GUWAHATI: After the Union Health Ministry has appealed to all the states and Union Territories (UTs) to declare mucormycosis or black fungus as a notifiable disease under the Epidemic Disease Act, 1897, the state health department on May 21 released a Standard Operating Procedure (SOP) with regards to the same.
As per the order, "Therefore in order to screen, diagnose and manage such cases of mucormycosis (black fungus) in COVID patients, the Standard Operating Procedure is notified with immediate effect in order to contain the further spread of the disease and in order to provide treatment as per protocol to the patients affected by such disease."
Following is the Standard Operating Procedure for screening, diagnosis, and management of mucormycosis in Covid patients:
Pre-disposing factors:
It can develop in patients:
With uncontrolled diabetes mellitus especially diabetic ketoacidosis. • Immuno suppressed patients (post-transplant malignancy, injudicious use of a high dose of steroids, Etolizumab/Tocilizumab
Prolonged ICU stay
People with HIV
Malnutrition
Trauma including bum
When to suspect?
If people having predisposing factors mentioned above develop: Nasal blockage, pain over cheekbone eyes, blood-stained or blackish nasal discharge, congestion or redness and swelling of eyes and nose, difficulty in vision e.g. blurred vision, painful eye movement, double vision, and blindness.
Headache and fever, seizures, altered mental state.
Cough and blood-stained sputum, shortness of breath with worsening respiratory problem.
Toothache, loosening of teeth & jaw involvement.
Redness, blackish discoloration in the skin with necrosis.
How to diagnose?
A high index of clinical suspicion with special reference to pre-disposing factors
Scrapping of the affected skin and examination with KOH preparation
Nasal swab for fungal budding hype
Fungal culture & skin biopsy
Blood investigation – CBC, LFT, KFT, Electrolytes, Blood sugar (fasting, PP, HBA1C)
Imaging – CT scan/MRI of the brain, PNS, and chest
An investigation related to pre-existing diseases
How to prevent?
COVID patients in hospital:
Better control of blood sugar during COVID with or without steroids
Use steroids judiciously observing correct timing, correct doe & correct duration.
Use antibiotics/anti-fungus judiciously
Use clean, sterile water for humidifiers during the oxygen therapy
COVID patients in Home isolation:
Patients who have comorbid conditions like Diabetes Mellitus, on immune suppressant drugs, renal transplant patients or those or steroids for medical cause need to observe the following warning symptoms:
Facial Pain/ Cheek pain
Bloody & foul-smelling nasal discharge
Nasal stuffiness
Eye Symptoms like — Eyelid edema, redness in the eye, any visual disturbance.
Community in general:
Use masks if you are visiting dusty construction site
Wear shoes, long trousers, long sleeve shirts & gloves while handling soil (Gardening), moss or manure.
Maintain personal hygiene including thorough scrub bath.
Seek immediate medical attention in case of developing any or combination of symptoms.
Often mucormycosis is reported due to poor maintenance of humidifiers. Hence the following SOP is prescribed for strict adherence:
Always use distilled or sterile water
Never use unboiled tap water nor mineral water.
Fill up to about 10 mm below the maximum fill line
Do not let the water level pass below the minimum fill line
The water level checked twice daily and topped up as necessary
The water in the humidifier should be changed daily
A humidifier should be washed in mild soapy water, rinsed with clean water, and dried in the air before reuse.
Once a week (for the same patient) and in between patients, all the components of the humidifier should be soaked in a mild antiseptic solution for 30 minutes, rinsed with clean water and dried in air
Treatment:
Medical management Antifungal Therapy:
1) Hydrate the patient with 500 ml of NS before Amphotericin-B
2) Inj. Liposomal Amphotericin-B — 5-10 mg/kg/day to be diluted in 500 ml of 5% Dextrose over 4-5 hours for 14-21 days in hospital.
Or
3) Inj. Amphotericin-B — 1-1.5mg/kg/day mixed with 500 ml 5% Dextrose over 4-5 hours for 14-21 days in hospital. Special precaution to be taken during Amphotericin-B infusion as this drug is photosensitive.
4) Monitor S. Creatinine and S. Potassium every 72 hours
5) Patients who are intolerant to Amphotericin-B can be given alternative agents like Posoconazole Tab. 300mg twice daily on day one followed by 300 mg once a day for 3-6 months.
6) Monitor patient clinically microbiologically and with radio imaging for assessing & disease progression.
7) After 3-6 weeks of Amphotericin-B therapy, consolidation therapy with Posaconazole for 3-6 months to be instituted. Duration of therapy depends on clinical response and radiological resolution and has to be individualized.
Surgical management:
Surgical debridement to remove all necrotic material, by ENT and Ophthalmology team –
Dr Pankaj Adhikari, Professor, HoD, Dermatology & Member Secretary; Dr Basanta Hazarika, Professor of Pulmonary, Medicine & member; Dr Kalpana Sharma, Prof. & HoD, ENT & member;
Dr. DN Choudhury, Prof. & HOD, Gastroenterology & Member;
Dr Marami Das, Prof & HOD, Neurology & Member.
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