Rhino-orbito-cerebral Mucormycosis in Diabetes

Mucormycosis in Diabetes

Rhino-orbito-cerebral mucormycosis is an uncommon but serious fungal infection with high morbidity and mortality, caused by the angiotropic fungus. Mucormycosis has suddenly become a household term, causing great fear and panic during this second wave of COVID pandemic in India.

It usually occurs in immunocompromised individuals including people with uncontrolled diabetes, hematologic cancers, HIV/ AIDS, those with solid organ transplants or stem cell transplants and those on immunosuppressants like steroids.

The suspicion or diagnosis of rhino-orbital cerebral mucormycosis triggers a medical as well as surgical emergency with special stress on the need for interaction and coordination among the inter-professional team to improve treatment outcomes in this life-threatening disease.

Who is predisposed/ at risk?

1. Uncontrolled diabetes
2. Immuno-suppression with steroids
3. Treated for Covid-19 with immunomodulators or steroids
4. Other comorbidities like malignancy, post-transplant
5. Prolonged stay in ICU
6. On mechanical ventilation/oxygen therapy for a long period
7. HIV/ AIDS

Symptoms

• Facial pain/ cheekbone pain/ toothache
• Sinus headache
• Stuffy nose
• Blood discharge from nose
• Redness of the eyes
• Double vision/ blurry vision/ sudden loss of vision

Signs

• Facial swelling/ discoloration
• Palatal eschar/ Nasal Eschar (blackish material)
• Ptosis (drooping of the eyelid)
• Proptosis (protrusion of eye)
• Ophthalmoplegia (paralysis of eye muscles) / Restricted extraocular movements
• Pan-ophthalmitis
• Central Retinal Artery Occlusion (CRAO) with a cherry-red spot at the macula

Do’s to prevent

• Control blood sugar level
• Judicious use of steroids
• Monitoring of blood glucose post-Covid-19 in individuals with and without diabetes
• Use of sterile water for humidifiers –while on oxygen therapy
• Watch for early warning symptoms/ signs

Wear a clean mask and maintain personal hygiene

Dont’s

• Do not use any medications like steroids or antifungal agents without consulting a physician
• Don’t waste crucial time. Consulting your diabetologist / ENT doctor or Eye doctor immediately is essential.

Investigations

1. Haemogram
2. Fasting / post-prandial blood glucose levels, HbA1c
3. Renal function tests
4. CT scan of Paranasal sinuses
5. MRI scan of Brain and orbit
6. Deep nasal swab/sputum examination
7. Diagnostic nasal endoscopy/ broncho-alveolar lavage

Management

1. Urgent medical and surgical management by a team approach involving the Diabetologist, ENT specialist, Ophthalmologist, Intensivist, Maxillo-facial surgeon, Microbiologist and Neurologist.
2. Tight control of blood glucose levels and management of diabetic ketoacidosis (DKA). DKA if present, will mostly need insulin for control.
3. Increase frequency of self-monitoring of blood glucose by glucometer. If possible, use continuous glucose monitoring by wearing a sensor.
4. If a patient is still on steroids, reduce the dose and discontinue it as soon as possible.
5. To discontinue the immunomodulatory drugs, if the patient is on any.
6. Proper guidelines of anti-fungal therapy like Amphotericin B or others.
7. Extensive surgical debridement when indicated.