Question Description

Please read the peers discussions and respond to them APA format with reference

Discussion 1

Mucor is a type of fungi from the group of molds called mucorcycetes. This type of mold is able to thrive in in various surroundings, predominantly in decaying fruits and vegetables, soil, leaves, manure and rotting wood (Centers for Disease Control and Prevention [CDC], 2015). Predominantly people who are in an immuno- compromised state can develop this uncommon infection called mucomyosis by inhaling mucor spores or by the spores entering through a break in the skin (CDC, 2015).

Mucomyosis is an opportunistic infection. It affects the immunocompromised whose own defense mechanisms are not working properly. People 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 are able to reach and infect the lungs due to the lack of macrophages and the process of phagocytosis. Evidence has shown that the phagocytic process is a primary defense against mucomyosis (Spellberg, Edwards, & Ibrahim, 2005). It would be helpful for the nurse to be knowledgeable of the risk factors associated with mucomyosis and be able to rapidly suspect a patient that presents with symptoms of pneumonia. Rapid diagnosis and initiation of antifungal drug therapy is key due to its rapid progression. Other medical/nursing interventions would include collecting a sputum culture, bronchial washing, CT scan and interventions that would treat the symptoms such as supplemental oxygen, pain medication and administering antipyretics for fever (CDC, 2015).

Abnormal lab values:

Fasting Glucose 138mg/dL. A fasting glucose above 126mg/dL on two separate occasion indicates diabetes.

WBC= 15,200/mm. A white count >10,000 indicates infection. This reflects the current infection with pneumonia from mucormyosis.

Lymphocytes =10%. Are produced in the bone marrow and differentiate into B cells (responsible for production of antibodies) and T cells (play a role in immunity). The immunocompromised are the people most susceptible to mucormyosis.

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 give 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. So the patient is now also developing metabolic alkalosis because it is passed the acute phase.

Three medications that are likely to be described in this case are the antifungals:

Lipid preparations of amphotericin B are first line treatments due to the cost and safety. They are able to be given in higher initial doses without harming the kidneys (Crum-Cianflone, 2015).

Posaconazole is used in patients who cannot be treated with amphotericin B. This drug is offered in oral form to follow up with after IV amphotericin B (Crum-Cianflone, 2015).

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- Mucormysosis can spread very quickly through penetration into the blood vessels causing tissue necrosis. This penetration in the blood vessels also allows the fungus to easily be carried to other organs. Surgical intervention can help to 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).

Reference

Crum-Cianflone, N. F. (2015). Mucormycosis medication. Retrieved from http://emedicine.medscape.com/article/222551-medic…

Miceli, M. H., & Kauffman, C. A. (2015). Isavuconazole: a new broad-spectrum triazole antifungal agent. Clinical Infectious Diseases61(10), 1558-1565. Retrieved from https://academic.oup.com/cid/article/61/10/1558/30…

Centers for Disease Control and Precention. (2015). Definition of Mucormyosis. Retrieved from https://www.cdc.gov/fungal/diseases/mucormycosis/d…

Spellberg, B., Edwards, J., & Ibrahim, A. (2005). Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Clinical microbiology reviews18(3), 556-569. Retrieved from http://cmr.asm.org/content/18/3/556.fu

Discussion 2

Mucor is type of mold/fungus that can infect the respiratory passages of humans. Mucor normally infects Immunocompromised patients such as those with Aids, uncontrolled diabetes or patients taking immunosuppressant therapies (Taber’s,2017).

Immunocompromised patient inhales fungus spores from the environment, raking up leaves as an example, the spores transport to the lungs via the respiratory tract. The mold then penetrates the blood vessels in the lungs causing infarcts to the lung tissue resulting in necrotic lung tissue (Pulmonary Mucormycosis, sect 3, para 5, 2012)

Monitor vital signs, particularly the 02 saturation level, to determine if supplimental 02 becomes necessary for this patient. Feed patient high calorie diet to ensure energy is available to increased metabolic activity.

Abnormal lab values: Ca+ is slightly low 8.7 (8.8-10.3)

Fasting glucose is elevated 138 (70-100) possibly diabetic,

check HA1C, possible immunocompromised

WBC’s elevated 15.2 (4-10) Infection, immunosuppression

Lymphocytes low 10% (25%-33%) AIDS, Cancer

Much of this patient’s abnormal lab values can point to an imminocompromised state. Patient with Mucro are most often imminocompromised as a normal immune system protects against this type of Fungal pneumonia.

