Triple whammy in pandemic: COVID-19, mucormycosis and myiasis

Mucormycosis is a fatal opportunistic fungal infection most commonly seen in immunocompromised individuals. The mortality can vary depending on the extent of the disease, starting in the paranasal sinuses, reaching the orbit, and eventually spreading intracranially. The sudden surge of Mucormycosis along with COVID-19 infections has rightfully been described as an epidemic amidst a pandemic. While the exact etiological factor is still being investigated, uncontrolled diabetes seems to be the most common inciting factor. Mucormycosis being angioinvasive, often leads to thrombus formation in the vessels, which leads to the necrosis of the tissues and bones, most commonly the maxilla. This necrotic tissue forms an ideal culture for various organisms and is a potential source for maggots' infestation. The presence of nasal myiasis further worsens the clinical status of the patients, making them prone to life-threatening complications. Thus, nasal myiasis seems to be an independent prognosticating factor in such cases. Here, we have described two such cases, our approach to management and mortality despite the best possible management. Two cases are being presented of elderly patients with comorbidities of type 2 diabetes mellitus and coronary artery disease. Both patients had a recent onset of COVID-19 and presented with intraorbital and intracranial disease extension along with nasal myiasis. Both patients succumbed to the fulminant pathology despite aggressive management. Mucormycosis, COVID-19 and nasal myiasis combine together to form a fatal triad, which despite early identification and aggressive management, carries a poor prognosis.