While India is battling against the notorious COVID-19 infection, there is a silent invader trying to complicate the recovery of post-covid patients. Mucor is a normal commensal fungus that resides in the nasal passage of all people. Invasive mucormycosis is a rare and aggressive fungal infection that affects the immunocompromised people like diabetics, post-transplant patients who are on immune-suppressants, etc.
The recent trends shows increase in the incidence of mucormycosis in patients who have been infected with SARS-CoV2. Steroid is an integral part of treatment of covid infection in order to reduce the inflammation. The use of steroids in a diabetic patient leads to deranged blood glucose levels that in turn increase the chances of opportunistic infections like mucormycosis. Covid infection, diabetes and use of steroids have become the triad of this devastating disease.
Mucormycosis commonly manifests as a sino-nasal disease leading to necrosis of the area and spreads via the blood vessels. Nose and paranasal sinuses are in close relation to the eye and brain and any sino-nasal infection has the propensity to invade these areas if not treated. The incidence of Rhino-Orbito-Cerebral Mucormycosis is high among the post-covid patients and poses a significant mental and financial turmoil on both the patient and their family who are barely recovering from treacherous Covid-19 infection.
The usual presentation of this disease is nasal bleeding or crusting with obstruction. However swelling and loss of vision attracts the attention of the patients forcing them to consult a doctor. In most of our patients numbness of the cheek region was the first symptom which rapidly progresses to loss of vision in 2-3 days. Fungal meningitis, infarct or hemorrhage leading to hemiplegia can occur if the infection has spread to the brain. We noted an unusual presentation of facial swelling involving facial muscles, parotid gland leading to facial palsy (weakness of the face) in most of our patients along with the classical symptoms over the past few weeks.
MRI scan of the nose, eye and brain is necessary to evaluate the extent of the disease and to plan the treatment process. The treatment comprises of both surgical debridement of the disease as well as anti-fungal medications along with diabetic control. Thorough clearance of the infection along with release of compression over the eye and optic nerve (nerve for vision) plays a vital role for better prognosis. The anti-fungal medication like amphotericin needs to be administered over few days to weeks for achieving the complete disease clearance. Multi-disciplinary treatment comprising of ENT and Head Neck Surgeon, Neurologist, Infectious Disease Specialist and General Physician is mandatory for the comprehensive treatment of the patient.
Over the past month we have encountered a huge number of invasive mucormycosis all of them who presented with loss of vision. We have treated all the patients with completely endoscopic technique which involves removal of part of maxilla (cheek bone) and extensive debridement of the disease.
We emphasize on the fact that nasal crusting, cheek numbness or palatal discoloration may be a subtle warning signs of this dreaded infection and an early aggressive treatment with extensive surgical debridement, anti-fungal along with control of blood glucose levels forms the back-bone of management. The clinicians should have a high suspicion for post-covid patients with similar clinical picture and guide the patients for timely treatment.