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Mucormycosis

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Mucormycosis - Facts in brief

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Mucormycosis

  1. 1. MUCORMYCOSIS Dr. Ashwin Menon
  2. 2. Introduction  Mucormycosis is an invasive fungal infection (IFI) first described by Paulltauf A in 1885.  Mucormycosis are the group of invasive infection caused by filamentous fungi of the Mucoraceae family.  Mucormycosis also known as Zygomycosis is an opportunistic fungal infection with a fulminant course and high Mortality rate.  Rhizopus species are the most common causative organisms.  The Rhinocerbral variant of Mucormycosis involves facial,orbital,paranasal sinus and cerebral regions.
  3. 3. Prevalence & incidence of Mucormycosis  Ress et al reported an annual incidence rate of 1.7 cases per million people in the united states.  Biter et al reported an average annual incidence rate of 0.9 per million people in France.  The Rhinocerbral accounting for 30-50% of all cases of Mucormyscosis  Overall Mucormycosis Prevalence of 0.14 cases per 1000 population in India.  A Meta analysis of all the zygomycosis cases reported from India, Diwakar et al. describe an overall prevalence of ROC (58%), Cutaneous (14%), Pulmonary (6%), Disseminated(7%), Gastrointestinal (7%) and Isolated renal(7%).
  4. 4.  The annual incidence of mucormycosis reported from different case series in India  It is difficult to determine the exact incidence and prevalence of mucormycosis in the Indian population. The computational-model-based method estimated a prevalence of 14 cases per 100,000 individuals in India
  5. 5. Based on the Clinical presentation and particular site of involvement six manifestations of the disease can be described:  Rhino cerebral (ROC),  Pulmonary  Cutaneous  Gastrointestinal  Disseminated  Localized infection Different types of Mucormycosis
  6. 6. Different types of Mucormycosis Rhino cerebral Mucormycosis (RCM) Rhino Orbital (ROC) Rhino Maxillary (ROM) A. MALLIS, S.N. MASTRONIKOLIS Rhinocerebral mucormycosis: an update, 2010; 14: 987-992
  7. 7. Common Causative Organisms  Mucormycosis-causing species are the filamentous fungi of mucoraceae family of the order mucorales,subphylum Mucormycotina.  Mucor  Cunninghamella  Apophysomyces  Absidia  Saksenaea,  Rhizomucor, and other species. A. MALLIS, S.N. MASTRONIKOLIS Rhinocerebral mucormycosis: an update, 2010; 14: 987-992
  8. 8. Pathophysiology OF MUCORMYCOSIS
  9. 9. Risk factors for Mucormycosis Diabetic Patients Neutropenia Patients Patients with haematological malignancies Increased serum Iron Immunocompromised state due to organ transplantation Haematological malignancies Chronic Corticosteroid treatment Hemochromatosis A. MALLIS, S.N. MASTRONIKOLIS Rhinocerebral mucormycosis: an update, 2010; 14: 987-992
  10. 10. Risk factors for Mucormycosis
  11. 11. Mucormycosis in Covid-19  Spores germinate in hypoxia, acidosis & hyperglycemic state  Increased use of voriconazole  Increased use of broad spectrum antibiotics  Deferoxamine  Endothelial damage Spores get attached  High flow oxygen Mucosal injury
  12. 12. Doubtful associations  Increased use of Zinc  Industrial oxygen usage  Impure humidifiers  Inappropriate mask usage
  13. 13. Mortality Rates  Mucormycosis carries a mortality rate of 50-85%.  Cutaneous disease carries the lowest mortality rate (15%).  The mortality rate associated with rhino cerebral disease is 50-70%.  Pulmonary and gastrointestinal (GI) diseases carry an even higher mortality rate, because these forms are typically diagnosed late in the disease course.  Disseminated disease carries a mortality rate that approaches 100%.
  14. 14. Red flag signs  U/L Nasal block  U/L Headache  Nasal discharge  Foul smell  Redness of the eyes  Lid edema  Retro orbital pain
  15. 15. Clinical Presentation  Eye  Redness  Edema  Drooping  Proptosis  Retroorbital pain  Diplopia
