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Santosh Kumar Swain, MS, DNB, MNAMS. *, Pragnya Paramita Jena, M.D.**, Somadatta Das, MA.***, Ankit Gupta, M.D.****
*Department of Otorhinolaryngology, IMS and SUM hospital, Siksha “O” Anusandhan University, K8, Kalinganagar,Bhubaneswar-751003, Odisha,
India, **Department of Microbiology, IMS and SUM hospital, Siksha “O” Anusandhan University, K8, Kalinganagar,Bhubaneswar-751003, Odisha,
India, ***Central Research Laboratory, IMS and SUM hospital, Siksha “O” Anusandhan University, K8, Kalinganagar,Bhubaneswar-751003, Odisha,
India, ****Department of Microbiology, Pushpawati Singhania Hospital & Research Institute, New Delhi-110017, India.
COVID-19 Associated Mucormycosis in Head and
Neck Region: Our Experiences at a Tertiary Care
Teaching Hospital of Eastern India
ABSTRACT
Objective: To study the COVID-19 associated mucormycosis in the head and neck region of the patients along
with patient details, clinical manifestations and management.
Materials and Methods: is is a descriptive and retrospective study of COVID-19 associated mucormycosis
(CAM) carried out at a postgraduate teaching hospital. is study was conducted between March 2020 to April
2021. A patient prole such as age, sex, comorbidities, clinical presentations, diagnosis and treatment of the CAM
were analyzed.
Results: ere were 11 patients of CAM were enrolled in this study. ere were eight male and three female patients,
aged from 3 years to 72 years. Out of the 11 patients, 8 were diabetic (72.72%). ree patients (27.27%) were taking
prolonged systemic steroids with a long hospital ICU stay. One child (9.09%) was under chemotherapy for acute
leukemia. e common clinical symptoms were facial swelling, facial pain, nasal block and nasal discharge. e
diagnosis was conrmed by histological examination and fungal culture with Sabourauddextroseagar (SDA)
showing Rhizopus oryzae. All were treated with endoscopic surgical debridement and amphotericin B. One case
died because of cerebral involvement.
Conclusion: Early diagnosis and prompt treatment for CAM are required. Aggressive endoscopic surgical
debridement for local control and appropriate systemic antifungal treatment will help to improve the prognosis
and survival of the patients.
Keywords: COVID-19; SARS CoV-2; COVID-19 associated mucormycosis; head and neck region; amphotericin B
(Siriraj Med J 2021; 73: 423-428)
Corresponding author: Santosh Kumar Swain
E-mail: santoshvoltaire@yahoo.co.in
Received 15 May 2021 Revised 2 June 2021 Accepted 4 June 2021
ORCID ID: http://orcid.org/0000-0001-7933-4414
http://dx.doi.org/10.33192/Smj.2021.56
INTRODUCTION
Coronavirus disease 2019 (COVID-19) is caused
by acute respiratory syndrome coronavirus 2 (SARS
CoV-2), which has been considered a global public
health emergency.
1
COVID-19 has rapidly spread to
212 countries and made approximately five million
laboratory confirmed cases and more than 310,000
deaths worldwide by May 18
th
2020.
2
e rst case of
SARS-CoV-2 infection was detected in Wuhan, China.
3
As this virus is a novel virus, data in relation to clinical
manifestations of this COVID-19 disease are insucient.
4,5
Mucormycosis is an invasive fungal infection caused by
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an opportunistic and ubiquitous fungus that belongs to
the class Phygomycetes, subclass Zygomycetes, order
mucrorales, family mucroraceae.
6
Histopathological study,
direct, microscopy and culture from the clinical samples
are the important diagnostic modalities for mucormycosis.
7
Early diagnosis and treatment with endoscopic surgical
debridement are key for preventing this fatal clinical
entity. COVID-19 associated mucormycosis (CAM) is
less frequently documented in the literature. e aim of
this study is to analyze the detail of patient prole and
management of the CAM.
