CME INDIA Case Presentation by Dr. Chandrakant Tarke, MD, DNB, DM, MNAMS, EDRM, Pulmonologist, Apollo Hospital, Hyderabad.
CME INDIA Case Study
Clinical Input
- Loss of vision left eye. Left headache. Post COVID 20 days.
- Right eye normal vision.
- Known case of T2 DM
Spot the diagnosis
CME INDIA Discussion
Dr Meena Chhabra, Delhi: Mucormycosis.
Dr Raju Sharma, Sr Physician, Jamshedpur: Why jaundice?
Dr Ranjeet Kumar, Ramgarh: Cavernous sinus thrombosis? Was he treated with Steroids?
Dr Chandrakant Tarke: 40 mg BD for 5 days. Followed by tapering of steroids.
Dr Meenakshi Sahapathi, DNB Family Med, Faridabad: In this patient steroid was started on which day?
Dr Chandrakant Tarke: Day 6-7.
Dr Santosh Malpani, Nanded: (On 18th April 2021): Mucormycosis is becoming a great problem in post Covid patients. We started with second wave earlier than rest of the country. I suggest:
1. Use steroids very judiciously,
2. Do A1c of all patients who are admitted.
3. Monitor glycemia twice till discharge.
4. Ask patient to monitor sugar at home.
5. Preferably put all patients on insulin if show trend of increasing BSL after steroids.
6. Do not ignore any headache, eye pain even slightest.
7. Counsel patient about this type of pain.
8. Use lowest possible dose of steroids.
Problem
After discharge patient is not called for follow up at COVID facility. Patients are hesitant to visit other physicians. Also, other physicians are not available. Lockdown adds to this.
Dr Chandrakant Tarke, Pulmonologist, Hyderabad:
Tips to avoid invasive fungal infection in COVID:
1. Avoid steroid in in patients with saturation 95 and above.
2. Strict sugar control.
3. Avoid unnecessary broad-spectrum antibiotics.
4. Avoid use of fluconazole.
5. Taper steroid earlier.
6. Diagnose co-existent diagnosis of muocor from day 1 of COVID (Seen few cases).
7. Send HbA1c in every admitted patient with COVID.
(Use of fluconazole lead to growth of mucor/Rhizopus. (Normal fungal commensal get suppressed and mucor grows). Fluconazole use should be restricted. Also be careful with voriconazole prophylaxis…Can Lead to Zygomycosis Only medicines that can work against Zygomycetes are AMPHOTERICIN B, POSACONAZOLE AND ISAVUCONAZOLE).
Further Course of the patient: Case of sino-orbital mucomycosomis… After exentration (removal of left eyeball) and left maxillary, ethmoid and spenoid sinus exploration and debridement by transpalatal approach…
CME INDIA Learning Points
- Mucormycosis is a life-threatening, opportunistic infection, and patients with moderate to severe COVID-19 are more susceptible to it.
- High index of suspicion, early diagnosis, and appropriate management can improve survival.
- Mucormycosis (zygomycosis) is frequently seen in conditions where the immune system is suppressed such as uncontrolled diabetes, hematological malignancy, immunosuppressive and corticosteroid therapy. It is rarely seen in healthy individuals
- The most common clinical pictures are with rhinocerebral, pulmonary and cutaneous involvement. The area of involvement can be affected by the underlying condition. While rhinocerebral involvement is observed in diabetic patients, rhinocerebral and pulmonary involvement is observed in patients who develop neutropenia due to bone marrow transplantation and leukemia. Gastrointestinal involvement is more common in patients with malnutrition.
- A case of rhinocerebral mucormycosis with extensive cavitary lesions coronavirus disease (Post COVID-19).
- Contamination occurs through inhalation. The phagocytic cells destroy the spores of the inhaled fungus, but in immunocompromised individuals, the spores can infect the vascular endothelium by invasion
- Invasive mucormycosis has been observed even in patients with mild to moderate SARS- CoV-2 infections. The strongest predisposing factor appears to be hyperglycemia in undiagnosed or uncontrolled diabetics. Hyperglycemia leads to increased expression of the endothelial receptor GRP78, resulting in polymorphonuclear dysfunction, impaired chemotaxis and defective intracellular killing.
- Corticosteroids themselves cause impairment in the neutrophil migration, ingestion, and phagolysosome fusion. Coupled with the potential implications of steroid-induced hyperglycemia, the diabetic COVID 19 patient receiving corticosteroids or other immunosuppressants is exceptionally vulnerable to the development of mucormycosis.
- The clinical hallmark is tissue necrosis manifested as a necrotic lesion, eschar or black discharge in the nasal or oral cavity. Orbital, ocular and cranial nerve involvement are ominous signs that must be taken seriously. Alternative erroneous diagnoses lead to antibacterial and further steroid use which add fuel to the fire.
- There is no biomarker for mucormycosis and hence a negative galactomannan and beta-d-glucan are useful pointers to rule out other mould infections. A false positive galactomannan due to generic piperacillin tazobactam use etc. can lead to the erroneous diagnosis of invasive aspergillosis.
- Treatment with voriconazole for suspected invasive aspergillosis increases the pathogenicity of Mucor with obvious dire consequences.
- Rapid diagnostic methods include biopsy, KOH mount and Calcofluor stain. Mucor is difficult to routinely culture.
- Biopsy remains the mainstay of diagnosis and the benefits of the procedure outweigh the risk, even in a ‘difficult to access’ location or in the presence of coagulopathy.
- Treatment principles include antifungal agents, surgical debridement, reversal of underlying predisposing factors and adjuvant therapy. Amphotericin B has been the standard of treatment for invasive mucormycosis.
- Mucormycosis developing in the post COVID-19 setting ‘breaks the back’ of a patient’s family that is barely recovering from a treacherous viral infection. This scenario is nothing short of ‘RECOVERY from the frying pan and into the fire.’
Further Readings:
- Lim S, Bae JH, Kwon HS,et al. COVID-19 and diabetes mellitus: from pathophysiology to clinical management. Nat Rev Endocrinol 2021; 17:11–30.
- Prakash H, Chakrabarti A. Global Epidemiology of Mucormycosis. J Fungi (Basel) 2019; 5:26.
- Chakrabarti A, Kaur H, Savio J, et al. Epidemiology and clinical outcomes of invasive mould infections in Indian intensive care units (FISF study). J Crit Care 2019; 51:64-70.
- Mucor in a Viral Land-A Tale of Two PathogensSen, Mrittika; Lahane, Sumeet1; Lahane, Tatyarao P1; Parekh, Ragini1; Honavar, Santosh G.Indian Journal of Ophthalmology: February 2021 – Volume 69 – Issue 2 – p 244-252 doi: 10.4103/ijo.IJO_3774_20
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