Fungus in a Viral Land-Orbital Mucormycosis in Patients With COVID-19 Infection.
Authors: Imam Sufia , Mukherjee Dattatreya , Harikrishnan Suriya Narayan , Sinha Aayushi Raj 
Published: May 2021

The coronavirus disease 2019(COVID-19) infection caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be associated with a wide range of disease patterns, ranging from mild to life-threatening pneumonia[1].During the current pandemic of COVID-19, a myriad of manifestations and complications has emerged and are being reported frequently. We are discovering patients with COVID-19 are at increased risk of acute cardiac injury, arrythmias, thromboembolic complications (pulmonary embolism and acute stroke), and secondary infections[2]. Recently, we have noticed that there is an increase in the incidence of invasive fungal infections in COVID-19 disease manifesting as orbital compartment syndrome,orbital cellulitis and rhino-orbital-cerberal mucormycosis. Several such cases have been reported during the course of COVID-19 disease or as a sequelae. In general mucormycosis infections are rare and opportunistic and are associated with high mortality ranging from 25-62%[3].Mucormycosis is an invasive fungal infection caused by mold fungi of the genus Mucor Rhizopus, Rhizomucor and Absidia, which are in the Mucorales order of the Zygomycetes class [4]. The most common type is Rhizopus Oryzae and approximately 60% of mucormycosis cases in humans; it is responsible for 90% of the rhino-orbital-cerebral form [5]. The pathogenesis of mucormycosis include killing of mucorales by mononuclear and polymorphonuclear phagocytes of normal hosts through generation of oxidative metabolites and defensins, hence neutropenic patients and those with dysfunctional phagocytes are susceptible to develop invasive mucormycosis[6,7]. A hallmark of mucormycosis infection is the presence of extensive angioinvasion with resultant vessel thrombosis, infarction and tissue necrosis[8].In COVID-19 there is endothelial barrier disruption, dysfunctional alveolar-capillary oxygen transmission and impaired oxygen diffusion capacity[9]. Profound lymphopenia with reduced numbers of T lymphocytes, CD4+T, and CD8+T cells, may alter the immune response of COVID-19 patients enhancing the risk of invasive fungal infections[10].We conducted a literature search online and read several published papers on ‘mucormycosis post COVID-19 infection. Here we present to you the risk factors, clinical profile, investigations, treatment and prevention of this rare disease which is causing havoc during the COVID-19 pandemic.Risk Factors: Preexisting morbidities like uncontrolled diabetes mellitus and lung disease, ventilator-associated pneumonia, neutropenia, elevated free iron levels, deferoxamine, hematological malignancies, stem cell transplants, and organ transplant patients on immunosuppressants, use of corticosteroids and tocilizumab, iatrogenic immunosuppressions, COVID-19 infection &amp; its treatment causing immunosuppression.Clinical Profile: fever, pain, redness, and periocular swelling, acute and progressive, drooping of eyelids, limitation of ocular movements, and painful loss of vision. The progression is usually rapid, an average of two days from the onset. Eyelid and periocular edema, complete ptosis, total ophthalmoplegia, proptosis and relative afferent pupillary defect, unilateral facial or orbital pain, headache, periocular swelling, double vision or diminution of vision,congestion with conjunctival edema and signs of exposure keratitis, chemosis, sinusitis, nasal discharge and neurological signs and symptoms if intracranial extension is present. The patients may exhibit one or more of the above mentioned signs and symptoms depending on the severity of disease.