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Dip in Covid cases post peak, long-term use of steroid, BiPAP & high-flow oxygen possibly behind mucormycosis rise: Experts

More than 400 patients are currently undergoing treatment at major government hospitals in Ahmedabad, Rajkot, Vadodara, Surat and Jamnagar, even as experts are yet to understand why Gujarat is reporting higher mucormycosis cases than other states.

Written by Sohini Ghosh , Aditi Raja , Kamaal Saiyed | Ahmedabad, Surat |
Updated: May 11, 2021 10:19:53 pm
At least 110 mucormycosis patients are currently undergoing treatment at Ahmedabad Civil Hospital too against the just 15-20 patients the hospital would see in pre-Covid times. (PTI/File)

AN ALARMING rise in mucormycosis, a fungal infection, as a post-Covid-19 complication or as an additional infection, in Gujarat has emerged as a new challenge for patients already struggling to get access to medicines and doctors.

More than 400 patients are currently undergoing treatment at major government hospitals in Ahmedabad, Rajkot, Vadodara, Surat and Jamnagar even as experts are yet to understand why Gujarat was reporting higher mucormycosis cases as compared to other states.

Dr RS Trivedi, the medical superintendent at PDU Hospital in Rajkot, told The Indian Express on Monday that the hospital was currently treating 150 mucormycosis patients while it has provisioned a total 250 beds for such cases.

A part of the national taskforce for Covid-19 specifically guiding on mucormycosis, Dr Trivedi said, the fungal infection affected tissues and bones and could lead to a rapid decay in the flesh, and so antifungal treatment combined with surgical intervention was a preferred choice of treatment in such cases.

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“On average we are conducting six to seven surgeries a day. Resources as well as manpower are limited. We have arranged for private practitioners to render their services for limited duration at our hospital. Treatment requires antifungal drug involved before, during, and after infection with a prescribed 21-day course, and administering (antifungal drug- Aphotericin B) injections four to five times a day. One injection costs Rs 7,000 (in liposomal form) and right now there is a shortage in across Gujarat, requiring procurement from Bengaluru,” he said.

According to Dr Trivedi, possible reason behind the spike in mucormycosis, especially in Gujarat vis-a-vis other states, “could be because Gujarat has almost peaked in its second wave and we are thus seeing a greater number of cases of mucormycosis as a post-Covid complication. I suspect, a similar pattern might emerge in other states as well once they are out of their peak. It is also possible that we are diagnosing it earlier than other states”.

Ahmedabad-based infectious disease specialist Atul Patel, who is a part of the national taskforce which has designed an evidence-based advisory for mucormycosis in times of Covid-19, as issued by ICMR, responding to a query on the high incidence of mucormycosis cases in Gujarat as against other states, said “a large number of mucormycosis cases in Covid (patients) are reported from Chennai, Bengaluru, Hyderabad, Chandigarh, Christian Medical College in Vellore and other parts of India”.
Adding that it was subject to research as to why a similar spurt in the fungal infection was not seen post the first Covid-19 wave, Dr Trivedi said, “…There may be some relation with the changes (mutations) in the virus and its changed behaviour (in the second wave).” Dr Trivedi also pointed out that more patients required breathing masks and apparatus in the second wave and the region often remained moist. “Plus, we also realised that this could also have happened because the masks and apparatus were being cleaned with tap water till now. We are now cleaning this with distilled water,” he added.

In Jamnagar, Dr SS Chatterjee, the nodal Covid-19 officer at Guru Gobind Singh Government Hospital, said the cases of the fungal disease post the second Covid-19 wave had drastically gone up from a maximum of 15 cases recorded in a year. Over the last two weeks, Jamnagar has reported at least 45 patients – 39 at the GG Hospital and five to six others at the Government Dental College.

At MP Shah Medical College, affiliated to the GG Hospital, dean Dr Nandini Desai claimed that most patients were yet to be clinically diagnosed with mucormycosis as the specific microbial fungal culture can take up to 15 days. Biopsy, results for which are out in two to three days, and a less-specific KOH test are also being used to diagnose such patients, she added.