MATERIALS AND METHODS
is descriptive retrospective study was conducted
at the otorhinolaryngology postgraduate department of a
teaching hospital. is study was conducted between March
2020 to April 2021. Our Institutional Ethics Committee
(IEC) accepted this study with the reference number IEC/
IMS/SOA/12/08.03.2020. COVID-19 patients infected with
mucormycosis during the treatment period at COVID
hospital or aer discharge from the COVID hospital were
included in this study. All of the reverse transcription
polymerase (RT-PCR) positive for viral RNA and diagnosed
COVID-19 at the time of hospitalization. For RT-PCR
testing, the nasopharyngeal swab was used and the sample
was taken from nasopharyngeal secretions with wearing
personal protective equipment. e COVID-19 patients
without mucormycosis or Non-COVID-19 patients with
mucormycosis were excluded from this study. All the
patients underwent diagnostic nasal endoscopy for assessing
the bilateral nasal cavity and nasopharynx. Computed
tomography (CT) scan of the nose and paranasal sinus
and magnetic resonance imaging (MRI) done to nd out
the extent of the diseases into orbit and brain. During
nasal endoscopy, the tissue from the nasal cavity sent for
microscopy, culture and histopathological examination
showing broad non-septate hyphae with 900 branchings
(Fig 1). Ophthalmological and neurological consultations
were done in all cases to nd the loss of vision or not
and neurological involvement. ere were 11 COVID-19
patients with mucormycosis enrolled in this study. Out
of 11 patients, 7 was already discharged from COVID
hospital attached to our Medical college and the rest 4
were diagnosed during the treatment at COVID hospital.
Biopsy was taken from all the cases, which showed the
picture of mucormycosis with some foci of non-septate
fungal hyphae with right-angled hyphae branches. e
diagnosis was based on histopathological examination
and fungal culture. e fungal culture was done with SDA
showing mycelia growth, features of Rhizopus oryzae.
All patients underwent endoscopic debridement of the
mucormycosis along with exenteration of the orbit in
two cases, followed by parenteral infusion amphotericin
B (1-1.5 mg/kg/day) and a total dose of 2.5-3 gm. Patient
follow-up was done aer 6 months’ interval aer surgery.
SPSS Statistics for Windows, version 20, was used for all
statistical analyses (IBM-SPSS Inc., Chicago, IL, USA).
RESULTS
Out of 11 patients with mucormycosis, there were
8 male (72.72%) and 3 female (27.27%) patients with a
male to female ratio of 2.6:1. e age range of the patients
was from 3 year to 72 years. Out of the 11 patients, 8
(72.72%) were diabetic. All 8 diabetic mellitus patients were
under treatment with oral hypoglycemic agents/insulins
regularly, but their blood sugar was poorly controlled.
One child (9.09%) was diagnosed with acute leukemia
and three patients (27.27%) were taking a high dose of
steroids during the treatment of the COVID-19 infection.
Out of the 11 patients, 6 (54.54%) were diagnosed with
sinonasal mucormycosis, 2 (18.18%) had rhino-orbital
mucormycosis, 1 (9.09 %) had sinonasal and palatal
involvement of the mucormycosis and one had rhino-
orbital-cerebral mucormycosis. All the patients presented
with foul-smelling nasal discharge and nasal block. Out
of the 11 patients, 9 (81.81%) of them were presenting
with facial pain, but 6 (54.54%) were presented with
orbital and facial swelling (Fig 2A&B). ree (27.27%)
patients were presenting with headache, one (9.09%)
had proptosis, one had nasal septal perforation and one
had altered sensorium. (TABLE 1)
Fig 1. Histopathology microphotograph showing broad non-septate
hyphae with 900 branching (Eosin stain and 400 X magnication).
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Before the surgical debridement, the nasal swab
sent for KOH mount where all patients showed aseptate
hyphae. Culture of the nasal discharge showed Rhizopus
oryzae in nine patients and the rest showed no growth.
All cases underwent endoscopic surgical debridement
under general anesthesia. All the patients were also
administered an intravenous infusion of amphotericin B.
One case (9.09%) was fatal due to cerebral involvement
who died during the treatment period.
DISCUSSION
e ongoing COVID-19 pandemic started in Wuhan,
China, in December 2019 and became a global pandemic
because of its rapid spread.
8
e spectrum of clinical
presentations of symptomatic COVID-19 patient ranges
from mild to critical.
