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Purpose: Outbreaks of mucormycosis were reported worldwide throughout the COVID-19 pandemic. We report clinical outcomes of a treatment protocol for COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM)., Methods: Patients with biopsy-proven mucormycosis and COVID-19 were included. All received intravenous amphotericin B deoxycholate 1 mg/kg and surgical endoscopic sinus debridement (FESS). Those with rhino-orbital or cerebral disease limited to the cavernous sinus were eligible for transcutaneous retrobulbar amphotericin B (TRAMB). Patients were followed with weekly imaging, endoscopic examinations, and serial debridement as necessary. Patients were discharged on oral posaconazole for 6 months., Results: In total, 264 patients were followed for a mean of 2.5 months. On presentation, 163 patients (174 eyes) had eye involvement. Of these, 141 eyes (81.0%) had light perception or worse vision. By the last follow-up, 163 patients (176 eyes) were affected, and of these, 96 eyes (54.5%) had no light perception. Twenty-one patients (8%) died and 3 orbits (0.5%) were exenterated. There was no change in mortality ( p  = 0.38) or exenteration ( p  = 0.38) in the 55 patients who received TRAMB compared to patients with rhino-orbital or cerebral disease limited to the cavernous sinus who did not. Asymptomatic COVID-19 was associated with higher mortality than symptomatic COVID-19 ( p  = 0.025). Uncontrolled diabetes was a risk factor for death ( p  = 0.022). New diabetes was associated with increased mortality versus pre-existing diabetes ( p  = 0.005)., Conclusion: A multidisciplinary approach is crucial to manage COVID-19-ROCM. In our cohort, TRAMB therapy did not increase mortality or exenteration rates. While poor vision on presentation was profound, some vision recovery was noted with treatment. COVID-19 immune dysregulation may predispose patients to ROCM, particularly those with asymptomatic disease.

Purpose: Rhino-orbital-cerebral mucormycosis (ROCM) is the most common presentation of mucormycosis. Sinonasal-orbital debridement with exenteration is a life-saving procedure in ROCM patients in view of severe involvement of sinuses and the eyeball. Following the second wave of coronavirus disease 2019 (COVID-19), there was a massive surge in mucormycosis cases in India in post-COVID-19 patients. Of over 300 cases of mucormycosis admitted in our hospital, many underwent exenteration and these specimens were evaluated histopathologically, where fat necrosis was found to be a prominent finding. The spectrum of fat necrosis in ROCM in orbital fat has not been described in literature. Hence, we sought to evaluate the significance and spectrum of orbital fat necrosis in ROCM., Methods: This 3-month retrospective study included 15 cases of ROCM which underwent exenteration. Clinical data, radiologic details, and histopathologic findings were tabulated. Sections were also subjected to Periodic acid Schiff (PAS) and Gomori's methenamine silver (GMS) stains for confirming the fungus., Results: All 15 cases showed fat stranding on computed tomography (CT) scan. On histopathologic examination, various tissue reaction patterns observed included acute/chronic inflammatory infiltrate, suppurative granulomas with giant cells, coagulative and fat necrosis, broad aseptate fungal hyphae with or without angioinvasion, and neural invasion. Fungal hyphae were confirmed with PAS and GMS stains. The spectrum of fat necrosis observed in all the cases included 1) acute necrotizing fat necrosis, 2) ghost adipocytes with or without saponification, and 3) crystalline/gouty fat necrosis., Conclusion: Fat necrosis is a significant finding in ROCM, both on CT scan and histopathology. All three patterns of fat necrosis may be observed simultaneously in a case of ROCM., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Objective: To assess the utility of an intraoperative scoring system for mucormycosis and to predict prognosis by comparing the score with postoperative outcomes., Methods: This study was conducted among 80 patients with mucormycosis who underwent surgical management with mandatory pterygopalatine fossa and infratemporal fossa exploration. All cases were scored using our intraoperative scoring assessment tool. Postoperative outcomes in terms of favourable prognosis and mortality were evaluated and compared with demographics, clinical history and intraoperative findings., Results: An intraoperative score of more than 25 was statistically significant in predicting mortality (p < 0.0001). In all, 86.7% of patients with a score above 25 succumbed to the disease. Statistical significance of mortality (p < 0.05) was observed in those with involvement of pterygopalatine fossa (78.9%), orbit (73.7%), infratemporal fossa (57.9%), cribriform plate (36.8%) and those with history of intake of antiviral drugs (47.4%), use of supplemental oxygen (31.6%) and renal failure (26.3%)., Conclusions: This study enabled better prediction of postoperative prognosis in mucormycosis and reiterated the importance of exploration of pterygopalatine fossa and infratemporal fossa in management and prognostication of invasive fungal sinusitis., (Copyright © 2024 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Objectives: The primary source of facial mucormycosis is through inhalation of fungal sporangiospores, resulting in invasive disease in paranasal sinuses. However, dental onset mucormycosis has not been well documented in literature. The aim of this study was to describe the clinical characteristics and outcomes of patients with odontogenic onset mucormycosis., Methods: From a large cohort of mucormycosis involving the face between July 2020 and October 2021, we selected patients who had dental symptoms at onset and predominant alveolar involvement with little to no paranasal sinus disease as shown by baseline imaging. All patients had a confirmed diagnosis of mucormycosis through histopathology, with or without the growth of Mucorales in fungal culture., Results: Out of 256 patients with invasive mucormycosis of the face, 8.2% (21 patients) had odontogenic onset. Uncontrolled diabetes was a common risk factor, affecting 71.4% (15/21) of the patients, while recent COVID-19 illness was noted in 80.9% (17/21) of patients. The median duration of symptoms at presentation was 37 days (IQR, 14-80 days). The most common symptoms were dental pain with loose teeth (100%), facial swelling (66.7% [14/21]), pus discharge (28.6% [6/21]), and gingival and palatal abscess (28.6% [6/21]). Extensive osteomyelitis was found in 61.9% (13/21) of the patients, and 28.6% (6/21) had oroantral fistulas. The mortality rate was low, at 9.5% (2/21), with only 9.5% (2/21) of the patients having brain extension and 14.2% (3/21) in the orbit., Conclusion: This study suggests that odontogenic onset invasive mucormycosis may be a separate clinical entity with its own distinct clinical features and prognosis., (Copyright © 2023 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

