Predicting intracranial involvement: Unveiling perineural spread in COVID-19-associated mucormycosis, a novel phenomenon.

This study aimed to investigate the risk factors associated with intracranial involvement in COVID-19-associated mucormycosis (CAM) and to develop a nomogram model for predicting the risk of intracranial involvement, with a specific focus on perineural spread. An ambispective analysis was conducted on 275 CAM patients who received comprehensive treatment. Univariable and multivariable logistic regression analyses were performed to identify independent risk factors, and a nomogram was created based on the results of the multivariable analysis. The performance of the nomogram was evaluated using a receiver operating characteristic (ROC) curve, and the discriminatory capacity was assessed using the area under the curve (AUC). The model's calibration was assessed through a calibration curve and the Hosmer Lemeshow test. In the results, the multivariable logistic regression analysis revealed that age (OR: 1.23, 95% CI 1.06-3.79), HbA1c (OR: 7.168, 95% CI 1.724-25.788), perineural spread (OR: 6.3, 95% CI 1.281-19.874), and the disease stage were independent risk factors for intracranial involvement in CAM. The developed nomogram demonstrated good discriminative capacity with an AUC of 0.821 (95% CI 0.713-0.909) as indicated by the ROC curve. The calibration curve showed that the nomogram was well-calibrated, and the Hosmer Lemeshow test yielded a P-value of 0.992, indicating a good fit for the model. In conclusion, this study found that CAM particularly exhibits perineural spread, which is a predictive factor for intracranial involvement. A nomogram model incorporating age, HbA1c, disease stage, and perineural spread was successfully developed for predicting intracranial involvement in CAM patients in both in-patient and out-patient settings.

Discovery of perineural spread in COVID-19-associated mucormycosis reveals a new predictive model for intracranial complications which is crucial for early intervention.

COVID-associated rhinocerebral mucormycosis: a retrospective analysis of presentation and outcomes.

OBJECTIVES: To comprehensively analyse the disease presentation and mortality of COVID-associated rhino-orbito-cerebral mucormycosis. METHODS: A retrospective analysis of the demographics, clinical and radiographic findings was performed. A binary logistic regression analysis was performed to examine the survival of patients with mucormycosis from hypothesised predictors. RESULTS: A total of 202 patients were included in this study. Statistical significance was demonstrated in the predilection to the male gender, recent history of SARS-COV-2, history of use of corticosteroid and hyperglycemia in this cohort of CAM. The mortality rate was 18.31%. Advanced age, raised HbA1c and intra-orbital extension were found to be predictors adversely affecting survival. CONCLUSION: Early diagnosis, aggressive surgical therapy, early and appropriate medical therapy can help improve outcomes. LEVEL OF EVIDENCE: Level 4.

Battling the emerging epidemic of rhino-orbital-cerebral mucormycosis (ROCM) in COVID-19 pandemic: an interventional study.

PURPOSE: The most recent challenge being faced by the healthcare system during the worldwide COVID-19 pandemic is increase in the incidence rate of coinfection or superinfection; one of the most fatal being mucormycosis. This study aimed to estimate the risk factors, symptoms and signs, treatment outcome and prognosis of COVID-19-associated mucormycosis (CAM) patients. METHODS: This is an interventional study of 35 patients diagnosed and managed as CAM at a tertiary care centre in New Delhi, India. RESULTS: The mean age of patients was 40.45 ± 6 years with a male preponderance. CAM did not affect healthy individuals; the major risk factors included diabetes in 65.7% and injudicious steroid use in 51.4% patients. Orbital/facial edema was the most common presenting symptom (25.7%) as well as sign (28.57%). 68.5% patients were stage 3 (involvement of orbit) at presentation; 33.3% showed medial wall involvement. Treatment included intravenous Amphotericin and oral Posaconazole in all patients, paranasal sinus (PNS) debridement in 94.2%, orbital exenteration was done in 8 patients. Adjuvant retrobulbar Amphotericin B injection was administered in 12 patients with radiological resolution seen in 50% after 1 cycle. In patients with Stage 4 disease who underwent exenteration along with PNS debridement, survival rate was 100% at 30 days, and disease reduction occurred in 87.5% patients (P < 0.01). Overall, 68.5% responded to therapy, 8.5% showed progression and mortality rate was 22.85%, at a mean follow up period of 59.5 days. CONCLUSION: A multidisciplinary and aggressive approach is essential in the management of CAM patients.

