Making sense of mucormycosis

Rhino-orbito-cerebral mucormycosis is an uncommon but serious fungal infection with high morbidity and mortality, caused by the angiotropic fungus.

Dr V Mohan

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