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Table of Contents
CLINICAL ARTICLE
Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 18-23

Care of patient with mucormycosis


1 Nurse Educator, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
2 Chief Nursing Officer, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
3 Head of the Department, Department of ENT Surgery, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
4 Staff Nurse, Bangalore Baptist Hospital, Bengaluru, Karnataka, India

Date of Submission10-Aug-2021
Date of Decision16-May-2022
Date of Acceptance23-May-2022
Date of Web Publication05-Jul-2022

Correspondence Address:
Ms. Glory Paul
Nursing Division, Bangalore Baptist Hospital, Hebbal, Bellary Road, Bengaluru - 560 024, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_75_21

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  Abstract 

Mucormycosis is the second-most frequent mould infection in immunocompromised patients and can progress rapidly. Early diagnosis, surgical debridement, systemic antifungal therapy and control of underlying conditions are the key elements in the successful management of this infection.

Keywords: Antifungal therapy, early diagnosis, immunocompromised, mould infection, mucormycosis


How to cite this article:
Paul G, Leena V, Manjula, Praveena. Care of patient with mucormycosis. Indian J Cont Nsg Edn 2022;23:18-23

How to cite this URL:
Paul G, Leena V, Manjula, Praveena. Care of patient with mucormycosis. Indian J Cont Nsg Edn [serial online] 2022 [cited 2022 Aug 16];23:18-23. Available from: https://www.ijcne.org/text.asp?2022/23/1/18/349825


  Introduction Top


Fungal Spores are ubiquitous. There are millions of fungal species, but only a few hundred of them can make people sick. The incidence rate of mucormycosis globally varies from 0.005 to 1.7 per million population.

The prevalence of mucormycosis is estimated at 140/million population in India. It is 80 times higher than the prevalence in developed countries due to the increased prevalence of diabetes mellitus. Hence, the Government of India directive and many states in India made mucormycosis a notifiable disease in May 2021.[1]

Mucormycosis (Mucor-(Plants) any fungus belonging to the genus Mucor, which comprises many common moulds. Mycosis-are infectious diseases caused by pathogenic fungi).

Mucormycosis (sometimes called zygomycosis) is a serious, but rare fungal infection caused by a group of moulds called mucormycetes. These fungi live throughout the environment, particularly in soil and in decaying organic matter, such as leaves, compost piles or rotten wood [Figure 1].
Figure 1: Agents of mucormycosis. https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/infectionus-diseases/agents-of-mucormycosis-microbiology

Click here to view


Fungal spores are naturally found in the nose, post nasal spaces and para nasal sinuses. When the body has lowered immune system due to uncontrolled diabetes mellitus and ketoacidosis, environmental fungus becomes pathogenic and starts encasing the vessel. Mucormycosis can also develop on the skin after the fungus enters the skin through a cut, scrape, burn or another type of skin trauma.[2]

Rhizopus is the most common genus causing human Mucormycetes (formerly Zygomycetes) infections in most case series, followed by genera such as Mucor.

Types of Mucormycosis

  • Rhino orbito cerebral (sinus and brain) mucormycosis is an infection in the sinuses that can spread to the brain. This form of mucormycosis is most common in people with uncontrolled diabetes and in people who have had a kidney transplant[2]
  • Pulmonary (lung) mucormycosis is the most common type of mucormycosis in people with cancer and in people who have had an organ transplant or a stem cell transplant[2]
  • Gastrointestinal mucormycosis is more common among young children than adults, especially premature and low-birthweight infants <1 month of age, who have had antibiotics, surgery or medications that lower the body's ability to fight germs and sickness[2]
  • Cutaneous (skin) mucormycosis occurs after the fungi enter the body through a break in the skin (for example, after surgery, a burn or other type of skin trauma). This is the most common form of mucormycosis among people who do not have weakened immune systems.[2]
  • Disseminated mucormycosis occurs when the infection spreads through the bloodstream to affect another part of the body. The infection most commonly affects the brain but also can affect other organs such as the spleen, heart and skin.[2]


Symptoms of Mucormycosis The symptoms of mucormycosis depend on the site of infection. Symptoms of rhinocerebral (sinus and brain) mucormycosis include:[2],[3]

  • One-sided facial swelling, numbness, toothache and loose tooth
  • Headache
  • Nasal or sinus congestion
  • Black lesions on the nasal bridge or upper inside of the mouth that quickly become more severe
  • Fever.


