1) A 24-year-old male presented with headache and facial pain after a tooth extraction and was found to have hyperglycemia and hypertension. CT scan showed infiltration in the right maxillary sinus indicating bone invasion.
2) The patient was given IV fluids, insulin, liposomal amphotericin B, and transferred to the ICU for management of mucormycosis. Treatment involved antifungals like amphotericin B and posaconazole as well as surgical debridement.
3) Risk factors for mucormycosis include hyperglycemia, corticosteroid use, and underlying conditions like diabetes or cancer. Diagnosis involves tissue biopsy and microscopy showing characteristic hyphal structures
3. CASE
• 24-year-old male patient with no known past
medical history presented to the emergency
department with a severe headache and right-
sided facial pain.
• On the prior day, the patient had a wisdom tooth
extraction without any complications. On the day
following the procedure, he began to experience
severe headache and right-sided facial pain. Was
found out to be hyperglycaemic and hypertensive
4. CASE CONTD
• CT scan of the neck was performed that
showed infiltration of the right retroantral fat
plane, a subtle but critical finding (Figure 1).
This radiographic finding indicates that the
disease has invaded through the bone of the
right maxillary sinus, apart from blood count
5. Management of this case
• Multiple disciplinary approach
• The patient was given IV fluids, started on an
insulin drip and liposomal amphotericin B, and
transferred to an intensive care unit
for management. Due to the continuous
insulin drip and amphotericin B treatment, he
was frequently hypokalemic and required
persistent potassium replenishment.
• Broad spectrum antibiotics
6. Complete information on
Mucormycosis
• Learning objective
• To be able to describe sign and symptom of
disease
• Should be able to identify the risk factors
• To able to review clinical presentations of
different type of mucormycosis
• To be able to enumerate and assess the
laboratory investigation required for same
• To be to manage the case of mucormycosis which
include drug therapy
7. A. INTRODUCTION:
Mucormycosis is a disease caused by fungus of Mucorales
species.
These fungi are present in the environment in soil or decaying
organic matter.
In COVID 19 a three pronged assault make the patients
susceptible:
• COVID19 : immune dysregulation, ciliary dysfunction
thrombo-inflammation
• Hyperglycemia : polymorphonuclear neutrophils (PMN)
dysfunction, impaired chemotaxis and intracellular killing
• Corticosteroid : impairment in the neutrophil migration,
ingestion, and phagolysosome fusion. Also exacerbates
hyperglycemia.
8.
9. Important features
• Reasons for increase in mucormycosis in Covid – 19 patients:
• Hyperglycemia due to uncontrolled pre-existing diabetes and high
prevalence rates of mucormycosis in India per se.
• 2. Rampant overuse and irrational use of steroids in management
of Covid – 19.
• 3. New onset diabetes due to steroid overuse or severe cases of
Covid – 19 per se.
• 4. Prolonged ICU stay and irrational use of broad spectrum
antibiotics
• 5. Pre-existing co-morbidities such as hematological malignancies,
use of immunosuppressants, solid organ transplant etc.
• 6. Breakthrough infections in patients on Voriconazole (anti –
fungal drug) prophylaxis.
• Delta variant and humidifiers use without clean water
10. Types
• Rhinocerebral Mucormycosis infection generally starts in
the nose and may progress to the Eye and the Brain
• Nose and sinuses Mucor infection (relatively early disease)
Early detection at this stage can enable early treatment and
minimize complications.
• • Headache and nasal obstruction- especially if persistent
or severe and not responding to pain medicines
• . • Nasal crusting and nasal discharge which could be
brownish or blood tinged
• • Pain or loss of sensation on face • Discolouration of skin
of face / localised Facial puffiness
• • Loosening of teeth/ discoloration or ulceration of palate
11. B. PRESENTATION:
Eye / Orbital Mucor infection ( moderately
advanced disease
• • Eye swelling or redness, double vision, loss of
vision, Eye pain, drooping eyelid
• • Rhino-orbito-cerebral mucormycosis (ROCM)
• • Pulmonary
• • Gastrointestinal
• • Cutaneous
• • Disseminated
12. C. RISK FACTORS
• a) Hyperglycemia in undiagnosed or uncontrolled
diabetic.
• b) Ketoacidosis
• c) Corticosteroid and anti-IL-6-directed strategies
in COVID patients
• d) Cancer or post-transplant patient
• e) Neutropenia, on chemotherapy
• f) Patients on Immunomodulators
• g) Voriconazole therapy
13. D. HOW TO SUSPECT:
Classical hallmark of mucormycosis is rapid
onset of tissue necrosis with and without
fever, associated with features of involvement
of blood vessels and thrombosis.
