Perineural spread of rhino-orbitocerebral mucormycosis caused by Apophysomyces elegans

A New Proposed Combined CT and MRI Staging System for Covid-19-Associated Rhino-Orbito-Cerebral Fungal Infection: A Multi-center Study with Pathological Correlation

RATIONALE AND OBJECTIVES

To propose a combined computed tomography (CT) and magnetic resonance imaging (MRI) based classification system in the management of COVID-19-associated rhino-orbito-cerebral (C-ROC) fungal infection and to assess the reliability of such proposed staging system.

MATERIALS AND METHODS

This was a multi-center prospective study conducted on 122 adults with previously confirmed COVID-19 infection. CT and contrast-enhanced MRI (CE-MRI) were performed for all patients. Three radiologists (with experience of 8, 10, and 14 years) independently assessed all images. Then, each patient was assigned a radiological stage based on the five stages of the proposed system according to the radiological extent of the fungal infection. The intra-class correlation coefficient (ICC) test assessed the inter-rater agreement. Based on the pathological evaluation of post-operative specimens, a diagnosis of fungal infection was documented.

RESULTS

The most prevalent severity stage among all raters was stage IV in 29.5-31.1% patients. The overall inter-rater agreement of the proposed staging system was excellent (ICC 0.971, 95% CI;0.960-0.979). Moreover, the most common detected pathogen was Mucormycosis (n = 87, 71.3%). Furthermore, there was a statistically significant association between the patients' outcome and the severity stage (P value 0.001) and there was no statistically significant association between ethmoid and sphenoid sinus affection and cranial extension (P value 0.081).

CONCLUSION

Our proposed combined CT and MRI severity staging system has a high inter-rater agreement. Moreover, it can aid in the early detection of the C-ROC fungal infection, improve preoperative planning, and subsequently improve the patient's outcome.

Outcome of Total Surgical Debridement of Covid Associated Rhino-Orbito-Cerebral Mucormycosis Based on a New Surgical Staging System: A Cohort Study

To propose a surgical staging system with management protocol for post-covid Rhino-orbito-cerebral mucormycosis (ROCM) with central skull base osteomyelitis. A prospective cohort study of a total of 193 post-covid ROCM patients was conducted between May 2021 and January 2022 at a tertiary care centre. Patients were assessed radiologically and staged from I to V. Follow up period was 16 months and the surgical outcome in terms of recurrent disease was assessed. A total of 193 patients (129 primary and 64 revision) were studied. Maxilla was found to be the epicenter of anterior disease (69.3%) and pterygoid wedge was noted to be the epicenter of posterior disease (85.6%). More than 65% of our patients, at the time of presentation, presented with involvement of the central skull base. Intracranial disease was noted in 13.9% of patients and the mortality rate was 6.2%. This staging system provides a systematic step-by-step protocol for the management of ROCM, with emphasis on meticulous disease clearance at the central skull base.

Predicting intracranial involvement: Unveiling perineural spread in COVID-19-associated mucormycosis, a novel phenomenon

This study aimed to investigate the risk factors associated with intracranial involvement in COVID-19-associated mucormycosis (CAM) and to develop a nomogram model for predicting the risk of intracranial involvement, with a specific focus on perineural spread. An ambispective analysis was conducted on 275 CAM patients who received comprehensive treatment. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors, and a nomogram was created based on the results of the multivariable analysis. The performance of the nomogram was evaluated using a receiver operating characteristic (ROC) curve, and the discriminatory capacity was assessed using the area under the curve (AUC). The model's calibration was assessed through a calibration curve and the Hosmer Lemeshow test. In the results, the multivariable logistic regression analysis revealed that age (OR: 1.23, 95% CI 1.06-3.79), HbA1c (OR: 7.168, 95% CI 1.724-25.788), perineural spread (OR: 6.3, 95% CI 1.281-19.874), and the disease stage were independent risk factors for intracranial involvement in CAM. The developed nomogram demonstrated good discriminative capacity with an AUC of 0.821 (95% CI 0.713-0.909) as indicated by the ROC curve. The calibration curve showed that the nomogram was well-calibrated, and the Hosmer Lemeshow test yielded a P-value of 0.992, indicating a good fit for the model. In conclusion, this study found that CAM particularly exhibits perineural spread, which is a predictive factor for intracranial involvement. A nomogram model incorporating age, HbA1c, disease stage, and perineural spread was successfully developed for predicting intracranial involvement in CAM patients in both in-patient and out-patient settings.

