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POST 1

Mucoraceae are common fungal molds that can be found in soil, dust, water, carpeting, and rotting fruits and vegetables. Mucor produces spores that when inhaled, can easily develop into disease. Individuals who are immunocompromised such as those suffering from uncontrolled diabetes Mellitus or people on steroid therapy are most vulnerable to mucormycosis (Crum-Cianflone, 2013). In healthy individuals, mucor cannot typically cause infection (AntigenLab, n.d.). The bodily defense mechanisms- the immune system, the structure or the nasal and pharyngeal passages, the ability to cough, and the sweeping action of the cilia, help "protect the alveoli from microorganisms, antigens, and other foreign substances" (GCU, 2014). However, in immunocompromised individuals, their defense mechanisms are impaired. Specifically, in diabetics, elevated blood glucose disrupts the function of neutrophils and macrophages (Ljubic et al., 2004) - neutrophils are normally the key host defense against these fungi (Crum-Cianflone, 2013)-…hence, foreign bodies are more able to enter the lungs. "Bronchoalveolar macrophages have decreased ability to inhibit spore generation, resulting in rapidly progressive pulmonary infection with hematogenous dissemination and death" (Ljubic et al., 2004).

The abnormal lab values for this patient are:

Lymphocytes Low= Lymphocytes produce antibodies to foreign antigens, however, without a sufficient number (because of steroid therapy= immunosuppressant), the immune system is unable to protect the body against opportunistic infections (GCU, 2014).

WBC High= elevated as part of the inflammatory response in response to an infectious process.

Glucose fasting High= indicates Diabetes Mellitus.

 The arterial blood gases, HC03 and pH are both high while the PaCO2 and PaO2 are low. Together these equal "Primary respiratory alkalosis -oxygen is low probably due to dyspnea from decreased pulmonary compliance due to pneumonia (Brandis, n.d.)  with Secondary metabolic acidosis from Diabetic ketoacidosis (Chen, 2014).

As there is not much information given regarding this patient’s health history and physical assessment, based on the lab values and information provided, I am speculating the following:

This patient was possibly on steroid therapy. Glucocorticoids (GC’s) are immunosuppressive drugs, thus the patient was immunocompromised. An effect of GC’s is steroid induced diabetes mellitus (Case-Lo, 2013). Patients who are immunocompromised, plus have diabetes are at an increased risk of infection. Pneumonia is a predisposing factor to diabetic ketoacidosis, because infection results in increased production of adrenaline, which leads to decrease production of insulin (Wint& Leonard, 2012). Patients who have diabetic ketoacidosis are more prone to mucormycosis (Hopley&Schalkwyk, 2006). "Acidosis temporarily disrupts the capacity of transferrin to bind iron and suggest that this alteration abolishes an important host defense mechanism that permits growth of Rhizopusoryzae", a mucor agent (Artis et al., 1982).

This patient should be monitored for vitals and 02 saturation. They will most definitely need supplemental oxygen because with pneumonia, the lungs become inflamed, affecting the ability of the lungs to maintain proper oxygenation. Patient should be placed in position to maximize lung expansion (Gutierrez &Peterson, 2002). If mucormycosis is suspected, then a biopsy should be obtained stat from site and tested for fungal elements. When mucormycosis is diagnosed, IV amphotericin should be administered starting at dose of 1mg/kg, and over a period of several months. This drug is used to treat serious fungal infections, and works by inhibiting fungal growth (WebMD, 2014). Posaconazole, 400 mg PO, is another drug of choice that is prevents fungal growth (Crum-Cianflone, 2013). Antibiotics such as amoxicillin or bactrim would be helpful in treating the pneumonia (Kaplan, 2010). "The role of surgery in pulmonary mucormycosis is not clear, but some would advocate resection" of the whole lesion (Hopley&Schalkwyk, 2006). If patient is in diabetic ketoacidosis, they will need "insulin, correction of acidosis with sodium bicarbonate, and rehydration". If they are on steroid therapy, it would be good to wean them off. For pneumonia, supportive measures to improve oxygenation may include nebulized respiratory therapy and chest physiotherapy" (Gutierrez & Peterson, 2002).

　

 

AntigenLab (n.d.). Mucor (mucorracemosus) http://www.antigenlab.com/wp-content/uploads/mold-mucor.pdf

 

Artis, W.M, Fountain, J.A., Delcher, H.K., & Jones, H.E. (1982). A mechanism of susceptibility to mucormycosis in diabetic ketoacidosis: transferrin and iron availability.

