SARS-CoV-19-associated Rhino-orbital and cerebral mucormycosis: clinical and radiological presentations

Abstract

We describe presenting clinical and imaging manifestations of SARS-CoV-19-associated rhino-oculo-cerebral mucormycosis (ROCM) in a hospital setting during the second wave of SARS-CoV-19 pandemic in India. Data on the presenting manifestations was collected from March 01 to May 31, 2021. Associations between clinical and imaging findings were explored, specifically: (1) the presence or absence of orbital pain and infiltration of superior orbital fissure on imaging; (2) the presence of unilateral facial nerve palsy and pterygopalatine fossa infiltration and geniculate ganglion signal on contrast magnetic resonance imaging and (3) vision loss and optic nerve findings on imaging. Orbital pain was reported by six of 36 subjects. A fixed, frozen eye with proptosis and congestion was documented in 26 (72%), complete vision loss in 23 (64%) and a unilateral lower motor neuron facial nerve palsy in 18 (50%). No association was found between the presence of orbital pain and superior orbital fissure infiltration on imaging. The ipsilateral geniculate ganglion was found to enhance more profoundly in seven out of 11 subjects with facial palsy and available MR imaging, and the ipsilateral pterygopalatine fossa was found infiltrated in 14. Among 23 subjects with complete loss of vision, nine (39%) demonstrated long-segment bright signal in posterior optic nerve on diffusion MR images. We conclude that orbital pain might be absent in SARS-CoV-19-associated ROCM. Facial nerve palsy is more common than previously appreciated and ishaemic lesions of the posterior portion of the optic nerve underlie complete vision loss.

Imaging Features of Invasive Fungal Rhinosinusitis: A Systematic Review

“…[37][38][39][40] Other sites of involvement include the orbit (27%-92% of cases), intracranial (2%-60% of cases), the cavernous sinus (8%-100% of cases), the infratemporal fossa (21%-71% of cases), and the internal carotid artery in 6% to 60% of cases. 38,39,[41][42][43][44][45][46][47][48][49][50][51] The distinction between imaging modalities for identifying COVID-associated ROCM is poorly defined in the current literature.…”

COVID-19 and ocular complications: A review of ocular manifestations, diagnostic tools, and prevention strategies

“…Rhino-orbital cerebral mucormycosis is the most common orbital involvement in patients with COVID-19, reported in several case series. 53 , 54 , 55 Mucormycosis induced by COVID-19 is more common in patients with diabetes mellitus and who are suffering from critical or severe COVID-19. 56 Immunologic changes in diabetic patients are a potential risk factor for such fungal conditions.…”

Mucormycosis: update on clinical presentation, diagnosis, and treatment

“…In CAM cases, symptom onset has often occurred within 7-25 days of hospital presentation [29,30 && ]. Some presentations of rhino-orbital-cerebral CAM have been unusual, including facial palsy, gum ulcers, cheek abscess, nasal maggots, and cerebellar infarct [31][32][33]. Eye pain was absent in some patients despite orbital involvement, while a fixed frozen eye with proptosis and congestion was suggestive [33].…”

“…Some presentations of rhino-orbital-cerebral CAM have been unusual, including facial palsy, gum ulcers, cheek abscess, nasal maggots, and cerebellar infarct [31][32][33]. Eye pain was absent in some patients despite orbital involvement, while a fixed frozen eye with proptosis and congestion was suggestive [33]. Very few cases of pulmonary [12 & ] or gastrointestinal [34] MCR were observed.…”