Invasive rhinocerebral mucormycosis: Imaging the temporal evolution of disease in post COVID-19 case with diabetes: A case report

BACKGROUND

Rhinocerebral mucormycosis (RCM) is a rare, fatal, invasive fungal infection infecting mainly patients with immunocompromised conditions, such as diabetes mellitus, hematologic malignancies, and organ transplantations. Coronavirus disease 2019 (COVID-19) disease in these patients further weakens the immune system due to several factors, including hypoxia, corticosteroid usage (further increasing hyperglycemic status), mechanical ventilation, increased serum ferritin levels, endothelitis due to free radicals, and glucose receptor protein upregulation. Timely diagnosis, judicious treatment decisions, and diabetes control with proper treatment guidelines in patients with coexisting COVID-19 disease can reduce complication rates and improve survival.

CASE SUMMARY

A 75-year-old male patient with diabetes and hypertension diagnosed with COVID-19 presented to the emergency department. Laboratory examinations revealed elevated blood glucose levels, as well as ketone bodies in the urine. He was treated with oxygen and steroids, as well as insulin to correct blood glucose levels. He complained of a headache 10 d later, and imaging demonstrated mucosal thickening in bilateral sphenoidal, ethmoidal, and maxillary sinuses with hyperdense foci in the right maxillary sinus but without central nervous system involvement. Surgical debridement was performed, and a histopathological study revealed fungi hyphae. Systemic antifungals (amphotericin b and posaconazole) were administered. Subsequently, on 15^th day he developed right lower limb weakness and left lateral rectus palsy. There was slow but steady progress, and he was discharged. However, he presented to emergency department 1mo later with altered sensorium and poor control of diabetes resulted in an intracranial spread of mucormycosis, which ultimately led to the patient’s poor prognosis and slow recovery.

CONCLUSION

Prompt early diagnosis, judicious treatment decisions, and diabetes control with proper treatment guidelines are necessary in patients with COVID-19 associated invasive RCM to reduce complication rates and improve patient survival.

Magnetic Resonance Imaging Features of Rhino-Orbito-Cerebral Mucormycosis in Post-COVID-19 Patients: Radio-Pathological Correlation

There has been a notable increase in rhino-orbito-cerebral mucormycosis (ROCM) post-coronavirus disease 2019 (COVID-19), which is an invasive fungal infection with a fatal outcome. Magnetic resonance imaging (MRI) is a valuable tool for early diagnosis of ROCM and assists in the proper management of these cases. This study aimed to describe the characteristic MRI findings of ROCM in post-COVID-19 patients to help in the early diagnosis and management of these patients. This retrospective descriptive study was conducted at a single hospital and included 52 patients with COVID-19 and a histopathologically proven ROCM infection who were referred for an MRI of the paranasal sinuses (PNS) due to sino-orbital manifestations. Two radiologists reviewed all the MR images in consensus. The diagnosis was confirmed by histopathological examination. The maxillary sinus was the most commonly affected PNS (96.2%). In most patients (57.7%), multiple sinuses were involved with the black turbinate sign on postcontrast images. Extrasinus was evident in 43 patients with orbital involvement. The pterygopalatine fossa was involved in four patients. Three patients had cavernous sinus extension, two had pachymeningeal enhancement, and one had epidural collection. The alveolar margin was affected in two patients, and five patients had an extension to the cheek. The awareness of radiologists by the characteristic MRI features of ROCM in post-COVID-19 patients helps in early detection, early proper management, and prevention of morbid complications.

Mucormycosis caused by Apophysomyces species: An experience from a tertiary care hospital in Western India and systematic review of global cases

