HCFI Dr KK Aggarwal Research Fund
15th and 22nd May, 2021, 11am-12pm
Key points from discussion
- Many cases of mucormycosis are being reported during the second wave. Earlier there were sporadic cases. But then a spurt of cases was reported from Maharashtra, Gujarat and even Delhi. The speed at which it is spreading in the country is very alarming.
- More than 1000 cases have been detected in a month and most of them are in medical colleges or big private hospitals.
- It is not seen in other parts of the world. Risk factors are climate, genetic, large number of diabetic population, steroid overuse.
- Mucormycosis is a fungal disease. Fungal spores are present in the environment – in the air and in the soil. Although rare, it is a serious disease. Hence, it is important to discuss its prevention and early detection.
- Risk factors include poorly controlled diabetes, hematopoietic malignancy, prolonged neutropenia, solid or stem cell transplant. Use of unsterilized water in oxygen humidifier is another risk factor. Prediabetic persons may be at risk if they are prescribed steroids.
- It presents as rhino-orbital-cerebral-mucormycosis, which involves the nose, paranasal sinuses, eyes and the brain. Pulmonary (most common); GI and cutaneous or disseminated mucormycosis are other forms of the disease. GI mucormycosis is common in children.
- Initial symptoms include fever, perinasal and periorbital pain, congestion, nasal discharge. In advanced disease, nasal ulceration or necrotic lesion can occur.
- Most patients present with unilateral sinusitis; in the later stage, the disease becomes bilateral. It can be diagnosed by color changes in the nasal mucosa, nasal endoscopy, be watchful in the third/fourth week after discharge, especially if the patient has diabetes. Sympathetic ophthalmitis is very rare.
- Microscopy is the confirmatory diagnostic test. Crust or deep tissue material is required for diagnosis. In some hospitals in Maharashtra, KOH smears are done as a routine at discharge, for any patient who is hospitalized for more than 21 days.
- First treatment option is intense medical treatment; surgery should be the last option.
- Surgical removal of mucormycosis is a big challenge; surgery itself is associated with high morbidity, especially in the immunocompromised persons.
- Prevention is the best treatment for this disease; proper oral and personal hygiene, wearing shoes, long trousers, full sleeve shirts and gloves when handling soil, good oral and nasal hygiene (povidone iodine), appropriate use of antibiotics and antifungals, tight glycemic control for first 3 months post Covid, optimised steroid use (use in right doses for the right time) and use of clean and sterile water in humidifier and oxygen therapy. Many ENT surgeons use amphotericin irrigation. Hydrogen peroxide irrigation can also be done; it is more economical.
- There is no medical need for water in oxygen supplementation system; it only indicates continuous flow of oxygen. If sterile/distil water is not available, then at least boiled water should be used. The bottle should be cleaned every day.
- Remove possible sources of fungus infection in hospitals such as oxygen humidifiers.
- Don’t miss warning signs. Detect it early and start treatment at the earliest. Manifestations picked up in the nose are critical to saving the eyes. There is no role of prophylaxis.
- Shortage of liposomal amphotericin is a challenge. It is the drug of choice, but it is also a very nephrotoxic drug. Posaconazole, another drug can be used; it is supposed to be kidney safe. Avoid variconazole.
- All case of blocked noses should not be considered as bacterial sinusitis. Be aggressive for microscopy, KOH and culture.
- Good ENT examination at the time of discharge (nasal endoscopy) “with all safety measures”, probably when the patient is Covid-negative may be considered.
- There should be robust data, which is regionally representative, on mucormycosis as it needs to be re-looked at, especially in Covid time, with regard to factors such as difference in clinical presentation etc.
- There is a need to sensitise all healthcare workers on this issue.
- There are now dedicated mucor wards in many tertiary care referral centers. Nursing care of high risk patients should be done very carefully.
- Careful monitoring and management of diabetes should be given equal importance as Covid treatment in those Covid patients who have comorbid diabetes. This may be key to reducing the number of cases of mucormycosis.
- There is a need to build up a referral mechanism and insist on good pharmacy and prescription practices.
- Effective implementation of Drugs and Cosmetics Rules is required.
- Strengthening of the primary healthcare is the need of the hour. Proper diagnostic facilities should be available in all PHCs and Health & Wellness Centers.
- The cost of medicines is presently prohibitive.
- There is an urgent need to follow preventive measures. Prevention of Covid-19 will automatically prevent mucormycosis.
- A presentation on “Covid-19 associated Rhino-orbital-cerebral-mucormycosis (ROCM)” was given by Dr AK Grover, Chairman, Dept. of Ophthalmology, Sir Ganga Ram Hospital and Chairman, Vision Eye Centres, Siri Fort Road and West Patel Nagar, New Delhi
- ROCM is a huge problem almost exclusive to India. In a review of published cases (up to May 13), out of total 101 cases, 82 were from India. 80% of patients had pre-existing diabetes and 76% patients had received steroids. Rhinological symptoms were the most common symptoms reported by almost 89% of patients.