14. Do’s & Dont’s for patients
• Dont’s •
• Self medicate, especially steroids
• Delay reporting symptoms of Mucor
• Ignore medical advice
• Do’s
• Give history of diabetes to doctor
• Get Sugar levels checked
• Watch for early signs of Mucor listed above.
• Maintain basic hygiene and cleanliness.
• Follow medical advice; Take complete course of
treatment as suggested by doctor
15. Investigation:
i. NCCT PNS ( to see bony erosion).
ii. HRCT chest ( ≥ 10 nodules, reverse halo sign, CT
bronchus sign etc.) and CT Angiography.
iii. MRI brain for better delineation of CNS
involvement
Diagnosis: i. KOH staining and microscopy,
histopathology of debrided tissue and culture
ii. MALDI-TOF if available
iii. Presence of Ribbon like aseptate hyphae 5-15 µ
that branch at right angles.
16. Treatment
• Treatment of Mucormycosis involves combination
of surgical debridement and antifungal therapy.
• Liposomal Amphotericin B in initial dose of
5mg/kg body weight (10 mg/kg body wt in case
of CNS involvement) is the treatment of choice.
Each vial contains 50 mg. It should be diluted in
5% or 10% dextrose, it is incompatible with
normal saline/ Ringer Lactate.
17. Antifungal
• Available preparations with dose and duration:
• 1. Amphotericin B deoxycholate (D-AmB)- 1.0-1.5
mg/kg/day for 3-6 weeks
• 2. Inj. Amphotericin B Lipid Complex (ABLC-
5mg/kg/day for 3-6 weeks
• 3. Liposomal amphotericin B (L-AmB) - 5-10mg/kg/day
for 3-6 weeks
• ABLC to be used preferably for pulmonary
mucormycosis.
• L -AmB to be used preferably for CNS involvement.
18. Amphotericin deoxycholate
• Consider giving one litre of normal saline solution with 20mEq of
potassium chloride (1 amp KCl) over two hours before each
controlled infusion of amphotericin B.
• Reconstitute each vial (50 mg) with 10 ml water for injection and
shake immediately to produce a 5mg/ml colloidal solution.
• Dilute further in 500 ml of 5% dextrose to a concentration of 100
micrograms/ml.
• Infuse over 2-4 hours or longer if not tolerated (initial test dose 10
ml i.e. 1mg over 20-30 minutes).
• Begin infusion immediately after dilution and protect from light
(cover with black sheet).
• It is incompatible with sodium chloride solution. Flush existing
intravenous line with glucose 5% or use separate line.
19. ABLC
• Allow suspension to reach room temperature, shake gently to
ensure no yellow settlement.
• Withdraw requisite dose (using 17 to 19 gauge needle) into one or
more 20 ml syringes.
• Replace needle with a 5 micron filter needle provided (fresh needle
for each syringe) and dilute to a concentration of 1 mg/ml (2 mg/ml
can be used in fluid restriction and in children).
• Preferably give via an infusion pump at a rate of 2.5 mg/kg/hour
(initial test dose of 1 mg given over 15 minutes).
• An inline filter (pore size no less than 15 microns) may be used.
• Do not use sodium chloride or other electrolyte solutions, flush
existing intravenous line with 5% dextrose or use separate line.
20. L-AmB
• Reconstitute contents of vial (50mg) with 10ml water
for injection, shake well for 2-5 minutes to generate
liposomes.
• Once you reconstitute all the vials, fill 10 ml syringe
with the reconstituted L-AmB.
• Remove needle, apply 5-micron filter to the syringe
nozzle and empty content in to 200 cc 5% dextrose.
Infuse L-AmB rapidly over 2-3 hours (initial test dose 1
mg over 10 minutes).
• It is incompatible with sodium chloride solutions, flush
existing intravenous line with 5% dextrose or use
separate line.
21. • 4.Patients who are intolerant to Amphotericin
B: Posaconazole (300mg twice on day 1,
followed by 300 mg daily for 3-6 months 5.
After 3-6 weeks of Amphotericin B therapy,
consolidation therapy (Posaconazole) for 3-6
months
22. Treatment continued
• several weeks after following which step down to
oral Posaconazole (300 mg delayed release
tablets twice a day for 1 day followed by 300 mg
daily) or
• Isavuconazole (200 mg 1 tablet 3 times daily for
2 days followed by 200 mg daily) can be done.
• Conventional Amphotericin B (deoxy cholate) in
the dose 1-1.5mg/kg may be used if liposomal
form is not available and renal functions and
serum electrolytes are within normal limits.