  16. 16. Clinical Presentation  Face  Facial edema  Numbness  Nose  U/L Nasal block  Dryness  Increased crust formation  Black eschar  Anosmia/ foul smell
  17. 17. Clinical Presentation  Oral cavity  Blackish discoloration  Numbness of teeth  Loosening of teeth
  18. 18. Warning signs  Reappearance of fever  Headache associated with nausea & vomiting  Altered sensorium  Unresponsive patient with DKA whose mental state not improving with normal electrolytes ---- Mucormycosis
  19. 19. Clinical stages
  20. 20. Differential Diagnosis Bacterial orbital cellulitis Cavernous sinus thrombosis Rapidly growing orbital tumor Aspergillosis Fusariosis Tuberculosis
  21. 21. Diagnosis  Timely diagnosis is paramount in cases of Mucormycosis.  DNE  CECT (PNS) / MRI (with Gadolinium)  For pulmonary disease, a bronchoalveolar lavage (BAL), biopsy, or both may assist in the diagnosis.  For cutaneous disease, a skin biopsy for pathology and culture should be obtained.
  22. 22. Investigations  CBC with ESR  CRP  FBS,PPBS  LFT  RFT with SE  S.Fe, S.Ferritin, IBC  Viral markers
  23. 23. Investigations  Biopsy  HPE  FUNGAL SMEAR  FUNGAL CULTURE  HPE 10% Formalin  Fungal culture Saline
  24. 24. Diagnosis of Rhino cerebral Mucormycosis . Walsh, M. Gamaletsou, M. Mcginnis, R. Hayden, D. Kontoyiannis/
  25. 25. Mucor on Sabouraud dextrose agar
  26. 26. Typical mucorales hyphae on grocott methenamine-silver staining
  27. 27. Therapeutic goals for Mucormycosis Early Diagnosis Reversal of underlying predisposing risk factors Surgical debridement where applicable Prompt antifungal therapy
  28. 28. Management  Correction of Predisposing Factors  Surgical Debridement  Systemic Antifungal Agents
  29. 29. Management  Correction of Predisposing Factors  Tapering or discontinuation of corticosteroids is advised  Neutropenia should be rapidly corrected by initiation of granulocyte colony stimulating factors (G-CSF) as well as discontinuation of chemotherapeutic agents responsible for marrow suppression
  30. 30. Management  Surgical Debridement  Early, aggressive and repeated surgical excision of necrotic craniofacial tissues is the cornerstone of successful management.  Repeated removal of necrotic tissue, extensive, disfiguring debridement of the sinuses and enucleation of orbit may be required to prevent dissemination to critical structures.
  31. 31. Anti Fungal Therapy  Liposomal and lipid complex amphotericin B  Dose - 5 mg/kg/day and 7.5-10mg/kg/day (CNS)  Amphotericin B deoxycholate  Dose - 1-1.5 mg/kg/d  Isavuconazole  Dose – 200mg TDS for 2 days followed by 200mg OD  Posaconazole  Dose – 300mg BD for 1 day followed by 300mg OD After 3-6weeks of Amph B – 3-6 months of Consolidation therapy
  32. 32. Adjunctive Treatments  Hyperbaric oxygen therapy  Deferasirox  Immune augmentation strategies – granulocyte macrophage colony-stimulating factor, interferon
  33. 33. References  1. Hora JF. Primary aspergillosis of the paranasal sinuses and associated areas. Laryngoscope.1965;75:768–73.  2. Chakrabarti A, Sharma SC, Chander J. Epidemiology and pathogenesis of paranasal sinus mycoses. Otolaryngol Head Neck Surg. 1992;107:745–50.  3. Hussain S, Salahuddin N, Ahmad I, Jooma R. Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals. Eur J Radiol. 1995;20:151–5.  4. Veress B, Malik OA, Tayeb AA, El Daoud S, El Mahgoub S, El Hassan AM. Further observations on the primary paranasal Aspergillus granuloma in Sudan. Am J Trop Med Hyg. 1973;22:765–72.  5. Gillespie MB, O’Malley Jr BW, Francis HW. An approach to fulminant invasive fungal rhinosinusitis in immunocompromised host. Arch Otolaryngol Head Neck Surg. 1998;124(5): 520–6.  6. Demuri GP, Wald ER. Sinusitis. In: Mandell GL, Benett JE, Dolin R, editors. Principles and practice of infectious diseases, vol. 2. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2010. p. 842.
  34. 34. Thank you
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Mucormycosis - Facts in brief

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