Apophysomyces species are an emerging cause of mucormycosis in several regions of the world, primarily affecting immunocompetent individuals. The present study addresses the global epidemiology, clinical presentation, management and outcome of mucormycosis caused by Apophysomyces spp. The study included patients diagnosed with Apophysomyces infection at our hospital between March 2019 and August 2020. In addition, cases published in PubMed and Google Scholar from inception to July 2022 were systematically searched and analysed. Only proven and probable cases that meet the eligibility criteria were included. The Indian cases were compared with those from other countries, and the results were analysed by descriptive statistics. In total, six cases of mucormycosis due to Apophysomyces spp. were diagnosed at our hospital, with additional 250 cases identified through literature search. The main underlying diseases were diabetes mellitus (24%), malignancy (3.2%) and chronic kidney disease (2.8%). The major predisposing factor was trauma (55.6%). Necrotizing fasciitis was the most common (63.2%) clinical presentation. Healthcare-associated mucormycosis accounted for 10.4% of the cases. Globally, A. elegans was the most common species (48.8%), whereas A. variabilis was predominant (86.2%) in India. Surgery was performed in 83.5% of patients. Among those treated with antifungal agents, 98% received amphotericin B and 8.1% received posaconazole. Inappropriate antifungal usage was observed in 12.7%. The overall mortality was 42.3%. A combined medical and surgical management was associated with higher survival. Our study highlights the knowledge gap among physicians regarding this infection. A timely diagnosis and aggressive management can improve the outcomes in such cases.

Rhinocerebral mucormycosis: a systematic review of case reports and case series from a global perspective

OBJECTIVE

Rhinocerebral mucormycosis (RCM) is the most common variant and the presenting features in the head and neck region are seldom pathognomonic. The aim of this systematic review was to obtain a thorough insight into the predisposing factors, clinical features, disease course, management protocol, outcome, and prognosis.

STUDY DESIGN

An electronic search was carried out using MEDLINE by PubMed, Scopus, Google Scholar, Web of Science, and EMBASE databases. Articles in which the clinical findings on the extra- and intraoral features of RCM were included for systematic review. Descriptive statistics was applied to obtain the results.

RESULTS

A total of 124 case studies (90 case reports, 34 case series) which yielded 219 patients. Diabetes mellitus (57.40%) was the most common comorbid condition. Neurologic manifestations were noted in 23.3% of the individuals. Maxillary/hard palate involvement was a common occurrence (59.2%). Intra-oral necrotic lesions with eschar were noted in 75/219 patients. Amphotericin B was the commonly used drug for the management, and surgical debridement was performed in majority of the cases. The mortality rate was 18.4%.

CONCLUSIONS

The clinical manifestations often mimic odontogenic symptoms, hence a sound knowledge about the pathogenesis and course of the disease will aid in the prompt diagnosis and management.

Intracranial manifestations of rhinocerebral mucormycosis: a pictorial essay

Rhinocerebral mucormycosis has emerged as a common coinfection in coronavirus disease 2019 (COVID-19) patients during the convalescence period. Frequent spread of disease from sinonasal mucosa to bone, neck spaces, orbit, and brain occurs along the perivascular/perineural routes or through direct invasion. Brain involvement represents severe manifestation and is often associated with poor functional outcomes and high mortality rates. Magnetic resonance imaging (MRI) is the modality of choice for the intracranial assessment of disease severity in mucormycosis. Early and accurate identification of intracranial extension is imperative to improve survival rates. With this pictorial essay, we aim to familiarize the readers with the cross-sectional imaging features of intracranial complications of mucormycosis. The radiological details in this essay should serve as a broad checklist for radiologists and clinicians while dealing with this fulminant infection.

A case of COVID-19-associated rhino-orbito-cerebral mucormycosis caused by Apophysomyces variabilis with a review of the literature

A fatal case of COVID-19-associated mucormycosis (CAM) affected a 40-year-old woman who was initially admitted to our hospital due to a SARS-CoV-2 infection. Her clinical condition worsened, and she finally died because of respiratory failure, hemodynamic instability, and mucormycosis with invasion into the orbit and probably the brain. According to DNA sequence analysis of the fungus isolated from the patient, Apophysomyces variabilis was involved. This is the first published case of CAM and the third case of mucormycosis due to this mold.

