#Black fungus disease #COVID

Zygomycosis or mucormycosis - Angio- invasive life threatnening disease

Causative agent

aseptate fungi Eg: Rhizopus, Mucor and Absidia

Where is this fungus present ?

Everywhere around us

How do they survive in human body ?

Agents of mucormycosis feed on iron in our body . So conditions with increased iron load are at higher risk of developing mucormycosis,

Who are at risk ?

• Uncontrolled Diabetes ,Diabetic ketoacidosis (DKA) is the most important risk factor

• Extensive use of immunosuppressive drugs - steroids ,toclizumab

• Extensive use of broad-spectrum antibiotics

• immunodeficiency

• Cancer

• End stage renal disease

• Patients taking iron therapy or deferoxamine (iron chelator)

• Defects in phagocytic functions (e.g. neutropenia ).

Why COVID patients are at increased risk ?

• COVID patients using mask , oxygen humidifiers and ventilators in hospital which are not properly sanitized can lead to fungus growth

• In covid even though serum iron levels decrease intracellular iron levels increase so during recovery from covid these intracellular cells undergo degeneration leading to release of iron and along with acidic pH helps fungus to grow

Why the black fungus is life threatening ?

These fungi are angioinvasive i.e directly invade blood vessels . Literally they may invade any part of the body .They rapidly progress in the body even a slight

delay in the diagnosis or appropriate management can have devastating implications on patient survival .

Most common organs involved are nose , brain , eye , lungs , skin , intestines.

What are the warning signs that needs immediate doctor consultation ?

• Nasal stuffiness

• Foul smell

• Epistaxis - bleeding from nose

• Black Nasal discharge- characteristic

• Nasal eschar

• Eyelid, periocular or facial edema / discoloration

• Regional pain – orbit, paranasal sinus or dental pain ,Facial pain

• Worsening headache

• Proptosis- popping out of eyeball

• Sudden loss of vision

• loss of Facial sensation

• ptosis or drooping of eye lid

• double vision

• Fever, paralysis, focal seizures

What are the investigations to be done to diagnose it ?

• Nasal endoscopy swab for KOH mount

• contrast-enhanced MRI or CT Scan of Head.

• Clinico-radiological features, coupled with microbiological confirmation

  • Biopsy of tissue (Histopathological stain )- broad aseptate hyaline hyphae with wide angle branching

  • Culture on Sabaroud dextrose agar at 25°C - appear as white and black / salt and pepper appearance

Why it is difficult to treat at small set up hospitals ?

Because it needs multi-disciplinary team of doctors comprising radiologist, microbiologist, pathologist, molecular biologist), physician (infectious disease,

neurology, critical care) and surgeon (otorhinolaryngologist, ophthalmologist, neurosurgeon) .

What are the treatments available ?

Guidelines according to The European Confederation of Medical Mycology (ECMM) and the Mycoses Study Group Education and Research Consortium (MSG ERC) are

Medical :

Intravenous amphotericin B -5-10 mg/kg - 4weeks

followed by

oral posaconazole 300 mg tab

day 1 - 1 tab morning & 1tab evening

day 2 - day 180 - 1 tab daily morning

Hybebaric oxygen therapy if required

Anti fungal treatment is required for 3 - 6 months

Surgical :

If medical treatment fails

Orbital exenteration

aggresive debridement of paranasal sinuses

turbinectomy

palate resection

orbital wall resection

How to prevent this in COVID 19 setting ?

For all patient

• strict control of diabetes(FBS <125 mg/dl)

• judicious use of steroids and higher antibiotics

For hospitalised patients

• Cleaning around mask areas with sponge wet with sanitiser

• Changing of oxygen mask weekly

• Clean sterile water should be used oxygen therapy

• Strict aseptic precautions while administering oxygen

For coma patients

• Thorough wash of body atleast weekly with sponge dipped in scrub or sanitiser

For normal or mild covid patient

• maintain personal hygeine