Diabetes.;31(12):1109-14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6816646

 

Brandis, K. (n.d.). Acid-base physiology.A case of pneumonia. Retrieved from

http://www.anaesthesiamcq.com/AcidBaseBook/AB9_6Case4.php

 

Case-Lo, C. (2013).Glucocorticoids. Retrieved from

http://www.healthline.com/health/glucocorticoids

 

Chen, J. (2014). Arterial blood gas (abg) analyzer. Retrieved from

http://www.mdcalc.com/arterial-blood-gas-abg-analyzer/

 

Crum-Cianflone, N.F. (2013). Mucormycosis. Mescape. Retrieved from

http://emedicine.medscape.com/article/222551-overview

 

Gutierrez, K.J. & Peterson, P.G. (2002).Pneumonia. Real world nursing survival guide: Pathophysiology. W.B. Saunders company.

 

Hopley, L. & van Schalkwyk  J. (2006). Mucormycosis. Retrieved fromhttp://www.anaesthetist.com/icu/infect/fungi/Findex.htm#mucor.htm

 

Kaplan Nursing (2010).The RN course book.Preparation for the NCLEX-RN examination.13th edition. Philadelphia.

 

Ljubic, S., Balachandran, A., Pavlic-Renar, I., Barada, A., &Metelko, Z. (2004).Pulmonary infections in diabetes mellitus.DiabetologiaCroatica 33(4). Retrieved from

http://www.idb.hr/diabetologia/04no4-1.pdf

 

National Heart, Lung, and Blood Institute (2011). What is pneumonia? Retrieved from

http://www.nhlbi.nih.gov/health/health-topics/topics/pnu/

 

Port, T. (2007). Fungal pneumonia- opportunistic. Retrieved from

https://suite101.com/a/fungal-pneumonia-opportunistic-a33219

 

Wint, C. & Leonard, M. (2012).Diabetic ketoacidosis. Retrieved from

http://www.healthline.com/health/type-2-diabetes/ketoacidosis

POST 2

Mucor is a microbial genus of moulds commonly found in soil, digestive systems, plants surfaces and rotten vegetable matter. Mucormycosis commonly may affect the pulmonary, rhinocerebral, gastrointestinal, cutaneous, or the central nervous systems. There are two main types of infection that people can get from mucor and these depend on the route of exposure. The pulmonary exposure occurs by inhaling fungal spores from the environment. These spores can cause an infection to develop in the lungs, sinuses, eyes, and face. In the cutaneous form, the fungus can enter the skin through cuts, scrapes, puncture wounds, or other forms of trauma to the skin. Mucormycosis is not contagious and does not spread from person to person. 

Mucormycosis is a rare infection caused by organisms that belong to a group of fungi called Mucoromycotina .These fungi are typically found in the soil and in association with decaying organic matter, such as leaves, compost piles, or rotten wood The pathophysiological progression of the infection is very fast and if not treated on time can have fatal results. The person who inhales the mucor usually ends up with pneumonia. When mucor invades the alveoli and the spores penetrates into spaces between cells and then it spread to adjacent cells. Spread of fungi in the lungs activates the immune system causes increase in leucocytes of patient and patient body responded to inflammation, fluids leaks from blood vessels to alveoli, leads to pneumonia and it impaired oxygen transportation. The immune system response results in chills, fever, and fatigue which are all common symptoms of pneumonia. 

 Nursing Interventions would include place the patient in high fowler position, administering oxygen to treat hypoxia and give medications as prescribed by doctor to treat fungal infection and help restore pulmonary function. Antipyretics as needed for fever. Emotional support and education about the disease is very important including teaching the patient to do deep breathing exercises and drinking lots of fluids.

WBC (15,200/mm3) are elevated, indicates an infection. Lymphocytes 10% denotes viral infection because the lymphocytes’ main function is to fight against bacterial and viral infection.  HCO3=29meq/L indicates alkalosis, PH=7.50indicates alkalosis; PaO2 =59mm/hg indicates hypoxia; PaCO2=25mm/hg indicates alkalosis. The lungs take more oxygen than required which causes hyperventilation leads to respiratory alkalosis. So the analysis of ABG indicates respiratory alkalosis.