9
COVID-19 patients usually show
higher levels of inammatory cytokines (interleukin
(IL)-2R, IL-6, IL-10 and tumor necrosis factor-alpha),
impaired cell-mediated immune response, aect both
CD4+ T and CD8+ T cells.
10
So, COVID-19 patients
have susceptibility towards fungal co-infections such
as mucormycosis is found.
11
Mucormycosis is an uncommon opportunistic
fungal infection characterized by infarction and necrosis
of the host tissue by the invasion of the blood vessels by
hyphae.
12
In the head and neck region of the body, the
common clinical manifestations of the mucormycosis are
due to rhino-orbital-cerebral infection, which secondary
to inhalation of the spores into the nose and sinuses.
13
In this study, out of the 11 patients, 6 (54.54%) were
diagnosed with sinonasal mucormycosis, 2 (18.18%) had
rhino-orbital mucormycosis, 1 (9.09 %) had sinonasal and
palatal involvement of the mucormycosis and one had
rhino-orbital-cerebral mucormycosis. e predisposing
factors for mucormycosis are diabetes mellitus, systemic
corticosteroid use, hematological malignancies, neutropenia,
stem cell transplant and immunocompromised persons.
14
e critical ill COVID-19 patients admitted to the intensive
care unit (ICU) and required mechanical ventilation or
had prolonged duration hospital stays, even as long as
50 days, are likely to get co-fungal infections.
15
In this
study, the most comorbidity associated with COVID-19
patient was diabetes mellitus (72.72%). Rest three patients
(27.27%) were taking a high dose of systemic steroids for
reducing COVID-19 infections and one patient (9.09%)
was a known case of acute myeloblastic leukemia.
Mucormycosis is a rapidly progressive fungal
infection and oen ended in a fatal outcome. Clinical
presentations of mucormycosis depend on the site of the
disease. e initial clinical symptoms of the CAM are
nasal block or congestion, nasal discharge. e color of
the nasal discharge appears as bloody or brown or black
and facial pain. e patient may present with numbness
over paranasal sinuses. Headache and orbital pain are
also important features of the CAM. Many patients of
CAM may present with fever, toothache, loosening of
the maxillary teeth, blurring of vision or double vision.
In this study, all the patients were presenting with foul-
smelling nasal discharge and nasal block. Out of the 11
patients of this study, 9 (81.81%) of them were presenting
with facial pain and 6 (54.54%) were presenting with
facial swelling. ree (27.27%) patients were presenting
with headache, one (9.09%) had proptosis, one had
nasal septal perforation and one had altered sensorium
in our study. Diagnostic nasal endoscopy shows black
and necrotic tissue (eschar) inside the nasal cavity.
Fig 2. A 14-year-old girl of CAM presenting swelling at the right side orbit (Fig. 2A) and face (Fig. 2B).
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TABLE 1. Clinical prole of the COVID-19 associated mucormycosis patients.
Patient’s Age Sex Affected Clinical Co-morbid Treatment Outcome
serial (years) part presentations diseases
1 3 M sinonasal Facial swelling, Acute Endoscopic Cured
facial pain, nasal lymphoblastic surgical
discharge leukemia debridement plus
amphotericin B
2 14 F Naso-orbital Facial pain, nasal Prolonged Endoscopic Cured
block, nasal discharge, use of steroids surgical
facial swelling, nasal debridement plus
septal perforation amphotericin B
3 37 M Sinonasal Facial pain, nasal Uncontrolled Endoscopic Cured
block, nasal discharge Diabetes surgical
debridement plus
amphotericin B
4 38 M Oronasal Facial pain, palatal Uncontrolled Endoscopic Cured
black eschar, nasal diabetes surgical
discharge, nasal block debridement plus
amphotericin B
5 41 F Sinonasal Facial pain, nasal Uncontrolled Endoscopic Cured
discharge, nasal block diabetes surgical
debridement plus
amphotericin B
6 53 F Naso-orbital- Facial swelling, Prolonged Endoscopic Death
cerebral headache, altered use of surgical due to
sensorium, proptosis, steroids debridement plus rapid
nasal discharge, amphotericin B spread
nasal block to brain
7 62 M Naso-orbital Headache, orbital pain, Uncontrolled Endoscopic Cured
nasal discharge, diabetes surgical
nasal block debridement plus
amphotericin B
8 63 M Sinonasal Facial swelling, facial Uncontrolled Endoscopic Cured
pain, nasal discharge, diabetes surgical
nasal block debridement plus
amphotericin B
9 65 M Naso-orbital Facial swelling, facial Uncontrolled Endoscopic Cured
pain, proptosis, nasal diabetes surgical
discharge, nasal block debridement plus
amphotericin B
10 68 M Sinonasal Facial swelling, Uncontrolled Endoscopic Cured
numbness over face, diabetes surgical
nasal discharge mellitus debridement plus
amphotericin B
11 72 M Sinonasal Headache,Numbness Uncontrolled Endoscopic Cured
over face,nasal diabetes surgical
discharge mellitus and debridement plus
taken steroids amphotericin B
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Rhino-orbital-cerebral infection is a typical presentation
of mucormycosis where fungi invade the paranasal sinuses
to orbit and brain.
