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Mucormycosis ( black fungal disease) 

What is Mucormycosis (black fungal disease) in Covid-19

Mucormycosis (previously called zygomycosis) is a serious but rare fungal infection caused by a group of molds called mucormycetes. These molds live throughout the environment. Mucormycosis mainly affects people who have health problems or take medicines that lower the body’s ability to fight germs and sickness. It most commonly affects the sinuses or the lungs after inhaling fungal spores from the air. It can also occur on the skin after a cut, burn, or other types of skin injury.

Types of mucormycosis 

• Rhinocerebral (sinus and brain) mucormycosis is an infection in the sinuses that can spread to the brain. This form of mucormycosis is most common in people with uncontrolled diabetes and in people who have had a kidney transplant. 
• Pulmonary (lung) mucormycosis is the most common type of mucormycosis in people with cancer and in people who have had an organ transplant or a stem cell transplant.
• Gastrointestinal mucormycosis is more common among young children than adults, especially premature and low birth weight infants less than 1 month of age, who have had antibiotics, surgery, or medications that lower the body’s ability to fight germs and sickness. 
• Cutaneous (skin) mucormycosis: occurs after the fungi enter the body through a break in the skin (for example, after surgery, a burn, or other type of skin trauma). This is the most common form of mucormycosis among people who do not have weakened immune systems.
• Disseminated mucormycosis occurs when the infection spreads through the bloodstream to affect another part of the body. The infection most commonly affects the brain, but also can affect other organs such as the spleen, heart, and skin.

Types of fungi that most commonly cause mucormycosis

•  Rhizopus species, Mucor species, Rhizomucor species, Syncephalastrum species, Cunninghamella bertholletiae, Apophysomyces species, and Lichtheimia (formerly Absidia) species.

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Mucormycosis Covid sign and Symptoms as follows.

• Pain and redness around eyes and 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 is mucormycosis ( black fungal disease) diagnosed?

Healthcare providers consider your medical history, symptoms, physical examinations, and laboratory tests when diagnosing mucormycosis. Healthcare providers who suspect that you have mucormycosis in your lungs or sinuses might collect a sample of fluid from your respiratory system to send to a laboratory. Your healthcare provider may perform a tissue biopsy, in which a small sample of affected tissue is analyzed in a laboratory for evidence of mucormycosis under a microscope or in a fungal culture. You may also need imaging tests such as a CT scan of your lungs, sinuses, or other parts of your body, depending on the location of the suspected infection.

 

 How to Prevent mucormycosis ( black fungal disease)

• Use mask if you are visiting dusty construction sites.
• Wear shoes, long trousers, long sleeve shirts and gloves.
• Maintain personal hygiene including thorough scrub bath

When to Suspect mucormycosis: (in COVID-19 patients, diabetics or immunosuppressed individuals)

• Sinusitis - nasal blockade or congestion, nasal discharge (blackish/bloody), local pain on the cheekbone.
• One-sided facial pain, numbness or swelling.
• Blackish discolouration over bridge of nose/palate.
• Toothache, loosening of teeth, jaw involvement.
• Blurred or double vision with pain; fever, skin lesion; thrombosis & necrosis.
• 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/ 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 Covid-19 patients on immunomodulators.
• Do not hesitate to seek aggressive investigations, as appropriate (KOH staining & microscopy, culture, MALDI-TOF), for detecting fungal etiology.
• Do not lose crucial time to initiate treatment for mucormycosis.

How to manage| Treatment for mucormycosis in Covid patient

• Control diabetes and diabetic ketoacidosis.
• Reduce steroids (if patient 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. ( According to guideline)
• Monitor patients clinically and with radio-imaging for response and detect disease progression.