Increased incidence of rhino-orbital mucormycosis in an educational therapeutic hospital during the COVID-19 pandemic in western Iran: An observational study

Impact of COVID-19 on mucormycosis presentation and laboratory values: A comparative analysis

BACKGROUND

The COVID-19 pandemic has led to an alarming increase in mucormycosis coinfections and its rapid progression. The overlapping risk factors and symptoms between COVID-19 and mucormycosis further complicate prompt detection, which is crucial for patient survival. This study aims to investigate potential differences in mucormycosis progression, initial symptom presentation, and laboratory value alterations in mucormycosis patients with COVID-19 history to enhance diagnostic accuracy and improve outcomes in this complex clinical scenario.

METHODOLOGY

This retrospective cohort study, conducted from April 1, 2021, to March 31, 2022, examined 102 patients diagnosed with mucormycosis at two primary teaching hospitals. Patients were categorized into two groups based on COVID-19 history. Variables included demographic information, clinical parameters, laboratory results, and outcomes. The study compared patient laboratory studies and presentation symptoms between COVID-19 history-positive and COVID-19 history-negative groups, with a particular focus on mortality rates and associated comorbidities such as diabetes, cancer and immunosuppressive treatment.

RESULTS

Initial clinical presentations differed significantly, eneralized Estimating Equations (GEE) analysis, adjusted for comorbidities, revealed COVID-19 history was associated with increased platelet counts (P = 0.0311) and decreased facial swelling (P = 0.049) and fever symptom reporting (P < 0.001). Cancer history, diabetes, and immunosuppressive treatment also showed significant associations with various clinical and laboratory parameters. Laboratory analysis revealed significant differences between mucormycosis patients with and without COVID-19 history. The COVID-19 history-positive group showed lower WBC counts (P = 0.002), and higher hemoglobin levels (P < 0.001) compared to controls. Diabetes was more prevalent in COVID-19 history-positive patients, while cancer history was more common in controls.

CONCLUSION

This study reveals intricate relationships between COVID-19 history, mucormycosis, patient presentation, challenging earlier findings. Mucormycosis patients with COVID-19 history exhibited higher platelet counts and altered symptom presentation. The research highlights varied symptom patterns across patient subgroups and underscores the complexity of interactions between COVID-19, cancer, and diabetes in mucormycosis cases. These findings advocate multivariate analytical approaches to better understand these multifaceted relationships.

COVID-19-associated rhino-orbito-cerebral mucormycosis: a single center prospective study of 264 patients

PURPOSE

Outbreaks of mucormycosis were reported worldwide throughout the COVID-19 pandemic. We report clinical outcomes of a treatment protocol for COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM).

METHODS

Patients with biopsy-proven mucormycosis and COVID-19 were included. All received intravenous amphotericin B deoxycholate 1 mg/kg and surgical endoscopic sinus debridement (FESS). Those with rhino-orbital or cerebral disease limited to the cavernous sinus were eligible for transcutaneous retrobulbar amphotericin B (TRAMB). Patients were followed with weekly imaging, endoscopic examinations, and serial debridement as necessary. Patients were discharged on oral posaconazole for 6 months.

RESULTS

In total, 264 patients were followed for a mean of 2.5 months. On presentation, 163 patients (174 eyes) had eye involvement. Of these, 141 eyes (81.0%) had light perception or worse vision. By the last follow-up, 163 patients (176 eyes) were affected, and of these, 96 eyes (54.5%) had no light perception. Twenty-one patients (8%) died and 3 orbits (0.5%) were exenterated. There was no change in mortality (p = 0.38) or exenteration (p = 0.38) in the 55 patients who received TRAMB compared to patients with rhino-orbital or cerebral disease limited to the cavernous sinus who did not. Asymptomatic COVID-19 was associated with higher mortality than symptomatic COVID-19 (p = 0.025). Uncontrolled diabetes was a risk factor for death (p = 0.022). New diabetes was associated with increased mortality versus pre-existing diabetes (p = 0.005).

CONCLUSION

A multidisciplinary approach is crucial to manage COVID-19-ROCM. In our cohort, TRAMB therapy did not increase mortality or exenteration rates. While poor vision on presentation was profound, some vision recovery was noted with treatment. COVID-19 immune dysregulation may predispose patients to ROCM, particularly those with asymptomatic disease.

Increased serum ferritin is associated with severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis: A quantitative analysis

CONTEXT

Effect of serum ferritin on severity of coronavirus disease 2019 (COVID-19)-associated rhino-orbito-cerebral mucormycosis.

PURPOSE

To study the association between increased serum ferritin and severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis.

SETTINGS AND DESIGN

A cross-sectional study.

METHODS

Hundred ( n ) out of 155 treatment-naive patients of COVID-19 infection presenting with the signs and symptoms of rhino-orbito-cerebral mucormycosis were enrolled in study. Based on the classification proposed by Honavar, the study patients were classified into four stages: Stage 1: involvement of the nasal mucosa ( n = 11), Stage 2: involvement of paranasal sinuses ( n = 14), Stage 3: involvement of the orbit ( n = 37), Stage 4: involvement of the central nervous system ( n = 38). Stage 3 was further divided into four substages: 3a: nasolacrimal duct, medial orbit, vision unaffected ( n = 4); 3b: diffuse orbital involvement (>1 quadrant or >2 structures), vision unaffected ( n = 15); 3c: central retinal artery occlusion or ophthalmic artery occlusion, superior ophthalmic vein thrombosis, involvement of superior orbital fissure, inferior orbital fissure, orbital apex, diminution or loss of vision ( n = 13); 3d: bilateral orbital involvement ( n = 5). Fasting blood sugar (FBS), postprandial blood sugar (PPBS), and inflammatory markers (serum ferritin, interleukin-6, C-reactive protein, and D-dimer) were assessed. Serum level of ferritin was analyzed by using chemiluminescence immunoassay method.

RESULTS

Mean FBS (mg/dl) was 165.03 ± 70.43 for stage 1, 185.67 ± 64.82 for stage 2, 159.05 ± 68.60 for stage 3, and 158.20 ± 62.05 for stage 4. Mean PPBS (mg/dl) was 238.70 ± 141.29 for stage 1, 252 ± 103.69 for stage 2, 257.09 ± 103.48 for stage 3, and 229.53 ± 76.81 for stage 4. Mean serum ferritin (μg/l) was 302.67 ± 266.95 in stage 1, 444.19 ± 116.36 in stage 2, 504.85 ± 205.99 in stage 3, and 825.95 ± 777.30 in stage 4. A statistically significant increase in serum ferritin levels with severity of disease ( P = 0.005) was noted. Similar trend was observed in substages of stage 3. Pearson correlation analysis showed a positive correlation between serum ferritin and severity of disease ( P = 0.0007).

CONCLUSION

Increased serum ferritin was significantly independently associated with severity of orbital disease in COVID-19-associated rhino-orbito-cerebral mucormycosis.

