Case Presentation on Covid associated Mucormycosis

1. Case presentation on: COVID- 19
associated MUCORMYCOSIS

2. • Mucormycosis sometimes appears as the diabetes-defining illness and remains one of the most
devastating complications in uncontrolled diabetics with mortality rates ranging between 40-80%.
India contributes to 40% of the global burden of this “rare mould” infection.
• Covid- 19 leads to a dysregulated innate immune response, ciliary dysfunction, cytokine storm,
thrombo-inflammation, microvascular coagulation and eventual immune exhaustion. This cascade of
events facilitates secondary bacterial and fungal infections especially in critically ill patients subjected
to emergency invasive procedures, mechanical ventilation, CRRT, ECMO, poor nursing ratios,
prolonged hospital stays and breaches in asepsis.
• Further, the use of corticosteroid treatment in these highly susceptible hosts along with high fungal
spore counts in the environment creates the perfect setting for mould infections.

3. Although the predisposing factors and pathogenesis are somewhat similar to that of other mould
infections, certain unique characteristics and key distinguishing factors must be kept in mind in
order to promptly suspect the infection, confirm the diagnosis and offer timely therapeutic
intervention.

4.  WHAT IS MUCORMYCOSIS?
• Mucormycosis is a general term for a group of uncommon infections cause by a fungus (fungal
infection). This fungal infection is caused by a group of related molds from the order ‘Mucorales’. The
most common species are Rhizopus spp, Mucor spp, Rhizomucor spp
and Lichtheimia (formerly Absidia) spp.
• These infections are usually acquired when spores from the molds are breathed in (inhaled) or, less
commonly, enter the body through a cut in the skin. Mucormycosis is an aggressive, life-threatening
infection that occurs in people whose immune system doesn’t function well (immune-compromised)
including people with uncontrolled diabetes mellitus, people who have low levels of
neutrophils(neutropenia), or people whose immune system is being suppressed by medications
(immunosuppression) as part of their treatment for blood cancer (hematological malignancy),
hematopoietic stem cell transplantation, or solid-organ transplant.
• The infection is not contagious; it cannot be spread from one person to another.

5. • Mucormycosis is an invasive fungal infection. These infections were once called ‘zygomycosis’, but the
organisms that cause the infection have been scientifically reclassified and the term ‘Mucormycosis’
is now preferred. Generally, these infections are broken down into five presentations: rhinocerebellar,
pulmonary, cutaneous, gastrointestinal, and disseminated.

6.  VULNERABLE POPULATION
Certain groups of people are more likely to get infected, such as people with:
Diabetes, especially with diabetic ketoacidosis
Cancer
Organ transplant/ Stem cell transplant
Long term corticosteroid use
Skin injury due to surgery, burns or wounds

7.  PATHOPHYSIOLOGY
• The Mucorales can be found in places with decaying organic matter, moist soil, animal dung, leaves,
etc.
• These spores can enter the human body by 3 routes:
1. Via inhalation (Spores enter lungs through the airways)
2. Via injury points (wounds on the skin)
3. Via ingestion of food contaminated with the spores
Normally, when the spores enter the human body, the immune system is activated, and the disease
is prevented.
In susceptible hosts, these spores further grow and cause Mucormycosis infection.

8. • Both mononuclear and polymorphonuclear phagocytes kill Mucorales by generation of oxidative
metabolites and cationic peptides. These phagocytes are the major host defense mechanism. As a
result, neutropenic patients and patients with dysfunctional phagocytes are at higher risk of
developing the infection.
• Hyperglycemia and acidosis impair the ability of phagocytes to kill the fungus by oxidative and non-
oxidative mechanisms.
• Corticosteroid treatments impair the ability of bronchoalveolar macrophages to prevent germination
of spores induced by intranasal inoculation.
• The exact mechanisms by which ketoacidosis, diabetes or steroids impair the function of the
phagocytes remain unknown.

