Mucormycosis ppt by Dr. Bomkar bam ENT M.S.

Mucormycosis
By Dr. Bomkar bam

Introduction
©drseshasai
• Mucormycosis (formerly Zygomycosis) – It is an acute,
granulomatous and oppurtunistic infection that occurs mostly in
immunocompromised patient.
• Ubiquitous in soil and forms Sporangiospores.
• It is commonly known as “black fungus” due to its black colour
formation in the affected area.
• Recently it is more commonly seen after covid recovery patient.
• Mortality rate of those affected patient is way more dangerous than
covid patient.

Species
 Most common species are
1. rhizopus sp.
2. Mucor sp.
3. Rhizomucor sp.

EPIDEMIOLOGY
 internationaly 1% patients with low
immunity.
 mucor mycosis carries a very high
mortality (50%-85%).
 no racial factors predispose.
 sex is not likely to affect.

MAJOR ROUTE OF
INFECTION
 INHALATION OF SPORES.
 INGESTION.
 TRAUMATIC INOCULATION.

 Agents of mucormycosis are ubiquitous and frequently
airborne.
 Infections mainly involves the lungs, sinuses and the brain
 Pathogenesis involves invasion of major blood vessels, with
consequent ischemia, necrosis, and infarction of
contiguous tissues
 Neutrophils play a central role in the defence of the host
against mucormycosis
 Ketoacidosis, hyperglycaemia, and hypoxia are excellent
growth conditions for these fungi
 Ketoacidosis decreases inflammatory responses and delays
local aggregation of granulocytes and fibroblasts
PATHOGENESIS

Types
©drseshasai
1. Rhino-cerebral – most common
2. Pulmonary
3. Disseminated – most deadly
4. Cutaneous/Soft tissue
5. Gastro Intestinal

Risk factors - major risk factors
 Uncontrolled diabetes mellitus in ketoacidosis 80-90%
of rhinocerebral mucormycosis
 Deferoxamine therapy
 Iron and aluminium overload
 Burns (major)
 Voriconazole therapy
 Severe trauma (tornados, tsunamis, war)
 Protein energy malnutrition

Risk factors - other risk factors
 Other forms of metabolic acidosis
 Treatment with immunosuppressive drugs
(corticosteroids, anti-neoplastics)
 Organ or bone marrow transplantation
 Neutropenia
 MalignanciesIV drug abuse
 HIV/AIDS
 Chronic kidney disease
 Liver cirrhosis and hepatic failure

RELATIONSHIP BETWEEN
PREDISPOSING FACTORS AND
SITE OF INFECTION
 diabetic ketoacidisis (DKA)- rhinocerebral.
 neutropenia- pulmonary & disseminated.
 steroids-
pulmonary,rhinocerebral,disseminated.
 malnutrion- GI tract
 trauma,catheter,skin maceration-
cutaneous/ subcutaneous
 deferoxamine-disseminated

1. RHINOCEREBRAL MUCORMYCOSIS
 50% of cases occur in patients with DM.
 50%CASES OF TOTAL CASES OF MUCOR
MYCOSIS.
 Usually occurs during an episode of DKA , with
disruption of host defense mechanisms thereby
permitting growth of Rhizopus oryzae. Such growth
is inhibited by correction of acidosis.

Clinical features
 Onset with nasal stuffiness
,epistaxis and facial pain.
 Later ,proptosis ,
visual loss
,chemosis and
ophthalmoplegia.
 Fever and confusion.
 Black necrotic eschar on the
nasal turbinates or palate :
very characteristic

Complications
 Cavernous sinusthrombosis.
 Multiple cranial nervepalsies.
 Visualloss.
 Frontal lobeabscess.
 Carotid artery or jugular vein thrombosis
causinghemiparesis.

 Punchbiopsy (GOLD STANDARD) of the
lesion followed by fungal stains andculture.
 Histological examination reveals the
characteristic broad , branching hyphae of
Rhizopus invading thetissue.
 CTor MRIof the head reveal air-fluid level in
the sinusesand involvement of deep tissues
Diagnosis

CT PNS – bony erosion of palate, septum and
maxilla.