Narrative review of factors associated with SARS-CoV-2 coinfection in Middle Eastern countries and the need to vaccinate against preventable diseases

This review evaluated the frequency of, and outcomes associated with, bacterial, fungal, and viral coinfection with SARS-CoV-2 in Middle Eastern countries via a PubMed search through February 2023. Ninety articles reported bacterial (n = 57), fungal (n = 32), and viral (n = 32) coinfections. High frequencies of coinfection with COVID-19 were identified, with rates and outcomes varying by setting, pathogen, surveillance/detection method, population characteristics, and drug-resistance status. Mortality rates were higher in patients with community-acquired (10.0 -42.9 %) and hospital-acquired (51.5 -66 %) bacterial coinfection versus those without (10.5 -21.7 %). Outcomes were worse with than without fungal coinfection, and fatality rates with mucormycosis coinfection reached 66.7 %. Outcomes with viral coinfection were highly variable; however, some data suggested a positive corelation between COVID-19 severity and influenza A and adenovirus coinfection. The negative outcomes associated with bacterial, fungal and some viral coinfections in individuals with COVID-19 support regular vaccination against vaccine-preventable diseases caused by these pathogens, especially among at-risk populations.

Potential activity of nanomaterials to combat SARS-CoV-2 and mucormycosis ‎coinfection‎

INTRODUCTION

Mucormycosis, popularly known as the black fungus, has become a worldwide concern in the continuing COVID-19 pandemic, causing increased morbidity and death in immunocompromised people. Due to multi-drug resistance and the limited number of antifungals, surgical interventions, ‎including the excision of infected tissue, remain a standard treatment option‎. Surgical treatment usually results in the loss of organs or their function, long-term intensive care, and a significant risk of reinfection during the procedure. A comprehensive approach is needed to treat the disease, and nanomaterials can be a powerful alternative therapeutic approach.

AREAS COVERED

We searched PubMed, Scopus, and Google Scholar with the keywords 'emerging role of nanomaterials,' and 'combating COVID-19-related mucormycosis,' and reviewed the related research paper. Antifungal nanomaterials and their delivery can significantly impact the treatment of COVID-19-related fungal infections like mucormycosis. However, the therapeutic options for mucormycosis are limited and drug resistance is also reported.

EXPERT OPINION

The current review encompasses a detailed overview of the recent developments in antifungal/antiviral nanomaterials and the properties of these therapeutic nanomaterials that may contribute to formulating an efficient strategy against invasive mucormycosis. Further extensive research is needed to develop nano-based therapeutics for the management of mucormycosis-viral coinfection with a definitive end-point.

Oral and Maxillo-facial Fungal Infections in COVID-19 Patients - A Systematic Review

The main objective of the current systematic review was to compile and evaluate the data on opportunistic maxillofacial mycotic infections in COVID-19 patients during the treatment and post-recovery period of SARS-CoV-2 infection. Comorbidities like diabetes, corticosteroid use, and mortality among COVID-19-associated patients presenting with oral and maxillofacial fungal infections were also assessed. The review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. A comprehensive search was carried out in the archives of Web of Science, Pubmed/Medline, Scopus, Google Scholar, Lilacs, and Livivo in combination with Boolean operators till 24th June 2022, and cross-sectional studies, case series, and case reports deliberating on maxillofacial mycoses in COVID-19 were included. The included studies were meted to the risk of bias using the Joana Briggs Institute Appraisal tools for prevalence studies, case series, and case reports. In a two-stage collection, 20 studies were included: 9 observational (3269 patients), 5 case-series (42 patients), and 6 case reports (8 patients) from 7 countries. Mucormycosis was the most commonly reported maxillofacial fungal infection (96.7%/3162 cases), followed by candidiasis (3.2%/105 cases) associated with COVID-19. Although aspergillosis was observed in only one case and one patient, a mixed mycotic infection demonstrating both aspergillus and mucor fungal elements was identified in one patient. Comorbidities like diabetes mellitus, indiscriminate corticosteroid use and immunosuppression leads to invasive maxillofacial fungal infections in COVID-19, which may prove to be fatal.

Ocular manifestations of COVID-19

There is an increasing body of knowledge regarding how COVID-19 may be associated with ocular disease of varying severity and duration. This article discusses the literature on the ocular manifestations associated with COVID-19, including appraisal of the current evidence, suggested mechanisms of action, associated comorbidities and risk factors, timing from initial infection to diagnosis and clinical red flags. The current literature primarily comprises case reports and case series which inevitably lack control groups and evidence to support causality. However, these early data have prompted the development of larger population-based and laboratory studies that are emerging. As new data become available, a better appraisal of the true effects of COVID-19 on the eye will be possible. While the COVID-19 pandemic was officially declared no longer a "global health emergency" by the World Health Organization (WHO) in May 2023, case numbers continue to rise. Reinfection with different variants is predicted to lead to a growing cumulative burden of disease, particularly as more chronic, multi-organ sequelae become apparent with potentially significant ocular implications. COVID-19 ocular manifestations are postulated to be due to three main mechanisms: firstly, there is a dysregulated immune response to the initial infection linked to inflammatory eye disease; secondly, patients with COVID-19 have a greater tendency towards a hypercoagulable state, leading to prothrombotic events; thirdly, patients with severe COVID-19 requiring hospitalisation and are immunosuppressed due to administered corticosteroids or comorbidities such as diabetes mellitus are at an increased risk of secondary infections, including endophthalmitis and rhino-orbital-mucormycosis. Reported ophthalmic associations with COVID-19, therefore, include a range of conditions such as conjunctivitis, scleritis, uveitis, endogenous endophthalmitis, corneal graft rejection, retinal artery and vein occlusion, non-arteritic ischaemic optic neuropathy, glaucoma, neurological and orbital sequelae. With the need to consider telemedicine consultation in view of COVID-19's infectivity, understanding the range of ocular conditions that may present during or following infection is essential to ensure patients are appropriately triaged, with prompt in-person ocular examination for management of potentially sight-threatening and life-threatening diseases.

Factors influencing mortality in COVID-19-associated mucormycosis: The international ID-IRI study

The emergence of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), triggered a global pandemic. Concurrently, reports of mucormycosis cases surged, particularly during the second wave in India. This study aims to investigate mortality factors in COVID-19-associated mucormycosis (CAM) cases, exploring clinical, demographic, and therapeutic variables across mostly Asian and partly African countries. A retrospective, cross-sectional analysis of CAM patients from 22 medical centers across eight countries was conducted, focusing on the first 3 months post-COVID-19 diagnosis. Data collected through the ID-IRI included demographics, comorbidities, treatments, and outcomes. A total of 162 CAM patients were included. The mean age was 54.29 ± 13.04 years, with 54% male. Diabetes mellitus (85%) was prevalent, and 91% had rhino-orbital-cerebral mucormycosis. Surgical debridement was performed in 84% of the cases. Mortality was 39%, with advanced age (hazard ratio [HR] = 1.06, [P < .001]), rituximab use (HR = 21.2, P = .05), and diabetic ketoacidosis (HR = 3.58, P = .009) identified as risk factors. The mortality risk increases by approximately 5.6% for each additional year of age. Surgical debridement based on organ involvement correlated with higher survival (HR = 8.81, P < .001). The utilization of rituximab and diabetic ketoacidosis, along with advancing age, has been associated with an increased risk of mortality in CAM patients. A combination of antifungal treatment and surgical intervention has demonstrated a substantial improvement in survival outcomes.

