Clinical study of rhino-orbital-cerebral mucormycosis in COVID-19 patients in a regional institute in South India

Abstract

BACKGROUND: Rhino-orbital-cerebral mucormycosis (ROCM) is usually seen in immunosuppressed conditions like uncontrolled diabetes mellitus (DM). The pandemic of severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) and its associated immunosuppression and indiscriminate use of corticosteroids emerged as a new risk factor for ROCM during its' second wave of coronavirus disease 2019 , especially in India. The lack of standardized management protocol for ROCM needs the attention of the ophthalmic community. COVID-19-associated risk factors have been linked to the pathogenesis of ROCM, which reached epidemic proportions during India's second wave of the pandemic. The aim of the present study was to document cases of ROCM and to evaluate risk factors, including co-morbidities, clinical characteristics, diagnosis, management, and outcome at tertiary care centers during the Sars-CoV-2 (2021) pandemic. MATERIAL AND METHODS: It is a retrospective study of 42 patients of biopsy-proven mucormycosis. These patients' records were reviewed from hospital data. All patients were subjected to complete ophthalmological, ortorhino-laringological examination, and imaging studies. The orbital staging was done. Each case was treated by a multidisciplinary approach with functional endoscopic sinus surgery (FESS) and intravenous (i.v.) amphotericin B (AMB). Retrobulbar liposomal AMB and exenteration were performed whenever indicated. Statistical analysis was done using the Chi square test. A p-value ≤ 0.05 was considered significant. RESULTS: Total 42 patients of ROCM were documented. The mean age was 50.48 years, with a male preponderance (82.9%). 99.8% of patients had diabetes (39 patients) and all patients were COVID-19-positive. Concurrent steroid use was seen in 83.3% where 73.1% of patients had received oxygen support during COVID-19 infection. The most common ophthalmologic presentation was orbital/facial oedema (33) and pain, diminution of vision (24), and ophthalmoplegia (26). Direct nasal endoscopy and biopsy were done to establish a diagnosis. All patients were treated with FESS and i.v. AMB. Retrobulbar AMB was given to 11 patients. Exenteration was done in (n = 4) 10.5% of cases. 41 patients recovered, and one patient died CONCLUSION: The most significant predisposing factors for developing COVID-19-associated ROCM are corticosteroids and DM. Patients with COVID-19 must be followed up even after recovery. For a favorable outcome with lower mortality in COVID-19 recovered patients, we must have a high index of clinical suspicion with awareness of red flag signs and make a timely diagnosis.