Screening, Diagnosis & Management of Mucormycosis

What is Mucormycosis

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.

What causes Mucormycosis?

Mucormycosis or black fungus is a complication caused by fungal infection. People catch mucormycosis by coming in contact with the fungal spores in the environment. It can also develop on the skin after the fungus enters the skin through a cut, scrape, burn, or other type of skin trauma.

The disease is being detected among patients who are recovering or have recovered from COVID-19. Moreover, anyone who is diabetic and whose immune system is not functioning well needs to be on the guard against this.

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

What are the common symptoms?

Mucormycosis can be categorized depending on which organ of the human body it attacks.  Signs and symptoms of the infection also vary depending on the affected body part.

• Rhino orbital cerebral Mucormycosis: Infection occurs when fungal spores are inhaled. It infects the nose, orbit of eye / eye socket, oral cavity and can even spread to the brain. Symptoms include headache, nasal congestion, nasal discharge (green colour), pain in sinus, bleeding nose, swelling on face, lack of sensation on face and skin discoloration.                                          
• Pulmonary Mucormycosis: When spores are breathed in and reach the respiratory system, it affects the lungs. Symptoms are fever, chest pain, cough and coughing of blood.
• The fungus can also infect gastrointestinal tract, skin, and other organs but the most common form is Rhino cerebral Mucormycosis.

Mucormycosis begins to manifest as skin infection in the air pockets located behind our forehead, nose, cheekbones, and in between the eyes and teeth. It then spreads to eyes, lungs and can even spread to the brain. It leads to blackening or discoloration over the nose, blurred or double vision, chest pain, breathing difficulties and coughing of blood.

The Indian Council of Medical Research has advised that not all cases of blocked nose should be considered as cases of bacterial sinusitis, particularly during/after the treatment of Covid-19 patients. One must seek medical help for detecting fungal infection.  

The warning sign and symptoms are as follows:

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

Mucormycosis - if uncared for - may turn fatal.

What predisposes

According to an advisory issued by the Indian Council of Medical Research, the following conditions in COVID-19 patients increase the risk of mucormycosis infection:

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

How it is related with COVID-19

The disease is caused by a set of micro-organisms known as mucormycetes, which are present naturally in the environment, seen mostly in soil and in decaying organic matter like leaves, compost and piles.

In normal course, our body’s immune system successfully fights such fungal infections. However, we know that COVID-19 affects our immune system. Moreover, the treatment of COVID-19 patients involves intake of drugs like dexamethasone, which suppress our immune system response. Due to these factors, COVID-19 patients face a renewed risk of failing the battle against attacks mounted by organisms such as mucormycetes.

In addition, COVID patients undergoing oxygen therapy in ICU, where humidifier is used, are prone to fungal infection because of exposure to moisture.

But this does not mean that every COVID patient will get infected by Mucormycosis. The disease is uncommon in those not having diabetes but can be fatal if not treated promptly. Chances of recovery depend upon early diagnosis and treatment.

How to prevent

• Controlling diabetes is one of the foremost prevention methods suggested by ICMR. Hence, COVID-19 patients who are diabetic need to take utmost care.
• Self-medication and over-dosage of steroids can result in fatal events and hence doctor’s prescription should be strictly followed. 
• For patients on oxygen therapy, it should be ensured that the water in the humidifier is clean and is refilled regularly. Attention should be paid to ensure there is no leakage of water (to avoid wet surfaces where the fungus can breed). Patients should maintain proper hygiene by keeping their hands as well as body clean.
• 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 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 and Donts

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

Donts

• 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

How to manage

• 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
  • 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 
• Monitor patients clinically and with radio-imaging for response and to detect disease progression

Source : Indian Council of Medical Research