Histopathological Study of Mucormycosis in Post COVID-19 Patients and Factors Affecting it in a Tertiary Care Hospital

Introduction. COVID-19 is an infection caused by severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) which may be associated with a wide range of bacterial and fungal co-infections. Mucormycosis is an opportunistic fungal infection occurring in post COVID-19 patients. Objectives. To study the role of histopathology in mucormycosis and the predisposing factors associated in development of mucormycosis in post COVID-19 patients. Materials and methods. A prospective observational study was conducted in our hospital in the pathology department over a period of 3 months on 200 patients with mucormycosis who were infected with SARS-CoV-2 virus. Results. Out of the 200 patients with mucormycosis studied in post COVID-19 patients, age ranged from 21-80 years, of which 132 were men and 68 were women. Sites involved by mucormycosis were sinuses, orbit, cranium, and cutaneous. Ethmoid sinus was most involved, followed by maxillary sinus. Diabetes was present in 162 patients and hypertension in 92 patients. On histopathological examination, fungal load was severe in 49 patients, angioinvasion was present in 48 patients, perineural invasion was present in 32 patients, and necrosis was present in 121 patients. The number of patients discharged after surgery was 169, whereas 31 died. Conclusion. Histopathological features of mucormycosis like angioinvasion, perineural invasion, severe fungal load, and large areas of necrosis were directly proportional to the mortality rate. Thus, histopathologists can help in assessing prognosis at the time of tissue diagnosis, so that clinicians can optimize treatment accordingly. Diabetes and history of corticosteroid intake for treatment of COVID-19 were the two commonest predisposing factors for development of mucormycosis.

Coronavirus Disease 2019 (COVID-19)-Associated Rhino-Orbito-Cerebral Mucormycosis: A Multi-Institutional Retrospective Study of Imaging Patterns

BACKGROUND

Mucormycosis infection of the maxillofacial region and brain has been associated with coronavirus disease 2019 (COVID-19) infection. Mucormycosis was relatively a rare infection before COVID-19, and imaging findings are not very well described.

MATERIALS AND METHODS

A retrospective imaging study of 101 patients diagnosed with COVID-19-associated mucormycosis by histopathology and/or culture was performed. All patients underwent computed tomography and/or magnetic resonance imaging based on the clinical condition of the patient and on consensus decision by the team of treating physicians. A simple 3-stage classification system based on imaging findings was adopted.

RESULTS

One hundred one cases were included in the final analysis (mean age = 55.1 years; male/female ratio = 67:34). The affected patients had diabetes in 94% of the instances (n = 95), 80.1% (n = 81) received steroids), whereas 59.4% (n = 60) patients received supplemental oxygen. The majority underwent surgical intervention, whereas in 6 cases, patients were treated with antibiotic regimens. Sixty subjects improved following therapy, whereas 18 eventually succumbed to the illness. We noted a significant positive correlation between the imaging stage and outcomes. No association was seen between other clinical parameters and final clinical outcomes. Salient imaging findings include lack of normal sinonasal mucosal enhancement, perisinus inflammation, ischemic optic neuropathy, perineural spread, pachymeningeal enhancement, and presence of strokes.

CONCLUSIONS

We describe the imaging findings in the largest cohort of patients with rhino-orbito-cerebral mucormycosis in the context of the current COVID-19 pandemic. A simplified staging system described here is helpful for standardized reporting and carries prognostic information.

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

Objective

To develop a systematic approach for magnetic resonance imaging (MRI) analysis, imaging spectrum, and classification system for the staging of post-COVID-19 head and neck mucormycosis.

Method

The study included 63 post-COVID-19 patients with pathologically proven mucormycosis who underwent head and neck MR imaging. Three independent radiologists assessed the imaging spectrum of mucormycosis, MRI characteristics of sino-nasal mucormycosis, and extra-sinus extension, and submitted a final staging using a systematic approach and a proposed categorization system. A consensus reading was considered the reference imaging standard. The kappa statistics were used to assess the categorization system's diagnostic reliability.

Results

The overall interreader agreement of the MR staging system was very good (k-score = 0.817). MR imaging spectrum involved localized sino-nasal mucormycosis (n = 7 patients, 11.1%), sino-nasal mucormycosis with maxillo-facial soft tissue extension (n = 28 patients, 44.5 %), sino-nasal mucormycosis with maxillo-facial bony extension (n = 7 patients, 11.1%), sino-naso-orbital mucormycosis (n = 13 patients, 20.6%), and sino-nasal mucormycosis with cranium or intracranial extension (n = 8 patients, 12.7%). Extra-sinus extension to the orbit and brain did not have significant association with involvement of the posterior ethmoid/sphenoid sinuses and maxillo-facial regions (p > 0.05). MRI-based staging involved four stages: stage 1 (n = 7, 11.1%); stage 2 (n = 35, 55.6%), and stage 3 (n = 13, 20.6%), and stage 4 (n = 8, 12.7%). Involvement of the bone and MR-based staging were significant predictors of patients’ mortality p = 0.012 and 0.033, respectively.

