CASE STUDY
Mucormycosis has increasingly been seen in Covid positive and recovered patients, among others, of late. Recovered patients are advised to stay in contact with doctors and immediately inform them in case of black fungus-related symptoms, asserts top doctors and health experts. Early detection will aid prompt treatment of this fungal disease.
A rare fungal infection affecting 1 in 10 lakh people, mucormycosis or black fungus is gradually taking the country into its grip. What is this black fungus? How does it spread in the body? Is there any link between mucormycosis and Covid-19? Top doctors and health experts answer common queries ranging from signs and symptoms to causes to prevention and treatment.
There is no official number of mucormycosis cases in India; however, estimation of fungal burden in India using computational models by international health experts predicts around 1,750 to 2,500 cases of mucormycosis daily in India. This is just a predictive model so the actual number may be higher.
Dr Atul Mittal, Director & HoD, Department of ENT, Head & Neck Surgery, Fortis Memorial Research Institute, Gurugram; Dr Manjunath Malige, Chief Endocrinologist and Diabetologist, Aster RV Hospital, Bengaluru; Dr Behram Pardiwala – Internal Medicine, Wockhardt Hospital Mumbai Central; Dr Deepak Jaiswal, Consultant Physician and Incharge Covid Care, Shri Balaji Hospital, Raipur; Dr Santosh Sivaswamy, Consultant – ENT, Columbia Asia Hospital Hebbal (A unit of Manipal Hospitals), Bengaluru; Dr ChandraVeer Singh, Consultant, Otorhinolaryngologist and Head & Neck Onco Surgeon, Wockhardt Hospital Mira Road, Mumbai; Dr Sanjay Dhawan, Director & Head – Ophthalmology, Max Super Speciality Hospital, Delhi and Gurugram; Dr Amitabh Malik, Chief, ENT Department, Paras Hospitals, Gurugram; Dr Mubasheer Ali, Senior Internal Medicine Consultant, Apollo TeleHealth; and Dr Bhavika Verma Bhatt, Consultant ENT Surgeon and Medical Consultant- ENTOD International share all that they know about black fungus.
Q. What is black fungus? What causes it? How is it linked with Covid-19?
Dr Atul Mittal: Mucormycosis or Black Fungus is a rare fungal infection that affects the sinuses, the brain, and the lungs. It can be life-threatening in diabetic or severely immune-compromised individuals such as cancer patients or people with HIV/AIDS.
In the current scenario, the infection is especially affecting Covid patients with weakened immunity due to comorbidities like diabetes, cancer, and kidney or heart failure. Steroids are the cornerstone of Covid treatment, helping to reduce inflammation in the lungs and appear to help stop some of the damage that can happen when the body’s immune system goes into overdrive, referred to as cytokine storm, to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid patients. It’s thought that this drop in immunity could be triggering these cases of mucormycosis.
Q. What are the warning signs and symptoms of this fungal infection? Which organs can it infect?
Dr Manjunath Malige: During the second wave of the Covid-19 pandemic, it has been found that there is a sudden increase in the cases of mucormycosis across the country. Some of the early symptoms are obstruction in the nose, unexplainable headache even after post-Covid recovery, pain in the teeth, numbness in the face, vision difficulties or loss of vision, local pain in ear, nose or orbital region, nose blocks experienced more towards one side, etc. In case a Covid positive patient experiences any of these symptoms, he/she must inform the treating doctor so that intervention measures can be introduced at the earliest. This infection mainly affects the sinus cavity and lungs and can spread to the brain. In some cases, if left untreated, it can affect the digestive system, heart, skin, or other organs in the body. Once you overcome the disease and are Covid-free, please do stay in touch with your endocrinologist to ensure that your health is well-monitored and there is no risk of developing severe mucormycosis.
Q. What is the possible reason behind the increasing number of mucormycosis cases in the country? What can be done to curb its spread?
Dr Behram Pardiwala: In Covid-19 we use steroids as part of therapy and it worsens preexisting diabetes. This is a very good nidus for the black fungus to grow. The only way that you can prevent the black fungus from growing is to control the patient’s diabetes very strictly. Further, one must have a high degree of suspicion for the existence of the fungus and look out for it in almost all diabetics. And when the black fungus is diagnosed it is imperative that you hit it very hard with appropriate drugs before it is allowed to spread.
Q. How can the possibility of black fungus be stalled amongst Covid-19 patients—both who are being treated and those who have recovered?
