Sunday, 23 May 2021

Mucormycosis Management


BACKGROUND

 The world is still facing the Coronavirus disease 2019 (COVID-19) pandemic. It all commenced in 2019 at Wuhan, China. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the causative agent of this disease. A rise in Covid-19 cases was seen globally after its onset in 2019, with its first wave hitting very hard in every corner of the world. 

 A guest post by Aparna Rane

   Rapid vaccine development has been the most positive aspect of this pandemic and is helping to control the spread of the disease. In 2020, post COVID-19 recovery, black fungal infection cases were on the rise in India. This infection was Mucormycosis. It is caused by the fungus of Order Mucorales. The mortality rate had seen an increase due to this infection. It mainly affects immunosuppressed people, Diabetic patients, Organ transplant patients, etc. With on-time diagnosis and treatment, many patients were able to fight this deadly fungus.

  With the second wave of COVID-19 hitting hard in India, a spike in COVID-19 cases is observed since April 2021. Concurrently, Black Fungal infections are also seen in these COVID-19 patients, causing a sharp rise in mortality rate.

 MUCORMYCOSIS and COVID-19

 

   The Mucoralean fungi are ubiquitous molds found in soil, compost, rotten wood material, etc. Although they are commonly found in nature, normally they don’t cause problems. However, individuals with weak or compromised immune systems face major problems when they contract Mucormycosis. Globally Rhizopus is the commonest cause of Mucormycosis followed by Apophysomyces, Lichtheimia species. The Same occurrence of species is also observed in India. The Clinical presentation of Mucormycosis is classified on its anatomical presence in a patient like pulmonary, rhino-orbital-cerebral (ROCM), renal, cutaneous, etc. ROCM is the most common form of Mucormycosis observed followed by pulmonary, renal Mucormycosis. 

  Mucormycosis cases are highest seen in India compared to other countries. Prevalence of Diabetes mellitus (DM) in India is the commonest cause for the occurrence of black fungal disease. A recent study for the fungal infection showed the presence of 57% DM patients and 18% Diabetic Ketoacidosis (DKA) patients in India. Evidence has shown that COVID-19 causes high expression of Angiotensin-converting enzyme 2 receptors in the pancreatic cells and insulin resistance due to cytokine storm in the patient. This results in acute DM and DKA in COVID-19 patients. The frequent use of corticosteroids for COVID-19 treatment worsens the glucose balance in the body leading to the opportunity of Mucormycosis infection. 

 

      SOURCE

   Along with hyperglycaemia, Iron metabolism alteration is also seen in COVID-19 patients. Excess of free Iron causes a favorable condition for black Fungus infection. The Immune response generated within the endothelium in blood vessels provides an opportunity for Mucormycosis infection. The endothelial receptor glucose-regulated protein (GRP78) and Mucorales adhesin spore coat protein homologs (COtH) create increased adhesion and penetration for Mucormycosis in the body. This GRP78 is also studied as it shows a role in COVID-19 infection, as it acts as a receptor for entry of the virus. 

 

  High and unregulated use of steroids for COVID-19 treatments is one of the causes for an increase in Mucormycosis infections. The hospital with its surrounding areas should maintain clean and hygienic conditions to stop any fungal spores spread. Taking into consideration the scenario, the Indian Council of Medical Research (ICMR) has developed an advisory for the management of Mucormycosis. It consists of Screening, Diagnosis, and management of Mucormycosis.

       

MUCORMYCOSIS MANAGEMENT

The Do's and Don’ts play an essential role in controlling the disease. 

 

Mucormycosis mainly affects in but not limited to: 

 

  • Diabetic patients (Diabetes mellitus (DM), Diabetic Ketoacidosis (DKA))
  • Immunosuppressed people
  • Organ transplant patients
  • Neutropenia
  • Pulmonary Disease patients
  • HIV patients
  • Steroid Therapy
  • Chronic diseases (Alcoholism and kidney disease)
  • Patients with Brach of skin.
  • Voriconazole therapy.

  With the onset of signs and symptoms as discussed in an earlier article, essential diagnostic tests and treatment are required. The diagnosis of Mucormycosis is challenging and difficulty in isolating the culture may cause underdiagnosis of the infection. Based on the patient’s history, signs and symptoms diagnostic tests should be carried out.

 

  • Biopsy of the affected tissue
  • CT or MRI scan 
  • Specific tissue staining techniques

Treatment

 

  • Reduce steroids usage
  • Control diabetes and Diabetic ketoacidosis
  • Stoppage of Immunomodulating drugs usage 
  • Use of amphotericin B and antifungal therapy as per the Doctor’s prescription.
  • Monitoring and doing a required diagnostic test of the patient to detect the disease progression and giving treatment as required.

Doctors with different area specialization are required for diagnosis and treatment of Mucormycosis. A team approach needs to be built up to prevent any mortality in this case. Timely detection and treatment are the only keys to a proper cure.

REFERENCES

 

1.      ICMR advisory

 

2.       John TM, Jacob CN, Kontoyiannis DP. When Uncontrolled Diabetes Mellitus and Severe COVID-19 Converge: The Perfect Storm for Mucormycosis. Journal of Fungi. 2021; 7(4):298. https://doi.org/10.3390/jof7040298

 

            3.   Infectious disease advisor

 

Pharmaceutical Microbiology Resources (http://www.pharmamicroresources.com/)

No comments:

Post a Comment

Pharmaceutical Microbiology Resources

Special offers