Ish, Pranav; Ish, SomyaRead More
There has been an increased realization of rhino-orbito-cerebral mucormycosis (ROCM) in coronavirus disease 2019 (COVID-19) and post-COVID-19 patients in the past few weeks. The editorial published recently in this journal is a consolidated review of the diagnosis, staging, and management of ROCM for the awareness of the medical fraternity. However, there are certain issues regarding the prevention of ROCM that need further evidence before recommending at the national level.
Prevention of ROCM in the COVID-19 era needs judicious use of steroids (both dose and duration), control of comorbidities (especially diabetes), and maintaining hygiene and cleanliness. The use of drugs such as posaconazole for prophylaxis is currently not recommended in the Indian guidelines for COVID-19. Even the international guidelines recommend posaconazole prophylaxis only for patients with neutropenia and in graft-versus-host disease, that too with moderate strength. The editorial discusses the role of posaconazole in high-risk cases of COVID-19. These high-risk factors mentioned include 3 weeks of oxygen, steroids, mechanical ventilation, or comorbidities with immunosuppression. The rationale of these suggestions requires clinical evidence of reduced incidence of ROCM before advocating the same. Posaconazole is an expensive drug with limited availability in India. This will create a huge subset of the population in India affected by the current wave for posaconazole prophylaxis. A reasonable suggestion can be vigilant screening for ROCM in all such patients for early diagnosis and appropriate therapy.
The classification into possible, probable, and proven ROCM has been aptly discussed. Although every attempt must be made to make a proven diagnosis, initiating antifungal therapy even in probable cases has a favorable risk–benefit ratio. When it is recommended by the author to clinically follow up with endoscopy and radiology without any antifungal drugs in possible ROCM, it makes the concept of drug therapy for prophylaxis redundant.
There are multiple therapies that are being used for severe COVID-19, including many immunosuppressants (tofacitinib, baricitinib, bevacizumab, and itolizumab), although only tocilizumab is mentioned in the national guidelines as an off-label therapy in India. Thus, they can be possible risk factors and must also be judiciously used with strict clinical monitoring, and ideally only in a trial mode setting.
The war with COVID-19 has rendered huge morbidity and mortality. ROCM is adding fuel to this fire and spreading across the country. Appropriate clinical practices, judicious use of drugs, early diagnosis, and early treatment are the most important strategies in the current times.