2. PULMONARY MUCORMYCOSIS
 Seen most commonly in- neutropenia,pateints
on chemotherpy,leukemia.
 Dysponea ,cough& chest pain &fever
 Radiologicaly- consolidation,isolated
masses,cavitaion,wedge shaped infarcts.
 Ct scan best method to detect the extent.

REVERSE HALO SIGN
Focal area of Ground Glass Opacity
surrounded by ring of consolidation

3. CUTANEOUS MUCORMYCOSIS
 Trauma is the predisposing factor.
 Invasive locally .
 May lead to necrotizing fascites - Mortality
upto 80%.
 Surgical debridement.

4. GASTROINTESTINAL MUCORMYCOSIS
 Rare, occurs in extremaly
malnourished, children.
 Stomach,colon & ileum are most commonly
involved.
 Abdominal pain, nausea, vomiting, May
present as intra abdominal abscess, or
perforation of the viscus. Needs biopsy.
 Prognosis very poor

General approach to Diagnosis
©drseshasai
Microscopy
Direct microscopy in 10-20 % KOH
– optical brighteners like
Blankophor and Calcofluor White
Hyphae are of variable width, non septate,
irregular ribbon like with wide angle
bifurcations (90˚)
Periodic acid-Schiff or Grocott Gomori’s
methenamine silver staining - highlight
fungal hyphae

©drseshasai
Culture
Tissue swabs, sputum, or BALcultures are usually nondiagnostic
Direct microscopy of bronchoalveolar lavage & transbronchial
biopsy may increase the yield
Rapid growth (3 to 7 days) on Sabouraud agar
and potato dextrose agar incubated at 25◦C to 30◦C
Aggressive vertical growth toward the lid of the Petri dish –
Lid lifters

Diagnosis-Radiology
©drseshasai
• Plain x-ray
• CT scan- Infiltrate, wedge-shaped consolidation, multiple
nodules (>10) , cavitation, mycetoma, lobar collapse, Halo
sign & Air Crescent sign , Reverse Halo Sign
• MRI scan

Diagnosis
©drseshasai
Histopathology
Hyphae will be seen
Neutrophilic or granulomatous inflammation
Absent in a few cases - immunosuppressed patients.
Invasive disease is characterized by prominent infarcts and
angioinvasion.
Perineural invasion may be present.
Angioinvasion - extensive in neutropenic patients

Diagnosis
©drseshasai
Molecular based methods
PCR, RFLP, DNA sequencing that targets the 18S
ribosomal DNA of Mucorales
Antigen Detection & Specific Tcells
Galactomannan and ß-D Glucan – If negative likely invasive
mucormycosis
Mucorales-specific Tcells - enzyme-linked immunospot
(ELISpot) assay Recommendation

Treatment
©drseshasai
General principles
Early diagnosis
Early administration of active antifungal agents
Reversal of underlying factors
Complete removal of all infected tissues
Use of various adjunctive therapies

©drseshasai
PRIMARY ANTIFUNGAL THERAPY
Liposomal Amphotericin-B first line recommended
agent
Fluconazole, Voriconazole,
Itraconazole –Absidia species
Posaconazole, Isuvaconazole can also be used as
first line therapy

Liposomal Amphotericin B
Can be given as 5mg/kg/day to 10mg/kg/day for
4-6 weeks
Surgery + Lip Amp Bincreases survival rates and
cure rates
Monitoring of kidney function every 3rd day
Blood pH, electrolyte and CBC.