Anticoagulation in the management of septic cavernous sinus thrombosis secondary to rhino-orbito-cerebral mucormycosis: A retrospective real-world experience

Background: COVID-19 was associated with an increased number of patients with mucormycosis (MCR), followed by septic cavernous sinus thrombosis (SCST). We evaluated the association between anticoagulation (AC) and mortality/morbidity of COVID-19-associated MCR (CAM)-induced SCST. Methods: In this retrospective study, neurological sequelae, functional outcomes, and in-hospital mortality were compared between AC receivers and non-receivers. In addition, the association between AC and survivability was examined. Results: Twenty-nine patients (17 male; mean age: 51.27 years) with CAM-induced SCST were included in the study. The median intervals between COVID-19 and MCR, and COVID-19 and SCST were 19 and 27 days, respectively. Among AC recipients, the interval between SCST and AC initiation was 18 days, with an AC duration of 37 days. Baseline and management-related characteristics were comparable between AC recipients and non-recipients (P > 0.050). AC receivers (n = 15) and non-receivers (n = 14) did not significantly differ in terms of the proportion of sequelae (6/15 vs. 5/14; P = 1.000), complete recovery (2/15 vs. 4/14; P = 0.687), and in-hospital mortality (3/15 vs. 3/14; P > 0.999). Nevertheless, AC recipients had a longer hospital stay (72.0 vs. 35.5; P = 0.016). AC-related characteristics (AC receiving, type, early initiation, and duration) were not significantly different between survivors and non-survivors, or between recovered and disabled patients. Conclusion: In our study, CAM-induced SCST in-hospital mortality/morbidity did not differ between AC receivers and non-receivers. AC characteristics were not different between survivors and non-survivors, or recovered and disabled patients. However, the small sample size may have limited the ability to detect significant differences, leading to inconclusive results.

COVID-19 associated Mucormycosis among ICU patients: risk factors, control, and challenges

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic is still difficult to be controlled. The spread of this virus and the emergence of new variants are considered a great challenge worldwide. Disturbance in infection control guidelines implementation, use of steroids, antibiotics, hospital crowdedness, and repeated use of oxygen masks during the management of critically ill COVID-19 patients lead to an increase in the rate of opportunistic infections. So, patients need to fight both the virus with its different variants and opportunistic pathogens including bacteria and fungi especially patients with diabetes mellitus, malignancy, or those who undergo hemodialysis and receive deferoxamine. During the pandemic, many cases of Mucormycosis associated with COVID-19 infection were observed in many countries. In this review, we discuss risk factors that increase the chance of infection by opportunistic pathogens, especially fungal pathogens, recent challenges, and control measures.

Diagnosis of mucormycosis using a simple duplex PCR assay: Analysis of 160 clinical samples from COVID-19 patients

Early diagnosis of mucormycosis, a severe and potentially fatal complication in immunocompromised and COVID-19 patients, is crucial for initiating timely antifungal therapy and reducing infection mortality. In this study, the diagnostic performance of a duplex polymerase chain reaction (PCR) assay was evaluated to detect Mucorales-specific and Rhizopus oryzae-specific targets in 160 clinical samples collected from 112 COVID-19 patients suspected of invasive fungal rhinosinusitis (IFRS). During potassium hydroxide (KOH) direct microscopy, non-septate hyphae were observed in 73 out of 160 samples (45.63%); however, using duplex PCR, 82 out of 160 specimens (51.25%) tested positive. Among the positive PCR samples, 67 (81.71%) exhibited a double band (both 175 and 450 base pairs [bp]) indicating the presence of R. oryzae, and 15 (18.29%) showed only a single band (175 bp), suggesting the presence of non-R. oryzae Mucorales. DNAs from 10 microscopically negative samples and 4 samples with septate hyphae in microscopy were successfully amplified in PCR. Considering Calcofluor white fluorescence microscopy as the gold standard for laboratory diagnosis of mucormycosis, the duplex PCR assay utilized in this study exhibited a sensitivity of 93.88%, a specificity of 100%, a negative predictive value of 91.18%, and a positive predictive value of 100% for detecting mucormycosis in IFRS specimens. The duplex PCR assay demonstrated higher sensitivity compared to direct examination with KOH (82 vs. 73) and culture (82 vs. 41), enabling rapid detection/identification of Mucorales even in samples with negative culture or in biopsies with only a few hyphal elements.

Sinonasal mucormycosis during 2 years of COVID-19 pandemic in central Iran: incidence rate and clinical features

INTRODUCTION

As a novel infectious disease, COVID-19 is caused by SARS-COV-2, spreading rapidly worldwide. ENT specialists have faced this challenging disease in various ways since the emergence of the COVID-19 pandemic. We are currently facing an increase in cases referred due to sinonasal mucormycosis which is a rare but invasive, rapidly progressive, and life-threatening infection. We provide an overview of this disease's incidence rate and clinical features.

METHODS

This descriptive cross-sectional study was conducted on 46 sinonasal mucormycosis patients who were histopathologically confirmed after sinonasal endoscopic surgery in our educational therapeutic hospital during 2 years of the COVID-19 pandemic from March 20, 2020, to March 20, 2022.

RESULTS

There was an increase in the incidence of mucormycosis more than twice as much as before. All patients had a history of COVID-19 and 69.6% were diabetic. The median time to symptom onset from COVID-19 detection was 3.3 weeks. A total of 60.9% received steroids while 85.7% were prescribed during COVID-19 treatment. The most common manifestation was orbital involvement (80.4%). Of the 46 study cases, unfortunately, 17 (37%) died. An exciting point in our study was the incidence of peripheral facial palsy which is associated involvement of multiple other cranial nerves (II, III, IV, V, VI) considered to be the likely occurrence of a rare phenomenon called Garcin's syndrome.

CONCLUSION

Based on the results of this study, during 2 years of the COVID -19 pandemic, there was an increase in the incidence of sinonasal mucormycosis more than twice as much as before.

Imaging Spectrum of Coronavirus Disease- 2019 Associated Rhino-Orbital-Cerebral Mucormycosis; From Sinonasal Inflammation to Intracranial Involvement

RATIONALE AND OBJECTIVES

Rhino‑Orbital‑Cerebral Mucormycosis (ROCM) is a life-threatening opportunistic fungal infection, which mostly affects immunocompromised patients. There has been a notable rise in the incidence of ROCM during the COVID-19 outbreak. In this study we described imaging characteristics of ROCM in detail, from early sinonasal inflammation to late intracranial involvement.