Conclusion

This study used a diagnostic-reliable staging method to define the imaging spectrum of post-COVID-19 head and neck mucormycosis and identify risk variables for extra-sinus extension.

Facial neuritis in coronavirus disease 2019 associated mucormycosis: study on clinico-radiological correlates

Objective

To elucidate the aetiopathogenesis of facial neuritis in coronavirus disease 2019 associated mucormycosis.

Methods

A retrospective review was conducted of coronavirus disease 2019 associated mucormycosis patients who presented with peripheral facial nerve palsy from January 2021 to July 2021. The clinico-radiological details of four patients were assessed to examine the potential mechanism of facial nerve involvement.

Results

Serial radiological evaluation with contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging revealed infratemporal fossa involvement in all cases, with the inflammation extending along fascial planes to reach the stylomastoid foramen. Ascending neuritis with an enhancement of the facial nerve was demonstrated in all cases.

Conclusion

The likely explanation for facial palsy in patients with coronavirus disease 2019 associated mucormycosis, backed by radiology, is the disease abutting the facial nerve at the stylomastoid foramen and causing ascending neuritis of the facial nerve.

Magnetic resonance imaging features of post-COVID-19 regional and invasive sino-nasal mucormycosis

Background

Sino-nasal mucormycosis is an opportunistic, invasive fungal disease which has shown a rising trend in the setting of COVID-19. The objective of this study is to document and analyze demographic data, clinical presentation and MR imaging spectra for early detection and management of post-COVID-19 sino-nasal mucormycosis.

Results

Sixty-two cases of sino-nasal mucormycosis were enrolled in this study; their mean age was 50.65 ± 8.25 years, with significant female predominance. Nine patients (14.5%) had active COVID-19 and 53 (85.5%) were recent COVID-19 cases. Sixty patients have not received COVID-19 vaccine. The mean duration from the initial COVID-19 laboratory confirmation to the detection of sino-nasal mucormycosis was 25.7 +/− 4.6 days. Thirty-five patients (56.5%) were kept in the hospital for COVID management and 4 of them received intensive care unit (ICU) treatment. Twenty-seven patients (43.5%) were treated in home isolation. Corticosteroids were administered in 48 cases (77.4%). Twenty-nine patients (46.8%) had been given oxygen for an average time of 11.2 ± 4.15 days. Diabetes was found in 56 cases (90.3%). The most common clinical symptoms were headache, seen in 52 patients (83.87%). The ethmoid sinus was the most common paranasal sinus involved in our study, seen in 47 cases (75.81%). In 36 cases (58%), multiple sinuses were involved. MRI staging according to the extent of regional involvement. Stage 1 seen in 2 cases (3.23%), stage 2 in 13 cases (20.97%), stage 3 in 35 cases (56.45%) and stage 4 in 12 cases (19.35%).

Conclusions

MRI shows a spectrum of findings in sino-nasal mucormycosis. Imaging plays a major role in staging and assessing the extent of involvement and complications. In light of this, mortality and morbidity can be dramatically decreased with adequate evaluation and therapy.

Surgical & medical management of ROCM (Rhino-orbito-cerebral mucormycosis) epidemic in COVID-19 era and its outcomes - a tertiary care center experience

Objective

To evaluate the outcome of patients with ROCM (Rhino-orbito-cerebral mucormycosis) following their medical and surgical management.

Materials and methods

It is a prognostic study based in a tertiary care center in North-Western India. Patients who developed ROCM post COVID-19 infection from 1st September 2020 to 30th June 2021 were included in this study. Surgical debridement and administration of antifungal therapy was done for the post-COVID-19 ROCM patients. Disease progression and survival was studied up to 5 months of follow-up in the second wave.

Results

A total of 145 ROCM patients were included. The mean age at presentation, male: female ratio was 48.2 years and 2:1 respectively. As per our proposed new staging system and treatment strategy, the majority of patients belonged to stage II (31.72%) and stage III (31.03%). On a follow-up period of 5 months, 26 (18%) patients have lost their life and rest of the patients are on strict follow-up.

