Post COVID-19 Head and Neck Mucormycosis: MR Imaging Spectrum and Staging

Metwally, Maha Ibrahim; Mobashir, Mohamed; Sweed, Ahmed Hassan; Mahmoud, Sara Mohamed; Hassan, Aya Gamal; ElKashishy, Kamal; Eesa, Mohamed; Elnashar, Ismail; Elmalt, Ashraf; Elsayed, Ahmed; Idris, Shaimaa Khaled; Elshetry, Al Shaimaa Fathi

doi:10.1016/j.acra.2021.12.007

Cited by 10 publications

(7 citation statements)

References 29 publications

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“…They proposed an MR imaging-based classification of mucormycosis staging depending on the site and extent of involvement into stage 1 to stage 4, stage 1 is limited to sinonasal, stage 2 is extrasinus maxillofacial, stage 3 is intraconal and stage 4 is intracranial involvement. The prevalence of mucormycosis in stages 1, 2, 3, and 4 in our study was 11.1%, 55.6%, 20.6%, and 12.7%, respectively [ 23 ].…”

Section: Discussionmentioning

confidence: 94%

Radiological Manifestations of Rhino-Orbito-Cranial Mucormycosis in COVID-19 Patients Correlated With Pathological and Clinical Outcomes and Emphasis on Magnetic Resonance Imaging-Based Scoring System

Patil¹,

Kumar²,

Battula³

et al. 2023

Cureus

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There was tremendous increase in the number of cases of mucormycosis among patients affected by coronavirus disease 2019 during the second wave of pandemic in South Asian countries. This invasive fungal infection primarily affects paranasal sinuses and can have orbito-facial and intracranial extension. We are presenting the radiological findings of invasive mucormycosis with pathological and clinical outcome correlation. It is important for radiologists to have the knowledge of various presentations of this opportunistic infection for early diagnosis and helping clinicians in planning the appropriate line of management. The study also emphasizes on the correlation between the extent of involvement with clinical outcome and we proposed a magnetic resonance imaging (MRI) based scoring system to standardize and prognosticate the patients affected with mucormycosis.Materials and methods: We utilized GE 1.5 tesla, 16-channeled MRI machine for scanning the clinically suspected mucormycosis patients and did plain and contrast study of the paranasal sinuses, orbito-facial study and included brain as and when required. Images were acquired in axial, coronal, and sagittal planes using T1, T2, and fat-saturated short tau inversion recovery sequences (STIR), fat-saturated contrast sequences for better evaluation of the extent of the disease. Diffusion-weighted sequence was also acquired to detect ischemic changes in optic nerve or brain parenchyma. Contrast study was used to detect any major vessel occlusion or cavernous sinus thrombosis in the study population.Results: Total number of cases (n) included in the study were 32. The mean age group was 41-50 years with the median age was 47 years. Out of 32 cases (n=32), in 16 cases (50%) the disease was limited only to the paranasal sinuses and in remaining 16 (50%) cases, disease has spread to other regions such as orbits, facial soft tissues, optic nerve, and brain parenchyma. All the 18 cases with Mild score (MRI ROCM score 1-3) survived and all those with severe score (2 cases) (MRI ROCM score 7-10) did not survive. Conclusion:During the second wave of COVID-19 pandemic, we observed a significant rise in acute invasive mucormycosis infection primarily involving the paranasal sinuses and spread to orbito-facial, cerebral parenchyma causing related complications and hence increased morbidity and death. Radiologically, using MRI, it was effectively possible to detect early extrasinonasal spread and other fatal complications thereby guiding the physicians and surgeons in the proper early aggressive management of the disease. Here, we have described the radiological characteristics of paranasal sinus mucormycosis and its spread to other regions. We also proposed an MRI-based Scoring System for standardized assessment of the disease severity. We observed in our study that the extent of disease on MRI is directly correlating with mortality.