1. Symptoms of pulmonary (lung) mucormycosis include

  • Fever
  • Cough
  • Chest pain
  • Shortness of breath.


2. Cutaneous (skin) mucormycosis can look like blisters or ulcers and the infected area may turn black. Other symptoms include pain, warmth, excessive redness or swelling around a wound.[3]

3. Symptoms of gastrointestinal mucormycosis include

  • Abdominal pain
  • Nausea and vomiting
  • Gastrointestinal bleeding


4. Disseminated mucormycosis typically occurs in people who are already sick from other medical conditions, so it can be difficult to know which symptoms are related to mucormycosis. Patients with disseminated infection in the brain can develop mental status changes or coma.[2],[3]


  Pathogenesis Top


The agents of mucormycosis are ubiquitous, mainly involving the infection of the brain, sinuses and lungs. Hence, the entire process begins with inhalation (Exposure) of these fungal spores from the external environment which further gets caught in the paranasal sinuses, leading to fungal colonisation (Adhesion) and blockage of macrophages, resulting in the deficiency of neutrophils and hyperglycaemia. The fungal pathogens then invade into the major blood vessels causing necrosis, ischaemia and reduced immune response with the further spread of infection to the Orbit.[4]

Diagnosis and testing for Mucormycosis

  1. Medical history, symptoms, physical examinations and laboratory tests[5],[6]
  2. Tissue from the nose for KOH staining and microscopy, histopathology of debrided tissue and culture [Figure 2]
  3. Culture of nonsterile sites (e.g. sputum) may be helpful in patients with the infection that is clinically consistent with mucormycosis.[5],[6]


  4. Computerised tomography (CT) and magnetic resonance imaging (MRI) scan of your lungs, sinuses or other parts of your body, depending on the location of the suspected infection

  5. Reverse transcription-polymerase chain reaction (RT-PCR) can also be helpful in detecting.
Figure 2: Medical illustration of mucormycocetes. https://www.cdc.gov/fungal/diseases/mucormycosis/causes.html

Click here to view


Treatment for mucormycosis

Early recognition, diagnosis and prompt administration of appropriate antifungal treatment are important for improving outcomes for patients with mucormycosis.

Mucormycosis is a serious infection and needs to be treated with prescription antifungal medicine, usually amphotericin B, posaconazole or isavuconazole. These medicines are given intravenously (amphotericin B, posaconazole, isavuconazole) or by mouth (posaconazole, isavuconazole).[6],[7] Lipid formulations of amphotericin B are often used as first-line treatment.

Medications active against Aspergillus such as voriconazole are not active against mucormycetes, and there is some evidence to suggest that preexposure to voriconazole may be associated with increased incidence of mucormycosis in some patients. Other medicines, including fluconazole, voriconazole and echinocandins, do not work against fungi that cause mucormycosis.

Often, mucormycosis requires surgical debridement or resection of infected tissue, particularly for rhinocerebral, cutaneous and gastrointestinal infections. Control of the underlying immune compromising condition should be attempted when possible.

Liposomal Amphotericin B in the initial dose of 5 mg/kg body weight (10 mg/kg body weight in case of central nervous system involvement) is the treatment of choice. Each vial contains 50 mg. It should be diluted in 5% dextrose. It has to be continued till a favourable response is achieved and disease is stabilised which may take several weeks following which step down to oral posaconazole (300 mg daily) or isavuconazole (200 mg 1 tablet three times daily for 2 days, followed by 200 mg daily) can be done.

Risk factors

Certain groups of people are more likely to get mucormycosis, including people with:[8]

  • Diabetes, especially with diabetic ketoacidosis
  • Cancer
  • Organ transplant
  • Stem cell transplant
  • Neutropenia (low number of white blood cells)
  • Long-term corticosteroid use
  • Injection drug use
  • Too much iron in the body (iron overload or hemochromatosis)
  • Skin injury due to surgery, burns or wounds
  • Prematurity and low birth-weight (for neonatal gastrointestinal mucormycosis).


