A rare but serious fungal infection, known as mucormycosis and colloquially as “black fungus”, is being detected relatively frequently among Covid-19 patients in some states. The disease often manifests in the skin and also affects the lungs and the brain. With a number of mucormycosis cases detected in Delhi, Maharashtra and Gujarat, experts in the national Covid-19 task force on Sunday issued an evidence-based advisory on the disease.
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Although rare, it is a serious infection. It is caused by a group of moulds known as mucormycetes present naturally in the environment. It mainly affects people who are on medication for health problems that reduces their ability to fight environmental pathogens, say experts from the Covid-19 task force task force.
Sinuses or lungs of such individuals get affected after they inhale fungal spores from the air. Doctors in some states have noted a rise in cases of mucormycosis among people hospitalized or recovering from Covid 19, with some requiring urgent surgery. Usually, mucormycetes does not pose a major threat to those with a healthy immune system.
Warning signs include pain and redness around the eyes or nose, with fever, headache, coughing, shortness of breath, bloody vomits, and altered mental status. According to the advisory, infection with mucormycetes should be suspected when there is:
* Sinusitis — nasal blockade or congestion, nasal discharge (blackish/bloody);
* Local pain on the cheek bone, one-sided facial pain, numbness or swelling;
* Blackish discoloration over bridge of nose/palate;
* Loosening of teeth, jaw involvement;
* Blurred or double vision with pain;
* Thrombosis, necrosis, skin lesion;
* Chest pain, pleural effusion, worsening of respiratory symptoms.
Experts advise that one should not count all cases of blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or Covid-19 patients on immunomodulators. Do not hesitate to seek aggressive investigations for detecting fungal infection, they advise.
While it is treated with antifungals, mucormycosis may eventually require surgery. Doctors have said that it is of utmost importance to control diabetes, reduce steroid use, and discontinue immunomodulating drugs. To maintain adequate systemic hydration, the treatment includes infusion of normal saline (IV) before infusion of amphotericin B and antifungal therapy, for at least 4-6 weeks.
Experts in the task force have stressed the need to control hyperglycemia , and monitor blood glucose level after discharge following Covid-19 treatment, and also in diabetics. One should use steroids judiciously — correct timing, correct dose and duration are important.
Management of Covid patients with mucormycosis is a team effort involving microbiologists, internal medicine specialists, intensivist neurologist, ENT specialists, ophthalmologists, dentists, surgeons (maxillofacial/plastic) and others.
Mucormycosis can lead to loss of the upper jaw and sometimes even the eye. “Patients would need to come to terms with loss of function due to a missing jaw — difficulty with chewing, swallowing, facial aesthetics and loss of self-esteem, doctors say. Be it the eye or upper jaw, these can be replaced with appropriate artificial substitutes or prostheses. While prosthetic replacement of the missing facial structures can commence once the patient stabilises after surgery, doctors it is important to reassure him about the availability of such interventions instead of leaving him to panic with the sudden unforeseen loss, augmenting a post-Covid stress disorder which is already a reality,” said Dr B Srinivasan, a maxillofacial prosthodontist. “Prosthetic reconstruction can be effected after surgery, but interim solutions should be planned even before surgery of the jaws for better long-term outcomes. Prosthetic reconstruction can ensure that the cure is not more dreadful than the disease itself,” he said.
One should remember that it is a rare disease. However, some groups of people are more vulnerable than others. What predisposes patients is uncontrolled diabetes mellitus, immunosuppression by steroids, prolonged ICU stay, and comorbidities — post transplant/malignancy, voriconazole therapy.
Experts advise that you use masks if you are visiting dusty construction sites. Wear shoes, long trousers, long-sleeved shirts and gloves while handling soil (gardening), moss or manure. Maintain personal hygiene including a thorough scrub bath.
While cases are on the rise, there has been no major outbreak. Niti Aayog member (health) Dr V K Paul said at a media briefing that there has been no major outbreak and they were monitoring cases being reported.
In Maharashtra, Dr Tatyarao Lahane, head of the Directorate of Medical Education and Research, has said that cases of mucormycosis are on the rise. “Traditionally we see a case every few months, usually in very poorly controlled diabetic and immunocompromised patients,” said Dr Parikshit Gogate, consulting ophthalmologist at Ruby Hall Clinic, Pune. “But in the past 2 to 3 weeks, I have seen almost 25-30 of them, mostly in Ruby Hall, some in D Y Patil Hospital.”
Mucormycosis developing in post Covid-19 setting breaks the back of a patient’s family that is barely recovering from this viral infection , infectious diseases consultant in Pune Dr Rajeev Soman wrote in the Journal of Association of Physicians of India in January this year.
Dr Soman is one of the expert members who drafted the advisory as part of the national Covid-19 task force. The also task force includes Dr Arunaloke Chakraborti, Head of the Department of Medical Microbiology, PGIMER, Chandigarh; Dr Atul Patel, infectious diseases specialist, Ahmedabad; and several others.
Patients most vulnerable to mucormycosis are those who have been treated with steroids and other drugs for Covid 19 to reduce inflammation. Efforts are underway to collect data for large studies being done by the Fungal Infections Study Forum and Clinical infectious Diseases Society, Dr Soman said.
Mucormycosis, commonly called black fungus, is a rare but serious fungal infection caused by a kind of fungus called mucormycete, which is abundant in the environment. It mainly affects people who have health problems or take medicines that lower the body’s ability to fight germs and sickness.
These include pain and redness around eyes and/or nose, fever, headache, coughing, shortness of breath, bloody vomits, and altered mental status. Warning signs can include toothache, loosening of teeth, blurred or double vision with pain.
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 those who have had an organ transplant.
Use masks if you are visiting dusty construction sites. Wear shoes, long trousers, long-sleeved shirts and gloves while gardening. Maintain personal hygiene including a thorough scrub bath.
It depends on the location of the suspected infection. A sample of fluid from your respiratory system may be collected for testing in the lab; otherwise a tissue biopsy or a CT scan of your lungs, sinuses etc may be conducted.
Mucormycosis needs to be treated with prescription antifungal medicine. In some cases, it can require surgery; it can lead to eventual loss of the upper jaw and sometimes even an eye.