[Late diagnosis of rhinocerebral mucormycosis in patients with COVID-19 (case studies)]. / Pozdnyaya diagnostika rinotserebral'nogo mukormikoza u bol'nykh COVID-19 (klinicheskie nablyudeniya).

From the beginning of the COVID-19 pandemic, the incidence of secondary infections (both bacterial and fungal) has increased due to immune suppression associated with the use of corticosteroids or broad-spectrum antibiotics as a part of COVID-19 treatment protocol, which may exacerbate a pre-existing fungal disease or cause a new infection. Ophthalmologists are often involved in taking medical and surgical decisions in these complex cases. In this regard, a strong clinical suspicion should be applied to possible secondary fungal infections in COVID-19. Their early diagnosis and treatment may reduce mortality due to COVID-19 associated rhinocerebral mucormycosis (ROCM). This article describes two clinical cases of late detection of ROCM with two different scenarios, and compare the features of these cases with the literature data.

COVID-19-associated mucormycosis, diabetes and steroid therapy: Experience in a single centre in Western Mexico.

BACKGROUND: COVID-19-associated mucormycosis (CAM) has emerged as a challenging complication as the current pandemic has increased the population requiring treatment with corticosteroids. CAM has caused a massive outbreak in India, reported to be causing cases in Iran, Egypt and The Netherlands. OBJECTIVES: To describe CAM cases occurring in a single centre in Western Mexico. METHODS: Our group carried out a retrospective study from May 2020 to May 2021 to identify CAM cases in patients with previous COVID-19 diagnosis. RESULTS: Six CAM cases occurred in a single centre in Western Mexico during the study period, most of them with diabetes (n = 5/6) and all received corticosteroid therapy even when only three had severe COVID-19. After analysing local COVID-19 burden, it was estimated that in this region, CAM was 300 times more frequent among COVID individuals than the estimates for general population. CONCLUSION: Similar to large reports in India and other countries, CAM cases reported in this study were diagnosed in individuals with diabetes, hyperglycaemic status and with history of previous use of corticosteroids. Identifying these individuals at risk can help the early identification of CAM. In addition, strict glycaemic control and avoidance of unnecessary corticosteroid in non-severe COVID-19 cases could help in preventing this complicated fungal infection.

Spectrum of intracranial complications of rhino-orbito-cerebral mucormycosis - resurgence in the era of COVID-19 pandemic: a pictorial essay.

Rhino-orbito-cerebral mucormycosis (ROCM) has regained significance following its resurgence in the second wave of the COVID-19 pandemic in India. Rapid and progressive intracranial spread occurs either by direct extension across the neural foraminae, cribriform plate/ethmoid, walls of sinuses, or angioinvasion. Having known to have a high mortality rate, especially with intracranial extension of disease, it becomes imperative to familiarise oneself with its imaging features. MRI is the imaging modality of choice. This pictorial essay aims to depict and detail the various intracranial complications of mucormycosis and to serve as a broad checklist of structures and pathologies that must be looked for in a known or suspected case of ROCM.

Rhino-orbital mucormycosis following COVID-19 in previously non-diabetic, immunocompetent patients.

PURPOSE: To report a series of 13 immunocompetent patients who developed new-onset uncontrolled diabetes mellitus (DM) following COVID-19 infection and presented as rhino-orbital mucormycosis (ROM). METHOD: Retrospective study. RESULTS: A total of 127 patients of COVID-19 Associated Mucormycosis (CAM) were evaluated at four centres in India. All patients underwent endoscopic sinus debridement surgery and received systemic amphotericin-B therapy. Five patients (5/13; 38.4%) received retrobulbar amphotericin-B injections. Orbital exenteration was performed in advanced orbital involvement or progression of orbital disease in spite of maximal medical therapy. In his cohort, 13/127 (10.2%) patients presented with new onset DM, where one patient had bilateral disease. The mean age was 35.9 years (range: 20-51 years) and the mean duration from diagnosis of COVID-19 to the diagnosis of mucormycosis was 14.2 days. While 7/13 (53.8%) of the patients received systemic corticosteroids during the course of their treatment for COVID-19, six patients received no steroids or immunomodulators. The mean follow-up period was 9.2 weeks (range: 3-18 weeks) following discharge. Life salvage was possible in 100% of the cases. While overall globe salvage was possible in 42.8% (6/14 eyes), the globe could be preserved in 4/5 patients who received retrobulbar amphotericin-B injections. CONCLUSIONS: Those involved in the care of COVID-19 patients should be aware about the possibility of recent-onset DM, even in patients without a history of corticosteroid therapy. Rarely, recent-onset DM following COVID-19 may present as rhino-orbital mucormycosis, which requires aggressive surgical and medical intervention.