An increasing incidence of rhinoorbitocerebral mucormycosis (ROCM) among patients with COVID-19 has recently been reported in India. We report the imaging findings for 25 patients with COVID-19 and invasive ROCM at a single hospital in India. Findings included sinus wall erosions ( n = 20), air within bony sinus structures ( n = 11), and focal mucosal nonenhancement ( n = 8). Orbital, vascular, and intracranial complications were also observed. Radiologists should recognize the increasing incidence of ROCM among patients with COVID-19 to facilitate early diagnosis.

Aim: To analyse combined computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of invasive rhino-orbital mucormycosis (IROM) in post-COVID-19 infection patients for accurate diagnosis and delineation of the extent of involvement., Materials and Methods: A retrospective analysis was undertaken of 50 patients who developed IROM post-COVID-19 infection who underwent combined CT/MRI evaluation., Results: The age range of the 50 affected patients was 23-73 years. Out of these, 41 were diabetic. CT/MRI showed predominant involvement of the maxillary (n=26) and ethmoid (n=19) sinuses. Extension of disease to the orbit (n=35), cavernous sinus (n=18), hard palate (n=15), skull base (n=8), and intracranial involvement (n=3) was seen. Perineural spread of the disease was analysed along all divisions of the trigeminal nerve and its branches. MRI showed T2-hypointense soft-tissue thickening with heterogeneous contrast enhancement with corresponding hyperdensities on CT diagnosing the presence of fungal elements., Conclusion: Clinicians should be aware of the possibility of IROM post-COVID-19 infection. Conjunctive use of CT, which depicts bone destruction and other reactive bony changes along with MRI, which reveals characteristic findings of soft-tissue thickening of the involved sinuses with extension of disease to the orbits, cavernous sinus, dura, hard palate, skull base, and intracranial structures. Accurate diagnosis and early recognition of the disease and its extension with appropriate use of these techniques helps to initiate appropriate and timely treatment, which is vital to prevent a fatal outcome., (Copyright © 2021 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Among the ever-increasing literature of the coronavirus disease 2019 (COVID-19), there have been reports on several complications in association with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), such as secondary bacterial and fungal infections. We report a 61-year-old woman with a past history of diabetes mellitus who presented to our hospital suffering from COVID-19 infection. During the course of her hospitalization, the patient developed chemosis and proptosis in both eyes, ultimately leading to a diagnosis of invasive rhino-orbital-cerebral mucormycosis and cerebrovascular thrombosis. This study strengthens the possible association between the occurrence of COVID-19 and invasive mucormycosis infection, providing new impetus for further investigations to substantiate this correlation., (© 2021. Journal of NeuroVirology, Inc.)

