Emergence of Invasive Fungal Rhinosinusitis in Recently Recovered COVID-19 Patients

Objective: The risk of invasive fungal rhinosinusitis is increased in Coronavirus disease 2019 (COVID-19) because of its direct impact in altering innate immunity and is further exacerbated by widespread use of steroids/antibiotics/monoclonal antibodies. The study aims to describe this recently increased clinical entity in association with COVID-19. Method: A prospective, longitudinal study including patients diagnosed with acute invasive fungal rhinosinusitis (AIFRS) who recently recovered from COVID-19 infection or after an asymptomatic carrier state. A single-center, descriptive study investigating demographic details, clinical presentation, radio-pathological aspects, and advocated management. Result: A total of 21 patients were included with a mean age of 49.62 years (SD: 14.24). Diabetes mellitus (DM) was the most common underlying disorder (90.48%), and 63.16% of all patients with DM had a recent onset DM, either diagnosed during or after COVID-19 infection. Nineteen patients (90.48%) had recently recovered from active COVID-19 infection, and all had a history of prior steroid treatment (oral/parenteral). Remaining 2 patients were asymptomatic COVID-19 carriers. Surprisingly, 2 patients had no underlying disorder, and 5 (23.81%) recently received the Covishield vaccine. Fungal analysis exhibited Mucor (95.24%) and Aspergillus species (14.29%). Most common sign/symptom was headache and facial/periorbital pain (85.71%), followed by facial/periorbital swelling (61.90%). Disease involvement: sinonasal (100%), orbital (47.62%), pterygopalatine fossa (28.58%), infratemporal fossa (14.29%), intracranial (23.81%), and skin (9.52%). Exclusive endoscopic debridement and combined approach were utilized in 61.90% and 38.10%, respectively. Both liposomal amphotericin B and posaconazole were given in all patients except one. Conclusion: A high suspicion of AIFRS should be kept in patients with recent COVID-19 infection who received steroids and presenting with headache, facial pain, and/or facial swelling. Asymptomatic COVID-19 carriers and COVID-19 vaccinated candidates are also observed to develop AIFRS, although the exact immuno-pathogenesis is still unknown. Prompt diagnosis and early management are vital for a favorable outcome.

Invasive fungal rhinosinusitis associated with COVID-19: An observational study

Respiratory Viral infections predispose patients to various coinfections and this may lead to enhanced disease severity and mortality. Despite the proven importance of co-infections, these are understudied during the large outbreaks of respiratory infections. Occurrence of invasive fungal respiratory superinfections in patients with COVID-19 has gained increasing attention recently. This study aims to assess Clinical & Microbiological profile of patients with invasive sinusitis in setting of COVID-19 disease at our institute Study Design: A retrospective observational study. Study included patients diagnosed with acute invasive fungal rhinosinusitis (AIFR) suffering from or having a history of coronavirus disease infection over the period of three months.(April 21 – June 21). The patients’ presentation details, imaging findings, co-morbidities, management details, and follow-up information were obtained, recorded and analysed. A total of 32 patients with AIFR with a mean age of 54.46±13.13 years old were included. Most common associated disease was diabetes mellitus (62.5%). Mycological analysis revealed most common fungi isolated from these patients were Mucor species.(56.25%) followed by Aspergillus species(15.62%) while coinfection with both of these species was seen in 5 patients.(15.62%) Candida species was isolated from samples of 4 patients (12.5%). Radiological studies of nose and paranasal sinuses showed that ethmoid (62.5%) and maxillary (46.87%) sinuses being the most commonly affected sinuses followed by Frontal (31.25%) and sphenoid (21.87%) sinuses. Peri-orbital invasion was seen in 5 (15.62%) cases whereas intracranial involvement was seen in 1 patient.(3.12%) In 8 (25%) patients only medical line of treatment was sufficient whereas 20 (62.5%) patients required surgical debridement during the treatment. 4 patients were lost to follow up. Overall survival was 90.62% (29/32) at the conclusion of the study. We are still learning the new and long-term complications of COVID- 19.The puzzle still remains unsolved about the cause and increased prevalence of invasive fungal infections in post-covid-19 population. High clinical suspicion and early and accurate diagnosis of AIFR in COVID-19 patients are essential for better prognosis.

