CHEARS

Even as a deadly second wave and upcoming third wave of Covid-19 ravages India, doctors are now reporting a rash of cases involving a rare infection - also called the "black fungus" - among recovering and recovered Covid-19 patients.  The issue of post COVID-19 sepsis has emerged as a significant problem. India bears the dubious distinction of being the diabetes, as well as the mucormycosis, ‘capital’ of the world. COVID -19 and its treatment, against this backdrop, amounts to a recipe for disaster.

WHAT IS MUCORMYCOSIS?

Mucormycosis is a very rare infection. It is caused by exposure to mucor mould which is commonly found in soil, plants, manure, and decaying fruits and vegetables. It 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. According to the US Centre for Diseases Control and Prevention (CDC), mucormycosis or "black fungus" infection is caused by a group of molds called mucormycetes that are widely found in the environment.

Doctors believe mucormycosis, which has an overall mortality rate of 50%, may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients.

Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients.

It's thought that this drop in immunity could be triggering these cases of mucormycosis.

GROUPS OF PEOPLE WHO ARE MORE LIKELY TO GET MUCORMYCOSIS:

• Diabetes, especially with diabetic ketoacidosis

• Cancer

• Organ transplant

• Stem cell transplant

• Neutropenia

• Long-term corticosteroid use

• Injection drug use

• Too much iron in the body (iron overload or hemochromatosis)

• Skin injury due to surgery, burns, or wounds

• Prematurity and low birthweight (for neonatal gastrointestinal mucormycosis)

HOW DOES MUCORMYCOSIS ENTER ONE'S BODY?

People get mucormycosis through contact with fungal spores in the environment. Mucormycosis infections can occur if someone inhales the spores from the air or if the fungus enters the skin through a scrape, burn, or other type of skin injury.

1. Symptoms of sinus and brain mucormycosis are :

• One-sided facial swelling

• Headache

• Nasal or sinus congestion

• Black lesions on nasal bridge or upper inside of the mouth that quickly become more severe

• Fever

2. Symptoms of lung mucormycosis are:

• Fever

• Cough

• Chest pain

• Shortness of breath

3. Symptoms of skin mucormycosis are:

• Skin mucormycosis on the skin often looks like blisters or ulcers. The infected area may turn black.

• Pain

• Warmth

• Excessive redness

• Swelling around the wound

The symptoms of mucormycosis or black fungus usually appear two-three days after a person has recovered from the Covid-19 infection. In some cases, the infection appears during recovery.

From the sinus, the infection takes about two-four days to invade the eyes

RISK FACTORS:

Not all people who have contracted coronavirus infection and are on treatment for COVID-19 obtain mucormycosis. Certain individuals are more prone to getting affected by the fungal infection, such as:

• People with diabetes mellitus who are unable to keep blood sugar levels within the normal range

• Persons with comorbid conditions taking immunosuppressant steroid medications to manage pre-existing illnesses as well as COVID-19, over an extended length of time

• Being treated in the Intensive Care Unit i.e. ICU wing of hospitals for a prolonged interval of time

• Having a vulnerable immune system that is weakened owing to comorbidities such as previous organ transplant surgeries or cancer therapy procedures

• Already taking prescription antifungal drugs to combat infections

TREATMENT:

Treatment principles include antifungal agents, surgical debridement, reversal of underlying predisposing factors and adjuvant therapy. Amphotericin B has been the standard of treatment for invasive mucormycosis. COVID-19 patients may have developed acute or chronic renal failure which may be mitigated by switching to a less- or non-nephrotoxic alternative. Therefore Posaconazole or Isavuconazole may have to be used. The latter has the added advantage of shortening the QT interval which may have been affected by HCQ, Azithromycin which many patients still continue to receive. Surgical debridement, the earlier the better, is pivotal in the management of mucormycosis. The optimal time of surgery to reduce the operative risk to the patient with COVID-19 and the risk of transmission to the operating team is a contentious issue. Replication competent virus has not been recovered from patients with mild to moderate illness after ten days, from patients with severe illness after fifteen days or from any critically ill patient after twenty days.

Adjuvant therapy with caspofungin, deferasirox, statins, aspirin, and hyperbaric oxygen may have to be considered. Mucormycosis needs to be actively managed by a team which includes members from almost all departments in the hospital. Therapy is toxic and very resource intensive. In a recent Indian study, 24.3% patients left the hospital against medical advice due to the anticipated cost, morbidity of surgery and prognosis.

HOW TO PREVENT MUCORMYCOSIS?

Simple preventive measures go a long way in lowering the chances of acquiring mucormycosis post COVID-19 recovery, such as:

• Ensuring personal hygiene by bathing and scrubbing the body thoroughly, particularly after returning home from work, working out or visiting neighbours, relatives, friends

• Wearing face masks and face shields when going to dirty polluted environments such as construction sites

• Making sure to don fully covered clothing of concealed shoes, long pants, long-sleeved shirts and gloves while coming in contact with soil, moss, manure, like in gardening activities