Via The Lancet: Mucormycosis after COVID-19 in a patient with diabetes.
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.
Credit: Chauhan et al.
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.
Contrast-enhanced MRI showed non-enhancement of the bilateral middle and inferior turbinate: the characteristic so-called black turbinate sign. 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. 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. 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.
