How Risky is Black Fungus? What are the Symptoms and Treatment?

COVID-associated black fungus has especially affected individuals in India. The association also appeared in Russia. One elaboration for why the association has surfaced remarkably in India is high rates of COVID infection and high rates of diabetes. In the month of May 2021, the ICMR issued guidelines for the recognising and treating COVID-associated black fungus.

Due to its rapidly growing number of cases, the Government of Rajasthan declared it an epidemic on 19’th May 2021. Along with the government of Rajasthan, the Tamil Nadu, Haryana, Telangana, Bihar and Gujarat governments have also now declared this an epidemic.

What is Black Fungus?

Black Fungus commonly referred to as Mucormycosis is a very rare infection. It is caused by exposure to the mucor mould, found in the plants, soil, manure, and decaying fruits and vegetables. It is ubiquitous and found in the soil and air and even in the nose and mucus of healthy individuals.

It specifically affects the sinuses, the brain and the lungs and can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS.

Specialists suggest the fungus, which has a 50 % of overall mortality rate, may be being triggered by the use of steroids, which is a life saving treatment option for severe/critically hospitalized patients with COVID-19. 

Steroids are involved in reducing the lung inflammation for COVID-19 and appear to be effective for preventing some of the damage that happens when the body’s immune system goes into overdrive in order to fight off coronavirus. But they are also responsible for reducing the immunity and increasing blood sugar levels in diabetics as well as non-diabetic COVID-19 patients. It is believed that this reduction in immunity is responsible in order to trigger these cases of Black Fungus.

Diabetes is responsible for lowering the body’s immune systems, coronavirus exacerbates it, and then steroids which help fight COVID-19 act like fuel to the fire.

Use of typical tap water in the flow meters of oxygen cylinders is also being blamed for such fungal infections. Cases of this condition may be triggered by the mold tainted oxygen pipes as well as humidifiers.

What are the symptoms of Black Fungus?

According to the Indian Council of Medical Research (ICMR), certain early symptoms of the black fungus include: sinus pain or nasal blockage on one side of the face, swelling or numbness, one-sided headache, toothache and loosening of teeth.

On behalf of reports from various top hospitals across India, blurred vision, discoloration or blackening of the tissue on the nose and cheeks and black lesions inside the mouth or discharge from the nose are certain other reported symptoms. 

Which group of people are at higher risk of black fungus?

Medical science suggests, diabetes patients are more vulnerable to fungal infections such as mucormycosis. So are immuno-suppressed individuals who have been recently cured of COVID-19.

Specific care is needed for COVID patients who are also diabetic. Indian Council of Medical Research suggests that controlling diabetes is the effective preventive measures for Black Fungus.

According to the Union Health ministry, “The Black Fungus is being majorly detected in those individuals who have recovered from the COVID, or are recovering.” In absence of treatment, black fungus can lead to lethal bloodstream infection.

How are black fungus treated?

Once an individual gets infected, the fungus doesn’t remain static but spreads through the nose, attacks the eyes, and eventually reaches the brain, it becomes completely deadly. This necessitates multi-discipline expertise to treat it. In maximum cases, especially if undetected for long, a number of different parts end up getting affected due to mucormycosis. So it calls for a combined team of microbiologists, intensivist neurologists, internal medicine specialists, ophthalmologists, ENT specialists, surgeons, dentists etc.

As part of life-saving procedures, all infected tissues need to be surgically eliminated. A few patients end up losing the eye/s and, in minor cases, the upper jaw. Patients might require an intravenous anti-fungal procedure spanning 4-6 weeks.

How risky is Black Fungus?

The rate of fatality in the cases of Black Fungus is quite high. As per existing data, mortality is as high as 80% if a patient goes untreated, or remains untreated for a longer period of time. If treated, it is still 40 to 50%. In cases where the black fungus is detected at the sinus stage itself, patients mostly completely recover.

In addition, specialists suggest drugs used in order to treat this condition come with strong adverse reactions. That can, in minor cases, lead to kidney issues, neurological dysfunction and stroke.

What Predisposes:

• Prolonged ICU stay
• Voriconazole therapy
• Uncontrolled diabetes mellitus
• Co-morbidities: post transplant or malignancy
• Immunosuppression by steroids

How to Prevent:

• Prefer masks in case you are visiting dusty construction sites
• During gardening, moss or manure, always wear long sleeve shirts, long trousers, shoes, and gloves
• Maintain personal hygiene including thorough scrub bath

Dos:

• Control hyperglycemia
• Use antibiotics/antifungals judiciously
• Monitor the level of blood glucose post COVID-19 discharge and also in diabetics
• Consider steroid judiciously: apt timing, apt dosage and duration
• Consider clean, sterile water for humidifiers while on oxygen therapy

Dont’s

• Avoid missing the warning signs and symptoms
• Avoid considering all the cases with blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators
• Avoid hesitation in order to seek the aggressive investigations, as appropriate (KOH staining & culture, microscopy, MALDI-TOF), for detecting the fungal etiology
• Do not waste crucial time in order to initiate the treatment for black fungus or mucormycosis

How to Manage:

• Control your diabetes and diabetic ketoacidosis
• Discontinue the administration of immunomodulating drugs
• Reduce steroids (in case patient is still on) with aim to halt rapidly
• Extensive Surgical Debridement: in order to eliminate all the necrotic materials
• No antifungal prophylaxis required
• Medical treatment:
  1. Install peripherally inserted central catheter (PICC line)
  2. Maintain adequate systemic hydration
  3. Infuse Normal saline IV prior to the Amphotericin B infusion
  4. Antifungal Therapy, for at least 4 to 6 weeks
• Assess patients clinically and with radio-imaging for the response and to detect the disease progression

Reference:

https://www.india.com/health/black-fungus-why-is-it-dangerous-and-how-to-protect-ourselves-from-it-doctor-explains-4677817/

https://indianexpress.com/article/explained/mucormycosis-black-fungus-covid-patients-explained-quixplained-7323887/