What is mucormycosis, and how is it linked with COVID-19? we’ve seen reports of an infection called mucormycosis, often termed “black fungus”, in patients with COVID, or who are recovering from COVID, in India. Fungal infections can be devastating. And in this case mucormycosis is adding to the burden of suffering in a country already in a deep COVID crisis.
2. Overview
Meaning
Reservoir
Transmission
Etiologic agents
Types
Predisposing factors
Prevention
Warning signs and symptoms
When to suspect
Do’s and don’ts
How to manage
Prognosis
3. What is mucormycosis?
Mucormycosis (sometimes called zygomycosis
and black fungus) is a serious but rare fungal
infection caused by a group of molds called
mucormycetes, that mainly affects people who
are on medication for other health problems
that reduces their ability to fight environmental
pathogens.
4. Reservoir
These fungi live throughout the environment,
particularly in soil and in decaying organic
matter, such as leaves, compost piles, or
rotten wood
5. Transmission
People get mucormycosis by coming in
contact with the fungal spores in the
environment. Transmission occurs
through inhalation, inoculation, or
ingestion of spores from the
environment
After fungal spores are inhaled from the
air sinuses or lungs of such individuals
get affected
Mucormycosis can also develop on the
skin after the fungus enters the skin
through a cut, scrape, burn, or other
type of skin trauma
6. Etiologic Agent
Rhizopus species
Mucor species
Rhizomucor species
Lichtheimia (formerly Absidia) species
7. 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 : Common among
young children than adults, especially premature and
LBW 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.
8. 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.
9. What predisposes (Risk
factors)
Uncontrolled diabetes mellitus with diabetic
ketoacidosis
Immunosuppression by streroids
Prolonged ICU stay
Co- morbidities- post transplant/ malignancy
Iron overload or hemochromatosis
Skin injury due to surgery, burns, or wounds
Prematurity and low birthweight (for neonatal
gastrointestinal mucormycosis)
10. How to prevent
Protect yourself from the environment
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 to reduce the chances of
developing a skin infection
11. Warning signs and symptoms
Pain and tenderness around eyes and/ or nose
Fever
Headache
Coughing
Shortness of breath
Bloody vomitus
Altered mental status
12. When to suspect
(in COVID-19 patients, diabetics or
immunosuppressed individuals)
The symptoms of mucormycosis depend on
where in the body the fungus is growing
Symptoms of rhinocerebral (sinus and brain)
mucormycosis include:
Sinusitis- Nasal blockade or congestion
Nasal discharge (blackish/ bloody)
local pain on the cheek bone
One sided facial pain, numbness or swelling
Headache
13. Blackish discoloration over bridge of nose/
palate
Toothache, loosening of teeth, jaw involvement
Blurred or double vision with pain; fever
14. Symptoms of pulmonary (lung)
mucormycosis include:
Fever
Cough
Chest pain
Pleural effusion
Haemoptysis
Shortness of breath
Worsening of respiratory symptoms
15. Cutaneous (skin) mucormycosis
Skin lesion; thrombosis & necrosis (eschar)
Other symptoms include pain, warmth,
excessive redness, or swelling around a
wound.
16. Symptoms of gastrointestinal
mucormycosis include:
Abdominal pain
Nausea and vomiting
Gastrointestinal bleeding
Disseminated mucormycosis
Patients can develop mental status changes or
coma.
17. Do’s
Control hypoglycemia
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
18. Don’ts
Do not miss 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, tissue biopsy,
MALDOTOF), for detecting fungal etiology
Do not lose crucial time to initiate treatment for
mucormycosis
19. 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
20. How to manage- cont.
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
e.g. CT scan of lungs, sinuses or other body
21. Team approach works best
Microbiologist
Internal medicine specialist
Intensivist
Neurologist
ENT specialist
Opthalmologist
Dentist
Sugeon (maxillofacila/ plastic)
Biochemist
Nursing and other paramedical staff
22. Prognosis
Prognosis depends on several factors
Rapidity of diagnosis and treatment
Site of infection
Patient’s underlying conditions
Degree of immunosupression
The overall mortality rate is 50%, although
early identification and treatment can lead to
better outcome