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Standard Operating Procedure for screening, diagnosis and management of MUCOR MYCOSIS in Covid patients

What is mucor mycosis(black fungus)?
Mucor mycosis is a rare serious fungal infection caused by fungus mucor.people gets mucor mycosis by coming in contact with its spores in the environment. It can also  deveop in the skin after the fungus enters the skin through a cut, abrasion, burn or other types of skin trauma.

Pre disposing factors: 
It can develop in patients
# with uncontrolled diabetes mellitus specially diabetic keto acidosis.
#immuno suppressed patients (Post transplant/ malignancy/ injudicious use of high dose of steroids,  Etolizumab/tocilizumab)
# prolonged ICU stay
# people with HIV
#malnutrition
#Trauma including burn

When to suspect?
Is people having pre disposing factors mentioned above develop
#nasal blockage, pain over cheek bone, 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 and jaw involvement.
#redness, blackish discoloration on the skin with necrosis.

How to diagnose?
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 hyphae.
# fungal culture and skin biopsy
# blood investigation- CBC,LFT, KFT, electrolytes, blood sugar (fasting,PP, HBA1C)
# imaging-CT scan/MRI brain,PNS and chest
# 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 dose, and correct duration
#use antibiotics/antifungal judiciously
#use clean, sterile water for humidifier 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 on steroids for medical cause need to observe the following warning symptoms:
#facial pain/cheek pain
#bloody and 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.

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 un- boiled tap water nor mineral water.
#fill up to about 10mm below the maximum fill line
#donot let the water level pass below the minimum fill line
#The water in the humidifier should be changed daily
#humidifier should be washed in mild soapy water, rinsed with clean water and dried in air before reuse.
#once a week (for the same patient) and in between patients,all the components of the humidifier should be soaked in 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 1-1.5 mg/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 300 mg 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 and disease progression.

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