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Lethal Mucormycosis: How steroids act as trigger and what is the treatment?

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‘Mucormycosis’, recently well known as the Black Fungus and very rare infection, has been the centre of attraction in the last few weeks.

Lethal Mucormycosis: How steroids act as trigger and what is the treatment?
‘Mucormycosis’, recently well known as the Black Fungus and very rare infection, has been the centre of attraction in the last few weeks.
Mucormycosis, previously called Zygomycosis, refers to several different diseases caused by infection with fungi, in order Mucorales.
Rhizopus species are the most common causative organisms.
It is caused by exposure to mucor mould which is commonly found in soil, plants, manure and decaying fruits and vegetables.
It is ubiquitous and found in soil and air and even in the nose and mucus of healthy people.
Doctors believe Mucormycosis, which has an overall mortality rate of 50-85 percent, maybe being triggered by the use of steroids, a life-saving treatment for severe and critically ill COVID-19 patients.
Steroids lead to a drop in immunity, which indeed leads to triggering these cases of Mucormycosis.
Based on anatomic localization, Mucormycosis can be classified into 6 forms:
  • Rhinocerebral
  • Pulmonary
  • Cutoneous
  • Gastra Intestinal
  • Disseminated
  • Uncommon Presentations
  • The major route of infection is via inhalation of Conidia; other routes include ingestion and traumatic inoculation.
    When spores are deposited in the nasal turbinates, rhino cerebral disease develops. When spores inhaled into the lungs it becomes a pulmonary disease.
    When ingested, ‘GI’ diseases ensue.
    When the agents are introduced through interrupted skin, the cutaneous disease develops.
    Warning signs and symptoms:
    • 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
      • Comorbidities- Post Transplant / Malignancy
      • VoriConazole Therapy
      • Neutropenia
      • When to suspect?
        In COVID-19 patients, diabetics or immunosuppressed individuals
        1. Sinusitis- Nasal blockage or congestion, nasal discharge (blackish/bloody), local pain on the cheekbone
        2. One-sided facial pain, numbness or swelling
        3. Blackish discolouration over the bridge of nose/palate
        4. Toothache, loosening of teeth, jaw involvement
        5. Blurred or double vision with pain, fever, skin lesion, thrombosis and necrosis
        6. Chest pain, pleural effusion, haemoptysis, worsening of respiratory symptoms
        7. Dos:
          • Control Hyperglycemia
          • Monitor blood glucose level post-COVID-19 discharge and also in diabetics
          • Use steroids judiciously- Correct timing, correct dose and duration
          • Use clear, sterile water for humidifiers during oxygen therapy
          • Use antibiotics/antifungals judiciously
          • Don’t’s:
            • Do not miss warning sign and symptoms
            • Do not consider all the cases with a 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 investigation, as appropriate (KOH Staining & Microscopy Culture, MALDI – TOF) for detecting fungal aetiology
            • Do not lose crucial time to initiate treatment for Mucormycosis
            • How to manage?
              • Control Diabetes and Daibetic Ketoacidosis
              • Discontinue immunomodulating drugs
              • Reduce Steroids (with an aim to discontinue rapidly)
              • No antifungal prophylaxis needed
              • Extensive Surgical Debridement (to remove all necrotic materials)
              • Medical Treatment
                1. Install peripherally inserted central catheter (PICC / ins)
                2. Maintain adequate systemic hydration
                3. Infuse Normal Saline IV before Amphotericin B infusion
                4. Antifungal Therapy for at least 4-6 weeks
                5. Monitor patients clinically and with radio-imaging for response and to detect disease progression
                6. Treatment
                  • Intravenous Amphotericin B is the drug of choice for initial therapy
                  • Posaconazole or Isavuconazole is tased as stepdown therapy for patients who have responded to Amphotericin B
                  • Posaconazole or Isavuconazole can also be used as salvage therapy for patients who don’t respond to or cannot tolerate Amphotericin B
                  • Surgery- Aggressive surgical debridement of involved tissues should be considered as doon as the diagnosis of any form of Mucormycosis is suspected.
                  • —Dr Sanket Jain is a Consultant Pulmonologist at Masina Hospital, Mumbai.
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