CT and MR Imaging in the Diagnosis of Mucormycosis in COVID-19 Era - An Overview
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International Journal of Science and Healthcare Research
DOI: https://doi.org/10.52403/ijshr.20210440
Vol.6; Issue: 2; April-June 2021
Website: ijshr.com
Review Article ISSN: 2455-7587
CT and MR Imaging in the Diagnosis of
Mucormycosis in COVID-19 Era - An Overview
Tamijeselvan S
Asst. Professor in Radiography, Mother Theresa PG and Research Institute of Health Sciences
(Government of Puducherry Institution) Indira Nagar, Puducherry, INDIA 605006
ABSTRACT Mucormycosis infection of the
sinuses that typically affects
Mucormycosis is a rare but serious fungal immunocompromised patients with an
infection caused by mucormycetes. impaired neutrophilic response. Persons can
Mucormycosis mainly affects people who take include those with uncontrolled diabetes
medicines that lower the ability of the body to
mellitus, iatrogenic immunosuppression,
fight germs and have health problems. The
involvement and the extension of the disease acquired immunodeficiency syndrome and
can be investigated with the medical imaging haematological malignancies, and those
modalities like CT scan and Magnetic who have underwent organ transplantation.4
Resonance Imaging. The knowledge and the Mucormycosis is delineated by the
interpretation of medical imaging is very useful presence of hyphal invasion of sinus tissue
in the treatment planning. CT scan and and a time period of less than four weeks.5,6
Magnetic Resonance Imaging is very useful in Clinically, rhinocerebral mucormycosis can
finding the intra-orbital involvement which is be present with atypical signs and symptoms
common in mucormycosis. similar to chronic sinusitis, such as nasal
blockage, proptosis, facial pain and oedema,
Key words: Mucormycosis, CT scan, MR
chemosis, ptosis, and ophthalmoplegia, with
Imaging, Covid-19
headache and fever and various neurological
INTRODUCTION symptoms if intracranial extension is
Mucormycosis is a rare but serious present.7,8 A black eschar is often seen over
fungal infection caused by mucormycetes, a the hard palate region or in the nasal cavity
group of molds. Mucormycosis mainly .9,10 Histological features include mycotic
affects people who are taking infiltration of blood vessels, tissue
immunosuppressive drugs have health infarction, vasculitis with thrombosis, ,
problems. Mucormycosis is also known as haemorrhage and acute neutrophilic
phycomycosis. It was initially described in infiltrate.11
1885 by Paltauf, is an uncommon and Without early diagnosis and
aggressive fungal infection that usually treatment, there may be rapid progression of
affects patients with alteration of their the disease, with reported mortality rates
immunological system.1 It is consider to be from intracranial and intra-orbital
a lethal fungal disease, with rhinocerebral complications of 50–80 per cent.12 Even
presentation being its most common form.2 with prompt diagnosis, aggressive medical
Although it has a low incidence rate, and surgical intervention treatment of
varying from 0.005 to 1.7 per million underlying diseases, the management is
population, many cases have been reported often not very effective, leading to an
recently, amounting to a notable increase in extension of the infection and ultimately
its incidence in the ongoing covid-19 death.13
pandemic.3
International Journal of Science and Healthcare Research (www.ijshr.com) 222
Vol.6; Issue: 2; April-June 2021
Tamijeselvan S. CT and MR imaging in the diagnosis of mucormycosis in COVID-19 era - an overview
A complex interplay of factors that fungal infections to colonise. Hence, it is
include any previous respiratory pathology, important to be careful that Covid-19
diabetes mellitus, immunosuppressive patients can develop further fungal
therapy, nosocomial infection sources and infections during the treatment and latter
systemic immune alterations of Covid-19 stages of this disease, also especially
infection itself may lead to secondary severely ill individuals.15
infections. These are increasingly being Mostly patients had a primary
recognised in view of their impact on disease infection involving the ethmoid
morbidity and mortality.14 Extensive use of sinus air cells. The maxillary sinus was
steroids in managing Covid-19 can also affected in most of the cases. Sphenoid and
suppress immunity, allowing opportunistic frontal involvement was less common.
Medical Imaging in Mucormycosis
Fig. 1: (a–c) Coronal, non-contrast computed tomography scans of the paranasal sinuses, showing involvement of the sinuses with
intracranial involvement.
Fig. 2: (a–f) Axial, magnetic resonance imaging scans showing intra-orbital extension of mucormycosis.
International Journal of Science and Healthcare Research (www.ijshr.com) 223
Vol.6; Issue: 2; April-June 2021
Tamijeselvan S. CT and MR imaging in the diagnosis of mucormycosis in COVID-19 era - an overview
Fig. 3: (a–h) Coronal, magnetic resonance imaging scans showing intra-orbital extension of mucormycosis.