Conclusion

ROCM is an extremely aggressive fungal infection which rapidly became an epidemic following the COVID-19 pandemic. The diverse and unique presentation led us to evolve a new strategy to classify and manage these patients.

A multicentric observational study of imaging findings in COVID-19-related rhino-orbito-cerebral mucormycosis: a new Pandora’s box

Background

There is a sudden rise of fungal infection with corona virus disease. This is attributed to the immunomodulation by the disease and the drugs used, diabetes mellitus, steroid use, oxygen inhalation using dirty water, use of zinc and iron supplements, etc. Early diagnosis and prompt medical and surgical intervention is the mainstay of treatment. This can greatly reduce the high morbidity and mortality associated with this disease. The objective of the study is to describe the imaging findings of acute invasive rhino-orbito-cerebral mucormycosis (ROCM) in 25 patients with severe acute respiratory syndrome corona virus 2, from three different centers with proven mucormycosis. Special emphasis is placed on the signal enhancement patterns of sinonasal mucosa, the earliest and most common findings. Statistical analysis was performed using descriptive statistics.

Results

Computed tomography (CT) and magnetic resonance imaging (MRI) of 25 patients showed most commonly involved sinuses as maxillary and ethmoid sinuses (19, 76%) together. Sino-nasal mucosal thickening was the most common finding (24, 96%). Periantral infiltration (18, 72%) preceded before orbital (15, 60%), cerebral (5, 20%) and vascular (2, 8%) complications, with grossly intact bones. Sinus wall erosions were seen in only 2 patients (8%). Palatal (22%) and maxillary alveolar arch erosion (39%) were frequent findings. CT showed minimally enhancing hypodense soft tissue thickening as the predominant finding in involved areas, while MRI showed T1 and T2 iso- to hypointense mucosal thickening (62%) and intense (43%) and no (33%) contrast enhancement as the main finding.

Conclusions

Contrast enhanced MRI is better at demonstrating early mucosal abnormalities, turbinate necrosis, non-enhancing devitalized tissues, orbital apex involvement and intra-cerebral extension. Imaging findings of inflammatory tissue infiltration adjacent to the paranasal sinuses in premaxillary, retroantral fat, facial muscles, pterygopalatine fossa, temporal, infratemporal fossa and extraconal orbital fat along with typical patterns of sinonasal mucosal enhancement should raise the suspicion of acute invasive fungal etiology given the short duration of history and immunocompromised status. High incidence of periantral and orbital extension of the disease is suggestive of acute invasive form of fungal infection. Also the rapidly progressive inflammatory changes without much bone involvement should suggest the suspicion of ROCM. Bony, cerebral and vascular involvements are relatively late complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43055-021-00631-w.

Spectrum of MR imaging findings of sinonasal mucormycosis in post COVID-19 patients

During rapid spread of coronavirus disease (COVID-19) globally, ever since WHO declared COVID-19 as pandemic, there have been various patterns of disease in terms of diagnosis, management and complications. Secondary infections are reportedly common in hospitalized and severely ill COVID-19 patients among which fungal being 10 times more common. Mucormycosis is amongst the most lethal form of Zygormycosis occurring in post COVID-19 patients. A varied patterns of disease involvement and spectrum of imaging features are observed in patients with mucormycosis in post COVID-19 patients. MRI has better efficacy than CT in detecting early invasion of mucormycosis. The goal of this review is to familiarize radiologists about the MR imaging spectrum of mucormycosis in post COVID-19 patients with potential diagnostic pitfalls in CT.

Spectrum of intracranial complications of rhino-orbito-cerebral mucormycosis - resurgence in the era of COVID-19 pandemic: a pictorial essay

Rhino-orbito-cerebral mucormycosis (ROCM) has regained significance following its resurgence in the second wave of the COVID-19 pandemic in India. Rapid and progressive intracranial spread occurs either by direct extension across the neural foraminae, cribriform plate/ethmoid, walls of sinuses, or angioinvasion. Having known to have a high mortality rate, especially with intracranial extension of disease, it becomes imperative to familiarise oneself with its imaging features. MRI is the imaging modality of choice. This pictorial essay aims to depict and detail the various intracranial complications of mucormycosis and to serve as a broad checklist of structures and pathologies that must be looked for in a known or suspected case of ROCM.

