2. AGENDA
What is black fungus ( Mucor mycosis)?
Mycology
History
Black fungus in India
Black fungus in Egypt
Types of Mucor mycosis
How mucor mycosis spread ?
Clinical picture of mucor mycosis
Diagnosis
Is black fungus affecting children ?
Prevention
Approach to treatment
What is white fungus?
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 2
3. INTRODUCTION
WHAT IS MUCORMYCOSIS?
Mucormycosis is a fungal infection that causes blackening or discoloration over the nose,
blurred or double vision, chest pain, breathing difficulties and coughing blood.
It is caused by exposure to mucor mould which is commonly found in soil, plants,
manure, and decaying fruits and vegetables.
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 3
4. WHAT IS
MUCORMYCOSIS
?
It affects the sinuses, the brain and the lungs and
can be life-threatening in diabetic or severely
immunocompromised individuals, such as cancer
patients or people with HIV/AIDS.
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 4
Mucor mould is found in soil, plants,
manure and decaying fruits
5. MYCOLOGY
T hese organisms are ubiquitous in nature and can be found on decaying vegetation and in the
soil. These fungi grow rapidly and release large numbers of spores that can become airborne.
The fact that mucormycosis is a rare human infection reflects the effectiveness of the intact
human immune system
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 5
6. Rhino-orbital-cerebral and pulmonary mucormycosis are acquired by the inhalation of spores.
In healthy individuals, cilia transport these spores to the pharynx and they are cleared through
the gastrointestinal tract.
In susceptible individuals, infection usually begins in the nasal turbinates or the alveoli
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 6
Magnified black fungus
7. HISTORY
On Saturday morning, Dr Akshay Nair, a Mumbai-based
eye surgeon, was waiting to operate on a 25-year-old
woman who had recovered from a bout of Covid-19 three
weeks ago.
Inside the surgery, an ENT specialist was already at work
on the patient, a diabetic.
He had inserted a tube in her nose and was removing tissues
infected with mucormycosis, a rare but dangerous fungal
infection. This aggressive infection affects the nose, eye and
sometimes the brain.
After his colleague finished, Dr Nair would carry out a
three hour procedure to remove the patient's eye.
"I will be removing her eye to save her life. That's how this
disease works," Dr Nair told me.
8. Data from the U.S. Centers for Disease
Control and Prevention shows that
mucormycosis has a mortality rate of 54%,
which can vary depending on the condition of
the patients and the body part affected.
States across India have reported more than 5,000
cases of the otherwise rare disease in recent
weeks, mostly in people infected with
COVID-19 or recovering from the disease.
Till 22 May, India has reported about 8,848 cases
of black fungus or mucormycosis, according to a
statement by Union minister Sadananda Gowda
9. COVID AND BLACK
FUNGUS
Doctors believe mucormycosis, which has an
overall mortality rate of 50%, may be being
triggered by the use of steroids, a life-
saving treatment for severe and critically ill
Covid-19 patients.
Steroids reduce inflammation in the lungs
for Covid-19 and appear to help stop some of
the damage that can happen when the body's
immune system goes into overdrive to fight off
coronavirus.
But they also reduce immunity and push
up blood sugar levels in both diabetics and
non-diabetic Covid-19 patients.
It's thought that this drop in immunity could
be triggering these cases of
steroids which help fight Covid-19 act like fuel
10. WHY DOES INDIA HAVE SO MANY CASES OF POST-
COVID MUCORMYCOSIS?
The improper use of steroids to treat Covid-19
patients, coupled with poorly managed diabetes. But
steroids in themselves are not the villains.
there is no strict prescription check in India, and most
drugs—even those that need a prescription—can be
easily bought over-the-counter.
India has an epidemic of type 2 diabetes, and a
significant proportion of patients with diabetes are
diagnosed late in the illness,
11. COVID AND BLACK FUNGUS
IN EGYPT
Authorities deny emergence of black fungus among
COVID-19 patients in Egypt
Thu, 27 May 2021 - 01:28 GMTA
A source at the Ministry of Health said that black
fungus has not appeared as a symptom for those
recovering from coronavirus, and that Samir
Ghanem’s case had been carefully examined for
the existence of this symptom
62-year old lady in Fayoum, who recently
recovered from COVID-19, was diagnosed with the
fungal infection.
12. MANSOURA UNIVERSITY
HOSPITAL REPORTS
BLACK FUNGUS CASES
AL-MASRY AL-YOUM MAY 28, 2021
4 CASES
All were admitted into the ENT department
Two of the cases previously had coronavirus, one
case had a malignant breast tumor
and another had kidney failure.
All of these cases suffered from severe weakening
of immunity, which is the main reason for infection
Some cases respond to treatment and others need
endoscopic intervention to clean the fungus
13. It is noted that the Ministry of Health and Population
has denied that the Indian variation has appeared in
Egypt.
he pointed out that the spread of black fungus in
India does not have to become a worldwide
phenomenon.