Mucormycosis is not contagious and it can't spread between people or between people and animals.[9],[10]

Prevention

It's difficult to avoid breathing in fungal spores because the fungi that cause mucormycosis are common in the environment. There is no vaccine to prevent mucormycosis. There are some ways to lower the chances of developing mucormycosis.[8],[11]

  1. People with risk factors should protect themselves from the environment[12]


    • Avoid areas with a lot of dust like construction or excavation sites and wear an N95 respirator (a type of face mask)
    • Avoid activities that involve close contact to soil or dust, such as yard work or gardening. If this is not possible


    • Wear shoes, long pants and a long-sleeved shirt when doing outdoor activities such as gardening, yard work or visiting wooded areas
    • Wear gloves when handling materials such as soil, moss or manure
    • Clean skin injuries well with soap and water, especially if they have been exposed to soil or dust to prevent skin infections.


  2. Prophylactic – Antifungal medication. If at high risk for developing mucormycosis (for example, if you have had haematologicalmalignancies, renal transplant or a stem cell transplant).[8],[11]
  3. Management of uncontrolled sugars. – Daily monitoring of blood sugars (Pre and Post meal).


  4. Teach the patient on how to do self-monitoring of blood glucose.

    Insulin therapy initiation as per the Doctors orders and teach self-administration of insulin.

  5. Appropriate management of central and peripheral line– Always maintain the aseptic technique


  6. Daily assessment of peripheral intravenous catheters (PIVC)/Central venous catheter (CVC) (peripherally inserted venous catheter) insertion site.

  7. Dressing of the PIVC and CVC to be done as per the infection control protocol.


Prognosis

A Mucormycosis case review signifies an overall cause of mortality rate of 54% and this rate also depends on the varied underlying condition of the patient, fungus type and the affected body site. As per the review, 46% of patients had sinus infection, 76% had pulmonary infection and 96% were presenting with disseminated mucormycosis.[1],[13],[14]

The overall prognosis depends on several factors, including the rapidity of diagnosis and treatment, the site of infection and the patient's underlying conditions and the degree of immunosuppressant.

Nursing management

Nursing management of a patient with Mucormycosis presented using a case report.[15]


  Case Report Top


On the 9th of May, a 43-year-old lady presented to the emergency department of Bangalore Baptist Hospital with complaints of nose block, left side eye and cheek swelling for 2 days, existing illness of COVID-19 positive and co-morbidity of Diabetes mellitus. She had nil significant family history, surgical or hospitalisation history in the past.

On initial assessment, patient was seen by an ear, nose and throat surgeon; her vital parameters were within the normal range. On clinical examination, the patient had left periorbital and cheek swelling and crusting in the left side nose. The patient underwent (CT of the Paranasal Sinus) with contrast and was found to have left maxillary, ethmoidal sinusitis and pterygopalatine fossa involvement.

On the 11th of May, patient had undergone MRI and was diagnosed to have Mucormycosis with orbital cellulitis. On the 12th of May, left endoscopic debridement and left FESS (Functional endoscopic sinus surgery) were done.

The post-debridement patient was shifted to the COVID isolation ward since she was continued to be positive. Postoperatively, the patient had complained of headache and left-side facial pain (Pain score scale-4-5/10) She maintained Spo2 96% in room air. Other vital parameters were normal. She was started on liposomal amphotericin B, IV antibiotics, antipyretics, analgesics, emetics, regular dressings and daily monitoring of blood glucose level. On the 12th of May patients fasting Gamma-ray bursts (GRBS) was 138 mg/dl, Post Prandial [GRBS] was 264 mg/dl and HbA1c of 15.3%. She was started on insulin infusion at 3 ml/h, followed by hourly monitoring of the blood glucose and insulin infusion continuation as per the sliding scale.

Sliding Scale

81-150 = 1 ml/h

151-200 = 1.5 ml/h

201-250 = 2 ml/h

251-300 = 3 ml/h

301-350 = 4 ml/h

351-400 = 5 ml/h

401-450 = 7 ml/h

>500 = 8 ml/h

On the 18th of May, repeat RT PCR test revealed negative status and the patient was shifted out to the non-COVID ward.

On the 24th of May a repeat MRI brain was done which revealed the progression of the disease including left orbit and intracranial extension. Re-debridement with intracranial extension was performed on the same day. The patient did not develop post-operative complications. Antifungal continued for a week and she was discharged on the 10th of June with oral antifungal for 9 months, glucose monitoring pre- and post-meal with T. Metformin SR 500 mg twice a day after food and Insulin Mixtard S/C 30/70 (15u – 0-10u) before food and nasal cleaning as per the advice.


