While India battles with COVID-19, the issue of post-COVID-19 sepsis has emerged as a significant problem.
Diabetes, with close to 77 million cases in adults, is India’s fastest growing epidemic. A cross-sectional study of individuals aged 15 – 49 years from all states of India published in BMC Med 2019 revealed that about 47 per cent of Indians are unaware of their diabetic status. In addition, only a quarter of all diabetic patients achieved adequate glycemic control upon treatment. The unholy link between diabetes and the severity of COVID-19 infection has been established in various studies repeatedly worldwide.
Mucormycosis, also known as ‘Black Fungus’, often appears as one of the most devastating complications in uncontrolled diabetics recovering from COVID-19.
COVID-19 and Black Fungus
The world is aware of the repercussions India is facing because of the second wave and the new variants of COVID-19. With more than 27 million confirmed cases since January 2020, the WHO made an announcement to educate the world on the seriousness of the B.1.617 variant of COVID-19, which is rapidly spreading across India.
What is Black Fungus or Mucormycosis?
Mucormycosis is an infection that is caused by exposure to ‘mucor mould’ called mucormycetes that is found commonly in plants, manure, soil, and decaying fruits and vegetables. It is ever-present and found in air and dirt (soil), and even in the nose and mucus of healthy individuals.
Mucormycosis can be fatal. It affects the sinuses, the lungs, brain and can be life-threatening for diabetic or severely immunocompromised people, such as HIV/AIDS or cancer patients. It starts from the nostril, travels towards the eye and then towards the brain.
One of the rarest types of fungal infections encountered by the people of India, the black fungus occurs when there is exposure to fungi called mucormycetes. These fungi usually live in the environment, leaves, soil, compost, and even animal dung. It can enter your body when you breathe, i.e., through the organs helping you inhale, and can also travel from skin wounds.
How Do You Get It?
When our body’s immune system is extremely weak, there is a possibility of getting affected by Mucormycosis, also called black fungus, black fungus skin, or black fungus nail. It is a rare yet serious infection that requires urgent medical attention or surgery.
Symptoms of Black Fungus or Mucormycosis
Like COVID-19, this disease also has variants and various effects. It chooses different areas of the body to cause potential damage, such as the brain, the lungs (pulmonary), the gastrointestinal tract, and finally, skin mucormycosis. Black fungus symptoms include cough, fever, chest pain, nasal or sinus congestion, severe headaches, and shortness of breath.
It also causes skin-related issues and can spread to any part of your body. The black fungus can give you blackened skin tissue, redness, swelling, tenderness, ulcers, blisters.
- Stuffy and bleeding nose
- Swelling of eyes and pain in the eye
- Drooping of eyelids
- Blurred and finally, loss of vision.
There could be black patches of skin around the nose.
In COVID-19 patients with diabetes and people on immuno-suppressed medications, one should suspect mucormycosis if there is sinusitis, blackish discoloration over the bridge of the palate or nose, one-side facial pain or numbness, blurred or double vision with pain, thrombosis, toothache, chest pain, skin lesion and worsening respiratory symptoms.
Mucormycosis (Black Fungus) and COVID-19 Infection – The Link
Mucormycosis is emerging as the most significant challenge in the second wave of COVID-19 infections. This is a serious fungal infection that generally does not pose any serious threat to individuals with a healthy immune system. However, experts have now noticed a rise in mucormycosis among people hospitalised for or recovering from COVID-19 infection.
How Is The COVID-19 Surge Related To The Black Fungus Outbreak?
Several scientists believe that COVID-19 can severely affect the body’s immune response, eventually increasing an individual’s vulnerability to other infections. In India, approximately 90 people have lost their lives to black fungus. This infection is considered an epidemic by India’s health authorities and the Centers for Disease Control and Prevention (CDC).
States such as Maharashtra, Madhya Pradesh, Telangana, Gujarat, and Haryana have recorded around 3,200 cases, and the worst part, the availability of the medication required to treat this illness is low in India. Among these states, Maharashtra is the worst hit, with more than 2,000 cases, 800 people hospitalized, and 90 succumbing to the black fungus infection.
Risk factors for Black Fungus or Mucormycosis, especially for COVID Patients
- Low immune system or diabetes: Whether you are an asymptomatic or symptomatic COVID-19 patient, you may be at risk. The most crucial risk factors include poor immune function and diabetes (or high blood sugar).
- Water contamination in humidifiers during oxygen therapy
- Use of certain drugs and steroids to treat COVID-19: Doctors also opine that patients most susceptible to mucormycosis are those who were treated with steroids as well as other drugs for COVID-19 to reduce the inflammation. However steroids are a life saving medication in certain categories of COVID 19 infection .Some of the drugs administered during COVID-19 treatment can suppress the immune system. In addition, usage of steroids during COVID-19 treatment can create an imbalance in the blood sugar level. It is more damaging to those having high blood sugar (diabetes).
