The COVID-19 pandemic spread across our nation in waves, due to emergence of new COVID virus strains . The first wave was witnessed from Mar 2020 to December 2020 while the second wave peaked in April 2021 . The second wave saw a tremendous spike in COVID infectivity and transmissibility . The variant was deadlier than the first wave causing high rates of mortality . This led to the emerging trend of unrestricted usage of steroids either via teleconsultations or over the counter prescriptions . The aftermath was the rise in mucormycosis cases nationwide. The patients with risk factors for the disease included diabetes, immunocompromised status, patients on chemotherapy, etc. . Mucormycosis was a rare entity seen in the pre-COVID era with incidence of 0.14 per 1000 . However, post-COVID, there was a huge surge in these cases especially from May to July, that is, just after COVID second peak . The surge was clinically associated with the injudicious usage of steroids like dexamethasone, prednisolone, and methylprednisolone . The second peak was heralded in April 2021 with a far greater magnitude of cases than seen in the first wave. The medical fraternity was overwhelmed by the number of cases which thereby led to unrestricted, unmonitored usage of Steroidal medications in the form of oral and parenteral medication . The steroidal medications were responsible for high glycemic index and uncontrolled diabetes. Further patients receiving immunosuppressive therapies reported in large numbers to COVID centers which further contracted mucormycosis .
Participants of our study included 60.9% males and 39.1% females. Aranjani et al. as well as Satish et al also had similar findings in their critical review analysis and case series respectively [6, 7].
Out of the total patients, 73.9% patients had diabetes as a risk factor. Similar results were found in several case reports, case series as well as review analysis done all across India [8,9,10,11].
Earlier in the pre-COVID era, mucormycosis was established as a rare clinical entity seen only in patients with uncontrolled diabetes and immunocompromised patients. The major change seen in post-COVID mucormycosis was the rise in COVID positivity. In our study, we found that the majority of patients, either inpatients or outpatients, developed mucor after testing COVID-positive in the preceding days of presenting to us. Earlier, in our experience, the cases used to report to otorhinolaryngeal centers with complaints of vision loss, chemosis, or features of cavernous sinus involvement. However, the cases we dealt with during COVID, included patients ranging from a simple complaint of dental pain, nasal obstruction, epistaxis, headache etc. to vision loss, delirium, and comatose state. The patients were received both, in ambulatory condition as well as in ICU with poor Glasgow coma scale (GCS) and deteriorating health. This led to serious concern regarding all patients who were currently on treatment at the hospital and the fear of developing mucor in many patients. This also led to a unanimous decision of keeping a high index of suspicion for the presenting complaints about this disease. All patients with any of the otorhinolaryngeal or ophthalmological symptoms like nasal blockage, epistaxis, swelling over the eye, loss of vision, blackish discolouration over the nose/eye and unilateral nasal discharge were evaluated further in detail. Patients with additional features of headache, fever, disorientation, dental pain, etc. were also evaluated in relation to mucor.
82.6% patients had received steroid therapy during treatment for COVID. Sarkar et al., Sen et al., Mehta et al., and Garg et al. also reported similar cases [2, 12,13,14].
All patients were subjected to a standard protocol of examination including complete otorhinolaryngeal, medical, and ophthalmological evaluation. The otorhinolaryngeal evaluation of such patients included a biopsy from the nasal cavity bedside which would then be sent for KOH sampling. The oral cavity, oropharynx, nasal cavity, and nasopharynx examination were done bedside by a portable fiberoptic laryngoscope. The patients with high suspicion of mucormycosis were started empirically on intravenous Amphotericin. Further, the patients underwent imaging in the form of CECT PNS plus Orbits. Contrast enhanced MRI was done in a few cases with suspicion of extensive orbital involvement and intracranial extension. After a complete evaluation and aggressive workup, patients were slated for surgical debridement within 2 days of admission.
All patients were treated as suspected rhinorbitocerebral mucormycosis cases up till the definitive report from fungal culture came out as invasive Aspergillosis or mixed Infections. The medical management in invasive aspergillosis was then changed to Voriconazole.
The surgical management included endoscopic medial maxillectomies, modified Denker's approach and open maxillectomy with orbital clearance, if necessary. Modified Denker’s approach was used in the majority of cases using unipolar cautery. Drilling was done in the medial and lateral walls of the maxilla by using otodrill. The posterior wall of the maxillary sinus was opened using a gouge creating a rectangular window. The disease was removed from pterygopalatine fossa and infratemporal fossa via this window. Internal maxillary artery was clipped using Ligaclip.
The rest of the sinuses were cleared using standard FESS techniques. Lamina papyracea and floor of the orbit were removed along with the removal of periorbital fat sparing the optic nerve/bulb and the orbital muscles. The patients were kept on intravenous Amphotericin-B or liposomal Amphotericin until the culture reports came back. Patients were shifted to Voriconazole if fungal culture reports suggested Aspergillosis. Patients were given injectable Amphotericin for 14 days on average. They were then shifted on oral tablets Posaconazole. The duration of oral therapy was kept as 6 months. Patients also received injectable antibiotics, oxygen therapy and symptomatic management from the medical side. Regular monitoring of liver function tests and renal function tests were done at regular intervals along with monitoring of input-output charts.
Follow-up was done for up to 6 months, wherein, a repeat fiberoptic examination/nasal endoscopy was done to conclude no evidence of recurrence or regrowth. This standard treatment of care was followed in all the patients only except for patients with an extremely guarded prognosis.