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Mucormycosis

Other Names: Black fungus. (previously called zygomycosis)

Description:
*Mucormycosis is a rare but serious angio-invasive infection caused by a group of fungi called mucormycetes.

*Spores of these ubiquitous fungi (commonly found in soil, fallen leaves, compost, animal dung and air) can be inhaled and then infect the lungs, sinuses, and extend into the brain and eyes. Less often, infection may develop when the spores enter the body through a cut or an open wound.

*Mucormycosis is not a contagious disease, it cannot be spread from one person to another.

*Mucormycosis mainly affects people who are immunocompromised, or patients already infected with other diseases. High risk groups include people with diabetes (especially diabetic ketoacidosis), solid organ transplantation, neutropenia (low neutrophils, a type of white blood cells), long-term systemic corticosteroid use, and iron overload (hemochromatosis). The risk is high for people living with HIV, and those using immunomodulating drugs, including the anti-fungal voriconazole in some high-risk groups.

*Clinical presentation is classified according to the organ involvement. It can be rhino-orbital cerebral, pulmonary, cutaneous, gastrointestinal, or disseminated.

*Mucormycosis is an aggressive, life-threatening infection requiring prompt diagnosis and early treatment. Treatment usually consists of antifungal medications and surgery.

Mucormycetes are present in the environment and they enter the human body either through artificial oxygen support that is given to severe COVID-19 patients or in some cases other environmental factors like use of contaminated water to produce medical oxygen. Use of certain combinations of steroids for treating COVID patients has also emerged to be one prominent reason as to why COVID survivors are complaining of black fungus. Patients with a low-immunity level or have compromising health conditions like diabetes, cancer or HIV, are more prone to the risk of getting caught with this infection.

Currently, this fungal infection has created much havoc nationwide, until much recently this was considered to be rare, but is now showing devastating effects.

Mucormycetes enter the body through nose, mouth or eyes and directly attack the sinus cavities, chest cavities and lungs. If not treated in time, the infection can prove lethal and cause brain damage, ultimately causing demise of the infected. Unhygienic way of delivering oxygen to the patients, provides an entry point to the molds to enter the body. The infection is not contagious and does not spread from one person to another, unlike coronavirus.

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Symptoms
The symptoms of mucormycosis depend on where in the body the fungus is growing. The most common presentation is a sinus infection (sinusitis) that is accompanied by nasal congestion, nasal discharge, and sinus pain. A fever and headache may also occur.

Type of Mucormycosis:
(1)..Rhinocerebral (sinus and brain) mucormycosis
Symptoms of this type are:

*One-sided facial swelling
*Headache
*Nasal or sinus congestion
*Black lesions on nasal bridge or upper inside of mouth that quickly become more severe
*Fever
*Lethargy, seizures, slurred speech, partial paralysis

(2)…Pulmonary (lung) mucormycosis:
Symptoms of this type are:

*Fever
*Cough
*Chest pain
*Shortness of breath
*Hemoptysis

(3)..Cutaneous (skin) mucormycosis:

Symptoms of this type are:

Skin lesion that resembles blisters or ulcers. The infected area may turn black. Other symptoms include pain, warmth, excessive redness, or swelling around a wound.

(4)Gastrointestinal mucormycosis :

Symptoms of this type are:

*Abdominal pain
*Nausea and vomiting
*Gastrointestinal bleeding

(5)Disseminated mucormycosis:

Symptoms of this type are:

Tends to occur in people who are already sick from other medical conditions, which makes it difficult to identify which symptoms are related to mucormycosis. Patients with disseminated infection in the brain may develop mental status changes or coma.

Causes:
Mucormycosis is a fungal infection caused by fungi in the order Mucorales. In most cases it is due to an invasion of the genera Rhizopus and Mucor, common bread molds. Most fatal infections are caused by Rhizopus oryzae. It is less likely due to Lichtheimia, and rarely due to Apophysomyces. Others include Cunninghamella, Mortierella, and Saksenaea.

The fungal spores are in the environment, can be found on for instance moldy bread and fruit and are breathed in frequently, but cause disease only in some people. In addition to being breathed in to be deposited in the nose, sinuses and lungs, the spores can also enter the skin via blood or directly through a cut or open wound, or grow in the intestine if eaten. Once deposited, the fungus grows branch-like filaments which invade blood vessels, causing clots to form and surrounding tissues to die. Other reported causes include contaminated wound dressings. Mucormycosis has been reported following the use of elastoplast and the use of tongue depressors for holding in place intravenous catheters, Outbreaks have also been linked to hospital bed sheets, negative-pressure rooms, water leaks, poor ventilation, contaminated medical equipment, and building works.

Diagnosis:
*Early recognition, diagnosis and prompt administration of appropriate antifungal treatment and surgical debridement (as needed) are important for improving outcomes for patients with mucormycosis.

*Diagnostic methods include biopsy and fungal staining (KOH mount), which remains the mainstay of laboratory diagnosis. Facilities where fungal culture and susceptibility testing are available can help to confirm the species of mucormycosis. Treatment initiation, however, should not wait for fungal culture results.

*Imaging tests such as a CT scan of lungs, sinuses, or other parts of body, depending on the location of the suspected infection, may also be used to support the diagnosis.

Treatment:
Mucormycosis is difficult to treat. It may sometimes requires both intravenous antifungal therapy and surgical excision, thus necessitating a multidisciplinary team approach in a facility setting.

Liposomal amphotericin B is the drug of choice and needs to be initiated early. Other antifungals like posaconazole, or isavuconazolehave also been described for treatment.

The Directorate General of Health Services (DGHS) has released detailed guidelines on managing mucormycosis in COVID-19 in India.

The overall prognosis depends on several factors, including the rapidity of diagnosis and treatment, the site of infection, and the patient’s underlying conditions and degree of immunosuppression. The overall case fatality is approximately 50%, although early diagnosis and treatment lead to better outcomes.

Ayurvedic Treatment: LEECH THERAPY

CLICK & SEE : Covid 19: Patients diagnosed with black fungus opt for leech therapy

Preventions:
Prevention of COVID-associated mucormycosis needs to focus on addressing the underlying risk factors:

  • Aiming for better glycemic control in those with diabetes,

*Apropriate use of systemic corticosteroids and

*Prevention of unnecessary use of antibiotic, antifungal and other immunomodulators.

IPC measures at the facility level are essential to prevent the environmental spread of this pathogen. These include:

*Sterilization and disinfection of the equipment used by multiple patients (tracheal tubes, ventilators), ventilation systems ( if there is poor ventilation in the hospital that can contribute to dampness and dust);

*Proper wound management (bandage, tape, adhesives, including tapes to secure medical devices such as endotracheal tubes, ostomy devices must be sterilized and changed regularly);

*Proper line management in health facilities

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
https://en.wikipedia.org/wiki/Mucormycosis
https://www.medipulse.in/blog/2021/6/7/mucormycosis-or-black-fungus-infection-causes-and-symptoms
https://www.who.int/india/emergencies/coronavirus-disease-(covid-19)/mucormycosis

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