Since the onset of the Covid-19 pandemic there have been multiple reports across the country of very high incidence of mucormycosis among Covid-19 patients, especially in those who are diabetic and have received steroids.
Covid Associated Mucormycosis (CAM) has been associated with high morbidity and mortality, exorbitant treatment costs and has led to shortage of antifungal drugs.
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Speaking to The Indian Express, Professor Arunaloke Chakrabarti, Head, Department of Medical Microbiology, PGI, and in charge, Centre of Advanced Research in Medical Mycology, shares the recommendations of the Fungal Infection Study Forum, of which he is the Chairman, to clarify misconceptions regarding CAM, and DR RAJESH GERA, senior consultant of internal medicine at Paras Hospital also weighs in.
Patients with COVID-19 (active/recovering/post-discharge) with Rhino-Orbito-Cerebral Mucormycosis (ROCM) complain of nasal blockade or congestion, nasal discharge (bloody or brown/ black), and localised pain. Patients may also complain of facial pain, numbness or swelling, headache, orbital pain, toothache, loosening of maxillary teeth, jaw involvement, blurred or double vision with pain. Other symptoms include paresthesia, fever, skin lesion, thrombosis and necrosis (eschar). Pulmonary mucormycosis may present itself in the form of fever, cough, chest pain, pleural effusion, haemoptysis, and worsening of respiratory symptoms.
A cutaneous mucormycosis shows skin involvement with blisters or ulcers on areas affected. Other symptoms will include pain, warmth and swelling around blisters.
A disseminated mucor develops in severely immuno-compromised people, where the fungus spreads throughout the body and causes several organs to dysfunction which may lead to shock and death.
Mucormycosis is a medical emergency even when clinically suspected. Team approach is required with infectious disease specialist, microbiologist, histopathologist, intensivist, neurologist, ENT specialist, ophthalmologist, dentist, surgeons, radiologists etc. It is important to control diabetes and diabetic ketoacidosis. Reduce steroids (if patient is still on them) with aim to discontinue rapidly. Discontinue other immunomodulating drugs if the patient is taking these.
As poorly controlled diabetes is the major issue, good glycemic control during management of COVID 19 patients is required. Systemic steroids should only be used in patients with hypoxemia. Oral steroids are contra-indicated in patients with normal oxygen saturation on room air. If systemic steroid is used, blood sugar should be monitored. The dose and duration of steroid therapy should be limited to dexamethasone (0.1mg/kg/day) for 5-10 days. Universal masking reduces exposure to Mucorales; avoidance of construction sites is recommended. During discharge of the patients, advice about the early symptoms or signs of mucormycosis (facial pain, nasal blockage and excessive discharge, chest pain, respiratory insufficiency).
Persons immunocompromised including organ transplant patients, patients with uncontrolled diabetes, HIV positive patients, cancer patients as well as persons taking immunosuppressive drugs including steroids must keep a watch. Black lesions on any part of the body are an indicator that they could be harboring this fungus.
Mucorales are not black fungi. Black fungi are a different category of fungi having melanin in the cell wall. Mucormycosis is not contagious. It does not spread from one person to another. Mucormycosis is not spread by oxygenation, humidifier, and water. The fungi remain in the indoor and outdoor environment. The spores enter the respiratory tract via air. No antifungal prophylaxis is recommended as the incidence is not more than 10% in any Covid cohorts. No slow escalation of amphotericin B during therapy. Full dose per day should be given on day 1. Voriconazole, fluconazole and echinocandins are not effective against Mucorales.