16
is clinical situation can result in
orbital apex syndrome such as complete ophthalmoplegia
with rapid loss of vision, involves cranial nerves such
as II, III, IV, V and VI, which need urgent treatment
with surgical intervention, antifungal drugs and control
of risk factors for preventing such morbidity and fatal
outcome.
17,18
Clinical suspicion and early diagnosis
and prompt treatment are key steps for preventing
the morbidity of the fatal condition like rhino-orbital-
cerebral mucormycosis.
19
Proper history taking, physical
examination and imaging are important components for
the diagnosis of the suspected mucormycosis. In CAM,
computed tomography (CT) scan will oen show bone
destruction. Brain magnetic resonance imaging (MRI) is
helpful to rule out any involvement of the brain, sinuses
and orbit.
20
An MRI of the brain may show multiple areas
of infarction and ischemia, indicating invasive fungal
disease. In case of unstable hemodynamic and poor
respiratory status with the inability to keep the patient
in a supine position without oxygen, desaturation made
it unfeasible for performing MRI. Bedside diagnostic
nasal endoscopy can be done in a timely manner and
histopathological processing in case of active COVID-19
infection is useful for starting the treatment for rhino-
orbital mucormycosis. Mucor is usually demonstrated
via a nasal biopsy and subsequent culture. Tissue is sent
for histopathological examination and KOH mount,
which conrm the mucormycosis.
21
Direct microscopy,
histopathology and culture from the clinical samples are
important diagnostic modalities for mucormycosis.
22
To avoid morbidity in this lethal clinical entity, clinical
suspicion and early therapy, as well as endoscopic surgical
debridement, is essential. e treatment of the CAM requires
a team approach which includes otorhinolaryngologists,
neurologist, ophthalmologist, dentist, microbiologist and
infection disease specialist. e patient needs control of
diabetes and diabetic ketoacidosis. e immunomodulating
drugs, if they continue, should be stopped. Endoscopic
surgical debridement should be done immediately aer
conrmation of the CAM. en amphotericin should be
started without delay. Liposomal amphotericin B (L-Amb)
is a preferred medical treatment. e dose of the L-Amb
is 5 mg/kg/day, diluted in 200 ml 5% dextrose over 2 to
3 hours infusion (avoid slow escalation; higher dose 10
mg/kg/day may be given in cerebral mucormycosis).
23
Amphotericin B deoxycholate (D-Amb) can be given if
the cost and availability of L-Amb is an issue. D-Amb is
given as 1 mg/kg/day in 5% dextrose, slow infusion for 6 to
8 hours. Premedication may be needed to avoid infusion
reaction. Renal function and potassium levels should be
monitored while treating amphotericin B. Patients who are
intolerant to amphotericin B, alternative antifungals such
as posaconazole or isavuconazole (injection/tablets) can
be started. e dose of posaconazole is Tab. Posaconazole
300 mg twice daily a day on the rst day followed by 300
mg once a day. e dose of the isavuconazole is 200 mg
three times a day for two days, followed by 200 mg once
a day.
24
e patients should be monitored clinically and
radiologically for the response of the treatment or disease
progression. Aer 3 to 6 weeks of amphotericin B therapy,
consolidation therapy (posaconazole/isavuconazole) for
3 to 6 weeks. In this study, all had undergone radical
debridement of the mucormycosis along with orbital
exenteration in two cases, followed by parenteral infusion
of amphotericin B (1-1.5 mg/kg/day) and a total dose of
2.5-3 gm.