Mucormycosis-A clinicoepidemiological review of cases over 10 years.

BACKGROUND: Limited data exist for epidemiology and outcomes of various agents causing mucormycosis in various clinical settings from developing countries like India. OBJECTIVES: To study the epidemiology and outcomes of various agents causing mucormycosis in different clinical settings in a tertiary care hospital from South India. PATIENTS AND METHODS: We reviewed details of 184 consecutive patients with culture-proven mucormycosis with consistent clinical syndrome and supporting features from September 2005 to September 2015. RESULTS: The mean age of patients was 50.42 years; 70.97% were male. Unlike developed countries, R microsporus (29/184; 15.7%) and Apophysomyces elegans (20/184; 10.8%) also evolved as important pathogens in addition to R arrhizus in our setting. Paranasal sinuses (136/184; 73.9%) followed by musculoskeletal system (28/184; 15.2%) were the common areas of involvement. Apophysomyces elegans typically produced skin and musculoskeletal disease in immune-competent individuals with trauma (12/20; 60%) and caused significantly lower mortality (P = 0.03). R microsporus was more common in patients with haematological conditions (25% vs 15.7%) and was less frequently a cause for sinusitis than R arrhizus (27.58% vs 10.9%). The overall mortality was 30.97%. Combination therapy with surgery and antifungals offered the best chance for cure. CONCLUSIONS: Agents causing mucormycosis may have unique clinical and epidemiological characteristics.

Hoveyda-Grubbs catalysts with an N→Ru coordinate bond in a six-membered ring. Synthesis of stable, industrially scalable, highly efficient ruthenium metathesis catalysts and 2-vinylbenzylamine ligands as their precursors.

A novel and efficient approach to the synthesis of 2-vinylbenzylamines is reported. This involves obtaining 2-vinylbenzylamine ligands from tetrahydroisoquinoline by alkylation and reduction followed by the Hofmann cleavage. The resultant 2-vinylbenzylamines allowed us to obtain new Hoveyda-Grubbs catalysts, which were thoroughly characterised by NMR, ESIMS, and X-ray crystallography. The utility of this chemistry is further demonstrated by the tests of the novel catalysts (up to 10-2 mol %) in different metathesis reactions such as cross metathesis (CM), ring-closing metathesis (RCM) and ring-opening cross metathesis (ROCM).

Stereochemistry of ring-opening/cross metathesis reactions of exo- and endo-7-oxabicyclo[2.2.1]hept-5-ene-2-carbonitriles with allyl alcohol and allyl acetate.

The ROCM reactions of exo- and endo-2-cyano-7-oxanorbornenes with allyl alcohol or allyl acetate promoted by different ruthenium alkylidene catalysts were studied. The stereochemical outcome of the reactions was established. The issues concerning chemo- (ROCM vs ROMP), regio- (1-2- vs 1-3-product formation), and stereo- (E/Z isomerism) selectivity of reactions under various conditions are discussed. Surprisingly good yields of the ROCM products were obtained under neat conditions.

Early trends of secondary acquired nasolacrimal duct obstruction in COVID-19 associated sino-orbital mucormycosis: SALDO update study (SUP) - Paper IV.

Purpose: To study the emerging trend of development of secondary acquired nasolacrimal duct obstruction (SALDO) in the cases treated for rhino-orbito-cerebral mucormycosis (ROCM). Observations: Prospective, interventional case series of five patients who developed SALDO post-surgical and medical management of ROCM. The mean age was 45.4 years (range: 40-62 years), all five being males. Right lacrimal drainage pathways was involved slightly more than the left (right:left = 3:2). Epiphora and discharge were the main presenting features. All five patients were treated with extensive debridement of the nose, sinuses, orbit and cerebral involvement as needed followed by medical management for ROCM. CT- Dacryocystography for all 5 patients showed obstruction at the lower end of the nasolacrimal duct. The patients underwent external dacryocystorhinostomy with mitomycin-C with or without intubation with good anatomical and functional outcomes at 6 months follow-up. Conclusions and importance: The present series highlights the possible etiology of development of SALDO in cases treated for ROCM, its management and discusses the role of Computed Tomography Dacryocystography (CT-DCG) in understanding the pathophysiology of the development of SALDO along with delineating the spatial relationship of the lacrimal drainage system with the surrounding structures.