Member of the Scientific Committee for Combating
COVID-19 Mohamed al-Nadi pointed out that a
polluted environment is a significant factor either.
For instance, getting exposed to large quantities of
dust and rotten vegetables and fruits frequently
coupled with low immunity can incur black fungus
infection. No need to worry about black fungus spreading
in Egypt: presidential health advisor
14. MAY 29, 2021
EGYPT’S FIRST
SUSPECTED CASE OF
BLACK FUNGAL
INFECTION ANNOUNCED
IN MENOUFIA
15. TYPES OF MUCORMYCOSIS
1-Rhinocerebral (sinus and brain) mucormycosis:
most common in people with uncontrolled diabetes and in people who have had a kidney
transplant.
2-Pulmonary (lung) mucormycosis:
in people with cancer and in people who have had an organ transplant or a stem cell
transplant.
3-Gastrointestinal mucormycosis:
premature and low birth weight infants less than 1 month of age,
4- Cutaneous enter the body through a break, This is the most common form of
mucormycosis among people who do not have weakened immune systems
5- Disseminated spreads through the bloodstream , most commonly affects the brain
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 15
16. HOW BLACK FUNGUS SPREAD ?
The disease is caused by fungal spores found in soil and organic
matter, usually inhaled by humans from the air.
The mould enters the body and then manifests around the nose
and eye sockets, causing the nose to blacken, and if not stopped
will move fatally into the brain.
The disease is not contagious and doesn’t spread from one
person to another.
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 16
17. WHAT ARE THE CLINICAL FEATURES OF MUCORMYCOSIS
INFECTION?
1-Nasal blockage, bleeding, discharge from the nose are initial features of mucormycosis.
On endoscopic visualization of the nasal cavity an unmistakable black eschar (slough or dead
tissue) coated masses will be present which gives away the diagnosis.
2-As the disease progresses the palate may be destroyed as a large black necrotic mass may be
seen on opening the mouth.
3-When the orbit is involved there will be proptosis (protrusion of eyeball), loss of movements
of the eyeball with consequent double vision. Eye pain, redness with blindness can follow.
4-If the brain is invaded due to blood vessel blockage there will be strokes, hemorrhages, and
even death. Patients can also have headaches, drowsiness, limb weakness, seizures and even
death.
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 17
21. Can there be other fungal infections in COVID 19
patients?
In western countries, Mucor has not caused as much havoc as it has in
India. However, there has been an increased incidence of other fungal
infections like aspergillosis and candidiasis in COVID-19 patients
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 21
22. DIAGNOSIS OF BLACK FUNGUS
1-medical history and physical exam.
2-fluid or tissue samples send them to a lab.
3-CT scan or MRI.
4-There are no specific blood tests to detect mucormycosis.
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 22
23. RHINOCEREBRAL MUCORMYCOSIS DIAGNOSIS
Punch biopsy of the lesion followed by fungal stains and culture.
Histological examination reveals the characteristic broad , branching
hyphae of Rhizopus invading the tissue.
CT or MRI of the head reveal air-fluid level in the sinuses and
involvement of deep tissues
PRESENTATION TITLE 2/11/20XX 23
25. 73 year old patient presenting with pain in the
left side of face and orbit.
(A) Coronal CT shows soft tissue density
involving both ethmoid sinus and left maxillary
sinus with extension into extraconal space of the
left orbit (blue arrow).
(B) Axial CT shows soft tissue density in the
orbital apex region (red arrow).
PRESENTATION TITLE 2/11/20XX 25
27. PRESENTATION TITLE 2/11/20XX 27
Chest x-ray shows opacification of the left upper lobe, multiple air/fluid levels, and a 4 cm round
mass-like lesion projecting over one of the air/fluid levels.
Juan F Fernandez et al. Respir Care 2013;58:e60-e63
(c) 2012 by Daedalus Enterprises, Inc.
28. Black fungus in pediatrics
As compared to adults, children are less likely to have
diabetes or an immunocompromised immunity, which is why
they are less prone to any form of fungal infection caused
during COVID-19 infection.
However, recent reports have suggested rare cases of
mucormycosis or black fungus infection in children.
PRESENTATION TITLE 2/11/20XX 28
29. BLACK FUNGUS IN PEDIATRICS
First case of Black fungus detected in children from
Karnataka; condition critical
•Both the children were suffering from ‘acute juvenile
diabetes’ and had contracted Covid-19, which came to light
when they were taken to a hospital
By hindustantimes.com | Edited by Ayshee Bhaduri, Hindustan Times, New Delhi
UPDATED ON JUN 01, 2021 03:34 PM IST
PRESENTATION TITLE 2/11/20XX 29
30. Two cases of Mucormycosis have been reported among
children in Karnataka on Monday -- an 11-year-old girl from
Ballari district and a 14-year-old boy from Chitradurga
district -- making it the first-of-its-kind in the state.
These are the first cases of mucormycosis being reported in children .
