Mucormycosis in detail and how it is related with covid 19 in detail.

1. MUCORMYCOSIS
Dr. Rubina Subhani
Department of Practice of Medicine
PG Part I

2. OVERVIEW
• DEFINITION
• TYPES
• SITE OF INFECTION
• SIGNS AND SYMPTOMS
• RISK FACTORS
• DIAGNOSIS
• TREATMENT
• PREVENTION
• PROGNOSIS
• RECENT RESEARCH

7. In Ahmedabad, 44 cases
including nine deaths were
reported by mid-December
2020.
India reports over 11,700 black
fungus cases as of May 25,
according to the govt.
total of 19,727 active cases of
mucormycosis as of June 3rd.
SITUATION IN INDIA

8. • Before the pandemic, mucormycosis was already far more common in
India than in any other country. It affects an estimated 14 in every 100,000
people in India compared to 0.06 per 100,000 in Australia, for example.

10. DEFINITION
MUCOR- It is a
filamentous fungus found
in soil, plants, decaying
fruits and vegetables.
MYCOSIS- Fungal infection
• Previously called
ZYGOMYCOSIS.
• Serious but rare
fungal infection
caused by a group
of molds called
mucormycetes.
• IT IS AN
OPPORTUNISTIC
INFECTION

11. • Fungi belonging to the order Mucorales.
• Rhizopus species are the most common causative organisms.
• Mucorales are ubiquitous fungi that are commonly found in soil and in
decaying matter.
• Rhizopus oryzae is the most common organism isolated from patients
with mucormycosis and is responsible for ∼ 70% of all cases of
mucormycosis.

13. WHY IT IS CALLED BLACK FUNGUS ?
• It's also called 'black fungus' infection because it's characterised by black
nasal discharges and black patches of skin around the nose in the initial
stages.
• In the laboratory, these fungi grow rapidly and have a black-brown fuzzy
appearance.
• COVID-19-associated mucormycosis,commonly referred to as black fungus.

18. SITE OF INFECTION
P.S : MAINLY AFFECTS THE AFFECTS THE MUCOUS MEMBRANE.

21. INHALATION --> INVASION--> DISSEMINATION

22. Mucoraceae are molds in the
environment that become
hyphal forms in tissues.
Once the spores begin to grow,
fungal hyphae invade blood
vessels, producing tissue
infarction, necrosis, and
thrombosis.
Neutrophils are the key host
defense against these fungi;
thus, individuals with
neutropenia or neutrophil
dysfunction (eg, diabetes,
steroid use) are at highest risk.
Few cases of mucormycosis
have been reported in patients
AIDS, suggesting that the host
defense against this infection is
not primarily mediated by
cellular immunity.

24. WHY IN COVID PATIENTS ?
COVID 19
STEROIDS
HIGH SUGAR LEVELS
LOW IMMUNITY

25. WHY IN DIABETIC PATIENTS ?
• When diabetes is poorly controlled, blood sugar is high and the tissues
become relatively acidic – a good environment for Mucorales fungi to
grow.
• LOW pH --> phagocytes are dysfunctional and have impaired chemotaxis
and defective intracellular killing.
• This was identified as a risk for mucormycosis in India and worldwide well
before the Covid-19 pandemic.

26. • The clinical observation that patients with DKA are uniquely susceptible to
mucormycosis lends support to the role of iron uptake in the pathogenesis of
the disease.
• Patients with DKA have elevated levels of free iron in their serum, and such
serum supports growth of R. oryzae at acidic pH.
• A recent summary of Covid-19-associated mucormycosis showed 94% of
patients had diabetes and it was poorly controlled in 67% of cases.
• Patients receiving dialysis who are treated with the iron chelator
deferoxamine are also uniquely susceptible to a deadly form of mucormycosis.

27. FIG :
Postmortem photograph of a woman with diabetes
and left rhinocerebral mucormycosis complicating
ketoacidosis. Rhizopus oryzae was the causative
organism. Note the orbital and facial cellulitis and the
black nasal discharge.

28. TYPES OF MUCORMYCOSIS
• Infection in the sinuses that can
spread to the brain.
• Most common in people with
uncontrolled diabetes and in people
who have had a kidney transplant.
1. Rhinocerebral
(sinus and brain)
mucormycosis
(ROCM)
• Most common type of mucormycosis
in people with cancer.
2. Pulmonary
(lung)
mucormycosis

29. • More common among young children than adults, especially
premature and low birth weight infants less than 1 month
of age.
3.Gastrointestinal
mucormycosis
• Occurs after the fungi enter the body through a break in the
skin.
• most common form of mucormycosis among people who
do not have weakened immune systems.
4.Cutaneous
(skin)
mucormycosis
• when the infection spreads through the bloodstream to
affect another part of the body.
• most commonly affects the brain, but also can affect other
organs such as the spleen, heart, and skin.
5.Disseminated
mucormycosis

30. CAN MUCORMYCOSIS AFFECT NON COVID
PATIENTS ?
• This fungal infection can happen even to people without COVID-19 disease.
• The combination of uncontrolled diabetes and some other significant
disease may lead to black fungus
• A diabetes patient becomes vulnerable to black fungus when one’s blood
sugar level reaches 700-800—a situation medically known as diabetic
ketoacidosis.

