Mortality High After COVID-19-Associated Rhino-Orbitocerebral Mucormycosis

Black Fungus Infections Add To Covid Crisis
ALLAHABAD, INDIA – JUNE 05: An ear, nose and throat (ENT) specialist doctor inspects a patient before surgery to remove mucormycosis from the patient, who recovered from Covid-19, at Swaroop Rani hospital on June 05, 2021 in Allahabad, India. Mucormycosis, or “black fungus”, is a rare but potentially deadly fungal infection that affects the respiratory tract, sometimes causing swelling and discoloration around the eyes and mouth. Cases of the infection have been rising rapidly primarily among those recovering from the coronavirus. India’s prolonged and devastating wave of Covid-19 infections has gripped cities and overwhelmed urban health resources, but it has also reached deep into rural India, where the true extent of devastation is unknown because of the lack of widespread testing or reliable data. (Photo by Ritesh Shukla/Getty Images)
Patients with severe COVID-19, or presenting with severe orbital disease, are more likely to die within 10 days of admission.

Mortality after COVID-19-associated rhino-orbitocerebral mucormycosis (CAM) is high, according to results of a retrospective case-control study, published in JAMA Ophthalmology.

Patient records between March and May 2021 from the BYL Nair Charitable Hospital in India were retrospectively reviewed. Trends and mortality rates were assessed among patients with confirmed CAM.

Patients were aged mean 53.5 years (range, 32-86 years, 66% men), and 89% of those who disclosed their vaccination status had not received any vaccine and 11% had not received the second dose.

Most patients had unilateral sinus (77%) and orbital (85%) involvement. Few patients (7%) were without orbital involvement. Central nervous system involvement was observed among 8%.

COVID-19-related risk factors included diabetes (74%), use of insulin (62%), and uncontrolled diabetes (57%).

Prior to diagnosis of CAM, 3% were receiving home and ambulatory care, 10% were hospitalized without oxygen support, 59% were hospitalized with oxygen support, 19% were hospitalized on non-invasive ventilation, and 4% were on mechanical ventilation.

A total of 36% of patients with CAM did not survive. Mortality rates were 26% at day 7, 42% at day 14, and 53% at day 21.

The cohort of patients who did not survive CAM had a higher instance of uncontrolled diabetes (P =.001), they used insulin (P =.01), had increased high-resolution computed tomography scores during COVID-19 (P =.01), they received ventilation support (P =.02), fewer underwent diagnostic nasal endoscopy (P =.03), and were given a shorter duration of intravenous antifungal treatment (P =.001). In addition, death from CAM associated with no visual acuity to light perception (P =.02) and proptosis (P =.02).

The significant predictors of CAM mortality included need for noninvasive ventilation (hazard ratio [HR], 8.98; 95% CI, 2.13-38.65; P =.003) and visual acuity of light perception (HR, 0.56; 95% CI, 0.32-0.98; P =.04).

This study was limited by its low sample size and retrospective, single center design.

Taken together, these data indicated CAM was associated with a high mortality rate (>50% at week 3), especially among those with more severe COVID-19, no light perception, and proptosis. The authors found that intravenous antifungal agents combined with functional endoscopic sinus surgery likely was the most effective approach to salvage life.


Choksi T, Agrawal A, Date P, et al. Cumulative mortality and factors associatedwith outcomes of mucormycosis after COVID-19 at a multispecialty tertiary care center in India. JAMA Ophthalmol. Published online December 9, 2021. doi:10.1001/jamaophthalmol.2021.5201