MATERIALS AND METHODS

In this retrospective study, Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) of 48 patients with proven ROCM in biopsy or culture were evaluated. All the patients had a history of COVID-19 infection within the previous three months. The imaging findings were described and the frequency of different parameters was reported.

RESULTS

Paranasal inflammation was detected in all the patients on imaging. The most common involved paranasal sinuses were ethmoid sinuses (97.9%). On diffusionweighted images, restricted diffusion was seen in the paranasal sinuses of 81.1% of the patients. In addition, sinus wall bone involvement was observed in 87.5% of the cases. The most common anatomical sites for extrasinus involvement were the retroantral soft tissue (89.6%) and orbital cavity (87.5%). Dacryocystitis in 50%, optic nerve inflammation in 43.2%, globe involvement in 18.9%, and trigeminal nerve involvement in 16% of the patients were detected. There was extension of inflammation through the cavernous sinuses and alongside the internal carotid arteries in 24% of the patients.

CONCLUSION

Characteristic imaging findings of ROCM not only play a vital role in the early diagnosis of this infection, but they also contribute to the assessment of the extension of inflammation, which is vitally important in surgical planning.

Comparative Study of Clinical Severity and Biochemical Markers in Pre COVID-19 and COVID-19 Rhino-Orbito Cerebral Mucormycosis

In view of high surge of sinonasal mucormycosis cases after the second wave of covid 19, present study was planned to know and compare the clinical severity of the disease and also to better understand the difference in the biochemical markers during precovid and post covid period. This retrospective observational study included all cases of sinonasal mucormycosis which were treated in our institute from August 2012 to August 2021. Details of these cases were collected from hospital database system. Biochemical parameters included FBS, HbA1C, urine ketone bodies, blood pH and creatinine. Clinical severity score was measured using self-structured severity scoring system. We found that out of 74 cases treated in our hospital 28 cases were in pre covid period while 46 cases belonged to covid 19 period. Higher male predominance was seen during post covid period (76% vs. 60%). Urine ketone bodies were positive in 7% patients in precovid period compared to 26% in post-covid period. FBS and HbA1C were high approximately 80 and 90% patients respectively in both groups. Clinical severity was significantly high in post covid patients. The present study showed that in spite of similar biochemical profile. The severity of mucormycosis was high in covid positive patients. This study shows that Covid-19 is an independent high risk factor in mucormycosis patients.

Demographic and clinical characteristics and outcomes of COVID-19 patients admitted to a university hospital in the west of Iran: a retrospective study in the third wave

COVID-19 is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The characteristics of this infectious disease vary from a country to another and from one peak to the next. The aim of the present study was to describe the COVID-19 patients hospitalized in Kermanshah, a city in the west of Iran, in the third peak of the disease and to identify in-hospital mortality determinants in this disease. Methods: In this retrospective study, the clinical and demographic characteristics, laboratory findings, prescribed treatments and outcome of all COVID-19 patients (definitive, suspected, and probable) were collected from the medical records department of Farabi Hospital affiliated with Kermanshah University of Medical Sciences, Kermanshah, Iran from 22 October to 20 November 2020. Results: In total, 665 COVID-19 patients (265 females and 400 males, mean age: 58.7 years) were enrolled, including 479 confirmed, 15 probable, and 30 suspected cases. About 84% of the patients presented with low oxygen saturation levels. The most common comorbidities were hypertension (15%), diabetes (10%), and cardiovascular disease (3%). The median (IQR) length of hospital stay was 6 (Nojomi et al., 2021; Flores-Vega et al., 2022; Fattahi et al., 2021; Cusinato et al., 2022; Avatef Fazeli et al., 2021 (4., 5., 6., 7., 8.)) and 7 (Javadi Mamaghani et al., 2021; Abdolahnejad et al., 2022; Nojomi et al., 2021; Flores-Vega et al., 2022; Fattahi et al., 2021; Cusinato et al., 2022; Avatef Fazeli et al., 2021; Sayad et al., 2021; Hesni et al., 2022; Buttenschøn et al., 2022; Smits et al., 2022; Rosenberger et al., 2021; Shi et al., 2022 (2., 3., 4., 5., 6., 7., 8., 9., 10., 11., 12., 13., 14.)) day in discharged and deceased patients, respectively. Eighty-two out of 655 patients admitted to the hospital and 39of the 60 patients admitted to the ICU died. In total, in-hospital mortality rate was 12.33%. Regarding lab variables, in the adjusted model, no significant difference was observed between discharged and deceased patients.The results of multivariable logistic regression showed that each one-unit increase in oxygen saturation (SPO2) increased the odds of survival by 0.88 times (aOR 0.88, 95% CI 0.78-0.99, p = 0.043). Moreover, each one-day increase in the length of ICU stay reduced the odds of mortality by 0.49 times (aOR 0.82, 95% CI 0.26-0.95, p = 0.035). Conclusion: Hospitalized COVID-19 patients were generally more ill during the third peak so that about 85% of the patients had SPO2 ≤ 93%. The in-hospital mortality rate was also high. Demographic and paraclinical variables (except SPO2 level) were not suitable predictors of mortality.

Mortality and its determinants after an outbreak of post COVID-19 associated rhino-orbito-cerebral mucormycosis in Central India

AIM

To report cumulative mortality rates using survival analysis from an outbreak of 211 patients with post COVID-19 rhino-orbito-cerebral mucormycosis (ROCM) in central India.

METHODS

Case files of eligible patients were evaluated and mucor was identified from deep nasal swabs using freshly prepared KOH mount. All patients underwent contrast enhanced MRI and disease staging was done based on the extent of anatomical involvement. All patients received intravenous Amphotericin B and sinus debridement was done when possible. Orbital exenteration was reserved for patients with advanced orbital disease.

RESULTS

The mean age was 50.7 ± 10.2 of which 147 (70%) were men. At presentation, ROCM was limited to sinuses in 72 (34%), orbital extension was seen in 102 (48%) and 31 (15%) had CNS extension. Sinus debridement was possible in 82% cases (n = 173). Thirty-five (16.6%) patients died due to ROCM. The mean follow-up of patients who survived was 126.6 ± 16.4 days. The cumulative mortality rate at day 10 was 4.8% (95%CI = 2.6-8.8%) and increased 13.1% (95%CI = 9.1-18.7%) at day 30 and to 18.4% (95%CI = 13.6-24.8%) at day 60. Majority of deaths (n = 26, 75%) occurred within 1-month of ROCM presentation. Multivariable hazards analysis showed that patients with CNS involvement had a 6.5 times higher risk of death (Hazard Ratio = 6.71, 95% CI = 2.9-15.5, p < 0.001).

CONCLUSION

We report significantly lower mortality rates compared to recent literature that varies from 30 to 80% at 1-month follow-up. Timely sinus debridement and systemic Amphotericin B can help reduce mortality. Presence of CNS extension significantly increased the mortality risk with patients with ROCM.