9. • An important virulence trait of Mucorales is the ability to acquire iron from the host which is an
essential element for its growth. In conditions of ketoacidosis, free iron becomes readily available in
the serum. This excess endogenous iron is efficiently taken up by the Mucorales through
siderophores or iron permeases, further enhancing their virulence. These effects are greatly amplified
by the use of corticosteroids and immunosuppressants in susceptible hosts.
• It has been observed that patients treated with the iron chelator deferoxamine have increased
incidence of invasive Mucormycosis as the fungi utilizes deferoxamine as a siderophore that supplies
iron which was previously unavailable to the fungus (the Rhizopus spp. have an exceptional
requirement of iron). So, this drug is contraindicated in this infection.

10. • A hallmark feature is the extensive angioinvasion with resultant vessel thrombosis and tissue
necrosis. This angioinvasion is associated with the ability of the organism to hematogenously
disseminate from the original site of infection to other target organs.
• Hence, damage of and penetration through endothelial cells lining blood vessels is likely a critical step
in the organism’s pathogenetic strategy.

11.  CLINICAL PRESENTATION
GENERAL:
• The most common presentation is a sinus infection (sinusitis) that is accompanied by nasal
congestion, nasal discharge, and sinus pain. A fever and headache can also occur. If the infection
spreads outside the sinuses, symptoms can include necrosis of the roof of the mouth (palate),
disintegration of septum that divides the nostrils, swelling of the perinasal area, and redness
(erythema) of the skin overlying the sinus and the orbit.
• Sometimes, there is bluish discoloration of the skin near the sinuses or the eye socket due to a lack of
oxygen (cyanosis). Sometimes, blurry vision or double vision can develop. If unrecognized and
untreated, significant necrosis can occur and the infection can significantly damage facial structures.

12. CEREBRAL:
• Sometimes, mucormycosis can spread to the brain. This can
cause lethargy, seizures, slurred speech, partial paralysis,
abnormalities of the nerves of the face and eyes (cranial
neuropathies), a brain abscess, altered consciousness, and
coma. When the sinuses and brain is involved, this infection
can be referred to as rhinocerebral mucormycosis.
OPTHALMIC:
• When the infection spreads to the eye, there can be swelling
due to fluid buildup around the eyes (periorbital edema),
bulging or displacement of the eye (proptosis), vision loss, and
potential blindness. Some affected individuals experience
paralysis or weakness of the muscles that move the eyes
(ophthalmoplegia), making it difficult or painful to move the
eyes.

13. PULMONARY:
• Mucormycosis can affect the lungs (pulmonary mucormycosis),
most often when the spores are breathed in and reach the
respiratory system. Pulmonary mucormycosis is often a rapidly
progressive disease characterized by fever and a cough that
does not produce any mucous (nonproductive cough). Less
often, hemoptysis, chest pain, and dyspnea will occur.
CUTANEOUS:
• When mucormycosis affects the skin (cutaneous
mucormycosis), affected individuals can develop a single,
painful, hardened area of the skin and inflammation of the
underlying tissue. Nearby skin may become reddened, warm,
swollen and painful. Sometimes, ulcers and blisters will form,
and necrosis can occur with the affected tissue turning black.
Affected individuals may have a fever.
• Cutaneous mucormycosis can develop slowly or be severe and
sudden in onset (fulminant).

14. GASTROINTESTINAL:
• Sometimes, the gastrointestinal
system can be affected. This most
likely occurs when spores are
breathed into the mouth and
swallowed or contaminated food is
eaten.
• Symptoms can include abdominal
pain and vomiting of blood
(hematemesis). Lesions can develop
that cause perforation. Peritonitis
can also develop. Sometimes, bowel
infarction occurs, and affected
individuals can go into shock
because of significant blood loss
(hemorrhagic shock).

15. • Disseminated mucormycosis is a rare form often seen in individuals who are severely immune-
compromised. In this form, the infection spreads to other areas of the body and becomes widespread
(disseminated). Other areas that can be affected include the brain, heart, spleen, skin, and other
organs.
• In rare instances, mucormycosis can affect or spread to affect the kidneys, the inner lining of the
chambers of the heart and the heart valves (endocarditis), and the bone (osteomyelitis). Signs and
symptoms of disseminated mucormycosis vary greatly depending upon the organ system involved.