 

Medical treatment for this patient includes administration of oxygen and maintains high fowler position to maintain adequate oxygenation. Monitor patient’s vital signs very closely. It is very important to reassure the patient to calm down the patient because sometimes patient get anxious when they are unable to breath. In order to fast the healing process and correct the alkalosis, monitoring and controlling blood sugar is very important because high blood sugar suppress the immune system.

 Amphotericin B has been the drug of choice against mucormycosis for over 50 years due to its superior effectiveness compared to other therapies. Treatment duration is usually between 3 and 6 weeks and the total dose that needs to be administered ranges from 2.0-4.0 g, depending on the specific case. Among the different formulations of this drug are liposomal amphotericin B (LAmB) and cochleate-containing amphotericin B (CAmB). LAmB is relatively low in toxicity and does not have many adverse effects, making it the favored choice. Mortality rates among patients with hematological malignancies who have mucormycosis remain high despite antifungal therapy. Surgical intervention and debridement is the gold standard of treatment for eradicating the infection (Pak, Tucci, Vincent, Sandin, Greene, 2008).  

Fever reducers and analgesics, such as aspirin or ibuprofen, acetaminophen and codeine to control the fever and pain.If sugar remains high, doctors might prescribe the patient oral medicines such as metformin, glipizide or insulin as per the patient, need. Cough medicine, to calm the patient’s cough so he can rest, is a good idea but it is not a good idea to eliminate the cough completely because coughing helps loosen mucus and move fluid from the lungs.

References

CDC. (2012).Treatment & Outcomes of Mucormycosis. Retrieved fromhttp://www.cdc.gov/fungal/mucormycosis/treatment.html

Ed4Nurses. (2014). The 6 Easy Steps to ABG Analysis. Retrieved fromhttp://www.ed4nurses.com/ECommerce/ItemDetails.aspx?ResourceCode=TELE90002&md=1

Pak J, Tucci VT, Vincent AL, Sandin RL, Greene JN. Mucormycosis in immunochallenged patients. J Emerg Trauma Shock [serial online] 2008 [cited 2014 Jan 29];1:106-13. Available from:http://www.onlinejets.org/text.asp?2008/1/2/106/42203

 Spellberg, B; Edwards, J; and Ibrahim, A. (2005). Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1195964/

POST 3

One of the causes of pneumonia is mucor infection. Mucor refers to a mold that grows very fast and that can be found both inside the house and outdoors. Mucor can be found in decaying organic matter and its infection progresses very quickly (Centers for Disease Control and Prevention [CDC], 2013). The end of mucor stalks has spherical structures which contain spores. Human exposure to mucor occurs when these spheres rupture, dispersing the spores into the air. The dispersed spores can also spread through water and therefore, leaking plumbing in homes facilitates the growth and spreading of the mold. Mucor grows into a fluffy gray or white mold. Infection takes place when individuals inhale the mucor spores. A patient is infected when mucor gains access to the individuals’ mucous membranes of the nose and lungs (CDC, 2013). These organisms multiply and invade the blood vessels. The patient experiences symptoms such as cough, fever and chest pain and this indicates the development of the infection into pneumonia. One of the nursing interventions for a patient with pneumonia is oxygen therapy which is aimed at maintaining the patients’ saturation. Rehydration of patients with dehydration signs can also be useful in making it easier for them to expectorate secretions. Patients should also undergo medication therapy tailored to the organism responsible for causing the pneumonia Many classes of antifungal agents can be prescribed , including the classic antibiotics; first-, second-, and third-generation triazoles; and the echinocandins. The patient should take antifungal medication to treat the mucor infection. (CDC, 2013).

Some of the laboratory values from the blood tests and arterial blood gases are abnormal.

The pH is 7.50 and is therefore slightly higher than the normal 7.35-7.45. Therefore, the patient is experiencing alkalosis. The partial pressure of carbon dioxide (PaCo2) is lower than normal. Therefore, the patient is experiencing respiratory alkalosis since the pH is higher than normal while the PaCO2 is lower (American Thoracic Society, 2014). PaCO2 and pH change is in the opposite direction in respiratory disorders. Respiratory alkalosis refers to low carbon dioxide levels resulting from excessive breathing. Rapid breathing or hyperventilation is the main cause of respiratory alkalosis. Hyperventilation causes the quick expulsion of carbon dioxide from the blood. This leads to a rise in pH levels (American Thoracic Society, 2014). Pneumonia is one of the causes of respiratory alkalosis. Hyperventilation also lowers the PaCO2. The partial pressure of oxygen (PaO2) is also lower. Low PaO2 is as a result of hypoventilation or slow breathing. A fasting glucose level that is higher than normal indicates that the patient is at risk of type 2 diabetes. This condition is referred to as hyperglycemia. High glucose levels in pneumonia patients increase their risk of complications and mortality. Lymphocytes are lower than normal and this condition is called lymphopenia. The white blood cell count is higher than normal. This indicates the presence of an infection. The purpose of white blood cells is to fight infections in the body and therefore, they increase when an infection occurs (Sircar, 2008).

