Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1

Purpose

COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.

Methods

This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.

Results

Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).

Conclusion

: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Bloodborne pathogen exposures in a developmental center: 1993-2000

In a developmental center, 257 potential bloodborne pathogen exposures (119 bites, 91 scratches, 30 sharps injuries, 17 mucosal breaks) occurred during 8 years (13,187 employee-years and 6,980 resident-years). Of the residents, 9% were hepatitis B virus (HBV) surface antigen carriers. Serological follow-up of exposed, susceptible employees and residents identified no transmission of HBV, hepatitis C virus (HCV), or human immunodeficiency (HIV) virus. This outcome has been due primarily to hepatitis B immunization and low prevalences of HCV or HIV infections among the subjects. Proper follow-up of all potential exposures is crucial to identify transmission promptly, allay anxiety, and prevent unwarranted workmen's compensation claims. Measures are suggested to reduce exposure further.

Epidemiology and control of enterobiasis in a developmental center

OBJECTIVE

To determine if enterobiasis could be controlled in a developmental center.

DESIGN

Population-based study. Annual screening of all residents by perianal swabs for enterobiasis and on admission or discharge. Treatment of infected residents and their contacts with mebendazole, 100 mg orally, with two doses given 14 days apart.

MAIN OUTCOME MEASURES

The number of residents with enterobiasis and the cost of the program.

RESULTS

The prevalence of enterobiasis fell rapidly and progressively, from 21% before mass medication to 1% after 3 years.

CONCLUSION

Mass medication of residents with enterobiasis and their contacts was beneficial, harmless, and cost effective.

Fracture epidemiology and control in a developmental center

During 3.5 years, 182 fractures occurred among 994 residents of a developmental center. The fracture rate was 5.2 per 100 person-years (1.7 times greater than the rate in the US population). Fracture rate was significantly greater in residents with: epilepsy, older age, male gender, white race, independent ambulation, osteoporosis, and residence in intermediate care (versus skilled nursing) units; it was not affected by severity of mental retardation. Hand and foot bones were fractured in 58% of cases. Femur fracture occurred in 13 cases (7%). Fracture was caused by a fall in 41 cases (23%); its cause was indeterminable in 105 cases (58%). Fractures, occurring without significant injury, may be an important cause of preventable disability in this population. Control measures are suggested.

Eighteen fractures in a man with profound mental retardation

A 39-year-old man with generalized tonic clonic epilepsy and profound mental retardation sustained 18 fractures (15 in appendicular and 3 in axial bones) during 19 years. Both femoral necks were fractured, requiring surgical repair. Although he had been on antiepileptic drugs for 35 years, he had no radiographic or biochemical sign of osteomalacia. He had a very low bone mineral density, suggesting osteoporosis. This case illustrates an important medical problem affecting people with developmental disability and a management challenge for their caretakers.

School eye health appraisal

School children form an important large target group which must be screened adequately for early detection of eye diseases and prevention of blindness. A total approach in a school eye health programme must include teacher orientation and health education of children in addition to screening for eye diseases. The ocular morbidity pattern in 5135 school children of Jodhpur is discussed in this paper and it is hoped that it will be an indicator to all eye care agencies to help plan their priorities in the delivery of school based eye care.

Xerophthalmia in school children

The prevalence of xerophthalmia was studied in 5135 school children of Jodhpur ranging between 6 and 16 years of age. The total prevalence of xerophthalmia was found to be 9.89%. Night blindness (XN) and milder conjunctival form (XIA, XIB) of the disease were predominantly prevalent in the studied population. Corneal disease (X2, X3A, X3B) was found in 8 cases and xerophthalmia scar (XS) in only one case. Recognition of early xerophthalmia and urgent vitamin A therapy is of paramount importance to preclude the onset of the corneal stage and irreversible blindness. It is suggested that xerophthalmia screening be made an essential component of routine medical check-up in schools with XN (night blindness with or without conjunctival xerosis) and XIB (Bitot's spots) used as criterion for screening to effectuate early detection and treatment of xerophthalmia.

Serum alpha fetoprotein in 714 mentally retarded carriers of hepatitis B surface antigen

Sera from 714 mentally retarded carriers of hepatitis B surface antigen were screened for alpha fetoprotein (AFP) by monoclonal radioimmunoassay. Serum AFP levels were less than 20 mcg/L in 708 (99.2%) carriers. One 29-year-old carrier with normal liver function had serum AFP level of 1500 mcg/L, which increased to 12,500 mcg/L after 72 days. She died of multifocal hepatocellular carcinoma (HCC) with cirrhosis. Five other carriers with serum AFP levels between 20 and 165 mcg/L are alive without clinical HCC. No correlation was found between serum AFP level and race, age, sex, Down's syndrome, serum alanine aminotransferase level, and hepatitis B e antigen positivity. Single cross-sectional serum AFP screening by itself is not sufficient for early diagnosis of HCC.