Poorly controlled diabetes mellitus is a major issue
while managing the CAM, so good glycemic control
should be done during the management of COVID-19
patients. Systemic corticosteroids should be used only in
case of hypoxemia.
24
Oral steroids should be avoided in
patients with normal oxygen saturation on room air. If
systemic corticosteroid is used, blood glucose should be
monitored. e dose and duration of the corticosteroid
treatment should be limited to dexamethasone (0.1 mg/
kg/day) for 5 to 10 days. Patients should be advised to use
a face mask for reducing the Mucorales. During discharge
of the COVID-19 patients, the patient should be advised
about the early symptoms or signs of mucormycosis
such as facial swelling, facial pain, nasal blockage and
excessive discharge, loosening of tooth, chest pain and
respiratory insuciency. e worldwide case fatality rate
of mucormycosis is approximately 46%.
25
e diagnosis
of mucormycosis is oen dicult. However, the early
diagnosis and prompt treatment are always important
and late or even six days is associated with doubling of
mortality rate from 35% to 66%.
25
A high suspicion of
mucormycosis is considered in immunocompromised
patients. In the case of a high-risk person, the diagnosis
of mucormycosis can be anticipated if there is associated
with one side facial swelling, pain over the face, orbital
swelling or proptosis. e late sign is tissue necrosis which
acts as a hallmark for mucormycosis, which occur due
to vascular invasion and thrombosis.
26
If the diagnosis is
conrmed, prompt surgical opinion is required, followed
by antifungal agents. Early diagnosis and prompt treatment
are necessary for the improvement of the outcome of
mucormycosis in COVID-19 patients.
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CONCLUSION
Mucormycosis is a dreaded fungal disease resulting in
angio-invasion by the hyphae leading to thrombosis and
necrosis of the host tissue. Patients with diabetes mellitus or
taking systemic steroids or under any immunosuppressive
medication with COVID-19 are at greater susceptibility
for mucormycosis. In a COVID-19 patient, the severity
of the mucormycosis is due to its rapid progression
and angio-invasive nature. The clinician should act
promptly to identify the mucormycosis, particularly
in immunocompromised patients or poorly controlled
diabetes mellitus. e widely accepted treatment for
mucormycosis is amphotericin B, along with surgical
debridement. e rising of mucormycosis or black fungus
in COVID-19 patients can be managed eectively if
identied early with adequate treatment with amphotericin
B, surgical debridement and controlling of the associated
risk factors.
Study limitation
is study has a rather small sample size and may
restrict the outcome of the aforementioned interpretation.
However, the conclusion of this study will undoubtedly
inspire the future research eort in this catastrophic
clinical entity called COVID-19 associated mucormycosis.
REFERENCES
1. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A
pneumonia outbreak associated with a new coronavirus of
probable bat origin. Nature 2020;579(7798): 270–3.
2. Gorbalenya AE, Baker SC, Baric RS, de Groot RJ, Drosten C,
Gulyaeva AA, et al. e species severe acute respiratory syndrome
related coronavirus: classifying 2019-nCoV and naming it
SARS-CoV-2. Nat Microbiol 2020;5: 536-44.
3. Swain SK, Jena PP. Clinical implications and future perspective
of COVID-19 pandemic-a review. Int J Adv Med 2021;8(2):334-
40.
4. Moura DT, McCarty TR, Ribeiro IB, Funari MP, Oliveira PV,
Miranda Neto AA, et al. Diagnostic characteristics of serological-
based COVID-19 testing: a systematic review and meta-analysis.
Clinics 2020;75: e2212.
5. Swain SK, Das S, Padhy RN. Performing tracheostomy in
intensive care unit-A challenge during COVID-19 pandemic.
Siriraj Medical Journal2020 ;72(5):436-42.
6. Martínez-López R: Ecología de los hongos patógenos para el
hombre. Rev Mex Mic 2005; 21:85-92.
7. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al.
A pneumonia outbreak associated with a new coronavirus of
probable bat origin. Nature 2020;579(7798): 270-3.
