Imaging of COVID-19-associated rhino-orbital-cerebral mucormycosis: imaging analysis of 120 patients

Abstract

Background With the ongoing pandemic of COVID-19, there has been a rapid upsurge in cases of rhino-orbital-cerebral mucormycosis (ROCM). It is an opportunistic fungal infection associated with high morbidity and mortality. Rapid and appropriate application of clinical and radiological methods is crucial for early diagnosis, to limit the associated morbidity and improve post-treatment outcomes. In our study, we analyzed imaging features, common sites, and the extent of infection in patients suffering from ROCM. Results The majority of the patients were either diabetics or developed uncontrolled blood glucose levels during COVID-19 infection. 79.17% of patients had a history of treatment with steroid therapy. Headache and facial pain were the most common clinical features seen in 76.67% and 60% of patients, respectively. Maxillary and ethmoid sinuses were commonly involved. The most common extra-sinus site of involvement was periantral fat and orbit, seen in 91 (75.83%) and 84 (70%) patients, respectively. Bone erosion or marrow edema was seen in 72 (60%) patients. Intracranial extension in the form of meningitis, cavernous sinus thrombophlebitis/thrombosis, and brain abscess were seen in 20%, 10%, and 3.3% of patients, respectively. MRI-based staging showed that 24.7% of patients had stage I, 5.83% had stage II, 50% had stage III, and 20% had stage IV disease. Conclusion The spread of COVID-19-associated rhinomucormycosis to extra-sinus sites is common, which can be detected adequately on MRI. The radiological signs of invasion and devitalization of tissues are crucial for the early diagnosis of ROCM.

Post-COVID-19 Rhino-Orbito-Maxillary Mucormycosis Defect: Our Surgical Experience with Single Stage Delayed Reconstruction Using Free Flap

“…DM was also present in the majority of the patients with COVID-19-associated mucormycosis reported in the literature. 4,5,14,15 In our study, 2 of 8 patients were diagnosed with COVID-19-associated mucormycosis within 2 months of COVID-19 infection, 4 patients were diagnosed in the third month, 1 patient after 5 months, and 1 patient after 160 days of COVID-19 infection. Various surgical procedures that were performed in each of these patient as a part of the management protocol included bilateral (B/L) maxillectomy along with an alveolar process and hard palate removal (patient 1); B/L infrastructure maxillectomy þ B/L frontal sinusotomy (patient 2); right maxillectomy with orbital exenteration (patient 3); B/L maxillectomy involving anterior two-thirds hard palate with B/L frontal and ethmoidal sinusotomy (patient 4); B/L maxillectomy with B/L ethmoidal and maxillary sinusotomy (patient 5); right maxillectomy including alveolar process along with a bony defect wall of the maxillary and frontal sinus with right orbital exenteration (patient 6); right maxillectomy along with removal of the right zygoma, maxillary sinus, and right pterygoid plate (patient 7); and left suprastructure maxillectomy along with orbital exenteration (patient 8).…”

“…Thus, it is anticipated that most of the survivors of COVID-19-associated mucormycosis will approach for reconstruction surgeries over a period of time. 1 Numerous cases series have described the clinical presentation, radiological investigations, neurological aspect, and management of patients with COVID-19associated mucormycosis, [4][5][6][7][8][9] and various local flaps like submental flap, facial artery musculomucosal flap, and various free flap including radial artery forearm free flap, deep circumflex iliac artery flap, anterolateral thigh (ALT) flap, and free fibula flap, but none of the studies have included details regarding the postoperative clinical outcomes of delayed reconstructive surgeries performed for rhino-orbito-maxillary (ROM) defects that occurred due to COVID-19-associated mucormycosis with DM. This study was conducted to evaluate the clinical outcomes in view of the quality of life, aesthetics, speech, and deglutition for short duration in patients with ROM defects due to COVID-19-associated mucormycosis with DM undergoing single stage delayed free flap reconstruction.…”

Radiological spectrum of rhino-occulo-cerebral mucormycosis

“…In our study, 59.6% of patients had periantral fat involvement. Agrawal et al showed periantral involvement in 75.83% of cases (15).…”

“…In our study, we also found variable signal intensity on T2WI (60% hyperintense, 25% isointense and 4% hypointense) and all showed hypointensity on T1WI. The accumulation of hemosiderin and paramagnetic materials such as calcium, iron, magnesium, and manganese has been linked to hypointensity on T1WI and T2WI in fungal disease (3,14,15).…”

“…The presence of heterogeneous enhancement or non-enhancing areas within the lesion suggests that it is caused by an invasive fungal aetiology. The disease is known to devitalize the sinonasal mucosa through vascular invasion and infarction, resulting in non-enhancing tissues on contrast administration (15).…”