Posaconazole 800mg/day in 2 or 4 divided doses
– first line, Salvage therapy
Isuvaconazole – 200mg OD. But VITAL study
showed higher mortality rates and poor
response
Azoles

©drseshasai
Duration of Treatment
Highly individualized
Near normalization of radiograph, negative
biopsy specimens and cultures, recovery from
immunosuppression

Treatment - Surgery
©drseshasai
• Removal of necrotic tissue – Increases
penetration of antifungals
• Lobectomy, Pneumonectomy or wedge
resection Surrounding infected healthy-looking
tissues should be removed
• Groll A et al. – Mortality reduced by 79%

Treatment - SalvageTherapy
If disease is refractory or intolerance
towards previous antifungal therapy.
Posaconazole(A)
Polyenes + Posaconazole(B)
Lipid complex, liposomal, Colloidal
dispersion (B)
Polyenes + Caspofungin(C)

Treatment – Adjunctive
©drseshasai
Hyperbaric Oxygen – 100% O2 at 2atm pressure for 90
min twice a day (C)
Cytokine therapy in hematological malignancy –
Granulocyte transfusion +/- IFNγ (C)
Lovastatin
VT-1161(otesaconazole) – Inhibits fungal CYP51
Nivolumumab and IFNγ

Treatment – Adjunctive
©drseshasai
Deferasirox-AmBisome Therapy for Mucormycosis (DEFEATMucor)
study
First randomized trial for any treatment of mucormycosis
45%(5) mortality at 30 days, 82%(9) mortality at 90 days
Deferasirox (iron chelator) cannot be recommended as
part of an initial combination regimen for the treatment
of mucormycosis.

How to prevent
 Use mask if you are visiting dusty construction sites
 Wear shoes, long trousers, long sleeve shirts and
gloves while handling soil (gardening), moss and
manure.
 Personal hygiene.

When to suspect
 Sinusitis – nasal blockage or congetion, nasal
discharge (blackish/bloody), local pain on cheek bone
 One side facial pain, numbness or swelling
 Blackish discolouration over bridge of nose/palate
 Tooth ache, loosening of teeth, jaw involvement
 blurred or double vision with pain, fever, skin lesion,
necrosis
 Chest pain, hemoptysis, respiratory depression

Do’s
 Control hyperglycemia
 Monitor blood glucose level post COVID-
19 discharge and also in diabetics
 Use steroid judiciously – correct timing,
correct dose and duration
 Use clean, sterile water for humidifiers
during oxygen therapy
 Use antibiotics/antifungals judiciously

Don’ts
 Do not miss warning signs and symptoms
 Do not consider all the cases with blocked
nose as cases of bacterial sinusitis,
particularly in the context of immunosuppression
and COVID -19 patient on immunodulators
 Do not hesitate to seek aggressive investigations
 Do not lose crucial time to initiate treatement for
mucormycosis

Prophylaxis
©drseshasai
Neutropenic or immunosuppressive outbreaks –
Posaconazole 600mg/day (Controversy)
Surgery and Past h/o mucormycosis – Strong
recommendation

 Prognosis is generally poor but variable (late
diagnosis, extensive spread)
 All-cause mortality rate ~54%
 Mortality rates depends on:-Clinical form (body site
affected),Type of fungus
 Severity Underlying risk factors
 Use of surgical intervention
PROGNOSIS

CLINICAL FORM MORTALITY
1. Mucormycosis in HIV/AIDS~100%
2. Disseminated mucormycosis~90%
3. Rhino-cerebral mucormycosis~30-85%
4. Sinus mucormycosis~46%
5. Pulmonary mucormycosis~76%
6. Cutaneous mucormycosis~4-10%
7. Isolated renal mucormycosis~35%

Conclusion
©drseshasai
• More common in immunocompromised
• No specific clinical or radiological features
making diagnosis more difficult and challenging
• Diagnostic options are limited with variable
results
• Invasive diagnostics have more yield which is
not possible in some patients

Conclusion
©drseshasai
• Early diagnosis means early treatment and leading to
less mortality Rates
• Reversal of underlying factors, Surgery and Liposomal
amphotericin Bincreases cure rates
• Duration of treatment is highly individualized
• Posaconazole, Isuvaconazole can also be tried
• Salvage therapy in refractory or intolerant pts
• Adjunctive therapies need to proved in large trials and
standardized

Mucormycosis ppt by Dr. Bomkar bam ENT M.S.

In this document

More Related Content

What's hot

Similar to Mucormycosis ppt by Dr. Bomkar bam ENT M.S.

Recently uploaded

Mucormycosis ppt by Dr. Bomkar bam ENT M.S.