A 44-year-old man attended our hospital reporting reduced vision in his left eye. 10 days earlier he had been started on treatment with supplemental oxygen, intravenous antibiotics, and corticosteroids because of a moderately severe pneumonia caused by SARS-CoV-2. The patient explained that a blackish patch-extending from just below his left eye to the left side of his face to the level of his mouth-had also developed 2 days earlier (figure).The patient was a known diabetic; he had no history of malignancy.On examination his temperature was 37°C, pulse was 84 beats per min, blood pressure was 118/82 mm Hg, and respiratory rate was 16 breaths per min; pulse oximetry showed an oxygen saturation of 96% on room air. The patient had exophthalmos, ophthalmoplegia, and chemosis of his left eye. Best corrected visual acuity was 20/20 in his right eye, but he reported no perception of light in his left eye.Laboratory investigations showed a random blood sugar concentration of 298 mg/dL (normal 140 or below), glycated haemoglobin A1c of 9•8% (normal 4-5•6), arterial blood pH 7•4 (normal 7•35-7•45), serum bicarbonate concentration 24 mEq/L (normal 23-30), and a mild neutropenia (1510 neutrophils per µL; normal 1800-6300).Examination of a potassium hydroxide mount of nasal scrapings showed broad, pauci-septate hyphae; and Sabouraud dextrose agar culture and lactophenol cotton blue mount were suggestive of Rhizopus arrhizus (figure).Contrast-enhanced MRI showed non-enhancement of the bilateral middle and inferior turbinate: the characteristic so-called black turbinate sign (figure). Contiguous extension of non-enhancing soft tissue into the left middle and ethmoidal air cells, with a breach in the cribriform plate to involve the basal frontal region was noted (figure). T2-hyperintense diffuse inflammatory changes were seen in the soft tissues of the left orbital region-involving the pre-septal, post-septal, and intraconal and extraconal compartments with orbital fat stranding (figure). Heterogeneously enhancing softtissue inflammatory changes were noted on the left side of the face involving the premaxillary region, buccal fat pad, and infra-temporal fossa (figure). Together-the clinical picture and the radiological findings-indicated mucormycosis.The patient was started on intravenous liposomal amphotericin B at a dose of 5 mg/kg per day; an insulin infusion was also continued because of persistent hyperglycaemia. Extensive debridement, a left total maxillectomy, and orbital exenteration were done under a general anaesthetic; however, the patient died 6 days later.During the second wave of the COVID-19 pandemic in India, an unprecedented surge in cases of mucormycosis was observed: immune dysregulation caused by the SARS-CoV-2 and the use of broad-spectrum antibiotics and corticosteroids-particularly in patients with poorly controlled diabetes with ketoacidosis-is likely to have contributed to the rise.COVID-19 followed by mucormycosis carries a very high mortality rate and timely detection, antifungal therapy, and aggressiv...

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This study aimed to review the current literature for epidemiology, pathogenesis, clinical spectrum and management of rhino-orbito-cerebral-mucormycosis (ROCM), especially highlighting the association between ROCM and COVID-19 disease and factors resulting in its resurgence during the pandemic. Mucormycosis is a rare, but an important emerging opportunistic fungal infection, often associated with high morbidity and mortality. ROCM is the commonest and also the most aggressive clinical form occurring in debilitated patients in conjunction with sinus or para-sinus involvement due to the propensity for contiguous spread. Recently ROCM has shown an unprecedented resurgence during the current pandemic. Reports from different parts of the world indicated an increased risk and incidence of ROCM in patients who had required hospital admission and have recovered from moderate-to-severe COVID-19 disease. A majority of mucormycosis cases have been reported from India. The presence of diabetes mellitus (DM) and use of corticosteroids for COVID-19 pneumonia were found to be the key risk factors, resulting in higher mortality. Amidst the ongoing pandemic, with the third wave already having affected most of the world, it becomes imperative to adopt a risk-based approach toward COVID-19 patients predisposed to developing ROCM. This could be based on the most recently published literature and emerging data from centers across the world. The present review intended to elucidate the causes that brought about the current spike in ROCM and the importance of its early detection and management to reduce mortality, loss of eye, and the need for mutilating debridement.