  1. Nursing Diagnosis Top


Acute pain related to increase in sinus pressure, secondary to the inflammation of para nasal sinuses.

Interventions

  • Assessed the patient's characteristics of pain
  • Assessed the level of pain using numerical/facial pain scale (Pain score was 5/10)
  • Additional stressors or sources of discomfort were removed
  • Lights were turned off when not needed
  • Visitors restriction was done to reduce further stress and rate of infection
  • Provided peaceful and quiet environment to facilitate rest
  • Administered analgesics (Inj. Tramadol 50 mg IV STAT) as prescribed (Pain score was 1/10).


Evaluation

Pain was reduced as evidenced by decrease in pain score (1/10) and normal vital signs.


  2. Nursing Diagnosis Top


Ineffective airway clearance is related to the presence of copious thick nasal secretions secondary to inflammation of the sinuses.

Interventions

  • Assessed the rate and depth of respiration
  • Assessed nasal secretions and sputum for colour, amount, odour and consistency
  • Assessed the patency of the nasal cavity
  • Administered saline nebulisation
  • Provided nasal irrigation with topical Amphotericin [Figure 3]
  • Provided optimal positioning such as fowlers position to facilitate comfort
  • Taught the importance of ambulation and frequent position changes to promote lung expansion.
Figure 3: Nasal irrigation. https://o.vg/DuFtD

Click here to view


Evaluation

Patient's airway was maintained as evidenced by normal breath sounds, rate and depth of respiratory pattern.

https://o.vg/DuFtD


  3. Nursing Diagnosis Top


Fluid volume excess related to renal injury, secondary to injection Amphotericin regimen.

Intervention

  • Monitored vital signs
  • Assessed the patients intake output closely
  • Monitored serum creatinine and potassium since injection Amphotericin causes hypokalaemia
  • Monitored patients weight every day and signs of oedema
  • Administered potassium supplements since the patient had hypokalaemia (serum potassium – 2.56 mmol/L (Injection KCL 20 meq in 100 ml of NS, IV over 5 h and followed by Syp. Potklor 5 ml oral, TID) as prescribed
  • Avoided Amphotericin with other nephrotoxic drugs and administered Inj. amphotericin using photo guard intravenous set.


Evaluation

Fluid and electrolytes were balanced as evidenced by no episodes of hypokalaemia and weight loss.


  4. Nursing Diagnosis Top


Anxiety is related to a lack of clients' knowledge about the disease and medical procedures and stress.

Interventions

  • Assessed the level of anxiety since some patients appear agitated and irritable during the course of hospitalisation and experiences diaphoresis, urinary urgency and frequency
  • Acknowledged the patient feeling
  • Assessed patients level of understanding about the posted surgery and provided with pre- and post-operative instruction to aid with the better coping mechanism
  • Provided successfully recovered case stories postsurgery to the patient and family to help them cope better
  • Rendered support and approachability to the patient and the family
  • Educated the patient and family about the disease condition, treatment modalities and probable side effects and strategies to cope up with
  • Advised patient to reduce stress by listening to music or engaging in other activities which reduce the stress.


Evaluation

She understood the disease progression. Family members verbalised that they will render their constant support and encourage her to continue the treatment and follow-up.


  5. Nursing Diagnosis Top


Risk for noncompliance to treatment regimen related to the duration of the treatment.

Intervention

  • Assessed the patients' health perceptions and knowledge
  • Assessed whether patient and family members are ready to comply with the therapy recommended
  • Prepared patients physically and mentally to undergo surgical interventions by introducing them to similar successful recovered mucormycosis case stories
  • Assisted patient with the change of nasal pack along with the doctor on postoperative day 1, followed by that assisted patient with nasal irrigation and taught her to do it by herself
  • Educated the patient and family members on the treatment regimen that the patient will undergo and the expected side effects such as nausea, vomiting and ways to cope up with them
  • Created awareness among patients and families regarding the importance of completing the prescribed treatment
  • Motivated the patient to discuss the treatment plan with the immediate family members.


