Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India – Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1
Authors: Sen Mrittika , Honavar Santosh G , Bansal Rolika , Sengupta Sabyasachi , Rao Raksha , Kim Usha , Sharma Mukesh , Sachdev Mahipal , Grover Ashok K , Surve Abhidnya , Budharapu Abhishek , Ramadhin Abhishek K , Tripathi Abhishek Kumar , Gupta Adit , Bhargava Aditya , Sahu Animesh , Khairnar Anjali , Kochar Anju , Madhavani Ankita , Shrivastava Ankur K , Desai Anuja K , Paul Anujeet , Ayyar Anuradha , Bhatnagar Aparna , Singhal Aparna , Nikose Archana Sunil , Bhargava Arun , Tenagi Arvind L , Kamble Ashish , Nariani Ashiyana , Patel Bhavin , Kashyap Bibbhuti , Dhawan Bodhraj , Vohra Busaraben , Mandke Charuta , Thrishulamurthy Chinmayee , Sambare Chitra , Sarkar Deepayan , Mankad Devanshi Shirishbhai , Maheshwari Dhwani , Lalwani Dilip , Kanani Dipti , Patel Diti , Manjandavida Fairooz P , Godhani Frenali , Agarwal Garima Amol , Ravulaparthi Gayatri , Shilpa Gondhi Vijay , Deshpande Gunjan , Thakkar Hansa , Shah Hardik , Ojha Hare Ram , Jani Harsha , Gontia Jyoti , Mishrikotkar Jyotika P , Likhari Kamalpreet , Prajapati Kamini , Porwal Kavita , Koka Kirthi , Dharawat Kulveer Singh , Ramamurthy Lakshmi B , Bhattacharyya Mainak , Saini Manorama , Christy Marem C , Das Mausumi , Hada Maya , Panchal Mehul , Pandharpurkar Modini , Ali Mohammad Osman , Porwal Mukesh , Gangashetappa Nagaraju , Mehrotra Neelima , Bijlani Neha , Gajendragadkar Nidhi , Nagarkar Nitin M , Modi Palak , Rewri Parveen , Sao Piyushi , Patil Prajakta Salunkhe , Giri Pramod , Kapadia Priti , Yadav Priti , Bhagat Purvi , Parekh Ragini , Dyaberi Rajashekhar , Chauhan Rajender Singh , Kaur Rajwinder , Duvesh Ram Kishan , Murthy Ramesh , Dandu Ravi Varma , Kathiara Ravija , Beri Renu , Pandit Rinal , Rani Rita Hepsi , Gupta Roshmi , Pherwani Ruchi , Sapkal Rujuta , Mehta Rupa , Tadepalli Sameeksha , Fatima Samra , Karmarkar Sandeep , Patil Sandeep Suresh , Shah Sanjana , Shah Sankit , Shah Sapan , Dubey Sarika , Gandhi Saurin , Kanakpur Savitha , Mohan Shalini , Bhomaj Sharad , Kerkar Sheela , Jariwala Shivani , Sahu Shivati , Tara Shruthi , Maru Shruti Kochar , Jhavar Shubha , Sharma Shubhda , Gupta Shweta , Kumari Shwetha , Das Sima , Menon Smita , Burkule Snehal , Nisar Sonam Poonam , Kaliaperumal Subashini , Rao Subramanya , Pakrasi Sudipto , Rathod Sujatha , Biradar Sunil G , Kumar Suresh , Dutt Susheen , Bansal Svati , Ravani Swati Amulbhai , Lohiya Sweta , Rizvi Syed Wajahat Ali , Gokhale Tanmay , Lahane Tatyarao P , Vukkadala Tejaswini , Grover Triveni , Bhesaniya Trupti , Chawla Urmil , Singh Usha , Une Vaishali L , Nandedkar Varsha , Subramaniam Venkata , Eswaran Vidya , Chaudhry Vidya Nair , Rangarajan Viji , Dehane Vipin , Sahasrabudhe Vivek M , Sowjanya Yarra , Tupkary Yashaswini , Phadke Yogita 
Published: June 2021

Purpose:
COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India’s second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.

Methods:
This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.

Results:
Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).

Conclusion:
Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.