The potential for rapid antigen testing for mucormycosis in the context of COVID-19.

INTRODUCTION: Mucormycosis is a highly aggressive angio-invasive disease of humans caused by Mucorales fungi. Prior to the COVID-19 pandemic, mucormycosis was a rare mycosis typically seen in immunocompromised patients with hematological malignancies or in transplant recipients. During the second wave of the pandemic, there was a dramatic increase in the disease, especially in India where a unique set of circumstances led to large numbers of life-threatening and disfiguring rhino-orbital-cerebral mucormycosis (ROCM) infections. AREAS COVERED: The review examines mucormycosis as a super-infection of COVID-19 patients, and the risk factors for COVID-19-associated mucormycosis (CAM) that drove the ROCM epidemic in India. The limitations of current diagnostic procedures are identified, and the measures needed to improve the speed and accuracy of detection discussed. EXPERT OPINION: Despite increased awareness, global healthcare systems remain unprepared for further outbreaks of ROCM. Current diagnosis of the disease is slow and inaccurate, negatively impacting on patient survival. This is most evident in low- to middle-income countries which lack suitably equipped diagnostic facilities for rapid identification of the infecting pathogens. Rapid antigen testing using point-of-care lateral-flow assays could potentially have aided in the quick and accurate diagnosis of the disease, allowing earlier intervention with surgery and Mucorales-active antifungal drugs.

A Case Series of Prosthetic Rehabilitation of Post-COVID Rhinorbitocerebral Mucormycosis Ocular Defects: A Digital and Analog Experience.

Removal of a part of or the entire orbit results in facial defect, causing psychological trauma to the patient, apart from anatomic loss. This case series presents 6 clinical cases of prosthetic rehabilitation of ocular defects related to post-COVID-19 ROCM by both analog and digital workflow. The basic objective of this case series was to achieve a well retained, user-friendly, maxillofacial ocular prosthesis with esthetic accuracy. Unique size and shape of the ocular defect in each case, variety of skin tones, age range of patients and compromised neuromuscular control made each of the six cases challenging. This clinical series apart from proposing a digital & analog algorithm for rehabilitating ocular defects also illustrates analog workflow for 4 cases and digital workflow for 2 cases for fabrication of ocular prosthesis.

The Radiological Spectrum of Rhino-Oculo-Cerebral Mucormycosis.

Aim We aim to study the spectrum of imaging findings in patients with rhino-oculo-cerebral mucormycosis (ROCM). Materials and methods This retrospective descriptive study was performed in histopathologically confirmed cases of rhino-oculo-cerebral mucormycosis in a tertiary care center in Bihar, India. The case records of patients with radiological, cultural, and histological evidence of acute invasive ROCM were retrospectively evaluated for relevant radiological and clinical data between May 2021 and June 2022. Results The radiological evaluation included computed tomography (CT) and magnetic resonance imaging (MRI) scans done on 52 patients. The patient's average age was 48 years. The ethmoid sinus was involved in 51 (98%) cases and the maxillary sinus in 50 (96%) cases. Bilateral sinus involvement (45, 86%) was the most common, followed by pansinus involvement (27, 52%). The orbit was involved in 39 (75%) cases, the face in 25 (47%) cases, and retroantral fat stranding in 24 (46%) cases. Mucosal thickening (91%) was the most common pattern of involvement, followed by complete opacification (77%). Osseous involvement was seen in 17 of 44 patients who had CT scans, and the majority of patients had extrasinus extension with intact bone. MRI revealed variable T2SI, with T2 hyperintensity being the most common pattern. Heterogeneous enhancement in post-contrast imaging was the most common. Conclusion ROCM is a life-threatening invasive fungal infection, especially in an immunocompromised state. ROCM is characterized by a variety of imaging abnormalities on CT and MRI, although nonspecific. Imaging aids in suspicion or early diagnosis in appropriate clinical contexts, particularly in an immunocompromised state, and in determining the degree of involvement and complications. Early detection of ROCM and its complications enables proper treatment, which can lower the cost of care, morbidity, and mortality.

