As the second wave of COVID-19 continues to rage across India, some parts of the country have begun witnessing the resurgence of COVID-19-induced “black fungus” cases. This fungal infection, which caused many patients to lose their eyesight last year, has emerged in several hospitals in Delhi and Gujarat this week.
In spite of its prevalence since the beginning of the pandemic, doubts still linger over the nature of this fungal infection. Here are some answers to those doubts and other frequently asked questions:
Q. What is black fungus?
Black fungus, also known as MUCORMYCOSIS, is a rare fungal infection. It is called “black” because of the color of the fungal growth. It is caused by exposure to mucor mold which is found in soil, manure, and rotten/decaying fruits & vegetables. It is ubiquitous, and even present in the nose/mucosa of healthy individuals.
This disease usually affects the sinuses, eye orbit, and brain. That is why it is also called “rhino-orbital-cerebral” mucormycosis. That said, there can be long term involvement.
It may be life-threatening in immunocompromised individuals (cancer patients, HIV/AIDS) and people with uncontrolled diabetes.
According to the Centre for Diseases Control and Prevention (CDC), mucormycosis cases have an overall all-cause mortality rate of 54%. However, this rate varies depending on the underlying patient condition, type of fungus, and the body site affected.
Since the beginning of the pandemic, the black fungus has pushed several COVID-recovered patients back into the ICUs. The infection causes excruciating pain and has even led to blindness among 20-30% of the infected individuals, as per reports. The loss of eyesight is caused when the fungus grows behind the eye, thereby compressing the optic nerve.
Q. What causes black fungus?
This infection is caused by a group of molds called mucormycetes. These fungi are naturally present in the environment, especially in soil and other decaying organic matter like leaves, compost piles, and animal dung.
Since most people come in contact with microscopic fungal spores every day, it is almost impossible to completely avoid these mucormycetes.
But with that said, avoiding direct and close contact with soil, dust, and polluted water could lower one’s chances of developing mucormycosis.
Q. Who can get infected by black fungus?
For most people with functional immune systems, black fungus presents no threat.
With that said, individuals with low immunity are particularly vulnerable to this fungal infection. In fact, it has been a cause of disease and death for transplant and ICU patients for a long time.
In the current scenario, the infection is especially affecting COVID-19 patients with weakened immunity and high blood sugar. COVID-positive individuals with added comorbidities like diabetes, cancer, and kidney or heart failure, along with COVID patients that are being treated using steroids, also feature on the list of rapidly rising black fungus cases of late.
Q. How does the fungal infection spread?
Mucormycosis is not contagious, and therefore, it cannot transmit between people and animals. Individuals contract this infection by coming in contact with the fungal spores in their environment.
If inhaled, the spores can infect the lungs or sinus. If the fungus enters the skin through a cut, scrape, burn, or other types of skin trauma, mucormycosis can also develop on the skin. The infection can subsequently spread to the bloodstream, and reach organs like the brain, heart and spleen as well.
While most cases of mucormycosis are sporadic, outbreaks of mucormycosis have occurred in the past. In healthcare settings, healthcare-associated mucormycosis outbreaks have been linked to adhesive bandages, wooden tongue depressors, hospital linens, negative pressure rooms, water leaks, poor air filtration, non-sterile medical devices, and building construction.
Community-onset outbreaks have also been associated with trauma sustained during natural disasters.
Q. What are the symptoms of mucormycosis?
According to the CDC, the symptoms of mucormycosis depend on where the fungus is growing in the body.
For rhinocerebral (sinus and brain) mucormycosis, the symptoms are one-sided facial swelling, headache, nasal or sinus congestion, fever, and black lesions on the nasal bridge or upper inside of the mouth that quickly become more severe.
For pulmonary (lung) mucormycosis, the symptoms include fever, cough, chest pain, and shortness of breath.
Early recognition and diagnosis of this infection, followed by prompt administration of appropriate anti-fungal treatment, are crucial for improving outcomes for patients with mucormycosis.
