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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 32

Endemic in pandemic: Mucormycosis


Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India

Date of Submission18-Jul-2021
Date of Decision27-Jul-2021
Date of Acceptance03-Aug-2021
Date of Web Publication27-Sep-2021

Correspondence Address:
Dr. Rajesh Subhash Joshi
77, Panchatara Housing Society, Manish Nagar, Somalwada, Nagpur - 440 015, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_102_21

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  Abstract 


Orbital mucormycosis is a dreaded condition and may lead to fatal intracranial infection if it spreads to the intracranial sinuses. The infection is caused by fungi of the order Mucorales. Rhizopus has been reported to be the causative pathogen. The main route of infection is through inhalation of the fungal spores, which may cause lung infection. However, patients with diabetes, immunosuppression, and steroid use are more prone to the infection. We present a case of orbital mucormycosis in a patient who had recovered from coronavirus disease 2019. Early diagnosis and management helped salvage the vision of the patient.

Keywords: Coronavirus disease 2019, diabetes mellitus, mucormycosis, Rhizopus


How to cite this article:
Joshi RS, Tamboli S, Surwade T, Bansode N, Rasal A, Goel P. Endemic in pandemic: Mucormycosis. Pan Am J Ophthalmol 2021;3:32

How to cite this URL:
Joshi RS, Tamboli S, Surwade T, Bansode N, Rasal A, Goel P. Endemic in pandemic: Mucormycosis. Pan Am J Ophthalmol [serial online] 2021 [cited 2021 Nov 27];3:32. Available from: https://www.thepajo.org/text.asp?2021/3/1/32/326831




  Introduction Top


Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with a wide range of secondary infections, affecting nearly all organs of the body. Various ophthalmic manifestations have been reported worldwide.[1] Due to immunosuppression, patients with coronavirus disease 2019 (COVID-19) are prone to various bacterial and fungal infections. Preexisting comorbidities such as diabetes increase the risk of the development of secondary infections. Nosocomial infections might also be responsible for the varied manifestations.

Currently, there has been a surge in the development of ocular infections by Mucorales species.[2],[3],[4] We report a case of orbital mucormycosis with involvement of the paranasal sinuses and ocular tissue in the early postrecovery stage of COVID-19.


  Case Report Top


A 51-year-old man presented with complaints of lid edema, redness, watering, pain, and swelling of the right eye for 2 days. Upon examination, the visual acuity of 6/9 was observed in the right eye. Upper and lower lid edema, mild conjunctival congestion, and chemosis of the bulbar conjunctiva were present. Periorbital edema with mild proptosis of the right eye was also observed. Ocular movements were restricted in all directions [Figure 1]. Local tenderness was present on palpation of the right eye. The left eye had a visual acuity of 6/9. Slit-lamp examination of both eyes revealed normal pupillary size and reaction to light with immature senile cataract. Dilated 90-D retinal examination and indirect ophthalmoscopy findings were normal. The patient was diagnosed with COVID-19 4 weeks before presentation to the ophthalmology department. The reverse transcription–polymerase chain reaction (RT-PCR) test of the patient from a nasopharyngeal swab was positive, and computed tomography (CT) scan of the chest showed 12–14 patchy ground-glass opacities in both the lungs, which were suggestive of COVID-19 infection. However, systemic parameters and oxygen saturation of the patient were well maintained. Therefore, the patient was advised home isolation, and a standard COVID-19 treatment protocol was recommended. The patient was on oral antibiotics, antivirals, antipyretics, and supplementary multivitamins along with steroids (tablet prednisolone 30 mg twice daily).
Figure 1: Preoperative examination showing proptosis of the right eye with restriction of ocular movements

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The patient was hypertensive but nondiabetic. However, the blood sugar level was elevated (452 mg%) at the time of his admission for ocular complaints. Blood sugar monitoring and insulin administration were performed to control diabetes. CT scan of the orbit and paranasal sinuses showed mucosal thickening of the right maxillary, ethmoid, frontal, and sphenoid sinuses without any bone erosion. Fluid accumulation was observed in the extraconal compartment of the right orbit, which was suggestive of right orbital abscess and orbital cellulitis.

