Clinical Presentations, Management and Outcomes of Rhino-Orbital-Cerebral Mucormycosis (ROCM) Following COVID-19: A Multi-Centric Study

Abstract

Purpose: To report clinical presentations and factors affecting outcomes in rhino-orbital-cerebral mucormycosis following COVID-19. Methods: Retrospective multi-centric interventional case series of 58 eyes with rhino-orbital-cerebral mucormycosis. Demography, clinical parameters and management outcomes were noted. Factors affecting outcome and mortality were analyzed. Outcome was defined as favorable when complete resolution or stabilization without further progression of the infection was noted at last visit. Results: Mean age was 55 ± 11 years (median 56). The mean HbA1c value was 10.44 ± 2.84 mg% (median 10.5). The duration between the diagnosis of COVID-19 and rhino-orbital-cerebral mucormycosis was 16 ± 21 days (median: 8 days). Thirty-six eyes (62%) had no vision at presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (41%), cavernous sinus involvement (30%), and central nervous system (CNS) involvement (33%). All the patients were treated with systemic Liposomal amphotericin-B and sinus debridement. Twenty-two eyes (38%) underwent exenteration. One eye underwent transcutaneous retrobulbar amphotericin-B. The mean follow-up duration was 5.62 ± 0.78 months (median 6). Favorable outcome was seen in 35 (60%) cases. Presence of uncontrolled diabetes ( p = 0.001), orbital apex involvement ( p = 0.04), CNS involvement ( p = 0.04), and history of steroid use ( p < 0.0001) resulted in unfavorable outcome. CNS involvement was the only factor predicting mortality ( p = 0.03). Mortality was seen in 20 (34%) patients. Conclusion: Over a third of patients with rhino-orbital-cerebral mucormycosis following COVID-19 have an unfavorable clinical outcome. Uncontrolled diabetes mellitus at presentation, involvement of the orbital apex, CNS, and the usage of steroids were associated with poorer outcomes. CNS involvement was a factor determining mortality.

Battling the Emerging Epidemic of Rhino-Orbital-Cerebral Mucormycosis (ROCM) in COVID-19 Pandemic: A Prospective Interventional Study

“…Contrast enhanced MRI has been proved to be a superior imaging technique over Contrast enhanced CT. ( 9) MRI was the preferred modality to monitor the extent of the disease The latest retrospective series on CAM from a geographically different location published by T.V. Dave et al (15) analysed 58 cases and noted that Intracranial extension was seen in 33%, comparable to 22.85% in current study. (p = 0.2).…”

“…The most common side effects noted included chemosis (85%), pain (60%), and proptosis (15%). In the recent reports published on CAM, retrobulbar amphotericin was given in one patient in the recent study by Dave et al, (15) and they reported radiological resolution with uneventful follow up at 6 months of follow up. Although there is paucity of literature on the safety and e cacy pro le of the treatment method, we found that retrobulbar Amphotericin injection, when indicated, caused radiological resolution in atleast 50% patients after 1 cycle of therapy and in 65% patients after 2 cycles.…”

Rhino-orbital mucormycosis following COVID-19 in previously non-diabetic, immunocompetent patients

“…23 Steroidinduced diabetes is known to be to be an independent risk factor for invasive fungal infections, such as mucormycosis. 24 Also, cases of mucormycosis that received corticosteroids during COVID-19 treatment are shown to be associated with poorer outcomes. 25 Sen et al reported that in their series of patients of ROCM, 98% of the patients who developed ROCM showing complete ptosis of the left eye.…”

COVID-19–associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic’s second wave in India

“…A recent systematic review of 15 studies had confirmed the role of diabetes in CAM [ 57 ]. Managing diabetes is thus crucial for controlling both COVID-19 and CAM [ 58 , 59 ].…”