Clinicoepidemiological study of acute invasive fungal rhinosinusitis in a tertiary care centre

<p class="abstract"><strong>Background: </strong>Coronavirus disease 2019 (COVID-19) accounted for severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), which was declared a global pandemic by World health organization (WHO) in March 2020. In second wave of COVID there was notable surge in Acute invasive fungal rhinosinusitis (AIFRS). We observed that use of systemic corticosteroids in treatment of COVID 19 especially among patients with poorly controlled diabetes mellitus increased the incidence of AIFRS.</p><p class="abstract"><strong>Methods:</strong> This is retrospective observational study carried out in a Tertiary care Hospital GMC Akola from period of February 2021 to august 2021 were patients with the suspected diagnosis of AIFRS were admitted and evaluated following a standardized protocol, including clinical examination diagnostic nasal endoscopy, radiological evaluation. Diagnosis of AIFRS was confirmed on histopathology.</p><p class="abstract"><strong>Results:</strong> Study was conducted in GMC, Akola of 136 patients out of which 97 were males and 39 were females. In our study 78.67% patients had history of covid infection, followed by diabetes mellitus in 54.41%, history of steroid treatment found in 64.70% patients. On HPE 69.85% were positive for mucor and mixed infection (mucor and aspergillus) were found in 6.61%. Most common presenting feature was facial pain and swelling in 66.91%, palatal changes with dental pain in 45.58%, diminution of vision 17.64%, headache in 27.94% patients.</p><p><strong>Conclusions:</strong> Early and prompt diagnosis in high level of clinical suspicion in suspicious patient of AIFRS is vital to improve outcomes as it is known to have high morbidity and mortality (18-80%).</p>

Post COVID-19 acute invasive fungal rhinosinusitis caused by Scedosporium apiospermum: a covert pathogen

<p class="abstract">Immune dysregulation caused by COVID-19 and the presence of risk factors such as diabetes, steroid therapy and immune-modulatory drugs significantly increase the risk of secondary invasive fungal infections. <em>Scedosporium apiospermum </em>is an emerging pathogen and is rarely reported as a cause of fungal rhinosinusitis. This was a previously unreported case of post COVID-19 acute invasive fungal rhinosinusitis caused by <em>S. apiospermum</em> with rare complications of cranial nerve palsies and ruptured mycotic intracranial aneurysm.</p>

Acute Invasive Fungal Rhinosinusitis-Related Orbital Infection: A Single Medical Center Experience

Backgrounds. Acute invasive fungal rhinosinusitis (AIFRS) is a hazardous infectious disease with rapid progression and high mortality and morbidities. Further orbital involvement is commonly seen. This study aims to analyze risk factors, clinical characteristics, and outcomes between patients with or without orbital involvement. Methods. A retrospective review was performed in a single tertiary medical center over a span of 13 years (2005–2018). A total of 21 patients with diagnosis of AIFRS were enrolled. We reviewed the patients’ basic characteristics, comorbidities, clinical presentations, image study findings, culture pathogens, and treatment outcomes and analyzed the differences between orbital-involved and orbital sparing disease. Results. The most common comorbidities in AIFRS were diabetes mellitus (DM) and hematological malignancy. Nine the 21 AIFRS patients had orbital-involved disease. Patients with orbital involvement had a higher prevalence of DM ( p < 0.05 ). Image studies revealed significant infection of the ethmoid sinus, sphenoid sinus, and frontal sinus in the group with orbital complication ( p < 0.05 ). Mucor, Rhizopus, and Aspergillus were cultured in both groups. Five patients in the orbital involvement group expired, with all of them having an initial presentation of conscious disturbance ( p < 0.01 ). Rhino-orbital-cerebral fungal infection was noticed in 3 of the 5 expired patients. Conclusion. In AIFRS patients, DM other than hematological malignancy was the main risk factor for orbital-involved disease. Patients with ethmoid, sphenoid, or frontal sinusitis had a higher possibility of orbital complication. Poor consciousness at initial presentation revealed highest possibility of rhino-orbital-cerebral fungal infection and led to death.