling following coronavirus disease 2019 (COVID-19). Imaging studies revealed a single large space-occupying lesion in the frontal lobe extending to the left orbit and sinusitis. An excisional biopsy was taken from the middle meatus of the nasal cavity and histopathology findings were broad aseptate hyphae branching at the right angle which suggests mucormycosis. Liposomal amphotericin B was started but the patient developed acute kidney injury (AKI) and bi-cytopenia (thrombocytopenia and anemia) followed by sepsis resulting in death. Though this is a rapidly progressing disease with a high mortality rate, a strong level of suspicion and early diagnosis can save lives.

Sinonasal and Orbital Imaging Findings in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis During the Second Wave of COVID-19: A Retrospective Cohort Study in a Tertiary Hospital in Central India

Background Mucormycosis is a consequence of the angioinvasive disease caused by filamentous fungi that belong to the order Mucorales, particularly Mucor, Rhizopus, and Rhizomucor. Rhizopus oryzae is the most prevalent form. The invading hyphae lead to damage of blood vessels leading to thrombosis and consequent tissue necrosis. The incidence of this disease entity witnessed a significant rise during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. Timely diagnosis and prompt treatment are crucial to diminish both the mortality and morbidity associated with this disease. Imaging plays a pivotal role in diagnosing the ailment, evaluating its extent, identifying complications such as thrombosis, and facilitating surgical planning. It demonstrates exceptional sensitivity in detecting the disease at its early stages, often before symptoms manifest. Due to the angioinvasive nature of Mucor, early detection assumes utmost importance as it necessitates intensive antifungal therapy and the removal of devitalized tissue through debridement. Methodology We conducted a retrospective cohort study to analyze computed tomography (CT) imaging findings in patients with COVID-associated rhino-orbito-cerebral mucormycosis (ROCM) confirmed by histopathological examination. We compared these findings with CT findings of the nose and paranasal sinuses in patients without mucor following COVID-19 sinusitis (non-ROCM). Results All 16 cases in the non-ROCM group were in stage 1 disease. In contrast, in the ROCM group, three patients had stage 1 disease, five patients had stage 2 disease, and 10 patients had stage 3 disease (p = 0.0001). The pterygopalatine fossa was significantly affected in 10 of 18 ROCM patients and in none of the non-ROCM patients. Conclusions Imaging plays a crucial role in the early detection of mucormycosis. It assists treating physicians in initiating prompt and aggressive treatment, thereby improving the prognosis of this frequently fatal disease.

Isolated cerebral mucormycosis: A case discussion

We report a case of a 32-year-old male with a history of type 1 diabetes, inhaled drug use, and alcohol use disorder, who presented with encephalopathy, holocranial headaches, neck pain, confusion, and generalized tonic-clonic seizures. The patient initially presented at a rural community hospital with a fever and was found to be in diabetic ketoacidosis (DKA). He was also hemodynamically stable but stuporous, prompting intubation to protect his airway. Despite initial treatment measures, his neurological condition worsened and he remained ventilator-dependent. Key findings include a high glucose level, presence of ketones, and evidence of drug use. Blood cultures showed no growth, but his febrile state persisted. Cerebrospinal fluid (CSF) analysis revealed mild pleocytosis, hyperglycorrhachia but normal protein, with no growth. Neuroimaging showed right hemispheric slowing on EEG and diffusion restriction in the right frontal lobe on MRI. The patient's neurological status worsened on the second day of admission, manifesting as sluggish pupillary reflexes, right third nerve palsy, and decerebrate posturing. Emergent MRI suggested cerebral edema, leading to initiation of hypertonic saline. This case highlights the diagnostic challenges and critical management considerations in a patient with multiple comorbidities presenting with unexplained neurological deterioration, emphasizing the importance of a comprehensive and timely approach to diagnosis and treatment.

Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies

The incidence rate of invasive mucormycosis (IM) in patients with hematological malignancies (HMs) is increasing year by year, ranging from 0.07% to 4.29%, and the mortality rate is mostly higher than 50%. With the ongoing pandemic of COVID-19, COVID-19-associated mucormycosis (CAM) also became a global health threat. Patients with high risk factors such as active HMs, relapsed/refractory leukemia, prolonged neutropenia may still develop breakthrough mucormycosis (BT-MCR) even under the prophylaxis of Mucorales-active antifungals, and such patients often have higher mortality. Rhizopus spp. is the most common genus associated with IM, followed by Mucor spp. and Lichtheimia spp. Pulmonary mucormycosis (PM) is the most common form of IM in patients with HMs, followed by rhino-orbital-cerebral mucormycosis (ROCM) and disseminated mucormycosis. The prognosis of IM patients with neutrophil recovery, localized IM and receiving early combined medical-surgical therapy is usually better. As for management of the disease, risk factors should be eliminated firstly. Liposome amphotericin B (L-AmB) combined with surgery is the initial treatment scheme of IM. Those who are intolerant to L-AmB can choose intravenous formulations or tablets of isavuconazole or posaconazole. Patients who are refractory to monotherapy can turn to combined antifungals therapy.

Epidemiology of COVID-19-Associated Mucormycosis

Purpose of the Review

To describe the epidemiology and risk factors for Coronavirus disease-19 (COVID-19)-associated mucormycosis (CAM) based on current published literature.

Recent Findings

COVID-19 is associated with an increased risk of secondary infections. Mucormycosis is an uncommon invasive fungal infection that typically affects people with immunocompromising conditions and uncontrolled diabetes. Treatment of mucormycosis is challenging and is associated with high mortality even with standard care. During the second wave of the COVID 19 pandemic, an abnormally high number of CAM cases were seen particularly in India. Several case series have attempted to describe the risk factors for CAM.

