Supplementary notes for management of covid19 and mucormycosis co-infection

Supplementary notes for Management of COVID-19 and Mucormycosis coinfection!

1. Initial Diagnosis is as per Clinical features A)

Patients in the High-Risk category

• Covid-19 is the most recent.

• Diabetes/Impaired Sugar Control • Recent use of steroids and/or immune compromising therapy B) Clinical characteristics as outlined in the Treatment Organization and Guidance document (reproduced below) Checklist of sentinel signs/symptoms in Covid-19 patients hospitalized • Sinuses and nose Infection with Mucor (relatively early disease) Headache and nasal obstruction- particularly if they are chronic or severe and are not responding to pain relievers.

Nasal crusting and purulent discharge; gangrenous, discolored nasal turbinates Face pain or lack of feeling Discoloration of the skin of the face / localized Puffiness of the face Loosening of teeth/palate discoloration or ulceration • Mucor infection of the eye or orbit (moderately advanced illness) Swelling or redness of the eyes, double vision, vision loss Drooping eyelids, ocular ache.

2. Investigations: •

RTPCR / CBNAT Status of Covid

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Persistent RTPCR +vity beyond 2 weeks after initiation is common in

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Patients are classified according to their Covid Status for admission to separate designated wards for Covid+ve and Covid -ve patients.

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Swab & KOH Smear Testing- Swabbing from the most suspect location (crust/ulcer on turbinate or palate) must be sent for KOH mount and testing.

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Swab yields are unsatisfactory, but this is a solid starting point.

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Endoscopically guided Tissue Biopsy specimens from necrotic/gangrenous tissue offer higher yields. This must be done cautiously for patients with Covid +ve status.

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PNS NCCT or CECT can offer a fast evaluation of disease extent; however, MRI is preferable for assessing orbital or intracranial disease spread.

3. Factors Of Diagnosis And Treatment •

Rhinologic/Rhino-Orbital/-The involvement of the brain is associated with a very unfavorable prognosis.

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The state of the underlying immune system

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Systemic illness/diabetes management

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Time to start medical therapy is one of the treatment parameters.

4.Management Principles

• Urgent action is required to prevent progression and death/loss of vision.

• Treatment of co-morbid illness/blood sugar management, as well as Covid sickness • To examine Covid therapies to reduce immune compromise.

• Evaluation of the Covid Checklist twice a day for the advancement of orbital/intracranial involvement. Antifungal therapy with Amphotericin B/ Posaconazole.

• After systemic sickness has been stabilized, surgical debridement should begin as soon as possible, with facilities for post-surgical care/ventilation available.

• Given the higher documented risk of complications and death in Covid +ve patients, the risks and benefits of surgery must be evaluated in severely ill patients.

Antifungal Treatment • Antifungals must be started immediately because of high clinical suspicion, while smear/biopsy results are awaited.

• Amphotericin B is the preferred medication.

In greater doses, liposomal formulations are less toxic and better tolerated. Can be used at a dose of 5 mg/kg/day up to a maximum of 5-7 gram.

If renal functions are normal, conventional amphotericin (dosage 1-1.5 mg/kg/day) can be administered.

As a step-down treatment, tablets of Posaconazole 300 mg od or Isavuconazole 200 mg od may be used.

Doses of liposomal amphotericin B are titrated to toxicity.

The first dose is a test dosage, followed by 3-5 mg/kg/day.

Some liposomal amphotericin formulations require that the suspension be sonicated.

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Before administration The liposomal version does not require premedication with hydrocortisone. Giving hydrocortisone unnecessarily might affect glycemic management.

Toxicity-titrated conventional amphotericin B- (Amphotericin B deoxycholate) dosages The first dose is a test dosage, followed by 1-1.5 mg/kg/day.

If the liposomal version is unavailable and renal function is not affected, this medication may be used (we should not assume that everyone with diabetes will have an eGFR which will preclude initiation and escalation of non-liposomal amphotericin). non-liposomal amphotericin is often delivered in dextrose; consequently, if the patient has diabetes, insulin neutralization is required. If it is not neutralized, it might contribute to a deterioration of glucose control.

Glycemic control should be implemented as soon as possible. The MoHFW recommendations for screening and management of hyperglycemia in Covid 19 patients may be found here: https://www.mohfw.gov.in/pdf/ClinicalGuidanceonDiabetesManagementatCOVID 19PatientManagementFacility.pdf Surgical Debridement: Removal of all necrotic tissue in the PNS and orbit until the bleeding periphery is reached. An orbital exenteration may be required. The surgical approach (endoscopic/sublabial denker's/transfacial), scope, and timing of operation can all be adapted to the clinical circumstance.