16.  DIAGNOSIS
The diagnosis is based upon identification of characteristic symptoms, a detailed patient history, a
thorough clinical evaluation and a variety of specialized tests.
A diagnosis of mucormycosis is challenging because the symptoms are common to many conditions
including other types of infection. A diagnosis is made by identifying mold in affected tissue and
sometimes can be confirmed by a test called a fungal culture. A prompt diagnosis is important so
treatment can begin as early as possible. Samples can include fluid from the respiratory system or
mucus coughed up from the lungs (sputum) if lung infection is suspected. Surgical removal of a small
sample of skin tissue can be taken in cutaneous mucormycosis. A tissue sample can then be taken
and used for a fungal culture.
• This test can determine the presence and type of fungal infection. However, sometimes a fungal
culture does not reveal a fungal infection despite the presence of infection. Thus, a negative result on
a fungal culture does not rule out mucormycosis.

17. A diagnosis of mucormycosis can be suspected when affected individuals who have been identified as
having a fungal infection do not respond to antifungal medications that target Aspergillosis, especially
when Aspergillosis biomarkers are absent. Biomarkers for Aspergillosis include
the Aspergillus galactomannan antigen. Antigens are substances that cause a response from the
immune system; biomarkers are measurable substances that can indicate the presence of disease.
There are no identified biomarkers for mucormycosis.
Imaging techniques such as computerized tomography (CT) scanning may be used to determine the
exact location and extent of an infection. In individuals with pulmonary mucormycosis, a CT scan of
the lungs can reveal a reverse halo sign. This diagnostic clue is an area of necrosis that resembles
ground glass on the film. It is suggestive of mucormycosis infection.

18. • REVERSE HALO SIGN

19.  TREATMENT
There are 4 critical factors for eradicating Mucormycosis infection:
1. Rapidity of diagnosis
2. Appropriate antifungal therapy
3. Appropriate surgical debridement of infected tissue
4. Reversal of the underlying predisposing factors (if possible)

20. MEDICAL MANAGEMENT:
• Treatment for mucormycosis will include antifungal medications. Antifungal medications inhibit the
growth of and destroy fungal infections and are essential in controlling the spread of infection.
• The most commonly used medication is called Amphotericin B. Initially, high doses of this medication
are given intravenously. If an affected individual shows improvement, which can take several weeks,
doctors may have the patient switch to oral antifungal medications, such as posaconazole or
isavuconazole (Cresemba®). This is called step-down therapy. In 2015, the U.S. Food and Drug
Administration (FDA) approved Cresemba for the treatment of adults with invasive mucormycosis.
• If affected individuals do not respond to amphotericin B, or cannot tolerate the medication due to
side effects, then posaconazole or isavuconazole may be given intravenously. This is called salvage
therapy.
• Echinocandins such as caspofungin and micafungin show synergistic effect when paired with
Amphotericin B. These can be used as combination therapy in serious case of Mucormycosis.

21. DOSING REGIMEN
Various Amphotericin B formulations available : (IV)
• Liposomal amphotericin B & Amphotericin B lipid complex: 10-15mg/ kg/ day
• Amphotericin B deoxycholate: 1- 1.5 mg/ kg/ day
Isavuconazole: 200mg every 8 hours for 6 doses followed by maintenance dose of 200mg OD (IV &
PO)
Posaconazole: 300mg tablets twice on day 1 followed by 300mg once daily with or without food (PO)

22. SURGICAL DEBRIDEMENT:
• The numerous agents of Mucormycosis have a broad range of susceptibilities to anti- fungal agents;
some strains may be highly resistant to Amphotericin B.
• Furthermore, the hallmark angioinvasion, thrombosis, and tissue necrosis result in poor penetration
of anti- infective agents to the site of infection. Therefore, even if the causative organism is
susceptible to the treating antifungal agent in vitro, it may be ineffective in vivo.
• Surgery may be necessary due to the massive amount of tissue necrosis occurring during
Mucormycosis, which cannot be prevented by killing the organism. Surgical debridement of infected
and necrotic tissue should be performed on an urgent basis. For e.g., individuals with rhinocerebral
mucormycosis can experience significant changes to facial appearance. Surgical debridement should
be done as soon as the infection is confirmed.
• Several case studies show that low mortality rate is observed in cases treated with antifungal agents
plus surgery compared to antifungals alone.