Summary

A common risk profile identified for CAM includes uncontrolled diabetes and treatment with steroids. COVID-19-induced immune dysregulation as well as some unique pandemic specific risk factors may have played a role.

Central Retinal Artery Occlusion in COVID-Associated Mucormycosis

Introduction

Significant surge of mucormycosis was reported in the Indian Subcontinent during the second wave of the COVID-19 pandemic. COVID-associated mucormycosis (CAM) was defined as the development of features of mucormycosis with prior or current history of COVID-19 infection. Rapid angioinvasion is an important characteristic of mucormycosis. Authors intended to find out the prevalence of retinal arterial occlusion and its association with vascular embolic occlusion elsewhere in the body among CAM patients in this study.

Methods

This was an observational study. All consecutive-confirmed cases of mucormycosis (n = 89) and age-/gender-/risk factor-matched controls (n = 324) admitted in the designated COVID center were included in the study. All cases and controls underwent comprehensive ophthalmological, otorhinological, and neurological examinations. All necessary investigations to support the clinical diagnosis were done. Qualitative data were analyzed using the Chi-square test. Quantitative data for comparison of means between the cases and controls were done using unpaired t-test.

Results

Twenty-one (23.59%) patients manifested the defined outcome of central retinal artery occlusion (CRAO). Among age-matched control, with similar diabetic status, none had developed the final outcome as defined (P < 0.05). About 90.47% of subjects with CRAO presented with no perception of light vision. Thirteen subjects (61.9%) with the final outcome developed clinical manifestations of stroke during the course of their illness with radiological evidence of watershed infarction (P = 0.001). Orbital debridement was performed in 9 (42.85%) subjects while orbital exenteration was done in 8 (38.09%) subjects.

Conclusions

CRAO in CAM patients was found to have aggressive nature turning the eye blind in a very short period of time. CRAO can serve as a harbinger for subsequent development of more debilitating and life-threatening conditions such as stroke among CAM patients.

Rhino-Orbital Cerebral Mucormycosis: A Fatal Evolution

Rhino-orbital cerebral mucormycosis is a rare and serious fungal infection caused by fungi of the Mucorales order, most commonly by the species Rhizopus oryzae. It occurs generally in an immunocompromised host, and the contamination of healthy subjects remains exceptional. The clinical presentation is not specific. The diagnosis of rhino-orbital cerebral mucormycosis is difficult based on a range of clinical, microbiological, and radiological arguments. Imaging studies may include CT/MRI of the orbit, brain, and sinuses and show signs of aggressiveness, intracranial complications, and evolution under treatment. The standard treatment is antifungal therapy and necrosectomy. We report a case of a 30-year-old patient admitted to intensive care for the management of postpartum hemorrhage complicating severe preeclampsia who presented with rhinocerebral mucormycosis with left orbital extension. Adequate therapeutic management in the intensive care unit was provided; however, the patient died within seven days of septic shock with multiorgan failure. The mortality is determined by the correction of risk factors, the timing of initiation of the antifungal therapy, and surgical debridement.

Is low dose of liposomal amphotericin B effective in management of acute invasive fungal rhinosinusitis? Our conclusions from Al-Mowassat University Hospital, Syria: a prospective observational study

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFRS) is a fatal infection associated with high morbidity and mortality. Although it is a rare disease, upsurge of AIFRS was noticed during the second wave of COVID-19 disease. Early diagnosis and management is the cornerstone for good outcomes. However, management of AIFRS is challengeable especially in developing countries due to limited resources and high prices of antifungal agents. No previous studies have been conducted to evaluate the outcomes of management of AIFRS in Syria. The purpose of this study is to report the results of management of AIFRS with low doses of liposomal amphotericin B in our tertiary hospital in Syria.

METHODS

The outcomes of management of AIFRS cases were followed through a prospective observational study between January 2021 and July 2022. The required medical data were collected for each individual. Three-month mortality rate was studied. SPSS v.26 was used to perform the statistical analysis. Pearson Chi-square test was used to study the associations between different variables and mortality. Survival curves were plotted by the Kaplan-Meier to compare the survival probability. Log Rank (Mantel-Cox) test and Cox regression were conducted to evaluate the factors affecting survival within the follow up period.

RESULTS

Of 70 cases, 36 (51.4%) were males and 34 (48.6%) were females. The mean age of patients was 52.5 years old. The most common underlying risk factor was diabetes mellitus (84.3%). The used dose of liposomal amphotericin B ranged between 2-3 mg/kg per day. The overall 3-month mortality rate was 35.7%. Significant association was found between survival and the following variables: Age, orbital involvement, stage, and comorbidity.

CONCLUSION

The overall mortality rate was close to other studies. However, survival rate was worse than comparable studies in selected cases of AIFRS (older ages, involved orbits, advanced stages, and chronic immunodeficiency). Therefore, low doses of liposomal amphotericin B could be less effective in such cases and high doses are recommended.

The application of metagenomic next-generation sequencing in patients with infection or colonization caused by Lichtheimia species

Background

Mucormycosis is considered the fourth most common invasive fungal disease after candidiasis, aspergillosis and cryptococcosis. Lichtheimia species accounted for 5%-29% of all mucormycosis. However, available data on species-specific analysis of Lichtheimia infections are limited.

Methods

This study included nine patients hospitalized in five hospitals in two cities in south China with mucormycosis or colonization caused by Lichtheimia species, diagnosed mainly by metagenomic next-generation sequencing (mNGS). The corresponding medical records were reviewed, and the clinical data analyzed included demographic characteristics, site of infection, host factors and type of underlying disease, diagnosis, clinical course, management, and prognosis.

Results

In this study, nine patients with Lichtheimia infections or colonization had a recent history of haematological malignancy (33.3%), solid organ transplants (33.3%), pulmonary disease (22.2%), and trauma (11.1%) and were categorized as 11.1% (one case) proven, 66.7% (six cases) probable mucormycosis and 22.2% (two cases) colonization. Pulmonary mucormycosis or colonization was the predominant presentation in 77.8% of cases and mucormycosis caused by Lichtheimia resulted in death in four out of seven patients (57.1%).