- Factors predisposing to RCOM include: diabetes/hyperglycemia, steroids, immunodeficiency, malignancy, stem cell transplantation and iron overload.
- Lowering of innate immunity by Covid, lowered immunity due to use of steroids/tocilizumab, hyperglycemia aggravated by steroids, oxidative stress, high ferritin levels, zinc and use of antibiotics facilitating breakthrough infections may cause covid-associated ROCM. Not much is still known, except hyperglycemia is certainly an important contributory factor.
- Diagnosis of ROCM has been divided into possible, probable and proven.
- Possible ROCM: typical signs and symptoms in the clinical setting of recently (≤6 weeks) treated Covid-19, diabetes, immunosuppression, use of systemic steroids/tocilizumab, mechanical ventilation or oxygen supplementation
- Probable ROCM: supportive evidence clinically and on diagnostic nasal endoscopy and/or contrast enhanced MRI/CT scan. No evidence on direct microscopy or culture or histopathology with special stains or molecular diagnostics
- Proven ROCM: supportive evidence clinically and on diagnostic nasal endoscopy and/or contrast enhanced MRI/CT scan. Confirmation on direct microscopy or culture or histopathology with special stains or molecular diagnostics
- Patient examination involves rhinological, ophthalmic and neurological examination in addition to systemic examination.
- Ocular signs and symptoms of ROCM are periocular or facial edema, conjunctival congestion, sudden ptosis/double vision or motility restriction, proptosis and even sudden loss of vision.
- Early presentation is lid edema and congestion; lid edema and motility restriction or ocular motility restriction and ptosis may also occur. In advanced stage, there is proptosis and formation of a large black eschar. The disease may become bilateral with necrosis. Cerebral involvement may occur in severe disease.
- Along with medical therapy, sinus debridement surgery is done; sometimes exenteration requires to be done if there is more than two-quarter involvement of the orbit. This is a dilemma.
- General signs and symptoms are regional/facial pain, fever, worsening headache, facial palsy, focal seizures.
- Microscopic examination of tissue from nose (KOH) showing non septate hyphae, angioinvasion is important for diagnosis. Direct microscopy has a sensitivity of 90%.
- Contrast enhanced MRI is the imaging modality of choice.
- There is tenting of the globe in the later stage. There may be bilateral optic nerve involvement.
- Imaging is very important in assessment to find out the extent of involvement.
- A multidisciplinary approach is critical for management.
- Treatment is IV liposomal amphotericin, strict metabolic control and monitoring of renal function or IV posaconazole/isavuconazole. Aggressive debridement of PNS is required; turbinectomy/palatal wall/orbital wall resection may need to be done.
- In the first wave, Sir Gangaram Hospital (SGRH) had 31 cases of mucormycosis; of these 29 had diabetes while in the second wave, there have been 89 cases (till 26th May); 72 had long-standing diabetes, while 17 had recently been diagnosed as having diabetes; 40 patients were hypertensive. Predominantly males were more affected than females. Most patients required oxygen supplementation.
- A 6-weekly follow up is done for 3-6 months to assess regression or stabilization of disease, both clinically and via imaging.
- Several reasons have been put forth for the epidemic of mucormycosis in India. To name a few: tropical climate, more dust/environment with spores, poor metabolic control and contamination of oxygen delivery.
- Covid-associated ROCM can be prevented and can be treated adequately to prevent its devastating impact.
- Recognise the red flags: purulent nasal discharge with or without epistaxis with sinusitis, decreased sensation inside the nose, nasal ulceration and necrosis, grey or reddish mucosa, black eschar in the nasal septum, palate, eyelid, face or orbital areas, facial pain on one side, swelling or numbness.
- Prevention measures include education of the general public and medical community, strict glycemic control, rational use of steroids, use of distilled water in oxygen delivery systems, isotonic saline nasal spray at least twice daily.
Dr AK Agarwal
Dr Suneela Garg
Dr Ashok Grover
Dr Mahesh Verma
Dr Girdhar Gyani
Dr Anita Chakravarti
Dr Alex Thomas
Dr Ashok Gupta
Dr Sumit Mrig
Dr DR Rai
Dr Jayakrishnan Alapet
Mr Bejon Misra
Ms Balbir Verma
Mrs Upasana Arora
Dr Anuradha Sapra
Dr Reena Arora
Dr Promod Kumar
Dr Russell D’Souza, Australia
Dr KK Kalra
Dr Anil Kumar
Ms Ira Gupta
Dr S Sharma