Mucormycosis is relatively uncommon, fulminant, progressive, life threatening fungal disease which is most often seen in debilitating patients with immunocompromised condition. Mucormycosis cases are seen in patients with the use of systemic steroids in the treatment of severely affected COVID-19 cases and also in the patients with uncontrolled diabetes which causes immunosuppression are being reported with mucormycosis. The main symptoms of this disease include pain on the temporal and the orbital region of the affected side which could be throbbing or lancinating type, mobility of the teeth, jaw pain and often swelling is present which could be extraoral and intraoral both or sometimes only intraorally. The diagnostic approach in such cases is done with the help of clinical diagnosis, histopathology and with advanced imaging like cone beam computed tomography, magnetic resonance imaging and computed tomography. We here used cone beam computed tomography imaging that revealed haziness in the sinuses and breach in cortical bone of the affected area which confirmed the diagnosis of mucormycosis. Early treatment planning like administration of antifungal drugs and surgical debridement will be life saving in such a deadly disease., Competing Interests: The authors declare no competing interests., (Copyright: Dhaman Gupta et al.)

Aim: To report the frequency and factors affecting patients', globe and vision survivals in rhino-orbito-cerebral mucormycosis (ROCM)., Methods: This is a retrospective study of 63 patients (79 eyes) with biopsy-proven ROCM at a university hospital 2008-2016. Systemic and ophthalmic manifestations, imaging, management and final outcomes were recorded. Globe survival was defined as no exenteration and vision survival as final visual acuity of light perception and more., Results: Mean age was 55.5 (SD 12.9) years with no gender preference. Diabetes was the most common underlying disease (68.3%). Patient survival was observed in 57.1 % (36/63). Presence of frozen eye (OR 4.6), nasal mucosal involvement (OR 7.3) and shorter duration of antifungal therapy (OR 1.03) were significantly associated with lower patient survival. Exenteration did not significantly change the survival. Globe survival was detected in 43% (34/79). Higher white blood cell (WBC) count was associated with a lower globe survival (p=0.02). Vision survival was observed in 25.3% (20/79) in whom younger age was significantly associated with a worse vision survival., Conclusion: Patient, globe and vision survivals were 57%, 43% and 25%, respectively. Exenteration did not affect the patients' survival. While frozen eye and nasal mucosal involvement were significantly associated with a lower survival, higher WBC count significantly increased the risk of exenteration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Mucormycosis is a severe infection that affects a variety of patients, including immunocompromised children and neonates. Given improved survival rates from advances in the treatment of malignancies, the population at risk for mucormycosis is increasing. We conducted a systematic review of cases of mucormycosis in children in the English-language literature reported between August 2008 and June 2017 and analyzed the clinical characteristics, diagnosis, management, and outcome of those infections. The most common underlying diagnoses included neutropenia (41%), hematologic malignancy (39%), prematurity (13%), and hematopoietic stem cell transplant (11%). Sinus disease (28%) and disseminated disease (24%) were the most common presentations. Rhizopus spp were the most common organisms isolated (22%). Amphotericin B remains the backbone of treatment and was prescribed in 86% of these cases. The resulting mortality rate remains high (32%). We provide here the results of a literature review of mucormycosis in children, including its epidemiology and clinical manifestations, and describe current advances in its diagnosis and treatment., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In this report, we describe the case of a young, diabetic girl with ketoacidosis who suffered sudden loss of vision of the right eye. The loss of vision was caused by an invasive rhino-orbital-cerebral fungal infection (mucormycosis) with extensive periorbital thrombosis. Despite maximal antifungal and surgical treatment (including exenteration of the right orbit), the clinical situation deteriorated. It was only after overcoming the difficulties of managing her hyperglycaemia that the patient's condition stabilised and her life was saved. Another factor contributing to this girls' survival was the swift diagnosis of mucormycosis, which was made soon after the onset of symptoms. Because of this, treatment could be started almost immediately., Competing Interests: Competing interests: Icmje-forms have been signed by all authors., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Early diagnosis of acute invasive fungal rhinosinusitis (AIFR) is crucial for patients prognosis and may reduce the extent of surgical debridement. Initial evaluation usually includes paranasal Computed Tomography (CT), with an emphasis on bony erosion which is considered a specific but insensitive radiologic sign. Most studies made no distinction between Aspergillus and Mucor species while addressing CT findings. In this study, we seek to evaluate whether bony erosion on paranasal CT is a significant and reliable finding in the initial evaluation of invasive paranasal mucormycosis., Methods: A retrospective review of pre-operative non-contrast craniofacial CT scans of patients diagnosed with acute invasive fungal rhinosinusitis (AIFR) caused by Mucor species for the presence of bony erosion., Results: A total of 13 patients (9 males, 4 females) were included. Twelve patients were immunosuppressed due to various hematological malignancies. Six patients underwent debridement due to gross intraoperative findings of bony fungal invasion, but only one patient had evidence of bony erosion on the pre operative paranasal CT., Conclusion: Bony erosion on paranasal CT is an exceptionally insensitive radiologic sign for establishing or rejecting the diagnosis of Mucor induced AIFR. The mainstay of confirming or rejecting the diagnosis of AIFR is by physical examination, endoscopy and oriented biopsy of suspicious mucosal lesions.