Conclusion

These cases highlight the importance of early diagnosis and combined therapy for these sporadic yet life-threatening infections. Further studies on the diagnosis and control of Lichtheimia infection in China are required.

Management of Invasive Infections in Diabetes Mellitus: A Comprehensive Review

Patients with diabetes often have more invasive infections, which may lead to an increase in morbidity. The hyperglycaemic environment promotes immune dysfunction (such as the deterioration of neutrophil activity, antioxidant system suppression, and compromised innate immunity), micro- and microangiopathies, and neuropathy. A greater number of medical interventions leads to a higher frequency of infections in diabetic patients. Diabetic individuals are susceptible to certain conditions, such as rhino-cerebral mucormycosis or aspergillosis infection. Infections may either be the primary symptom of diabetes mellitus or act as triggers in the intrinsic effects of the disease, such as diabetic ketoacidosis and hypoglycaemia, in addition to increasing morbidity. A thorough diagnosis of the severity and origin of the infection is necessary for effective treatment, which often entails surgery and extensive antibiotic use. Examining the significant issue of infection in individuals with diabetes is crucial. Comprehensive research should examine why infections are more common amongst diabetics and what the preventive treatment strategies could be.

Isolated cerebral mucormycosis that looks like stroke and brain abscess: A case report and review of the literature

BACKGROUND

Cerebral mucormycosis is an infectious disease of the brain caused by fungi of the order Mucorales. These infections are rarely encountered in clinical practice and are often misdiagnosed as cerebral infarction or brain abscess. Increased mortality due to cerebral mucormycosis is closely related to delayed diagnosis and treatment, both of which present unique challenges for clinicians.

CASE SUMMARY

Cerebral mucormycosis is generally secondary to sinus disease or other disseminated disease. However, in this retrospective study, we report and analyze a case of isolated cerebral mucormycosis.

CONCLUSION

The constellation of symptoms including headaches, fever, hemiplegia, and changes in mental status taken together with clinical findings of cerebral infarction and brain abscess should raise the possibility of a brain fungal infection. Early diagnosis and prompt initiation of antifungal therapy along with surgery can improve patient survival.

Unmasking the Deadly Fungus: A Case Report of Rhino-Orbital-Cerebral Mucormycosis in a Diabetic Patient With Unusual Presentation

Mucormycosis (zygomycosis) is a rare, rapidly progressive fungal infection that is opportunistic and usually affects immunocompromised individuals, most commonly patients with diabetes mellitus. It is a fatal infection that requires high clinical suspicion and early disease identification. The global burden of mucormycosis is unknown as it is a rare disease. However, the burden of mucormycosis is increasing worldwide, with the emergence of new risk factors and causative agents. In the Saudi population, the discovered cases and the overall prevalence were low. Herein, we present a case of mucormycosis infection aiming to illustrate the clinical characteristics and the management strategy, besides adding another case to the literature.

Subperiosteal inferior maxillectomy in mucormycosis patients: case series

OBJECTIVE

Mucormycosis is a rapidly progressive and fulminant fungal infection mainly affecting the nose and paranasal sinuses and often requiring aggressive surgical debridement, which commonly includes inferior maxillectomy. Conventional inferior maxillectomy involves removal of the bony hard palate and its mucoperiosteum. This can lead to formation of an oroantral fistula and thereby increase the morbidity in these patients leading to prolonged rehabilitation. Subperiosteal inferior maxillectomy involves sparing of the uninvolved mucoperiosteum of the hard palate. This flap is used for closure of the oroantral fistula, which preserves the functional capabilities of the patient, such as speech, mastication and deglutination.

METHOD

This case series describes the experience of using the technique of mucosa-preserving subperiosteal inferior maxillectomy in five patients with mucormycosis.

RESULTS

With the technique used in this study, complete oronasal separation was achieved in all six patients. The overall surgery time was also decreased when compared with free tissue transfer. Patients also did not have to bear the weight of prosthesis.

CONCLUSION

Mucoperiosteal palatal flap-preserving subperiosteal inferior maxillectomy is an excellent approach for all patients with mucormycosis and healthy palatal mucosa.

A Proposed Diagnostic Algorithm for Fungal Orbital Infections after 20 Years of Experience in a Tertiary Eye Care Center- Egypt

METHOD

Medical Records of cases with orbital fungal infection from January 2000 to December 2019 were reviewed.

RESULTS

The study included 45 patients. Mucormycosis was proven in 32 (71.1%) and aspergillosis in 13 (28.9%) patients. Thirty-five (77.8%) patients had predisposing factors mainly uncontrolled diabetes. Twenty-seven (60%) patients presented with orbital apex syndrome, 10 (22.2%) with orbital cellulitis and 8 (17.7%) with proptosis. The prognosis was generally poor (31.1% mortality, 8.88% exenteration and 11.1% self-evisceration). The proposed algorithm composed of six atypical clinical presentations mainly acute orbital apex and fulminating orbital cellulitis plus any radiological or microbiological findings.

CONCLUSION

The proposed algorithm markedly reduced the complications after 5 years of the study. Once fungal orbital infection is suspected, treatment should start immediately.

Central Retinal Artery Occlusion in Rhino-Orbital-Cerebral Mucormycosis: An Inflammatory-Prothrombotic State

PURPOSE

The aim was to evaluate patient profiles of rhino-orbital-cerebral mucormycosis (ROCM) cases with central retinal artery occlusion (CRAO) postcoronavirus disease 2019.

DESIGN

A nonrandomized retrospective case-control study.

