Magnetic resonance imaging in rhino-orbital-cerebral mucormycosis

Rhino-orbito-cerebral mucormycosis after allogeneic hematopoietic stem cell transplantation for very severe aplastic anemia in a child: a case report

Rhino-orbito-cerebral mucormycosis (ROCM) is a rare and life-threatening fungal infection that predominantly affects immunocompromised individuals, such as those undergoing hematopoietic stem cell transplantation (HSCT). This report describes the case of a 10-year-old girl with very severe aplastic anemia (VSAA) who underwent an haploidentical HSCT from her father. She initially achieved successful engraftment with a donor chimerism rate of 98.25% on day 60. However, on day 65 post-transplant, she developed severe right-eye pain, progressive swelling, and visual impairment. Comprehensive evaluations, including contrast-enhanced magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) analysis, revealed extensive orbital and cerebral involvement consistent with ROCM. Intensive antifungal therapy with liposomal amphotericin B and posaconazole, along with endoscopic surgical debridement of the infected sinuses and orbital regions, was initiated. Post-treatment MRI scans demonstrated a significant reduction in cerebral edema and other abnormalities, while repeated CSF analyses confirmed the absence of fungal elements. This case underscores the critical need for early diagnosis and aggressive management of ROCM in immunocompromised patients, particularly following HSCT.

Orbital compartment syndrome in orbital mucormycosis: spot the threat through radiologist's eye

PURPOSE

To illustrate the imaging findings of orbital compartment syndrome (OCS) in patients with orbital mucormycosis and to identify the red flag signs on imaging for prompt diagnosis and timely intervention.

METHODS

We conducted a retrospective analysis of CT and MRI scans from patients diagnosed with sino-nasal mucormycosis within three months of a confirmed COVID-19 infection. Microbiologically proven cases of mucormycosis were included. Images were analysed for: Route of spread; proptosis; tenting of globe, Retro-orbital fat/extraocular muscle (EOM) nonenhancement; Intra-orbital abscess, superior ophthalmic vein (SOV) thrombosis, stretching/thickening/enhancement/diffusion restriction of optic nerve, orbital coat, and EOM. Descriptive statistics were elaborated in the form of mean/standard deviations for continuous variables and frequencies and percentages for categorical variables.

RESULTS

Out of 138 patients with mucormycosis, 49 had orbital involvement, OCS was present in 16 orbits. The mean age was 48.6 years with M: F of 2.75:1. Adjacent sinuses were involved in all patients. Spread along nerves and nasolacrimal duct was seen in 94% patients. Globe tenting was seen in all and thickening/coat enhancement in 53.3%. Optic nerve (ON) was thickened in 87.5%, diffusion restriction of ON and EOM in 78.5% cases. Non enhancement of retro-orbital fat was seen in 50% and intra-orbital abscess in 62.5% cases.

CONCLUSIONS

OCS is a vision-threatening orbital emergency, leading to OIS and permanent blindness, if not managed promptly. Imaging features that warrant immediate clinical/ surgical intervention to avoid permanent loss of vision are distorted globe, posterior tenting of the globe, stretching of the optic nerve, non-enhancement of retro-bulbar fat and extra-ocular muscles (EOMs).

Subacute onset rhino-orbital mucormycosis caused by Cunninghamella in a Chinese leukemia patient: A case report and literature review

PURPOSE

We herein report a case of subacute-onset rhino-orbital mucormycosis (ROM) in an acute leukemia patent caused by the rare but most lethal pathogenic fungus - Cunninghamella. To the best of our knowledge, this is the first case of ROM caused by Cunninghamella reported in China.

CASE DESCRIPTION

A 50-year-old Chinese female with acute leukemia (M2 type) who, following the completion of two cycles of chemotherapy, began to exhibit naso-ocular symptoms. The patient was initially diagnosed with extramedullary leukemia. As the disease progressed, the patient began to develop specific black crust-like necrosis of the right eyelids. Following multidisciplinary treatment (MDT) consultation and tissue biopsy, the patient was finally diagnosed with a rare type of ROM caused by Cunninghamella infection. Although the mortality associated with Cunninghamella infection was significantly greater than that associated with infections caused by other Mucorales, the infection was eventually controlled through the adjustment of the antifungal drug regimen and timely surgical intervention.

CONCLUSIONS

ROM infection with Cunninghamella is an extremely rare and fatal fungal infection, and early recognition and diagnosis of the disease is critical to the prognosis. The subacute nature of this case may have been a positive factor in the patient's preservation of life.