COVID-19 associated mold infections: Review of COVID-19 associated pulmonary aspergillosis and mucormycosis

COVID-19-associated mold infection (CAMI) is defined as development of mold infections in COVID-19 patients. Co-pathogenesis of viral and fungal infections include the disruption of tissue barrier following SARS CoV-2 infection with the damage in the alveolar space, respiratory epithelium and endothelium injury and overwhelming inflammation and immune dysregulation during severe COVID-19. Other predisposing risk factors permissive to fungal infections during COVID-19 include the administration of immune modulators such as corticosteroids and IL-6 antagonist. COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated mucormycosis (CAM) is increasingly reported during the COVID-19 pandemic. CAPA usually developed within the first month of COVID infection, and CAM frequently arose 10-15 days post diagnosis of COVID-19. Diagnosis is challenging and often indistinguishable during the cytokine storm in COVID-19, and several diagnostic criteria have been proposed. Development of CAPA and CAM is associated with a high mortality despiteappropriate anti-mold therapy. Both isavuconazole and amphotericin B can be used for treatment of CAPA and CAM; voriconazole is the primary agent for CAPA and posaconazole is an alternative for CAM. Aggressive surgery is recommended for CAM to improve patient survival. A high index of suspicion and timely and appropriate treatment is crucial to improve patient outcome.

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

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.

Emergence of Cerebral Mucormycosis in the Post-COVID Period: A Detailed Analysis of Risk Factors, Clinical Progression, and Management of This Opportunistic Fungal Infection

BACKGROUND

An epidemic of Mucorales was reported following the second wave of COVID-19 in India, and intracranial extension of the same was one of the most dreadful complications.

METHODS

A total of 62 patients with cerebral mucormycosis were recruited and followed up till 12 weeks to evaluate the risk factors, incidence, clinical manifestations, management, and prognosis of cerebral mucormycosis.

FINDINGS

A median age of 51.5 years with male predominance (74%) was noted. The majority of subjects reported a history of COVID infection (93.5%) and diabetes mellitus (83.87%). The first symptom of mucormycosis appeared after a mean period of 17.63 ± 8.9 days following COVID. Facial swelling and ptosis were the most common symptoms. Only 55% of patients had neurological presentations, and hemiparesis was the most common neurological sign (30.6%). Radiologically, the involvement of maxillary sinus (90.32%) and ethmoid sinus (87.10%) was commonly noted. Cerebral findings included temporal lobe (50%) and parietal lobe (30.06%) involvement, cavernous sinus thrombosis (30.06%), and internal carotid artery thrombosis (22.58%). Acute cerebral infarction was notable in 37% of subjects (p-value=0.0015, significant association with the outcome). Conventional and liposomal amphotericin B were used in 91.94% and 53.23% of patients, respectively. Retrobulbar amphotericin injections used in 11.3% of subjects significantly affected the outcome (p-value=0.03, significant). Posaconazole step-down therapy was used in 72.5% of subjects (p-value=0.0005, significant). Surgical interventions were performed in 53 (85.48%) subjects (p-value=0.004, significant). Functional endoscopic sinus surgery was the most common (in 64.52% of subjects), followed by maxillectomy (20.97% of subjects) and craniotomy (17.7% of subjects). At the end of 12 weeks, 33.87% of patients died and 59.68% were alive; the rest (6.45%) were lost to follow-up.

INTERPRETATION

The absence or late presentation of neurological symptoms led to a delayed diagnosis of cerebral mucormycosis. The presence of acute cerebral infarction indicated a worse prognosis. However, there was a significant influence of step-down posaconazole therapy, retrobulbar amphotericin injections, and surgical intervention on the prognosis of cerebral mucormycosis.

Rhino-orbital-cerebral mucormycosis as a complication of coronavirus disease 2019

Coronavirus disease 2019 is a highly contagious respiratory disease caused by severe acute respiratory syndrome coronavirus 2. This disease as well as its various treatments like steroids, antivirals, and antibacterials can alter the immune state of the affected individuals and result in secondary infections such as mucormycosis. Mucormycosis is a well-known opportunistic fungal infection that affects immunocompromised subjects, particularly those with diabetes mellitus, prolonged antibiotic or steroid use, and patients with organ trans-plantation, neutropenia, and hematological malignancies. Rhino-orbital-cerebral mucormycosis is an aggressive disease owing to its ability to invade the blood vessels by fungal hyphae, leading to necrosis of the involved structures. Large cases were reported from India, indicating that this clinical entity shows a geographical variation. The affected patients are suffering on a clinical spectrum depending on the stage of the disease. Radiological assessment, including computerized tomography and magnetic resonance imaging, is necessary to evaluate the stage of the disease and choose the appropriate surgical treatment. A multidisciplinary approach is required to treat rhino-orbital-cerebral mucor-mycosis and includes local or intravenous antifungal drugs, debridement of the dead tissues, and appropriate management of any predisposing conditions. The disease has a very poor prognosis with a death rate of 50%. This review aimed to sum-marize the demographic and clinical risk factors, investigations, treatments, and outcomes of coronavirus disease 2019 patients with rhino-orbital-cerebral mucormycosis.

Mucormycosis in pre-COVID-19 and COVID-19 era: A study of prevalence, risk factors and clinical features

OBJECTIVE

Mucormycosis is a rare yet devastating fungal disease with a frequently fatal outcome. The purpose of this study was to compare the prevalence of mucormycosis, evaluate its risk factors, and assess the patients' outcomes in pre-COVID-19 and COVID-19 era.

METHODS

In this retrospective observational study, clinical data of 158 patients with confirmed histopathological diagnosis of mucormycosis were collected from the medical records departments of Imam Reza and Ghaem hospitals, Mashhad, Iran during 2018-2021. The collected data were risk factors associated with mucormycosis including age, gender, underlying diseases, details of corticosteroid administration, and complications such as blindness and mortality.

RESULTS

Of 158 studied patients, 48 patients were diagnosed in the pre-pandemic period whereas 110 cases were admitted during the pandemic era. COVID-19 associated mucormycosis (CAM) was observed in 58.1% of the pandemic cases. In the pre-pandemic period, cancer (89.5% vs. 39%, p < .001) was significantly more prevalent while during the pandemic era, the prevalence of diabetes mellitus (16.7% vs. 51%, p < .001) was remarkably higher. Moreover, the mortality rate of mucormycosis was considerably reduced after the pandemic (64.6%-45.4%), especially in CAM patients (35.9%).

CONCLUSION

The COVID-19 pandemic has led to an increased prevalence of mucormycosis, due to the convergence of interlinked risk factors such as diabetes mellitus, corticosteroid therapy, and COVID-19. Therefore, clinicians must be aware of the probable occurrence of mucormycosis in the first or second week of COVID-19 infection in vulnerable patients and use the steroids cautiously.

