COVID-19 and the risk of Mucormycosis

COVID-19 and the risk of Mucormycosis

Introduction

• Diabetes control can lower the chances of dangerous side-effects in COVID-19 treatment such as this fungal infection

Details of Covid-19 impacts

• While 70%-80% of those affected with COVID-19 recover without many side-effects, about 20%-30% of patients affected with symptomatic COVID-19 might require hospitalisation — here, a minority can get worse and require treatment in an intensive care unit (ICU).
• People with comorbidities such as being of an older age, obese, having uncontrolled diabetes, heart or respiratory diseases and malignancies, who fare badly.

Mucormyosis

• The new fear after the treatment of COVID-19, especially in an ICU setting, is contracting a severe disease known as mucormycosis.
• This is a serious, but rare, fungal infection caused by a group of fungi known as mucormycetes.
• Mucormycosis usually affects people who have poor immunity, and those with uncontrolled diabetes have the highest risk of developing it.
• Other risk factors of mucormycosis include steroid treatment, those who have malignancies, HIV/AIDS and those who have been treated with medicines such as deferoxamine for iron overload conditions.
• When the COVID-19 infection takes a more serious turn, heavy doses of steroids are given to the patient as a life-saving measure.
• Unfortunately, this can precipitate new onset diabetes in those who do not have diabetes, or substantially raise blood glucose levels in those persons who already have diabetes.
• This sets the scene for the development of mucormycosis.

Types and diagnosis

Rhino-orbital-cerebral mucormycosis.

• Mucormycosis is of several types, of which the commonest is rhino-orbital-cerebral mucormycosis.
• This starts as a common cold or sinusitis, but soon spreads to the eyes producing redness of the eyes, and later bulging of the eyes known as proptosis.
• It may eventually lead to paralysis of some of the eye muscles, or even to blindness.
• It can also spread to the brain, and if this occurs, the prognosis is very grave.

Pulmonary form of mucormyosis

• Other forms of mucormycosis include the pulmonary form in which the lungs are mainly involved and less common cutaneous mucormycosis or disseminated mucormycosis, where it spreads throughout the body.
• The last two are also associated with very poor prognosis.

Steps to be taken

• A very high index suspicion of mucormycosis is needed by the clinician treating COVID-19 cases, particularly in the setting of diabetes and steroid use.
• If the condition is diagnosed early and aggressive treatment given, the prognosis is good.

• Antifungal drugs such as Amphotericin B are used, but they are quite toxic and also expensive.
• If the involvement is extensive, radical surgery may be needed as a lifesaving measure in some cases, including removal of the jaw or the eye.

Sugar control, steroid use

• It is very important for those with diabetes to keep their sugar levels under very good control.
• The dose of antidiabetic drugs will have to be adjusted and, in most cases, insulin would be needed to keep the sugars under control throughout the day.
• If steroids have to be used, their judicious use is recommended.
  • For e.g., steroids should be given only at the appropriate stage of the disease, in optimal doses, and for as short a period of time as possible.
• Meticulous hygiene and care of the equipment inside the ICU including oxygen tubes and ventilators should be done in order to reduce the risk of fungal and other infections.
• It is worth emphasising the point that steroids do not have any role in the prophylaxis or the prevention of COVID-19.
• Indeed, steroids reduce one’s immunity and may actually increase the risk of developing COVID-19.
• Also, in the initial phase of viremia (medical term for viruses present in the bloodstream), the use of steroids can actually disseminate the virus widely, thereby worsening the COVID-19 infection.
• It is only when the cytokine storm is suspected, (which usually occurs in the second week of the COVID-19 infection) that steroids should be used, and that too with discretion.

Monitor blood glucose

• Many patients who were put on steroids for COVID-19, their blood glucose levels are not adequately monitored, leading to extremely, and often dangerously, high blood glucose levels.
• This can also precipitate diabetic ketoacidosis — a classic situation where the more dangerous forms of mucormycosis occur.
• Hence, those treating COVID-19 infection must pay equal importance to the control of diabetes.

Way forward

• To those with diabetes to have a healthy diet which has a lot of vegetables and less cereals (rice or chapati) and include more protein in the form of bengal gram, green gram, black gram, or mushroom.
• They must also have an active and regular exercise programme.
• It is very important for them to have their medicines regularly and if the sugars are not under control, to switch over to insulin if needed.
• Frequent monitoring of sugar levels should be done by using a hand-held, blood glucose meter.
• it is possible to wear a small sensor patch on the upper arm which can continuously monitor a person’s blood glucose levels and thus keep it under good control throughout the day.
• It is also very important to get oneself fully vaccinated.