Black fungus and covid

black fungus and covid

1. Black fungus and COVID Dr magdy shafik Senior pediatric and neonatology Consultant Diploma, M.S, Ph.D Pediatric

2. Agenda What is black fungus ( Mucor mycosis)? Mycology History Black fungus in India Black fungus in Egypt Types of Mucor mycosis How mucor mycosis spread ? Clinical picture of mucor mycosis Diagnosis Is black fungus affecting children ? Prevention Approach to treatment What is white fungus? Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 2

3. Introduction WHAT IS MUCORMYCOSIS ? Mucormycosis is a fungal infection that causes blackening or discoloration over the nose, blurred or double vision, chest pain, breathing difficulties and coughing blood. It is caused by exposure to mucor mould which is commonly found in soil, plants, manure, and decaying fruits and vegetables . Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 3

4. WHAT IS MUCORMYCOSIS ? It affects the sinuses, the brain and the lungs and can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS. Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 4 Mucor mould is found in soil, plants, manure and decaying fruits

5. MYCOLOGY T hese organisms are ubiquitous in nature and can be found on decaying vegetation and in the soil. These fungi grow rapidly and release large numbers of spores that can become airborne.  The fact that mucormycosis is a rare human infection reflects the effectiveness of the intact human immune system Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 5

6. Rhino-orbital-cerebral and pulmonary mucormycosis are acquired by the inhalation of spores. In healthy individuals , cilia transport these spores to the pharynx and they are cleared through the gastrointestinal tract. In susceptible individuals , infection usually begins in the nasal turbinates or the alveoli Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 6 Magnified black fungus

7. History On Saturday morning, Dr Akshay Nair, a Mumbai-based eye surgeon, was waiting to operate on a 25-year-old woman who had recovered from a bout of Covid-19 three weeks ago. Inside the surgery, an ENT specialist was already at work on the patient, a diabetic. He had inserted a tube in her nose and was removing tissues infected with mucormycosis , a rare but dangerous fungal infection. This aggressive infection affects the nose, eye and sometimes the brain. After his colleague finished, Dr Nair would carry out a three hour procedure to remove the patient's eye. "I will be removing her eye to save her life. That's how this disease works," Dr Nair told me.

8. Data from the U.S. Centers for Disease Control and Prevention shows that mucormycosis has a mortality rate of 54%, which can vary depending on the condition of the patients and the body part affected. States across India have reported more than 5,000 cases of the otherwise rare disease in recent weeks, mostly in people infected with COVID-19 or recovering from the disease. Till 22 May , India has reported about 8,848 cases of black fungus or mucormycosis , according to a statement by  Union minister Sadananda Gowda

9. Covid and black fungus Doctors believe mucormycosis , which has an overall mortality rate of 50%, may be being triggered by the use of steroids , a life-saving treatment for severe and critically ill Covid-19 patients. Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients . It's thought that this drop in immunity could be triggering these cases of mucormycosis .   steroids which help fight Covid-19 act like fuel to the fire

10. Why does India have so many cases of post-Covid mucormycosis ? The improper use of steroids to treat Covid-19 patients, coupled with poorly managed diabetes . But steroids in themselves are not the villains. there is no strict prescription check in India , and most drugs— even those that need a prescription—can be easily bought over-the-counter. India has an epidemic of type 2 diabetes , and a significant proportion of patients with diabetes are diagnosed late in the illness ,

11. Covid and black fungus in Egypt Authorities deny emergence of black fungus among COVID-19 patients in Egypt Thu, 27 May 2021 - 01:28 GMT A A source at the Ministry of Health said that black fungus has not appeared as a symptom for those recovering from coronavirus, and that Samir Ghanem’s case had been carefully examined for the existence of this symptom 62-year old lady in Fayoum , who recently recovered from COVID-19, was diagnosed with the fungal infection.

12. Mansoura University Hospital reports black fungus cases Al- Masry Al- Youm May 28, 2021 4 CASES All were admitted into the ENT department Two of the cases previously had coronavirus , one case had a malignant breast tumor  and another had kidney failure . All of these cases suffered from severe weakening of immunity, which is the main reason for infection Some cases respond to treatment and others need endoscopic intervention to clean the fungus

13. It is noted that the Ministry of Health and Population has denied that the Indian variation has appeared in Egypt. he pointed out that the spread of black fungus in India does not have to become a worldwide phenomenon . Member of the Scientific Committee for Combating COVID-19 Mohamed al- Nadi pointed out that a polluted environment is a significant factor either . For instance, getting exposed to large quantities of dust and rotten vegetables and fruits frequently coupled with low immunity can incur black fungus infection.   No need to worry about black fungus spreading in Egypt: presidential health advisor