The Algorithmic Role of Critical Radiographic Features in the Treatment of Angioinvasive Fungal Sinusitis

INTRODUCTION

Angioinvasive fungal sinusitis (AIFS) is a rapidly progressive, highly morbid infection. It can be challenging to obtain an early diagnosis, but intervention in the acute period is crucial for prognosis. Previous literature has identified numerous radiographic features with high sensitivity and specificity for AIFS, even in early disease. Bedside nasal endoscopy can substantiate the diagnosis but can also yield false negative results. Initially, these patients may present to the ophthalmologist. Thus, to avoid visual and potentially life-threatening complications, subtle clinical signs in conjunction with suspicious radiographic features must be promptly recognized by the ophthalmologist and escalated appropriately. We review, for the benefit of the ophthalmic community, the salient radiographic features of AIFS and integrate them into a decision-making algorithm for diagnostic workup and management.

METHODS

A literature search was conducted using a comprehensive keyword search in the Pubmed and Embase databases. English studies from 1988 to 2022 describing the radiographic features of AIFS queried. Literature on the newly described entity, COVID-19 COVID-19-associated mucormycosis was included. The authors collected the most frequently reported indicators of AIFS.

RESULTS

The authors review 4 radiographic findings that are frequently associated with AIFS, including in the early stages of disease: 1) loss of contrast enhancement in the nasal turbinate and maxilla (i.e., "black turbinate and maxillary sign"), (2) periantral involvement seen as changes in density, fat stranding or obliteration of the anterior, retromaxillary, or retroantral fat planes on CT, (3) Tissue invasion without bony erosion, (4) Hypointense T2W sinonasal secretions on MRI in the setting of acute sinusitis. The authors additionally propose an algorithm that suggests surgical exploration for patients with clinical concern for AIFS and these radiographic features, even if bedside nasal endoscopy is inconsistent with AIFS.

CONCLUSION

The radiographic signs highlighted herein should heighten suspicion for AIFS in the appropriate clinical setting, prompting urgent surgical exploration regardless of nasal endoscopy findings.

Estimation of the pattern of ocular manifestations, risk factors, and imaging of rhino-orbital-cerebral mucormycosis in COVID-19 patients

Purpose

To estimate the pattern of ocular manifestations, as observed clinically and radiologically, and associated risk factors in cases of coronavirus disease 2019 (COVID-19)-related rhino-orbital cerebral mucormycosis (ROCM) during the second wave at presentation to the hospital in northern India.

Materials and Methods

A total of 35 patients of ROCM associated with active cases of COVID-19 or recovered cases of COVID-19 presenting to the Ophthalmology outpatient department or admitted in the COVID ward of the hospital with clinical features suggestive of ROCM. They were confirmed as mucormycosis on KOH and fungal cultures of nasal scrapings and histopathology of debrided tissue. This is an ambispective study with retrospective medical records review for COVID-19 analysis and prospective assessment of ROCM-associated COVID-19 during the second outbreak of the COVID-19 pandemic.

Results

The total patients included were 35, which ranged in the age group of 52.91+/- 11.93 years, and the male-to-female ratio was 24:11. The duration between the first positive COVID report and onset of COVID-19-associated ROCM was 9.46+/-11.63 days. The majority (82.9%; n-29) either were diabetics or had high blood glucose levels during the recent COVID-19 infection. 45.7% of patients gave a history of steroid therapy. The most common ocular clinical features were ptosis (80%) and loss of vision 48.7%, respectively. There was diffuse involvement of sinuses in 18 cases (51.4%). Staging based on magnetic resonance imaging scans showed that 7 (20%) had stage II, 20 (57.1%) had stage III, and 28.7% had stage IV disease. Ten patients had varied intracranial extension ranging from meningitis and cavernous sinus thrombophlebitis/thrombosis to brain abscess.

Conclusions

COVID-associated ROCM was very rapidly spreading and more destructive. Ptosis and loss of vision related to third nerve involvement and CRAO, respectively, were alarming signs and bad prognostic indicators to the patient. Intracranial involvement and CRAO were poor prognostic features in this type of mucormycosis.

Epidemiology, pathogenesis, clinical characteristics, and treatment of mucormycosis: a review

AIM

This review aims to summarize the epidemiology, etiology, pathogenesis, clinical manifestations, and current diagnostic and therapeutic approaches for mucormycosis. The goal is to improve understanding of mucormycosis and promote early diagnosis and treatment to reduce mortality.

METHODS

A comprehensive literature review was conducted, focusing on recent studies and data on mucormycosis. The review includes an analysis of the disease's epidemiology, etiology, and pathogenesis, as well as current diagnostic techniques and therapeutic strategies.

RESULTS

Mucormycosis is increasingly prevalent due to the growing immunocompromised population, the COVID-19 pandemic, and advances in detection methods. The pathogenesis is closely associated with the host immune status, serum-free iron levels, and the virulence of Mucorales. However, the absence of typical clinical manifestations complicates diagnosis, leading to missed or delayed diagnoses and higher mortality.