LEVEL OF EVIDENCE

4 Laryngoscope Investigative Otolaryngology, 2022.

Onset of Mucormycosis in Patients with COVID-19: A Systematic Review on Patients' Characteristics

Mucormycosis has a significant impact on patients' standard of living and, therefore, a high clinical suspicion, prediagnosis, and rapid treatment are critical in easing patients' suffering and fast recovery. Our focus is to conduct an organized review based on various variables on the patients' characteristics having mucormycosis in severe novel coronavirus disease 2019 (COVID-19). We examined Embase, PubMed-Medline, LitCovid, Web of Science, Scopus, and the reference lists of included case reports up to September 20, 2021, using the Medical Subject Heading (MeSH) phrases and other keywords related to this topic. Subsequently, we investigated associated comorbidities, patient characteristics, position of mucormycosis, steroids use, body involvements, and outcomes. Overall, 77 studies were conducted and among these, 72 studies mentioned that the patients' age to be 48.13±14.33 (mean±standard deviation [SD]) years. Diabetes mellitus (DM) was reported in 77.9% (n=60) of cases. Studies showed that central nervous system (CNS) and bone involvement were reported in 62.3 (n=48) and 53.2% (n=41), respectively. More fatalities were observed in patients with mucormycosis with the active form of COVID-19. Also, men infected with mucormycosis significantly affected by COVID-19. In the end, mortality was higher in males with mucormycosis. As a result, a solid investigation into the root cause of mucormycosis, especially in COVID-19, should be included in the study plan. If the patient is COVID-19-positive and immunosuppressed, this opportunistic pathogen diagnostic test should not be overlooked.

Mortality-Related Risk Factors for Coronavirus Disease (COVID-19)-Associated Mucormycosis: a systematic review and meta-analysis

Purpose of Review

Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) can increase the susceptibility of individuals to contracting mucormycosis through several mechanisms. Nowadays, coronavirus disease (COVID-19)-associated mucormycosis (CAM) is a serious public health concern, particularly in developing countries. This meta-analysis aims to identify the risk factors that affect the mortality rate of patients with CAM.

Recent Findings

We systematically searched PubMed, Google Scholar, Scopus, Cochrane library, and preprint databases using pertinent keywords and the reference lists of the included relevant articles from inception till October 27, 2021. In order to reduce the effects of small-scale studies, we only selected cross-sectional, case–control, and cohort studies and case series with at least four patients. We identified 26 articles that included 821 patients with CAM. The effect size (ES) of mortality rate was 28% (95% confidence interval (CI) 20%–38%; I² =82.28%; p for Cochran Q<0.001). The CAM patients with a history of comorbidities other than diabetes (malignancies, transplant, or renal failure), mechanical ventilation due to COVID-19, pulmonary and cerebral mucormycosis, and those who only received medical treatment for mucormycosis had the highest mortality rate.

Summary

Coronavirus disease (COVID-19)-associated mucormycosis (CAM) is a major public health problem, particularly in developing countries. Severe COVID-19 infection, history of mechanical ventilation, early CAM, comorbidities other than diabetes (malignancies, transplant, or renal failure), pulmonary and rhino-orbito-cerebral mucormycosis, and delivering only medical treatment for mucormycosis were the worst prognostic factors in CAM patients. Identifying the mortality-related risk factors in CAM patients may help reduce the mortality rate by implementing optimized treatment approaches.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12281-022-00440-2.

COVID-19-associated fungal infections in Iran: A systematic review

Objectives

This systematic review aims to summarize the mycological and clinical features of COVID-19-associated fungal infections (CAFIs) in Iran.

Methods

PubMed, Web of Science, Scopus, Cochrane Library, SID, Magiran, IranDoc, and Google Scholar were searched for Persian and English articles published from January 1, 2020, to November 5, 2021, using a systematic search strategy. Studies on Iranian patients suffering from CAFIs were included in the review.

Results

Twenty-two studies comprising 169 patients were retrieved. Reported CAFIs included candidiasis (85, 50.30%), mucormycosis (35, 20.71%), aspergillosis (29, 17.16%), fusariosis (6, 3.55%), three cases caused by rare pathogens (Rhodotorula mucilaginosa, Diaporthe foeniculina, and Sarocladium kiliense) and 11 (6.51%) uncharacterized mold infections. The most common underlying diseases were diabetes (67/168, 39.88%), cardiovascular diseases (55/168, 32.74%), and hypertension (43/168, 25.59%). The use of antibiotics (111/124, 89.52%), corticosteroids (93/132, 70.44%), and mechanical ventilation (66, 51.16%) were the most common predisposing factors. Totally, 72 (50.35%) of 143 patients with CAFIs died (data were not available for 26 patients).

Conclusion

Fungal infections are evident to be a complication of COVID-19 in Iran; thus, clinicians should consider them as a differential diagnosis, especially in patients with comorbidities and previous antibiotic or corticosteroid use.

Histomorphological features of mucormycosis with rise and fall of COVID-19 pandemic

Introduction

Due to Corona Virus disease -19, India saw a surge of mucormycosis cases, associated with high death rate. India, during the month of May to July 2021 saw a surge of mucormycosis from all states, with close to 50,000 cases just in a span of 3 months.

Objective

To examine the histopathological appearances of rhino-orbital/rhino-maxillary/sino-nasal mucormycosis in the backdrop of the ongoing COVID 19 pandemic.

Material and methods

The study involved analysis of 60 biopsy samples of suspected rhino-maxillary /rhino-orbital mucormycosis received from post-COVID-19 patients. A preliminary review of the slides showing hyphal forms of fungal organisms with un-doubtful tissue / mucosal invasion was included. All samples were examined under Hematoxylin and Eosin stains along with special fungal stains. Data thus obtained were analyzed statistically. Special stains for fungus namely Periodic Acidic Schiff (PAS) and Gomori Methenamine silver (GMS) were utilized to confirm and/or to differentiate the fungal organisms and to highlight the cell wall of the fungus.

Results

The mean age of the patients with mucormycosis was 51.68 years and 72 (83.33%) of them were males. Acute type of inflammation was noted in 44 (73.33%), granulomatous inflammation in 14 (23.33%) of cases. Bony invasion and perineural invasion was observed in 5 (8.33%) and 55 (91.67%) cases, respectively. The dominant fungus were mucorales in 58 (96.67%), aspergillous, along with mucorales in 12 (20%) and combination of mucorales and candida identified in 8 (13.33%) cases.

Conclusion

Besides all the histological appearance of angioinvasion, bone, and soft tissue invasion, a notable aspect was the shift in inflammatory pattern, which was more granulomatous in nature, with a decrease in fungal load correlating with the drop of COVID second wave. This proves that as immunity develops, the host's response to secondary opportunistic infections changes.