Early Surgical Intervention Followed by Antifungals in Rhino-Orbital Mucormycosis in Patients With COVID-19 Favors Clinical Outcome: A Case Series

Mucormycosis is an invasive fungal infection occurring in patients with or without preexisting medical illnesses. During the ongoing coronavirus disease 2019 (COVID-19) pandemic, there have been increasing reports of bacterial and fungal coinfections among some COVID-19 patients with preexisting comorbid illnesses such as diabetes and hypertension, with mucormycosis being one of them. The management of this dreaded fungal infection demands early and prompt surgical intervention to thoroughly remove the infected tissue and necrotic material to reduce the tissue burden of this invasive organism. This should be accompanied by expeditious initiation of amphotericin B along with supportive therapy. Here we present five cases of rhino-orbital mucormycosis in patients with COVID-19, all of whom presented with orbital and facial swelling (three had symptoms of impending blindness) under the backdrop of COVID-19 symptoms in the form of intermittent fever and slight dyspnea. Our treatment strategy comprised an expeditious use of early surgical intervention and amphotericin B along with the control of cytokine storm and hyperglycemia. This treatment strategy eventually resulted in an improved clinical outcome.

COVID-19 associated mucormycosis: Staging and management recommendations (Report of a multi-disciplinary expert committee)

Even before the onslaught of COVID-19 pandemic could settle, the unprecedented rise in cases with COVID-19 associated mucormycosis pushed the medical health to the fringe. Hyperglycaemia and corticosteroids appear to be the most consistent associations leading to the commonest manifestation of mucormycosis, Rhino-Orbito-Cerebral Mucormycosis. To address challenges right from categorisation and staging of the disease to the management of relentless progression, a multi-disciplinary expert committee was formed to handle the task in an evidence-based format to enforce best practices. The report of the committee on one hand attempts to succinctly present the currently available evidence while at the other also attempts to bridge the evidence-deficient gaps with the specialty-specific virtuosity of experts.

Cerebral mucormycosis: neuroimaging findings and histopathological correlation

INTRODUCTION

Mucormycosis are infections caused by molds of the order Mucorales. These opportunistic infections are rare, difficult to diagnose, and have a poor prognosis. We aimed to describe common radiographic patterns that may help to diagnose cerebral mucormycosis and search for histopathological correlations with imaging data.

METHODS

We studied the radiological findings (CT and MRI) of 18 patients with cerebral mucormycosis and four patients' histopathological findings.

RESULTS

All patients were immunocompromised and/or diabetic. The type of lesions depended on the infection's dissemination pathway. Hematogenous dissemination lesions were most frequently abscesses (59 lesions), cortical, cortical-subcortical, or in the basal ganglia, with a halo aspect on DWI for lesions larger than 1.6 cm. Only seven lesions were enhanced after contrast injection, with different presentations depending on patients' immune status. Ischemia and hemorrhagic areas were also seen. Vascular lesions were represented by stenosis and thrombosis. Direct posterior extension lesions were bi-fronto basal hypodensities on CT and restricted diffusion without enhancement on MRI. A particular extension, perineural spread, was seen along the trigeminal nerve. Histopathological analysis found endovascular lesions with destruction of vessel walls by Mucorales, microbleeds around vessels, as well as acute and chronic inflammation.

CONCLUSIONS

MRI is the critical exam for cerebral mucormycosis. Weak ring enhancement and reduced halo diffusion suggest the diagnosis of fungal infections. Involvement of the frontal lobes should raise suspicion of mucormycosis (along with aspergillosis). The perineural spread can be considered a more specific extension pathway of mucormycosis.

Imaging features of perineural and perivascular spread in rapidly progressive rhino-orbital-cerebral mucormycosis: A case report and brief review of the literature

Background:

Rhinocerebral mucormycosis (ROCM) is an opportunistic fungal infection originating from the paranasal sinuses with extension to the brain. A delayed diagnosis can rapidly result in a poor prognosis. ROCM commonly affects patients with diabetes or immunocompromised states with a variable progression.

Case Description:

We report the case of a 59-year old patient with an untreated diabetes who developed a ROCM with rapidly progressive neurological symptoms. From the onset of sinus pain, nasal congestion, he rapidly developed facial swelling and masticatory dysfunction. The patient underwent sinus surgery which allowed Rhizopus oryzae to be isolated. Accordingly, a systemic therapy by intensive intravenous amphotericin B was started. Nevertheless, the infection rapidly resulted in bilateral cavernous sinuses thrombosis and occlusion of the left internal carotid artery providing the subsequent patient death.