Dr Deepak Jaiswal: The chances of this fungus infection have increased in patients with weak immune systems, on long term immunosuppressive drugs and steroids, Covid-19 positive and diabetic. Such patients can get affected by mucormycosis. There is nothing like all Covid positive patients will be affected. In case you get infected by it, proper diagnosis and treatment are crucial. If any Covid patient experiences any black fungus-related symptoms, then they should consult the doctor immediately. Mucormycosis is a medical emergency with high morbidity and mortality. A team approach is required with specialist microbiologist, histopathologist, intensivist, neurologist, ENT specialist, ophthalmologist, dentist, surgeon and radiologist.
Q. Can you tell us about the people who are more prone to developing mucormycosis? Can they take any precautions?
Dr Santosh Sivaswamy: Mucormycosis is a deadly fungal disease. With increasing Covid-19 cases, we are witnessing a lot of patients coming to us with mucormycosis condition post-Covid-19 infection. We had seen quite a few cases during the first Covid wave as well. This infection can develop when there is an increase in the usage of steroids and uncontrolled diabetes. Not only do these two factors contribute to the occurrence of the mucormycosis, but other factors like age, high ferritin levels in the blood, usage of unrationalised antibiotics, and the rate of overall immunosuppression of the patients can also lead to this infection. The incidence of mucormycosis is most commonly seen in the coastal belts and people with uncontrolled diabetes. A hot and humid climate is one of the reasons to develop this infection. To prevent patients from developing this infection, it is advised to avoid high steroid dosages, blood sugar control, Covid-appropriate behaviour, and rationalised use of antibiotics.
Q. What is the treatment for this fungal disease?
Dr ChandraVeer Singh: Antifungals Amphotericin B and surgical debridement wherein surgery is done to remove all fungus debris help treat the black fungus. Steroids and globulins can also help tackle the infection. However, the treatment may vary from person to person.
Q. Is mucormycosis also affecting young people?
Dr Bhavika Verma Bhatt: No, mucormycosis is rare, but it’s more common among people who have health problems or take medicines that lower the body’s ability to fight germs and sickness. Black fungus generally affects Covid-19 recovered patients who have other comorbidities like diabetes, kidney or heart failure, cancer as well as patients who are on steroids or have had a transplant, irrespective of their age. However, it is most common in diabetic patients, as per the Centers for Disease Control and Prevention (CDC) of the United States.
Dr Mubasheer Ali: There is no specific age group who are more susceptible but mainly it affects people with diabetes mellitus and other immunodeficiency disorders. Though there is no official number of mucormycosis cases in India, estimation of fungal burden in India using computational models by international health experts predicts around 1,750 to 2,500 cases of mucormycosis daily in India. This is just a predictive model so the actual number may be higher.
Dr Amitabh Malik: It is affecting young people also with all age groups, who have recovered from Covid-19. Vulnerable groups include people who have health problems or take medicines that lower the body’s ability to fight germs and sickness. These include those with diabetes, cancer, or people who have had organ transplants.
Q. What can be the repercussions if this fungal disease spreads to the lungs?
Dr Sanjay Dhawan: In the cases that I have come across and treated so far, it hasn’t reached the lungs. The Black fungus is an opportunistic pathogen that affects and invades the body only when its defences are low, otherwise, it will not as this fungus is always there in the environment at all times. It starts spreading from the nasal sinus and move upwards to the eyes and then the brain. The fungus forms a layer on the surface of paranasal sinus walls (hollow air spaces), it doesn’t go into the tissues directly. It first grows in the walls of the sinuses and from there it starts taking nutrition from the walls of sinuses and begins invading the blood vessels, causing blockage in blood vessels and thereby deriving nutrition for itself. It doesn’t go into the tissues directly. This is also the reason why the drugs given or even injected intravenously do not reach the body of the fungus and thus, surgical debridement is needed. We are using a new technique at our hospital whereby we are able to save the eyeball and structures around the eye to some extent, we introduce a special device into the orbit and directly deliver the drug into the orbit. But it is possible only in early cases and not in advanced ones. After surgical debridement, we treat the patients with an intravenous high dose of antifungal drugs that are quite toxic.
Q. In what scenario do you have to surgically remove the eye or the jaw bone to stop the spread of the black fungus?
Dr Ali: Aggressive repeated surgical debridement, in combination with appropriate antifungal therapy, proves successful in most of the cases of mucormycosis. Appropriate surgical intervention prevents ascending dissemination of mucormycosis and certainly reduces the risk of patient mortality as a direct result. In the present scenario where mucormycosis has a high mortality rate, anti-fungal therapy should be used secondarily or as an adjunct together with surgical debridement, or as an alternative when surgical intervention is not feasible.