Purpose: To describe the non-exenteration management of sino-orbital fungal infection, a life-threatening condition for which orbital exenteration is generally considered a first-line treatment., Methods: A retrospective case series is presented of 7 orbits in 6 consecutive patients admitted and treated at 2 major metropolitan tertiary teaching hospitals in Sydney, New South Wales, Australia., Results: Seven orbits in 6 consecutive patients with sino-orbital fungal infection were treated conservatively with surgical debridement and intravenous antifungal agents. Four patients were immunosuppressed and the other 2 patients were otherwise healthy. All presented with pain, proptosis, or loss of vision. Causative organisms found were Mucormycoses, Aspergillus, and Scedosporium prolificans. Exenteration was avoided in all patients as part of their planned management and 5 patients, including 1 with bilateral disease, survived their disease without exenteration. Medical treatment included intravenous liposomal amphotericin B or voriconazole. A single immunosuppressed patient deteriorated and as a last resort, exenteration was performed, but this made no difference to his clinical course and in retrospect could have been avoided as he died of multiple cerebral metastases diagnosed shortly after his deterioration., Conclusion: The authors recommend that patients with sino-orbital fungal disease preferably be treated conservatively, without orbital exenteration.

Background: Rhino-orbito-cerebral mucormycosis(ROCM) is an invasive fungal infection that usually occurs in immunocompromised patients and sometimes presents as orbital apex syndrome(OAS) initially. It is rapidly fatal without an early diagnosis and treatment. We report the cases of invasive ROCM presenting with OAS initially in order to raise the attention of clinicians., Methods: We retrospectively investigated eleven cases of invasive ROCM presenting initially with OAS admitted between January 2006 and December 2013. We analyzed clinical features, results of laboratory and radiological examinations, nasal endoscopy, aggressive surgical excision and debridement, and medical management outcomes of each case., Results: A total of eleven cases of invasive ROCM with OAS as an initial sign were presented. Mucormycosis was accompanied by type II diabetes mellitus in nine cases, renal transplant in one case, and injury caused by traffic accident in one case. Anterior rhinoscopy revealed palatine or nasal necrotic lesions in all patients, and transethmoidal optic nerve decompression was carried out in three patients at the same time. CT scan revealed rhino-orbital-cerebral involvement in every patient. All patients were given intravenous amphotericin B. Nine patients underwent surgical debridement of necrotic tissue. Three patients survived., Conclusions: ROCM is a severe, emergent and fatal infection requiring multidisciplinary management. It may often present with OAS initially. For ophthalmologist, mucormycosis must be considered in immunocompromised patients presenting with OAS initially, and anterior rhinoscopy is imperative before hormonotherapy, even in the cases absent of ketoacidosis induced by diabetes mellitus.

The purpose of this case report is to illustrate the cause of this patient's headache and sinus pain in the setting of a unique environmental exposure: the patient ingested yogurt only days before presentation. This particular brand of yogurt caused controversy in early September 2013 when the manufacturer voluntarily recalled all flavors. The yogurt was found to be contaminated with Mucor circinelloides. The recall was triggered by the FDA, after receiving many complaints from consumers affected by temporary gastrointestinal symptoms such as abdominal cramping, diarrhea, and nausea. This patient was diagnosed with Rhinocerebral mucormycosis through fungal culture of the affected area. He was specifically colonized with Mucor circinelloides, a variant that rarely causes disease in humans. According to a literature review, only eight cases of mucormycosis in adults caused by this strain were documented before 2009.

Surgery and antifungals are the reference standard for rhino-orbito-cerebral mucormycosis (ROCM) treatment. The impact of local control on survival of 22 consecutive ROCM adults was studied on day 90: none vs. 75% died, respectively, with or without local control (p <0.0001). Hence, repeated surgical procedures are recommended to achieve local control of ROCM., (© 2013 The Authors Clinical Microbiology and Infection © 2013 European Society of Clinical Microbiology and Infectious Diseases.)