23. ADJUNTIVE THERAPY:
• Adjunctive treatment is a treatment given in addition to the initial,
primary therapy. Some affected individuals may receive adjunctive
treatment with hyperbaric oxygen.
• Hyperbaric oxygen involves exposing the patient to pure oxygen in a
pressure room or medical tube and has been effective in treating
other types of serious infection. There is some research that shows
that hyperbaric conditions can inhibit infection.
• It may be useful for treating Mucormycosis in conjunction with the
standard therapy because higher oxygen pressure improves the
ability of neutrophils to kill the organism. High oxygen pressure also
inhibits germination of fungal spores and growth of mycelia.
• Unlike deferoxamine, other iron chelators (e.g., hydroxypyridine
chelating agents) can be used as anti- fungals as they donot allow
the organism to take up iron and donot support its growth. E.g.,
deferiprone, desferrioxamine, deferasirox.
• Colony stimulating agents can be used in neutropenic patients

24. MANAGEMENT OF CO- MORBIDITIES:
• Doctors will also treat the underlying risk factor that can be associated with mucormycosis infection.
Controlling underlying conditions is important in the treatment of this infection. This can include:
 medications to increase the levels of white blood cells in people with neutropenia;
insulin for people with uncontrolled diabetes;
iron chelators that lower the level of iron in the blood and deferiprone for people with iron overload.
It is extremely important that an iron chelator called deferoxamine is avoided because this
medication promotes the growth and spread of mucormycosis in the body.

25. COVID- 19 ASSOCIATED
MUCORMYCOSIS
CASE PRESENTATION

26.  PATIENT
DEMOGRAPHICS
• Name: Mr. Ramshankar Parwar
• Age/ Gender: 56 yrs/ Male
• Ward: ICU
• DOA: 21/12/20
• DOD: 26/12/20

27. PATIENT
COMPLAINTS
• Cough and fever before 6-7 days
• Generalised weakness
• Pain in the right eye since 7 days along with swelling
of the right orbit and lacrimation since 3 days
 PMH
• Pt. was being treated for covid- 19 at home with
oral antibiotics and Inj. Remdesivir from 14/12
• K/C/O: - HTN & DM (on medication)
- Covid +ve on 14/12/20 (HRCT- 14/25) (RAT
+ve)
• Family History: Not Significant

28. On Examination:
Conscious, oriented
BP: 130/90 mmHg
P: 76/min
Temperature: Febrile
SpO2 : 96% on room air
Rt. eye ptosis seen
Vision: normal
B/L pupil: normal
Patient is vitally stable

29.  DAILY
VITALS
Vitals 22/12 23/12 24/12 25/12 26/12
BP
(mmHg)
120/80 120/90 117/64 133/82 120/60
Temp F F F AF AF
Pulse
(/min)
76 94 112 100 85
SpO2 (%) 96 96 96 93 96
I/O (ml) 1620/ 1200 1635/1150 1840/1050 510/300
RBS
(mg/dl)
199 356 289 207 124

30.  LABORATORY
INVESTIGATIONS
Lab Parameter 21/12 24/12 Normal Range
Hb 13.5 12.4 13-17 gm/dl
TLC 12,100 14,020 4000- 10000/ µl
Platelet 6,66,000 6,34,000 1,50,000-
4,50,000
RENAL
Serum Creatinine 0.81 1.01 0.8- 1.2 mg/dl
Urea 37.10 30.60 7- 20 mg/dl
Na+ 131 140 136- 145 nmol/L

31. Lab Parameter 21/12 24/12 Normal Range
K+ 4 4.1 3.5- 4.5 mmol/L
Cl 97 109 98-107 mmol/L
HCO3 25.2 26 22- 28 mmol/L
HEPATIC
Total Protein 5.79 6.4- 8.30
S. Albumin 3.05 3.50- 5.20
A/G Ratio 1.11 1- 2
SGOT 45.40 0- 35
SGPT 33.50 0- 45
Alkaline Phosphatase 122 38- 141
Total Bilirubin 0.51 Total: 0- 1.20
Direct 0.23 Direct: 0-1.10
Indirect 0.28 Indirect: 0.0- 0.3