CONCLUSION

An enhanced understanding of the epidemiology, pathogenesis, and clinical presentation of mucormycosis, along with the adoption of improved diagnostic and therapeutic approaches, is essential for reducing mortality rates associated with this opportunistic fungal infection. Early diagnosis and prompt treatment are critical to improving patient outcomes.

Unusual orbital mucormycosis due to pecking injury: clinical characteristics and outcomes of four immunocompetent pediatric patients

Mucormycosis is a serious fungal infection caused by fungi in the order of Mucorales. Orbital mucormycosis occurs more frequently in rhino-orbital, sino-orbital, and rhino-orbito-cerebral forms of the disease, while isolated orbital mucormycosis is much less common. Herein, we present four cases of immunocompetent children who developed primary cutaneous mucormycosis, which subsequently invaded and progressed to orbital mucormycosis following direct traumatic injury caused by pecking from Acridotheres tristis (Common Myna). Given the low prevalence of orbital mucormycosis in healthy children, an unknown source of infection and delayed diagnosis followed by late therapeutic interventions could result in life-threatening conditions and serious sequelae.

Manifestations of Mucormycosis and Its Complications in COVID-19 Patients: A Case Series Study

OBJECTIVE

Mucormycosis is an opportunistic fungal disease that affects immunocompromised patients. With the advent of SARS-CoV-2, this opportunistic disease has increased.

METHODS

A case series of 47 patients with COVID-19 associated mucormycosis have been analyzed. Demographic information, signs, symptoms, laboratory investigations, imaging studies, and their association with ICU admission and 30-day mortality were assessed.

RESULTS

Total number of 47 consecutive rhino-orbital cerebral mucormycosis (ROCM) cases were analyzed. Periorbital swelling was the most common sign among patients. Majority of cases had diabetes. All patients received liposomal Amphotericin B. Debridement was performed for all cases.

CONCLUSIONS

SARS-CoV-2 increases the susceptibility to mucormycosis infection in various ways. Uncontrolled level of HbA1c in all patients, even non-diabetic individuals, indicates hyperglycemia over the past three months. Diabetes, orbital exenteration, ptosis, periorbital swelling, DKA, LOC, brain involvement, and mechanical ventilation all correlated with a higher rate of ICU admission and 30-day mortality. In addition, a higher white blood cell count is related to the higher probability of ICU admission. While considering all of the inflammatory laboratory data and HbA1c could help predict 30-day mortality.

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.

Post-COVID mucormycosis osteomyelitis and its imaging manifestations in the North of Iran: case series

Mucormycosis is an invasive fungal infection that usually affects patients with immunocompromised conditions. In the context of the COVID-19 pandemic and the following corticosteroid therapy, mucormycosis prevalence has increased. The situation may be more complicated with some underlying diseases such as diabetes mellitus. In addition, due to the vicinity of maxillary bone to the nasal cavity and paranasal sinuses, which are the main routes for the infection to spread, dentists, maxillofacial radiologists, and surgeons may be the first to encounter these patients. Post-COVID mucormycosis osteomyelitis is one of the complications of this infection Bone destruction and the erosion or breach of cortical boundaries of the maxilla and the bone structures in the vicinity of paranasal sinuses are the most critical radiographic findings of post-covid osteomyelitis. Herein, there are some cases of post-covid mucormycosis osteomyelitis involving the maxillary and other facial bones.

Predictors of disease severity in COVID-19 associated mucormycosis: impact of HbA1C levels, time lag to mucormycosis onset, and radiologic patterns of paranasal sinuses and spaces involvement

BACKGROUND

Identifying early predictors of severe Covid-19 associated mucormycosis (CAM) can help improve management and treatment outcomes.

OBJECTIVES

Primary: To identify clinical and radiological predictors of disease severity in CAM. Secondary: To describe patterns of central nervous system (CNS) involvement in CAM.

METHODS

A total of 71 patients with CAM were included in the study. Based on the anatomical extent of involvement on MRI, patients were divided into three groups: Sinus (paranasal sinuses), Orbit (orbital spread), and CNS (CNS spread). Clinical parameters and radiological patterns of involvement of sinuses and extra sinus spaces were studied between the three groups. Patterns of CNS involvement were also described.

RESULTS

A shorter time lag between COVID-19 infection and CAM, as well as high HbA1C levels, were found to be associated with severe disease. Involvement of the sphenoid, ethmoid and frontal sinuses, T1 hyperintense signal in the sphenoid, as well as bony involvement of the sphenoid sinus, were significantly associated with severe disease. Extra-sinus spread into pre/retroantral space, pterygopalatine fossa, and masticator spaces were also significantly associated with a severe disease course. The most common pattern of CNS spread was cavernous sinus involvement, followed by pachymeningeal spread and cranial nerve involvement.