31. IS MUCORMYCOSIS CONTAGIOUS?

32. SIGNS AND SYMPTOMS

33. , FEVER

35. SYMPTOMS OF PULMONARY MUCORMYCOSIS:
• Fever
• Cough
• Chest pain
• Shortness of breath

36. CUTANEOUS MUCORMYCOSIS
• Blisters or ulcers, and the
infected area may turn black.
• Pain, warmth, excessive redness,
or swelling around a wound.

37. • The skin barrier represents a host defense against cutaneous
mucormycosis, as evidenced by the increased risk for developing
mucormycosis in persons with disruption of this barrier.
• The agents of mucormycosis are typically incapable of penetrating intact
skin.
• However, burns, traumatic disruption of the skin, and persistent
maceration of skin enables the organism to penetrate into deeper tissues.
• Contaminated surgical dressings and nonsterile adhesive tape have been
shown to be the source of primary cutaneous mucormycosis

38. SYMPTOMS OF GASTROINTESTINAL
MUCORMYCOSIS :
• Abdominal pain
• Nausea and vomiting
• Gastrointestinal bleeding

39. DISSEMINATED MUCORMYCOSIS
• Patients with disseminated
infection in the brain can
develop mental status changes
or coma.

41. APPROACH CONSIDERATIONS IN MUCORMYCOSIS PATIENT
• Timely diagnosis
• Computed tomography (CT) imaging of the paranasal sinuses and an
endoscopic examination of their nasal passages with biopsies of any
suggestive lesions.
• Obtaining a biopsy specimen of the involved tissue, Tissue should also be
sent for routine pathology examination and cultures.
• For pulmonary disease, a bronchoalveolar lavage (BAL), biopsy, or both
may assist in the diagnosis.
• For cutaneous disease, a skin biopsy for pathology and culture should be
obtained.

42. LABORATORY TESTS
• to assess for neutropenia.
Complete blood cell
(CBC) count
• to monitor homeostasis and
direct correction of acidosis.
Blood glucose,
bicarbonate, and
electrolytes
• determine the degree of acidosis
and guide corrective therapy.
Arterial blood gas
(ABG) study

43. • to assess the presence of iron overload
as shown by high ferritin levels and a
low total iron-binding capacity.
Iron studies
• cerebrospinal fluid (CSF) findings may
include elevated protein levels.
• A CT scan should precede a lumbar
puncture to assess for evidence of
elevated intracranial pressure, which
could lead to herniation.
Central nervous
system (CNS)
involvement

44. RADIOLOGIC STUDIES
• Head and facial CT imaging should be used as the initial investigation in
rhinocerebral infections.
• CT scans may show sinusitis of the ethmoid and sphenoid sinuses, as well as
orbital and intracranial extension. As the disease progresses, bony erosion may
occur and the infection may spread into the brain or orbits.
• Magnetic resonance imaging (MRI) of the facial sinuses and brain is superior
to a CT scan in assessing the degree of tissue invasion and need for ongoing
surgery.
Rhinocerebral
infections

45. • Chest radiography is often the initial test performed, its sensitivity and
specificity for mucormycosis are low.
• In Nonenhanced high-resolution CT scanning, The most common findings
include pleural effusion, nodules, consolidation, and ground-glass opacities.
• With disease progression, consolidation can become multilobar. The reverse
halo sign (ie, a nodule with central ground-glass opacity and a ring of
peripheral consolidation) strongly suggests pulmonary mucormycosis
Pulmonary
disease

46. • Abdominal CT scans may show a mass associated with the GI tract.
• Esophagogastroduodenoscopy (EGD) may show areas of tissue necrosis
amenable to biopsy.
Gastrointestinal
disease

55. APPROACH CONSIDERATIONS FOR TREATMENT
• Diabetic ketoacidosis requires insulin and volume repletion with
intravenous fluids.
• Neutropenia associated with hematologic malignancy and its treatment
should be reversed, if possible, with the use of colony-stimulating factors
and the withdrawal of cytotoxic chemotherapy.
• Wean glucocorticosteroids and other immunosuppressive drugs.
• Interrupt deferoxamine therapy.

56. TREATMENT
• Amphotericin B therapy
• Surgical removal of the "fungus
ball".

57. PROGNOSIS
• The prognosis of mucormycosis is poor and the disease has varied
mortality rates depending on its form and severity.
• In the rhinocerebral form, the mortality rate is between 30% and 70%.
• Disseminated mucormycosis presents with the highest mortality rate in
an otherwise healthy patient, with a mortality rate of up to 90%.
• Patients with AIDS have a mortality rate of almost 100%.

58. RECENT RESEARCH

61. TAKE HOME MESSAGE
• Prevention is always better than cure.
• Cleanliness is next to Godliness - be clean and maintain hygiene.
• Complete knowledge about the disease condition.
• EDUCATE PEOPLE IN AND AROUND YOUR LOCALITY.
• Properly follow Do’s and Dont’s.
• Eat healthy, stay safe.