How to fight deadly black fungal infection in post Covid phase.. read Centre’s advisory

New Delhi: Recently, reports have emerged about rising number of survivors of Covid-19 suffering from black fungus infections or mucormycosis. In light of such events, Centreal govt. has released an advisory for screening, diagnosis and management of the disease.

Mucormycosis is a fungal infection which mainly affects people who are on medication which reduces their body’s ability to fight environmental pathogens. The infection can turn fatal if not taken care of properly. It usually attacks the sinuses or lungs of such people as they inhale the fungal spores present in the air.

The Union Ministry of Health and Family Welfare and Indian Council of Medical Research (ICMR)  have issued guidelines on the management of Mucormycosis fungal infection in COVID-19 patients.

Warning signs and symptoms that can lead to serious disease

• Pain and redness around eyes and/or nose
• Fever
• Headache
• Coughing
• Shortness of breath
• Bloody vomits
• Altered mental status
• Predisposition
• Uncontrolled diabetes mellitus
• Immunosuppression by steroids
• Prolonged ICU stay
• Co-morbidities – post transplant/malignancy
• Voriconazole therapy

DOs

• Control hyperglycemia
• Monitor blood glucose level post COVID-19 discharge and also in diabetics
• Use steroid judiciously – correct timing, correct dose and duration
• Use clean, sterile water for humidifiers during oxygen therapy
• Use antibiotics/antifungals judiciously

DON’Ts

• Do not miss warning signs and symptoms
• Do not consider all the cases with blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators
• Do not hesitate to seek aggressive investigations, as appropriate (KOH staining & microscopy, culture, MALDITOF), for detecting fungal etiology
• Do not lose crucial time to initiate treatment for mucormycosis

How to prevent

• Use masks if you are visiting dusty construction sites
• Wear shoes, long trousers, long sleeve shirts and gloves while handling soil (gardening), moss or manure
• Maintain personal hygiene, including thorough scrub bath

When to suspect (in COVID-19 patients, diabetics or immunosuppressed individuals)

• Sinusitis – nasal blockade or congestion, nasal discharge (blackish/bloody), local pain on the cheek bone One sided facial pain, numbness or swelling
• Blackish discoloration over bridge of nose/palate
• Toothache, loosening of teeth, jaw involvement
• Blurred or double vision with pain; fever, skin lesion; thrombosis & necrosis (eschar)
• Chest pain, pleural effusion, haemoptysis, worsening of respiratory symptoms

How to manage

• Control diabetes and diabetic ketoacidosis
• Reduce steroids (if patient is still on) with aim to discontinue rapidly
• Discontinue immunomodulating drugs
• No antifungal prophylaxis needed
• Extensive Surgical Debridement – to remove all necrotic materials
• Medical treatment

i) Install peripherally inserted central catheter (PICC line)

ii) Maintain adequate systemic hydration

iii) Infuse normal saline IV before Amphotericin B infusion

iv) Antifungal therapy, for at least 4-6 weeks (follow guidelines)

Monitor patients clinically and with radio-imaging for response and to detect disease progression

Team approach

• Microbiologist
• Internal Medicine Specialist
• Intensivist Neurologist
• ENT Specialist
• Ophthalmologist
• Dentist Surgeon (maxillofacial/plastic)
• Biochemist