CONCLUSION

Early identification of the above-described predictors in patients presenting with CAM can help detect those at risk for developing severe disease. A longer duration of amphotericin, combined with a more aggressive surgical approach in selected cases, may lead to better long-term outcomes.

Radiological features of COVID-19-associated mucormycosis: A report of 36 cases along with a literature review

The pandemic of COVID-19 along with high use of corticosteroids resulted in the emergence of invasive fungal infection. Here, we reported the radiologic feature of mucormycosis in COVID-19-infected cases and reviewed with available literature.

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.

Optimization of Oral Posaconazole Step Down Therapy in Management of Rhino-Orbital-Cerebral Mucormycosis (ROCM): Outcome of an Institutional Protocol

All cases of ROCM received antifungal for a prolong period in step down phase. There is no definite guidelines regarding duration. We have formulated and followed an institutional protocol with good results. To determine the outcome of an institutional protocol and required optimum duration of oral posaconazole therapy to cure ROCM in step down phase, 30 ROCM patients were followed up in step down phase. Oral posaconazole tablet was given for minimum 3, 4 & 1/2 and 6 months to stage-II, III & IV cases respectively, with a provision of extension for another 6 weeks in suspected active diseases. Nasal endoscopy, MRI, histopathology /culture of suspected tissue and hematologic investigations were done routinely to identify the residual active disease or recurrences at earliest. Outcome of this protocol proved excellent as all cases of ROCM were cured. Oral posaconazole step down therapy for a duration according to the stages of disease cured 18 cases (60%) of ROCM. Fourteen patients required extended duration of therapy as per provision of our treatment protocol. Only one patient needed re-debridement. The cases with deformities needed extended period of posaconazole therapy. No one needed posaconazole therapy for more than 7and1/2 months.

The Radiological Spectrum of Rhino-Oculo-Cerebral Mucormycosis

Aim We aim to study the spectrum of imaging findings in patients with rhino-oculo-cerebral mucormycosis (ROCM). Materials and methods This retrospective descriptive study was performed in histopathologically confirmed cases of rhino-oculo-cerebral mucormycosis in a tertiary care center in Bihar, India. The case records of patients with radiological, cultural, and histological evidence of acute invasive ROCM were retrospectively evaluated for relevant radiological and clinical data between May 2021 and June 2022. Results The radiological evaluation included computed tomography (CT) and magnetic resonance imaging (MRI) scans done on 52 patients. The patient's average age was 48 years. The ethmoid sinus was involved in 51 (98%) cases and the maxillary sinus in 50 (96%) cases. Bilateral sinus involvement (45, 86%) was the most common, followed by pansinus involvement (27, 52%). The orbit was involved in 39 (75%) cases, the face in 25 (47%) cases, and retroantral fat stranding in 24 (46%) cases. Mucosal thickening (91%) was the most common pattern of involvement, followed by complete opacification (77%). Osseous involvement was seen in 17 of 44 patients who had CT scans, and the majority of patients had extrasinus extension with intact bone. MRI revealed variable T2SI, with T2 hyperintensity being the most common pattern. Heterogeneous enhancement in post-contrast imaging was the most common. Conclusion ROCM is a life-threatening invasive fungal infection, especially in an immunocompromised state. ROCM is characterized by a variety of imaging abnormalities on CT and MRI, although nonspecific. Imaging aids in suspicion or early diagnosis in appropriate clinical contexts, particularly in an immunocompromised state, and in determining the degree of involvement and complications. Early detection of ROCM and its complications enables proper treatment, which can lower the cost of care, morbidity, and mortality.

Part 1: Mucormycosis: Prevalence, Risk Factors, Clinical Features and Diagnosis

INTRODUCTION

Mucormycosis (MCR) is caused by filamentous molds within the Class Zygomycetes and Order Mucorales. Infections can result from inhalation of spores into the nares, oropharynx or lungs, ingestion of contaminated food or water, or inoculation into disrupted skin or wounds. In developed countries, MCR occurs primarily in severely immunocompromised hosts. In contrast, in developing/low income countries, most cases of MCR occur in persons with poorly controlled diabetes mellitus and some cases in immunocompetent subjects following trauma. Mucormycosis exhibits a propensity to invade blood vessels, leading to thrombosis and infarction of tissue. Mortality rates associated with invasive MCR are high and can exceed 90% with disseminated disease. Mucormycosis can be classified as one of six forms: (1) rhino-orbital-cerebral mucormycosis (ROCM); (2) pulmonary; (3) cutaneous; (4) gastrointestinal or renal (5); disseminated; (6) uncommon (focal) sites.