METHODS

The ROCM cases presenting with CRAO were compared with a control ROCM group without CRAO at a tertiary care center. Demography, systemic status, clinical features, histopathology, imaging, and blood profile were assessed for any specific risk factors.

RESULTS

A total of 12 patients were seen in the CRAO group and 16 in the non-CRAO group. The male-to-female ratio was 3:1 with a mean age of 49.5 years. In the CRAO group, 75% had diabetes mellitus with mean hemoglobin A1c of 9.03%, and 66.7% had received steroid treatment. All cases were histopathologically confirmed positive for mucor. There was a significant difference in mean D-dimer and serum ferritin between the 2 groups, with higher level in the CRAO group. All patients with CRAO had light perception-negative vision, with total ophthalmoplegia and proptosis seen in 66.7% of cases. Four patients had orbital apex involvement, 5 had cavernous sinus involvement, and 8 had intracranial involvement in the CRAO group.

CONCLUSIONS

Inflammatory markers D-dimer and serum ferritin were significantly associated with CRAO, suggestive of hyperinflammatory and hypercoagulable state. A high index of suspicion should be maintained in cases with elevated markers and prophylactic anticoagulants can be started to prevent CRAO in a subset of patients.

Spectral Domain Optical Coherence Tomography Findings in Vision-Threatening Rhino-Orbital Cerebral Mucor Mycosis-A Prospective Analysis

Rhino-orbital cerebral mucor mycosis is a rare disease entity, where retinal involvement is described in the literature mostly as CRAO. However, pathological studies have shown mucor invading the choroid and retina with a neutrophilic reaction. So, it is pertinent that retinal inflammation secondary to invading mucor has some role in microstructural changes seen in the vitreous and retina of these patients. This novel study aims to describe the vitreal and retinal features of patients with vision-threatening rhino-orbital cerebral mucor mycosis and how they evolve on spectral domain optical coherence tomography (SD-OCT). This study shall also provide insight into the pathophysiology of these vitreoretinal manifestations by in vitro analysis of the exenterated orbital content. Fifteen eyes of fifteen patients with vision-threatening ROCM treated with standard care were enrolled in this study and underwent complete ophthalmic examination, serial colour fundus photography, and SD-OCT for both qualitative and quantitative analysis, at baseline and follow-up visits. SD-OCT on serial follow-up revealed thickening and increased inner-retinal reflectivity at presentation followed by thinning of both, other features such as the loss of the inner-retinal organized layer structure, external limiting membrane (ELM) disruption, necrotic spaces in the outer retina, and hyperreflective foci. Vitreous cells with vitreous haze were also seen. There was a significant reduction in CMT, inner and outer retinal thickness, total retinal thickness (all p < 0.05) with time, the quantum of reduction concentrated primarily to the inner retina. In summary, in vivo and in vitro analysis revealed that early microstructural changes were primarily a result of retinal infarctions secondary to thrombotic angioinvasion. With the late microstructural changes, there was possible sequelae of retinal infarction with some contribution from the inflammation, resulting from mucor invading the choroid and retina.

COVID-19-associated mucormycosis: an update of anesthetic management

Background

Mucormycosis is uncommon, progressive fungal infection with mortality rate on higher side. The anesthetic management of surgical debridement in mucormycosis is challenging.

We evaluated the anesthetic management of mucormycosis patients associated with problems of airway management, predisposing factors, and adverse effect of antifungal therapy who underwent surgical resection of necrotized tissues.

Results

Fifty-six patients presented with uncontrolled diabetes mellitus. All patients had history of COVID-19 infection and received steroid during treatment. Nasal endoscopic debridement was done in 43 patients, total maxillectomy in 14 patients. Temporalis flap was needed in five patients, and orbital exenteration was required in three patients. Central venous catheter was inserted in 17 patients, and invasive arterial monitoring was done in ten patients. All patients administered lyophilized amphotericin B (deoxycholate) in combination with surgical debridement.

Thirteen patients were shifted to ICU for further management and continuous hemodynamic monitoring. Fifteen patients were expired, and the mortality rate was 26.31%.

Conclusions

Challenges include difficult intubation and renal function impairment due to prolonged antifungal therapy. Postoperative ICU management is important in mucormycosis patients due to comorbidities and rapid progressive infection after surgery.

Magnetic Resonance Imaging Prognostic Findings for Visual and Mortality Outcomes in Acute Invasive Fungal Rhinosinusitis

PURPOSE

To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020.

METHODS

A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality.

MAIN OUTCOME MEASURE

Identification of initial, preintervention MRI findings associated with visual and mortality outcomes.

RESULTS

The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; P < 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001).

CONCLUSIONS

Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality.

Determinants of stroke in patients with rhino cerebral mucormycosis seen during the second wave of COVID-19 pandemic: A prospective cohort study

BACKGROUND

Rhino cerebral mucormycosis is an uncommon opportunistic infection of the nasal sinuses and brain, and a group of saprophytic fungi causes it. During the second wave of COVID-19, India witnessed an unprecedented number of patients with rhino cerebral mucormycosis. Invasion of the cavernous sinus and occlusion of the internal carotid artery in many cases resulted in a stroke. The study aimed to assess the clinical and neuroimaging predictors of stroke in patients with rhino cerebral mucormycosis. We also evaluated the predictors of death in these patients at 90 days.

METHODS

A prospective study was performed at a tertiary care centre in India between July 2021 and September 2021. We enrolled consecutive microbiologically confirmed patients of rhino cerebral mucormycosis. All patients underwent neuroimaging of the brain. Treatment comprised of anti-fungal drugs and endoscopic nasal/sinus debridement. We followed the patients for 90 days and assessed the predictors of stroke and mortality RESULTS: Forty-four patients with rhino cerebral mucormycosis were enrolled. At inclusion, in 24 patients, the RT-PCR test for SARS-COV-2 was negative. Diabetes mellitus was the most frequent (72.7 %) underlying risk factor; in most, diabetes mellitus was recently discovered. At inclusion or subsequent follow-up, stroke was seen in 11 (25 %) patients. Only seven patients had hemiparesis. Imaging revealed internal carotid artery occlusion in 17 (38.6 %) patients. Hypertension, corticosteroid use, and cavernous sinus thrombosis were independent predictors of stroke. Nine (20.5 %) died during follow-up, and stroke was an independent predictor of death.

