Mucormycosis: an emerging entity during a pandemic

Mucormycosis is a very rare infection. It is caused by exposure to mucor mould which is commonly found in soil, plants, manure, and decaying fruits and vegetables. It is ubiquitous and found in soil and air and even in the nose and mucus of healthy people.

It affects the sinuses, the brain and the lungs and can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS.

Doctors believe mucormycosis, which has an overall mortality rate of 50%, may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients. It's thought that this drop in immunity due to steroids could be triggering these cases of mucormycosis.

Fig1: pathophysiology of mucormycosis.

Symptoms of Mucormycosis

The symptoms of mucormycosis depend on where in the body the fungus is growing. 1,4 Contact your healthcare provider if you have symptoms that you think are related to mucormycosis.

Symptoms of rhinocerebral (sinus and brain) mucormycosis include:

· 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

Symptoms of pulmonary (lung) mucormycosis include:

· Fever

· Cough

· Chest pain

· Shortness of breath

Cutaneous (skin) mucormycosis can look like blisters or ulcers, and the infected area may turn black. Other symptoms include pain, warmth, excessive redness, or swelling around a wound.

Symptoms of gastrointestinal mucormycosis include:

· Abdominal pain

· Nausea and vomiting

· Gastrointestinal bleeding

Disseminated mucormycosis typically occurs in people who are already sick from other medical conditions, so it can be difficult to know which symptoms are related to mucormycosis. Patients with disseminated infection in the brain can develop mental status changes or coma.

How to prevent?

· Use mask if you are visiting dirty construction sites

· Wear shoes, long trousers, long sleeve shirts and gloves while handling soil (gardening), moss and manure

· Maintain personal hygiene including through scrub bath

When to suspect?

• Sinusitis – nasal blockage or congestion, nasal discharge (blackish/bloody), local pain on the cheekbone or one-sided facial pain, numbness or swelling

• Blackish discolouration over the bridge of nose/palate

• Toothache, loosening of teeth, jaw involvement

• Blurred or double vision with pain; fever, skin lesion; thrombosis & necrosis (eschar)

• Chest pain, pleural effusion, haemoptysis, worsening of respiratory symptoms

How to manage?

1. Control diabetes and diabetic ketoacidosis

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

3. Discontinue immunomodulating drugs

4. No antifungal prophylaxis needed

5. Extensive Surgical Debridement - to remove all necrotic materials

6. Medical treatment for mucormycosis

a. Install peripherally inserted central catheter (PICC line)

b. Maintain adequate systemic hydration

c. Infuse normal saline IV before Amphotericin B infusion

d. Antifungal therapy, for at least 4-6 weeks (follow guidelines)

7. Monitor patients clinically and with radio-imaging for response and to detect disease progression