ABG: pH Alkalosis 7.50 (7.35-7.45)

Pa02 low 59mm HG on room air (75-100) Normal treatment for respiratory alkalosis in to have patient rebreath C02 by breathing into a bag however this patient has a low 02 level, I would be inclined to use supplimental 02. I am not sure if this would be contraindicated.

PaC02 25 (35-45)

HC03 increased 29 (22-26) metobolic alkalosis

This patient is uncompenated respiratory alkalosis. The treatment for respiratory alkalosis in to rebreathe C02, generally having the patient breath into a paper bag. Supplemental 02 in the situation would generally not be advisable, as it would exacerbate the alkalosis, however this patient Pa02 in low on RA. I am not sure if 02 is contraindicated in this situation.

Medications: 1. Amphotericin B or Liposomal Amphotericin B Anti-fungal to treat Murco infection. (Treatment for Mucormycosis, Para, 1, 2015).

2. Pain medication such as Norco to decrease pain so patient is able to expand lungs fully, and cough forcefully enough to mobilize secreations.

3. Guaifenesin Thin secretions to increase patient able expectorate mucus.

Treatments: 1. Diagnosis through biopsy is important to get a definitive diagnosis.

2. Surgical removal of necrotic tissue is often necessary. 3. Treatment of underlying immune deficiency. Strengthening immune system will provide enhanced health going forward.

References:

Pulmonary Mucormycosis: An Emerging Infection Case Reports in Polmonology Volume 2012, Article ID 120809, 3pages https://dx.doi.org/10.1155/2012/120809

Treatment for Mucormycosis (December 30, 2015) retrieved from https://www.cdc.gov/fungal/diseases/mucormycosis/t…

Taber’s Medical Dictionary. (2017). In D. Venes (Ed.), Taber’s Cyclopedic Medical Dictionary (23). [Unbound software platform]. Retrieved from Unbound Medicine Nursing Central App

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2018). Davis Drug Guide (15 ed.). [Unbound Mobile Platform]. Retrieved from Unbound Nursing Mobile App

Discussion 3

According Centers for Disease Control and Prevention (2015), Thermotolerant species such as Mucor (mold) indicus sometimes cause opportunistic infections known as Mucormycosis, includes infections in mucous membranes, nasal passages and sinuses, eyes, lungs, skin, and brain, as well as renal and pulmonary infections and septic arthritis. Mucor are present throughout the environment, particularly in found in soil, plants, manure, and decaying organic matter. There are about 50 species may plague water-damaged or moist building materials which can trigger allergies on exposed people. Mucormycosis mainly affects people with weakened immune systems, diabetes, extensive burns, intravenous drug users, and AIDS. It most commonly affects the sinuses or the lungs after inhaling fungal spores from the air, or the skin after the fungus enters the skin through a cut, scrape, burn, or other type of skin trauma.

According to Spellberg, Edwards, and Ibrahim (2005), both mononuclear and polymorphonuclear phagocytes, the major host defense mechanism, kill Mucorales by the generation of oxidative metabolites and the cationic peptides defensins. Neutropenic patients, dysfunctional phagocytes, hyperglycemia and acidosis are known to impair the ability of phagocytes to move toward and kill the organisms. Additionally, corticosteroid treatment affects the ability of mouse bronchoalveolar macrophages to prevent germination of the spores in vitro or after in vivo infection induced by intranasal inoculation. people with weakened immune systems breathing in mucormycete spores can cause an infection in the lungs or sinuses which can spread to other parts of the body.

The nursing interventions that would be helpful in treating the patient with pneumonia: Elevate head of bed, have patient perform deep breathing and coughing exercises, provide warm liquids to help mobilization and expectoration of secretions. Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy, such as incentive spirometer and percussion. Administer medications per order.

The abnormal lab values include fasting Glu (138 mg/dL) indicating diabetes, WBC (15,200/mm 3 ) indicating infection, PH (7.50), PaO2 (59mmHg), and PaCO2 (25mmHg) indicated respiratory alkalosis, PH (7.50) and HCO3 (29meq/L) indicated metabolic alkalosis, and Lymphocytes (10%) indicates that the patient is immunocompromised.