Mucormycosis is an opportunistic fungal infection with a high mortality rate. Although mucormycosis is relatively rare, recent studies suggest that the incidence is on the rise as a result of increased use of chemotherapy and steroids. The authors present an unusual case of invasive mucormycosis in a hospitalized patient with AIDS who was receiving short-term, high-dose steroids and who had associated steroid-induced diabetes. The patient was otherwise healthy, with no underlying risk factors such as neutropenia or intravenous drug use. The patient developed acute onset of proptosis, vision loss, and invasive Mucor in the left maxillary sinus that extended along the optic nerve intracranially. Despite aggressive treatment, the patient died. Physicians should be aware of steroid-induced diabetes as a risk factor for invasive fungal infections such as mucormycosis.

Background: Rhinocerebral mucormycosis is a rare, rapidly progressive life threatening opportunistic fungal disease that usually occurs in immunocompromised patients., Aim: The aim of the study is to present a case series of six immunocompromised patients who were diagnosed with rhinocerebral mucormycosis, review the diagnostic criteria and treatment approach., Patients and Materials: Six patients were treated in our department between the years 2005-2010. Their diagnostic criteria, surgical treatment and mortality rate are analyzed and discussed., Results: All six immunocompromised patients suffered from a primary hematological malignancy and received chemotherapy to treat their primary disease. Symptoms such as pain mimicking sinusitis, facial swelling, oral or dental pain, and fever were found in most patients. The diagnosis was based on both clinical signs and a biopsy for microbiological culture and histological examination. All patients underwent aggressive surgical resection and were treated simultaneously with anti fungal therapy. Four patients died from their primary illness. One patient died due to uncontrolled spreading of mucormycosis and one patient, the youngest and with the most extensive form of the disease (brain invasion) survived and clinically recovered with no evidence of recurrent disease following the surgical management., Conclusions: Rhinocerebral mucormycosis is a rapidly progressing disease with a high mortality rate, which requires immediate surgical and medical intervention. It seems from the data presented that the presence of mucormycosis is an ominous sign in immunocompromised patients. The extent of the disease is of less prognostic value, since the only patients in our series who survived had the most extensive disease, yet his primary haemato-oncological disease was under control. Controlling the underlying disease with early diagnosis and aggressive surgical intervention appears to be the most important factor for survival., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Mucormycosis is an opportunistic fulminant fungal infection, which affects nose and paranasal sinuses by direct invasion or through the blood vessels mainly in diabetic and immunocompromised patients. In the present study, a rhino-orbito-cerebral mucormycosis in a 24-year-old female with diabetes mellitus as underlying disease was reported. Computed tomography (CT scan) demonstrated an increase in the soft tissue densities in the left nasal cavity, maxillary and ethmoid sinuses and destruction of the antral wall with soft tissue densities in the pterygopalatine fossa and retromaxillary fissure. In histopathology, wide ribbon-shape non-septate hyphae were seen in tissue sections stained with hematoxylin-eosin (H&E). The etiologic fungus isolated from tissue biopsy on mycological media was identified by the amplification and sequencing of the 5.8S RNA gene and of the adjacent internal transcriber spacer domains, ITS1/ITS4, as Rhizopous oryzae. Recognition of the unique patterns of this high mortality rhinocerebral fungal infection in patients with diabetes is a key to early diagnosis and successful treatment., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

In many cases of mucormycosis, immediate surgical treatments are necessary because of its fulminant course and destructive characteristics in an immunocompromised patient. However, a chronic indolent type is also observed in a healthy group of people. We experienced rhinomucormycosis in a 56-year-old woman with diabetes who previously had pulmonary mucormycosis. She was treated successfully through endoscopic sinus surgery and nasal irrigation with antifungal agent. Herein, we report the clinical courses and symptoms of this patient with literature review.

Rhinosinusitis infection due to Saksenaea vasiformis is extremely rare. The present case describes a rhino-orbital infection in a 21-month-old Chadian immunocompetent male child with a 2-month history of excessive tearing from the right eye, followed by swelling of the right upper and lower eye lids, associated with right facial swelling and dark coloration surrounding the lower eye lid. Coronal computed tomography (CT) scan of the paranasal sinuses showed opacification of the right nasal cavities with extension to the orbit. Non-septate fungal hyphae were diagnosed by tissue sections and a Blankophor P fluorescent stain microscopy. The culture grew zygomycetes, S. vasiformis that failed to sporulate on Sabouraud dextrose agar, the organism was sporulated after 1 week on Czapek agar medium, and produced flask-shaped brown pigmented sporangium with lateral rhizoids and hemispherical columella filled with spores. The patient underwent a right functional endoscopic sinus surgery, where debridement of both right maxillary and ethmoid sinuses was done. Treatment with amphotericin B lipid complex was started and continued for 41 days. The patient was clinically doing better with decreased eye and facial swelling, and his erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were decreased to normal values. The patient continued with treatment on posaconazole after his discharge, and his condition resolved without further sequelae. Rhinosinusitis due to mucormycosis should be considered in any patient, even in young children, presenting with progressive rhinosinusitis infection, whether immunocompromised or not. Early diagnosis may lead to a successful treatment and good prognosis.