AREAS COVERED

The authors discuss the prevalence, risk factors and clinical features of mucormycosis.A literature search of mucormycosis was performed via PubMed (up to November 2022), using the key words: invasive fungal infections; mold; mucormycosis; Mucorales; Zyzomyces; Zygomycosis; Rhizopus, diagnosis.

EXPERT OPINION

Mucormycosis occurs primarily in severely immunocompromised hosts. Mucormycosis can progress rapidly, and delay in initiating treatment by even a few days worsens outcomes.

Microbiology Profile of COVID-19-Associated Rhino-Orbital Mucormycosis Pathogens in South India

This study describes the microbiological and histopathological features of patients with COVID-19-associated rhino-orbital mucormycosis (ROM) seen at the L V Prasad Eye Institute between May and August 2021. Diagnosed clinically and radiologically, 24 patients with ROM were included in the study. Deep nasal swabs or endoscopically collected nasal swabs or orbital tissues were submitted for microbiological evaluation and in vitro susceptibility testing by microbroth dilution for natamycin, amphotericin B, caspofungin, posaconazole, ketoconazole, and voriconazole. Cultures were processed by 28S ribosomal DNA polymerase chain reaction and molecular sequencing. A portion of orbital tissues was also sent for histopathological evaluation. The age of the patients ranged from 27 to 75 (mean 48.58 ± 14.09) years and the majority (79%) were male. Nineteen patients were known to be diabetic prior to developing ROM and 18 patients had recovered from active COVID-19 infection. Thirteen patients had a history of hospitalization during COVID-19 infection and eight received steroids. Of the 24 samples, microbiological evaluation identified Rhizopus arrhizus in 12, Rhizopus microsporus in 9, Lichtheimia ramosa in 2, and Rhizopus delemar in 1. Twelve isolates were tested for antifungal susceptibility and all were susceptible to natamycin and amphotericin B. The susceptibility to posaconazole was high, with minimum inhibitory concentration (MIC) < 2 µg/mL for 10/12 (84%) isolates, whereas the MIC of other drugs varied. Histopathological examination of tissues showed acute fulminant disease, granuloma formation, and vascular invasion by the fungal pathogens in these specimens. Rhizopus arrhizus was predominantly associated with ROM and most isolates were susceptible to amphotericin B and posaconazole. Further studies are needed to corroborate the findings and explain possible underlying links.

COVID-Associated Sinonasal Mucormycosis: Radiological Pathological Correlation and Prognostic Value of MR Imaging

Purpose  Our aim was to assess the sinonasal magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) in coronavirus disease (COVID)-associated mucormycosis (CAM) and to correlate these with histopathology and patient outcome in terms of duration of hospital stay and survival at 10 weeks. Methods  Twenty patients with histopathologically confirmed sinonasal CAM underwent MRI (including postcontrast T1-weighted and diffusion-weighted imaging). Histopathological findings (presence of coagulative necrosis, granulomatous reaction, and fungal burden) were recorded and all patients were followed up at 6 and 10 weeks. Statistical analysis was done using chi-square test and Fischer's exact test. Results  Enhancement patterns seen in our subjects included homogeneous, heterogeneous, and lack of contrast enhancement (LOC), with LOC being the most common (65%). Diffusion restriction was found in 90% patients. Statistically significant correlation was found between LOC pattern and presence of coagulative necrosis ( p -value = 0.007), extent of fungal hyphae ( p -value = 0.047), and duration of hospital stay ( p -value = 0.004). Restricted diffusion was also seen to correlate with a high fungal load ( p -value = 0.007). Conclusion  Our study describes the MRI findings of AIFRS in CAM and highlights the imaging features which may be surrogate markers for coagulative necrosis and fungal burden.

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.

Rhino-orbital mucormycosis

PURPOSE OF REVIEW

The current article will update and review the clinical and radiological manifestations and management of rhino-orbital mucormycosis (ROM).

RECENT FINDINGS

There has been an increase in cases of ROM worldwide, especially in India. Immunosuppression (especially diabetes mellitus) is a known predisposing risk factor for ROM. Delayed diagnosis and treatment of ROM can be vision or life-threatening. This article reviews the clinical and radiologic features, treatment, and prognosis of ROM with special emphasis on new and emerging therapies.

SUMMARY

ROM is an angioinvasive fungal infection that affects the sinuses and orbits and may present to ophthalmologists. Clinicians should have a high index of suspicion for ROM, especially in patients with poorly controlled diabetes mellitus or other immunosuppression. Corticosteroid treatment (including the recent COVID-19 pandemic) may be a predisposing risk factor for ROM.