Amphotericin B, posaconazole, and isavuconazole are active against most mucormycetes. Lipid formulations of amphotericin B are often used as first-line treatment (According to Centers for Disease Control and Prevention, 2015, para 1). Amphotericin B is often utilized as primary therapy for mucormycosis, while posaconazole is often used in sequence after amphotericin B therapy or as primary therapy in those patients unable to tolerate amphotericin B therapy. isavuconazole is a viable alternative treatment option for patients with mucormycosis who are not able to tolerate or fail amphotericin B or posaconazole therapy(Wilson, et al. 2016, para.27). According to Centers for Disease Control and Prevention (2015), treatment of mucormycosis need to be fast and aggressive. Most patient will require both surgical and medical treatments. Mucormycosis often requires surgery to cut away the infected tissue because the patient has suffered significant tissue damage that cannot be reversed. Medication plays important role. Administration of Amphotericin B, posaconazole, and isavuconazole because it is important for improving outcomes for patients with mucormycosis pneumonia. Oxygen therapy may apply if needed. treatment the underlying immunocompromising condition to improve immune system for fighting with the infection.

Reference:

Centers for Disease Control and Prevention. (2015). Definition of Mucormycosis. Retrieved from https://www.cdc.gov/fungal/diseases/mucormycosis/d…

Spellberg, B., Edwards, J., & Ibrahim, A. (2005). Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management. Clinical Microbiology Reviews, 18(3), 556–569. http://doi.org/10.1128/CMR.18.3.556-569.2005

Wilson, D. T., Dimondi, V. P., Johnson, S. W., Jones, T. M., & Drew, R. H. (2016). Role of isavuconazole in the treatment of invasive fungal infections. Therapeutics and Clinical Risk Management, 12, 1197–1206. http://doi.org/10.2147/TCRM.S90335

Mold & Bacteria Consulting Laboratories. (2018

Discussion 4

Explain what Mucor is and how a patient is likely to become infected with Mucor. Describe the pathophysiologic progression of the infection into pneumonia and at least two medical/nursing interventions that would be helpful in treating the patient.

Mucormycosis (previously known as zygomycosis) is a serious but rare fungal infection caused by a group of molds called mucormycetes. These molds live throughout the environment. Mucormycosis mainly affects people with weakened immune systems and can occur in nearly any part of the body. Similarly, pulmonary mucormycosis occurs after inhalation of fungal sporangiospores. Mucormycosis agents being angioinvasive cause infarction of the affected tissues. Fungus causes necrosis and can invade tissue to spread locally or disseminate systemically. It can present with mild to severe symptoms such as fever, cough, chest pain, dyspnea, hypoxia, and hemoptysis. Pulmonary mucormycosis has a predilection to invade the adjacent organs such as the pericardium, chest wall, and mediastinum. Invasion of the large mediastinal vessels can lead to massive hemoptysis, which could occasionally be fatal.

According to the case report in pulmonology (2018), “Diagnosis can be particularly challenging in part because of its relative rarity. On chest imaging, pulmonary mucormycosis may present with focal consolidation, lung masses, pleural effusions, or multiple nodules.” Direct histological examination of the tissue biopsy remains the gold standard for diagnosis. Since in most cases it affects the sinuses or the lungs after inhaling fungal spores from the air, or the skin after the fungus enters the skin through a cut, scrape, burn, or other type of skin trauma. If mucormycosis is suspected, amphotericin B therapy should be immediately administered due to the rapid spread and high mortality rate of the disease. Also, some nursing interventions would help in the treatment of mucormycosis. The interventions might include; frequent monitoring of vital signs and pain, if the patient is not yet receiving hyperbaric treatment, place them on oxygen; either nasal cannula or mask.

Explain each abnormality and discuss the probable causes from a pathophysiologic perspective.

The abnormal laboratory values comprise: WBC- 15,200/mm3 (indicating infection), PH of 7.50, PaO2 of 59mg, HCO3 of 29, and PaCO2 of 25 (indicated the body is alkaline but partially compensated – through hyperventilation), and Lymphocytes 10% (patient is immunocompromised).

List at least three medications and three treatments. Provide rationale for each of the medications and treatments you suggest.

Referring to Philip J McDonald (2017), “Effective management requires a 3-pronged combination of medical and surgical modalities along with correction of the predisposing underlying condition(s).” Amphotericin B or its newer lipid formulation—liposomal Amphotericin—B (L-AmB) along with extensive surgical debridement to remove the necrotic tissue, remains the mainstay of therapy. Despite aggressive treatment, invasive mucormycosis carries a high mortality rate. The overall mortality in those with pulmonary mucormycosis is high (76%) (Philip J McDonald, 2017). Thus it is important that clinicians maintain a high degree of suspicion for pulmonary mucormycosis in case of immunocompromised patients with nonresolving pneumonia. Early diagnosis and aggressive treatment might reduce the mortality associated with this devastating fungal infection. Below are listed medications and possible treatments:

1. Amphotericin B

Amphotericin B deoxycholate is a medication that can be used to treat mucormycosis, particularly when other formulations prove too costly, unlike other drugs, this medicine is readily available

2. Isavuconazole

Isavuconazole offers several advantages over other triazoles (ie, posaconazole, voriconazole), apart from its wider spectrum of antifungal activity. The drug has excellent oral bioavailability not reliant on food intake or gastric pH and is also available in an intravenous formulation, which does not contain the nephrotoxic solubilizing agent cyclodextrin.