CONCLUSION

Stroke indicated poor prognosis among rhino cerebral mucormycosis patients encountered during the second wave of the COVID-19 epidemic.

Management of Mucormycosis in Post COVID-19 Patients and Its Outcome in a Tertiary Care Center: Our Experience

To assess the common presentation and extent of disease involvement clinically and radiologically and treatment modalities, sequalae of the disease, complications and treatment response. Mucormycosis is a life-threatening infection that most commonly affects immunocompromised individuals and an exponential increase in the incidence of Rhino-orbital-cerebral mucormycosis was witnessed in the second wave of the COVID-19 pandemic, despite aggressive multimodal treatment carries a significant risk of mortality. A high index of suspicion is required in order to begin the appropriate diagnostic workup and treatment. This study is conducted to access the outcome and management of mucormycosis in post covid 19 patients. The prospective study includes 180 Patients, who are attending to E.N.T. outpatient department, Triage and patients referred from other departments who had suspected/confirmed Rhino-orbital-cerebral mucormycosis/underwent surgery and/or medical treatment or both. In our study mucormycosis predominantly affected age group between 40 and 60 years, more common in males (77.8%) than females (22.2%), 77.8% patients had post covid status. Most common risk factor was diabetes mellitus.76% patients had undergone endoscopic/open surgery and 24% patients underwent only medical treatment. Among 138 patients operated, 40% had recurrence and mortality was 16.1% (significantly reduced). Early diagnosis and prompt intervention is paramount to reduce morbidity and mortality. Liposomal Amphotericin B is most effective antifungal with manageable side effects. Patients who underwent Radical debridement either endoscopically or open approach, had better outcome with minimal recurrence rates. Combined medical and surgical treatment has better outcome, lesser recurrence and mortality.

Rhino-Orbito-Cerebral Mucormycosis: An Audit

This study aims at identifying the predisposing factors, clinical and radiological features that dictated the treatment outcome of Rhino-orbito-cerebral mucormycosis (ROCM). This is a retrospective observational study. Medical records of 39 patients with ROCM proven by fungal smear or histopathology (HPE), admitted in Sri Ramachandra Institute of Higher Education and Research from Jan 2015 to Dec 2019 were reviewed and audited. The mean age of the patients was 52.6 years and they were predominantly men (76.9%). There is a statistically significant association between uncontrolled diabetes and increasing severity of the disease in this study and an important cause of mortality. Fungal smear and HPE plays a crucial role in diagnosis. Radiological evaluation helps in identifying the extent of spread and in this study 31% of patients had intraorbital and 20% had intracranial extension. In-hospital mortality was 13%. Our results showed better outcome when combined medical and surgical intervention was undertaken. Rhino-orbito-cerebral Mucormycosis is a rapidly spreading invasive fungal infection with significant mortality and morbidity. Early diagnosis and proactive surgical and medical intervention is crucial for better outcome. Hence the clinician should be highly alert to certain subtle clinical signs and radiological features in a diabetic patients for improving the treatment outcomes and avoiding potentially fatal complications.

Incidence of Mucormycosis in a Tertiary Care Hospital During Covid First Wave-A Retrospective Study

Rhino orbital cerebral mucormycosis is a medical emergency; though rare it's a life threatening infection in patients. It commonly occurs in immunocompromised patients due to various causes. A retrospective study was conducted in tertiary care centre wherein 30 non-covid, diabetic patients were treated for mucormycosis. All underwent intensive debridement and diabetic management along with antifungal- amphotericin. All the cases improved with aggressive therapy: medical and surgical. Early recognition and treatment is needed to prevent morbidity and mortality.

Clinicoradiological profile and outcome of cavernous sinus syndrome with coronavirus disease-2019-associated rhino-orbito-cerebral mucormycosis

Objective

With coronavirus disease 2019 (COVID-19) pandemic across the world, there had been an exponential increase in rhino-orbito-cerebral mucormycosis (ROCM). Extension of infection to cavernous sinus leads to cavernous sinus syndrome (CSS). This study aims to describe incidence, clinicoradiological profile, and outcome of CSS positive along with comparative analysis of CSS negative COVID-19-associated ROCM.

Material and Method

This was a prospective and observational study conducted from May 1, 2021, to July 31, 2021. Subjects included ROCM with active or recovered COVID-19 (past 6 weeks) and were categorized and staged. CSS was defined as involvement of two or more of third, fourth, fifth, or sixth cranial nerve with one each direct and indirect qualitative neuroradiological features. Clinicoradiological features of CSS-positive and negative COVID-19-associated ROCM groups were compared.

Results

Incidence of CSS with COVID-19-associated ROCM was 28%. Mean age of subjects was 44 ± 15 years with 60% being males and 73% were proven ROCM. Significant differences seen across the CSS-positive and negative groups were ocular, nasal, and cerebral findings including eyelid and periocular discoloration, ptosis, proptosis, ophthalmoplegia, nasal discharge, mucosal inflammation, and fever. Oculomotor, trochlear, and abducens nerves were significantly involved more in CSS-positive group. Significant radiological findings across two groups included indirect features in orbit, nose, and paranasal sinuses along with direct features in cavernous sinus. Surgical intervention was more common in CSS-positive group. Mortality in CSS-positive group at 8-24 weeks was 13 and 27%, respectively.

