Abstract

Relevance: Rhino-orbito-cerebral mucormycosis (ROCM) is a fulminant and dangerous disease caused by invasive fungi. These pathogens, which are present saprophytically everywhere in the environment, can get caught into the body during breathing. Then they can expand the mucosa of the nasal cavity and paranasal sinuses, and after that – spread to the palate, orbit and brain. It should be noted that mucormycosis is a rapidly progressing angioinvasive infection. Before the occurrence of the COVID-19 pandemic, this pathology was endemic and was mostly found in the countries with a tropical and subtropical climate. However, after the onset of the second wave of the COVID-19 pandemic and the appearance of COVID-associated invasive fungal rhinosinusitis, the cases of mucormycosis have unprecedented increased not only in countries with tropical climates, but also throughout the world.

Objective: to study the risk factors and manifestations of the onset of the disease in patients with ROCM to prevent the occurrence of the disease and to find the possibility of early diagnosis and treatment of this pathology.

Materials and methods: In State Institution “O.S. Kolomiychenko Institute of Otolaryngology of National Academy of Medical Sciences of Ukraine” during 2020-2023 we examined and treated 6 patients with signs of invasive fungal rhinosinusitis. All patients underwent X-ray examinations, which included computed tomography (CT) of the chest, nasal cavity, and paranasal sinuses. Enhanced magnetic resonance imaging (MRI) was performed with orbital or intracranial spreading was suspected.

Results and discussion: According to the anamnesis, all 6 patients became ill with a COVID-19 infection. Acute rhinosinusitis of various degrees of severity began to be observed in all patients after suffering from a COVID-19 infection, and after a few weeks osteomyelitis of the bones of the skull appeared with varying degrees of damage and spreading. 4 out of 6 patients had diabetes of varying degrees of severity, 1 patient was HIV-infected and had hepatitis C, and 1 patient was diagnosed with cancer.

3 patients complicated on occurrence of chronic phlegmon of the orbit and the appearance of a fistula in the inner corner of the eye. Destruction of endonasal bone structures was noted in 3 patients. 1 patient suffered from ptosis, amaurosis and thrombosis of both cavernous sinuses with thrombosis of both internal carotid arteries. The ethmoid sinuses were involved in the pathological process in all cases, maxillary sinuses – in 4 patients, sphenoid sinuses – in 3, frontal sinuses – in 2 cases.

All 6 patients underwent surgical treatment, which depended on the degree of damage, clinical and radiological assessment of the spreading of the disease. The tissue from the affected areas was taken for histopathological examination in all cases.

Unfortunately, there are no pathognomonic symptoms of mucormycosis, and it may present with nonspecific and occult symptoms such as persistent fever, nasal congestion, facial pain, exophthalmos, diplopia, visual loss, and altered mental status. Numbness of the nasal cavity mucosa or the skin of face may indicate an invasive process.

Conclusion. Rhino-orbital-cerebral mucormycosis is a rare disease. There is a significant increase of its frequency after the occurrence of the COVID-19 pandemic.

We didn`t notice patients with rhino-orbital-cerebral mucormycosis before COVID-19 epidemic in Ukraine. This disease was considered endemic to countries with a tropical and subtropical climate. However, due to the appearance of COVID-associated invasive fungal rhinosinusitis, the spread of invasive fungal infections has expanded, which should be kept in mind during examination of such patients.

The absence of blackened necrotic scabs during diagnostic endoscopy of the nasal cavity does not exclude the diagnosis of mucormycosis.

A high index of suspicion is necessary in any patient with immunosuppressive conditions, especially with a history of COVID-19 infection, with signs of osteomyelitis of the maxilla and/or the bones of the skull base and should prompt the doctor to immediately re-examine the patient.

Key words: Rhino-orbito-cerebral mucormycosis, acute fungal invasive rhinosinusitis, fungal invasion, COVID-19 infection, diabetes, immunosuppressive conditions.