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

Abstract

Introduction Mucormycosis emerged as a wildfire in post-covid-19 infected patients. Most frequently involved sites of mucormycosis are rhino-orbital, rhino-sinusal and rhino-orbito-cerebral. The hallmark sign of mucormycosis is tissue necrosis, which is often a late sign. The fatality rate of mucormycosis is 46% globally. Despite early aggressive combined surgical and medical therapy, the prognosis of mucormycosis is poor. Methods We searched the electronic database of PubMed, web of science, Embase, Scopus and Google Scholar from Jan 2020 until December 2021 using keywords. We retrieved all the granular details of original research articles, case reports/series of patients with rhino-orbito-cerebral mucormycosis (ROCM), and COVID-19 reported worldwide. Subsequently, we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, treatment given and its outcome in people with COVID-19. (Prospero registration-CRD42021256830, June 4, 2021).Results Overall, 544 rhino-orbito-cerebral mucormycosis patients were included in our review with a history of Covid-19 infection. Out of which 410 patients had diabetes mellitus which has proven to be major contributing immunocompromised disease. Other diseases like hypertension, chronic kidney diseases, hypothyroidism, etc., were also attributed as an immunocompromised disease causing increased number of covid associated mucormycosis cases. We found out that total number of patients alive after taking only antifungal drug treatment were 25 in number, whereas total number of patients alive when antifungal drugs were combined with surgical intervention were 428 which was significantly higher. Conclusion Our systematic review concluded that surgical debridement should be performed whenever feasible in parallel to antifungal treatment in order to reduce the mortality rate of COVID-19 associated rhino-orbito-cerebral mucormycosis patients. KeywordsRhino-orbito-cerebral mucormycosis • Covid associated rhino-orbito-cerebral mucormycosis • Covid associated mucormycosis • Mortality • Treatment * Sneha Setiya

A clinical update on fungal disease of human skin

“…24 The coronavirus disease 2019 (COVID-19) pandemic is thought to have driven a spike in the incidence of mucormycosis, as at-risk populations (particularly diabetics) were treated with prolonged courses of immunosuppressing steroids. 25 A meta-analysis of management and outcomes of mucormycosis found significant 90-day mortality benefit with combined surgical debridement and antifungal therapy, compared to antifungals alone. 26 Similarly, a systematic review concluded that surgical debridement should be performed whenever feasible concomitant to antifungal therapy to best reduce mortality in COVID-19-associated cases of rhino-orbito-cerebral mucormycosis.…”

“…26 Similarly, a systematic review concluded that surgical debridement should be performed whenever feasible concomitant to antifungal therapy to best reduce mortality in COVID-19-associated cases of rhino-orbito-cerebral mucormycosis. 25 MMS could also have some utility in this regard. 23 Isavuconazole, a second-generation broad-spectrum triazole, has been shown to have a similar efficacy to liposomal amphotericin B and a favorable safety profile.…”

“…Mortality is high in mucormycosis cases, and emergent administration of lipid‐formulated amphotericin B only partly reduces this risk 24 . The coronavirus disease 2019 (COVID‐19) pandemic is thought to have driven a spike in the incidence of mucormycosis, as at‐risk populations (particularly diabetics) were treated with prolonged courses of immunosuppressing steroids 25 . A meta‐analysis of management and outcomes of mucormycosis found significant 90‐day mortality benefit with combined surgical debridement and antifungal therapy, compared to antifungals alone 26 .…”

“…A meta‐analysis of management and outcomes of mucormycosis found significant 90‐day mortality benefit with combined surgical debridement and antifungal therapy, compared to antifungals alone 26 . Similarly, a systematic review concluded that surgical debridement should be performed whenever feasible concomitant to antifungal therapy to best reduce mortality in COVID‐19‐associated cases of rhino‐orbito‐cerebral mucormycosis 25 . MMS could also have some utility in this regard 23 …”

Anesthetic Management of Mucormycosis Cases Requiring Surgical Debridement

“…The characteristic sign of mucormycosis is tissue necrosis, which is often a late sign. The mortality rate of mucormycosis is 46% worldwide (6).…”