BLACK FUNGUS in patient with DKA after COVID19 vaccination

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Dr. Saicharan kulkarni - ICU pg

Dr. Rakesh Biswas - prof & HOD General Medicine.

A 65 year old daily waged labouror was brought to casuality with : 

altered sensorium since 1 day, 

weakness of Right upperlimb and lower limb since 3 days,

Ocular swelling since 3-4 days

Facial puffiness since 3-4 days

Fever since 12 days.

Patient was apparently asymptomatic 3 years back and went to local hospital in/v/o Regular checkup and came to diagnosed with Hypertension since then he was on regular medication.

Then on 19th April 2021 he took his first dose of COVID19 Vaccine, then he developed fever on 22nd April 2021 i.e, 3days after vaccination, which was high grade not associated with vomitings or diarrhoea, no loss of taste and smell sensation.

Then he developed swelling of both eyes ( left more than right) since 3-4days associated with serosanginous discharge from left eye and with facial puffiness.

Then he developed weakness of Right upperlimb and lower limb since 3 days.

O/E : 

Pt was drowsy but arousable, irritable.

GCS - E1V2M5 : 8/15

No pallor

No cyanosis

No clubbing

No lymphnodes

Facial puffiness and eye lid edema seen.

Peri orbital cellulitis

Conjunctival congestion and chemosis

HYPHEMA OF LEFT EYE with HAZY cornea.

Blackish serosanginous collection in medial canthus of left eye

blackish discoloration (eschar) on palate.

Oral examination: 

BP : 110/70mmhg

PR : 120bpm regular

RR : 28 com

Grbs : 590 @ admission

Temp : Afebrile to touch

CVS: S1, S2 heard, No murmurs

RS : Decreased air entry on Left IAA, IMA

         Crepts present in B/L IAA, ISA.

CNS : 

         Reflexes        Rt       Lt

       Biceps.             -           -

        Triceps            -.          -

        Supinator         -         -

        Knee                -.         -

       Ankle                -         - 

      Plantar           mute.     Mute

      Tone :

             UL   decreased       normal

             LL   decreased       normal

ECG :

CXR

CT brain showing soft tissue swelling in maxillary sinus

CT brain showing mucosal thickenings of sinus

                                           CT was done and images showing Preseptal cellulitis

                                   CT showing acute infarcts in frontal and temporal lobes

Labs : 

Hemogram

CUE 

RFT

LFT

HbA1c  

ABG analysis : 

RBS 

Urine for ketones: 

Urine Protein creatinine ratio

Fungal elements was seen on KOH mount. (Nasopharyngeal swab )

Provisional diagnosis : 

ACUTE ORO RHINO ORBITAL MUCORMYCOSIS WITH DIABETIC KETO ACIDOSIS WITH RIGHT SIDED CVA (ACUTE INFARCT IN LEFT FRONTAL AND TEMPORAL LOBE) WITH DENOVO DETECTED DIABETES MELLITUS 2 WITH AKI AND HYPERTENSION SINCE 2 YEARS 

EXPERT OPINION WAS TAKEN : 

OPTHALMOLOGY OPINION:  

ENT OPINION :

Day 0 : 

Treatment : 

Inj. HAI 6U IV STAT f/b

Infusion. HAI 1ml(40IU) in 39ml NS started @ 6ml/hr tappered according to GRBS

Inj.NEOMOL 1gm IV Stat

IVF NS & RL @ 75ml/hr

Vitals monitoring

Grbs monitoring 6th hourly

Strict I/O  Charting

Day 1 : 

itraconazole 200mg (only drug currently available) adjusted to his creatinine clearance which is 43ml/min

Inj. HAI 6U IV STAT f/b

Infusion. HAI 1ml(40IU) in 39ml NS started @ 6ml/hr tappered according to GRBS

Inj.NEOMOL 1gm IV Stat

IVF NS & RL @ 75ml/hr

Vitals monitoring

Grbs monitoring 6th hourly

Strict I/O  Charting

Proposed treatment for oculo-rhino-cerebral Mucormycosis is

1. Liposomal AMPHOTERCIN B

2. POSCONAZOLE

3. ITRACONAZOLE.

Update on May 5, 2021( Next day of admission)

The Nasal swab sample has been inoculated in culture medium.

cranial MRI couldn’t be done as he's very restless.

