TNOA Journal of Ophthalmic Science and Research

PHOTO ESSAY
Year
: 2022  |  Volume : 60  |  Issue : 2  |  Page : 207--209

Orbital Mucormycosis in Covid- 19: A Case Presentation


Rajakannan Durairaj 
 Department of Ophthalmology, ESICPGIMSR, Chennai, Tamil Nadu, India

Correspondence Address:
Rajakannan Durairaj
191, 100 Feet Bypass Road, Vijaya Nagar, Velachery - 42, Chennai, Tamil Nadu
India

Abstract

A 53–year-old male presented with a left eye swelling, proptosis, loss of vision, and complete ophthalmoplegia. Orbital mucormycosis is leading to the diagnosis of COVID 19,the patient was treated for the same. The author wants to insist that Orbital mucormycosis can develop in COVID-19 patients with comorbidities and patients under treatment with corticosteroidsfor COVID-19, which requires prompt diagnosis and management.



How to cite this article:
Durairaj R. Orbital Mucormycosis in Covid- 19: A Case Presentation.TNOA J Ophthalmic Sci Res 2022;60:207-209


How to cite this URL:
Durairaj R. Orbital Mucormycosis in Covid- 19: A Case Presentation. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2023 Jan 27 ];60:207-209
Available from: https://www.tnoajosr.com/text.asp?2022/60/2/207/349513


Full Text



 Introduction



COVID 19 pandemic is an outbreak of coronavirus disease caused by Severe acute respiratory syndrome corona virus 2 (SARS CoV2), continues to be a significant problem worldwide because of contagious spread. The severity of the disease ranges from asymptomatic infection to respiratory failure and death.[1] Patients with associated comorbidities are at higher risk for poor prognosis. While several treatment options have been evaluated, a systemic corticosteroid is the main treatment modality followed worldwide. Along with the risk factors, widespread use of glucocorticoids may predispose to secondary fungal or bacterial infections or coinfection, which ultimately increases morbidity and mortality in these patients.[2] Of the secondary fungal infection Candidiasis and invasive pulmonary aspergillosis complicating the course of COVID 19 is widely recognized.[3] Mucormycosis – a black fungus is less commonly suspected in COVID 19 patients.[4],[5]

Herein we report a case of orbital mucor mycosis –a black fungus in a 53-year-old patient leading to the diagnosis of COVID 19 at ESICH, Chennai.

 Case Presentation



A 53-year-old man with type 2 diabetes mellitus (DM) on irregular treatment came to the eye opd on 18.05.21 with complaints of left-sided facial pain, left eye pain, lid edema, redness of the eye, loss of total movement of the left eye for 6 days. C/o progressive visual loss in left eye for 3 days. History of left sided tooth ache, and left sided nasal block was present for 10 days. No h/o of fever and cough was reported. Ocular examination showed complete blepharoptosis and ophthalmoplegia together with conjunctival conjection and chemosis of the left eye [Figure 1]. Mild proptosis on the left eye. No perception of light in the left eye. Normal ocular motilities were observed in the right eye. Both pupils were fixed and dilated. Magnetic Resonance Imaging (MRI) Short Tau Inversion (STIR) Hyperintense signals with thickening of the medial rectus scans showed inferior rectus and superior rectus in the left orbit. A mild mass effect is noted on the left optic nerve. Complete blood count (CBC) showed lymphopenia and random blood sugar was 350 mg/dl. The patient was diagnosed with the above clinical and MRI finding as orbital mucormycosis and real- time Reverse Transcription polymerase chain reaction (RT- PCR) for COVID 19 was taken, which turned out to be positive. The patient was started with systemic antibiotics including IV meropenam and vancomycin. IV Amphotercin b 4 mg/kg/day was started patient was referred to a higher center for further management. He is under treatment to date.{Figure 1}

 Discussion



Mucormycosis is an acute fungal infection caused by fungi related to the Mucoraceae family.[6] Asexual spores of mucormycosis are a pathogen, which can infect oral and nasal cavities through inhalation. Normally the spores are removed by the phagocytic leucocytes.[7] When the patient had predisposing factors like uncontrolled DM, malignancy, renal failure, organ transplantation, patients on immmuno suppressive drugs, AIDS, and extensive burns these asexual pathogenic spores can transform into hyphae form and proliferate.[7],[8] It invades the vessel wall of the infected region and results in thrombosis, ischemia, and necrosis. The infection can directly spread into paranasal sinuses and invade orbital and intracranial space either by direct spread or by blood dissemination.[9] Rhino orbital mucormycosis is the most common type of human mucormycosis.[8] Cutaneous, pulmonary, gastrointestinal, and disseminated forms can occur.[10] The symptoms of rhino orbital mucormycosis include facial pain and paresthesia, headache, periorbital and nasal swelling, eyelid drooping, proptosis, ophthalmoplegia, visual loss, and necrosis of palate and nasal mucosa. From oral and nasal mucosa the disease spreads to paranasal sinuses and propagates into orbital space through the lamina papyracea.

