IP Journal of Otorhinolaryngology and Allied Science

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Gupta, Srivastava, and Singh: Rhino-orbito-Cerebral mucormycosis during COVID 19 pandemic in western Uttar Pradesh India


Introduction

Mucormycosis are a group of invasive infections caused by filamentous fungi of the Mucoraceae family.1 It is the third invasive mycosis in order of importance after candidiasis and aspergillosis.2 The incidence of mucormycosis is approximately 1.7 cases per 1000000 inhabitants per year, and the main risk-factors for the development of mucormycosis are ketoacidosis (diabetic or other), iatrogenic immunosuppression, use of corticosteroids or deferoxamine, disruption of mucocutaneius barriers by catheters and other devices, and exposure to bandages contaminated by these fungi.2

Rhino-orbito-cerebral is the most common clinical subtype of disease. Mucormycosis is a difficult to diagnose rare disease with high morbidity and mortality.3 This form presents with sinusitis, facial and eye pain, proptosis, progressing to signs of orbital structure involvement.4, 5, 6, 7 Necrotic tissue can be seen on nasal turbinates, septum and palate. This may look like a black eschar.7, 8 Intracranial involvement develops as the fungus progresses through either the ophthalmic artery, the superior fissure, or the cribiform plate.4, 5, 6, 7

Diagnosis of mucormycosis rests upon the presence of predisposing conditions, signs and symptoms of disease, observation of fungal elements of specific morphology in histological sections, and direct smears of material, and, to a lesser extent, culture results.6, 7 There are no reliable serological tests for diagnosis at present.8

The incidence of mucormycosis has risen more rapidly during the second wave compared with the first wave of COVID 19 in Western Uttar Pradesh India, with atleast 28,252 mucormycosis cases on 7th June 2021. 86% of them are known to have history of COVID 19 and 62.3% of them are known to be diabetic.9

AIM

To study various risk factors, clinical features, diagnosis, treatment and outcome of mucormycosis patients during second wave of COVID 19 in Western Uttar Pradesh India.

Study design

Multi-centric Retrospective

Sample size

No of cases- 51 Study period- 14th April 2021- 31st May 2021

Inclusion Criteria

All the following criteria was satisfied

Patient presented during 14th April 2021 midnight- 31st May 2021 midnight. COVID 19 RT PCR positive at any time during the study period or within 28 days before beginning of study period. Biopsy proven mucormycosis and/or patient had features clinically consistent with diagnosis of mucormycosis, that is, two or more of following on presentation: Black eschar within oral cavity and/or blackish eschar within nasal cavity and/or blackish eschar over face severe facial pain and facial swelling of onset within last 28 days. Eye swelling and/or ptosis and/or proptosis Computerised tomography or magnetic resonance and imaging suggestive of invasive fungal rhinosinusitis.

Exclusion criteria

Oral and sino-nasal malignancies, other conditions associated with oro-mucosal ulcerations, absence of present or recent COVID 19 status.

Material and Methods

After all inclusion and exclusion criteria were satisfied, records were checked for presence and absence of various predisposing factors, treatment offered, histopathology reports, surgeries performed and outcome.

All the data was gathered and tabulated in Microsoft Excel 2008 spreadsheet. SPSS 24 was used for statistical calculations. Results were systemized and summarized.

Observations

Table 1

Sex distribution of cases

Sex

No of cases

Male

28

Female

23

Total

51

Table 2

Age distribution of cases

Age distribution

No of cases

Less than 31

2

31-45

22

46-60

18

More than 60

9

Total

51

Table 3

COVID status of patients

COVID Status

No of cases

Active COVID

25

Post COVID

26

Total

51

Table 4

Various risk factors for mucormycosis with delta stain of COVID 19 noted in our study

Risk Factor

No of cases

Association

Diabetic

43

Strong

Recent history of Steroids

49

Strong

Either Diabetes or steroids

51

Definitive

Oxygen support

16

Weak

History of Tocilizumab

zero

Cannot comment

Steam inhalation more than one hour a day

1

Absent

Table 5

Clinical features in 51 patients of mucormycosis with COVID 19

Clinical Feature

No of cases

Frequency

Eye swelling

34

66.67

Diminished vision

29

56.86

Ptosis

28

54.90

Black eschar

25

49.02

Facial swelling

23

45.10

Proptosis

18

35.29

Facial pain

16

31.37

Loss of vision

11

21.57

Nasal discharge

8

15.69

Nasal bleed

4

7.84

Altered sensorium

1

1.96

Figure 1

Clinical features of mucormycosis. clockwise: Facial swelling, oral cavity eschar, eye swelling, facial eschar, congestion, diminished vision and ptosis of eyes.