The CT does show an infarct around the left corona radiata (he has right hemiparesis) along with inflammatory exudates in his maxillary and sphenoidal sinuses. 

creatinine has reduced from 2.4 to 1.7 on Day1.

Affordability issues:

Deoxycholate ampB required is 70mg OD, but 50mg costs @ 500-700 rps 

Liposomal ampB requirement is 350mg once daily but 50mg costs 2400 to 3000 rupees per day.

Liposomal ampB is still available for 30% lesser price. 

Posaconazole price is 15000 rps starting. 

 

And he  was referred to one of the Top Government general hospitals in the Hyderabad where he was given one dose of deoxycholate amphotericin B.

Despite of all the efforts of family members, patient has died On 6th may around 10 am.( D3)

Discussion:

Tables and flow charts in the below discussion are directly taken from Indian journal of ophthalmology 

1.Honavar SG. Code Mucor: Guidelines for the Diagnosis, Staging and Management of Rhino-Orbito-Cerebral Mucormycosis in the Setting of COVID-19. Indian J Ophthalmol 2021;69:1361-5.

Mucormycosis is a potentially lethal, angioinvasive fungal infection predisposed by diabetes mellitus, corticosteroids and immunosuppressive drugs, primary or secondary immunodeficiency, hematological malignancies and hematological stem cell transplantation, solid organ malignancies and solid organ transplantation, iron overload, etc.

Table.1 : Warning symptoms and signs of rhino-orbito-cerebral mucormycosis

• Nasal stuffiness

• Foul smell

• Epistaxis

• Nasal discharge - mucoid, purulent, blood-tinged or black

• Nasal mucosal erythema, inflammation, purple or blue discoloration, white ulcer, ischemia, or eschar

• Eyelid, periocular or facial edema

• Eyelid, periocular, facial discoloration

• Regional pain – orbit, paranasal sinus or dental pain • Facial pain

• Worsening headache

• Proptosis

• Sudden loss of vision

• Facial paresthesia, anesthesia

• Sudden ptosis

• Ocular motility restriction, diplopia

• Facial palsy

• Fever, altered sensorium, paralysis, focal seizures

Diagnosis : 

Staging of ROCM

TREATMENT: 

Table 2: Prevention of rhino-orbito-cerebral mucormycosis in the setting of COVID-19

• Judicious and supervised use of systemic corticosteroids in compliance with the current preferred practice guidelines

• Judicious and supervised use of tocilizumab in compliance with the current preferred practice guidelines

• Aggressive monitoring and control of diabetes mellitus

• Strict aseptic precautions while administering oxygen (sterile water for the humidifier, daily change of the sterilized humidifier and the tubes)

• Personal and environmental hygiene

• Betadine mouth gargle (not nasal drops)

• Barrier mask covering the nose and mouth

• Consider prophylactic oral Posaconazole in high-risk patients (>3 weeks of mechanical ventilation, >3 weeks of supplemental oxygen, >3

weeks of systemic corticosteroids, uncontrolled diabetes mellitus with or without ketoacidosis, prior history of chronic sinusitis, and co-morbidities with immunosuppression)

References : 

1.Honavar SG. Code Mucor: Guidelines for the Diagnosis, Staging and Management of Rhino-Orbito-Cerebral Mucormycosis in the Setting of COVID-19. Indian J Ophthalmol 2021;69:1361-5.

2. Sen, Mrittika; Lahane, Sumeet1; Lahane, Tatyarao P1; Parekh, Ragini1; Honavar, Santosh G Mucor in a Viral Land, Indian Journal of Ophthalmology: February 2021 - Volume 69 - Issue 2 - p 244-252

doi: 10.4103/ijo.IJO_3774_20