In this report, we present a case of rhino-orbital mucormycosis in a 57-year-old female with poorly controlled diabetes mellitus. The only mold cultured at 25°C, 37°C, and 40°C from a specimen of the nasal crust was identified phenotypically and independently using nuclear ribosomal DNA sequence data as Thamnostylum lucknowense. To our knowledge, this report presents the first data implicating this mucoraceous fungus as a mycotic agent of human infection.

Mucormycosis is an opportunistic infection caused by fungi of the order Mucorales. It is characterized by rapid progression and high morbidity and mortality in the absence of early diagnosis and prompt treatment. It was an infrequent disease, but in recent years, its incidence appears to have increased. The aim of this paper is to report the cases of mucormycosis diagnosed from 1982 to 2010 at the Hospital de Clinicas José de San Martín, University of Buenos Aires. We diagnosed 10 cases of mucormycosis; the first three between 1982 and 2004 and the last 7 between 2005 and 2010. The incidence from 1980 to 2004 was 0.13 patient-years and the frequency 0.1/10 000 discharges (95% CI 0.00- 0.3). In the period 2005 to 2010, the incidence was 0.86 patients per year with 1.1/10 000 discharges (95% CI 0.5-2.4). There was a pulmonary mucormycosis case (in a patient treated with corticosteroids) and nine rhinocerebral cases, two in neutropenic and seven in diabetic patients. The diagnosis was made by observation of cenocytic hyphae in 10/10 patients. Mucorales were recovered in 8/9 cultures (5 Rhizopus spp and 3 Mucor spp.). In one case diagnosis of pulmonary mucormycosis was made post-mortem. Nine patients were treated with amphotericin B deoxycholate (in 3 patients supplemented with liposomal amphotericin B) and surgery. Three patients underwent hyperbaric chamber. Seven patients had favorable outcome. In conclusion, mucormycosis is a rare disease, but its incidence has increased over the past five years. A good evolution of the patients is linked to early diagnosis and treatment.

Mucormycosis is a rare opportunistic infection caused by fungi belonging to Mucorales order. The infection usually starts in the middle or inferior nasal meatus and then spreads to the paranasal sinuses and the orbit. Then it reaches the brain through the ethmoid and the orbit apex and can lead to lethargy, paralysis, and death. The majority of cases of rhinocerebral mucormycosis are diagnosed in patients with immunologic and metabolic disorders. Early diagnosis is fundamental, and so is medical therapy with amphotericin B along with surgical toilet of the compromised tissues. This article presents and discusses the management of 3 cases of rhinocerebral mucormycosis with different onsets, progressions, and outcomes., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objective: Mucormycosis is an aggressive fungal infection which may still cause fatal complications. However, the rarity of this disease has made optimal treatment a controversial issue. This study aimed to evaluate the use of topical amphotericin B in endoscopic management of rhinocerebral mucormycosis., Subjects and Methods: Thirty patients with infection limited to the nose and sinuses were selected. Patients underwent endoscopic debridement of all necrotic tissue; cottonoid pledgets soaked in amphotericin B solution were then placed in the nasal cavity. Subsequently, long-term antifungal therapy was administered., Results: The overall survival rate was 60 per cent (18 cases); survival rates in the diabetic and malignancy groups were 70.58 and 40 per cent, respectively. Apart from predisposing factors, orbital and maxillary sinus involvement also had a significant correlation with patient outcome., Conclusion: Topical use of amphotericin B combined with endoscopic surgical debridement, followed by intravenous amphotericin B treatment, may constitute acceptable management for selected patients, with less morbidity than conventional treatments.

Objective: In this retrospective study, we describe our experience in the diagnosis and management of rhinocerebral mucormycosis (RCM), a rapidly lethal fungal infection., Methodology: Between 1997 and 2007, five patients hospitalized for suspicion of RCM. Computed tomography was performed in all cases, and diagnosis was confirmed after anatomopathological or mycological examination. All patients underwent medical and surgical treatment. Follow-up was clinical and radiological with a mean period of 17 months., Results: All patients were diabetic. Exophthalmia, rhinorrhea, and ophthalmoplegia were the most frequent symptoms observed. One patient had loss of visual acuity and another exhibited peripheral facial palsy. One patient had extensive hemifacial cutaneous necrosis. Nasal endoscopy revealed black necrotic lesions in one case, and another patient had a tumefaction localised in the left middle meatus. Necrotic lesions were most often found in the orbit, the maxillary and the ethmoidal sinuses on computed tomography (four cases for each site). One patient had thrombophlebitis of the cavernous sinus, and another had an intracranial extension. All patients were administered ordinary insulin and intravenous amphotericin B. Surgical debridement of the nasal cavity and the involved sinuses was performed through lateral rhinotomy (four cases) or endoscopy (one case). Unilateral orbital exenteration was associated in two cases. Progression was favourable in four cases; one patient died from sepsis despite aggressive treatment., Conclusion: Early diagnosis is crucial for the management of RCM. Treatment of underlying disorders, use of intravenous amphotericin B, and aggressive surgical intervention are key in reducing morbidity and mortality rates.