Optimization of Oral Posaconazole Step Down Therapy in Management of Rhino-Orbital-Cerebral Mucormycosis (ROCM): Outcome of an Institutional Protocol.

All cases of ROCM received antifungal for a prolong period in step down phase. There is no definite guidelines regarding duration. We have formulated and followed an institutional protocol with good results. To determine the outcome of an institutional protocol and required optimum duration of oral posaconazole therapy to cure ROCM in step down phase, 30 ROCM patients were followed up in step down phase. Oral posaconazole tablet was given for minimum 3, 4 & 1/2 and 6 months to stage-II, III & IV cases respectively, with a provision of extension for another 6 weeks in suspected active diseases. Nasal endoscopy, MRI, histopathology /culture of suspected tissue and hematologic investigations were done routinely to identify the residual active disease or recurrences at earliest. Outcome of this protocol proved excellent as all cases of ROCM were cured. Oral posaconazole step down therapy for a duration according to the stages of disease cured 18 cases (60%) of ROCM. Fourteen patients required extended duration of therapy as per provision of our treatment protocol. Only one patient needed re-debridement. The cases with deformities needed extended period of posaconazole therapy. No one needed posaconazole therapy for more than 7and1/2 months.

A Comparison Between Potassium Hydroxide (KOH) Microscopy and Culture for the Detection of Post-COVID-19 Rhino-Orbital-Cerebral Mucormycosis.

Background and objective Mucormycosis is an emerging and serious angioinvasive infection caused by filamentous fungi related to the order of Mucorales and the class of Mucormycetes. There was a marked increase in the number of cases of mucormycosis in India following the second wave of the coronavirus disease 2019 (COVID-19) pandemic in the year 2021. In this study, we aimed to compare potassium hydroxide (KOH) microscopy with culture for the detection of post-COVID-19 rhino-orbital-cerebral mucormycosis (ROCM). Materials and methods The KOH microscopy was performed with a 10% or 20% KOH-mounted slide with specimens collected from suspected cases of post-COVID-19 ROCM. Simultaneously, the culture was done on Sabouraud dextrose agar (SDA). These were incubated at 37 ℃ and 25 â„ƒ for 28 days. Diagnostic parameters were calculated by comparing KOH with gold standard culture. Results KOH mount was positive for broad aseptate fungal hyphae in 322 (54.1%) cases, while it was negative in 244 (41.0%) cases. KOH mount was positive for other fungi in 29 (4.8%) samples. The diagnostic accuracy of the KOH mount for Mucorales was 70.3%. KOH mount had a sensitivity of 84.9%, specificity of 61.5%, positive predictive value (PPV) of 56.9%, and negative predictive value (NPV) of 87.2%. Conclusions Based on our findings, the KOH microscopy positivity rate was higher in tissue samples compared to nasal swabs, with a sensitivity of 84.9%, specificity of 61.5%, PPV of 56.9%, and NPV of 87.2%. The overall diagnostic accuracy of the KOH mount for Mucorales was 70.3%.

A clinico-pathological study of COVID-19 associated rhino-orbital-cerebral mucormycosis.

Purpose: Known predisposing factors for mucormycosis are neutropenia and diabetes. Though COVID-19 is associated with hyperinflammatory response, a high surge in rhino-orbital-cerebral mucormycosis (ROCM) cases was observed during the second wave. The histopathological features reflect the background pathogenesis. This study analyzes the histopathological features and clinical presentation of COVID-19-associated ROCM. Methods: In this retrospective observational study, the clinical details of 89 proven ROCM patients treated during May-July 2021 were collected from the case records. Histopathological features were correlated with clinical staging groups and outcomes. The mean neutrophil-to-lymphocyte ratio (NLR) of clinical and outcome groups were compared. Results: The mean age was 54.71 ± 11.03 years, with male patients constituting a majority (78.7%). Uncontrolled diabetes mellitus was noted in 70.8% of patients, and 3.4% had normal range of blood sugar. The mean blood sugar was 298.08 ± 99.51 mg/dL. The mean duration of onset of symptoms of mucormycosis from the diagnosis of COVID-19 was 17.36 ± 7.392 (3-45) days. Poor outcome with disease progression or death occurred in 21.3% of patients. Clinical group II patients (44.9%) with ROCM stages 3c and above had poor outcomes (P = 0.005). Histopathological analysis showed minimal inflammation in 25.8%, neutrophil extracellular trap (NET) in 75.3%, and angio-invasion in 28.1% of patients. Minimal inflammation was associated with clinical group II (P = 0.004) and poor outcome (P = 0.001). Angio-invasion correlated with poor outcome (P = 0.007). Patients with severe clinical group and poor outcome had higher mean NLR with P = 0.017 and P = 0.007, respectively. Conclusion: Vision loss and cerebral involvement had poor outcomes. The histopathologic features such as inflammation and angio-invasion along with NLR aid as prognostic indicators in the management of ROCM. The role of NET in the pathogenesis of COVID-19-associated ROCM needs further studies.

