Early Detection and Prevention of Black Fungus (Mucormycosis)

Introduction:

The second wave of COVID infection has led to an increasing number or spike in black fungus or mucormycosis cases that can prove fatal, especially in immunosuppressed patients and diabetics. AIIMS (All India Institute of Medical Sciences) has released a new set of guidelines for the early detection and prevention of black fungus.

Who Are at High Risk?

Identification of high-risk patients in the COVID ward:

• Uncontrolled diabetes, diabetic ketoacidosis, and diabetics on steroids/Tocilizumab.
• Patients on immunosuppressants or anticancer treatment or those with chronic debilitating illnesses.
• Patients on high-dose steroids and/or long duration of steroids/Tocilizumab.
• Severe COVID disease.
• On oxygen support.

What Are the Guidelines Given for Ophthalmologists by AIIMS?

1) Examination of high-risk patients in the COVID ward.

2) Examination should be performed by an ophthalmologist:

- Baseline

- Weekly thereafter till the time of discharge.

- Follow-up after discharge to be explained.

Depending on the patient's condition, follow-up must be advised as follows:

1. Every two weeks for six weeks.

2. Monthly thereafter by teleconsultation for a period of three months from the time of discharge.

Ophthalmic Examination

History of nasal congestion or blockage, vision loss, double vision, pain, swelling, drooping of the lid, inability to close eyes, numbness or tingling around eyes or cheeks, difficulty in chewing, prominence of the eye, or any other ocular symptoms.

Examination:

1) Vision assessment (preferably aided) – subjective as reported by the patient, objectively with finger counting till a distance of 6 m.

2) Torchlight examination for facial asymmetry.

3) Full face examination, including the periorbital area for swelling, bluish or blackish discoloration/crust, induration, or tenderness.

4) Presence of proptosis by Worm's eye view.

5) Retropulsion test to assess the infiltration of the orbit (both eyes simultaneously will help to compare), Ptosis/ lagophthalmos, conjunctival chemosis or congestion ocular movements/ squint cornea, and anterior segment. Pupillary reactions V1 and V2 sensations Fundus examination if recent-onset visual complaints or RAPD - if possible educate the patient and caregiver about the signs and symptoms of rhino-orbital disease

6) Immediate consultation with ENT specialist.

7) Imaging with contrast to other relevant consultations on an urgent basis.

What Is the Advice Given to the Patients and Caregivers for Detection and Prevention?

Danger signs of Black Fungus (mucormycosis):

• Abnormal black discharge or crust or blood from the nose.
• Nasal blockage.
• Headache or eye pain.
• Swelling around the eyes, double vision, redness of the eye, loss of vision, difficulty in the closing eye, inability to open the eye, prominence of the eye.
• Facial numbness or tingling sensation.
• Difficulty in chewing or opening mouth.
• Regular self-examination - Full face examination in daylight for facial swelling (especially nose, cheek, around the eye) or black discoloration, hardening, and pain on touch.
• Loosening of teeth.
• Black areas and swelling inside the mouth, palate, teeth, or nose (oral and nasal examination using torchlight, as far as possible you can see).

How to Prevent the Spread of Mucormycosis?

The national COVID-19 task force in India has issued an evidence-based advisory on the main measures to be taken for controlling the spread and precautionary measures on an everyday basis for both the patients who have recovered from the COVID infection and the patients in the ICU wards and COVID wards. The following measures need to be implemented by any individual affected by the COVID virus hence:

• Firstly, self-medication by the patient is strictly not indicated. Mucormycosis is a dangerous fungal infection with deep-rooted systemic manifestations that mainly target the brain, sinuses, and lungs. Any of the symptoms pertaining to mucormycosis should be strictly reported by the patient or those in contact with the patient to curb its spread as an epidemic.
• Immediate consultation with the ENT doctor, ophthalmologist, or treating doctor in case of any abnormal findings. MRI/CT with contrast - paranasal sinuses and orbit, if needed-on doctor's advice.
• It is important for the physician to monitor the patient's blood sugar levels and to reduce steroid usage, and, if possible, discontinue the use of immunomodulating drugs.
• The patient's treatment for mucormycosis specifically should not be discontinued at least for 4-6 weeks or, as advised by the physician, to rule out the possibility of recurrent infection in the individual.
• As steroid usage in the treatment of COVID infection and in mucormycosis is implemented by many doctors, the patient should maintain extra personal hygiene and environmental hygiene. As the effects even after treatment by steroids continue to last 3-4 weeks and the patient's immune response may not be normal, it will still be in a state of immune suppression, hence the need for extra precaution after treatment.
• As the oral immune defense is breached primarily in mucormycosis, oral hygiene maintenance is of pivotal importance. Regular mouth washing with betadine gargle or an antiseptic mouthwash every day, along with disinfection of the toothbrush in an antiseptic solution, will definitely reduce the risk of transmission of the fungal infection via the oral route. Also, toothbrushes need to be disposed of after recovery from COVID infection, and in the absence of a mouthwash, daily rinsing with warm saline or saltwater will also aid in maintaining oral hygiene. Toothbrushing twice a day and mouth washing are essential to keep the immune response of the oral cavity from the reservoir of fungal or viral pathogens that it is prone to.
• Physicians in COVID wards are instructed to check the patient's nose (the nostrils) and skin for signs of any infection. The water used in oxygenation should be cross-checked for contamination, and the patient's oxygen mask and cannula need to be sterile to prevent the fungal invasion by the pathogens.
• Proper use of masks (three-ply masks), gloves, and fully covering one's arms and legs while staying in damp or dusty places for the COVID patient will prevent the spread of infection. If possible, damp and dusty places need to be avoided by the COVID patient.

Hence timely detection and diagnosis in high-risk cases and patients affected by COVID is the need of the hour to prevent the spread and the secondary infections that follow because of mucormycosis.