Conclusion

Extension of ROCM to CSS was more common in young males in advanced stages of proven ROCM with concurrent COVID-19. CSS-positive group had significant difference in clinicoradiological features involving orbit, nose, paranasal sinuses, and central nervous system as compared to CSS-negative group. This study highlights the need to develop an objective scoring system considering clinical and radiological features for diagnosis of CSS with COVID-19-associated ROCM.

The impact of mucormycosis (black fungus) on SARS-CoV-2-infected patients: at a glance

The emergence of various diseases during the COVID-19 pandemic made health workers more attentive, and one of the new pathogens is the black fungus (mucormycosis). As a result, millions of lives have already been lost. As a result of the mutation, the virus is constantly changing its traits, including the rate of disease transmission, virulence, pathogenesis, and clinical signs. A recent analysis revealed that some COVID-19 patients were also coinfected with a fungal disease called mucormycosis (black fungus). India has already categorized the COVID-19 patient black fungus outbreak as an epidemic. Only a few reports are observed in other countries. The immune system is weakened by COVID-19 medication, rendering it more prone to illnesses like black fungus (mucormycosis). COVID-19, which is caused by a B.1.617 strain of the SARS-CoV-2 virus, has been circulating in India since April 2021. Mucormycosis is a rare fungal infection induced by exposure to a fungus called mucormycete. The most typically implicated genera are Mucor rhyzuprhizopusdia and Cunninghamella. Mucormycosis is also known as zygomycosis. The main causes of infection are soil, dumping sites, ancient building walls, and other sources of infection (reservoir words "mucormycosis" and "zygomycosis" are occasionally interchanged). Zygomycota, on the other hand, has been identified as polyphyletic and is not currently included in fungal classification systems; also, zygomycosis includes Entomophthorales, but mucormycosis does not. This current review will be focused on the etiology and virulence factors of COVID-19/mucormycosis coinfections in COVID-19-associated mucormycosis patients, as well as their prevalence, diagnosis, and treatment.

Facial Nerve Palsy as a Common Presentation during the Epidemic of Coronavirus Disease Associated Rhinocerebral Mucormycosis

Purpose

The main purpose of this study is to highlight the involvement of the facial nerve as one of the presenting symptoms in patients suspected of coronavirus disease associated mucormycosis (CAM).

Methods

This is a retrospective observational study conducted at a tertiary care referral centre which included 300 patients with past history of being treated for coronavirus disease and who presented to our department with symptoms of invasive fungal sinusitis. All the patients were evaluated clinically and radiologically for presence of facial nerve palsy (FNP) in suspected cases of CAM. All the patients were managed with combined modality treatment with antifungal therapy and radical endoscopic debridement of the necrotic tissue and fungal debris.

Results

The data were analysed to assess the possible epidemiological factors linked to CAM. Diabetes mellitus was the most common associated factor identified for aggravating of CAM. FNP is also one of the common presentation seen among 53 patients with CAM.

Conclusion

FNP is an unusual but significant sign in presentation of mucormycosis. It could be easily misdiagnosed as cerebrovascular accident leading to delay in the treatment. During this era of Covid-19 pandemic where wearing of masks has become mandatory, there is a high probability of this finding to be missed. Thus, our study emphasises for thorough cranial nerve examination in all cases of CAM, for an early and an immediate intervention to prevent the spread of the disease and also to improve the overall general condition of the patient.

Retrobulbar Injection of Amphotericin B in Patients With COVID-19 Associated Orbital Mucormycosis: A Systematic Review

PURPOSE

Following COVID-19 infection a rising count of rhino-orbito-cerebral mucormycosis is observed, requiring orbital exenteration, a disabling lifetime affecting surgery. One of the potential interventions for globe salvage in these patients is retrobulbar injections of amphotericin B. This study was conducted to review protocols, outcomes, and side effects of retrobulbar injection of amphotericin B in patients with COVID-19 associated rhino-orbito-cerebral mucormycosis (CAM).

METHODS

The PubMed, Scopus, Web of Science, and Embase databases were searched using a comprehensive string of relevant keywords. All English studies with the confirmed diagnosis of CAM infection were included. We excluded all studies in which retrobulbar injection of amphotericin B was not implemented in any of the patients or there was a lack of clarified and detailed data about this procedure among participants.

RESULTS

A total of 647 cases had a history of retrobulbar injection(s) of amphotericin B in 13 reviewed studies with 3,132 subjects of CAM. The most common protocol was the retrobulbar injection of 1 ml of 3.5 mg/ml liposomal amphotericin B for 3 doses daily or on alternate days. We discerned that the globe salvage rate was 95.0% in eyes with a history of retrobulbar injection(s). The total rate of orbital exenteration was 14.9%, regardless of the history of retrobulbar injection of the drug. Other outcomes of this intervention were vision salvage and reduced major ophthalmic complaints, including pain, swelling, chemosis, ptosis, and ophthalmoplegia. The side effects of this intervention were not serious, and most of them were transient. They included swelling at the injection site, restriction of ocular motilities, exacerbation of orbital inflammation, and even intensification of visual impairment in a few cases.

CONCLUSIONS

Retrobulbar injection of amphotericin B should be considered a nearly safe and protective intervention against orbital exenteration in patients with CAM. It may also be effective in saving vision. Since the effectiveness of orbital exenteration in the survival of patients is not ascertained, retrobulbar injections can be considered an alternative intervention.