Long-term use of steroid, coupled with higher requirements of BiPAP and high-flow oxygen, Dr Desai and Dr Chhaterjee hypothesise, could be a probable reason for the recent spike.

Dean of Government Dental College in Ahmedabad Dr Girish Parmar, who is also a part of the national taskforce, dubbed the spurt as “exponential”. From few mucormycosis patients in pre-Covid years, the hospital has conducted 60 surgeries on mucormycosis patients post the outbreak in March 2020 until now. Currently, 30 more patients are admitted at the hospital. “Our ward had a 22-bed capacity but we have now expanded it to now accommodate 30 patients,” Dr Parmar said.

At least 110 mucormycosis patients are currently undergoing treatment at Ahmedabad Civil Hospital too against the just 15-20 patients the hospital would see in pre-Covid times. A hospital official admitted there was also a shortage of liposomal form of Aphotericin B injection, especially used in those with compromised immune system — such as patients with cancer, HIV or abnormal kidney function.

At Vadodara’s SSG hospital, 43 patients are admitted for mucormycosis treatment at present. The hospital has seen a total of 75 cases of mucormycosis since the outbreak of Covid-19 last year, of which 70 cases have been reported since March this year. Of these, 21 patients have succumbed — a mortality rate of 28 per cent.

Dr Ranjan Aiyer, ENT surgeon and medical superintendent of SSG hospital, said the death rate for cases that were operated upon for debridement was 10 per cent while those patients, who have been unable to undergo surgery due to their incapacity to withstand general anesthesia, have reported 90 per cent mortality.

Early diagnosis and treatment are the keys to recovery, Dr Aiyer added. “At SSG, we have performed at least four orbital exenterations, so far. The patients are generally not willing to consent to the same but they end up arriving in the hospital at a stage where the infection has spread to the orbital region and there is no other solution other than removal to attempt for survival,” he said.

“Earlier, we were witnessing cases in people above 55 years mostly with pre-existing conditions of diabetes; steroids and the use of Tocilizumab to control Covid-19 have been leading to an adverse imbalance in the autoimmune systems. But now, we are seeing younger patients, not necessarily with diabetes, developing mucormycosis,” Dr Aiyer added.

In Surat, at least 40 patients are undergoing treatment at present, medical superintendent of New Civil Hospital (NCH), Dr Raghini Verma said, “We have made a separate ward for mucormycosis patients in NCH and 10 patients are undergoing treatment here. These patients had taken Covid-19 treatment from private hospitals and were admitted at NCH post recovery. There are 10 other patients who are under suspicion.”

At Surat’s Kiran Hospital, Dr Hardeep Maniyar said, “There are 30 patients who are admitted at our hospital and their condition is not critical. They are at recovering stage.”

On Monday, Dr Tejas Patel, an Ahmedabad-based cardiologist cautioned while “diabetes is an important risk factor, it doesn’t mean that if diabetes is not there mucormycosis won’t happen”.

In a 2021 a review, titled ‘Epidemiology of Mucormycosis in India’, published in the journal ‘Microorganisms’, it was noted that while exact incidence and prevalence of mucormycosis in the Indian population remains unknown, in the absence of population-based studies, it was hypothesised that the estimated prevalence in India is much higher than that in developed countries and possible reasons for the same could be “the abundant presence of mucorales in the community and hospital environment, large number of susceptible hosts, especially diabetics, and the neglect for regular health check-up that left people with undetected diabetes”.

Apart from diabetes, the review concluded that “other emerging risk factors of mucormycosis were pulmonary tuberculosis, chronic kidney disease, and critically ill patients”. The review also found that other “predisposing factors associated with mucormycosis in India are chronic kidney disease (CKD), steroid therapy, pulmonary tuberculosis, and chronic obstructive pulmonary disease (COPD),” with chronic kidney disease being “a new risk factor for mucormycosis”.

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