It was a prospective, longitudinal study conducted under Neurosurgery department in Basaveshwara Medical College and Hospital, Chitradurga, Karnataka during the months of 1st May to 30th June 2021. Structured data collection methods were employed.

Patients who were also in active phase of COVID-19 infection were given parallel treatment for the same. Post operatively, antifungal drugs were given for 3-4 weeks. HRCT reports of all patients were collected for diagnostic purposes and to quantify the CT severity. CT scoring was used to compare COVID-19 severity with the incidence and severity of Mucormycosis. A unique classification system was devised by our team to grade and assess the severity of Mucormycosis based on the extent of involvement.

I – sinus involvement

II – sinus involvement along with extension to the skull base

III – sinus involvement, extension to skull base, along with orbital involvement

IV – intracranial extension

‘m’ symbolizes metastasis of Mucormycosis through the blood in the form of septic emboli

CT PNS, CT brain and MRI PNS, orbit and brain along with post operative tissue sample histopathology and KOH mounts were used for initial diagnosis and follow up for all patient of Mucormycosis. Surgical strategy was based on radiological characteristics of each case. Caldwell luc approach was employed for maxillary sinus debridement whereas FESS was employed for pansinusitis cases. Craniotomy was preferred for cases with intracranial involvement.

From the above data, 87.5% of the study participants lie in the 31-60 years age range with maximum (33%) in 31-40 years age range.

From the above data, 87% of the study participants were males while 13% were females.

Majority of the Mucormycosis patients show normal to elevated total white cell counts with 34% in the 9001-11000 range, with 25% above 14000 cells/mm^3.

Above data shows that 37.5% of the patients had neutrophil counts in 81-90% range while another 37.5% of the patients were in 71-80% range

Lymphopenia is the predominant finding in the laboratory data of Mucormycosis, with 33% of the cases having 10-14.9%, 21% having 20-24.9%, 17% having 5-9.9%, 8% of the cases with 25-29.9% and 35-39.9% each.

Majority of the cases of Mucormycosis have elevated serum ferritin levels with 25% of the cases coming under the range of 301-500ng/ml, 17% coming under the range of 501-700 and 701-900 ng/ml each, 16% cases with very high ferritin levels and only 13% of the cases with normal levels.

D-dimer values are elevated in majority of the patients with 83% of the cases lying under the range of 101-1000 ng/ml and only 17% lying under the normal range

Majority of the patients have levels of sodium that lie under the range of 131-135 meq/L with 54% having marginally reduced levels and only 29% in the normal range

66% of the cases have moderate COVID disease, whereas only 16.6 % of the cases have severe COVID diseases and 8.3% of the cases have mild COVID infection.

No mortality was reported in our study and clinical outcome of 22 patients (91.66%) was good.2 patients (8.34%) had headache and blurring of vision but no permanent loss for any higher function was observed after surgery in our study. In this study, we found that age, gender, neutrophil counts, monocyte count, ferritin levels, CT severity, diabetic status and usage of steroids and oxygen had a major role in the pathogenesis of mucormycosis.

Figure 1

Figure 2

A total of 24 cases of Mucormycosis were analyzed in this study. There is clear distinction in the gender involvement of Mucormycosis with 90% of the patients being male and 10% being females. This implies that male gender is a clear predisposing factor for Mucormycosis. We hypothesize that in the Indian settings, this could be due to male specific risk factors such as smoking, alcohol intake that affect the local immunity of the paranasal sinuses, thus causing increased chances of mucormycosis when associated with severe COVID infection even though this specific data wasn’t available. This result is in concordance with other studies 5, 7. On analysis of the age of the patients suffering from Mucormycosis, it was found that the age range of 41-50 had the maximum number of cases with the mean age being 45.9 years. This result coincides with other studies 8, 9. We analyzed the total count, neutrophil count, lymphocyte and monocyte values for all the patients and reached to a conclusive result that majority of the patients with Mucormycosis have an increase of neutrophil count with 38% of them lying in the range of 81-90%. This result coincides with another study 10. Monocyte counts were elevated, either marginally or significantly in majority of the patients with mucormycosis. On the other hand, lymphocytes were well within the normal range in majority of the cases, thus suggesting that lymphocytes may not have a pivotal role in the pathogenesis of Mucormycosis. This result is in concordance with another study regarding the same 11. Serum ferritin values of Mucormycosis patients during their COVID illnesses were analyzed and it was found that serum ferritin levels were markedly increased with majority of the values ranging between 700-900 ng/ml. This suggests a definite relation between elevated levels of serum ferritin and occurrence of Mucormycosis in the post COVID period. This is in concordance with other studies 5. It was also observed that majority of Mucormycosis patients had deranged electrolytes, especially sodium levels with majority of them coming under the range of 131-135meq/L. There are not many studies conducted that have shown a link between marginally low sodium levels and mucormycosis and further research is required in this area to substantiate sodium levels as a useful prognostic indicator for Mucormycosis 12. Waiting for cultures is impractical and may lead to an inadvertent delay in the initiation of treatment. If a clear clinical picture of mucormycosis exists, positive KOH mounts may be sufficient for initiating treatment HRCT severity score of all the patients were collected and it was observed that majority of the patients had severe form of the disease, i.e, >15/25 severity score, following or during which, they developed Mucormycosis as seen in other studies 13, 1. We analyzed the history, FBS and HbA1c levels of all our patients and the results were conclusive. Almost all our patients were diabetic, majority of them were on medication with urine ketone bodies positive in some cases. This suggests a probable link between diabetic status and occurrence of Mucormycosis as seen with other studies 5, 14, 15. In our study, all our patients had been treated with steroids and oxygen during the course of their COVID illness as was seen in other studies 16, 17. However, in a parallel study that we conducted that is yet to be published, wherein we compare this data with control group of patients with COVID, it was found that despite the same treatment, they did not develop mucormycosis.

Early diagnosis of COVID-19 mucormycosis through sharp clinical acuity and initiation of early surgical intervention seems to be the key to control this disease burden and prevent its numerous debilitating complications. The surgical treatment of RCM requires early diagnosis, aggressive surgical debridement, and early reconstructive surgery. The debridement should be continued until clear resection margins are obtained based on the assessment of microscopical findings of hyphae, fungal cultures, and/or fungal DNA detected by PCR. Considering the good clinical outcome achieved in our study with prompt and aggressive management, the significance of high degree of clinical suspicion, the earliest recognition and treatment of mucormycosis with aggressive surgical debridement in combination with antifungal medication cannot be overstated.

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