32. Lab Parameter 21/12 24/12 Normal Range
COAGULATION PROFILE
PCT (Procalcitonin Quantitative) 0.09 ng/ml 0.1 <0.05- Healthy
<0.50- Low risk of sepsis; Not likely
0.50- 2.0- Moderate risk for sepsis
>2.0- High risk for sepsis/ Septic shock
S. Ferritin 375.60 23.90- 336.20 ng/ml
D- Dimer 580 <500ng/l
CRP 19.7 60 0- 8

33. Lab Parameter 21/12 24/12 Normal Range
LDH 614.60 225- 450 µ/l
HbA1c 11.73 <6.4 %
Mean RBS 289 0- 140 mg/dl
BNP (NT- PRO
BNP)
<70.0 pg/ml <300 pg/ ml- Chronic HF
unlikely
300- 1800 pg/ ml- Uncertain
diagnosis
>1800 pg/ml- Chronic HF likely

34. • CECT- PNS and ORBIT
(CONTRAST):
- Right sided
pansinusitis and left
sided maxillary and
ethmoid sinusitis with
bony erosions
• MRI Brain
- Right cavernous sinus
syndrome (Rt. 3,4,5,6)

35. DIAGNOSIS: COVID- 19 associated
MUCORMYCOSIS

36.  Advice
• Day 1
- Start Amphotericin B and Caspofungin STAT
• Day 2
- Right cavernous sinus syndrome – Rt. 3,4,5,6
(MRI Brain)
• Day 3
- Inj. HAI @ 2 IU/hr
- Rt. eye and face swelling regressed, and vision
preserved
- Pt. hemodynamically stable

37. • Day 4
- Insulin drip given
• Day 5
- Posoconazole started
- Bone biopsy for maxilla and zygomatic

38.  TREATMENT CHART
Drug Generic Name Dose/
Frequency
21/12 22/12 23/12 24/12 25/12 26/12
Inj. Cefbact Ceftriaxone 1gm/ BD Y Y Y Y Y Y
Inj. Azee Azithromycin 500mg/ OD Y Y Y Y Y Y
Inj. Pandeep Pantoprazole 40mg/ BD Y Y Y Y Y T. PAN (OD)
Inj. Paracip Paracetamol 1gm/ SOS Y Y Y Y
Inj. Emeset Ondansetron 4mg/ SOS Y Y Y Y
Inj. Clexane Enoxaparin 0.6mg/ SC BD Y Y Y Y
Inj. Covifor Remdesivir 200mg Y

39. Drug Generic Name Dose/ Frequency 21/12 22/12 23/12 24/12 25/12 26/12
Amphotericin B (50mg) 4 unit in 5% Dextrose (STAT) Y Y Y Y Y Y
Inj. HAI (Human Actrapid Insulin) (acc. To BSL) Y Y Y
Inj. Lantus Long acting insulin 16 unit @ 10pm Y Y Y
Inj.
Caspofungin
70mg OD f/b
50mg OD
Y
Inj. NS +
Optineuron
40ml/hr 1 pint Y Y Y Y Y
Tab. Fluvir Oseltamivir 75mg/ 1-0-1 Y Y Y Y
T. Montair LC Levocetrizine+
Montelukast
10mg/ 0-0-1 Y Y Y Y Y
T. Glykind- M Gliclazide+
Metformin
1-0-1 Y Y Y Y Y Y

40. Drug Generic Name Dose/
Frequency
21/12 22/12 23/12 24/12 25/12 26/12
T. Voglistar Voglibose 0.2mg/ BD Y Y Y Y Y Y
T. Vorier Voriconazole 300mg/ 1-0-1 Y Y Y Y Y Y
T. Ecosprin Aspirin 75mg/ OD Y
T. Posoconazole 300mg/ BD
then OD
Y
(BD)
Y
Zymar eye drops Gatifloxacin TDS Rt. eye Y Y Y Y Y Y
Refresh eye drops Carboxymethylcellulose TDS Rt. eye Y Y Y Y Y Y

41. • Following the treatment, the patient’s condition improved and was
discharged.

