22/05/2021
Recommendations to the specialist treating COVID-19 patients regarding diagnosis, management, and referral of patients with COVID-19 Associated Mucormycosis (CAM) of RhinoOrbitoCerebral type (ROCM) BY APOS OCULOPLASTY SURGEONS FORUM
When to suspect mucormycosis in a COVID-19 patient under your care
Patients with predisposing factors like
1. Uncontrolled diabetes mellitus
2. Those who have received inhalational oxygen therapy
3. Using/used oral corticosteroids/higher antibiotics
4. Patients with in an immunocompromised status
Patients with following clinical signs and symptoms
Ocular signs and symptoms
1. Sudden loss or decrease in vision
2. Sudden onset ptosis, proptosis, total or partial ophthalmoplegia either in a white or inflamed eye
3. Clinical signs suggestive of uveitis/endophthalmitis/panophthalmitis
4. Fundus examination revealing CRAO/ NAION/ Disc Edema
5. Presence of unexplained epiphora, orbital pain, periorbital edema
Have a high index of clinical suspicion for CAM
Non-ocular signs and symptoms
1. Facial pain/ edema/sinus pain
2. Nasal stuffiness/ black or mucopurulent discharge/ epistaxis
3. Presence of black eschars (dark crusty tissue) on nasal mucosa/ hard palate/buccal mucosa
What is the next step to be taken if a possible or probable diagnosis of CAM is made
Time is of the essence as a delay in treatment can increase the mortality rate exponentially
1. If possible advise MRI with the contrast of Brain, orbits, and PNS
2. Can attempt to take a deep nasal swab and do a KOH mound to confirm the diagnosis
3. Immediate referral to an ENT surgeon and an Ophthalmologist for further management
4. Refrain from prescribing oral Voriconazole/ Fluconazole
5. Can prescribe oral Posaconazole, but not to delay ENT and Ophthalmology consult
What are the preventive measures to protect patients from CAM-ROCM
1. Strict glycemic control
2. Judicious use of all forms of steroids with an appropriate tapering regimen
3. Judicious use of higher antibiotics like Tocilizumab
4. At least biweekly examination of vision/pupil reactions/ocular movements/fundus/ presence of black or purulent discharge from nose/eschars on the nasal mucosa and or hard palate/facial and periocular edema and erythema has to be carried out in patients admitted in the ICU
5. Maintain hygiene of the oxygen delivery systems
6. To use sterile water in oxygen humidifiers
7. To educate patients and attenders regarding signs and symptoms of CAM and sensitive them to seek immediate medical attention if they note said signs or symptoms
How to follow up on patients who have completed treatment for mucormycosis
1. Educate the patient that they will need long term antifungal treatment
2. To look for signs of recurrence, if noted prompt referral
