Making sense of mucormycosis
CHENNAI: Rhino-orbito-cerebral mucormycosis is an uncommon but serious fungal infection with high morbidity and mortality, caused by the angiotropic fungus. Mucormycosis has suddenly become a household term, causing great fear and panic during this second wave of Covid pandemic in India.
It usually occurs in immunocompromised individuals including people with uncontrolled diabetes, hematologic cancers, HIV/ AIDS, those with solid organ transplants or stem cell transplants and those on immunosuppressants like steroids.
The suspicion or diagnosis of rhino-orbito-cerebral mucormycosis triggers a medical as well as surgical emergency with special stress on the need for interaction and coordination among the inter-professional team to improve treatment outcomes in this life-threatening disease.
Who is at risk?
- Those with uncontrolled diabetes
- Those on immunosuppression with steroids
- Those who have been treated for COVID-19 with immunomodulators or steroids
- Those with other comorbidities like malignancy, posttransplant
- Those having a prolonged stay in the ICU
- Those on mechanical ventilation/ oxygen therapy for a long period
- HIV/AIDS patients
Symptoms
- Facial pain/cheekbone pain/toothache
- Sinus headache
- Stuffy nose
- Blood discharge from nose
- Redness of the eyes
- Double vision/blurry vision/ sudden loss of vision
Signs
- Facial swelling/ discolouration
- Palatal eschar/Nasal Eschar (blackish material)
- Ptosis (drooping of eyelids)
- Proptosis (protrusion of eye)
- Ophthalmoplegia (paralysis of eye muscles)/Restricted extraocular movements.
- Pan-ophthalmitis
- Central Retinal Artery Occlusion (CRAO) with a cherry- red spot at the macula
Dos
- Control blood sugar level
- Judicious use of steroids
- Monitoring of blood glucose post-COVID-19 in individuals with and without diabetes
- Use of sterile water for humidifiers while on oxygen therapy.
- Watch for early warning symptoms/signs, wear a clean mask and maintain personal hygiene.
Don’ts
- Do not use any medications like steroids or antifungal agents without consulting a physician
- Don’t waste crucial time consulting your diabetologist/ ENT doctor or eye doctor
Investigations
- Haemogram
- Fasting / post-prandial blood glucose levels, HbA1c
- Renal function tests
- CT scan of Paranasal sinuses
- MRI scan of Brain and orbit
- Deep nasal swab/sputum examination
- Diagnostic nasal endoscopy/ broncho-alveolar lavage
Management
- Urgent medical and surgical management by a team approach involving the diabetologist, ENT specialist, ophthalmologist , intensivist,maxillo-facial surgeon, microbiologist and neurologist.
- Tight control of blood glucose levels and management of diabetic ketoacidosis (DKA). DKA if present, will mostly need insulin for control.
- Increase frequency of selfmonitoring of blood glucose by glucometer. If possible, use continuous glucose monitoring by wearing a sensor.
- If a patient is still on steroids, reduce the dose and discontinue as soon as possible.
- To discontinue the immunomodulatory drugs, if the patient is on any.
- Proper guidelines of antifungal therapy like Amphotericin B or others.
- Extensive surgical debridement when indicated.
DR R RAJALAKSHMI And DR V MOHAN