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Section: Discussionmentioning

confidence: 94%

Radiological Manifestations of Rhino-Orbito-Cranial Mucormycosis in COVID-19 Patients Correlated With Pathological and Clinical Outcomes and Emphasis on Magnetic Resonance Imaging-Based Scoring System

Patil¹,

Kumar²,

Battula³

et al. 2023

Cureus

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“…The study conducted by Therakathu et al [ 11 ] also showed orbits as the most common site of extra-sinus spread seen in 76% of patients, followed by facial soft tissue (57%). Metwally et al [ 7 ] also found periantral soft tissue involvement in 74.6% of patients. However, pterygopalatine fossa invasion was more common in their study (77.8%).…”

Section: Discussionmentioning

confidence: 97%

“…The radiological images were studied to look for common sites and the signal intensities of the lesions along with the changes in surrounding tissues. Based on the radiological extent, the severity of the disease was graded into four stages [ 7 ]. Data were tabulated in a Microsoft Excel sheet, for the analysis of data.…”

Section: Methodsmentioning

confidence: 99%

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

Agrawal

Dixit

Yonati

et al. 2022

Egypt J Otolaryngol

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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.

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“…Clinical manifestations of head and neck mucormycosis include headache, loosening of teeth, black necrotic turbinate, facial pain, facial palsy, peri-orbital or facial swelling, skin induration and blackish discoloration [ 35 ]. Symptoms attributed to nasal and oral cavity invasion include epistaxis, bloody nasal discharge and palate destruction.…”

Section: Clinical Presentationmentioning

confidence: 99%

“…The “black turbinate sign” on MRI is characterized by lack of contrast enhancement as a result of turbinate necrosis but can also be found in other circumstances [ 8 ]. CT and MRI-scan imaging are necessary for disease staging [ 35 ]. In pulmonary CAM, imaging findings recorded in CT were a reversed halo sign (8% of patients), consolidation (83%), cavitation (33%) and nodules (6%) [ 57 ].…”

Section: Imagingmentioning

confidence: 99%

Clinical Phenotypes of COVID-19 Associated Mucormycosis (CAM): A Comprehensive Review

et al. 2022

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A mucormycosis surge was reported during the COVID-19 pandemic in India. A literature search until 14 July 2022, with the aim of updating COVID-19-associated mucormycosis (CAM), identified 663 studies and 88 met inclusion criteria (8727 patients). India reported 8388 patients, Egypt 208 and Europe 40. Rhino-orbito-cerebral mucormycosis (ROCM) was identified among 8082 (98.3%) patients, followed by 98 (1.2%) with pulmonary. In India, 82.6% of patients had diabetes mellitus, with 82% receiving corticosteroids. In Europe, 75% presented pulmonary CAM, 32.5% had diabetes and 40% were immunocompromised. CAM was identified at a median of 17.4 days (IQR 7.5 days) post COVID-19 diagnosis, and PCR was performed in five studies. Rhino-orbital invasion is clinically obvious, while cerebral involvement presents with cavernous sinus thrombosis, meningitis and cerebrovascular disease. Symptoms of pulmonary CAM usually overlap with severe COVID-19 pneumonia. High-dose liposomal Amphotericin B (and early surgical debridement in ROCM) are the mainstay of therapy. The median mortality rate was estimated to be 21.4% (IQR 31.9%), increased by the presence of pulmonary (80% (IQR 50%) or cerebral involvement (50% (IQR 63.9%). In summary, different CAM clinical phenotypes need to be distinguished, influenced by geographical presentation. Opportunities exist for diagnosis and therapy optimization, based on earlier high-dose antifungal therapy, early source control, strict glycemic control and restriction of steroids to COVID-19 patients with oxygen requirements.

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Post COVID-19 Head and Neck Mucormycosis: MR Imaging Spectrum and Staging

Cited by 10 publications

References 29 publications

Radiological Manifestations of Rhino-Orbito-Cranial Mucormycosis in COVID-19 Patients Correlated With Pathological and Clinical Outcomes and Emphasis on Magnetic Resonance Imaging-Based Scoring System

Radiological Manifestations of Rhino-Orbito-Cranial Mucormycosis in COVID-19 Patients Correlated With Pathological and Clinical Outcomes and Emphasis on Magnetic Resonance Imaging-Based Scoring System

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

Clinical Phenotypes of COVID-19 Associated Mucormycosis (CAM): A Comprehensive Review

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