Considering the presence of pansinusitis and accumulation of fluid in the retrobulbar space, functional endoscopic sinus surgery was performed immediately. Diseased mucosa was removed, and the specimen was further processed for bacterial and fungal staining as well as for culture and sensitivity tests. Potassium hydroxide mount revealed aseptate filamentous fungal hyphae, suggestive of Rhizopus arrhizus, and the lactophenol cotton blue mount was prepared to confirm the finding [Figure 2]. Results confirmed the diagnosis of mucormycosis. The patient responded to intravenous injection ofliposomal amphotericin B (5 mg/kg/day) for 3 weeks. No further deterioration was observed until the last follow-up. Lid swelling, chemosis, and proptosis were disappeared and ocular movements were normal [Figure 3].
Figure 2: Lactophenol cotton blue staining showing nonfilamentous fungal hyphae, suggestive of Rhizopus arrhizus

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Figure 3: Postoperative examination showing reduction in the inflammatory signs and the improvement in the ocular movements

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  Discussion Top


SARS-CoV-2 has been associated with a wide range of infections not only during the course of COVID-19 but also after recovery. An array of manifestations and complications has been reported and new ones are emerging. Various factors have been implicated in secondary infections after recovery from COVID-19. These factors include diabetes mellitus, neutropenia, elevated free iron level, obstructive airway diseases, steroid therapy, patients on ventilator, and patients admitted to the high-dependency unit for COVID-19. Various opportunistic infections have been reported in the postrecovery phase of COVID-19.[5] However, Rawson et al. reviewed bacterial and fungal coinfections in patients with COVID-19 and suggested that despite the use of broad-spectrum empirical antimicrobials, data are not available to support the association of COVID-19 with bacterial/fungal infections.[6] Therefore, factors other than the use of antimicrobials must be responsible for the development of opportunistic infections. There have been isolated reports of infection from Rhizopus spp. of order Mucorales.[2],[3],[4],[7],[8] We report a case wherein the patient presented with the signs and symptoms of ocular disorder after recovery from COVID-19. The patient had received antibiotics, antivirals, and steroids. Steroids were given to halt the progression of the lung infection undercover of antivirals. In addition, the patient was nondiabetic; however, the blood sugar level of the patient was high at the time of his presentation with ocular symptoms. In a study on rhino-orbital mucormycosis by Sen et al., all patients were diabetic and all of them except one had received oral or intravenous steroids.[4] Diabetic ketoacidosis has been shown to be the main reason for the development of mucormycosis.[2] In a study by Sharma et al., 21 out of 23 patients had diabetes and all patients had received steroids during treatment for COVID-19.[9] Mehta and Pandey documented a case of mucormycosis, wherein the patient had diabetes for the last 10 years.[3] Maini reported a case, wherein the patient was not having diabetes.[8] Therefore, diabetes either preexisting or developing during the recovery period should be monitored carefully to prevent the development of secondary infections.

In the present case, the patient presented with orbital symptoms 4 weeks after testing positive in the RT-PCR test. Sen et al. reported the development of rhino-orbital mucormycosis 30–42 days after the diagnosis of COVID-19.[4] Sharma et al. reported that a few patients with mucormycosis (n = 4) presented at the time when they were positive for SARS-CoV-2, whereas many of them (n = 19) presented after recovery.[9] Mehta and Pandey reported mucormycosis in a patient 10 days after the diagnosis of the disease.[3] These findings suggest that variability exists in the time of presentation, which could be due to the presence of comorbidities. Strict monitoring of the symptoms and awareness of the disease among patients are important to halt the progression of this disease.

In the present case, the patient presented with lid swelling, periorbital edema, and mild proptosis. Rhino-orbital mucormycosis usually originates from the paranasal sinuses, with bone destruction and subsequent invasion of the orbit and eye.[10],[11]

Early diagnosis and treatment are essential because the mortality rate is 40%–80% depending on the underlying condition and the sites of infection.[12],[13] Acute lesions are associated with hemorrhagic infarction, coagulation necrosis, infiltration by neutrophils, and perineural invasion. Orbital invasion may lead to loss of vision, and intracranial involvement could be life threatening.