Rhinocerebral or rhino-orbito cerebral (mucormycosis) usually occurs among patients with poorly controlled diabetes mellitus (especially those with ketoacidosis), in patients undergoing treatment with glucocorticosteroid agents, or in post-Covid patients who were on immune modulators and long term oxygen therapy. The fungus may spread to invade the palate, sphenoid sinus, cavernous sinus, orbits, or cranially to invade the brain. Pain and swelling precede oral ulceration and the resulting tissue necrosis can result in palatal perforation. Infection can sometimes extend from the sinuses into the mouth and produce painful, necrotic ulceration of the hard palate. If untreated, infection usually spreads from the ethmoid sinus to the orbit, resulting in the loss of extraocular muscle function and proptosis. Surgical treatment includes the resection of involved tissues of the face, including skin and muscle, any skin of the nose that is involved, maxillary and ethmoid sinuses, necrotic tissue of the temporal area and infratemporal fossa, and orbital exenteration along with the mandibular part. The keys to successful therapy include early diagnosis and early recognition of the signs and symptoms and complications, correction of underlying medical disorders and quick surgical intervention. An aggressive surgical approach has appeared to enhance survival in many scientific studies conducted.
Dr Bhatt: While it is treated with antifungal drugs, mucormycosis may eventually require surgery. This disease affects the tooth, eye, and sinus. Involvement of the eye is an advanced stage that starts affecting the nervous system, thus the removal of the eye takes place.
So, it is of utmost importance to control diabetes, reduce steroid use, and discontinue immunomodulating drugs. To maintain adequate systemic hydration, the treatment includes an infusion of normal saline (IV) before the infusion of amphotericin B and antifungal therapy, for at least four to six weeks.
Dr Malik: The eye is cosmetically preserved but the dead tissue is removed around the eyeball in the Endoscopic Endonasal approach which is currently being practised. Removal of Jawbone is done if the disease spread involves the bone.
Q. What are your views on the severity and the frequency of this disease?
Dr Malik: Mucormycosis, has an overall mortality rate of 50%, maybe triggered by the use of steroids, a life-saving treatment is done in case of severe and critically ill Covid-19 patients with this disease. Steroids reduce inflammation in the lungs for Covid-19 patients and appear to help stop some of the damage that can happen when the body’s immune system goes into overdrive to fight off the virus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients. The drop in immunity could be triggering these cases of mucormycosis.
Dr Ali: Complications of mucormycosis can be dire: blindness, organ dysfunction, loss of body tissue due to infection and debridement, and death. Its prognosis (outcomes) range from fair to poor. So the early detection of the signs and symptoms and early intervention will have a better outcome.
Dr Bhatt: Eight out of 200 patients treated so far in various parts of Maharashtra have died due to black fungus. They survived Covid-19 but the fungal infection attacked their weak immune system which proved fatal.
Also, Delhi’s Sir Ganga Ram Hospital has reported a rise in the number of Covid-induced mucormycosis cases. Sir Ganga Ram Hospital in New Delhi reported over 15 cases of mucormycosis amongst patients on the path to recovery who had been admitted to the Covid-19 ward.
In Gujarat, more than 100 cases of black fungus have been notified across state government hospitals and Gujarat Medical Education Research Society (GMERS) hospitals. Currently, Ahmedabad’s Zydus Hospital has around 40 such patients while Vadodara’s SSG hospital is treating 35 patients.
We had a Covid-19 patient who was a diabetic and on admission, his fasting sugar was around 200 and post-lunch it was 300 and HbA1c 9.6. He had temperature also and we started giving him remdesivir immediately and also started giving him rapid-acting insulin. The saturation on admission was about 97-98 with two litres of oxygen on the first day. By the second day, oxygen came down further and the patient still had a high temperature. Under these circumstances, we decided to shift him to ICU overnight as he was deteriorating rapidly. We gave him a high flow of nasal oxygen. With the high flow of nasal oxygen, gradually the patient started improving, we continued with the insulin and brought the sugar under control. After 72 hrs in ICU, we shifted him to a ward where we maintained nasal prong oxygen and his saturation was about 96-97% with two litres of oxygen. Gradually it improved until the three-minute walk showed a saturation of 97%. At the time of discharge, he had a headache. But after the discharge, he started complaining about pain in the head and behind the eye, which was alarming. We called him in immediately. His eye was red. We did a CT Scan immediately, we discovered that he had mucormycosis. His sugar at that time was a little high and we got him admitted and started giving him intravenous amphotericin for 15 days and he recovered rapidly. A repeat scan showed almost complete resolution, shares Dr Behram Pardiwala – Internal Medicine, Wockhardt Hospital Mumbai Central.