Mucormycosis: Before and after COVID-19

Even before the pandemic, the prevalence of black fungus in India accounted for 70 per cent of the global prevalence. The estimated prevalence in India before this pandemic was about 14 cases per 1,00,000 population, according to a health expert

Last year, COVID-19 came as a jolt for India. This year, it has brought mucormycosis to focus. Also known as black fungus, mucormycosis is a rare serious fungal infection caused by the fungus named mucor. It is said that people can come in contact with the black fungus pores that are present in the environment. The disease is not new but it got triggered due to COVID-19 since steroids were used to treat patients with comorbidities suffering from COVID-19, according to health experts.

“Being an opportunistic infection, mucormycosis is triggered by uncontrolled diabetes, indiscriminate steroid use, immune-suppressive drugs like tocilizumab and trauma. Patients with COVID have a weakened immune system, and many of them are given steroids to regulate an over-active immune system. COVID patients are more prone to this infection as a result of these variables. It is an opportunistic fungal infection of nose, paranasal sinuses, eyes and brain termed as Rhino Orbito Cerebral Mucormycosis (ROCM),” informed Dr Syed Asghar Hussain Naqvi, Head – Clinical Services, Dr Agarwal’s Eye Hospital, Telangana.

Sharing similar views as that of Dr Naqvi, Dr Ashutosh Kumar Singh, Senior Consultant, Sharp Sight Eye Hospitals, also told that mucormycosis is a rare fungal infection that usually affects nose, sinuses and orbit of patients who are on immunosuppressant or have uncontrolled diabetes.

“COVID-19 has triggered mucormycosis due to widespread use of steroids in these patients. Other factors responsible for triggering this infection are dysfunctional blood cells and rise of acute phase reactants (like ferritin) in COVID patients. Even before the pandemic, the prevalence of black fungus in India accounted for 70 per cent of the global prevalence. The estimated prevalence in India before this pandemic was about 14 cases per 1,00,000 population,” he explained.

As an eye surgeon, Dr Kasu Reddy’s, Chief Surgeon, founder and mentor, and co-Chairman, MaxiVision Eye Hospitals exposure to mucormycosis, presenting condition in reality, is ROCM, that is when it affects the nose, the eye and the brain.

He said, “Mucormycosis fungus co-existed with us since the beginning of time with the fungus present all around us in the decaying matter and in the soil. However, in comparison to the rest of the world, it is seen more in India due to the prevailing unhygienic conditions and also with diabetes being a major risk factor for the same. In the present COVID-19 conditions, the virus itself is causing hyperglycemia, i.e., diabetes mellitus; and the COVID-19 treatment requires steroids that is like adding fuel to the fire. COVID virus causing diabetes, COVID treatment requiring steroids and steroids again inducing hyperglycemia, leads to reduced immunity and mucormycosis.”

He also highlighted, “Diabetes has always been one of the commonest risk factors to get mucormycosis even before COVID-19 pandemic.”

The impact and treatment

As per Dr Reddy, the impact of mucormycosis can be anything from mild symptoms like black nose, bleeding or discharge from the nose, swollen and protruding eye to removing all the parts inside the nose, including the septum and removing the eye.

“The mucormycosis infection is rare, and not contagious. Nevertheless, in the present pandemic, the sudden surge in the number of cases and the fact that the surgical treatment is debilitating, has made the condition far more recognised by doctors. Unlike COVID-19, the mortality rate is high amounting to about 54 per cent and the mortality distribution is 31.8 per cent in ROCM, 21.2 per cent in disseminated, 17.8 per cent in pulmonary, 14.8 per cent in gastro intestinal, 9.9 per cent in renal and 4.5 per cent in cutaneous cases,” he notified.

Dr Naqvi clarified that COVID-19 is damaging the retina.

“In COVID patients, there are incidences of localised inflammation – what we term retinitis – in addition to the blood vessel obstruction. ROCM can be life-threatening if it is not attended to on time. For proven cases, liposomal amphotericin B is the first line of management. Even if mucormycosis infection affects the eyes, it can be treated with medications or surgery. Many severe cases require a combined approach by ENT surgeon and an eye specialist for extensive debridement of infected nasal cavity, sinuses and exenteration of orbit as a life-saving measure.”

