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Black Fungus among children below 18 years: Here’s the details on symptoms and treatment

The guidelines for the management of COVID-19 in children below 18 years have been released by the Directorate General of Health Services (DGHS) along with the guidelines for the management of Mucormycosis/black fungus disease in children.

According to the government, Mucormycosis is a serious fungal disease seen in patients with underlying/predisposing factors such as immunosuppression, poorly controlled diabetes mellitus (especially diabetic ketoacidosis), misuse/overuse of steroids, cancer, organ/stem cell transplantation, and those under prolonged ICU treatment.

It usually happens through inhalation of fungal spores present in dust/air and it is not contagious; presentation is variable but usually occurs in the third week after onset of COVID-19 symptoms.

The government advice not to wait for culture results to initiate therapy as mucormycosis is an emergency. Early complete surgical debridement is the cornerstone of treatment and may be repeated as required.

Mucormycosis/black fungus disease Signs and symptoms:

Rhino-cerebral mucormycosis

Facial pain, pain over sinuses, periorbital swelling

Conjunctival injection or chemosis, blurring of vision/diplopia

Paraesthesia/decreased sensation over half of face

Blackish discolouration of the skin over nasolabial groove/alae nasi; nasal crusting and nasal discharge which could be blackish, or blood-tinged

Loosening of teeth, pain in teeth and gums

Discolouration (pale) of palate/turbinates insensitive to touch, eschar over the palate

Worsening of respiratory symptoms, haemoptysis, and chest pain; headache, alteration of consciousness and seizures etc.

Gastro-intestinal Mucormycosis

Symptoms and signs are very non-specific and mimic other gastrointestinal (GI) conditions but have a progressively worsening course

Unexplained feed intolerance, abdominal distension, GI bleeding in a child with several risk factors (shock, vasopressors, broad-spectrum antibiotics)

Persistent elevation of serum lactate in the absence of haemodynamic instability, liver dysfunction or other known causes

Mucormycosis treatment as per the guidelines:

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

– Reconstitute in water for injection, and dilute in 5% dextrose (do not use normal saline/Ringer’s lactate); start with test dose: 1 mg IV infusion over 20-30 min

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

Liposomal Amphotericin B or Amphotericin lipid complex: Prolonged infusion over 2–3 hours through a central venous catheter or PICC and closely monitoring KFT and electrolytes

Reconstitute in water for injection, and dilute in 5% 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)

Continue till a favourable response is achieved which may take 3-6 weeks following which step down to oral Posaconazole (delayed-release tablets, children ≥3 years and adolescents ≤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, however, if required to be given, the dose for weight >30kg: 200 mg 1 tablet 3 times daily for 2 days followed by 200 mg daily, <30kg: half the dose for >30 kg children) may have to be taken for a prolonged period as per the advice of paediatrician, the DGHS guidelines said.

Posaconazole should be given as salvage therapy in cases who cannot be given Amphotericin B

Injection IV

Children <11 years: Loading dose: 7-12 mg/kg/dose IV twice on the first day and maintenance dose: 7-12 mg/kg IV once a day, starting on second day (max: 300 mg/dose)

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

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

Oral delayed-release tablets: Children 7 to 12 years – Initial dose should be 200 mg/dose thrice daily and maximum dose can be 800 mg/day

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

Oral suspension (for infants and children) as syrup in a strength of 40 mg/ml. The recommended dose for children with body weight <34 kg is 4.5 to 6 mg/kg/dose 4 times daily.

Maximum dose 800 mg/day: For those children and adolescents with body weights >34 kg the dose is 200 mg/dose 3 times daily (maximum 200 mg 4 times a day).