Emergence of Cerebral Mucormycosis in the Post-COVID Period: A Detailed Analysis of Risk Factors, Clinical Progression, and Management of This Opportunistic Fungal Infection

Abstract

Background: An epidemic of Mucorales was reported following the second wave of COVID-19 in India, and intracranial extension of the same was one of the most dreadful complications.Methods: A total of 62 patients with cerebral mucormycosis were recruited and followed up till 12 weeks to evaluate the risk factors, incidence, clinical manifestations, management, and prognosis of cerebral mucormycosis.Findings: A median age of 51.5 years with male predominance (74%) was noted. The majority of subjects reported a history of COVID infection (93.5%) and diabetes mellitus (83.87%). The first symptom of mucormycosis appeared after a mean period of 17.63 ± 8.9 days following COVID. Facial swelling and ptosis were the most common symptoms. Only 55% of patients had neurological presentations, and hemiparesis was the most common neurological sign (30.6%). Radiologically, the involvement of maxillary sinus (90.32%) and ethmoid sinus (87.10%) was commonly noted. Cerebral findings included temporal lobe (50%) and parietal lobe (30.06%) involvement, cavernous sinus thrombosis (30.06%), and internal carotid artery thrombosis (22.58%). Acute cerebral infarction was notable in 37% of subjects (p-value=0.0015, significant association with the outcome). Conventional and liposomal amphotericin B were used in 91.94% and 53.23% of patients, respectively. Retrobulbar amphotericin injections used in 11.3% of subjects significantly affected the outcome (p-value=0.03, significant). Posaconazole step-down therapy was used in 72.5% of subjects (p-value=0.0005, significant). Surgical interventions were performed in 53 (85.48%) subjects (p-value=0.004, significant). Functional endoscopic sinus surgery was the most common (in 64.52% of subjects), followed by maxillectomy (20.97% of subjects) and craniotomy (17.7% of subjects). At the end of 12 weeks, 33.87% of patients died and 59.68% were alive; the rest (6.45%) were lost to follow-up.Interpretation: The absence or late presentation of neurological symptoms led to a delayed diagnosis of cerebral mucormycosis. The presence of acute cerebral infarction indicated a worse prognosis. However, there was a significant influence of step-down posaconazole therapy, retrobulbar amphotericin injections, and surgical intervention on the prognosis of cerebral mucormycosis.

Survival from rhino-orbital-cerebral mucormycosis in SARS-COV-2 positive diabetic patients: Two case reports

“…In some regions of India, MM was declared an epidemic [ 2 ]. Immuno-dysregulating effects or endothelial dysfunction seems to play a role [ 6 , 7 ]. Risk factors include severe and/or active COVID-19 infection, steroid administration, and male sex.…”

“…Resection reduces mortality by 49% but comes at the cost of high cosmetic and functional sacrifices [ 15 ]. Resection of cavernous sinus, ICA, skull base and even dura and brain tissue is technically possible [ 16 ], and certainly necessary for limiting the disease [ 7 ], but entail considerable perioperative risk and need to be discussed thoroughly. The therapy of choice is 5–10 mg/kg/day liposomal amphotericin B. Retrobulbar injection of amphotericin B can reduce infective activity within the orbit [ 17 ].…”

Survival of Rhino-Orbital-Cerebral Mucormycosis in a Diabetic Patient with Incomplete Surgical Debridement: A Case Report

“…1 Immuno-dysregulating effects or endothelial dysfunction due to the SARS-CoV-2-virus seem to play a role. 6,7 Risk factors include severe and/or active COVID-19 infection, corticosteroid administration and male sex. Vaccination against COVID-19 seems to be protective.…”

“…Signs and symptoms of ROCM depend on the stage of the disease and range from sinonasal symptoms to purulent or granular nasal discharge, nasal congestion, facial swelling and pain, hypesthesia, palatal or palpebral necrosis, signs of systemic infection, as well as orbital symptoms (ophthalmoplegia, vision loss, proptosis) or altered mental status. 5,7 Nasal endoscopic findings typically include black or necrotic eschars. Symptoms may evolve over a few days up to several weeks.…”

“…16 Resection of infected cavernous sinus, internal carotid artery, skull base and even dura and brain tissue are technically possible 17 and may improve the outcome. 7 However, they are associated with considerable perioperative risks and need to be discussed with patients and their relatives.…”