Introduction: A patients with undiagnosed type II diabetes mellitus presented with infective rhinocerebral mucormycosis. INVESTIGATION RESULTS: Initial magnetic resonance imaging scans demonstrated an aggressive disease process involving the left orbit and paranasal sinuses. A repeated scan following treatment excluded intracranial spread or recurrence. Pus from the paranasal sinuses grew Rhizopus arrhizus on microbiological culture., Management: Initial treatment comprised intravenous liposomal amphotericin B, intravenous co-amoxiclav and surgical debridement. The patient's diabetes was managed medically. The development of drug-induced transaminitis required a change of medication. The dose of liposomal amphotericin B was reduced, and then titrated back up as the liver function test results improved. Posaconazole was also introduced and the patient was eventually discharged on this alone, as the maximum recommended cumulative dose of liposomal amphotericin B had been reached., Conclusions: Posaconazole may be used effectively in conjunction with surgical debridement in the treatment of patients with infective rhinocerebral mucormycosis who develop hepatotoxic side effects to liposomal amphotericin B. Posaconazole may also allow a reduction in the dose of liposomal amphotericin B, resulting in better tolerance.

Mucormycosis is an aggressive, opportunistic infection caused by fungi belonging to the class of Phycomycetes. Rhino-oculo-cerebral mucormycosis is the commonest anatomical presentation of mucormycosis and is a potentially fatal disease. We report here a case of a 65-year-old diabetic female who presented with a locally invasive type of mucormycosis and was treated successfully by surgical debridement along with medical treatment (Amphoterecin-B and insulin).

A 53-year-old healthy patient was admitted with unilateral nasal obstruction of one month duration which was suspected to be a malignancy because of mass-like finding on radiology and peripheral eosinophilia. The biopsy of the involved sinus showed tissue invasion by aseptate hyphae suggestive of a zygomycete and tissue infiltration of eosinophilia. He was diagnosed as invasive paranasal mucomycosis and treated with complete endoscopic sinus surgery and amphotericin B deoxycholate. Paranasal symptoms with peripheral eosinophilia might be a presentation of invasive fungal sinusitis.

Rhinocerebral or rhino-orbitocerebral (mucormycosis) zygomycosis (ROCZ) usually occurs among patients with poorly controlled diabetes mellitus (especially those with ketoacidosis), solid malignancies, iron overload or extensive burns, in patients undergoing treatment with glucocorticosteroid agents, or in patients with neutropenia related to haematologic malignancies. The disease process starts with inhalation of the fungus into the paranasal sinuses. The fungus may spread to invade the palate, sphenoid sinus, cavernous sinus, orbits or cranially to invade the brain. Pain and swelling precede oral ulceration and the resulting tissue necrosis can result in palatal perforation. Infection can sometimes extend from the sinuses into the mouth and produce painful, necrotic ulcerations of the hard palate. If untreated, infection usually spreads from the ethmoid sinus to the orbit, resulting in the loss of extraocular muscle function and proptosis. Surgical treatment includes the resection of involved tissues of the face, including skin and muscle, any skin of the nose that is involved, maxillary and ethmoid sinuses, necrotic tissue of the temporal area and infratemporal fossa, and orbital exenteration. The keys to successful therapy include suspicion of the diagnosis and early recognition of the signs and symptoms, correction of underlying medical disorders such as ketoacidosis, and aggressive medical and surgical intervention.

