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Letters to the Editor

COVID-19 and orbital mucormycosis

Sarkar, Sandip; Gokhale, Tanmay; Choudhury, Sushmita Sana1; Deb, Amit Kumar

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Indian Journal of Ophthalmology: April 2021 - Volume 69 - Issue 4 - p 1002-1004
doi: 10.4103/ijo.IJO_3763_20
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Dear Editor,

The 2019 novel coronavirus (2019-nCoV) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first reported in Wuhan, Hubei province in China, quickly spread to other parts of the world forming a global pandemic.[1] The disease pattern of COVID-19 can range from mild to life-threatening pneumonia with associated bacterial and fungal coinfections.[2] Due to the associated comorbidities (e.g., diabetes mellitus, chronic obstructive pulmonary disease) and immunocompromised conditions (e.g. corticosteroid therapy, ventilation, intensive care unit stay), these patients are prone to develop severe opportunistic infections. There are reports of the development of severe opportunistic infections such as oropharyngeal candidiasis, pneumocystis jiroveci pneumonia, pulmonary aspergillosis, bloodstream candida infections, etc., in patients affected with COVID-19 disease.[34] There are also few isolated case reports of rhino-orbital mucormycosis in COVID-19 disease.[25] Sen et al. recently reported a series of six cases of COVID-19 disease with rhino-orbital mucormycosis. One patient in this series had concurrent COVID-19 and mucormycosis at admission, while five other patients developed mucormycosis during treatment with systemic steroids for COVID-19.[6] We, hereby, report a cluster of 10 cases of clinically diagnosed orbital mucormycosis with concurrent COVID-19 illness at our institute over the last 2 months (October and November 2020). They presented to us with clinical features of orbital mucormycosis and COVID-19 was diagnosed on routine screening. Demographic and clinical profiles of the patients are provided in [Table 1]. Microbiological and radiological diagnosis along with treatment received and final outcome are provided in [Table 2]. Potassium hydroxide (KOH) wet mount and fungal culture/sensitivity were done from biopsy obtained during debridement or from nasal swab obtained during diagnostic nasal endoscopy. Microbiological diagnosis of mucormycosis was proven in six patients. Reverse transcriptase-polymerase chain reaction (RT-PCR) tests for COVID-19 were positive in all the patients. All patients in our series were known diabetics. Diabetic ketoacidosis (DKA) was evident in four patients during admission while five more patients developed DKA after the initiation of corticosteroid therapy for COVID-19 disease. All patients in our series had received intravenous dexamethasone for COVID-19 disease as per The National Institute of Health recommendations[7] and Liposomal Amphotericin B for mucormycosis. Besides, four patients received an injection of Remdesivir, and nine patients required ventilatory support during their hospital stay. The use of steroids, monoclonal antibodies, and broad-spectrum antibiotics for the management of COVID-19 illness can increase the chances of new-onset fungal infection or exacerbate a preexisting one.[2] All patients in our series had received intravenous dexamethasone for COVID-19 disease and Liposomal Amphotericin B for mucormycosis. Four patients in our series expired within 1 month of the diagnosis, five patients had satisfactory systemic outcomes, but with irreversible vision loss, while only one patient had both ocular and systemic favorable outcomes.

Table 1
Table 1:
Demographic and clinical profiles of the patients
Table 2
Table 2:
Radiological and microbiological diagnosis, treatment, and final outcome of the patients

COVID-19 disease has a propensity to cause extensive pulmonary disease and subsequent alveolo-interstitial pathology. This by itself may predispose to invasive fungal infections of the airways including the sinuses and the lungs.[28] Furthermore, there is an alteration of the innate immunity due to COVID-19-associated immune dysregulation characterized by decreased T cells, including CD4 and CD8 cells.[26] All physicians including ophthalmologists should, therefore, be mindful of the probability of development of fungal infections such as mucormycosis in patients with COVID-19 illness, especially in those with comorbidities and on immunosuppressive agents in the coming future.[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

1. Farnoosh G, Alishiri G, Hosseini Zijoud SR, Dorostkar R, Jalali Farahani A. Understanding the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease (COVID-19) based on available evidence-A narrative review J Mil Med. 2020;22:1–11
2. Mehta S, Pandey A. Rhino-orbital mucormycosis associated with COVID-19 Cureus. 2020;12:e10726
3. Salehi M, Ahmadikia K, Badali H, Khodavaisy S. Opportunistic fungal infections in the epidemic area of COVID-19: A clinical and diagnostic perspective from Iran Mycopathologia. 2020;185:607–11
4. Chowdhary A, Tarai B, Singh A, Sharma A. Multidrug-resistant Candida auris infections in critically Ill coronavirus disease patients, India, April–July 2020 Emerg Infect Dis. 2020;26:2694–6
5. Mekonnen ZK, Ashraf DC, Jankowski T, Grob SR, Vagefi MR, Kersten RC, et al Acute invasive rhino-orbital mucormycosis in a patient with COVID-19-associated acute respiratory distress syndrome Ophthalmic Plast Reconstr Surg. 2020 doi: 10.1097/IOP. 0000000000001889
6. Sen M, Lahane S, Lahane TP, Parekh R, Honavar SG. Mucor in a viral land: A tale of two pathogens Indian J Ophthalmol. 2021;69:244–52
7. COVID-19 Treatment Guidelines Panel. . Coronavirus disease 2019 (COVID-19) treatment guidelines National Institutes of Health. 2020Last accessed on 2020 Dec 23
8. Gangneux JP, Bougnoux ME, Dannaoui E, Cornet M, Zahar JR. Invasive fungal diseases during COVID-19: We should be prepared? J Mycol Med. 2020;30:100971 doi: 10.1016/j.mycmed.2020.100971
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