COVID-19-associated rhino-orbital mucormycosis: Presentation and outcome : Saudi Journal of Ophthalmology

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Case Report

COVID-19-associated rhino-orbital mucormycosis

Presentation and outcome

Saini, Sanchita1; Singh, Satya P.1; Singh, Vinod K.1; Kumar, Santosh1,; Singh, Sanskriti1; Rajak, Shiv D.1

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Saudi Journal of Ophthalmology 37(1):p 72-75, Jan–Mar 2023. | DOI: 10.4103/SJOPT.SJOPT_154_21
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We are reporting four accounts of rhino-orbital mucormycosis in patients during and after recovery from SARS-CoV-2 infection. The patients were diagnosed and treated for COVID-19 according to the current treatment protocols, following which they presented with sudden proptosis, ophthalmoplegia, and conjunctival injection, confirmed by magnetic resonance imaging and histopathological examination. The patients were treated with intravenous liposomal amphotericin B, and the outcome was observed. Early diagnosis and prompt intervention can substantially reduce the morbidity and mortality rates in these patients.


With the second wave of COVID-19 infection throughout the country, there has been an unpredictable increase in the incidence of opportunistic infections like mucormycosis, which has been responsible for high mortality and morbidity in the subset of patients during and after the recovery of COVID-19 infection.

This case series describes four cases of rhino-orbital mucormycosis in patients of SARS-CoV-2 during the disease and in recovery phase.

Mucormycosis is caused by Mucorales species of phylum Zygomycota and is a highly invasive and potentially lethal infection, especially in immunocompromised individuals.

However, in COVID-19 patients, the increased incidence is particularly seen in already immunocompromised patients or those on long-term steroid therapy and/or severely ill patients requiring prolonged hospitalization.


Case 1

A 38-year-old female patient presented to our hospital, a tertiary care center, 6 days after being tested negative for COVID-19 by reverse transcription–polymerase chain reaction (RT-PCR) with sudden ptosis, proptosis, and numbness over the right cheek for 5 days. On ocular examination, the patient had total ophthalmoplegia with complete ptosis, a mid-dilated and nonreactive pupil, proptosis and conjunctival congestion, and altered sensorium. Vision could not be evaluated [Figure 1a and b]. The diagnosis of rhino-orbital mucormycosis was confirmed by gadolinium contrast-enhanced magnetic resonance imaging (MRI) which showed signs of ethmoidal sinus and orbital involvement and histopathological examination done after obtaining sample from nasal swab, which revealed broad, aseptate hyphae [Figure 1c]. There was no history of diabetes mellitus or other comorbidities that could predispose to immunosuppressive state. The blood sample was sent for complete blood counts and came out to be deranged with TLC = 21500, neutrophil count 90%, lymphocyte count 6.2% with HbA1C levels of 15.6%, normal LFT, and C-reactive protein (CRP) levels of 17.4%.

Figure 1:
(a) Complete ptosis. (b) Fixed nonreactive pupil, conjunctival chemosis, and total ophthalmoplegia. (c) Coronal section showing heterogeneous mass involving the orbit and nasal cavity

The patient had a history of hospitalization for treatment of COVID-19 and had been on IV methylprednisolone 50 mg/ml for 5 days, tapered gradually over 10 days, after which she developed raised blood sugar levels.

After being discharged, she presented to our hospital and was diagnosed as a case of sino-orbital mucormycosis as mentioned above. She was immediately started on liposomal amphotericin B 300 mg after obtaining normal baseline kidney function tests (KFTs), which were repeated after every dose. The patient then deteriorated and finally died due to hypovolemic shock.

Case 2

A 65-year-old female, a known case of type II diabetes mellitus for 15 years, presented to us with complaints of fever and breathlessness. RT-PCR came out to be positive for SARS-COV-2 infection. The blood investigation revealed a total leukocyte count of 28,200 cells/cu mm, with 94.3% neutrophils (normal value: 30–60) and lymphocytes 3.2% (20–40). Serum ferritin was 2000 mg/ml (normal value: 4.63–204), serum lactate dehydrogenase 988.7 IU/l (normal value: 240–480), CRP 116.4 mg/L (normal value <6), erythrocyte sedimentation rate 36 mm/1 h (normal value up to 20), d-dimer 3.56 mcg/ml (normal value < 0.5), and computed tomography (CT) severity score of 17/25 (severe disease). The patient also complained of toothache and numbness over the right cheek and sudden complete ptosis at presentation for 2 days. On ocular examination, there was bilateral ptosis, chemosis, and complete ophthalmoplegia with no pupillary reaction in both eyes, with no light perception in both the eyes [Figure 2a]. Black coating over lateral nasal walls and hard palate was noted on oral examination [Figure 2b]. The diagnosis was confirmed by CT orbit and sinuses showing mucosal thickening with air-fluid level in the maxillary sinus and also involvement of orbital tissues. Histopathological examination was done by taking swabs from eschar and deep nasal swab but came out to be negative.

