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Year : 2021  |  Volume : 59  |  Issue : 2  |  Page : 216-217

Ruling out the obvious – Our tryst with rhino-orbital-cerebral mucormycosis

1 Jessly Eye Clinic, Villupuram, Chennai, Tamil Nadu, India
2 RIO GOH, Chennai, Tamil Nadu, India

Date of Submission09-Jun-2021
Date of Acceptance10-Jun-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Amogh Laxman Jambagi
Flat A012 DLF Commanders Court, Ethiraj Salai Egmore, Chennai - 600 008, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_79_21

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Atypical presentation of a typical disease can often leave the ophthalmologist looking for a needle in a haystack. Owing to the collateral damage caused by the COVID-19 pandemic, epidemics of rhino-orbital-cerebral mucormycosis (ROCM) are on the rise. It is a deadly fungal disease that invades tissues and causes infarction. We would like to present a case of ROCM who presented with persistent unilateral headache with otherwise normal ophthalmological findings.

Keywords: COVID-19, headache, rhino-orbital-cerebral-mucormycosis

How to cite this article:
Nainar AS, Jambagi AL. Ruling out the obvious – Our tryst with rhino-orbital-cerebral mucormycosis. TNOA J Ophthalmic Sci Res 2021;59:216-7

How to cite this URL:
Nainar AS, Jambagi AL. Ruling out the obvious – Our tryst with rhino-orbital-cerebral mucormycosis. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Jul 27];59:216-7. Available from: https://www.tnoajosr.com/text.asp?2021/59/2/216/319267

  Introduction Top

Rhino-orbital-cerebral-mucormycosis (ROCM) is a rapidly progressing fungal infection[1] which has caught the eye and the sinus of many COVID-19-infected and post-COVID-19-infected patients. It is a rapidly emerging disease, rising exponentially amid the pandemic owing to the use of steroids and immunosuppressants in the management of COVID-19 and due to the conducive environment created by the disease itself.[2] The damage caused by ROCM can be contained, provided it is diagnosed early and treated aggressively, the protocols on which are plenty.[3],[4],[5] Here, we will be presenting a case of ROCM with atypical symptoms and how paramount radiological imaging is in these cases.

  Case Report Top

A 56-year-old female presented with complaints of excruciating unilateral left-sided headache. On examination, her uncorrected visual acuity was 6/6 in both eyes. Ophthalmological examination was normal. She had no comorbidities and did not have a history of being infected with COVID-19. Her fundus examination was normal. Since it was her first episode, she was prescribed analgesics and asked to review if her symptoms persisted.

She presented 3 days later with a persistent unilateral headache. An ophthalmological examination of the left eye revealed palpebral fissure narrowing, epiphora, conjunctival congestion, with a 1 cm × 1 cm-sized swelling above the medial canthus [Figure 1]a. Examination of the right eye was normal. To rule the obvious, we decided to get a computerized tomography (CT) brain and paranasal sinus (PNS). The CT showed left maxillary, ethmoidal, and frontal sinusitis with osteomeatal unit obstruction along with inflammatory changes in the medial extraconal space of left orbit which were consistent with sinusitis, probably of fungal etiology [Figure 1]b.
Figure 1: (a) Color photograph of both eyes showing chemosis, palpebral fissure narrowing, swelling over medial canthus. (b) Computerized tomography of the brain with paranasal sinus revealing sinusitis

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She was immediately referred to an otorhinolaryngologist who diagnosed it as ROCM and started her on appropriate medications. She is yet to be reviewed at the time of publishing this article.

  Discussion Top

ROCM is a lethal disease caused by the angio-invasive fungus belonging to the group mucormycetes.[1] It is said to thrive in the nose and PNS of patients with uncontrolled blood sugars, immunocompromised individuals, and patients on steroid therapy. It is also postulated that they feed off the free iron and hence the affinity toward blood vessels. They invade vessels and cause ischemia leaving behind a black eschar. The fungus is said to inhabit the middle turbinate before making its way up the nasolacrimal duct into the medial side of the orbit and if not stopped, eventually making into way into the cranium.[3],[4]

The classical ocular symptoms of the patient include redness of eyes, diminution of vision, double vision, headache, and ocular pain. In most cases, headache is usually associated with ocular symptoms, but here in our case, on initial presentation, the patient had a unilateral headache with the unremarkable ophthalmological examination. Getting a neuroimaging done in a case of headache is of utmost importance, especially during this pandemic, given the prevalence of ROCM.[6] On estimation of the degree of involvement of orbit, PNS, or cranium, appropriate medical and surgical management can be undertaken. The final prognosis, however, depends on how early we catch the disease in its tracks.

In conclusion, we would like to reiterate that ROCM can present with a myriad of signs and symptoms and early diagnosis and management aided by radiological and histopathological investigations is the mainstay of treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Skiada A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and diagnosis of mucormycosis: An update. J Fungi (Basel) 2020;6:265.  Back to cited text no. 1
Ravani S, Agrawal G, Leuva P, Modi P, Amin K. Rise of the phoenix. Indian J Ophthalmol 2021;69:1563-8.  Back to cited text no. 2
  [Full text]  
Cornely OA, Alastruey-Izquierdo A, Arenz D, Chen SCA, Dannaoui E, Hochhegger B, et al. Global guideline for the diagnosis and management of mucormycosis: An initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis 2019;19:e405-21.  Back to cited text no. 3
Honavar S. Code mucor. Indian J Ophthalmol 2021;69:1361-5.  Back to cited text no. 4
  [Full text]  
Sipsas NV, Gamaletsou MN, Anastasopoulou A, Kontoyiannis DP. Therapy of mucormycosis. J Fungi (Basel) 2018;4:90.  Back to cited text no. 5
Herrera DA, Dublin AB, Ormsby EL, Aminpour S, Howell LP. Imaging findings of rhinocerebral mucormycosis. Skull Base 2009;19:117-25.  Back to cited text no. 6


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