Mucormycosis remains a serious fungal infection, with high mortality rates. Due to a large number of mucormycosis cases in India, the Centre's Directorate General of Health Services (DGHS) has announced new guidelines for managing mucormycosis, defining the requirements for the use of certain medications in therapy. This has been hailed by WHO for the first time.

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What is mucormycosis, and what are its effects?

Mucormycosis is a fungal illness that affects people with underlying illnesses and predisposing factors such as diabetes mellitus, widespread misuse/abuse of steroids, malignancies, and organ transplantation, among others. Infection occurs when fungal spores are inhaled from the air. It is not a contagious disease.

Time of presentation: Varies, but generally about the third week after the beginning of COVID-19 symptoms.

Mucormycosis in COVID-19 individuals is on the rise for a variety of reasons

1. Uncontrolled hyperglycaemia caused by a variety of factors.
2. Steroid abuse, overuse, and illogical usage.
3. Protracted stays in intensive care units, unsanitary humidifiers, and inappropriate use of broad-spectrum antibiotics.
4. Co-morbidities such as haematological malignancies, immunosuppression, solid organ transplantation, and so on.

Symptoms and signs

• Pain in the face, across the sinuses, and in the teeth and gums
• Paresthesia/loss of feeling in the lower part of the face
• Darkening of the skin above the nasolabial groove/alae nasi
• Nasal crusting and discharge that may be blackish or blood-tinged
• Chemosis or conjunctival injection
• Swelling around the eyes
• Blurry vision- Diplopia, a condition in which the vision is blurred
• Teeth loosening
• Palate discolouration (pale), unresponsive to touch turbinates, eschar across the palate
• Exacerbation of respiratory symptoms, such as haemoptysis and chest discomfort, headache, altered awareness, and seizures, among other things

Diagnosis

Mucormycosis is a medical emergency, therefore it is required to start the treatment right away. Diagnosis can be confirmed by:

1. Histopathology of debrided tissue (presence of ribbon-like aseptate hyphae 5-15 mm thick that branch at right angles), KOH mount and microscopy culture (don't wait for the results to come in).
2. Relevant radiographic examinations, such as a CT scan of the sinuses, a CT scan of the chest for probable pulmonary involvement (presence of more than 10 nodules, reverse halo sign, CT bronchus sign, etc.) MRI brain, etc. will help to determine the level of systemic involvement (pleural effusion-highly indicative of mucor).

Medication administration

1. In the presence of predisposing factors such as those listed above, one should have a high index of suspicion of invasive fungal infection such as mucormycosis. Initiation of on-time treatment lowers the risk of death. It is necessary to use a multidisciplinary team approach. Mucormycosis is treated with a mix of surgical debridement and antifungal medication.
2. The therapy of choice is liposomal amphotericin B at a starting dosage of 5 mg/kg body weight (10 mg/kg body weight if CNS involvement is present). It should be diluted with 5% dextrose before use. Normal saline and ringer lactate are incompatible. It should be administered over a period of 2-3 hours and should begin with the maximum dose on day one.
3. Kidney function tests and serum electrolytes levels should be monitored. It must be continued until a favourable response is obtained and the illness is stabilised, which may take 3-6 weeks, after which oral therapy should be used.
4. Isavuconazole (200 mg 1 tablet 3 times daily for 2 days followed by 200 mg daily) or Posaconazole (300 mg delayed-release tablets twice a day for 1 day followed by 300 mg daily) must be taken for an extended length of time as directed by a physician
5. The treatment must be continued until the clinical signs and symptoms of infection subsides, as well as the resolution of radiological indicators of active illness and the elimination of predisposing factors such as hyperglycaemia, immunosuppression, and other risk factors. It may be necessary to administer it over an extended period of time.
6. If liposomal Amphotericin B (deoxycholate) is not available, conventional Amphotericin B (deoxycholate) in the dosage range of 1-1.5 mg/kg may be utilised.
7. During the whole management period, kidney functions must be monitored.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.