Involvement of retinal vessels and optic nerve leads to visual loss. Intracranial spread can occur by direct spread from orbital orifices and sinus walls or through blood spread. Cavernous sinus thrombosis can lead to III, IV, VI cranial nerves involvement.[11] Regular examination and imaging studies are needed for prompt diagnosis and monitoring of the progression of the disease. Mucormycosis is confirmed by detection of blackish necrotic tissues and histopathological examination, KOH mount.

In COVID -19 superinfection and coinfection of fungus can occur.[12] In COVID -19 the CD4 and CD8 lymphocytes are low and inflammatory markers like IL-2, IL-6, IL-10, and TNF-α are markedly increased.[13] Covid -19 has never been reported as a predisposing factor for rhino orbital mucormycosis. So in COVID-19, the immunocompromised state of patients and patients on steroid therapy for modulating immune-related lung injury may be a predisposition to fungal infection. This case is a known uncontrolled type 2 DM presented with left-sided visual loss, proptosis, ptosis, no perception of light, and ophthalmoplegia of the left eye. MRI showed STIR Hyperintense signals with thickening of the medial rectus and inferior rectus and superior rectus of the left eye. A mild mass effect is noted in the left optic nerve.

Mucormycosis is a fatal infection with a mortality of more than 50%.[14] Survival depends on early diagnosis, treatment with systemic antifungals, and treatment of comorbidities. The patient was on IV amphotericin B and survived to date.

 Conclusion



COVID- 19 patients with associated comorbidities like DM and patients with corticosteroid therapy are predisposed to mucormycosis. In this study, for patients, only the ophthalmic findings of mucormycosis led to the diagnosis and conformation of COVID -19. So the patient with orbital findings should be evaluated promptly for life saving solutions.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Elsaie ML, Youssef EA, Nada HA. Herpes zoster might be an indicator for latent COVID 19 infection. Dermatol Ther 2020;33:e13666.
2Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62
3Hughes S, Troise O, Donaldson H, Mughal N, Moore LS. Bacterial and fungal coinfection among hospitalized patients with COVID-19: A retrospective cohort study in a UK secondary-care setting. Clin Microbiol Infect 2020;26:1395-9.
4Werthman-Ehrenreich A. Mucormycosis with orbital compartment syndrome in a patient with COVID-19. Am J Emerg Med 2020;42:264.e5-8.
5Mehta S, Pandey A. Rhino-orbital mucormycosis associated with COVID-19. Cureus 2020;12:e10726.
6Mohindra S, Mohindra S, Gupta R, Bakshi J, Gupta SK. Rhinocerebral mucormycosis: The disease spectrum in 27 patients. Mycoses 2007;50:290-6.
7Xu B, Fan CY, Wang AL, Zou Y-L, Yu Y-H, He C, et al. Suppressed T cell-mediated immunity in patients with COVID-19: A clinical retrospective study in Wuhan, China. J Infect 2020;81:e51-60.
8Xiao S, Luo D, Xiao Y. Survivors of COVID-19 are at high risk of posttraumatic stress disorder. Glob Health Res Policy 2020;5:29.
9Goel S, Palaskar S, Shetty VP, Bhushan A. Rhinomaxillary mucormycosis with cerebral extension. J Oral Maxillofac Pathol 2009;13:14-7.
10Viterbo S, Fasolis M, Garzino-Demo P, Griffa A, Boffano P, Iaquinta C, et al. Management and outcomes of three cases of rhinocerebral mucormycosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e69-74.
11Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
12Afroze SN, Korlepara R, Rao GV, Madala J. Mucormycosis in a diabetic patient: A case report with an insight into its pathophysiology. Contemp Clin Dent 2017;8:662-6.
13Mignogna MD, Fortuna G, Leuci S, Adamo D, Ruoppo E, Siano M. Mucormycosis in immunocompetent patients: A case-series of patients with maxillary sinus involvement and a critical review of the literature. Int J Infect Dis 2011;15: e533-40.
14Chen G, Wu D, Guo W, Cao Y, Huang D, Wang H, et al. Clinical and immunological features of severe and moderate coronavirus disease 2019. J Clin Invest 2020;130:2620-9.