Demographics, clinical characteristics, and outcomes of 27,256 hospitalized COVID-19 patients in Kermanshah Province, Iran: a retrospective one-year cohort study

BACKGROUND

Since the first official report of SARS-CoV-2 infection in Iran on 19 February 2020, our country has been one of the worst affected countries by the COVID-19 epidemic in the Middle East. In addition to demographic and clinical characteristics, the number of hospitalized cases and deaths is an important factor for evidence-based decision-making and disease control and preparing the healthcare system to face the future challenges of COVID-19. Therefore, this cohort study was conducted to determine the demographics, clinical characteristics, and outcomes of hospitalized COVID-19 patients in Kermanshah Province, west of Iran.

METHODS

This multicenter retrospective cohort study included all suspected, probable, and confirmed cases of COVID-19 hospitalized in Kermanshah Province, Iran during the first year of the COVID-19 pandemic. Demographics, clinical characteristics, outcomes and other additional information of hospitalized patients were collected from the COVID-19 database of the Medical Care Monitoring Center (MCMC) of Kermanshah Province.

RESULTS

Kermanshah Province experienced three waves of COVID-19 infection considering the hospitalization and mortality rates between February 20, 2020 and February 19, 2021. A total of 27,256 patients were included in the study: 5203 (19.09%) subjects were suspected, 9136(33.52%) were probable, and 12,917 (47.39%) were confirmed COVID-19 cases. The mean age of the patients was 53.34 ± 22.74 years and 14,648 (53.74%) were male. The median length of hospital stay among COVID-19 survivors and non-survivors patients were 4 (interquartile range [IQR] 1-6) and 4 (IQR 1-8) days, respectively. Among patients with COVID-19, 2646 (9.71%) died during hospitalization. A multivariable logistic regression revealed that odds of death among patients ≥ 85 years was significantly greater than among patients < 15 years (adjusted odds ratio [aOR] 4.79, 95% confidence interval [CI] = 3.43-6.71, p≤ 0.001). Patients with one (aOR 1.38, 95% CI 1.21-1.59, p = 0.04), two (aOR 1.56, 95% CI 1.27-1.92, p = 0.001) or more (aOR 1.50, 95% CI 1.04-2.17, p = 0.03) comorbidities had higher odds of in-hospital death compared to those without comorbidities. The male sex (aOR 1.20, 95% CI 1.07- 1.35, p = 0.002), ICU admission (aOR 4.35, 95% CI 3.80-4.97, p < 0.001), intubation (aOR 11.09, 95% CI 9.58-12.84, p < 0.001), respiratory distress (aOR 1.40, 95% CI 1.22-1.61, p < 0.001), loss of consciousness (aOR 1.81, 95% CI 1.45-2.25, p < 0.001), anorexia (aOR 1.36, 95% CI 1.09-1.70, p = 0.006) and peripheral oxygen saturation (SpO2) < 93(aOR 2.72, 95% CI 2.34-3.16, p < 0.001) on admission were associated with increased risk of death in patients with SARS-CoV-2 infection. Having cough (aOR 0.82, 95% CI 0.72-0.93, p = 0.003) and headache (aOR 0.70, 95% CI 0.50-0.97, p = 0.03) decreased the odds of death.

CONCLUSION

The mortality rate of the patients admitted to the general wards and ICU can be a guide for allocating resources and making appropriate plans to provide better medical interventions during the COVID-19 pandemic. Several risk factors are associated with the in-hospital mortality of COVID-19, including advanced age, male sex, ICU admission, intubation, having comorbidity, SpO2 < 93, respiratory distress, loss of consciousness, headache, anorexia, and cough. These risk factors could help clinicians identify patients at high risk for death.

Clinical Features and Mortality of COVID-19-Associated Mucormycosis: A Systematic Review and Meta-Analysis

The recent increase of COVID-19-associated mucormycosis (CAM) has been commanding global attention. However, basic epidemiologic characteristics have not firmly been established. In this systematic review and meta-analysis, we sought to determine the clinical manifestations, potential risk factors, and outcomes of CAM. Observational studies reporting CAM were searched with PubMed and EMBASE databases in January 2022. We collected data on comorbidities and treatment for COVID-19, and performed a one-group meta-analysis on the frequency of orbital exenteration procedure and mortality of CAM using a random-effect model. Fifty-one observational studies, including a total of 2,312 patients with proven CAM, were identified. Among the 51 studies, 37 were conducted in India, 8 in Egypt, and 6 in other countries. The most common comorbidity was diabetes mellitus (82%). While 57% required oxygenation, 77% received systemic corticosteroids. Among CAM, 97% were rhino-orbital-cerebral (ROCM), and 2.7% were pulmonary mucormycosis. Usual presentations were headache (54%), periorbital swelling/pain (53%), facial swelling/pain (43%), ophthalmoplegia (42%), proptosis (41%), and nasal discharge/congestion (36%). Regarding the outcomes, orbital exenteration was performed in 17% (95% CI: 12–21%, I² = 83%) of the COVID-19-associated ROCM patients. The mortality of CAM was 29% (95% CI; 22–36%, I² = 92%). In conclusion, this systematic review and meta-analysis indicated that the most prevalent type of CAM was ROCM, and most CAM patients had diabetes mellitus and received systemic glucocorticoids. Clinicians in the endemic areas should have a high index of suspicion for this invasive fungal complication of COVID-19 when a diabetic patient who received high-dose systemic glucocorticoids developed rhino-orbital symptoms.

Risk Factors for COVID-19 Associated Mucormycosis: The Ophthalmologist’s Perspective

The COVID-19 pandemic has led to a dramatic rise in the incidence of rhino-orbito-cerebral mucormycosis (ROCM) in India. The purpose of our report is to describe the prevalence of ROCM in the context of SARS-CoV-2 infection during the second Indian COVID-19 wave, as well as its diagnostics proceeding, and to discuss the challenges met in the time frame from the suspected diagnosis to the therapeutic decision in such patients. We conducted a retrospective multicentre case series study at six centres of Sudhalkar and Raghudeep group of hospitals in India. ROCM was confirmed in 38 (2.5%) of the 1546 patients admitted with SARS-CoV-2 infection. The average time to establish a diagnosis was 16 days. In total, 19 (50%) patients suffered from type 2 diabetes and were mostly treated with hypoglycaemic agents (in 90% of cases). The standard of care for SARS-CoV-2 management included systemic steroids therapy, intravenous remdesivir for 5 days, and concomitant prophylactic antibiotic therapy following admission. The median (IQR) blood glucose levels in all patients during the course of hospitalisation was 320 (250.5–375) mg/dl. A total of 16% of patients had an irreparable functional loss, and the mortality was 5%. We may hypothesise that excessive administration of antibiotics that profoundly affects human microbiota, coupled with poorly controlled glycaemia and unprotocolised haphazard steroid administration, contribute to a favourable setting for mucormycosis infections.

Risk factors for palatal and orbital involvement in mucormycosis epidemic-Report of a center in India

BACKGROUND

Mucormycosis of the nose and paranasal sinuses has emerged as an epidemic following COVID-19 pandemic. The management involves surgical debridement, the extent of which depends on the bulk of the disease. Extension to the orbit and palate depends on the involvement of specific sites in the nose and paranasal sinuses. This study intended to identify those sites.