Two Cases of Herpes Virus Infection of Nose Mimicking Acute Invasive Fungal Infection in Immunocompromised Hosts

Various invasive fungal infections can occur in immunocompromised hosts, and an acute invasive fungal infection (AIFI) can be fatal. Because of its high mortality rate, AIFI must be quickly diagnosed and treated, such as anti-fungal agents or surgical debridement. In an immunocompromised host, nasal herpes simplex infection, usually caused by herpes simplex virus (HSV) type-1, can have various clinical manifestations, some of which can mimic AIFI. However, the management of acute viral infection differs significantly from invasive fungal infections of the nose. A fast and accurate differential diagnosis is mandatory because a delay in the disease-specific treatment of acute invasive infections can lead to mortality. This report describes two immunocompromised patients with mucosal and skin lesions around the nose. We provide clinical clues when mucosal lesions of the nasal cavity and skin lesions around the nose develop in immunocompromised hosts.

Rhino-orbito-cerebral mucormycosis: aetiopathology, clinical features, outcome and the factors associated with outcome- a retrospective hospital record-based study

Purpose

Mucormycosis is a multisystemic, aggressive, and an opportunistic fungal infection. The most common type is rhino-orbito-cerebral mucormycosis (ROCM) accounting for almost 40% of the cases. In this study, we analyzed the etiopathology, clinical features, treatment outcome, and the factors associated with outcome in ROCM.

Methods

Case records of 52 patients of ROCM were analyzed. Clinical parameters, laboratory parameters, imaging findings, treatment regime, and treatment outcome details were retrieved from each case record. The outcome measures were evaluated as treatment success and treatment failure. Univariate and logistic regression analyses were performed to identify factors associated with treatment outcome.

Results

On univariate analysis, factors associated with poor treatment outcome were uncontrolled blood sugar, blood urea, diabetic ketoacidosis, duration of ocular symptoms, no perception of light at presentation, ptosis, conjunctival chemosis, relative afferent pupillary defect, two or more sinus involvement, bony erosion of orbital wall, intracranial extension, intraconal invasion, etc. On subsequent logistic regression analysis, factors that maintained significant association with poor treatment outcome were uncontrolled blood sugar (adjusted odds ratio [aOR], 1.17; p = 0.018), no perception of light at presentation (aOR, 10.67; p = .006), ptosis at presentation (aOR, 3.90; p = 0.03), conjunctival chemosis (aOR, 7.11; p = 0.024), relative afferent pupillary defect (aOR, 10.60, p = 0.01), central retinal artery occlusion at presentation (aOR, 3.54; p = 0.021) and two or more sinus involvement (aOR, 4.90; p = 0.009).

Conclusions

The current study identified newer factors in the form of presenting ocular and radiological features as predictors for aggressive systemic disease and poor treatment outcome. Future prospective studies are, however, needed to substantiate these associations.

Fungal Endophthalmitis in a Case of Rhino-Orbito-Cerebral Mucormycosis: Successfully Treated With Amphotericin B Colloidal Dispersion

Background

Rhino-orbito-cerebral mucormycosis (ROCM) is an acute, fulminant, opportunistic fungal infection that usually occurs in diabetes or immunocompromised patients. Amphotericin B combined with surgical debridement remains the standard treatment, although it is controversial due to its lager nephrotoxicity. Thus far, no studies have reported the treatment for ROCM-associated fungal endophthalmitis because the exact pathogenesis and transmission routes in ROCM remain unclear. Here, we reported a case of ROCM complicated with fungal endophthalmitis treated favorably with amphotericin B colloidal dispersion (ABCD) in combination with other antifungals and surgical debridement.

Case Presentation

A 34-year-old woman with diabetes was admitted to our hospital owing to right-sided headache for 8 days, blindness with swelling in the right eye for 5 days, and blindness in the left eye for 1 day. MRI showed that the patient had sphenoid sinus, sinuses, frontal lobe lesions, and proptosis of the right eye. Metagenomic sequencing revealed that the patient had Rhizopus oryzae infection. During hospitalization, the patient received intravenous ABCD, oral posaconazole, and topical amphotericin B and underwent surgical debridement. After 67 days of treatment, the patient’s condition was significantly improved, and limb muscle strength showed grade V. Rhizopus oryzae showed negative results, and conjunctival swelling decreased. Additionally, no nephrotoxicity occurred during treatment. After discharge, the patient’s treatment was transitioned to oral posaconazole and she was free of complaints during the 30-day follow-up without any additional treatment for ROCM.

Conclusion

Treatment with ABCD combined with other antifungal drugs and surgical debridement for ROCM complicated with fungal endophthalmitis showed remarkable efficacy and good safety. Hence, this regimen is a promising treatment strategy for this fatal disease.

Exenterate or Not: A Simple Proposed Management Algorithm for Mucormycosis During the Era of COVID-19 in a Tertiary Eye Care Center in Egypt

Purpose

To construct a simple management algorithm for cases with orbital mucormycosis during the COVID-19 era.

Methods

Retrospective study included records of 30 Egyptian patients with post COVID-19 orbital mucormycosis. They underwent full clinical examination, laboratory investigations, Computed tomography (CT)/magnetic resonance imaging (MRI) of the paranasal sinuses and pathological specimen examination. The proposed algorithm was based on all the available data of the included patients.

Results

The mean age of the studied patients was 62.47±11.13 years; 56.6% were females and 63.3% had uncontrolled diabetes mellitus. The main presentation was Orbital apex syndrome (OAS) in 43.3% of the cases. Twenty-six patients (86.6%) received systemic liposomal amphotericin B, while 4 patients (13.3%) received posaconazole. Orbital exenteration was done in 6 patients (20.0%), 4 of them died (66.7%). Twenty-four patients (80%) survived with clinical but not with visual improvement.

Conclusion

Systemic antifungal treatment and functional endoscopic sinus surgery (FESS) with extensive debridement of involved necrotic tissues were the main steps to control ROCM. Orbital exenteration should be kept for cases with periorbital tissue affection as it did not increase the final cure rate. The proposed management algorithm is supposed to be simple and easy to follow.

