Amid the rise in cases of mucormycosis or ‘black fungus’ infection among COVID-19 survivors, the government released an evidence-based advisory for screening, diagnosis and management of the disease. Stating that it may turn fatal if not cared for, the government said mucormycosis is a fungal infection that mainly affects people who are medication that reduces their ability to fight environmental pathogens. Sinuses or lungs of such individuals get affected after fungal spores are inhaled from air. The guideline was prepared by the Union Health Ministry and ICMR that have been in the frontline of the government’s war against the coronavirus pandemic.
This can lead to serious disease with following warning sign and symptoms
– Pain and redness around eyes and/or nose
– Fever
– Headache
– Coughing
– Shortness of breath
– Bloody vomits
– Altered mental status
Predisposition
– Uncontrolled diabetes mellitus
– Immunosuppression by steroids
– Prolonged ICU stay
– Co-morbidities – post transplant/malignancy
– Voriconazole therapy
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/antifungals 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 immunosuppression and/or COVID-19 patients on immunomodulators
– 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
Preventive Measures
– 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 immunosuppressed individuals)
– 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
Management of mucormycosis
– Control diabetes and diabetic ketoacidosis
– Reduce steroids (if patient is still on) with aim to discontinue rapidly
– Discontinue immunomodulating drugs
– No antifungal prophylaxis needed
– Extensive Surgical Debridement – to remove all necrotic materials
– Medical treatment
i) Install peripherally inserted central catheter (PICC line)
ii) Maintain adequate systemic hydration
iii) Infuse normal saline IV before Amphotericin B infusion
iv) Antifungal therapy, for at least 4-6 weeks (follow guidelines)
v) 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
The government also shared a link (https://www.ijmr.org.in/temp/IndianJMedRes1392195 -397834_110303.pdf) for detailed management guideline followed globally, which is an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium.
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