MATERIALS AND METHODS

This was a single-center case-control study. There were 3 groups according to the region involved (Palate, orbit and both). The fourth group with neither involvement was the control. Scoring system was used to estimate the bulk of disease according to the site involved in MRI scan. Odds ratio and chi-square tests were used to study risk and association respectively. ROC curve was obtained for the MRI scores of the cases and controls.

RESULTS

214 patients were studied in all; 44.39% and 61.68% had palate and orbit involvement, respectively. Maxillary sinus roof had significant association and the highest risk for spread of disease into the palate. The risk for the orbit to be involved was increased when there was disease in the cavernous and sphenoid sinus. For the orbit, the site with the significant association was the ethmoid sinus, infratemporal fossa and roof of the maxillary sinus.

CONCLUSION

Due attention should be given for clearance during surgical debridement to the high-risk sites to prevent recurrences and reduce morbidity and mortality. MRI scores were most helpful to identify the bulk of disease when both palate and orbit were involved.

COVID-19-associated mucormycosis: A review of an emergent epidemic fungal infection in the era of COVID-19 pandemic

At a time when the COVID-19's second wave is still picking up in countries like India, a number of reports describe the potential association with a rise in the number of cases of mucormycosis, commonly known as the black fungus. This fungal infection has been around for centuries and affects those people whose immunity has been compromised due to severe health conditions. In this article, we provide a detailed overview of mucormycosis and discuss how COVID-19 could have caused a sudden spike in an otherwise rare disease in countries like India. The article discusses the various symptoms of the disease, class of people most vulnerable to this infection, preventive measures to avoid the disease, and various treatments that exist in clinical practice and research to manage the disease.

Characteristics and Outcomes of a Series of COVID-Associated Mucormycosis Patients in Two Different Settings in Egypt Through the Third Pandemic Wave

PURPOSE

To report on the underlying risk factors, clinical characteristics, presentation, and survival of coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM) cases referred for ophthalmological consultation in two different Egyptian settings during the third viral pandemic wave (April to August of 2021).

METHODS

A multicentric, retrospective analysis involving one public and two private hospitals in metropolitan Cairo, and two university hospitals in upper Egypt (Aswan and Assuit). Cases that fulfilled the diagnostic criteria of mucormycosis, with a prior or concurrent COVID-19 infection, were included.

RESULTS

Of the 26 patients included in the final analysis, 15 (57.7%) were from Cairo and 11 (42.3%) were from upper Egypt. Twenty-five patients (96.2%) had poorly controlled diabetes mellitus and 20 (76.9%) had received corticosteroid treatment for COVID-19, of which 30.8% had mild or moderate disease. The median duration from COVID-19 till the onset of CAM was 20.5 days. No visual function could be detected in the affected eye of 16 patients (61.6%) on presentation. The mortality rate was 46.2% despite surgical debridement in half of the cases that died.

CONCLUSION

CAM continues to be a concrete threat throughout Egypt, especially in patients with poorly controlled diabetes mellitus and those who inadvertently receive steroid therapy. It remains to be seen if increased vaccination coverage and early detection due to increased awareness would result in declining rates and adverse sequelae of CAM. A national registry would allow for better monitoring of the disease trends.

Cumulative Mortality and Factors Associated With Outcomes of Mucormycosis After COVID-19 at a Multispecialty Tertiary Care Center in India

Importance

An outbreak of COVID-19-associated rhino-orbitocerebral mucormycosis (CAM) has occurred in many parts of the world. Although the clinical profile and risk factors for CAM have been studied, cumulative mortality and its risk factors have not.

Objective

To report the cumulative mortality rates at different times in cases with CAM and identify risk factors for CAM-associated mortality.

Design, Setting, and Participants

This retrospective case-control study was conducted from March 1 to May 30, 2021, in a tertiary care multispecialty hospital in western India. All patients diagnosed with CAM and with a minimum follow-up of 30 days or those who died before 30 days due to CAM were included.

Main Outcomes and Measure

Cumulative mortality in CAM using survival analysis.

Results

A total of 73 consecutive patients with CAM with a mean (SD) age of 53.5 (12.5) years were included in the analysis, of whom 48 (66%) were men. CAM developed at a median of 28 (IQR, 15-45; range, 4-90) days after recovery from COVID-19. Of the 73 patients with CAM, 26 (36%) died; the cumulative probability of death was 26% (95% CI, 16%-41%) at day 7 and doubled to 53% (95% CI, 39%-69%) at day 21. Sinus debridement was performed in 18 of 51 patients (35%), and 5 of 52 (10%) underwent exenteration, whereas intravenous lyophilized amphotericin B was administered to 48 patients (66%). A multivariate Cox proportional hazards regression analysis showed that receiving mechanical ventilation in the past was associated with a nearly 9-fold increased risk of death (hazard ratio [HR], 8.98; 95% CI, 2.13-38.65; P = .003), and patients who had visual acuity of light perception or better had a 46% lower risk of death (HR, 0.56; 95% CI, 0.32-0.98; P = .04). Intravenous amphotericin B administration was associated with a reduced rate of exenteration (0 vs 5 of 25 [20%]; P < .001). On multivariate analysis, those who received intravenous amphotericin B had a 69% reduced risk of death (HR, 0.31; 95% CI, 0.06-1.43; P = .13).

Conclusions and Relevance

These findings suggest that the mortality rate after rhino-orbitocerebral mucormycosis is high and that a subgroup of patients with severe COVID-19 or presenting with severe orbital disease are more likely to die within 10 days of admission.

COVID-19-associated mucormycosis, diabetes and steroid therapy: Experience in a single centre in Western Mexico

Background

COVID‐19–associated mucormycosis (CAM) has emerged as a challenging complication as the current pandemic has increased the population requiring treatment with corticosteroids. CAM has caused a massive outbreak in India, reported to be causing cases in Iran, Egypt and The Netherlands.

Objectives

To describe CAM cases occurring in a single centre in Western Mexico.

Methods

Our group carried out a retrospective study from May 2020 to May 2021 to identify CAM cases in patients with previous COVID‐19 diagnosis.

Results

Six CAM cases occurred in a single centre in Western Mexico during the study period, most of them with diabetes (n = 5/6) and all received corticosteroid therapy even when only three had severe COVID‐19. After analysing local COVID‐19 burden, it was estimated that in this region, CAM was 300 times more frequent among COVID individuals than the estimates for general population.

Conclusion

Similar to large reports in India and other countries, CAM cases reported in this study were diagnosed in individuals with diabetes, hyperglycaemic status and with history of previous use of corticosteroids. Identifying these individuals at risk can help the early identification of CAM. In addition, strict glycaemic control and avoidance of unnecessary corticosteroid in non‐severe COVID‐19 cases could help in preventing this complicated fungal infection.