Multimodal Imaging in Rhinoorbitocerebral Mucormycosis Associated with Type 2 Diabetes After COVID-19

PURPOSE

This case series analyzed the appropriateness of computed tomography (CT) and magnetic resonance imaging (MRI) for visualization of rhinoorbitocerebral mucormycosis (ROCM) patterns associated with type 2 diabetes (T2D) post-recovery from coronavirus disease 2019 (COVID-19).

METHODS

The study included 24 patients with invasive ROCM after having recovered from COVID-19. All patients underwent CT examinations and microbiological and histological verification; 5 patients underwent MRI.

RESULTS

The CT and MRI patterns noted in our patients revealed involvement of skull orbits, paranasal sinuses, large arteries, and optic nerves, with intracranial spread and involvement of the cranial base bones. Using brain scan protocol for CT provided better soft-tissue resolution. We found that extending the MRI protocol by T2-sequence with fat suppression or STIR was better for periantral fat and muscle evaluations.

CONCLUSION

Computed tomography of the paranasal sinuses is the method of choice for suspected fungal infections, particularly mucormycosis. However, MRI is recommended if there is suspicion of orbital, vascular, or intracranial complications, including cavernous sinus extension. The combination of both CT and MRI enables determination of soft tissue invasion and bony destruction, thereby facilitating the choice of an optimal ROCM treatment strategy. Invasive fungal infections are extremely rare in Europe; most of the related data are provided from India and Middle Eastern or African nations. Hence, this study is notable in its use of only diagnosed ROCM cases in Russia.

Management of Mucormycosis in Post COVID-19 Patients and Its Outcome in a Tertiary Care Center: Our Experience

To assess the common presentation and extent of disease involvement clinically and radiologically and treatment modalities, sequalae of the disease, complications and treatment response. Mucormycosis is a life-threatening infection that most commonly affects immunocompromised individuals and an exponential increase in the incidence of Rhino-orbital-cerebral mucormycosis was witnessed in the second wave of the COVID-19 pandemic, despite aggressive multimodal treatment carries a significant risk of mortality. A high index of suspicion is required in order to begin the appropriate diagnostic workup and treatment. This study is conducted to access the outcome and management of mucormycosis in post covid 19 patients. The prospective study includes 180 Patients, who are attending to E.N.T. outpatient department, Triage and patients referred from other departments who had suspected/confirmed Rhino-orbital-cerebral mucormycosis/underwent surgery and/or medical treatment or both. In our study mucormycosis predominantly affected age group between 40 and 60 years, more common in males (77.8%) than females (22.2%), 77.8% patients had post covid status. Most common risk factor was diabetes mellitus.76% patients had undergone endoscopic/open surgery and 24% patients underwent only medical treatment. Among 138 patients operated, 40% had recurrence and mortality was 16.1% (significantly reduced). Early diagnosis and prompt intervention is paramount to reduce morbidity and mortality. Liposomal Amphotericin B is most effective antifungal with manageable side effects. Patients who underwent Radical debridement either endoscopically or open approach, had better outcome with minimal recurrence rates. Combined medical and surgical treatment has better outcome, lesser recurrence and mortality.

Post-COVID-19 acute invasive fungal rhinosinusitis: a systematic radiological approach in the light of clinico-surgical characteristics

Background

The objective is to describe the radiological imaging findings of post-COVID-19 acute invasive fungal rhinosinusitis (AIFRS), being familiar with the wide variety of imaging spectrum, thus raising the suspicion for early diagnosis. Methods: In this retrospective study, we reviewed the imaging findings in 54 patients with proven post-COVID-19 AIFRS who underwent endoscopic/surgical debridement from April 2020 to September 2021. Most of these patients presented with facial or orbital swelling or facial pain. Medical records with a special emphasis on radiological imaging (50 NCCT of the paranasal sinuses and 17 MRIs of the orbit) were reviewed regarding the degree of mucosal disease of sinuses, nasal cavity, and nasopharynx, extra sinus soft tissue infiltration, especially orbital and cerebral extension (parenchymal, cavernous sinus, vascular or neuro-invasion).

Results

We reported findings in 54 patients with post-COVID-19 AIFRS, of whom 30 were men and 24 were women with a mean age of 48.06. Unexpectedly, infiltration of pterygopalatine fossa was found to precede mucosal opacification of sinuses nasal cavity and affection of nasopharynx. Out of 54 patients, 49 showed inflammatory changes involving pterygopalatine fossa, 29.6% of patients showed infiltration of orbital tissues, 22 patients suffered from a fungal invasion of the cavernous sinus and 3 patients had carotid artery involvement.

