[Screening, Diagnosis & Management of Mucormycosis (black fungus)]

Mucormycosis – if uncared for – may turn fatal

Mucormycosis is a fungal infection that mainly affects people who are on medication for other health problems that reduces their ability to fight environmental pathogens.

Sinuses or lungs of such individuals get affected after fungal spores are inhaled from the air

This can lead to serious disease with warning sign and symptoms as follows:

  • Pain and redness around eyes and/or nose
  • Fever
  • Headache
  • Coughing
  • Shortness of breath
  • Bloody vomits
  • Altered mental status

What predisposes

  • Uncontrolled diabetes mellitus
  • Immunosuppression by steroids
  • Prolonged ICU stay
  • Co-morbidities – post transplant/malignancy
  • Voriconazole therapy

How to prevent

  • Use masks if you are visiting dusty construction sites
  • Wear shoes, long trousers, long sleeve shirts and gloves while handling soil (gardening), moss or manure
  • Maintain personal hygiene including thorough scrub bath

When to Suspect (in COVID-19 patients, diabetics or immuno suppressed indiviuals )

  • Sinusitis – nasal blockade or congestion, nasal discharge (blackish/bloody), local pain on the cheek bone
  • One sided facial pain, numbness or swelling
  • Blackish discoloration over bridge of nose/palate
  • Toothache, loosening of teeth, jaw involvement
  • Blurred or double vision with pain; fever, skin lesion; thrombosis & necrosis (eschar)
  • Chest pain, pleural effusion, haemoptysis, worsening of respiratory symptoms

Dos

  • Control hyperglycemia
  • Monitor blood glucose level post COVID-19 discharge and also in diabetics
  • Use steroid judiciously – correct timing, correct dose and duration
  • Use clean, sterile water for humidifiers during oxygen therapy
  • Use antibiotics/anti fungals judiciously

Don’ts

  • Do not miss warning signs and symptoms
  • Do not consider all the cases with blocked nose as cases of bacterial sinusitis, particularly in the context of immuno suppression and/or COVID-19 patients on immuno modulators
  • Do not hesitate to seek aggressive investigations, as appropriate (KOH staining & microscopy, culture, MALDITOF), for detecting fungal etiology
  • Do not lose crucial time to initiate treatment for mucormycosis

How to manage

  • Control diabetes and diabetic ketoacidosis
  • Reduce steroids (if patient is still on) with aim to discontinue rapidly
  • Discontinue immuno modulating drugs
  • No antifungal prophylaxis needed
  • Extensive Surgical Debridement – to remove all necrotic materials
  • Medical treatment
    • Install peripherally inserted central catheter (PICC line)
    • Maintain adequate systemic hydration
    • Infuse Normal saline IV before Amphotericin B infusion
    • Antifungal Therapy, for at least 4-6 weeks (see the guidelines below )
  • Monitor patients clinically and with radio-imaging for response and to detect disease progression

Team Approach Works Best

  • Microbiologist
  • Internal Medicine Specialist
  • Intensivist
  • Neurologist
  • ENT Specialist
  • Ophthalmologist
  • Dentist
  • Surgeon (maxillofacial/plastic)
  • Biochemist

Detailed management guideline & information available on the following

Global guideline for the diagnosis and management of mucormycosis:

an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis. 2019 Dec;19(12):e405-e421. doi: 10.1016/S1473-3099(19)30312-3

https://www.ijmr.org.in/temp/IndianJMedRes1533311- 3965147_110051.pdf

https://www.ijmr.org.in/temp/IndianJMedRes1392195-397834-110303.pdf

Advisory developed by the following experts & National Task Force for COVID-19

  • Dr. Arunaloke Chakrabarti, Professor & Head, Department of Medical Microbiology, PGIMER, Chandigarh
  • Dr. Atul Patel, Infectious Disease Specialist, Ahmedabad
  • Dr. Rajeev Soman, Consultant Infectious Disease Physician, Pune
  • Dr. Prakash Shastri, Vice Chairman, Critical Care, Sir Ganga Ram Hospital, New Delhi
  • Dr. J P Modi, Medical Superintendent,
  • Dr. K J Upadhay, Head, Deptt. of Internal Medicine and Multi-disciplinary Clinical Management Group, BJ Medical College & Civil Hospital, Ahmedabad
  • Dr. Girish Parmar, Dean, Government Dental College & Hospital, Ahmedabad
  • Dr. Janak Khambolja, Professor, Deptt. of Internal Medicine, Smt. NHL Municipal Medical College, Ahmedabad
  • Dr. Hemang Purohit, Medical Microbiologist, Smt. NHL Municipal Medical College, Ahmedabad
  • Dr. R S Trivedi, Medical Superintendent, Pt. Dindayal Upadhyay Medical College, Rajkot
  • Dr. Pankaj Buch, Professor, Deptt. of Pediatrics, Pt. Dindayal Upadhyay Medical College, Rajkot
  • Dr. Sejal Mistri, Associate Professor, Deptt. of ENT, Pt. Dindayal Upadhyay Medical College, Rajkot
  • Dr. Deepmala Budhrani, Assistant Professor, Deptt. of Internal Medicine, Pt. Dindayal Upadhyay Medical College, Rajkot
  • Dr. Samiran Panda, Head, Epidemiology & Communicable Diseases (ECD), ICMR, New Delhi
  • Dr. Aparna Mukherjee, Scientist E, Clinical Trial & Health Systems Research Unit, ECD, ICMR, New Delhi
  • Dr. Madhuchanda Das, Scientist D, ECD, ICMR, New Delhi
  • Dr Tanu Anand, Scientist D, Clinical Trial & Health Systems Research Unit, ECD, ICMR, New Delhi
  • Dr Gunjan Kumar, Scientist C, Clinical Trial & Health Systems Research Unit, ECD, ICMR, New Delhi
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