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| EDITORIAL |
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| Year : 2021 | Volume
: 9
| Issue : 2 | Page : 49-50 |
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Rhino-cerebro-orbital mucormycosis: A new threat
Barun K Nayak
PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| Date of Submission | 10-Jul-2021 |
| Date of Decision | 13-Jul-2021 |
| Date of Acceptance | 13-Jul-2021 |
| Date of Web Publication | 31-Jul-2021 |
Correspondence Address:
Barun K Nayak
PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2320-3897.302205
How to cite this article:
Nayak BK. Rhino-cerebro-orbital mucormycosis: A new threat. J Clin Ophthalmol Res 2021;9:49-50 |
The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has taken the whole world by surprise. In the course of over a year and half since its emergence, it has given us many surprises. The disease was unknown, the characteristics and behavior were unclear, management of the diseases was a mystery, and the vaccine for this calamity was nowhere in sight. The new associations and rapidly mutating viruses with deadly different outcomes are constantly being noticed. Commendably, the management and treatment protocols are evolving at a rapid pace. At present, the disease is better understood, many vaccines are available,[1] and the behavior of the general public and their responses have improved. However, we certainly cannot claim to have conquered the COVID-19 pandemic, as new miseries keep being added at a regular interval. Sudden surge in cases of mucormycosis produced a new scare with unwanted outcomes. The purpose of this editorial is to apprise the reader certain facts about mucormycosis so that the morbidity and mortality can be minimized.
Rhino-orbito-cerebral mucormycosis (ROCM) is generally called as mucormycosis and sometimes referred to as “Black Fungus.” Sudden spurt in cases of ROCM cases has raised an alarm bell during the second wave of COVID pandemic all over the world including India.[2] The sudden rise in the number of cases itself is taking the shape of a new mucormycosis epidemic. The causative organism is saprophytic fungi. They belong to the class phycomycetes, order mucorales, and family mucoraceae. Various fungi included in this are Mucor, Rhizopus, Absidia, Cunninghamella genera, and Apophysomyces elegans.[3] Usually, these molds are present abundantly in soil and on organic matter. We also inhale these organisms in these environments but it does not cause any disease as the virulence is very low. These opportunistic organisms get a chance to grow in immunocompromised individuals in the nasal mucosa and sinuses. If not attended to immediately, it may spread to the sinuses, orbit, and the brain, with devastating outcomes. Various cases of mucormycosis have been reported during or following a recovery from the COVID-19.[4] The fungi get a chance to flourish in hot and humid conditions with poorly ventilated unhygienic environment, especially in tropical countries in summer season.
What is the pathophysiology of ROCM? Nasal cavity and sinuses form the ideal ground for its growth in susceptible individuals due to humid environment. Usual sites where the infection sets in are middle turbinate followed by middle meatus and septum. If left unattended, it spreads from these sites to bone and later to the sinuses, orbits, and intracranial space through direct invasion, bone erosion, through orbital apex, ethmoid sinuses, or invasion through the blood vessels. Increased incidence in diabetics is a well-established fact. Hematologic malignancy, solid organ transplant, severe burns, human immunodeficiency virus patient, malnutrition, and hemochromatosis are other risk factors worth mentioning.[5] Sometimes, it may occur even without any predisposing factor. Iron is also required for the growth of the bacteria and fungi. The use of iron-chelating agent enhances the fungal growth due to availability of more iron.[6]
What are the factors responsible for cases of mucormycosis following recovery from COVID-19? We have understood that immunodysregulation occurs in patients with COVID-19, which may lead to secondary infection, both bacterial and fungal. Opportunistic organisms get an upper hand and start growing at an alarming rate with devastating outcomes. The indiscriminate overzealous use of steroids coupled with broad-spectrum antibiotics, and at times, the use of monoclonal antibody can also help in the growth of an otherwise normal commensals. Diabetes and prolonged stay in the intensive care unit also aid in their growth. Even the improper institution of oxygenation, unsterile tubings for many a days are thought to be partially responsible for its spread. At times, the entire concentration of the treating team is on the primary disease of COVID-19, and thus, early signs and symptoms may get overlooked. Occasionally, the patient tends to feel relieved after the recovery and discharge from the hospital and ends up ignoring the early symptoms, thinking they are just the aftereffects of the disease.
What are the symptoms and signs of mucormycosis?[7] The disease earlier was very rare, and hence, the physicians are not very suspicious of the onset of this disease. The symptoms and signs are varied and have a wide spectrum. However, the good thing is that we are getting wiser with each passing day.