14. May 29, 2021 Egypt’s first suspected case of black fungal infection announced in Menoufia

15. Types of mucormycosis 1-Rhinocerebral (sinus and brain) mucormycosis : most common in people with uncontrolled diabetes and in people who have had a kidney transplant.  2- Pulmonary (lung) mucormycosis : in people with cancer and in people who have had an organ transplant or a stem cell transplant.   3-Gastrointestinal mucormycosis : premature and low birth weight infants less than 1 month of age,  4- Cutaneous   enter the body through a break, This is the most common form of mucormycosis among people who do not have weakened immune systems  5- Disseminated spreads through the bloodstream , most commonly affects the brain Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 15

16. How black fungus spread ? The disease is caused by fungal spores found in soil and organic matter, usually inhaled by humans from the air. The mould enters the body and then manifests around the nose and eye sockets, causing the nose to blacken, and if not stopped will move fatally into the brain. The disease is not contagious and doesn’t spread from one person to another. Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 16

17. What are the clinical features of mucormycosis infection? 1 -Nasal blockage , bleeding, discharge from the nose are initial features of mucormycosis . On endoscopic visualization of the nasal cavity an unmistakable black eschar ( slough or dead tissue) coated masses will be present which gives away the diagnosis. 2- As the disease progresses the palate may be destroyed as a large black necrotic mass may be seen on opening the mouth. 3 -When the orbit i s involved there will be proptosis ( protrusion of eyeball ), loss of movements of the eyeball with consequent double vision. Eye pain, redness with blindness can follow. 4- If the brain is invaded due to blood vessel blockage there will be strokes, hemorrhages, and even death . Patients can also have headaches, drowsiness, limb weakness, seizures and even death. Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 17

18. Invasive Fungal Orbitorhinocerebral Mucormycosis Rhino- oculo Cerebral Mucormycosis Resistant to Amphotericin B in a Young Patient with Diabetic Ketoacidosis Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 18

19. Rhinocereberal mucor mycosis Rhinocereberal mucor mycosis Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 19

20. Cutaneous mucormycosis cutaneous mucormycosis caused by  Saksenaea vasiformis  in a patient with systemic lupus erythematosus c PRESENTATION TITLE 2/11/20XX 20

21. Can there be other fungal infections in COVID 19 patients? In western countries , Mucor has not caused as much havoc as it has in India. However, there has been an increased incidence of other fungal infections like aspergillosis and candidiasis in COVID-19 patients Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 21

22. Diagnosis of black fungus 1-medical history and physical exam. 2-fluid or tissue samples send them to a lab. 3-CT scan or MRI. 4-There are no specific blood tests to detect  mucormycosis . Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 22

23. RHINOCEREBRAL MUCORMYCOSIS Diagnosis  Punch biopsy of the lesion followed by fungal stains and culture.  Histological examination reveals the characteristic broad , branching hyphae of Rhizopus invading the tissue.  CT or MRI of the head reveal air-fluid level in the sinuses and involvement of deep tissues PRESENTATION TITLE 2/11/20XX 23

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25. 73 year old patient presenting with pain in the left side of face and orbit. ( A) Coronal CT shows soft tissue density involving both  ethmoid sinus  and left  maxillary sinus  with extension into extraconal space of the left orbit (blue arrow). (B) Axial CT shows soft tissue density in the orbital apex region (red arrow ). PRESENTATION TITLE 2/11/20XX 25

26. Histopathology smear showing broad nonseptate hyphae of Mucor  PRESENTATION TITLE 2/11/20XX 26

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28. Black fungus in pediatrics As compared to adults , children are less likely to have diabetes or an immunocompromised immunity, which is why they are less prone to any form of fungal infection caused during COVID-19 infection. However, recent reports have suggested rare cases of mucormycosis or black fungus infection in children. PRESENTATION TITLE 2/11/20XX 28

29. Black fungus in pediatrics First case of Black fungus detected in children from Karnataka; condition critical Both the children were suffering from ‘ acute juvenile diabetes’ and had contracted Covid-19 , which came to light when they were taken to a hospital By  hindustantimes.com  | Edited by Ayshee Bhaduri , Hindustan Times, New Delhi UPDATED ON JUN 01, 2021 03:34 PM IST PRESENTATION TITLE 2/11/20XX 29

30. Two cases of Mucormycosis have been reported among children in Karnataka on Monday -- an 11-year-old girl from Ballari district and a 14-year-old boy from Chitradurga district -- making it the first-of-its-kind in the state. These are the first cases of mucormycosis being reported in children . Karnataka. Karnataka has reported 1250 cases of mucormycosis . 39 patients have lost their lives to the fungal disease even as18 of them have recovered. A total of 1,193 patients are currently under treatment for mucormycosis PRESENTATION TITLE 2/11/20XX 30

