Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1

Purpose: COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including...

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Published in:	Indian journal of ophthalmology Vol. 69; no. 7; pp. 1670 - 1692
Main Authors:	Sen, Mrittika, Rao, Raksha, Sharma, Mukesh, Sachdev, Mahipal, Gupta, Adit, Sahu, Animesh, Khairnar, Anjali, Kochar, Anju, Shrivastava, Ankur, Desai, Anuja, Paul, Anujeet, Ayyar, Anuradha, Bhatnagar, Aparna, Nikose, Archana, Tenagi, Arvind, Kamble, Ashish, Patel, Bhavin, Kashyap, Bibbhuti, Dhawan, Bodhraj, Vohra, Busaraben, Mandke, Charuta, Sarkar, Deepayan, Mankad, Devanshi, Lalwani, Dilip, Patel, Diti, Manjandavida, Fairooz, Godhani, Frenali, Agarwal, Garima, Ravulaparthi, Gayatri, Thakkar, Hansa, Ojha, Hare, Jani, Harsha, Gontia, Jyoti, Likhari, Kamalpreet, Porwal, Kavita, Dharawat, Kulveer, Bhattacharyya, Mainak, Das, Mausumi, Hada, Maya, Panchal, Mehul, Pandharpurkar, Modini, Ali, Mohammad, Porwal, Mukesh, Mehrotra, Neelima, Bijlani, Neha, Gajendragadkar, Nidhi, Modi, Palak, Patil, Prajakta, Giri, Pramod, Yadav, Priti, Bhagat, Purvi, Parekh, Ragini, Dyaberi, Rajashekhar, Kaur, Rajwinder, Duvesh, Ram, Dandu, Ravi, Kathiara, Ravija, Beri, Renu, Pandit, Rinal, Rani, Rita, Gupta, Roshmi, Sapkal, Rujuta, Mehta, Rupa, Karmarkar, Sandeep, Shah, Sanjana, Shah, Sankit, Shah, Sapan, Dubey, Sarika, Gandhi, Saurin, Kanakpur, Savitha, Mohan, Shalini, Kerkar, Sheela, Jariwala, Shivani, Tara, Shruthi, Maru, Shruti, Sharma, Shubhda, Gupta, Shweta, Kumari, Shwetha, Das, Sima, Menon, Smita, Burkule, Snehal, Rao, Subramanya, Pakrasi, Sudipto, Rathod, Sujatha, Biradar, Sunil, Kumar, Suresh, Dutt, Susheen, Ravani, Swati, Ali Rizvi, Syed, Gokhale, Tanmay, Lahane, Tatyarao, Grover, Triveni, Chawla, Urmil, Une, Vaishali, Nandedkar, Varsha, Subramaniam, Venkata, Eswaran, Vidya, Rangarajan, Viji, Sahasrabudhe, Vivek, Sowjanya, Yarra
Format:	Journal Article
Language:	English
Published:	Mumbai Wolters Kluwer India Pvt. Ltd 01-07-2021 Medknow Publications and Media Pvt. Ltd Medknow Publications & Media Pvt. Ltd Wolters Kluwer - Medknow Wolters Kluwer Medknow Publications
Subjects:	Amphotericin B Care and treatment Coronaviruses Corticosteroids COVID-19 covid-19-associated rocm Debridement Demography Diabetes mellitus Diagnosis Distribution Epidemics Epidemiology Expedited Publication, Original Forecasts and trends Fungal infections India Intravenous administration Mortality Mucormycosis orbital exenteration Pandemics Paranasal sinus paransal sinus debridement Patients rhino-orbital-cerebral mucormycosis Risk factors Sinus Sinuses staging of rhino-orbital-cerebral mucormycosis Testing India COVID-19 COVID-19-associated ROCM paransal sinus debridement staging of rhino-orbital-cerebral mucormycosis Corticosteroids rhino-orbital-cerebral mucormycosis orbital exenteration diabetes mellitus mucormycosis