3. Surgical debridement of necrotic tissue is mandatory. Removes necrotic tissue and prevents further spore growth.

References

Philip J McDonald (2017). Mucormycosis (Zygomycosis) Treatment & Management. Retrieved from https://emedicine.medscape.com/article/222551-trea…

Muqeetadnan, M., Rahman, A., Amer, S., Nusrat, S., Hassan, S., & Hashmi, S. (2012). Pulmonary mucormycosis: an emerging infection. Case reports in pulmonology2012.

Lehrer, R. I., Howard, D. H., Sypherd, P. S., Edwards, J. E., Segal, G. P., & Winston, D. J. (1980). Mucormycosis. Annals of Internal Medicine93(1_Part_1), 93-108.

The case report in pulmonology (2018). Case Report: Pulmonary Mucormycosis: An Emerging Infection. Retrieved from https://www.hindawi.com/journals/cripu/2012/120809…

Discussion 5

Mucor is a fungus mold that is generally found in soil, plants, fruits, and vegetables, as well as in food that is contaminated, (Mucor, 2018). Some mucor species can grow in warm temperatures causing infections to grow in humans known as zygomycosis, (Mucor, 2018). These types of zygomycosis infections can infect mucous membranes, nasal and sinus passage ways, eyes, lungs, skin, and brain, (Mucor, 2018). This fungus can enter the kidneys and lungs causing severe renal and pulmonary infections and most susceptible those who have a weakened immune system, (Mucor, 2018).

Pathophysiology

Mucormycosis also referred to as zygomycosis caused by the mucor fungus can enter the body through the nasopharynx and inhaled into the lungs multiplying rapidly resulting in to pulmonary mucormycosis, (Osborn, Wraa, Watson, & Holleran, 2014, p. 698). This an infection causes pulmonary obstruction and inflammation known as pneumonia, (Osborn, Wraa, Watson, & Holleran, 2014, p. 740).

Medical/Nursing Interventions

As a nurse it is important to monitor the patient’s oxygenation, (Osborn, Wraa, Watson, & Holleran, 2014, p. 742). Vitals are important, especially respiratory rate and O2 saturation levels because this will let the nurse if there is any decline or change in the patients breathing and airway. Continuous assessment of lung sounds or signs of cyanosis should be done, and ABGs to evaluate and monitor the patients prognosis, (Osborn, Wraa, Watson, & Holleran, 2014, p. 742). Other important intervention that should be given to the patient to help in treating provide is supplemental oxygen, medications, respiratory treatments, suction if needed, and encourage and educate the patient on cough and deep breath exercise, teach the use of an incentive spirometer, and encourage to spit up mucus (Osborn, Wraa, Watson, & Holleran, 2014, p. 749).

Abnormal Laboratory Results

Fasting Glucose Level 138 mg/dL (normal range 70-100 mg/dL)

-A high level may indicate patient is could be diabetic, however can also be an indication of infection in the body, (high Blood Sugar and Diabetes, 2018).

White Blood Cell Count (WBC) Level 15,200 (normal range 4,500-11,000)

-A high WBC level may indicate infection or inflammation in the body, (WBC Count, 2018).

Lymphocyte Level 10% (normal range 20-40%)

-A low lymphocyte level may indicate the patient is immunosuppressed, (Everything You should Know About Lymphocytes, 2018).

PH level 7.5

Low PaO2 level of 59 (normal range 75-100 mmHg)

Low Paco2 of level 25 (38-42 mmHg)

Slightly high HCO3 level of 29 (normal range 22-28 mEq/L)

-All are arterial blood gas levels indicating the patient is suffering from respiratory alkalosis that can be related to difficulty breathing and the patient hyperventilating because he is breathing rapidly and over breathing, (Respiratory Alkalosis, 2018).

Medications and Treatments

When treating fungal pneumonia the attending physician may order medications like antifungals like Amphotericin B, posacanozole, and isavicanozole drugs, and antipyretics to reduce fever. The physician may recommend or consider surgery to remove what’s infected, (CDC, 2018). The physician may also order oxygen therapy to help the patients breathing.

