In recent days, there has been an increase in the detection of a rare but deadly fungal infection known as mucormycosis or, more colloquially, “black fungus” in the Covid-19 patients. It appears in the skin and also affects the lungs and the brain. Cases of the infection have been reported from states like Maharashtra, Delhi, Gujarat and others. Doctors treating Covid-19 patients have flagged the possible risks of the advent of this new complication in the battle against the prevailing Coronavirus pandemic. The national task force for Covid-19 has issued an advisory based on the evidence emerging about the infection. As the infection spreads across the country, how real is the danger? Is it linked to Covid? How much of it is hype? What’s the truth? In an exclusive conversation with the Financial Express Online Dr Ravinder Gera, Director & HOD, Dept of ENT, Head and Neck Surgery, Max Healthcare, Gurugram, answers these questions: Excerpts:
What is Mucormycosis?
Mucormycosis is a common fungus, which is present mostly in soil and decaying vegetation but rarely affects humans. We all have ample exposure to this fungus during our day-to-day activities, but our immune system is extremely effective in preventing its infection. However, uncontrolled diabetes and immunosuppression are the two commonest scenarios where patients get this infection.
Why has it emerged now? What is its relation with Covid-19?
Uncontrolled diabetes and immunosuppression are the two commonest scenarios where patients get this infection. With a kill rate of 50%, this infection is to be feared and it can multiply the morbidity of covid 19 several fold. India seems to be the only country seeing a huge spike in these cases in the Covid-19 pandemic. What’s driving this deadly infection is uncertain, but it may be related to patient factors (diabetes, steroid use) and also virulence of the virus (suppression of patient’s immunity and low lymphocyte count). In western scientific literature, association of Covid-19 to mucormycosis is anecdotal and only cluster cases (less than 50) have been reported following tornado or tsunami.
Its recent occurrence reflects a lacuna in our healthcare system and hygiene conditions. Most of the mucormycosis cases follow a common theme – all patients have had Covid 19, received steroids, had diabetes or unmonitored sugars during treatment. Their lymphocyte count is low reflecting a compromised immunity. Steroids given either too soon, too much or too long can have deleterious effect on blood sugars and immunity, which further predispose to mucormycosis.
How do you recognize the symptoms?
Early recognition of symptoms i.e., eye swelling, jaw or teeth pain, bloody discharge from nose, severe headache or visual changes like double vision or sudden blindness can aid in early diagnosis and prompt treatment.
Mucormycosis is known to spread through blood vessels and can spread to lungs, skin and brain amazingly fast if it is not diagnosed early. Examination by ENT specialist, eye specialist and imaging by MRI confirms the diagnosis.
Covid treatment guidelines warn against use of steroids if the patient’s oxygen saturation is above 95% on room air. Self-medication with steroids or using them without physician guidance should be absolutely avoided. It cannot be over emphasized that blood sugar should be closely monitored by using home glucometer by every patient who is receiving steroids in treatment of Covid-19. Other factors which contribute to black fungus formation are blood high ferritin levels due covid 19 infection, need for dialysis and prolonged immunosuppression by IL6 inhibitor drug.
What are some myths about mucormycosis?
Mucormycosis is not black fungus. Medically, black fungi are a type of yeast which have black melanin pigment in walls. Mucormycosis causes tissue blackening by devitalizing its blood supply and this black appearance has been misreported as black fungus by the media.
There is no scientific evidence that oxygen pipes, oxygen supply or humidifier are responsible for its spread or origin. Unlike Covid-19, it is not contagious and does not spread from one person to another. All Covid patients are not susceptible to it and it is extremely uncommon in Covid patients who did not receive steroids and or had their diabetes under perfect control.
What is the cost of treatment?
The burden of treating mucormycosis patients is huge. They usually require multiple surgeries which can have high morbidity. Removal of the eye can render patients blind. If fungus has invaded the brain, then it has an 80% chance of death (rhino cerebral mucormycosis). Patients often need precious ICU resources and ventilator beds post surgically.
The cost of daily antifungal treatment and antibiotics can range from INR 20,000-40,000 per day and treatment would continue in hospital for at least two-three weeks after surgery. Patients also need a multi-disciplinary approach which may not be available at all places and resultant sub optimal treatment can cause more morbidity.
What should be done to prevent mucormycosis?
All focus should be on prevention of mucormycosis. Preventive strategies should be incorporated hand in hand with treatment of Covid. Good diabetes care and prediabetes care are critical to avoid contracting the infection.
Vaccination to reduce severity of covid obviates need for steroids. A good glycaemic control during Covid-19 infection, limiting the steroids to only hypoxic patients and that too with strict sugar monitoring, is important. In the recovery phase of Covid, active surveillance of symptoms and examination by ENT specialist can go a long way in preventing or doing early treatment of mucormycosis.