Dr. Wahied Khawar Balwan
Rare, life threatening Covid-19 complications appear to be escalating in India, creating a fresh wave of critical medical challenges in a country that has already seen short supplies of oxygen and other basic needs. Hospital across India have been reporting several cases of Mucormycosis, a rare fungal infection, affecting patients who have recently recovered from COVID-19. Once considered a rare “opportunistic” fungal infection in Covid-19 patients, mucormycosis has emerged as a dramatic bellwether for a raft of secondary ailments symptomatic of India’s inability to contain the world’s fastest growing coronavirus outbreak. The government has now declared it a ‘Notifiable Disease’.
INTRODUCTION
Mucormycosis, a rare but serious fungal infection, is being detected relatively frequently in Covid-19 patients across India. The disease, also known colloquially as “black fungus”, was made notifiable by the government in the 3rd week of May 2021, making it mandatory for states to report both suspected and confirmed cases to the Integrated Disease Surveillance Programme (IDSP).
Mucormycosis (previously zygomycosis), a rare but serious fungal infection, is affecting some COVID-19 patients. The disease manifests in the skin, affects lungs and brain, and can lead to loss of the upper jaw or eye. It has been declared a notified disease in Haryana and Rajasthan, the national COVID-19 task force has issued an advisory and the Union health ministry has asked states/UTs to declare Black fungus as an epidemic.
CAUSE
Mucormycetes, the group of fungi that cause mucormycosis, are present throughout the environment, particularly in soil and in association with decaying organic matter, such as leaves, compost piles, and animal dung. They are more common in soil than in air, and in summer and fall than in winter or spring. Most people come in contact with microscopic fungal spores every day, so it’s probably impossible to completely avoid coming in contact with mucormycetes. These fungi aren’t harmful to most people. However, for people who have 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. Several different types of fungi can cause mucormycosis. These fungi are called mucormycetes and belong to the scientific order Mucorales. The most common types that cause mucormycosis are Rhizopus species and Mucor species. Other examples include Rhizomucor species, Syncephalastrum species, Cunninghamella bertholletiae, Apophysomyces, Lichtheimia (formerly Absidia), Saksenaea and Rhizomucor.
INCIDENCE
Covid triggered black fungus infection is rising in India. So far, over 7,000 people have been infected with the disease and over 200 have lost their lives. Maharashtra has reported the highest number of cases of Mucormycosis, also known as black fungus. The state has reported the highest number of deaths due to black fungus, a new cause of concern for the health authorities. The Hindustan Times reports that at least 7,250 people have been infected with Mucormycosis. It has so far killed at least 219 people in the country, according to the figures shared by officials with HT. In the last couple of weeks, the states have reported a sharp rise in the number of black fungus cases. The Centre on Thursday asked the states to declare it a notified disease. Telangana, Odisha, Karnataka, Tamil Nadu, Rajasthan, Gujarat, and Haryana have already declared black fungus as a notified disease. According to HT, Gujarat is the second worst hit state in terms of fungus infection followed by Madhya Pradesh. Gujarat has reported 1,163 cases and 61 deaths whereas Madhya Pradesh has recorded 575 infections and 31 deaths. Haryana has reported 268 cases and eight deaths while Delhi has recorded 203 cases and one death. In Uttar Pradesh, 169 cases of mucormycosis and eight deaths due to it have been reported. Its neighbouring state Bihar has recorded 103 cases and 2 deaths. Chhattisgarh has reported 101 infection and one death, Karnataka reported 97 cases and no death, Telangana has 90 cases and 10 deaths, as per HT reports.
WHO IS AT RISK?
Infection is caused by Mucormycetes, a group of molds/fungus abundant in environment. It mainly affects sinuses/lungs of people with health problems or on medicines which lower body’s ability to fight germs/sickness, including those with diabetes, cancer, organ transplant, hospitalised or recovering COVID-19 patients (treated with cheap steroid and other anti-inflammatory drugs). Steroid depresses the body’s immune system, making patients more susceptible to secondary infections such as mucormycosis which may be triggered by mold-tainted oxygen pipes and humidifiers.
SYMPTOMS
Pain, redness around eyes and / or nose, fever, headache, coughing, shortness of breath, bloody vomits and altered mental status. The warning signs include toothache, loosening of teeth, blurred or double vision with pain, sinusitis (nasal blockade or blackish/bloody discharge), cheekbone or one sided facial pain or swelling, blackish discoloration of nose bridge/palate, thrombosis, skin lesion, chest pain.
PREVENTION
Use masks if you are visiting dusty construction sites. Wear shoes, long trousers, long sleeved shirts and gloves while gardening. Maintain personal hygiene (scrub bath). Control diabetes, monitor blood glucose level after COVID-19 treatment discharge, reduce steroid use, discontinue immunomodulating drugs and hydrate adequately.
TREATMENT
Some cases require surgery (As part of life-saving procedures, all infected tissues have to be surgically removed. Some patients end up losing the eye/s and, in some cases, the upper jaw). For others, respiratory tract fluid samples may be tested, tissue biopsy or CT scan (lungs/sinuses) may be conducted. Normal saline (IV) infusion is given before 4-6 weeks of antifungal Amphotericin B dose (3-4 mg per kg of body weight per day). Patients might need an intravenous anti-fungal procedure spanning four to six weeks.
CONCLUSION
The fatality rate in mucormycosis cases is very high.
As per data available thus far, mortality is as high as 80% if a patient goes untreated, or remains untreated long. If treated, it is still 40-50%. In cases where the infection is caught at the sinus stage itself, patients mostly completely recover. Besides, according to doctors, drugs used for treating this condition come with strong side-effects.
That can, in some cases, lead to kidney issues, neurological dysfunction. Doctors are currently using Liposomal Amphotericin B for treating black fungus infections. As many as 20 vials of this injection are required to treat each infected person. According to reports, each vial currently costs between Rs 5,000 and Rs 6,000. The availability situation for this medicine is currently alarming, because its supply is controlled by the government. In its absence, some doctors have said they’ve moved to second-line drugs like Posaconazole.
Self-medication is a strict no-no and black fungus medicines must only be used under prescription and medical supervision, say doctors. Also, one must watch out for over-dosage of steroids, they warn. |
