Covid-19 disease has plethora of clinical manifestations. There have been certain viral coinfection and presence of autoimmunity in Covid-19 disease. The predominant neurological manifestations of Covid-19 disease reported are encephalopathy, anosmia, headache, bell’s palsy, Guillain barre syndrome, acute transverse myelitis, acute demyelinating encephalomyelitis and strokes. In this illustration we presented an 11-year-old girl suffering from Covid-19 illness, presented with acute transverse myelitis along with Varicella-zoster co-infection substantiated by cerebrospinal fluid PCR positivity. There is a scarce literature of coexistence of varicella-zoster co-infection triggering myelitis in Covid-19 illness.

Background Rhino-Orbital-Cerebral Mucormycosis (ROCM) is an important infectious disease encountered in huge number in this recent post-covid 19 era. An alteration in defence immune system during covid-19 illness, in the presence of uncontrolled hyperglycaemia has led to the new epidemic of ROCM especially in developing nations like India. Method This case series of thirteen patients illustrates the various clinical presentation, laboratorical parameters, imaging features and outcome of patients of ROCM admitted in a tertiary care hospital in Northern India. Result In our case series, a total of 13 newly diagnosed cases of Rhino-Orbital-Cerebral Mucormycosis were studied. History of covid-19 illness was observed in 7 cases (53.8%), use of steroid during Covid-19 illness was seen in 5 cases (38.5%), oxygen therapy was given in 4 cases (30.8%). Co-morbid state in the form of diabetes mellitus was present in 12 cases (92.3%) with mean duration 16.69 months with an important finding of 6 cases (46.2%) having new-onset diabetes; hypertension in present in 3 cases (23.1%). Magnetic resonance imaging of paranasal sinuses showed involvement of multiple sinuses in all the 13 cases(100%), including maxillary and ethmoidal sinuses, with frontal in 12 cases (92.3%), sphenoidal in 11 cases (84.6%), symmetric in 9 cases (69.2%), mastoiditis in 4 cases (30.8%), maxillary space involvement in 4 cases (30.8%), palatal involvement in 1 case (7.7%). Multi-speciality approach treatment was given in the liposomal amphotericin B therapy in all the patients along with thorough endo-nasal debridement done in all cases, transcutaneous retrobulbar amphotericin B in 6 cases (46.2%) with exenteration done in 7 patients (53.9%). At 3 months of follow-up, there was substantial clinical improvement in all the cases. Conclusion There should be definite emphasis on high suspicion of mucor clinically for early diagnosis and aggressive management at initial state of diagnosis for better outcome. The need for sustained proper glycemic control during covid 19 era along with judicious use of steroid and public awareness for early symptoms and manifestations of mucor can curb the magnitude of such potentially opportunistic epidemic to a substantial rate. The longer the infection remains undetected, the greater the devastation ROCM can impose, of which blindness is an important hazard.

Rhino-orbital cerebral mucormycosis has increased in the recent second wave of post-Covid-19 illness, mainly in tropical countries like India. The burden of diabetes mellitus and rampant use of corticosteroid, environmental factors, post-covid-19 immunological derangement might be contributory factors to the development of extensive outbreak of ROCM. Cerebrospinal fluid rhinorrhea is rarely documented with such fungal infection in literature. This case report described a 45-year diabetic woman in the post-Covid-19 phase,who developed rhino-orbital cerebral mucormycosis, presenting with spontaneous cerebrospinal fluid rhinorrhea.