Several medications can be prescribed for this patient. A high number of white blood cells indicate that there is an infection. A pneumonia infection from mucor can be treated using antifungal drugs. Moreover, insulin can be used to reduce the fasting glucose levels. Hyperglycemia can be treated using medications such as meglitinide analogs and sulfonylureas in order to stimulate the secretion of insulin (Sircar, 2008). The patient can also undergo several medical treatments. Patients suffering from respiratory alkalosis can be treated by breathing using a mask or into a paper bag to help them breathe in the carbon dioxide (Sircar, 2008). This increases the levels of carbon dioxide in the body and relieves symptoms such as dizziness and lightheadedness. Blood glucose levels can also be reduced through a proper diet plan. Respiratory alkalosis resulting from lung disease can be treated using medications (Sircar, 2008). Fungal pneumonia can also be treated through surgical debridement, which is the removal of the tissues that are affected.

American Thoracic Society (2014). Interpretation of arterial blood gases. Retrieved January 22, 2014 from http://www.thoracic.org/clinical/critical-care/clinical-education/abgs.php  

Centers for Disease Control and Prevention [CDC] (2013). Sources of Mucormycosis. Retrieved January 22, 2014 from http://www.cdc.gov/fungal/mucormycosis/causes.html   

Sircar, S. (2008). Principles of Medical Physiology. New York: Thieme Publishers. Retrieved January 22, 2014 fromhttp://books.google.co.ke/books?

POST 4

Mucormycosis, or Mucor, is a rare infection caused by fungus found in decaying organic matter such as leaves, compost piles, or rotten wood (Center for Disease Control, 2012). Mucor spores can be transmitted through inhalation or cutaneous routes. The spores can be inhaled when a person comes in contact with decaying debris or leaves. The transmission of mucor spores can occur through the cutaneous route through cuts, scrapes, puncture wounds, and other trauma to the skin (Center for Disease Control, 2012). Once the spores have been inhaled, they can enter into the blood vessels and cause tissue death (Muqeetadnan et al, 2012). The infection can then spread within the lungs or throughout the body. Nursing interventions that would be appropriate for a patient with pneumonia due to mucormycosis would be to apply oxygen to keep saturations above 90%, place the patient in high fowlers position to support breathing, and inform the patient on the plan of care. 

 

The laboratory values that are abnormal for this patient are the ph of 7.50 (normal 7.35-7.45), PaO2 of 59 (normal 90-100), and PaCO2 of 25 (normal 35-45). The ABG results suggest respiratory alkalosis. An elevated ph could be from the patient hyperventilating. A low PaCO2 level indicates that the patient is hyperventilating and blowing off more CO2.  The low PaO2 indicates the patient is not able to get in enough air. The patient also has an elevated white blood cell count of 15.2, which indicates infection and fasting glucose of 138, which could mean that the patient is diabetic or pre-diabetic.

 

For a patient with pneumonia secondary to mucormycosis, medications that would be included in the treatment would be a strong antifungal such as Amphotericin B. Amphotericin B is a potent antifungal that can be given intravenously or intramuscular and should only be given for serious and potentially life-threatening fungal infections. Posaconazole is anther antifungal that may be prescribed that can be used in conjunction with Amphotericin B. Insulin may be another medication if the patient continues to have high blood sugar. A CT scan and/or MRI should be preformed to evaluate how much tissue damage has occurred from the infection. The patient may require surgery to get rid of any necrosis and prevent further damage to other parts of the body. Supplemental oxygen is necessary to keep saturations above 90%. The patient should also be evaluated for underlying causes of immunosuppression such as diabetes to prevent further complications.

 

References

Center for Disease Control (2012).Mucormycosis. Retrieved from: www.cdc.gov

 

Muqeetadnan, M., Rahman, A., Amer, S., Nusrat, S., Hassan, S., &Hashmi, S. (2012). Pulmonary Mucormycosis: An Emerging Infection. Retrieved from: www.hindawi.com