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Mucor is a fungus from a group of molds classified as mucoraceae. This mold is able to flourish in various surroundings but mainly in decaying fruits and vegetables, soil, leaves, manure and rotting wood (Center for Disease Control and Prevention [CDC], 2015). Individuals who are immuno-compromised can acquire this rare infection called mucomycosis by mucormycete spores being inhaled or by entering through a break in the skin (CDC, 2015).
Mucomycosis is an adaptable infection. It can affect the immune-compromised whose own defense systems are not working. Those at risk are usually in a neutropenic state and are unable to kill the Mucor fungus through phagocytosis. When the immune-compromised patient inhales the fungal spores, they infect the lungs due to the lack of macrophages, a type of white blood cell that engulfs and digests cellular debris, foreign substances, microbes, cancer cells, and anything else that does not have the type of proteins specific to healthy body, and the process of phagocytosis (CDC, 2015). Evidence has shown that the phagocytic process is a primary defense against mucomycosis (Spellberg, Edwards, & Ibrahim, 2005). It is helpful for the nurse to have knowledge of the risk factors that are associated with mucomycosis and to rapidly be able to question if a patient who presents with symptoms of pneumonia could have this infection. Immediate diagnosis and initiation of anti-fungal drug therapies is vital due to its rapid progression. Additional medical and nursing interventions would include collection of sputum for a culture analysis, bronchial washing, computerized tomography (CT) scan and interventions of providing supplemental oxygen, pain medication and antipyretics for fever that would treat the symptoms (CDC, 2015).
Abnormal lab values:
Fasting Glucose 138mg/dL. A fasting glucose above 126mg/dL on two separate occasions indicates diabetes.
WBC= 15,200/mm. A white count >10,000 indicates infection. This reflects the presence of a current infection with pneumonia from mucormycosis.
Lymphocytes =10%. Are produced in the bone marrow and differentiate into B cells (responsible for production of antibodies) and T cells (involved in immunity). The immune-compromised are individuals most susceptible to mucormycosis.
pH =7.50 (7.35-7.45). A high level indicates alkalosis.
PaCO2= 25mm Hg (35-45). Is controlled by the lungs. A low value indicates alkalosis.
HCO3= 29meq/L (22-26). Primarily controlled by the kidneys. High levels indicate alkalosis.
PaO2 =59mm Hg on RA (80-100). A low level indicates hypoxemia. The infection causes fluid and secretions to accumulate in the alveoli where gas exchange happens.
A decreased PaCo2 and an increased pH level gives you respiratory alkalosis. The HCO3 should be normal or low if he is compensating, but they are slightly elevated at 29. In the acute phase compensatory mechanisms would bring HCO3 to normal or even low. The patient is now also developing metabolic alkalosis because it has passed the acute phase.
Three medications that are likely to be described in this case are the antifungals:
Lipid preparations of amphotericin B are the first line of treatments due to the cost and safety. They are able to be given in higher initial doses without harming the kidneys (McDonald, 2018).
Posaconazole is used in patients who cannot be treated with amphotericin B. This drug is offered in an oral form to follow up with after IV amphotericin B (McDonald, 2018).
Isavuconazole can also be taken orally after initial treatment with amphotericin B. It is available in water soluble IV formula. In general, it is well tolerated with few side effects (Micelli & Kauffman, 2015).
Three treatments that are likely to be prescribed are:
Surgery- Mucormycosis spreads very quickly through entrance into the blood vessels causing tissue necrosis. This invasion into the blood vessels also allows the fungus to easily be carried to other organs. Surgical intervention can prevent spreading (Spellberg et al., 2005).
Biopsy- tissue sampling is the only definitive way to diagnose due to lack of serum and blood tests available (CDC, 2015).
Sputum or bronchiolar alveolar lavage- Cultures may be collected but may be negative in an infected person (Spellberg et al., 2005).
Amphotericin B is highly nephrotoxic and has led to the lipid formulation of amphotericin B. These formulations have been shown to decrease nephrotoxicity substantially as well as decrease other complications related to infusion in comparison. The lipid formulation is only used when the original formulation is contraindicated, such as in kidney disease until the lipid formulation proves to be of greater success. There is also a factor of cost with the lipid formulation, it is significantly more expensive (Herbrecht, Natarajan-AmÃ©, Nivoix, & Letscher-Bru, 2003).
Center for Disease Control and Prevention. (2015). Definition of mucormycosis. Retrieved March 18, 2019, from https://www.cdc.gov/fungal/diseases/mucormycosis/d…
Herbrecht, R., Natarajan-Ame, S., Nivoix, Y., & Letscher-Bru, V. (2003, March 02). The lipid formulations of amphotericin B. Journal of Expert Opinion on Pharmacotherapy, 4(8), 1277-1287. https://doi.org/10.1517/14656518.104.22.1687
McDonald, P. J. (2018). Mucormycosis (Zygomycosis) medication. Retrieved March 18, 2019, from https://emedicine.medscape.com/article/222551-medi…
Micelli, M. H., & Kauffman, J. A. (2015, November 15). Isavuconazole: A new broad-spectrum triazole antifungal agent. Clinical Infectious Diseases, 61(10), 1558-1565. https://doi.org/10.1093/cid/civ571
Spellberg, B., Edwards, J., & Ibrahim, A. (2005, July). Novel perspectives on mucormycosis: Pathophysiology, presentation, and management. Clinical Microbiology Reviews, 18(3), 556-569. https://doi.org/10.1128/CMR.18.3.556-569.2005