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How to prevent Mucormycosis? Dos and don’ts for black fungus in COVID patients

Mucormycosis or ‘black fungus’ infection, being found in COVID-19 patients with uncontrolled diabetes and prolonged intensive care unit (ICU) stay, may turn fatal if uncared for, the Centre said on Sunday.

In an advisory, it also said the fungal infection mainly affects people who are on medication that reduces their ability to fight environmental pathogens.

“Mucormycosis, if uncared for, may turn fatal. Sinuses or lungs of such individuals get affected after fungal spores are inhaled from the air,” it said.

The evidence-based advisory for screening, diagnosis and management of the disease was released by the Indian Council of Medical Research (ICMR) and the Union health ministry.

Warning signs and symptoms of Mucormycosis

  • Pain and redness around eyes and nose
  • Fever
  • Headache
  • Coughing
  • Shortness of breath
  • Bloody vomits
  • Altered mental status

When to suspect Mucormycosis

In COVID-19 patients, diabetes or immuno-suppressed individuals, one must suspect of mucormycosis if there is – 

– Sinusitis – nasal blockade or congestion, nasal discharge (blackish/bloody), local pain on the cheek bone One-sided facial pain, numbness or swelling

– Blackish discoloration over bridge of nose/palate

– Toothache, loosening of teeth, jaw involvement

– Blurred or double vision with pain; fever, skin lesion; thrombosis & necrosis (eschar)

– Chest pain, pleural effusion, haemoptysis, worsening of respiratory symptoms

Major risk factors for Mucormycosis

Uncontrolled diabetes mellitus, immunosuppression by steroids, prolonged ICU stay, malignancy and voriconazole therapy, the ICMR-health ministry advisory stated.

Evidence based Advisory in the time of #COVID-19 @MoHFW_INDIA @PIB_India @COVIDNewsByMIB @MIB_India #COVID19India #IndiaFightsCOVID19 #mucormycosis #COVID19Update pic.twitter.com/iOGVArojy1

— ICMR (@ICMRDELHI) May 9, 2021

How to prevent Mucormycosis

– 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

The disease can be managed by controlling diabetes, discontinuing immunomodulating drugs, reducing steroids and extensive surgical debridement- to remove all necrotic materials, according to the advisory.

DOs

– Control hyperglycemia

– 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

Don’ts

– Do not miss warning 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, MALDITOF), for detecting fungal etiology

– Do not lose crucial time to initiate treatment for mucormycosis

Management of Mucormycosis

1. Control diabetes and diabetic ketoacidosis

2. Reduce steroids (if patient is still on) with aim to discontinue rapidly

3. Discontinue immunomodulating drugs

4. No antifungal prophylaxis needed

5. Extensive Surgical Debridement – to remove all necrotic materials

6. Monitor patients clinically and with radio-imaging for response and to detect disease progression

Medical treatment of Mucormycosis

1) Install peripherally inserted central catheter (PICC line)

2) Maintain adequate systemic hydration

3) Infuse normal saline IV before Amphotericin B infusion

4) Antifungal therapy, for at least 4-6 weeks (follow guidelines)

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