Mucormycosis - Facts in brief

1. MUCORMYCOSIS
Dr. Ashwin Menon

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. 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.  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. 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. 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. 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. Pathophysiology OF
MUCORMYCOSIS

10. 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

11. Risk factors for
Mucormycosis

12. 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

13. Doubtful associations
 Increased use of Zinc
 Industrial oxygen usage
 Impure humidifiers
 Inappropriate mask usage

14. 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%.

15. Red flag signs
 U/L Nasal block
 U/L Headache
 Nasal discharge
 Foul smell
 Redness of the eyes
 Lid edema
 Retro orbital pain

16. Clinical Presentation
 Eye
 Redness
 Edema
 Drooping
 Proptosis
 Retroorbital pain
 Diplopia

17. Clinical Presentation
 Face
 Facial edema
 Numbness
 Nose
 U/L Nasal block
 Dryness
 Increased crust formation
 Black eschar
 Anosmia/ foul smell

18. Clinical Presentation
 Oral cavity
 Blackish discoloration
 Numbness of teeth
 Loosening of teeth

20. 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

22. Clinical stages

24. Differential Diagnosis
Bacterial orbital cellulitis
Cavernous sinus thrombosis
Rapidly growing orbital tumor
Aspergillosis
Fusariosis
Tuberculosis

25. 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.

26. Investigations
 CBC with ESR
 CRP
 FBS,PPBS
 LFT
 RFT with SE
 S.Fe, S.Ferritin, IBC
 Viral markers

27. Investigations
 Biopsy
 HPE
 FUNGAL SMEAR
 FUNGAL CULTURE
 HPE 10% Formalin
 Fungal culture Saline

29. Diagnosis of Rhino cerebral
Mucormycosis
. Walsh, M. Gamaletsou, M. Mcginnis, R. Hayden, D. Kontoyiannis/

31. Mucor on Sabouraud dextrose
agar

32. Typical mucorales hyphae on grocott
methenamine-silver staining

33. Therapeutic goals for
Mucormycosis
Early Diagnosis
Reversal of underlying predisposing risk factors
Surgical debridement where applicable
Prompt antifungal therapy

34. Management
 Correction of Predisposing Factors
 Surgical Debridement
 Systemic Antifungal Agents

35. 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

36. 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.

37. 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

39. Adjunctive Treatments
 Hyperbaric oxygen therapy
 Deferasirox
 Immune augmentation strategies –
granulocyte macrophage colony-stimulating
factor, interferon

42. 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.

43. Thank you