Outcomes of a Modified Treatment Ladder Algorithm Using Retrobulbar Amphotericin B for Invasive Fungal Rhino-Orbital Sinusitis

PURPOSE

To assess whether a modified treatment ladder algorithm incorporating transcutaneous retrobulbar amphotericin B (TRAMB) for invasive fungal rhino-orbital sinusitis can reduce the risk of exenteration without compromising survival.

DESIGN

Retrospective, comparative clinical study with historical control subjects.

METHODS

Fifty consecutive patients with biopsy-proven invasive fungal sinusitis and radiographic evidence of orbital involvement were evaluated at a single tertiary institution from 1999-2020. TRAMB was incorporated as part of the treatment algorithm in 2015. Demographics, underlying immune derangement, infective organism, ophthalmic examination, surgical care, and survival were compared in a quasiexperimental pre-post format, dividing patients into a pre-2015 group and a post-2015 group. Risk of exenteration and mortality were the primary outcomes.

RESULTS

Baseline characteristics did not differ significantly between the 2 groups. Nearly all patients underwent a surgical intervention, most commonly functional endoscopic sinus surgery with debridement. TRAMB was administered to 72.7% of the post-2015 group. Exenteration was more common in the pre-2015 group (36.4% vs 9.1% [95% confidence interval {CI} 5.2-48.8]; P = .014), while mortality was similar (40.0% vs 36.7% [95% CI -22.1 to 29.3]; P = .816). After adjusting for potential confounders, patients treated after 2015 were found to have lower risk of exenteration (relative risk 0.28 [95% CI 0.08-0.99]; P = .049) and similar risk of mortality (relative risk 1.04 [95% CI 0.50-2.16]; P = .919).

CONCLUSION

Compared with historical control subjects, patients with invasive fungal rhino-orbital sinusitis who were treated with a modified treatment ladder algorithm incorporating TRAMB had a lower risk of disfiguring exenteration without an apparent increase in the risk of mortality.

Rhinosinus Mucormycosis with Drug-induced Pancytopenia in an Immunocompromised Severe COVID-19 Patient: A Success

Secondary infections in coronavirus disease (COVID) are becoming common. We report a case of a female known case of diabetes, sarcoidosis on steroids and methotrexate admitted with COVID pneumonia. She was treated with steroids, remdesivir, and anticoagulants and was discharged. She revisited the hospital after 2 months with complaints of severe right-sided headache, eye pain, and vomiting. Magentic resonance image of brain and paranasal sinus revealed possibility of invasive rhinosinus mucormycosis. Functional endoscopic sinus surgery (FESS) was done and culture showed growth of mucor and methicillin resistant staphylococcus aureus (MRSA) following which she was started on amphotericin B and antibiotics. She also developed methotrexate and amphotericin B-induced pancytopenia for which injection folinic acid, granulocyte-colony stimulating factor (G-CSF), and erythropoietin were given and was switched over to liposomal amphotericin B. After 5 days of ventilatory support, she was discharged in a stable condition. Extensive steroids in an immunocompromised patient might have led to this event hence physicians should always keep this possibility of secondary fungal infection in COVID patients for understanding the impact of disease.

Fungi of the human eye: Culture to mycobiome

The focus of the current review is multi-fold and compares the diversity and abundance of fungi on the ocular surface by the conventional culture-based method with the more sensitive, high throughput, culture-independent NGS method. The aim is to highlight the existence of a core ocular mycobiome and explore the transition of the ocular fungal microbiota from the normal eye to the diseased eye. PubMed, Google Scholar and Medline were used to search for publications and reviews related to cultivable fungi and the mycobiome of the normal and diseased eye. The conventional cultivable approach and the NGS approach confirm that the eye has its own mycobiome and several confounding factors (age, gender, ethnicity etc.) influence the mycobiome. Further, dysbiosis in the mycobiome appears to be associated with ocular diseases and thus impacts the health of the human eye. Considering that the mycobiome of the eye is influenced by several confounding factors and also varies with respect to the disease status of the eye there is a need to extensively explore the mycobiome under different physiological conditions, different ethnicities, geographical regions etc. Such studies would unravel the diversity and abundance of the mycobiomes and contribute to our understanding of ocular health. Research focused on ocular mycobiomes may eventually help to build a targeted and individualized treatment.

New insights on mucormycosis and its association with the COVID-19 pandemic

COVID-19 continues to cause significant fatality worldwide. Glucocorticoids prove to play essential roles in COVID-19 management; however, the extensive use of steroids together with the virus immune dysregulation may increase the danger of secondary infections with mucormycosis, an angioinvasive fungal infection. Unfortunately, a definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. In this review, we discuss the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response, risk factors, clinical presentation, diagnosis and treatment. Special emphasis is given to its association with the current COVID-19 pandemic, including latest updates on COVID-19-associated mucormycosis cases globally, with recommendations for efficacious management.

A definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. This article can be used as comprehensive tool to help clinicians and the healthcare team in getting a clearer look on the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response. Risk factors, clinical presentation, diagnosis, treatment options and also the latest updates on COVID-19-associated mucormycosis are also discussed, which will help in the understanding of the fatal mucormycosis infection.

Infectious Causes of Stroke

Stroke is one of the primary causes of mortality and morbidity worldwide. It can be ischemic or hemorrhagic, and the former can be due to an in-situ thrombus or a distant embolus. Despite being a rare cause, stroke can also be caused in the setting of infection. Bacterial agents are the most common cause of stroke, among other infectious agents. Until the antibiotic era, rheumatic heart disease was a predisposing risk factor of infective endocarditis. VZV is the most common cause of strokes in pediatric and adult populations. Cryptococcus and Candida spp are the most common yeasts involved in CNS infections, especially in immunocompromised patients. In COVID-19 patients, ischemic strokes are more common than hemorrhagic strokes. In this review, we will discuss the most common infectious agents, with particular emphasis on COVID-19.