Amphotericin B, posacanozole, and isavicanozole drugs are used to treat fungal infections by slowing the growth of the organism or killing it, (Osborn, Wraa, Watson, & Holleran, 2014, p.746). In this case these antifungal medications would be appropriate to kill and rid of the pneumonia infection of mucormycosis.

Antipyretics like Acetaminophen are used to treat high temperatures (fevers) due to the infection. It is important to control to prevent further symptoms.

The physician may also recommend the patient breathing into a paper bag to control and normalize respiratory alkalosis. Breathing in to a paper back can help normalize blood gas levels, and help control the patients breathing by carbon dioxide, (Respiratory Alkalosis, 2018).

Difficulty breathing can cause the patient to panic and feel anxiety, therefore the physician may also order medications to relieve this anxious feeling. Medications that can be prescribed are Benzodiazepines like alprazolam, diazepam, clonazepam, or lorazepam, (Drugs to Treat Anxiety Disorder, 2018).

References

Centers for Disease Control. (2018). Treatment for Mucormycosis. Retrieved from https://www.cdc.gov/fungal/diseases/mucormycosis/t…

Drugs to treat Anxiety Disorder. (2018). Health Line. Retrieved from https://www.healthline.com/health/anxiety-drugs

Everything You Should Know About Lymphocytes. (2018). Health Line. Retrieved from https://www.healthline.com/health/lymphocytes#func…

High Blood sugar and Diabetes. (2018). WebMD. Retrieved from https://www.webmd.com/diabetes/guide/diabetes-hype…

Mucor. (2018). Mold and Bacteria Consulting Laboratories. Retrieved from https://www.moldbacteria.com/mold/mucor.html

Osborn, K., Wraa, C., Watson, A., & Holleran, R. (2014). Medical-surgical nursing preparation for practice second edition. New Jersey, USA: Julie Levin Alexander.

Respiratory Alkalosis. (2018). Health Line. Retrieved from https://www.healthline.com/health/respiratory-alka…

WBC/White Blood Cell Count. 2018. Health Line. Retrieved from https://www.healthline.com/health/wbc-count

Discussion 6

Mucormycosis is an infectious disease that targets patients with compromised immunity. Mucor is a type of fungus. It is able to survive in the body by using iron chelators. Typically, health care professionals treat patients with this illness using amphotericin, but there are other options available. These drugs interrupt the fungus’s metabolism, which limits growth. It is challenging to diagnose people with this illness, but it is important for health care professionals to be able to identify fungus as the cause of the patient’s sickness. As a fungus, mucor produces spores. When these spores are disrupted, they enter into the air and could therefore be inhaled (Spellberg et al., 2006). These spores are well-protected and can travel through the water, on people, and through the air. This fungus could have a negative impact on the brain, nervous system, and sinuses once it enters a host. Some patients are at increased risk for this illness because their immune system cannot fight against the fungus. These people tend to have illnesses like AIDS, cancer, and diabetes. Individuals who have gotten transplants might be impacted as well (Centers for Disease Control and Prevention, 2017). When mucor is in the lungs, it’s called pulmonary mucormycosis. When this occurs, the fungus is able to spread quickly to the nervous, cardiovascular, and respiratory system. The tissue near the bronchioles and alveoli become inflamed during an infection.

To provide aid to the patient, it would be necessary to closely monitor the patient’s vital signs to prevent sepsis caused by the fungus. During this process, it is necessary to address the patient’s electrolyte imbalance, manage the patient’s fever, and address hypoxemia (Spellberg et al., 2006). In addition, oxygen should be offered and maintained to the patient. The oxygen levels are low because the fungal infection is blocking the absorption of oxygen in the lungs. The patient should be positioned to maximize her breathing comfort. In addition, the room should be isolated to reduce the risk that other’s will become infected. Respiratory therapy is also needed.

This infection is deadly and therefore will require a series of anti-fungal medications. Two options are Itraconazole and Posaconazole (Spellberg et al., 2006). Combination therapy may be requested. It would also be helpful to offer the patient medications that serve as antiemetics, such as Zofran. It is common that patients become nauseous or will vomit when taking the aforementioned anti-fungals, so it is helpful to control this side effect of the medication to increase the patient’s comfort. It is also helpful for the care team to talk with the patient to discuss diet plans or therapies to control blood sugar.

References

Centers for Disease Control and Prevention. (2017). Mucormycosis. Retrieved from” http://www.cdc.gov/fungal/mucormycosis/definition….

Spellberg, B., Edwards, J., Ibrahim, A. (2006). Novel perspectives on mucormycosis: pathophysiology, presentation, and management. Clinical Microbiology Review, 18(3),556-69.

 

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