Objective: We report a rare case of internal carotid artery pseudoaneurysm owing to rhinocerebral mucormycosis and review 40 reported cases from 1980 to present., Clinical Presentation: A 38-year-old Caucasian man presented with a 3-day history of headache, diplopia, and numbness in the distribution of the left ophthalmic and maxillary branches of the trigeminal nerve. A complete left cavernous syndrome was discovered upon neurological examination. Magnetic resonance imaging scans revealed an inflammatory process involving the paranasal sinuses with extension into the left cavernous sinus, temporal fossa, and petrous bone., Intervention: The patient was immediately treated with amphotericin B, atorvastatin, and daily hyperbaric oxygen sessions before surgical intervention. The patient underwent endovascular treatment of the associated mycotic pseudoaneurysm after carotid test occlusion in addition to a radical bilateral debridement of the paranasal sinuses and infratemporal and temporal fossa., Conclusion: Aggressive multimodal therapy is imperative for late-stage rhinocerebral mucormycosis. Extensive resection of infected tissue combined with amphotericin B, atorvastatin, and hyperbaric oxygen seems to be the best course of management. If the internal carotid artery is involved, endovascular intervention is clearly an option to attain this goal. Further research and longer follow-up periods are required to better understand the long-term implications of endovascular coiling and hyperbaric oxygen therapy for rhinocerebral mucormycosis.

Young diabetics can sometimes have difficulty with insulin compliance for various reasons. This can be exacerbated if associated with body dysmorphic disorder or other eating disorders. The manipulation of insulin to lose weight can have devastating consequences. The authors describe a fatal case of rhino-orbital-cerebral mucormycosis secondary to insulin manipulation for the purpose of weight loss.

Four successive cases of rhino-occulo-cerebral mucormycosis [ROCM] in patients suffering from type 2 diabetes mellitus are described. The clinical presentation is given in details. The need for high degree of suspicion, prompt diagnosis and complete surgical evacuation of inflammatory mass; and prompt initiation of antifungal therapy is discussed. The side effects associated with amphoterecin and issue regarding its total dosage is discussed.

This is a retrospective study including 17 patients with rhino-orbito-cerebral mucormycosis diagnosed in a period of 16 years, between 1992 and 2007, in 8 men and 9 women. All patients were diabetic with ketoacidosis diabetes in 8 cases. Necrosis facial and ophthalmic symptoms were the most frequent presenting manifestations. The diagnosis was confirmed by mycological examination, with or without histopathology, identifying Rhizopus oryzae in 12 cases. Treatment consisted in systemic amphotericin B combined with surgical treatment in only 7 cases. The mortality rate was high (65%) due principally to the delay in diagnosis and absence of surgical treatment.

A 29-year-old man developed vision loss in the right eye due to ophthalmic artery, cavernous sinus, and superior ophthalmic vein occlusion in mucormycosis. Diffusion MRI obtained within 2 days of symptom onset showed that the apparent diffusion coefficient values of the optic nerve and retina were remarkably decreased on the affected compared with the unaffected side. A follow-up MRI study 21 days after symptom onset revealed the anticipated disappearance of these signal changes, confirming that they were a true reflection of ischemia in the optic nerve and retina. This report adds to an accumulating body of literature on restricted diffusion in these tissues in conditions producing severe ischemia.

A 56-year-old female patient presented with history of nasal blockage, nasal bleeding, headache, since one month. On admission the patient developed severe headache, decreased vision of eyes and blindness. Clinical diagnosis of rhino-orbital involvement was confirmed by computerized tomography of the paranasal sinuses. The diagnosis of fungal infection was confirmed by KOH examination, haematoxylin and eosin examination and Gomori's methanamine silver stain of the biopsy material. Diagnosis was confirmed by culture on Sabouraud Dextrose agar, slide culture on Czapek Dox medium and the isolate was identified as Saksenaea vasiformis. The patient was started on intravenous amphotericin B (received only one dose before succumbing), but she did not respond to the treatment, developed hemiparesis, slurred speech, diminished reflexes and ultimately died. The involvement of the brain was confirmed by computerised tomographic scan. We believe this case to be the first case of rhino-orbito-cerebral infection due to Saksenaea vasiformis and that of second case in an immunocompetent patient in the world.

Purpose: To report a case of bilateral ophthalmic artery occlusion in rhino-orbito-cerebral mucormycosis., Methods: Reviewed clinical charts, photographs, and fluorescein angiography, Results: An 89-year-old man with poorly controlled diabetes developed sudden bilateral ptosis, complete ophthalmoplegia of the right eye, and superior rectus palsy of the left eye. Brain and orbit magnetic resonance imaging showed midbrain infarction and mild diffuse sinusitis. On the 2nd day of hospitalization, sudden visual loss and light reflex loss developed. There were retinal whitening, absence of retinal arterial filling, and a total lack of choroidal perfusion on fluorescein angiography of the right eye. The left eye showed a cherry red spot in the retina and the absence of retinal arterial filling and partial choroidal perfusion on fluorescein angiography. On rhinologic examination, mucormyosis was noticed. Despite treatment, visual acuity and light reflex did not recover and he died 4 days after admission., Conclusions: Bilateral ophthalmic artery occlusion can occur in rhino-orbital-cerebral mucormycosis.