Clinical Profile of Central Nervous System Involvement in Patients with Rhino Orbital Cerebral Mucormycosis

Abstract

Mucormycosis is life threatening fungal infection that occurs in immunocompromised patients. Patients at risk are those with poorly controlled diabetes mellitus, immunosuppressed patients such as those undergoing treatment for hematological cancer or recipients of solid organ and hematopoietic stem cell transplantation. COVID 19 infection is known to produce a state of hyper inflammation with release of various cytokines this state of immune dysfunction is associated with development of opportunistic infections, of which Mucormycosis is on the rise currently. The widespread use of corticosteroids can cause secondary infections including mucormycosis. CNS penetration typically starts with nasal involvement followed by the paranasal sinuses and palate, ultimately invading the orbit and brain or by direct hematological spread which is called as Rhino-orbito-cerebral Mucormycosis (ROCM) .

Material: This is a cross sectional study conducted on 50 patients diagnosed with COVID 19 associated mucormycosis admitted to the hospitals attached to BMCRI from May2021 to August 2021.All the ROCM cases with CNS manifestation were included The relevant demographic data, clinical presentation, neurologic manifestations, underlying co morbidity, medical treatments, and surgical interventions done were recorded and analyzed.

Observation: A total of 50 patients were included mean age 49.3 year with 38 males and 12 females .Most common comorbidity was diabetes (94%)followed by hypertension (26%) .Most common symptom was headache (86%) followed by facial swelling (68%), facial pain (66%).40% Patients had CNS symptom among which most common was hemiparesis. EOM restriction(70%) and abnormal vision(70%) being most common examination finding. Most common sinus being involved was maxillary 94% followed by ethmoid sinus 92%. Neurological manifestation included acute infarct (56%), Cavernous sinus thrombosis (28%),ICA occlusion (10%) abscess (34%), 3 patients had dual fungal infection. 26% patient underwent craniotomy, 6%carniotomy with Denkers procedure, 30% underwent maxillectomy. Among the mortality group, average duration of diabetes was 11.5 years, average steroid use of 9.53 days, CRP was 104mg/l, D Dimer 755ng/dl, as compared to 5.89 years, 5.3 days, 58.9mg/l, 419ng/dl, respectively among recovered patients. Most patient were left with morbidity like vision loss and facial disfigurement (40%) being most common while hemiparesis in (14%) patients .

Conclusion: Diabetes mellitus being the main predisposing factor for ROCM. Delayed diagnosis or inappropriate treatment may result in massive tissue destruction and possible extension into the cranial base and/or vault and orbit. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability.