Mucormycosis In Adult Patients

Introduction:

  • Mucormycosis or Zygomycosis is a fungal disease caused by fungi of order Mucorales.
  • High risk group- Diabetes mellitus, diabetic ketoacidosis, steroid, cytotoxic drug therapy, HIV, immunosuppression, malignancy or haematological disorder including iron overload states.
  • New corona virus SARS COV 2 itself may serve as a risk factor – chronic respiratory disease, corticosteroid therapy, intubation /mechanical ventilation, deranged glucose metabolism, which may lead to secondary fungal infection.

Presenting features:

    • Facial findings

Facial swelling / Paresthesia / Discolouration of skin (necrosis)/ Infection in dangerous area of face
Facial findings 1Facial findings 2

    • Nasal findings:

Foul smelling nasal discharge/Nasal congestion/ Sinusitis/ Erythematous to violaceous to black necrotic eschar in nasal cavity

    • Intraoral findings:

Halitosis/ Intraoral pus discharge/ Ulceration & Blackening of mucosa/ Exposed palatal bone/Loosening of teeth/ Unhealed tooth socket/ Mobility of maxilla
Intraoral findings 1Intraoral findings 2

    • Orbital findings:

Vision loss/ Peri orbital cellulitis/ Chemosis/ Exophthalmos(Proptosis)/ Opthalmoplegia

Orbital findings 1

Specific points to be observed in history:

  • H/o COVID infection (Immunosuppressive drugs/ Ventilatory care, etc.)
  • Co morbid conditions: Diabetes mellitus/ Malignancy/ HIV/ Chronic kidney disease / Obesity/ Other systemic illness
  • Local factors (H/O tooth extraction or any other oral/surgical procedure/ Head injury)

Investigations:

  1. Lab parameters:
  2. Nasal endoscopic examination:
    Black necrotic eschar tissue

Nasal endoscopic

 

  • Radiographic Examination

Contrast enhanced CT scan with 3D Reconstruction findings:

  • MRI with contrast findings.

 

Biopsy:

Test

  • KOH
  • Fungal culture
  • Histopathology

Treatment:

Surgical Management:

  • Debridement of affected area as soon as possible to reduce fungal load

 

Medical management:

  • Mucormycosis should be treated with antifungal Injectable Amphotericin B.
  • Oral antifungal: Overlap with Injectable for 3-4 days before step down and to be continued 1 week after endoscopic biopsy is negative.
  • Liposomal amphotericin is preferred in cases having Renal complication due to Amphotericin and in case of cerebral parenchymal involvement.

1) First line antifungal therapy:
Inj Amphotericin B Deoxycholate(C-AmB): 

  • Inj Liposomal amphotericin B (LAmB):
  • Inj Amphotericin B lipid complex (ABLC) :

2) Second line- AZOLE Derivatives (Step Down or Salvage Therapy)
Step-down therapy — Posaconazole and isavuconazole are broad-spectrum azoles available in both parenteral and oral formulations
Posaconazole or isavuconazole for oral step-down therapy. Alternatively IV parenteral formulations can be used as salvage regimen in case of unresponsiveness to AmB.

  • Isavuconazole:
  • Posaconazole:

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