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Summary:	Purpose: COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management. Methods: This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021. Results: Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05). Conclusion: Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 ObjectType-Undefined-3 Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC) Study Group includes all the authors as listed in page 1670 and the following (listed in the alphabetical order of the first name): Abhilasha Maheshwari, Grecian Super-speciality Hospital, Mohali; Akruti Desai, Municipal Corporation of Greater Mumbai; Alay Banker, Banker's Retina Clinic and Laser Centre, Ahemdabad; Amit Kumar Deb, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; Anagha A Heroor, Anil Eye Hospital, Mumbai; Anil Jain, Roop Jeevan Hospital, Raipur; Anita Kumari, Railway Hospital, Ambala Cantonment, Haryana; Anuj Mehta, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi; Arpitha K, Sarojini Devi Eye Hospital, Hyderabad; Arun Alexander, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; Arundhati Malviya, Dr. Babasaheb Ambedkar Memorial Hospital, Central Railway, New Delhi; Ashwini Ghodse, Bowring and Lady Curzon Hospital, Bangalore Medical College and Research Institute, Bangalore; Avriel Gudkar, Anil Eye Hospital, Mumbai; Babu M S, Rangadore Memorial Hospital, Bengaluru; Beena Viramgama, Pandit Deendayal Upadhyay Medical College, Rajkot; Biswarup Ray, Bankura Sammilani Medical College and Hospital, Bankura; Chirag Pujara, Pandit Deendayal Upadhyay Medical College, Rajkot; Dhaivat Shah, Choithram Hospital and Research Centre, Indore; Dharmesh P Pandavadara, Pandit Deendayal Upadhyay Medical College, Rajkot; Deepali Gawai, Shree Bhausaheb Hire Government Medical College, Dhule; Dheeraj Kumar Jonnalagadda, Virinchi Hospital, Hyderabad; Dhwani Mehta, Pramukh Swami Medical College, Karamsad; Divya Khandelwal, Department of Ophthalmology, Maharaja Yeshwantrao Hospital, Mahatma Gandhi Memorial Medical College, Indore; Divyalakshmi Kaiyoor Surya, Yenepoya Medical College and Hospital, Mangalore; Ekta Singh Sahu, Retina Speciality Hospital, Indore; Elika Gupta, Sawai Man Singh Medical College, Jaipur; Faraz Ali, Aster Malabar Institute of Medical Sciences, Kozhikode; Gajendra Chawla, Vision Care and Research Center, Bhopal; Grace Budhiraja, Adesh Institute of Medical Sciences and Research, Bhatinda; Gunjan Tank, M and J Western Regional Institute of Ophthalmology, Byramjee Jeejeebhoy Medical College, Ahmedabad; Harshit Vaidya, Dr. Vaidya Eye Hospital, Mumbai; Hiral Bhalodia, Pandit Deendayal Upadhyay Medical College, Rajkot; Jay Rathod, M and J Western Regional Institute of Ophthalmology, Byramjee Jeejeebhoy Medical College, Ahmedabad; Jignesh Jethva, M and J Western Regional Institute of Ophthalmology, Byramjee Jeejeebhoy Medical College, Ahmedabad; K. Kiran Kumar, Bangalore Medical College and Research Institute, Bengaluru; Karthik Shamanna, Bangalore Medical College and Research Institute, Bengaluru; Keya Chakraborty, Sum Ultimate Medicare, Bhubaneswar; Memuna Bahadur, Dr. Babasaheb Ambedkar Memorial Hospital, Central Railway, New Delhi; Miti Shah, Pandit Deendayal Upadhyay Medical College, Rajkot; Neebha Anand, Regional Institute of Ophthalmology, Post Graduate Institute of Medical Sciences, Rohtak; Neeti Rushit Sheth, Pandit Deendayal Upadhyay Medical College, Rajkot; Nidhi Pandey, Indira Gandhi Eye Hospital and Research Centre, Lucknow; Niharika Chaurasia, Ratan Jyoti Netralaya, Gwalior; Nitin Kumar, Columbia Asia Hospital, Patiala; P. S. Kohli, Columbia Asia Hospital, Patiala; Piyush Bajaj, Dhir Hospital and Eye Institute, Bhiwani; Poonam Jain, Fortis Hospital, Shalimar Bagh, New Delhi; Preet Kanwar Singh Sodhi, Columbia