Post Covid Mucormycosis Superadded Fungal Infection

COVID-19 patients are more susceptible to Mucormycosis due to prolonged steroid use, immunomodulator use, high ferritin levels, acidosis in DIABETIC KETO ACIDOSIS and CHRONIC KIDNEY DISEASE, prolonged antibiotic use. This disease carries high morbidity and mortality. This includes loss of eye – exenteration. Cost of treatment is high. Liposomal Ampho-B treatment costs almost 12000-15000 Rs/ day. Posaconazole is also a costly alternative. Hence, all efforts must be done to prevent it, diagnose it at early stage, and manage effectively.

 

Predisposing Factors:-

·       Uncontrolled Diabetes Mellitus

·       Immunosuppression by steroids

·       Treatment with Immunomodulators – Tocilizumab, Itolizumab, etc.

·       Prolonged ICU stay

·       Long standing oxygen therapy – specially by nasal prongs

·       Comorbidities – post-transplant, malignancies

·       Voriconazole therapy

·       Long term Ryles tube feeding  

·       Humidifier bottle contamination

·       Prolonged use of higher antibiotics

·       Chronic Kidney Disease/ Chronic Liver Disease

Prevention:-

DOs	DONTs
Control of hyperglycemia – To maintain between 130-180 mg/dl in ICU and strict control in wards HbA1C to be kept below 6.5.	Don’t miss warning signs and symptoms
Monitoring blood glucose levels post-COVID19 discharge and also in diabetics	Don’t consider all cases of blocked nose as cases of bacterial sinusitis, especially in context of immunosuppression and/or COVID-19 patients on immunomodulators
Judicious use of steroids – low dose for 10 days only in hypoxic patients	Don’t hesitate to seek aggressive appropriate investigations (KOH staining & microscopy, culture, MALDI-TOF) to detect fungal etiology
Use of clean, sterile water for humidifiers during Oxygen therapy	Do not lose crucial time to initiate treatment for mucormycosis
Judicious use of antifungals and antibiotics

 

Suspect:-
(In COVID-19 patients, diabetics or immunosuppressed individuals)

·       Sinusitis: nasal blockade or congestion, nasal discharge (blackish/bloody), local pain on cheek bone

·       One sided facial pain, numbness or swelling

·       Blackish discoloration over bridge of nose or palate

·       Toothache, loosening of teeth, jaw involvement, swollen gums

·       Blurred or double vision with pain; fever, skin lesion; ptosis; thrombosis and necrosis (eschar)

·       Loss of vision (early or late feature)

·       Chest pain, pleural effusion, hemoptysis, worsening of respiratory symptoms.

·       Seizures, stroke – in cases of cerebral involvement

 

Warning Signs and Symptoms:-

·       Pain and redness around eyes and/or nose

·       Fever – usually mild

·       Epistaxis

·       Headache

·       Cough

·       Shortness of breath

·       Bloody vomiting

·       Altered mental status

 

Examination Findings:-

·       Facial swelling

·       Facial discoloration

·       Ptosis

·       Proptosis

·       Restricted extraocular movements

·       Central Retinal Artery Occlusion

·       Ophthalmoplegia

·       Panophthalmitis

·       Palatal eschar

·       Nasal eschar

 

Investigations:-

·       COMPLETE BLOOD COUNT Hemogram; Blood sugar levels – FBS, PPBS; HbA1C; RFT with Sr electrolytes

·       Deep nasal swab from Gram, KOH and Calcofluor White stain + plate blood agar and fungal media (SDA or PDA)

·       Diagnostic nasal endoscopy; Function Endo Scopic Sinus surgery.

·       CT Para Nasal Sinus

·        MRI Orbit, PNS and Brain with contrast

 

Management:-

(A) Medical management: Most important is to control blood sugar. While patient is on Ampho-B treatment, daily monitoring of RFT and Sr Electrolytes to check for hypokalemia is mandatory. Dose of Ampho-B needs to be titrated against GFR/ renal functions.

1)      Induction with Liposomal Amphotericin-B (L-AMB): 5-10 mg/kg/day for 2 weeks [All patients]
OR Deoxycholate formulation of Amphotericin-B: 0.7 - 1.0 mg/kg daily (this is more toxic)

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2)      Dual therapy: L-AMB + Oral Posaconazole (300 mg BD on Day 1 f/b 300 mg OD for 2 weeks) [All patients]
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3)      Oral Posaconazole 300 mg BD for a further 2-4 weeks till clinical resolution and radiological stabilization. [All patients]

 

(B) Surgical management: After dressing of Mucormycosis patient, gloves should be changed before touching another patient to avoid contact transmission of mucor to other patient.

1)      Early surgical debridement of sinuses [All patients]

2)      Transcutaneous Retrobulbar Amphotericin B (TRAMB):
1 ml of 3.5 mg/ml [Select cases only]

3)      Orbital Exenteration:
For patients with extensive orbital involvement.

In follow-up of this patient, recurrence should be closely monitored for.
Long term diabetic control is needed for the same
As surgical treatment involves disfigurement of face, intervention by plastic surgeon is needed.