- Cancer Patients, people with HIV-AIDs, as well as Transplant or Stem Cell Transplant patients are at risk
How is Mucormycosis Treated?
Mucormycosis is treated with antifungal medicines given through a vein (intravenous). These medicines generally include amphotericin B, posaconazole, or isavuconazole. The medicines are given for a few weeks till the fungus is completely controlled. Oral antifungal drugs are also prescribed.
The Drug Controller General of India (DCGI) has also approved use the anti-fungal medication Liposomal Amphotericin as a medical intervention for Mucormycosisin patients.
However, most of the times, mucormycosis needs surgery to cut away the infected tissue which harbours the fungus. Mucormycosis causes ischemic necrosis (dead tissue by clogging the blood vessels). It is essential to remove all the dead tissue altogether. Many procedures may be required to achieve this.
Key points for treating mucormycosis infection:
- Control diabetes as well as diabetic ketoacidosis
- Discontinue immunomodulating drugs
- Reduce steroids (if patient is still on)
- Extensive Surgical Debridement (to remove all necrotic materials)
- Install peripherally inserted central catheter (PICCline)
- Antifungal Therapy, for at least 4-6 weeks
- Infuse Normal saline IV before Amphotericin Binfusion
- Maintain adequate systemic hydration
- Monitor patients clinically and with radio-imaging to check their response and to detect disease progression
Here’s what you should not do:
- Do not consider all blocked nose cases as cases of bacterial sinusitis, mainly in the context of COVID-19 patients on immunomodulators and/or individuals on immunosuppression
- Do not miss warning signs and symptoms
- Do not hesitate to seek out aggressive investigations, as suitable (KOH staining & microscopy, culture, MALDI-TOF), to detect the fungal aetiology
- Do not lose or wate crucial time to initiate treatment for mucormycosis
Black Fungus Infection in Covid-19 Patients
How to prevent Mucormycosis?
To prevent this disease, blood glucose level should first be monitored post- COVID hospital discharge. In addition, steroids should be used judiciously in correct dose, correct timing and duration in diabetic patients; clean sterile water has to be used in humidifiers during the oxygen therapy; and antifungal and antibiotics medicines should be used correctly.
Here is what you can do to prevent getting infected:
- Control hyperglycemia
- Monitor blood glucose level post-COVID-19 hospitals discharge and similarly in diabetics
- Use clean, sterile water for humidifiers during the oxygen therapy
- Use steroid cautiously – correct timing, correct dose and correct duration
- Use antifungals/antibiotics cautiously only under medical advice
The disease can be managed by discontinuing immunomodulating drugs, controlling diabetes, reducing steroids and extensive surgical debridement- (to remove all necrotic materials).
Other precautions include:
- Wash hands often
- Wear a mask so that you do not end up inhaling the fungal spores
- Keep your home sufficiently ventilated
- Avoid picking your nose
- Do not rub your eyes
- Do not scratch your skin
- For COVID patients, one way to stop the possibility of fungal infection is to ensure that patients (both in treatment and after the recovery) are administered the right dose and duration of steroids only under medical supervision.
Apart from the above, another effective ways to avoid this deadly fungal infection is to strengthen your immune system. Likewise, take your medications on time and maintain a healthy diet rich in vitamins, minerals, fibres and proteins.
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Is Black Fungus Contagious?
Unlike COVID-19, mucormycosis is not contagious. Many people who come into contact with the same fungi do not develop an infection. It affects people who are weak, whose immune systems are not strong enough to fight the disease. People with weak immune systems facing an increased risk of mucormycosis include people with diabetes, cancer, HIV, a skin injury, or surgery.
As we wait for our turn to get inoculated, we are witnessing newer and more severe conditions related to COVID-19. Mucormycosis (black fungus) is one such deadly fungal infection witnessed among COVID-19 patients across hospitals in India.
People with diabetes, those on steroids and humidified oxygen for a long time, and COVID patients with pre-existing co-morbidities are the most vulnerable to this infection. Others include those on long-term immunosuppressive drugs and cancer patients.
It is vital to understand and be aware of such health complications and symptoms during the pandemic. It helps in initiating the necessary treatment on time.
1. How serious is black fungus?
Mucormycosis is a rare yet very dangerous infection that can affect any organ, leading to organ removal.
2. Does black fungus spread through the air?
The fungi causing the infamous black fungus infection are present in the air and the environment. Hence, it is impossible to avoid them. However, this infection only affects people with low immunity or those who have recently recovered from COVID-19.
3. Can black fungus be treated at home?
The Health Minister of India has declared that the medicines required to treat the black fungus infection cannot be purchased from medical stores, and this condition cannot be treated at home. It is also important to note that this lethal disease needs immediate medical attention that may also include surgery.