Conclusions

Imaging findings of AIFRS significantly vary from subtle mucosal thickening of paranasal sinuses, up to orbital and intracranial extension with vascular thrombosis and neuroinvasion. The hallmark inflammatory tissue infiltration into the pterygopalatine fossa and facial soft tissue may precede mucosal disease.

Mucormycosis in COVID-19 patients: predisposing factors, prevention and management

India is considered the diabetes capital of the world and has the highest burden of mucormycosis. Bacterial, viral and fungal co-infections are increasingly being reported in severe acute respiratory syndrome virus 2 (SARSCoV-2) infected patients. India is one of the worst affected countries during the second wave of the COVID-19 pandemic. This combination of diabetes mellitus, COVID-19 and mucormycosis has led to the drastic upsurge of COVID-19-associated mucormycosis (CAM) in India. Immunosuppression, iron disequilibrium, endothelial injury, ketoacidosis and hypoxia are some of the other COVID-19-related risk factors for CAM. There has been an increase in the proportion of mucormycosis affecting paranasal sinuses and central nervous system (CNS) in CAM compared to pre-COVID-19 literature due to the SARSCoV-2-related pathophysiological mechanisms, complications and treatment strategies. CAM is a medical and surgical emergency, and it can present with non-specific symptoms and signs initially resulting in diagnostic delay. High index of suspicion and regular screening for features of CAM are of paramount importance to prevent lethal consequences. Rapid action with a tripod approach consisting of withdrawal of immunomodulators, early antifungal therapy and extensive surgical debridement is considered the best possible treatment model. We review the published data to give a detailed account of the predisposing factors and their mechanisms, diagnostic work-up, treatment modalities and prevention strategies of CAM with special emphasis on CNS mucormycosis.

CT imaging features in acute invasive fungal rhinosinusitis- recalling the oblivion in the COVID era

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Conclusion

Isolated Cerebral Mucormycosis Caused by Lichtheimia Species in a Polytrauma Patient

Isolated post-traumatic cerebral mucormycosis represents an extremely rare and severe disease. A case of isolated cerebral mucormycosis infection caused by Lichtheimia spp. in a 21-year-old multi-trauma patient is presented. The patient was hospitalized in the intensive care unit and underwent craniotomy due to brain injuries. Two weeks following the initial procedure, pus drained from the surgical wound was microscopically examined and cultured, yielding Lichtheimia spp. Imaging showed parietal, temporal and frontal abscesses at the right side. The patient was commenced on amphotericin B and underwent surgical debridement, while histopathological examination of the affected tissue demonstrated broad, aseptate hyphae, findings typical for mucormycetes. The patient passed away due to heavy traumatic injuries after 2 months. It is speculated that direct inoculation was the portal of entry for infection, and that high steroid use for 2 weeks following inoculation contributed to the severity of infection that developed. Isolated cerebral mucormycosis in immunocompetent hosts is an extremely rare, but severe disease. Diagnosis is established through direct microscopy, histopathology and/or cultures. PCR-based techniques are useful either to detect mucormycetes in tissues, especially when cultures are negative, or to accurately identify the fungi grown in cultures at the species level. A high suspicion index, especially in the necrotic lesions of traumas, is of the utmost importance for early diagnosis. Appropriate surgical debridement, as well as antifungal therapy, including amphotericin B, represents the treatment of choice.

Image challenge: A diabetic man with facial swelling following recent Covid-19 infection

A 68-year-old man with diabetes presented with shortness of breath, left sided facial swelling, and nasal discharge. He had recently returned from India and PCR was positive for SARS-CoV-2 Delta variant. CT head and diffusion-weighted MRI sinuses were performed and the patient underwent endoscopic sinus surgery before being transferred to a specialist skull base centre.

A Retrospective Analysis of Risk Factors of COVID-19 Associated Mucormycosis and Mortality Predictors: A Single-Center Study

Background Mucormycosis has been identified with increasing frequency in patients with coronavirus disease 2019 (COVID-19). Aims We aimed to determine the in-hospital outcome of patients with COVID-19 associated mucormycosis (CAM). Materials and methods This was a single-center, retrospective, observational study. We included patients diagnosed with CAM from a tertiary care hospital in Pune, India. Clinical, laboratory, and in-hospital outcomes were noted. We analyzed factors associated with in-hospital mortality. Results Between February 2021 and June 2021, we identified 84 patients of CAM. The mean age was 49.3 ± 12.1 years. Of the included patients, 64.3% had diabetes mellitus, and 83.3% had received steroids. Mucormycosis was diagnosed after a median of 11 days from the COVID-19 diagnosis. Orbital and central nervous system (CNS) involvement was seen in 29.8% and 23.8% of patients, respectively. During a mean hospital stay of 12.5 ± 8.5 days, 15.5% of patients died. Compared to survivors, the presence of chronic kidney disease (CKD) (p<0.0001), orbital involvement (p=0.039), use of tocilizumab (p<0.0001), and development of renal dysfunction during hospitalization (p<0.0001) were seen in a significantly higher proportion of nonsurvivors. The proportion of patients with diabetes, those receiving steroids, and mean glycosylated hemoglobin (HbA1c) levels did not differ significantly in survivors and nonsurvivors. Conclusion In-hospital mortality in CAM is relatively lower in our institution. CKD, orbital involvement, use of tocilizumab, and renal dysfunction during hospital stay were found to be strong predictors of mortality.