A high blood sugar level at presentation to the outpatient department and recovery from COVID-19 raised suspicion of mucormycosis in the present case. The patient was referred to the otorhinology facility of the hospital. Immediate functional sinus endoscopy and debridement of the sinuses saved the patient's eye and life. Because the patient had good vision with no orbital involvement, orbital exenteration was deferred.


  Conclusion Top


High suspicion of orbital mucormycosis is absolutely essential in patients presenting with the orbital symptoms after or during recovery from COVID-19. Patients receiving steroids, antiviral agents, monoclonal antibodies, and broad-spectrum antibiotics should be monitored carefully for opportunistic infections. A collaborative approach is important in the management. Increasing the use of steroids and antiviral agents in the management of moderate and severe COVID-19 might lead to an increased incidence of opportunistic infections, adding to the burden on the health-care system. Therefore, awareness of mucormycosis while treating COVID-19 is essential. In the near future, we might face endemic mucormycosis along with the COVID-19 pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sen M, Honavar SG, Sharma N, Sachdev MS. COVID-19 and eye: A review of ophthalmic manifestations of COVID-19. Indian J Ophthalmol 2021;69:488-509.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Werthman-Ehrenreich A. Mucormycosis with orbital compartment syndrome in a patient with COVID-19. The American journal of emergency medicine. 2021 Apr 1;42:264-e5.  Back to cited text no. 2
    
3.
Mehta S, Pandey A. Rhino-orbital mucormycosis associated with COVID-19. Cureus 2020;12:e10726.  Back to cited text no. 3
    
4.
Sen M, Lahane S, Lahane TP, Parekh R, Honavar SG. Mucor in a viral land: A tale of two pathogens. Indian J Ophthalmol 2021;69:244-52.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Salehi M, Ahmadikia K, Badali H, Khodavaisy S. Opportunistic fungal infections in the epidemic area of COVID-19: A clinical and diagnostic perspective from Iran. Mycopathologia 2020;185:607-11.  Back to cited text no. 5
    
6.
Rawson TM, Moore LS, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, et al. Bacterial and fungal coinfection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis 2020;71:2459-68.  Back to cited text no. 6
    
7.
Mekonnen ZK, Ashraf DC, Jankowski T, Grob SR, Vagefi MR, Kersten RC, et al. Acute invasive rhino-orbital mucormycosis in a patient with COVID-19-associated acute respiratory distress syndrome. Ophthalmic Plast Reconstr Surg 2021;37:e40-80.  Back to cited text no. 7
    
8.
Maini A, Tomar G, Khanna D, Kini Y, Mehta H, Bhagyasree V. Sino-orbital mucormycosis in a COVID-19 patient: A case report. Int J Surg Case Rep 2021;82:105957.  Back to cited text no. 8
    
9.
Sharma S, Grover M, Bhargava S, Samdani S, Kataria T. Post coronavirus disease mucormycosis: A deadly addition to the pandemic spectrum. J Laryngol Otol 2021;135:1-6.  Back to cited text no. 9
    
10.
Bhansali A, Bhadada S, Sharma A, Suresh V, Gupta A, Singh P, et al. Presentation and outcome of rhino-orbital-cerebral mucormycosis in patients with diabetes. Postgrad Med J 2004;80:670-4.  Back to cited text no. 10
    
11.
Goh LC, Shakri ED, Ong HY, Mustakim S, Shaariyah MM, Ng WS, et al. A seven-year retrospective analysis of the clinicopathological and mycological manifestations of fungal rhinosinusitis in a single-centre tropical climate hospital. J Laryngol Otol 2017;131:813-6.  Back to cited text no. 11
    
12.
Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clin Infect Dis 2005;41:634-53.  Back to cited text no. 12
    
13.
Guinea J, Escribano P, Vena A, Muñoz P, Martínez-Jiménez MD, Padilla B, et al. Increasing incidence of mucormycosis in a large Spanish hospital from 2007 to 2015: Epidemiology and microbiological characterization of the isolates. PLoS One. 2017 Jun 7;12:e0179136.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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