42.  DISCHARGE
MEDICATION
Drug Generic Name Dose Frequency
T. Vorier Voriconazole 200mg 1-0-1
T. Glykind- M Gliclazide+ Metformin 80mg+ 500mg 1-0-1
T. Voglistar Voglibose 0.2mg 1-0-1
T. Picasa GR Posaconazole 100mg 3 tabs for 6
weeks
Zymar eye
drops
Gatifloxacin 1-1-1 (Rt.eye)
Refresh eye
drops
Carboxymethylcellulose 1-1-1 (Rt. Eye)
T. Pansec Pantoprazole 40mg 1-0-0
T. Ecosprin Aspirin 75mg 0-1-0

43. SOAP NOTE

44. SUBJECTIVE
• Cough and fever before 6-7 days
• Generalised weakness
• Pain in the right eye since 7 days along with swelling of the right
orbit and lacrimation since 3 days

45. OBJECTIVE
The following parameters were found to be abnormal:
TLC, Platelet, Urea, SGOT, S. Ferritin, CRP, LDH and Mean RBS were found elevated
Sodium, Total Protein and S. Albumin were found to be lower than normal range

46. ASSESSMENT
• COVID- 19 associated MUCORMYCOSIS

47. PLAN
• Treatment principles include antifungal agents, surgical debridement, reversal of
underlying predisposing factors and adjuvant therapy. Amphotericin B has been the
standard of treatment for invasive mucormycosis. COVID-19 patients may have
developed acute or chronic renal failure which may be mitigated by switching to a
less- or non-nephrotoxic alternative. Therefore, Posaconazole or Isavuconazole may
have to be used.
• Surgical debridement, the earlier the better, is pivotal in the management of
Mucormycosis.
• Adjuvant therapy with caspofungin, deferasirox, statins, aspirin, and hyperbaric
oxygen may have to be considered.

48. DRUG INTERACTIONS: No significant drug interactions
found
Drug Generic Name Dose Frequency Indication
T. Vorier Voriconazole 300mg 1-0-1 Antifungal
T. Glykind- M Gliclazide+ Metformin 80mg+ 500mg 1-0-1 Anti- diabetic
T. Voglistar Voglibose 0.2mg 1-0-1 Anti- diabetic
T. Picasa GR Posaconazole 100mg 3-0-0 (6 weeks) Antifungal
Zymar eye drops Gatifloxacin 1-1-1 (Rt.eye) Antibacterial
Refresh eye drops Carboxymethylcellulose 1-1-1 (Rt. Eye) To relieve irritation
and discomfort
T. Pansec Pantoprazole 40mg 1-0-0 Antacid
T. Ecosprin Aspirin 75mg 0-1-0 Anti- platelet

49. PATIENT COUNSELING
ABOUT DRUGS
T. VORIER- Voriconazole belongs to a group of medicines called antifungals. It works by stopping the
growth of fungus and is used to treat a wide range of fungal infections. It kills fungi by destroying the
fungal cell membrane.
• It should be taken in the dose and duration as prescribed by your doctor. It should be swallowed
whole. It should be taken one hour before or one hour after a meal, preferably at the same time
everyday.
• If you stop treatment too early, the infection may return and if you miss doses you can increase
your risk of infections that are resistant to further treatment.
• The most common side effects of this medicine include rash, vomiting, nausea, and headache. if
you think you might have a severe allergic reaction. Signs of this include rash, swelling of the lips,
throat or face, swallowing or breathing problems, feeling dizzy or faint, and nausea. Get emergency
help if this happens.
• It is unsafe to use during pregnancy as there is definite evidence of risk to the developing baby.

