Journal of Indira Gandhi Institute Of Medical Sciences

: 2022  |  Volume : 8  |  Issue : 1  |  Page : 71--72

Neurological manifestations of rhino-orbital-cerebral mucormycosis (zygomycosis)

Jamir Pitton Rissardo, Ana Letícia Fornari Caprara 
 Department of Medicine, Federal University of Santa Maria, Santa Maria, Brazil

Correspondence Address:
Jamir Pitton Rissardo
Av. Roraima, 1000 - Camobi, Santa Maria - RS, 97105-900

How to cite this article:
Rissardo JP, Caprara AL. Neurological manifestations of rhino-orbital-cerebral mucormycosis (zygomycosis).J Indira Gandhi Inst Med Sci 2022;8:71-72

How to cite this URL:
Rissardo JP, Caprara AL. Neurological manifestations of rhino-orbital-cerebral mucormycosis (zygomycosis). J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2023 Feb 5 ];8:71-72
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Dear Editor,

We read the article entitled “Mucormycosis during COVID-19 era: Double whammy in the pandemic” on the esteemed Journal of Indira Gandhi Institute of Medical Sciences with great interest. Kishor et al. analyzed the various clinicopathological characteristics of patients with mucormycosis and COVID-19 by an oncology department. A total of 45 individuals with mucormycosis participated in the study. All individuals have received steroids, and the majority of the patients were middle-aged adults with diabetes mellitus.[1]

Mucormycosis results from a variety of fungi that are innocuous in the environment, but it can affect predisposed individuals with diabetes mellitus, malignancies, or immunosuppressive therapy. In this way, general practitioners should have a high index of suspicion to diagnose this disease because the prognosis is primarily dependent upon the timing of the first therapeutic intervention. During the coronavirus pandemics, the steroid use as a standard recommendation and irrational use of antibiotics turn the population susceptible to the resurgence of uncommon neurological diseases such as mucormycosis.[2]

Herein, we would like to discuss recently published literature about neurological manifestations of rhino-orbital-cerebral mucormycosis [Figure 1].{Figure 1}

Dubey et al. studied the neurological clinical spectrum of mucormycosis in 55 patients. The most common clinical features reported were headache, proptosis, vision loss, and extraocular movement restriction. In addition, a new-onset upper jaw toothache was a striking observation in several cases. Radiological correlation with neuroaxis showed involvement of optic nerve, extraocular muscles, meninges, brain parenchyma, and internal carotid artery.[3]

Mucormycosis is a relatively rare angioinvasive opportunistic fungal infection, with a prevalence of two cases per million individuals. The recent zygomycosis epidemic was first noticed in India. Before the COVID-19 era, the disease burden of mucormycosis in India was estimated to be seventy times greater than the expected global costs. Besides India, mucormycosis related to coronavirus was described in several other countries such as Brazil, Iran, and the United States. Roushdy and Hamid described four individuals with mucormycosis in a tertiary hospital in Egypt. All their cases presented with total ophthalmoplegia.[4] The clinical diagnostic approach based on the center for disease control and prevention is facial swelling, headache, nasal/sinus congestion, and blackish discoloration. The inclusion of abnormal eye movements or visual impairment within these criteria is noteworthy, as almost all individuals have this clinical clue.[3],[4]

Another Egyptian study reported 14 cases of COVID-19 infection who developed rhino-orbito-cerebral mucormycosis during management. Alloush et al. hypothesized that the worsening of dysglycemia in COVID-19 individuals may occur due to damage of β-cell since SARS-CoV-2 can infect and replicate in the human islet cells. Interestingly, early visual disturbances appear to support the diagnosis of mucormycosis over bacterial cavernous sinus thrombosis, in which visual abnormalities are later in the clinical course.[5]

In the literature, mucormycosis and neurological manifestations were poorly described. Apparently, the main manifestation of this association before and during the pandemics is almost the same. Therefore, the COVID-19 era may provide an excellent opportunity to study these manifestations with a detailed clinical description and provide the effectiveness of other therapeutic agents.

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1Kishor K, Pawar SS, Kumar M, Raj S, Sinha DK, Kumar D, et al. Mucormycosis during COVID-19 era: Double whammy in the pandemic. J Indira Gandhi Inst Med Sci 2021;7:124-7.
2Rissardo JP, Caprara AL. Coronavirus disease 2019 (COVID-19) and neurological manifestations: A potential neuroinvasive pathogen. Ibnosina J Med Biomed Sci 2020;12:85-9.
3Dubey S, Mukherjee D, Sarkar P, Mukhopadhyay P, Barman D, Bandopadhyay M, et al. COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum. Diabetes Metab Syndr 2021;15:102267.
4Roushdy T, Hamid E. A case series of post COVID-19 mucormycosis-A neurological prospective. Egypt J Neurol Psychiatr Neurosurg 2021;57:100.
5Alloush TK, Mansour O, Alloush AT, Roushdy T, Hamid E, El-Shamy M, et al. Rhino-orbito-cerebral mucormycosis during the COVID-19 third wave in 2021: An Egyptian preliminary report from a single tertiary hospital. Neurol Sci 2022;43:799-809.