Diabetics on steroids at higher risk

Coronavirus disease 2019 (Covid-19) continues to be a significant problem worldwide.

Mucormycosis, also called as black fungus, is a rare, emerging fungal infection, with high morbidity and mortality. It is a life-threatening fungal infection mostly occurring in haematology, solid organ transplant, or diabetic patients, it may also affect immunocompetent patients (a person having normal immunity) following a trauma or burn. The deadly combination of severe Covid-19 infection, diabetes mellitus and steroid usage is leading to an increased incidence of black fungus cases in recent times.

Otherwise, black fungus is a quintessential opportunistic infection and generally affects severely compromised persons

Six distinct clinical syndromes caused by invasive mucormycosis can occur in susceptible hosts, including rhino-orbital (face), cerebral (brain), pulmonary (lungs), gastrointestinal (intestines), cutaneous (skin).

How it causes disease?

We are seeing a massive upsurge of mucormycotic cases after Covid -19 infections. There are many reasons for this. However, one of the most important reason is undiagnosed and untreated hyperglycemia (excessive glucose) in Covid -19 patients that leading to glucotoxicity. Mucor organisms have enzyme called ketone reductase which helps to thrive in high glucose and acidic environment.

In many cases, the disease progresses rapidly and may result in death unless underlying risk factors are corrected, and appropriate antifungal therapy and surgical procedures are initiated.

Why more cases of mucor in second wave?

• May be steroid usage was less or not standardised during first wave.
• Climate change - first wave peaked in September 2020, second wave is peaking in summer May 2021. Maybe, the current temperature conditions are also favourable for the survival of this fungi.

Risk factors for Covid patients:

• Uncontrolled diabetes mellitus
• Patients who were treated with steroids
• Patients who were treated with immune modulators
• Those put on mechanical ventilation.
• Patients who were treated with long-standing oxygen therapy

When to suspect - A Covid 19 positive patient with following symptoms

• Sinus headache
• Blurred vision
• Bloody nasal discharge
• Stuffy nose
• Decreased vision
• Dental pain

Signs

• Facial swelling
• Facial discolouration
• Bulging of eyes
• Blackish discoloration of palate
• Drooping of eyelids

Diagnosis for black fungus:

• Deep nasal swab for PCR
• Diagnostic nasal endoscopy
• CT scan
• MRI scan

Treatment:

1. Strict control of diabetes & diabetic ketoacidosis

2. Reduce steroids (if patient is still on) with aim to discontinue rapidly

3. Discontinue other immunomodulating drugs if patient is taking like: Baricitinib, Tofacitinib

4. Anti-fungal drug – Liposomal amphotericin B

5. Surgical procedures if it's extensive

Prevention

1) Avoid unnecessary use of steroids in mild disease,

2) also avoid

• Steam inhalations abuse
• Use of higher antibiotics
• Poor oro-nasal hygiene in hospitalised patients
• use of same mask/unhygienic cloth masks for prolonged time

3) A simple act of checking random blood sugar before the first dose of steroid and pre-empting the action of steroid can go a long way in preventing severe hyperglycemia and hopefully mucormycosis

4) educating the patient or care giver about the symptoms and signs of rhino-orbital disease,

Misinformation

• Mucormycosis is not contagious. It does not spread from one person to another.
• It is not spread by oxygenation,humidifier and water. The fungi remain in the indoor & outdoor environment. It enters the respiratory tract via air.
• No antifungal prophylaxis (prevent treatment) is recommended as the incidence is not more than 10 per cent in any Covid-19 group.

(Dr Ramanna Macherla,D.M(Gastro), is Associate Professor at Osmania Medical College,Hyderabad)