8. Velavan TP, Meyer CG. e COVID‐19 epidemic. Tropical
medicine & international health. 2020;25(3):278-80.
9. Broughton JP, Deng X, Yu G, Fasching CL, Servellita V, Singh J,
et al. CRISPR–Cas12-based detection of SARS-CoV-2. Nature
biotechnology 2020;38(7):870-4.
10. Swain SK, Acharya S, Sahajan N. Otorhinolaryngological
manifestations in COVID-19 infections: An early indicator
for isolating the positive cases. J Sci Soc 2020 ;47(2):63-8.
11. Song G, Liang G, Liu W. Fungal co-infections associated with
global COVID-19 pandemic: a clinical and diagnostic perspective
from China. Mycopathologia 2020; 185:599-606.
12. Swain SK, Behera IC, Mohanty JN. Mucormycosis in head-
and-neck region–Our experiences at a tertiary care teaching hospital
of Eastern India. Annals of Indian Academy of Otorhinolaryngology
Head and Neck Surgery 2019;3(2):58-62.
13. Jeong W, Keighley C, Wolfe R, Lee WL, Slavin MA, Kong DC,
et al. The epidemiology and clinical manifestations of
mucormycosis: a systematic review and meta-analysis of case
reports. Clinical Microbiology and Infection 2019;25(1):26-34.
14. Serris A, Danion F, Lanternier F. Disease entities in mucormycosis.
J Fungi. 2019;5(1): 23.
15. Yang X, Yu Y, Xu J, Shu H, Liu H, Wu Y, et al. Clinical course
and outcomes of critically ill patients with SARS-CoV-2 pneumonia
in Wuhan, China: a single-centered, retrospective, observational
study. e Lancet Respiratory Medicine 2020;8(5):475-81.
16. Tsagkovits A, Ioannidis D, Rokade A. e microscope drape
method to reduce aerosolisation during endoscopic sinus
and skull base surgery in the COVID era. How i do it. Eur
Arch Otorhinolaryngol 2021; 278(2):573-6.
17. Anders UM, Taylor EJ, Martel JR, Martel JB. Acute orbital
apex syndrome and rhino-orbito-cerebral mucormycosis. Int
Med Case Rep J2015; 8:93-6.
18. Kermani W, Bouttay R, Belcadhi M, Zaghouani H, Ben Ali
M, Abdelke´ M. ENT mucormycosis. Report of 4 cases. Eur
Ann Otorhinolaryngol Head Neck Dis2016; 133(2):83-6.
19. Swain SK, Sahu MC, Banerjee A. Non-sinonasal isolated facio-
orbital mucormycosis–a case report. Journal de mycologie
medicale 2018;28(3):538-41.
20. Sen M, Honavar SG, Sharma N, Sachdev MS. COVID-19 and
Eye: A Review of Ophthalmic Manifestations of COVID-19.
Indian Journal of Ophthalmology2021;69(3):488-509.
21. Swain SK, Sahu MC, Baisakh MR. Mucormycosis of the Head
and Neck. Apollo Medicine 2018;15(1):6-10.
22. Spellberg B, Edwards J, Ibrahim A. Novel perspectives on
mucormycosis: pathophysiology, presentation, and management.
Clin Microbiol Rev 2005;18(3):5.
23. Gupta N, Soneja M. Amphotericin-induced pancytopenia in
a patient with rhino-orbital mucormycosis. Postgraduate
medical journal 2020;96(1139):572-.
24. Salmanton-García J, Seidel D, Koehler P, Mellingho SC, Herbrecht
R, Klimko N, et al. Matched-paired analysis of patients treated
for invasive mucormycosis: standard treatment versus posaconazole
new formulations (MoveOn). Journal of Antimicrobial
Chemotherapy 2019;74(11):3315-27.
25. Chamilos G, Lewis RE, Kontoyiannis DP. Delaying amphotericin
B-based frontline therapy signicantly increases mortality
among patients with hematologic malignancy who have
zygomycosis. Clin Infect Dis 2008; 47:503-9.
26. Swain SK, Lenka S, Das SR. Rhino-orbital Mucormycosis-A
Dreaded Clinical Entity. Int J Cur Res Rev 2020;12(24):197-
203.
Swain et al.