Hepatocellular carcinoma in hepatitis B surface antigen carriers in eight institutions

We reviewed records of all persons dying between 1979 and 1986 in eight California institutions for the mentally retarded. Autopsies had been done in 71% of the 1,181 deaths. Nine deaths were due to hepatocellular carcinoma, which invariably developed in carriers of hepatitis B surface antigen (HBsAg) and was fatal within four months of diagnosis. The mean age at death was 32.7 years. The incidence of hepatocellular carcinoma in HBsAg carriers was 140 times greater than in the US population. Persistent hepatitis B infection was probably etiologically related to hepatocellular carcinoma in this population, which is relatively free of exposure to other hepatocarcinogens.

Aflatoxin content of foods served to a population with a high incidence of hepatocellular carcinoma

During three seasons, 36 samples of foods served to mentally retarded clients with a high incidence of hepatocellular carcinoma were analyzed for aflatoxin. Aflatoxin was not detected (less than 5 ppb) by thin-layer liquid chromatography in 35 food samples containing peanuts, corn, wheat or milk. One peanut butter sample contained 20 ppb aflatoxin. Aflatoxin content of these foods was at or below the level permitted by the Food and Drug Administration. Aflatoxin is probably not responsible for liver disease in this population.

Occupational risk of hepatitis B from institutionalized mentally retarded HBsAg carriers: a prospective study

In an institution for the mentally retarded, a total of 13 (2.4%) susceptible employees seroconverted for hepatitis B during 539 person-years. Two of them developed acute hepatitis B; the cost of their medical care and temporary disability was $7,772. Eleven seroconverters had no elevation of serum alanine aminotransferase, and all seroconverters recovered without chronic sequelae. Nine converters acquired antibody to HBsAg alone; three of these had no client contact. Difficulty in identifying nonoccupational causes of hepatitis B infection in the institutional setting often leads to labeling of all seroconversions as occupationally acquired. Hepatitis B vaccine is recommended for client-care personnel.

Epidemiology of hepatitis B infection in institutionalized mentally retarded clients

In 1,149 clients of an institution for the mentally retarded, the prevalences of hepatitis B surface antigen (HBsAg) and hepatitis B virus markers were 12 per cent and 66 per cent, respectively. HBsAg prevalence was higher in males, Down syndrome, ambulatory, and older clients, and those with longer institutionalization. Serum alanine aminotransferase levels were abnormal in 31 per cent of HBsAg positive and 10 per cent of HBsAg-negative clients.

Epidemiology of hepatitis B e antigen and antibody in mentally retarded HBsAg carriers

Screening for HBeAg and anti-HBe was performed on 133 carriers of HBsAg in an institution for the mentally retarded. By radioimmunoassay, the prevalences of HBeAg and anti-HBe were determined to be 16 and 78%, respectively. HBeAg prevalence was significantly different in the following pairs of carriers: 70% in blacks, 10% in whites, and 35% in carriers with Down's syndrome, 8% in carriers without Down's syndrome. Mean age of HBeAg-positive carriers (25.7 years) was lower than HBeAg-negative carriers (29.6 years, p less than 0.05). SGPT levels were abnormal in 66% of HBeAg-positive and 25% of HBeAg-negative carriers (p less than 0.01). This suggests an association between HBeAg positivity and functional liver impairment.

Hepatocellular carcinoma in young, mentally retarded HBsAg carriers without cirrhosis

In a Californian institution for the mentally retarded, surveillance by autopsy of all deaths (n = 138) identified three cases of hepatocellular carcinoma. Hepatocellular carcinoma cases occurred in young (mean age = 26 years) male carriers of HBsAg and were not associated with cirrhosis. They were of the nonfibrolamellar oncocytic type and were rapidly fatal. Hepatocellular carcinoma incidence in HBsAg carriers was estimated to be 246 times greater than United States males.

Occupational exposure to hepatitis B virus. Analysis of indications for hepatitis B vaccine

This retrospective study was undertaken to determine the incidence of acute and chronic morbidity due to hepatitis B infection among employees of an institution for the mentally retarded. Based on a review of medical records, surveillance data, and serologic testing, we found no evidence of excess morbidity among 2,000 employees in a 10-year period. Hepatitis B vaccination is neither warranted nor presently cost-effective for most client-care personnel.