Table 2.
Radiological and microbiological diagnosis, treatment, and outcome of ten COVID-19 associated mucormycosis- aspergillosis patients
| Case no. | Radiological findings | Microbiological findings | Histopathological findings | Management | Surgical | Intra-op findings | Follow-up/ final outcome | |
|---|---|---|---|---|---|---|---|---|
| KOH | Culture | |||||||
| 1 | Left M & F, B/L E & S -sinusitis | Thin hyaline septate hyphae-1st and 2nd sample, broad aseptate in 3rd sample | R. arrhizus and A. flavus | Sample not sent | Conservative injection of amphotericin B liposomal 5mg/kg for 7 days and Injection Piptaz | ND | Dead | |
| 2 | B/L Maxillary(R>L, B/L E & S sinusitis with right orbital extension into extraconal compartment | Broad pauciseptate | R. arrhizus & A. flavus | Broad aseptate with few thin septate hyphae. Presence of angioinvasion, tissue necrosis, inflammatory cells, and giant cell reaction | Inj. Amphotericin B 1425 mg Cumulative dose, Injection of Augmentin, Metrogyl | Surgical Debridement, Modified Dunker’s approach, Right frontal sinusotomy, septoplasty, left MMA, Right Ant & post ethmoidectomy, left anterior ethmoidectomy, left sphenoid sinusotomy, and right medial orbital decompression | Blackish crusts in nasal cavity, inferior turbinate necrosed, maxillary antrum-full of fungal debris, nasolacrimal duct inflamed, pus discharge present | Stable and on treatment |
| 3 | Right pansinusitis (M/F/E/S) with right orbital involvement Findings suggestive of invasive fungal sinusitis(STAGE III) | Broad pauciseptate with acute angle branching hyaline septate hyphae observed | A. fumigatus & R. arrhizus | H& E and PAS stain negative for fungal hyphae, Angioinvasion + | Injection of Lip. Amphotericin B 5125 mg Cumulative dose | B/L Endoscopic debridement | Stable and on treatment | |
| 4 | O/E B/L nasal polyps | Broad aseptate and thin hyaline septate hyphae suggestive of Aspergillus spp. | R. arrhizus & A. flavus | Sample not observed | Conservative Amphotericin B injection 1mg/Kg For 2 days | ND | Dead | |
| 5 | Right M/E/F/S sinusitis with blocked anterior and posterior draining pathways and internal contents, subtle mucosal and bony irregularities | 1. Broad aseptate perpendicular branching ribbon-like hyphae suggestive of mucormycosis with acute angle branching hyaline septate hyphae seen. | R. arrhizus and A. flavus | Broad aseptate with thin septate hyphae. Presence of angioinvasion, tissue necrosis, inflammatory cells and giant cell reaction | Amphotericin B injection (1675 mg cumulative dose) | Right total maxillectomy +right orbital exenteration | Blackish crust on middle turbinate and in anterior and posterior ethmoids, pus from the maxilla | Stable and on treatment |
| 6 | CXR- B/L Lung opacities; MRI BRAIN-Ethmodal and frontal sinusitis with left orbital cellulitis and optic neuritis. T2/FLAIR hyperintense signal in left anterior temporal lobe-likely Focal Cerebritis | Broad aseptate perpendicular branching with Acute angle branching hyaline septate hyphae seen | R. arrhizus and A. fumigatus | Broad aseptate along with a few thin septate hyphae. Presence of angioinvasion, tissue necrosis, and inflammatory cells | Liposomal Amphotericin B injection (8100 mg, cumulative dose) | Left total Maxillectomy +leftethmoidectomy+left sphenoid exploration | Necrosis of left maxilla left subcutaneous tissue, left periorbital fat, left inferior recti muscle, left sphenoid sinus mucosa | Stable and on treatment |
| 7 | Pansinusitis, findings suggestive of invasive fungal sinusitis with left orbital involvement and perineuritis on left side as described | Broad pauciseptate perpendicular branching ribbon like hyaline hyphae, Acute angle thin hyaline septate | R. arrhizus and A. flavus | angioinvasion and eosinophils present No fungal elements visible | Amphotericin B injection 1625 mg Cumulative dose | Surgical debridement, FESS with orbital decompression | Polypoid mucosa in right maxillary sinus, anterior and posterior ethmoid and sphenoid Left middle turbinate necrosed, polypodalmucoa in left maxillary sinus, anterior and posterior ethmoid, sphenoid snus | Stable and on treatment |
| 8 | Pansinusitis (S/M/E/F), preseptal cellulitis, orbital involvement, optic neuritis, Right eye proptosis | Broad aseptate perpendicular branching ribbon-like hyphae suggestive of Mucormycosis with Acute angle branching hyaline septate hyphae seen. | R. arrhizus & A. flavus | Broad aseptate along with a few thin septate hyphae. Presence of angioinvasion, tissue necrosis, and neutrophils | Amphotericin B injection (1525 mg cumulative dose) | B/L endoscopic debridement + right orbital exenteration | Lamina papyracea necrosed, infraorbital fat necrosed, blackened tissue present. | Stable and on treatment |
| 9 | Right maxillary and b/l ant and posterior sinusitis Findings suggestive of invasive fungal sinusitis | Broad pauciseptate perpendicular branching with acute angle septate hyaline hyphae | R. arrhizus & A. fumigatus | Broad aseptate along with a few thin septate hyphae. Presence of angioinvasion, tissue necrosis, and neutrophils | Amphotericin B injection (3075 mg, cumulative dose) | B/L endoscopic debridement | Black crust present in B/L anterior and posterior ethmoidal cells and pus in the right maxilla | Stable & on treatment |
| 10 | CXR- Non-homogenous opacities in B/L lung CORADS -5, CTSS -38/40 corresponding to 23/25 CT PNS- Soft tissue edema in both nose, Left maxillary sinus polyp | Broad aseptate perpendicular branching ribbon-like hyphae seen with acute angle branching thin hyaline septate hyphae observed. | R. arrhizus & A. flavus | Sample not sent | Conservative | ND | Dead | |