50. • Glykind-M (Gliclazide+ Metformin) Tablet belongs to a category of medicines known as anti-diabetic
drugs. It is a combination of two medicines used to treat type 2 diabetes mellitus in adults. It helps
control blood sugar levels in people with diabetes.
• Glykind-M Tablet should be taken with food. Take it regularly at the same time each day to get the
most benefit.
• The most common side effect of Glykind-M Tablet is low blood glucose levels (hypoglycemia).
Make sure you recognize the signs of having low blood glucose levels, such as sweating,
dizziness, headache, and shaking and know how to deal with it. To prevent this, it's important to
have regular meals and always carry a fast-acting source of glucose such as sugary food or fruit
juice with you.
• You should not take it if you have type 1 diabetes mellitus, if you have diabetic ketoacidosis (high
levels of acid in your blood), or if you have severe kidney or liver disease.
• T. Voglistar - MD 0.2 Tablet is a medicine used to treat type 2 diabetes mellitus. It helps control the
high blood sugar levels in your body after each meal. It is used when other similar medicines along
with a restricted diet, are unable to control abnormally high blood sugar levels.

51. • T. Picasa-GR Tablet is an antifungal medicine. It works by killing and stopping the growth of
fungus that is causing the infection.
• Picasa-GR Tablet belongs to a group of medicines called antifungals. It works by stopping the
growth of fungus and is used to treat fungal infection. It kills fungi by destroying the fungal cell
membrane.
• The most common side effects of this medicine include headache, diarrhea, feeling sick
(nausea), and low potassium level.
• Do not skip any doses and finish the full course of treatment even if you feel better.
• Take it with food, preferably at the same time every day.
• Do not take indigestion remedies (antacids) within two hours of taking Picasa-GR Tablet.
• Your doctor may check your liver function before starting treatment and regularly thereafter.
Inform your doctor if you notice yellowing of eyes or skin, dark urine, or stomach pain.

52. • Zymar Eye Drop is an antibiotic, used in the treatment of bacterial infections of the eye.
It relieves the symptoms of the infection by stopping the further growth of the causative
microorganisms.
• Refresh Tears Eye Drop is an eye lubricant or artificial tears used to relieve dry eyes.
This can happen because not enough tears are made to keep the eye lubricated. It helps
to soothe the irritation and burning seen in dry eyes by maintaining proper lubrication of
the eyes.
• Pansec Tablet is used to prevent stomach ulcers and acidity that may be seen with the
prolonged use of painkillers. It belongs to a class of medicines known as proton pump
inhibitors (PPIs). This medicine should be taken one hour before a meal, preferably in the
morning.
• Ecosprin 75 Tablet is an antiplatelet medicine used to treat and prevent heart attacks,
strokes, and heart-related chest pain (angina). It helps to prevent the formation of blood
clots in your blood vessels. It is a very widely used medicine for heart protection. It is
usually best taken with food otherwise it may upset your stomach.

53. PREVENTION
• Protect yourself from the environment. It’s important to note that although
these actions are recommended, they haven’t been proven to prevent
mucormycosis.
- Try to avoid areas with a lot of dust like construction or excavation sites. If
you can’t avoid these areas, wear an N95 respirator (a type of face mask)
while you’re there. Avoid direct contact with water-damaged buildings and
flood water after hurricanes and natural disasters.
- Avoid activities that involve close contact to soil or dust, such as yard work
or gardening. If this isn’t possible,
- Wear shoes, long pants, and a long-sleeved shirt when doing outdoor
activities such as gardening, yard work, or visiting wooded areas.
- Wear gloves when handling materials such as soil or manure.
- To reduce the chances of developing a skin infection, clean skin injuries
well with soap and water, especially if they have been exposed to soil or
dust.
• Antifungal medication. If you are at high risk for developing Mucormycosis (for
example, if you’ve had an organ transplant or a stem cell transplant), your
healthcare provider may prescribe medication to prevent Mucormycosis and
other mold infections. Doctors and scientists are still learning about which
transplant patients are at highest risk and how to best prevent fungal infections.

54. REFERENCES
• https://rarediseases.org/rare-diseases/mucormycosis/
(NATIONAL ORGANIZATION FOR RARE DISEASES)
• https://www.japi.org/x27464c4/post-covid-19-
mucormycosis-from-the-frying-pan-into-the-fire

55. THANKYOU