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.

1. MUCORMYCOSIS THE
FUNGAL INFECTION
AFFECTING COVID
PATIENTS IN INDIA
Prepared By:
Mrs. Shikha Malik

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

23. References
 https://www.cdc.gov/fungal/diseases/mucormy
cosis/treatment.html
 https://www.icmr.gov.in/pdf/covid/techdoc/Muc
ormycosis_ADVISORY_FROM_ICMR_In_CO
VID19_time.pdf