Karnataka. Karnataka has reported 1250 cases of mucormycosis. 39
patients have lost their lives to the fungal disease even as18 of them have
recovered. A total of 1,193 patients are currently under treatment for
mucormycosis
PRESENTATION TITLE 2/11/20XX 30
31. How to prevent mucormycosis
•Check your blood sugars when you get diagnosed with Covid-
19. The infection itself can cause a rise in blood sugars, and this can
be independent of whether you have pre-existing diabetes.
•Doctors need to avoid three pitfalls when it comes to using oral or
intravenous corticosteroids: their use too early (if oxygen levels have
not dropped), or their use routinely in higher doses than
recommended (6 mg Dexa a day, or 32 mg methylprednisolone a
day, or 40 mg prednisolone a day), or for longer periods than
recommended (up to 10 days).
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 31
32. •Avoid any therapy that does not have a proven role in treating
Covid-19, no matter how innocuous it may seem.
•When given for short periods, corticosteroids do not need to
be tapered and can be abruptly stopped safely.
•Extra caution needs to be exercised among patients with other
co-existing immunosuppressive conditions such as chronic
liver disease, kidney disease, or autoimmune diseases and
malignancies.
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 32
33. APPROACH TO TREATMENT
— Treatment of mucormycosis involves a combination
surgical debridement of involved tissues
and antifungal therapy .
Elimination of predisposing factors for infection, such as
hyperglycemia, metabolic acidosis,
deferoxamine administration,
immunosuppressive drugs, and neutropenia
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 33
34. Due to the difficulties in establishing a definitive diagnosis,
many patients will be empirically treated for mucormycosis
because they have risk factors for infection and positive
cultures
Intravenous (IV) amphotericin B (lipid formulation) is the
drug of choice for initial therapy
The usual starting dose is 5 -10 mg/kg daily
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 34
35. 1-Posaconazole or isavuconazole can also be used as salvage
therapy ( انقاذي عالجfor patients who don't respond to or cannot
tolerate amphotericin B;
2-loading dose of 300 mg IV every 12 hours on the first day,
followed by a maintenance dose of 300 mg every 24 hours
3-Combination therapy is not recommended in the major
treatment guidelines.
4- In patients who are able to take medications orally, we
use posaconazole delayed-release tablets
5-There is little experience using posaconazole or isavuconazole for this
indication
PRESENTATION TITLE 2/11/20XX 35
36. Duration of therapy —
, patients can be switched from a lipid formulation of
amphotericin B to delayed -
release posaconazole or isavuconazole tablets for oral step-down
therapy once a favorable clinical response has been achieved,
which usually takes several weeks.
Therapy should continue until there is clinical resolution of the
signs and symptoms of infection, as well as resolution of
radiographic signs of active disease.
Therapy often extends for months
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 36
39. Surgery —
Aggressive surgical debridement of involved tissues should be
considered as soon as the diagnosis of any form of mucormycosis
is suspected
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 39
40. OUTCOMES
Despite early diagnosis and aggressive combined surgical and medical
therapy, the prognosis for recovery from mucor mycosis is poor . An
exception is cutaneous involvement,
Rhino-orbital-cerebral infection : mortality rate from 25-67%
Pulmonary mucor mycosis : mortality rate as high as 87%
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 40
42. WHITE FUNGUS INFECTION
White fungus, also known as candidiasis, is a serious fungal infection,
can affect the blood, heart, brain, eyes, bones, or other parts of the body.
According to CDC, people who are at high risk for developing this
infection include those who:
•a lot of time in the intensive care unit (ICU)
•Have a weakened immune system
•Have recently received lots of antibiotics or steroids in the
hospital
•Have kidney failure or are on hemodialysis
•Have diabetes
PRESENTATION TITLE 2/11/20XX 42
43. It grows in the lab as white/ creamy white spots on plates of
agar.
In humans, they again appear as white, creamy spots on the
mucosa of the oral cavity most commonly.
PRESENTATION TITLE 2/11/20XX 43
44. SUMMARY
1-Mucormycosis is a fungal infection
that causes blackening or discoloration
over the nose, blurred or double vision,
chest pain, breathing difficulties and
coughing blood.
2-The disease is caused by fungal spores
found in soil and organic matter, usually
inhaled by humans from the air.
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 44
45. 4-India has large number of cases of black fungus infection
with covid patients .
5- Doctors need to avoid three pitfalls when it comes to using oral or
intravenous corticosteroids.
6-Intravenous (IV) amphotericin B (lipid formulation) is the drug of
choice for initial therapy.
7-Aggressive surgical debridement of involved tissues should be
considered as soon as the diagnosis of any form of mucormycosis is
suspected
Dr magdy shafik
Senior pediatric and neonatology Consultant
2/11/20XX 45
46. THANK YOU
Dr magdy shafik
Senior pediatric and neonatology Consultant
PRESENTATION TITLE 2/11/20XX 46
