Infectious diseases

QUESTION:  What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization  for the problem and what is the primary aetiology of the patient's problem?

1.     3 years ago- diagnosed with hypertension

2.     21 days ago- received vaccination at local PHC which was followed by fever associated with chills and rigors, high grade fever, no diurnal variation which was relieved on medication

3.     18 days ago- complained of similar events and went to the the local hospital, it was not subsided upon taking medication(antipyretics) 

4.     11 days ago - c/o Generalized weakness and facial puffiness and periorbital oedema. Patient was in a drowsy state

5.     4 days ago-  

a.     patient presented to casualty in altered state with facial puffiness and periorbital oedema and weakness of right upper limb and lower limb

b.     towards the evening patient periorbital oedema progressed

c.     serous discharge from the left eye that was blood tinged

d.     was diagnosed with diabetes mellitus

6.     patient was referred to a government general hospital 

7.     patient died 2 days ago

 

patient was diagnosed with diabetic ketoacidosis and was unaware that he was diabetic until then. This resulted in poorly controlled blood sugar levels. The patient was diagnosed with acute oro rhino orbital mucormycosis . rhino cerebral mucormycosis is the most common form of this fungus that occurs in people with uncontrolled diabetes ( https://www.cdc.gov/fungal/diseases/mucormycosis/definition.html ) the fungus enters the sinuses from the environment and then the brain.

The patient was also diagnosed with acute infarct in the left frontal and temporal lobe. Mucormycosis is associated with the occurrence of CVA ( https://journal.chestnet.org/article/S0012-3692(19)33482-8/fulltext#:~:text=There%20are%20few%20incidences%20reported,to%20better%20morbidity%2Fmortality%20outcomes. )

 

QUESTION:  What is the efficacy of drugs used along with other non-pharmacological treatment modalities and how would you approach this patient as a treating physician?

The proposed management of the patient was – 

1.     inj. Liposomal amphotericin B according to creatinine clearance 

2.     200mg Iitraconazole was given as it was the only available drug which was adjusted to his creatinine clearance

3.     Deoxycholate was the required drug which was unavailable

https://pubmed.ncbi.nlm.nih.gov/23729001/ this article talks about the efficacy and toxicity of different formulations of amphotericin B 

along with the above mentioned treatment for the patient managing others symptoms is also done by-

       I.          Management of diabetic ketoacidosis – 

(a)   Fluid replacement-  The fluids will replace those lost through excessive urination, as well as help dilute the excess sugar in blood.

(b)   Electrolyte replacement-The absence of insulin can lower the level of several electrolytes in blood. Patient will receive electrolytes through a vein to help keep the heart, muscles and nerve cells functioning normally.

(c)   Insulin therapy-  Insulin reverses the processes that cause diabetic ketoacidosis. In addition to fluids and electrolytes, patient will receive insulin therapy

QUESTION:  What are the postulated reasons for a sudden apparent rise in the incidence of mucormycosis in India at this point of time? 

 Mucormycosis is may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients. Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients. 

With the COVID-19 cases rising in India the rate of occurrence of mucormycosis in these patients is increasing