An alert should be sounded if we encounter any feature, even in its mildest form, especially in any COVID-19 patient with certain coexistent risk factors as it has wide spectrum of symptoms and signs. Headache which is not responding and increasing in intensity, stuffy and running nose, epistaxis, black discharge from nose, foul smell, congested nasal mucosa, black eschar formation, pain around the eyes, lid edema, onset of ptosis, black discoloration of skin around the eyes, toothache, pain in the ears, ocular muscle palsy, facial palsy, amaurosis fugax, blurring of vision, sudden loss of vision, diplopia, retro-orbital or periorbital pain, central retinal artery occlusion, proptosis, nausea, fever, and various focal palsies should all alert the treating physician present either in isolation or in various combinations. Central nervous system involvement may result in convulsions, dizziness, altered mental status, and abnormal gait. The symptoms and signs will also depend upon the various parts involved such as nasal mucosa, sinuses, orbit, and intracranial extension, but the involvement may not be in the same sequence when all of these are involved, it is called ROCM. Usually, it takes an acute form of infection, but sometimes, it may be chronic as well.
The management protocol is fast evolving and depends on the parts involved. In suspected cases, endoscopic biopsy should be obtained and subjected to microbiological and histopathological evaluation. Swab examination from the nose or sinuses may not be sufficient or may turn out to be negative. Computed tomography (CT) scan or magnetic resonance imaging is useful investigations. However, we must remember that CT scan can have false-positive or false-negative results. Early institution of treatment with amphotericin B, an antifungal medication, is mandatory to restrict morbidity and mortality resulting from mucormycosis infection apart from supportive treatment. Liposomal amphotericin B is preferable due to its less nephrotoxic effect over plain amphotericin B. However, it is more expensive and not easily available.[8] Constant monitoring of serum electrolytes and other renal function is mandatory. It has to be a multidisciplinary approach based on the parts involved. One has to resort to surgical options as well in advanced cases involving otorhinolaryngologist, ophthalmologist, and neurosurgeons. In a published series of 23 cases by Sharma et al.,[4] mucormycosis intraorbital spread was noticed in 43% cases, intracranial spread in 9% cases, and involvement of palate in 39% cases, indicating that intracranial spread is rare but intraorbital involvement was common. In the same series, various sinuses involved were ethmoids (100%), maxillary (52%), sphenoid (22%), and frontal sinuses (4%).
As a preventive measure while treating COVID-19 patients, we should resort to judicious use of steroids, broad spectrum of antibiotics, and other related medications. Strict control of diabetes is of paramount importance while treating COVID-19 patients. Proper strict aseptic measures and personal as well as environmental hygiene cannot be compromised. Importance of regular mouth gargle with Betadine cannot be overemphasized. High degree of suspicion should be the key factor. In case of doubt, we should err toward positive side of the overdiagnosis. One should refer these cases to the proper centers for its management because it needs specialized treatment and multidisciplinary approach for a better outcome which may include Infectious Disease and Medical Intensivist, Physician, Radiologist, Histopathologist, Otorhinolaryngologist, Ophthalmologist, Neurophysician, and Neurosurgeon.
This editorial is written with the sole purpose of sensitizing the ophthalmologists to the possible dangers and proper care of post-COVID-19 mucormycosis cases for optimum outcome.
| References | |  |
| 1. | Nayak BK. The conundrum of COVID-10 vaccine J Clin Ophthalmol Res 2021;9:1-2.  |
| 2. | Raut A, Huy NT. Rising incidence of mucormycosis in patients with COVID-19: another challenge for India amidst the second wave? Lancet Respir Med 2021. [doi: 10.1016/S2213-2600 (21) 00265-4]. |
| 3. | Brown SR, Shah IA, Grinstead M. Rhinocerebral mycormycosis caused by Apophysomyces elegans. Am J Rhinol 1998;12:289-92. |
| 4. | Sharma S, Grover M, Bhargava S, Samdani S, Kataria T. Post coronavirus disease mucormycosis: A deadly addition to the pandemic spectrum. J Laryngol Otol 2021;135:442-7. |
| 5. | Gonzalez CE, Couriel DR, Walsh TJ. Disseminated zygomycosis in a neutropenic patient: Successful treatment with amphtericin B lipid complex and granulocyte colony-stimulating factor. Clin Infect Dis 1997;24:192-6. |
| 6. | Anand VK, Alemar G, Griswold JA Jr. Intracranial complications of mucormycosis: An experimental model and clinical review. Laryngoscope 1992;102:656-62. |
| 7. | Bhandari J, Thada PK, Nagalli S. Rhinocerebral Mucormycosis. [Updated 2021 Jul 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559288. |
| 8. | Spellberg B, Walsh TJ, Kontoyiannis DP, Edwards J Jr, Ibrahim AS. Recent advances in the management of mucormycosis: From bench to bedside. Clin Infect Dis 2009;48:1743-51. |
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