Evaluation

She was compliant to the treatment regimen and cooperated well.


  6. Nursing Diagnosis Top


Risk for complications related to the disease process.

Interventions

  • Assessed patient for symptoms such as frontal headache, photophobia, ptosis, edema, chemosis, vision loss, purulent discharge. papilloedema, retinal haemorrhage and necrosis
  • Observed for altered mental status
  • Encouraged to complete the treatment regimen to ensure and prevent recurrence of infections
  • Advised regular follow-up visits to the hospital after discharge
  • Educated patient on preventive measures of Mucormycosis in their preferred language.


Evaluation

She did not deteriorate further.

Outcome

Surgery was uneventful without any post-operative complications and she was discharged on the 10th of May.


  Conclusion Top


Mucormycosis if identified and treated at an early stage has a good prognosis. Appropriate counselling, Multispeciality team approach, follow-up and prompt care will aid in the speedy recovery and uneventful postoperative period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pongas GN, Lewis RE, Samonis G, Kontoyiannis DP. Voriconazole-associated zygomycosis: A significant consequence of evolving antifungal prophylaxis and immunosuppression practices? Clin Microbiol Infect 2009;15:93-7.  Back to cited text no. 1
    
2.
Cornely OA, Alastruey-Izquierdo A, Arenz D, Chen SC, Dannaoui E, Hochhegger B, et al. Global guideline for the diagnosis and management of mucormycosis: An initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis 2019;19:e405-21.  Back to cited text no. 2
    
3.
Revannavar SM, Supriya PS, Samaga L, Vineeth VK. COVID-19 triggering mucormycosis in a susceptible patient: A new phenomenon in the developing world? BMJ Case Rep 2021;14:e241663.  Back to cited text no. 3
    
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5.
Mucormycosis | Fungal Diseases | CDC; 2021. Available from: https://www.cdc.gov/fungal/diseases/mucormycosis/index.html. [Last accessed on 2021 Aug 10].  Back to cited text no. 5
    
6.
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) | CDC; 2021. Available from: https://www.cdc.gov/ncezid/index.html. [Last accessed on 2021 Aug 10].  Back to cited text no. 6
    
7.
Mucormycosis. Available from: https://www.who.int/india/emergencies/coronavirus-disease-(covid-19)/mucormycosis. [Last accessed on 2021 Aug 10].  Back to cited text no. 7
    
8.
Mucormycosis in COVID-19 | AIIMS Covid Information Portal. Available from: https://covid.aiims.edu/mucormycosis-in-covid-19/. [Last accessed on 2021 Aug 10].  Back to cited text no. 8
    
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Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr 2021;15:102146.  Back to cited text no. 9
    
10.
Chakrabarti A, Dhaliwal M. Epidemiology of mucormycosis in India. Curr Fungal Infect Rep 2013;7:287-92.  Back to cited text no. 10
    
11.
Maini A, Tomar G, Khanna D, Kini Y, Mehta H, Bhagyasree V. Sino-orbital mucormycosis in a COVID-19 patient: A case report. Int J Surg Case Rep 2021;82:105957.  Back to cited text no. 11
    
12.
Lewis RE, Liao G, Wang W, Prince RA, Kontoyiannis DP. Voriconazole pre-exposure selects for breakthrough mucormycosis in a mixed model of Aspergillusfumigatus-Rhizopusoryzae pulmonary infection. Virulence 2011;2:348-55.  Back to cited text no. 12
    
13.
Prakash H, Chakrabarti A. Epidemiology of mucormycosis in India. Microorganisms 2021;9:523.  Back to cited text no. 13
    
14.
Sarkar S, Gokhale T, Choudhury SS, Deb AK. COVID-19 and orbital mucormycosis. Indian J Ophthalmol 2021;69:1002-4.  Back to cited text no. 14
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15.
Nursing Care Plans – 10th Edition. Available from: https://www.elsevier.com/books/nursing-care-plans/gulanick/978-0-323-71118-0. [Last accessed on 2021 Aug 10].  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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  In this article
Abstract
Introduction
Pathogenesis
Case Report
1. Nursing Diagnosis
2. Nursing Diagnosis
3. Nursing Diagnosis
4. Nursing Diagnosis
5. Nursing Diagnosis
6. Nursing Diagnosis
Conclusion
References
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