A 44-year-old man attended our hospital reporting reduced vision in his left eye. 10 days earlier he had been started on treatment with supplemental oxygen, intravenous antibiotics, and corticosteroids because of a moderately severe pneumonia caused by SARS-CoV-2. The patient explained that a blackish patch—extending from just below his left eye to the left side of his face to the level of his mouth—had also developed 2 days earlier (figure ).
Figure.
Mucormycosis after COVID-19
(A) Photograph of left side of the patient's face shows an extensive fungal lesion. (B) Lactophenol cotton blue mount shows hyphae suggestive of Rhizopus arrhizus. (C) T2-hyperintense images show diffuse inflammatory changes in the soft tissues of the left orbital region—involving the pre-septal (upper left green arrow), post-septal (red arrow), intraconal and extraconal compartments, with orbital fat stranding (lower right green arrow). (D) Heterogeneously enhancing soft-tissue inflammatory changes were noted on the left side of face involving the premaxillary region, buccal fat pad, and infra-temporal fossa (arrows).
The patient was a known diabetic; he had no history of malignancy.
On examination his temperature was 37°C, pulse was 84 beats per min, blood pressure was 118/82 mm Hg, and respiratory rate was 16 breaths per min; pulse oximetry showed an oxygen saturation of 96% on room air. The patient had exophthalmos, ophthalmoplegia, and chemosis of his left eye. Best corrected visual acuity was 20/20 in his right eye, but he reported no perception of light in his left eye.
Laboratory investigations showed a random blood sugar concentration of 298 mg/dL (normal 140 or below), glycated haemoglobin A1c of 9·8% (normal 4–5·6), arterial blood pH 7·4 (normal 7·35–7·45), serum bicarbonate concentration 24 mEq/L (normal 23–30), and a mild neutropenia (1510 neutrophils per μL; normal 1800–6300).
Examination of a potassium hydroxide mount of nasal scrapings showed broad, pauci-septate hyphae; and Sabouraud dextrose agar culture and lactophenol cotton blue mount were suggestive of Rhizopus arrhizus (figure).
Contrast-enhanced MRI showed non-enhancement of the bilateral middle and inferior turbinate: the characteristic so-called black turbinate sign (figure). Contiguous extension of non-enhancing soft tissue into the left middle and ethmoidal air cells, with a breach in the cribriform plate to involve the basal frontal region was noted (figure). T2-hyperintense diffuse inflammatory changes were seen in the soft tissues of the left orbital region—involving the pre-septal, post-septal, and intraconal and extraconal compartments with orbital fat stranding (figure). Heterogeneously enhancing soft-tissue inflammatory changes were noted on the left side of the face involving the premaxillary region, buccal fat pad, and infra-temporal fossa (figure). Together—the clinical picture and the radiological findings—indicated mucormycosis.
The patient was started on intravenous liposomal amphotericin B at a dose of 5 mg/kg per day; an insulin infusion was also continued because of persistent hyperglycaemia. Extensive debridement, a left total maxillectomy, and orbital exenteration were done under a general anaesthetic; however, the patient died 6 days later.
During the second wave of the COVID-19 pandemic in India, an unprecedented surge in cases of mucormycosis was observed: immune dysregulation caused by the SARS-CoV-2 and the use of broad-spectrum antibiotics and corticosteroids—particularly in patients with poorly controlled diabetes with ketoacidosis—is likely to have contributed to the rise.
COVID-19 followed by mucormycosis carries a very high mortality rate and timely detection, antifungal therapy, and aggressive surgical debridement remain key factors in the management (video).
Declaration of interests
We declare no competing interests.
Contributors
SK and DSa made the clinical diagnosis and cared for the patient. SK and KC proposed the manuscript and followed up the patient. SK, KC, and DSo contributed equally to the drafting, writing, and editing the manuscript. We all developed, and approved the manuscript, and verified the data. Written consent for publication was obtained from the patient's first-degree relatives.
Supplementary Material
Caution after SARS-CoV-2 infection: mucormycosis can occur
Fungal infection—mucormycosis—in patient post treatment for SARS-CoV-2
YouTube link:https://youtu.be/pEKvXtta8a4
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Caution after SARS-CoV-2 infection: mucormycosis can occur
Fungal infection—mucormycosis—in patient post treatment for SARS-CoV-2
YouTube link:https://youtu.be/pEKvXtta8a4