Successful Treatment of Acute Invasive Rhino-Orbito-Cerebral Mucormycosis Associated with COVID -19: Case Report and Literature Review

Background and Importance: 

Mortality associated with post- coronavirus disease 2019 (COVID-19) rhino-orbito-cerebral mucormycosis (ROCM) is an evolving concern. Association of COVID-19, corticosteroid therapy and uncontrolled diabetes mellitus (DM) is considered as predisposing factors for ROCM. We present two cases of successful treatment leading to patient survival for post-COVID-19, stage 4c-ROCM.

Two middle-aged men with poorly controlled DM were referred to our hospital for post-COVID-19 ROCM. They had received intravenous antivirals and dexamethasone as treatment in a primary center. Both patients had unilateral oculofacial pain and swelling followed by acute visual loss, unilateral proptosis, facial palsy, and trigeminal hypoesthesia. Computed tomography scan revealed opacity as well as bony erosion of paranasal sinuses (PNS). Obtained specimens confirmed mucormycosis agent on histopathological examination. After failure of conservative treatments, retrobulbar injections of liposomal-amphotericin B, along with PNS debridement and orbital exenteration, both patients developed blurred consciousness owing to extension of the infection into the intracranial cavity. Brain magnetic resonance imaging revealed right frontal lobe abscess in case1, and left frontal sinus abscess and involvement in case2. Both underwent transcranial debridement and resection of necrotic tissue and drainage of abscess. At follow-up, the patients were in good condition and the fungal cultures were negative for mucormycosis agent.

ROCM may be a complication of COVID-19 in high-risk patients. Control of the patient's underlying systemic condition and prompt treatment with antifungal agents along with timely aggressive resection of cerebral abscess and necrotic paranasal tissues are the mainstays of management for ROCM.