While India is still battling the coronavirus covid war for more than a year now, it is facing the wrath of another microorganism that holds the potential to transform into another pandemic. Mucormycosis, or more commonly known as the ‘Black Fungus’ is a disease extending its branches across the country. And according to the lab reports, it affects covid-19 recovered and current patients the most.
What is Mucormycosis?
It is a rare fungus whose trigger point is moisture. It feeds on moist surfaces and grows rapidly on such areas. Though rare, it is a potentially fatal infection with a mortality rate of 50%. It can grow anywhere- right from a slice of bread to the grains of soil.
Which countries are they largely found in?
As the fungus needs moisture to thrive, it grows in tropical and humid regions- more commonly in India as diabetes is exceedingly reported in people here. The nation houses lakhs of patients with uncontrolled diabetes- many of whom weren’t even aware they had diabetes until they were diagnosed with black fungus. This also brings light on the diminishing concern on health with health checkups not being conducted.
As per the country’s official National Health Portal, the prevalence of diabetes in the country is about 12% to 18% of the adult population, with urban areas taking up most of the cases.
Breach Candy Hospital, Mumbai’s Dr Hemant Thacker was quoted by CNN as saying that, “India is the diabetic capital of the world. We have tropical climates where the fungus festers. So, all this has led to the black fungus epidemic.”
It has been found in 5 states in India till now including Maharashtra, Gujarat, and Telangana. Two of these have declared the disease as an epidemic with 90 dead till now. Maharashtra has the highest number of cases.
Who are the most at risk?
Though this fungus isn’t harmful to most people, those with a weak immune system are highly susceptible to it, according to the United States CDC. Patients recently recovered from covid-19, currently fighting the viral disease, immune-system compromised individuals, diabetic patients, people on steroids, ventilator and those with any severe infection like cancer, HIV/AIDS, etc are more susceptible to Black Fungus.
However, it is to be noted that not all covid-19 recovered or actively fighting patients get infected with the fungus.
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“One of the most important reasons is uncontrolled diabetes, systemic use of steroids along with tocilizumab, patients on ventilation and taking supplemental oxygen. Within six weeks of Covid treatment if people have any of these factors they are at the highest risk of black fungus,” said Dr Chandra, a professor of neurosurgery at AIIMS.
He added that cold oxygen administration can be more harmful than beneficial to patients. Giving cold oxygen directly from the cylinder is very dangerous. Anti-fungal drug Posaconazole can be given to high-risk individuals to reduce incidents of black fungus,” the doctor said.
People with sinus infections are less likely to contract a severe form of the disease while those with lung infections are more likely to get the worse form.
Which organs are affected?
Though any organ can be infected, it more commonly involves the nasal cavity, lungs, brain, eyes, and mouth.
How is it spread?
It is spread by inhaling air contaminated with the fungus or breathing near infected areas/surfaces like soil, compost, etc.
What are the symptoms?
It can start as a facial swelling, fever, skin ulcer and black lesions in the mouth progressing “as a skin infection in the air pockets located behind our forehead, nose, cheekbones, and in between the eyes and teeth,” said the Indian Health Ministry in a statement on May 14. “It then spreads to eyes, lungs and can even spread to the brain. It leads to blackening or discolouration over the nose, blurred or double vision, chest pain, breathing difficulties and coughing of blood.”
Initially, patients will suffer from nasal blockage, bleeding and discharge from the nose. Endoscopic visualization of the nasal cavity will show an unmistakable black eschar or dead tissue coated masses at the site of interest. This gives clear proof of the fungus’ presence.
If not treated, further signs include destruction of the palate, visible as a large black necrotic mass when the patient opens his mouth. There can also be proptosis or protrusion of the eyeball, loss of eyeball movements, double vision, eye pain, redness and even blindness if the orbit gets affected. As the infection travels through the blood vessels and invades them the most, the fungus can reach the brain as well. There will be blood vessel blockage resulting in strokes, haemorrhages and subsequent death as well in such cases. Other patients can also experience headaches, limb weakness, seizures, drowsiness and even death.
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To understand the severity and extent of the infection and the lesion induced by it, an MRI and CT scan of the nasal cavity, sinuses and brain is performed.
If the lung gets involved, it shows similar symptoms as of covid-19- fever, shortness of breath, cough, etc., complicating the diagnosis. A doctor will run tests for black fungus if a covid patient isn’t recovering or rather deteriorating despite the treatment as per the protocol. A CT scan of the chest and microscopic evaluation of bronchopulmonary lavage aspirate is done to check the presence of lung lesions.
Is it contagious?
No, Black Fungus is not contagious and cannot spread from person to person, unlike covid-19.
Will the continued use of masks help?
They can, but only if their cleanliness is maintained. Cautioning against the long-term use of face masks, Dr Chandra said that N-95 masks have to be discarded after 5 uses while cloth masks need to be washed after each use. Masks should not be stored in damp areas as it increases their chances of catching the fungus.
“Rotatory use of masks is preferred, that is, keep one mask for every day of the week and rotate them again,” he added.
Why is the name ‘Black Fungus’ given to the disease?
Dr Thacker explained that one of the micromycetes’, the fungi causing the infection, ways of travel is by the invasion of blood vessels. As circulation to distal organs gets compromised due to this invasion, blood fails to reach these organs and leads to their necrosis or death of tissue. This non-vital tissue then becomes black, giving the disease its name.
How are covid patients more susceptible?
ICUs have humidifiers in the wards that can increase the moisture content in the air. The patients undergoing oxygen treatment here become the perfect host for the fungus as they get exposed to this moisture.
“The fungus takes the window of opportunity, invades the body. This body has a small opening because of Covid, because of the sugars (high glucose levels), because of the antibiotics — because of so many other things, (black fungus) gets a foothold,” Dr Thacker said.
However, the disease is uncommon in non-diabetic people.
How can it be treated?
Antifungal medicines given through IV are often used to treat black fungus. Lysosomal amphotericin B is the drug of choice. Unfortunately, this medicine is largely out of stock in many Indian states, inducing panic and tension amongst people already fighting with coronavirus.
Doctors are also using the conventional Amphotericin B to treat black fungus patients due to the newer version’s shortage. The older variant is much cheaper (Rs 9,000 for a 25-day course) compared to the lysosomal variant (Rs. 30,000).
The latter is hence being reserved for patients with its more severe form but who don’t have kidney-related issues.
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Many patients require surgery where the necrosed part has to be cut. Their upper jaw or mandible and sometimes the eye as well need to be cut away due to it, according to the Indian Health Ministry’s statement.
How common is it in India when compared to the rest of the world?
The disease is 70 times more common in India than anywhere in the world. A lab report in the US’s San Francisco Bay Area of 1992-93 revealed that the annual rate of black fungus there was 1.7 cases per million people.