Q. How can black fungus be treated?
As per the CDC, this serious infection needs to be treated with prescription anti-fungal medicine, usually amphotericin B, posaconazole, or isavuconazole. These medicines can be taken orally or through IV. The infection often requires surgery to cut away the infected tissue.
Q. What are the risk factors for acquiring black fungus?
Risk Factors are:
Uncontrolled Diabetes Mellitus
Treated for COVID-19 with corticosteroids
Treated for COVID-19 with immunomodulators
Treated for COVID-19 with mechanical ventilation
Prolonged oxygen therapy
Prolonged ICU stay
Immunocompromised state
Q. Why are sudden increase in black fungus cases?
It may be triggered by extensive use of steroids, which is a life-saving treatment for moderate to severe COVID-19 infection. Steroids lower the immunity and also cause a sudden up-shooting of blood sugar levels in diabetics as well as non-diabetic patients.
For patients on humidified oxygen, care should be taken to make sure there is no water leak, to prevent the growth of the fungus.
Q. How serious is this black fungus?
It is a vision-threatening and life-threatening condition. A high index of suspicion is very important here
Q. Do all Covid-19 positive patients need to be worried about black fungus?
No.
As discussed, high-risk patients need to be alert. Also, while covid recovery everyone should watch out for early signs and symptoms as I will discuss further in this video.
2 To 3 weeks post-recovery is when the patients are presenting to us.
Q. What precautions one should take to avoid black fungus?
Boost immune system- diet, hydration and exercise.
Rational use of steroids- follow guidelines.
Strict Blood sugar monitoring and control in all patients who are on steroids.
Q. What are early signs of black fungus?
Facial pain
Facial swelling/puffiness/discoloration
Sinus headache
Stuffy nose
The blurring of vision/decreased vision
Double vision
Drooping of eyelid
Blood stained nasal discharge
Dental pain
Q. Is black fungus treatable?
Yes. Early diagnosis and prompt multi-specialty team management both medical and surgical is a must step.
Q. Which specialist should I visit for black fungus?
ENT and eye specialists are central to this disease. The team includes care coordination with neurosurgeon endocrinologist and microbiologist.
Q. What regions does it involve?
It generally involves the sinuses, oral cavity, palate and teeth, EYE and eye socket, and in severe infections could involve the brain and the lungs
Q. How bad is this infection?
The infection is deadly with only 50% of the patients living despite aggressive treatment.
Q. How does this infection spread?
This infection spread through blood vessels causing death and decay of the tissues. The involved tissue turns black with complete loss of function and vitality (for example loss of vision and significant facial destruction).
Q. What investigations do I need?
Other than Blood investigations you will need a CT scan and an MRI to know the extent and severity of the disease
Q. How is this disease treated?
The treatment should be done by a multidisciplinary team of doctors involving, ENT surgeons, EYE doctors, neurologists, Kidney specialists, and medical specialists.
it requires both surgical and medical treatment often for a very long time.
Q. What kind of surgery is done?
Surgery is often aggressive with the removal of involved tissues for example; eyeball and eye socket, bones of the nasal cavity, and the oral cavity leading to disfiguring sequelae
Q. Can the only medical treatment be given for this condition?
Medical treatment alone may not suffice as patients will require aggressive SURGICAL treatment with anti-fungal medications given through the veins for many days.
Q. What is the cost of treatment?
Although the cost of surgical treatment is standardized some patients require multiple surgeries to save their life
Treatment with an intravenous anti-fungal agent (normally Liposomal Amphotericin B) will cost you approximately 15 to 20 thousand rupees per day. This treatment may be for 10 to 30 days. Some require other medications for a long time to control the infection. (like anti-diabetic treatment, oral anti-fungal medication).
Q. What are my chances of survival?
When the disease is picked up in the early stages there is a good chance of survival. One in 2 patients may survive despite BEST treatment.