Asia Hospital, Patiala; Rashmi S, Yenepoya Medical College and Hospital, Mangalore; Ravishankar Chandrashekhar, Bowring and Lady Curzon Hospital, Bangalore Medical College and Research Institute; Rekha Khandelwal, NKP Salve Institute of Medical sciences and RC, Nagpur; Ricky Vinay, Axon Eye Care, Mumbai; Ruddi Joshi, M and J Western Regional Institute of Ophthalmology, Byramjee Jeejeebhoy Medical College, Ahmedabad; Rukmendra P S Warkade, Sadguru Netra Chikitsalaya, Chitrakoot; Saloni Gupta, Northern Railway Central Hospital, New Delhi; Sameer Choudhary, Max Vision Eye Hospital, Nagpur; Sangita Basantaray, Hi-Tech Medical college and Hospital, Bhubaneswar; Sanket Oza, M and J Western Regional Institute of Ophthalmology, Byramjee Jeejeebhoy Medical College, Ahmedabad; Santanu Das, Sankara Eye Hospital, Bengaluru; Saptagirish Rambhatla, Sankara Eye Hospital, Bengaluru; Satish Reddy S, Bankura Sammilani Medical College and Hospital, Bankura; Saurabh Singh Jareda, Postgraduate Institute of Medical Sciences and Research and ESI Model Hospital, Basaidarapur, New Delhi; Shagil Khan, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh; Shailender Kumar Choudhary, Northern Railway Central Hospital, New Delhi; Shaunak Mokadam, Anjani Eye Care Hospital, Nagpur; Shikha Jain, Mahatma Gandhi Memorial Medical College, Indore; Shivanand Bubanale, Jawaharlal Nehru Medical College, Karnataka Lingayat Education Academy of Higher Education and Research, Belagavi; Shubhangi Bhave, Drishti Eye Clinic and Squint Centre, Nagpur; Smitha K. S., Jawaharlal Nehru Medical College, Karnataka Lingayat Education Academy of Higher Education and Research, Belagavi; Soumya Ray, Bankura Sammilani Medical College and Hospital, Bankura; Sruthi Rao, Rungta College of Dental Science and Research Centre, Raipur; Subashini Kaliaperumal, awaharlal Institute of Postgraduate Medical Education and Research, Puducherry; Subhashini V, Klakriti Eye Care Hospital, Chennai; Subina Narang, Government Medical College, Chandigarh; Sujithra Haridas, Amrita Institute of Medical Sciences, Kochi; Sumeet Lahane, Grant Medical College and Sir Jamshedjee Jeejeebhoy Group of Hospitals, Mumbai; Sunaina Chandana, Indira Gandhi Eye Hospital and Research Centre, Lucknow; Sunitha Mathew, Aster Malabar Institute of Medical Sciences, Kozhikode; Surbhi Joshi Kapadia, Sunayana Eye Care Centre and Venus Super-speciality Hospital, Vadodara; Supriya Khare, Department of Ophthalmology, Maharaja Yeshwantrao Hospital, Mahatma Gandhi Memorial Medical College, Indore; Swathi Y K, Sakra World Hospital, Bengaluru; Swati Samant, Sum Ultimate Medicare, Bhubaneswar; T. N. Ezhilvathani, Indira Gandhi Medical College and Research Institute, Puducherry; Umanath Nayak, Department of Head and Neck Surgery, Apollo Cancer Hospital, Hyderabad; Vaibhavi Patel, M and J Western Regional Institute of Ophthalmology, Byramjee Jeejeebhoy Medical College, Ahmedabad; Varsha Backiavathy, Sankara Nethralaya, Chennai; Vernon Miranda, Brahma Kumaris’ Global Hospital and Research Centre, Mumbai; Vinay Prasad, Axon Eye Care, Mumbai; Vishal Sharma, Apex Super-speciality Eye Care, Dehradun; Vishwanatha Borlingegowda, Bangalore Medical College and Research Institute, Bengaluru; Yamini Sahu, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
ISSN:	0301-4738 1998-3689
DOI:	10.4103/ijo.IJO_1565_21