Figure 2:
(a) Conjunctival chemosis and nonreactive, fixed pupil. (b) Black coating of eschar in the oral cavity

Following this, on radiological evidence and clinical suspicion, she was started immediately on intravenous liposomal amphotericin B (300 mg) once daily after obtaining normal baseline KFT. The patient's consciousness altered in a day, and then finally, she died due to pulmonary complications.

Case 3

This patient, a 56-year-old male with symptoms of fever, dry cough, and breathlessness, tested positive for SARS-COV-2 infection on RT-PCR 40 days back. Following this, he was managed according to the current treatment protocols of COVID-19. Intravenous dexamethasone 8mg was given twice daily for one week and was then gradually tapered. He had no history of any requirement of external artificial respiration. He had no history of diabetes mellitus or any factors predisposing for immunosuppression. The patient started complaining of abnormal sensation over his left cheek 20 days back, after which he developed proptosis followed by total ophthalmoplegia, ptosis, and hemorrhagic chemosis with nonreactive pupil in the left eye with no perception of light [Figure 3a and b]. Rhino-orbital mucormycosis was suspected and thus MRI was performed. MRI revealed diffuse infiltration. The patient was immediately started on intravenous liposomal amphotericin B (300 mg). Furthermore, oral posaconazole (300 mg) once daily was started along with liposomal amphotericin B, after which he started to show clinical improvement with reduction in conjunctival chemosis and proptosis. After stabilization of his general condition, exenteration was performed. The patient then developed a disseminated fungal infection and died.

Figure 3:
(a) Proptosis and complete ptosis with hemorrhagic chemosis. (b) Conjunctival chemosis, total ophthalmoplegia, and nonreactive pupil. (c) Coronal section showing involvement of the orbit, ethmoidal sinus, maxillary sinus, and nasal cavity. (d) Transverse section showing heterogeneous mass involving the orbit and ethmoidal sinus

Case 4

A 62-year-old male patient presented to us with the complaint of abnormal sensation over the left upper half of the face followed by sudden drooping of the left upper lid and pain over the left half of the face for 4 days. On examination, the vision in the affected eye was no light perception. There was complete ptosis with restriction of ocular motility in all the gazes and proptosis [Figure 4a and b]. The pupil was mid-dilated and unreactive. On fundus examination by indirect ophthalmoscopy, the color of the optic disc was pale, nasal margins were blurred. There was retinal whitening with arteriolar narrowing and cherry red spot was also observed. These findings were suggestive of central retinal artery occlusion. The patient had a history of COVID-19 infection 2 weeks back, for which he was admitted and later discharged after a week. Radiological investigations were done that revealed sino-orbital heterogeneous mass. The histopathological sample was taken from the nasal cavity, and the diagnosis of rhino-orbital mucormycosis was confirmed. The patient was then immediately started on intravenous liposomal amphotericin B. The patient, however, developed altered sensorium over a course of 1 day and died 2 days later.

Figure 4:
Central Retinal Artery Occlusion in a COVID19-Mucormycosis patient. (a) Fundus picture showing central retinal artery occlusion; (b) Photograph showing complete ptosis, proptosis in COVID-19 Mucormycosis patient


The incidence of mucormycosis is increasingly seen in patients of COVID-19 infection presenting as sino-orbital disease and then spreading into the orbit and intracranially. Mucormycosis infection can be classified as rhino-orbital or rhino-orbital-cerebral disease. Furthermore, this infection can be seen in the form of pulmonary, cutaneous, and gastrointestinal and in disseminated forms.[1]

The main predisposing factors attributable are immunocompromised patients following infection or due to steroid therapy needed in COVID infection, uncontrolled diabetic patients, and severely ill patients who required prolonged hospitalization and artificial and invasive ventilation during the course of disease.[2]

Mucormycosis is a life-threatening fungal disease, and current guidelines suggest intravenous liposomal amphotericin B with early debridement wherever possible.[3] However, early diagnosis with high clinical suspicion and prompt initiation of therapy available is required at this time to control the rising cases of mucormycosis causing higher mortality and morbidity among the patients in this second wave of COVID-19 pandemic.

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 initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. Brunet K, Rammaert B. Mucormycosis treatment: Recommendations, latest advances, and perspectives J Mycol Med. 2020;30:101007.
2. Maini A, Tomar G, Khanna D, Kini Y, Mehta H, Bhagyasree V. Sino-orbital mucormycosis in a COVID-19 patient: A case report Int J Surg Case Rep. 2021;82:105957.
3. Sugar AM. Mucormycosis Clin Infect Dis. 1992;14:S126–9

Amphotericin B; COVID-19; fungal infection; mucormycosis

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