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/00a50091-0a40-4aea-8c12-b938837578d0image1.png

Figure 2

Computerised tomography. a. Rt maxillary sinus non-hemogenous opacification

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/00a50091-0a40-4aea-8c12-b938837578d0image2.png

Table 6

Outcome in 51 patients of mucormycosis with COVID19

Outcome

No of patients

Frequency

Recovered during study period

18

35.29

Survived but did not recover during study period

23

45.10

Facial disfigurement

4

7.84

Permanent loss of vision from one eye

3

5.88

Permanent loss of vision from both eyes

1

1.96

Expired during study period

10

19.61

Table 7

Treatment offered interms of liposomal amphotericin B and debridement surgery to various patients

Treatment given

No of patients

Frequency

Liposomal Amphotericin B for 1-7 days

35

68.63

Liposomal Amphotericin B for 8-14 days

11

21.57

Liposomal Amphotericin B for more than 14 days

1

1.96

Debridement surgery

34

66.67

Figure 3

A. Black Eschar in Nasal Cavity. B. Debrided Remnant of Middle Turbinate. C. Post Debridement Image.

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/00a50091-0a40-4aea-8c12-b938837578d0image3.png

Table 8

Number of patients who took surgery charted with number of patients who survived the study period

Surgery and Survival

No of Patients who took Surgery

No of Patients who did not take Surgery

Total Patients

No of patients survived during study period

32

9

41

No of patients expired during study period

2

8

10

Total patients

34

17

51

Table 9

Effect of surgery on duration of amphotericin B therapy and hence cost of treatment

Duration of Amphotericin B Therapy

1-45 days

With Surgery

1-7 days

Without Surgery

1-45 days

Table 10

Figures of mortality from the time of presentation

Duration from Presentation

No of patients who expired

Within 24 hours

4

24-48 hours

2

48-72 hours

1

More than 120 hours

3

Total

10

Result

The disease is equally seen in both sexes. The disease is exclusively seen in either diabetics or those who have recently taken steroids. Immuno-compromised patients with Delta stain of COVID 19 Pango lineage B.1.617.2 have more risk of developing mucormycosis than their non COVID counterparts. Oxygen inhalation also contributes to the risk. There is no positive or negative effect of steam inhalation.

There is an increase in no of cases of mucormycosis because of delta strain of COVID 19. There is a shift of peak towards the younger age groups. There is increased frequency of eye involvement. Mortality is maximum within first 72 hours of presentation. However, mortality ratio is less when co-infected with delta strain of COVID 19.

Surgery offers significant benefit by decreasing mortality, decreasing duration of Liposomal Amphotericin B treatment and hence reducing cost of treatment.

Conclusion

Delta strain of COVID 19 Western Uttar Pradesh India has significantly increased the incidence of mucormycosis due to its immunosuppressive effect. Excessive use of steroids has also contributed to the same. Since, patients of younger age group are affected more with this strain, the peak of mucormycosis has also shifted in the same direction. In a young patient with unatherosclerosed and more patent vessels, there is early involvement of ethmoid and ophthalmic vessels and hence early necrosis of turbinate’s is seen along with prominent eye symptoms. The massive coverage of black fungus by media has made people extra conscious about the mucormycosis, which has also contributed to early presentation and early diagnosis of the disease. Early diagnosis coupled with early surgery in younger patient may have contributed to lower mortality when recorded over a short time span.

Source of Funding

None.

Conflict of Interest

None.

References

1 

A Mallis S N Mastronikolis S S Naxakis A T Papadas Rhinocerebral mucormycosis: an updateEur Revi Medi Pharmacol Sci2010141198792

2 

E Bouza P Munoz J Guinea Mucormycosis: an emerging disease?Clin Microbiol Infect200612772310.1111/j.1469-0691.2006.01604.x

3 

O A Cornely A A Izquierdo D Arenz S C A Chen E Dannaoui B Hochhegger Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research ConsortiumLancet Infect Dis202119124052110.1016/S1473-3099(19)30312-3

4 

G T Strickland Hunter's Tropical Medicine19844689

5 

E Koneman Allen S Diagnostic Microbiology J b Philadelphia Diagnostic Microbiology. Philadelphia19928124

7 

R Branscomb An overview of mucormycosis. CE Update microbiology and virology200233613

8 

J Rippon W b Philadelphia Medical mycology982199061537

9 

Black Fungus: These 2 states account for nearly 42% of India's 28252 mucormycosis cases2021https://www.livemint.com/news/india/black-fungus/amp-11623069135171.htm



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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Original Article


Article page

94-97


Authors Details

Keshav Gupta, Mohit Srivastava, Veenita Singh


Article History

Received : 16-09-2021

Accepted : 29-09-2021

Available online : 01-11-2021


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