Adding to it, Dr Reddy said that there are two types of treatment for mucormycosis – medical and surgical.

“Medical treatment is hospitalisation to give IV amphotericin B injections and these drugs have side effects. The disease is like gangrene of the feet in diabetes where it affects blood vessels and cuts off blood supply to the tissue killing the tissue matter and the only treatment at that stage is surgical, and we call the surgery as debridement of the black dead tissue. When the nose sinuses are involved, we remove all the internal black part of the nose, including the septum, and if it spreads to the eye, we try our best to save the eyeball and the optic nerve. However, if they are affected, the eye and the surrounding tissues will be completely removed, what we call an exenteration of the eye.”

Saying that the discriminative usage of steroids is definitely one of the major reasons of the spike in black fungus infection, Dr Reddy suggested that it is important to regulate the treatment protocol by the concerned medical authorities whereas amphotericin B usage is in a different context to steroids, and the availability of the drug in the present scenario is a far more serious issue than considering it as a regulated drug.

Dr Singh also stressed that steroids should be judiciously used in COVID patients – only after consulting a physician. Dr Naqvi advised the same.

“Judicious and supervised use of steroids is a must to prevent mucormycosis. Amphotericin B being a life-saving drug needs to be regulated, supplied and administered by authorised personnel only,” emphasised Dr Naqvi.

Some of the states that were highly affected due to mucormycosis include Gujarat, Maharashtra, Andhra Pradesh, Madhya Pradesh and Telangana. Warm and humid climate favours the growth of such fungi, informed Dr Singh.

Could mucormycosis be a hospital acquired infection?

In Dr Naqvi’s opinion, mucormycosis infection is determined by patient’s immune status and the source of infection.

“Contaminated oxygen and humidifiers can be sources of infection in pre-disposed individual. Thereby, it is mandatory to change the tubing regularly and have distilled water in oxygen humidifier to prevent the infection,” he said.

Dr Singh mentioned that mucormycosis has usually been seen in uncontrolled diabetics, immune-compromised patients and patients on steroids. It can’t spread from patient to patient. So, mostly, it is not a hospital-acquired infection.

“In few reports, it has been observed that COVID patients who developed black fungus, about 40-50 per cent of them never get oxygen supplement during treatment. So, oxygen alone cannot be held responsible for mucor infection,” he pointed out.

Dr Reddy cautioned that although mucormycosis outbreaks in the hospital environment are rare, suspicion should exist if black lesions appear next to a post-operative wound.

“Direct tissue examination, culture and histopathology should be performed in such a scenario. Hospital outbreaks can be caused due to adhesive bandages, ventilation systems, wooden tongue depressors, dirty sterile water in oxygen humidifiers and in nebulisation, and too much humidity in ICUs. Thus, sterile water should be used in the humidifiers and frequent change of filters in ventilation systems should be maintained. Besides, masks, especially the disposable type, are important. All post-COVID patients should continue wearing masks for one year,” he warned.

The post-COVID mucormycosis

Dr Naqvi cautioned that mucormycosis, which was not that common before the COVID era, has made us realise the importance of having a balanced and judicious approach to use of medications, failing which a mild fungus can also prove to be deadly.

Dr Reddy also opined that the perception about mucormycosis will definitely change after COVID-19 era since the awareness about the disease has increased. Therefore, people will come early to doctors.

“I am hoping hospitalised patients who got oxygen, diabetics, and those who had steroids, will be more careful after getting discharged. They will keep diabetes under control and consume healthy food to boost their immunity. In addition, it is expected that steroid usage in the future will be better monitored,” he said.

Dr Singh remarked that the incidence of mucormycosis should be significantly declined after the COVID-19’s second wave. The main reason that came up in the first wave was the inappropriate use of steroids. Further, being a rare disease in our country, there was limited production and stock of amphotericin-B.

“We hope our country is preparing well for the third COVID-19 wave and saving enough for black fungus as well,” he quipped.

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