Conclusion:

Mucormycosis is a life-threatening fungal infection in diabetic and/or immunosuppressed patients. Our case demonstrates the three main mechanisms for infection spreading that are direct, perineural, and perivascular diffusion. Clear identification of the main risk factors, proper assessment of clinical features, and radiological findings may improve the chance for an early diagnosis and patient survival.

Sino-orbital mucormycosis in a COVID-19 patient: A case report

INTRODUCTION

We report a case of post COVID-19 Sino-orbital Mucormycosis infection caused by Rhizopus oryzae and its management.

PRESENTATION OF CASE

The patient was diagnosed with COVID-19 and treated according to the persisting protocols. Following recovery, on the 18th day, the patient developed chemosis and pain in the left eye. A diagnosis of mucormycosis was established after Magnetic Resonance Imaging (MRI) and Functional Endoscopic Sinus Surgery (FESS). Initially, conservative management with intravenous (IV) Fluconazole & Amphotericin B was done and later on with surgical debridement. The patient recovered with minimal residual deformity.

DISCUSSION

Mucormycosis generally develops secondary to immunosuppression or debilitating diseases. In Head and Neck cases, the mold usually gains entry through the respiratory tract involving the nose and sinuses, with possible further progression into the orbital and intracranial structures. Hence, an early diagnosis and intervention is required for a good prognosis, decreasing the morbidity. This can be achieved on the basis of clinical picture and direct smears.

CONCLUSION

Research needs to be carried out in COVID-19 patients for better prevention and management of opportunistic infections in order to reduce its incidence and morbidity. Prophylactic treatment protocols need to be established, along with rational use of corticosteroids.

Rhinocerebral Zygomycosis Due to a Lichtheimia ramosa Infection in a Calf: Neural Spread Through the Olfactory Nerves

Here, we report a case of rhinocerebral zygomycosis due to a Lichtheimia ramosa infection in a calf. A histopathological examination revealed that a fungus had invaded the brain through the olfactory nerves. Lichtheimia ramosa was detected by polymerase chain reaction analysis of DNA extracted from formalin-fixed paraffin-embedded samples of the affected tissue. This is the first case of rhinocerebral zygomycosis to involve cattle. Also, this is the first such case to involve fungal invasion into the central nervous system through the cranial nerve itself, rather than through perineural tissue.

Chronic orbital and calvarial fungal infection with Apophysomyces variabilis in an immunocompetent patient

Apophysomyces is a rare fungal organism causing rhino-orbito-cerebral mycotic infections with high morbidity and mortality, typically in immunocompetent individuals. Several cases of Apophysomyces elegans orbital disease have been reported. Herein, we report a case of Apophysomyces variabilis infection involving the orbit, sinuses, and calvarium in an immunocompetent 74-year-old woman, with a review of the literature. Unlike prior cases of A. elegans classic rhino-orbito-cerebral infection, our case included diffuse calvarial lytic lesions and overlying soft tissue nodules, but without parenchymal intracranial involvement. There was radiographic and clinical evidence of infarction of the orbital contents and cavernous sinus thrombosis. Anastomoses between the superior orbital (ophthalmic) vein and diploic veins of the calvarium are believed to be primarily responsible for the unusual mode of spread on the extradural surface of the brain. Although the patient stabilized without definitive surgical intervention, her disease slowly and intermittently progressed for over a year after presentation, requiring multiple courses of antifungal treatment.

Perineural tumour spread from colon cancer, an unusual cause of trigeminal neuropathy--a case report

Malignant trigeminal neuralgia due to perineural spread along the branches of the trigeminal nerve, is known to commonly occur secondary to squamous cell carcinomas, lymphomas and adenoid cystic carcinomas in the head and neck region. Rarely metastases to the trigeminal nerve have been reported in breast cancer, prostate cancer and colon cancer. To the best of our knowledge trigeminal neuropathy due to skull base metastases and perineural spread along the maxillary (V2) and mandibular (V3) branches of the trigeminal nerve, secondary to colon cancer, has not been previously reported. The diagnosis in our index case was made on magnetic resonance imaging, and patient was treated accordingly by fractionated stereotactic radiotherapy, with subsequent relief of her pain.