31. How to prevent mucormycosis Check your blood sugars when you get diagnosed with Covid-19 . The infection itself can cause a rise in blood sugars, and this can be independent of whether you have pre-existing diabetes. Doctors need to avoid three pitfalls when it comes to using oral or intravenous corticosteroids: their use too early (if oxygen levels have not dropped), or their use routinely in higher doses than recommended (6 mg Dexa a day, or 32 mg methylprednisolone a day, or 40 mg prednisolone a day), or for longer periods than recommended (up to 10 days). Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 31

32. Avoid any therapy that does not have a proven role   in treating Covid-19 , no matter how innocuous it may seem. When given for short periods, corticosteroids do not need to be tapered and can be abruptly stopped safely. Extra caution needs to be exercised among patients with other co-existing immunosuppressive conditions such as chronic liver disease, kidney disease, or autoimmune diseases and malignancies. Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 32

33. Approach to treatment   —  Treatment of mucormycosis involves a combination surgical debridement of involved tissues and antifungal therapy . Elimination of predisposing factors for infection, such as hyperglycemia, metabolic acidosis,  deferoxamine  administration, immunosuppressive drugs, and neutropenia Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 33

34. Due to the difficulties in establishing a definitive diagnosis , many patients will be empirically treated for mucormycosis because they have risk factors for infection and positive cultures Intravenous (IV) amphotericin B (lipid formulation) is the drug of choice for initial therapy The usual starting dose is 5 -10 mg/kg daily Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 34

35. 1-Posaconazole or isavuconazole can also be used as salvage therapy ( علاج انقاذي for patients who don't respond to or cannot tolerate amphotericin B; 2-loading dose of 300 mg IV every 12 hours on the first day, followed by a maintenance dose of 300 mg every 24 hours 3-Combination therapy is not recommended in the major treatment guidelines. 4- In patients who are able to take medications orally , we use posaconazole delayed-release tablets 5-There is little experience using  posaconazole  or  isavuconazole  for this indication PRESENTATION TITLE 2/11/20XX 35

36. Duration of therapy  —  , patients can be switched from a lipid formulation of amphotericin B to delayed -release  posaconazole  or  isavuconazole   tablets for oral step-down therapy once a favorable clinical response has been achieved , which usually takes several weeks. Therapy should continue until there is clinical resolution of the signs and symptoms of infection, as well as resolution of radiographic signs of active disease. Therapy often extends for months Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 36

37. antifungal therapy دواء بوساكونازول Posaconazole دواء بوساكونازول Posaconazole Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 37

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39. Surgery   —  Aggressive surgical debridement of involved tissues should be considered as soon as the diagnosis of any form of mucormycosis is suspected Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 39

40. OUTCOMES Despite early diagnosis and aggressive combined surgical and medical therapy, the prognosis for recovery from mucor mycosis is poor . An exception is cutaneous involvement , Rhino-orbital-cerebral infection  : mortality rate from 25-67% Pulmonary mucor mycosis  : mortality rate as high as 87% Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 40

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42. White fungus infection White fungus, also known as candidiasis , is a serious fungal infection, can affect the blood, heart, brain, eyes, bones, or other parts of the body. According to  CDC , people who are at high risk for developing this infection include those who: a lot of time in the intensive care unit (ICU) Have a weakened immune system Have recently received lots of antibiotics or steroids in the hospital Have kidney failure or are on hemodialysis Have diabetes Have a  central venous catheter PRESENTATION TITLE 2/11/20XX 42

43.   It grows in the lab as white/ creamy white spots on plates of agar. In humans, they again appear as white, creamy spots on the mucosa of the oral cavity most commonly . PRESENTATION TITLE 2/11/20XX 43

44. Summary 1-Mucormycosis is a fungal infection that causes blackening or discoloration over the nose, blurred or double vision, chest pain, breathing difficulties and coughing blood. 2-The disease is caused by fungal spores found in soil and organic matter, usually inhaled by humans from the air. Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 44

45. 4-India has large number of cases of black fungus infection with covid patients . 5- Doctors need to avoid three pitfalls when it comes to using oral or intravenous corticosteroids. 6- Intravenous (IV) amphotericin B (lipid formulation) is the drug of choice for initial therapy. 7- Aggressive surgical debridement of involved tissues should be considered as soon as the diagnosis of any form of mucormycosis is suspected Dr magdy shafik Senior pediatric and neonatology Consultant 2/11/20XX 45

46. Thank you Dr magdy shafik Senior pediatric and neonatology Consultant PRESENTATION TITLE 2/11/20XX 46