Rhino-orbito-cerebral mucormycosis: an epidemic in a pandemic.

Background: Opportunistic cases of rhino-orbito-cerebral mucormycosis (ROCM) have increased in India during the coronavirus disease 2019 (COVID-19) pandemic. Aim: To study laboratory parameters, histopathological features of sinus mucosal biopsies and exenterated orbit specimens, and clinical aspects of patients with ROCM. Materials and methods: Retrospective analysis of nasal and sinus debridement biopsies and orbital exenteration specimens of 30 patients was undertaken, along with analysis of laboratory parameters, clinical history of predisposing conditions, and medication history during COVID-19. Results: All patients were either in recovery following COVID-19 or had ongoing infection. Most patients were diabetic with increased glycosylated haemoglobin, and most patients received steroids and antibiotics for COVID-19. Thirty sinonasal mucosal debridement specimens from various sites, nine orbital exenteration specimens and one frontal decompression craniectomy specimen were examined. Mucor spp. were observed in necrotic tissue, and the presence of vessel and nerve invasion was documented. There were four deaths. Conclusion: ROCM is a life-threatening disease. A high index of suspicion with prompt aggressive surgical and medical management by a multi-disciplinary team can be life saving. Efforts to maintain an optimal glycaemic index is likely to be helpful in preventing ROCM. Judicious use of steroids is mandatory to control the collateral epidemic of ROCM in India.

Orbital magnetic resonance imaging profile and clinicoradiological correlation in COVID-19-associated rhino-orbital-cerebral mucormycosis: A single-center study of 270 patients from North India.

PURPOSE: To study the clinical profile and magnetic resonance imaging (MRI) features in patients of COVID-19-associated rhino-orbital-cerebral mucormycosis (CA-ROCM) with orbital involvement and perform a clinicoradiological correlation. METHODS: A cross-sectional study was performed at a tertiary care center in north India from May 2021 to June 2021. Consecutive patients with clinical, nasal endoscopic, and/or microbiological evidence of CA-ROCM underwent MRI of paranasal sinuses, orbit, and brain as per the study protocol. Orbital MRI findings were studied in detail and were correlated with clinical signs. RESULTS: Two hundred and seventy patients were studied. The mean age was 48.4 (± 16.82) years. A male predilection was noted (male:female = 1.77). Orbital involvement was seen in 146 (54%) patients on clinical evaluation and in 184 (68%) patients on MRI. Unilateral orbital involvement was more common (134; 92%). The most common presenting symptom was periorbital and/or facial pain (141; 52.2%) and the most common clinical sign was periorbital edema (116; 43%). The most common MRI finding was suggestive of orbital cellulitis (160; 59%). Orbital compartment syndrome was found in 17 (6.3%) patients. The inter-rater agreement between clinical and radiological assessments to detect the involvement of infraorbital nerve and frontal nerve was found to be 85.56%, (κ 0.621) and 93.70% (κ 0.776), respectively. The diagnostic accuracy, sensitivity, and specificity of MRI to detect medial orbital wall defect were found to be 87.9%, 65%, and 97%, respectively. CONCLUSION: Orbital imaging features of a cohort of ROCM patients have been presented with clinicoradiological correlation.

COVID-19-related rhino-orbital-cerebral mucormycosis: Neurological manifestation and related risk factors in two cases.

Mucormycosis is an opportunistic infection that has become a serious concern as a result of the immunosuppressive drugs used during COVID-19. In this report, we describe two cases of rhino-orbital-cerebral mucormycosis with neurological presentation and ophthalmologic problems accompanied by a history of COVID-19 and diabetes.