Centre issues guidelines for black fungus disease management in children: Which medicines can treat the infection?

The Director General of Health Services (DGHC) under the Union Health Ministry issued guidelines for the management of Mucormycosis or black fungus disease in children below 18 years on June 9, 2021. 

The DGHC said in its guidelines, do not wait for culture results to initiate therapy as mucormycosis is an emergency. It added saying that early complete surgical debridement is the cornerstone of treatment of the infection. 

What is Mucormycosis or Black fungus?

Mucormycosis or Black fungus is a serious fungal infection seen in patients who have been under prolonged ICU treatment and have underlying/predisposing factors such as immunosuppression, poorly controlled diabetes mellitus, misuse/overuse of steroids, cancer or organ/stem cell transplantation. The fungal infection has been detected in many COVID-19 patients across the country. 

How is Black Fungus caused?

The black fungus disease is caused by a set of micro-organisms or molds called mucormycetes. The fungi generally live in the environment, particularly in soil and in decaying organic matter, such as compost piles, leaves or rotten wood and decaying fruits and vegetables. It is even found inside the nose and mucus of healthy people. 

People generally catch Black fungus by coming in contact with the fungal spores in the environment. The fungus can also develop on the skin and enter the skin through a cut, scrape, burn, or other types of skin trauma. 

Who are most at risk of catching Black Fungus?

The COVID patients undergoing oxygen therapy in the ICU, where a humidifier is used, are more prone to Mucormycosis because of exposure to moisture. 

Is Black Fungus fatal?

• Yes, black fungus infection has an overall mortality rate of 50 percent. The fungus generally starts as a skin infection in the air pockets between our eyes, teeth and behind our forehead, nose and cheekbones.

• It can turn fatal if uncared for, as it affects the sinuses, lungs and even the brain of a person. The fungus generally slowly spreads to the eyes, lungs and can be life-threatening if it reaches the brain. 

• The infection is especially more life-threatening for individuals who are diabetic or are severely immunocompromised such as cancer patients or people with HIV/AIDS.

• In some cases, the infection has caused the patients to lose their vision in both eyes and in rare cases, doctors have been forced to remove certain body parts like the eye or jaw bone to stop its spread to the brain. 

What is the treatment for Black Fungus?

The treatment of Mucormycosis or black fungus involves surgically removing all dead and infected tissues. 

The Director General of Health Services has advised following methods for treatment of Black Fungus in Children: 

1. Conventional Amphotericin B (deoxycholate) as a prolonged IV infusion through a central venous catheter or PICC; closely monitor kidney function and electrolytes during treatment. 

2. Reconstitute in water for injection and dilute in 5 percent dextrose (do not use normal saline/Ringer’s lactate, start with test dose: 1 mg IV infusion over 20-30 minutes. 

3. Loading dose: 0.25-0.5 mg/kg IV infused over 2-6 hours; which will gradually increase by 0.25 mg-increments/day to reach maintenance dose: 1-1.5 mg/kg/day.

4. Liposomal Amphotericin B or Amphotericin lipid complex, if available; prolonged infusion over 2-3 hours through a central venous catheter or PICC and closely monitoring KFT and electrolytes.

5. Reconstitute in water for injection, and dilute in 5 per cent dextrose (do not use normal saline/Ringer’s lactate); start full dose from the first day; 5 mg/kg/day (10 mg/kg/day in case of CNS involvement). This will be continued till favourable response is achieved, which may take 3-6 weeks. 

6. After this, step down to oral Posaconazole. For children below 3 years and adolescents above 17 years: 5-7 mg/kg/dose twice daily on day 1, followed by 5 to 7 mg/kg/dose daily) or Isavuconazole (not approved below 18 years of age but can be given if required) may have to be taken for a prolonged period as per the advice of the pediatrician.
7. Posaconazole can only be administered as salvage therapy in cases who cannot be given Amphotericin B. 

In Children below the age of 11 years: 7-12 mg/kg/dose IV twice on the first day and maintenance dose – 7-12 mg/kg IV once a day, starting on the second day.

In adolescents: 300 mg IV twice on the first day and maintenance dose 300 mg IV once a day, starting on the second day

8. Oral delayed-release tablets (100 mg) and Oral Suspension for infants and smaller children can be administered with fatty food:

1. Oral delayed-release tablets

For children aged between 7 to 12 years: The initial dose should be 200 mg/dose thrice daily and the maximum dose can be 800 mg/day

For Adolescents: 300 mg/dose twice on day 1, followed by 300 mg/dose once daily

2. Oral suspension (for infants and children) as syrup in a strength of 40 mg/ml. 

The recommended dose for children with bodyweight less than 34 kg is 4.5 to 6 mg/kg/dose 4 times daily.

For children and adolescents with body weights above 34 kg, the recommended dose is 200 mg/dose 3 times daily (maximum 200 mg 4 times a day). The maximum dose can be 800 mg/day.

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