Because of nonspecific clinical immediately after suspicion for
signs, a high index of suspicion should be histopathological study to confirm the
made in the existence of risk factors. Biopsy diagnosis. And the correct parallel
of antral necrotic tissue should be performed comparison between clinical and
International Journal of Science and Healthcare Research (www.ijshr.com) 224
Vol.6; Issue: 2; April-June 2021Tamijeselvan S. CT and MR imaging in the diagnosis of mucormycosis in COVID-19 era - an overview
histological features helps in diagnosis. patients suffering from or recovered from
Some clinicians prefer CT scan before Covid-19 are at increased risk of developing
biopsy because biopsy may take time.16. So, invasive fungal diseases, and gave a
to appraise the extent of disease and to get a management algorithm for such cases. 15 In
quick picture of disease CT scan is done a recent review, 8 per cent of coronavirus-
immediately before histopathology results. positive or recovered patients had secondary
Nearly 50 percentage of the patients, bacterial or fungal infections during hospital
had involvement of the eye. Intracranial admission, with widespread use of broad-
involvement was seen very rarely. The spectrum antibiotics and steroids.. Mucor is
classical black eschar on the hard palate was a saprophytic fungus; its spores exist widely
observed in nearly half of the patients. in nature, and are spread in soil, air, food
Imaging reveals the erosion of and decaying organic material. 13 due to the
bones, obliteration of sinuses, and MRI is low virulence potential, it's going to be
favored to visualize the soft tissue changes present within the nasal mucosa of healthy
but is more expensive. 17 people as a commensal. If the patient
becomes immunosuppressed, this fungus
DISCUSSION may germinate within the paranasal sinuses,
The Covid-19 infection caused by and spread intracranially or to other nearby
the novel SARS-CoV-2 has been associated structures like the orbit.
with a wide range of disease patterns, Non-contrast computerized tomography of
ranging from a mild cough to life- the paranasal sinuses is typically the
threatening pneumonia. 18 A myriad of primary investigation of choice, with
manifestations and complications are gadolinium-enhanced resonance imaging
documented, and new ones are emerging being resorted to if intra-orbital or
and being reported on with each passing day intracranial extension is suspected. Focal
as we learn more about this novel Covid-19 bony erosions and extrasinus spread are
pandemic. strongly implicational the diagnosis. 13
During the SARS-CoV infection
spread in 2003, the incidence of mycosis CONCLUSION
was 14.8–27 per cent, and it had been the Mucormycosis is a fungal infection
most explanation for death for severe acute with high mortality and rising incidence
respiratory syndrome patients, accounting associated with Covid19 disease affected or
for 25–73.7 per cent in all causes of death. recovered patients. The most common
19-21
Studies have shown that SARS-CoV sinuses involved are the ethmoids followed
and SARS-CoV-2 belong to the same by the maxillary sinus. The involvement and
species, and have similar prevalence rates the extension of the disease can be
and biological and clinical characteristics. 22 investigated with the medical imaging
supported our experience in 2003, it's modalities like CT scan and Magnetic
important that physicians pay critical Resonance Imaging. The knowledge and the
attention to the high probability of increased interpretation of medical imaging is very
incidence of fungal infections in Covid-19 useful in the treatment planning.
affected or recovered patients, almost like Uncontrolled diabetes mellitus increases
the finding observed in mucormycosis cases further risk.
here. White et al. studied 135 adults with CT scan and Magnetic Resonance
Covid-19 infection, and reported an Imaging is very useful in finding the intra-
incidence of 26.7 per cent for invasive orbital involvement which is common in
fungal infections. 23 Song et al. studied the mucormycosis. The intracranial involve-
association between Covid-19 and invasive ment is rare and also it can be diagnosed by
fungal sinusitis in April 2020, and the help of CT scan and MRI. Extensive
concluded that an outsized number of steroid and broad-spectrum antibiotic use
International Journal of Science and Healthcare Research (www.ijshr.com) 225
Vol.6; Issue: 2; April-June 2021Tamijeselvan S. CT and MR imaging in the diagnosis of mucormycosis in COVID-19 era - an overview
for Covid-19 management may cause or extension: a case report and review of
exacerbate fungal disease optimum management. J Laryngol Otol
2007;121:192-5
Acknowledgement: None 11. DeShazo, RD, Chapin, K, Swain, RE.
Fungal sinusitis. N Engl J Med 1997;337:
254-9
Conflict of Interest: None 12. Gillespie, MB, O'Malley, BW. An
algorithmic approach to the diagnosis and
Source of Funding: None management of invasive fungal
rhinosinusitis in the immunocompromised
Ethical Approval: Not Applicable patient. Otolaryngol Clin North Am 2000;
33:323-34
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