Discussion
Rhinocerebral mucormycosis is an aggressive infection and failure to
diagnose or treat can lead to high mortality. [1]. Mucormycosis has
five different spread sites: rhinocerebral, gastrointestinal, cutaneous,
respiratory, and disseminated. ROCM is the predominant manifestation of
the infection which can progress to the orbital and deeper sites of the
brain through paranasal sinuses[1, 5] and could result in uncommon
presentations such as seizures, reduced LOC, or ophthalmic involvement.
Mucormycosis infects the nervous system in 20% of hematological cases
and brain abscess occurs rarely in 2 of 43 patients with
mucormycosis[5, 6]. Unfortunately, It has been observed that
mucormycosis has been rising since the COVID-19 pandemic began, and
recently it has become an issue of concern for our health care
system[1]. The condition could be a consequence of a dysregulated
immune system due to a reduction in T cell count, altered CD4/CD8 ratio,
and overuse of immunosuppresses like corticosteroids following the
COVID-19 which is exacerbated by uncontrolled blood sugar in people with
undetermined diabetes cases[1]. Sharma et al . in their
prospective study believe diabetes is the most common risk factor for
the ROCM after COVID-19 which 57% of the cases presenting with
uncontrolled diabetes (HBA1c > 6.5 mg/dl)[7].
Diagnosis of ROCM is based on the clinical finding including headache,
nasal or sinus congestion, and blackish discoloration within the nose or
palate. Radiological findings such as CT or MRI and pathological
investigations are crucial for confirmation of the diagnosis.
Involvement of the paranasal sinuses and at the top of them ethmoid
sinus is the highly common form. However, it could progress to the other
sinuses and infect the orbit, extraocular muscles, and finally the
brain[8].
Rhinorage and the blackish plate were the most common presentation of
mucormycosis in our center during the COVID-19, however, the common
presentation was absent in our recent cases. Instead, these two patients
suffered from neurological problems such as seizures, low LOC, and OAS
which means we should be concerned more about mucormycosis in
immunosuppressed patients especially in tumor mimicking masses and
always keep it in our differential diagnosis.
visual defects were reported in mucormycosis cases, this may be caused
by infarctions in blood vessels supplying the retina or optic nerve, in
addition to the compression of the nerve through the cavernous sinus, as
well as infection and necrosis[8].
Amphotericin B plus posaconazole was the regimen commonly used in
previous studies [1]. consistent with our cases, other studies found
intraorbital and retrobulbar injection of amphotericin B useful[1,
9]. However surgical debridement is the final and crucial approach for
these patients.