COVID-19-associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic's second wave in India

Coronavirus Disease 2019 (COVID-19), during the second wave in early 2021, has caused devastating chaos in India. As daily infection rates rise alarmingly, the number of severe cases has increased dramatically. The country has encountered health infrastructure inadequacy and excessive demand for hospital beds, drugs, vaccines, and oxygen. Adding more burden to such a challenging situation, mucormycosis, an invasive fungal infection, has seen a sudden surge in patients with COVID-19. The rhino-orbital-cerebral form is the most common type observed. In particular, approximately three-fourths of them had diabetes as predisposing comorbidity and received corticosteroids to treat COVID-19. Possible mechanisms may involve immune and inflammatory processes. Diabetes, when coupled with COVID-19-induced systemic immune change, tends to cause decreased immunity and an increased risk of secondary infections. Since comprehensive data on this fatal opportunistic infection are evolving against the backdrop of a major pandemic, prevention strategies primarily involve managing comorbid conditions in high-risk groups. The recommended treatment strategies primarily included surgical debridement and antifungal therapy using Amphotericin B and selected azoles. Several India-centric clinical guidelines have emerged to rightly diagnose the infection, characterise the clinical presentation, understand the pathogenesis involved, and track the disease course. Code Mucor is the most comprehensive one, which proposes a simple but reliable staging system for the rhino-orbital-cerebral form. A staging system has recently been proposed, and a dedicated registry has been started. In this critical review, we extensively analyse recent evidence and guidance on COVID-19-associated mucormycosis in India.

Transcutaneous retrobulbar injection of amphotericin B in rhino-orbital-cerebral mucormycosis: a review

Mucormycosis is an aggressive and potentially fatal invasive fungal infection. The most common form of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). While it is commonly seen in immunocompromised patients, it is also known to affect healthy individuals. The global disease burden of ROCM has increased significantly following the surge in cases during the COVID-19 pandemic. Endoscopic sinus debridement, systemic antifungal therapy, and control of the underlying immunosuppressive condition are essential for the management of ROCM. Orbital involvement, however, presents a challenge to clinicians. Intervention strategies that have been described to treat orbital disease include orbital exenteration, conservative orbital debridement with or without irrigation with amphotericin B and transcutaneous retrobulbar injection of amphotericin B (TRAMB). Currently, there is a lack of clarity regarding the indications and outcomes of TRAMB as a treatment modality. In this review, the drug formulations used, the complications, and outcomes of previously described cases that have used TRAMB in cases of ROCM are discussed. Favorable outcomes following TRAMB depend on appropriate patient selection and radiological evidence of the orbital burden of the disease. This review aims to familiarize clinicians with objective parameters for patient selection for TRAMB, namely the extent of the disease, the clinical features, and radiological findings; viz. the clinical interpretation of areas of contrast uptake and those of necrosis. TRAMB can be considered as a viable option in select cases of orbital mucormycosis where exenteration or debridement are not indicated, or when there is limited orbital disease.

Coronavirus disease 2019 associated mucormycosis meandering its way into the orbit: a pictorial review

Background

There has been a recent deluge of coronavirus disease 2019 associated mucormycosis in our country. It affects the paranasal sinuses; however, it has a rapid extrasinus progression (the orbit being most common), which can be fatal if not detected early. It may meander into the orbit through various foramina without frank bone destruction.

Methods

This paper reviews the various gateways of the spread of coronavirus disease 2019 associated mucormycosis to the orbit, even before advent of bone destruction or ocular symptoms. Plausible pathways of invasion and subtle imaging findings are depicted, to enable an early diagnosis.

Results

Relevant anatomy and imaging examples have been illustrated to familiarise the surgeons with various routes of coronavirus disease 2019 associated mucormycosis spread to the orbit. Emphasis is laid on searching for subtle imaging findings for the detection of early orbital invasion.

Conclusion

Early detection and extension of coronavirus disease 2019 associated mucormycosis is facilitated by knowledge of its gateways of spread, which aids the surgeon in prognostication and planning of the surgical approach.