A 56-year-old Delhi resident, Kumar lost his wife and other two family members to COVID-19. He had barely completed the last rites of his wife when he experienced pain in his abdomen, a news report said.
He had also tested positive for COVID along with his wife and been experiencing mild covid symptoms. Since Kumar's abdominal pain was considered gastritis/ stress-related, he self-medicated for acidity, delaying a diagnosis and treatment by three days.
He was finally evaluated in the COVID emergency of Sir Ganga Ram Hospital. The CT scan revealed his small intestine (jejunum) had perforated - a black fungus infection or mucormycosis had infected his intestine. By then, his COVID-19 infection had worsened requiring ventilator support.
This has become a repetitive story for many COVID-19 patients in India. A difference is just in where the black fungus infection manifested.
As of May 21, over 8,400 black fungus cases have been recorded. Gujarat, Maharashtra and Andhra Pradesh account for almost 60 per cent of those cases. In Pune alone, for instance, as many as 353 new cases of black fungus and 20 deaths were reported, according to the official data of district administration on Saturday.
What is 'black fungus'?
According to the US Centers for Disease Control and Prevention (CDC), mucormycosis or black fungus (previously called zygomycosis) is a serious but rare fungal infection caused by a group of molds called mucormycetes. These moulds live throughout the environment. The infection can be caused by a mould found in soil and in decaying organic matter like rotting leaves.
People can get mucormycosis, of which there are several types, by breathing in the fungal spores. They can be spread in hospitals and homes by air humidifiers or oxygen tanks containing dirty water.
Black fungus infection commonly involves the 'rhino-orbital-cerebral' system (around the brain, sinuses and eyes) or the lungs. Intestinal mucormycosis is rarer, the kind found in Kumar, commonly involving the stomach or the large intestine. It can also occur on the skin after a cut, burn, or other type of skin injury.
A rare infection, black fungus usually affects people who have long-term health problems and/or take medicines that reduce the body's immunity. This includes individuals suffering from diabetes and cancer, recipients of organ or stem cell transplants, long term use of steroids, drug use via injection, post-surgery or injury wounds etc.
How deadly is it?
The infection needs to be caught early as it is aggressive and dead tissue has to be scraped away. Surgeons sometimes have to remove patients' nose, eyes or even their jaw to stop it getting to the brain.
Once infected, people can die within days. However it is not contagious, according to the CDC. Generally the body's defences repel the fungus and only those with severely weakened immune systems - for example organ transplant or cancer patients - are affected.
Why is it soaring now?
If it is so rare and limited, why is it increasing now? India normally only deals with a few dozen cases a year.
An answer to this, according to medical experts quoted in media reports, is the use of steroids against some of the serious effects of COVID-19 infections. One of the reasons for getting a black fungus infection is the use of corticosteroids.
One-sided facial swelling
Headache
Nasal or sinus congestion
Black lesions on nasal bridge or upper inside of mouth that quickly become more severe
Fever
Pulmonary (lung) mucormycosis:
Fever
Cough
Chest pain
Shortness of breath
Gastrointestinal mucormycosis:
Abdominal pain
Nausea and vomiting
Gastrointestinal bleeding
Source: CDC
In September 2020, the World Health Organisation recommended "the use of systemic (i.e. intravenous or oral) corticosteroid therapy (e.g. 6 mg of dexamethasone orally or intravenously daily or 50 mg of hydrocortisone intravenously every 8 hours) for 7 to 10 days in patients with severe and critical COVID-19." WHO also recommended that such treatment should not be given to patients with non-severe COVID-19 infections.
The fungus thrives on sugar
COVID and other such infections can trigger an overdrive of the immune system called a 'cytokine storm'. So doctors have been prescribing steroids to reduce the immune response that could potentially lead to organ failure.
But both these situations weaken the body's defences and increases sugar levels, which funguses thrive off. In addition to this, there have been reports of black fungus infections in diabetics who also have excessive sugar in their bloodstream.
Some hospitals and doctors have been over-prescribing steroids, and some people have been taking them at home without medical advice. "People have started using (steroids) liberally, excessively and inappropriately," Professor K. Srinath Reddy, from the Public Health Foundation of India, told AFP.
Treatment
According to the CDC, mucormycosis is a serious infection and needs to be treated with prescription antifungal medicine, usually amphotericin B, posaconazole, or isavuconazole. Surgery may also be required to remove the infected tissue.
India is facing severe shortages of the main anti-fungal drug to treat the infection, amphotericin B.
Then what is white fungus?
On Friday, there were reports of another fungal infection called the 'white fungus' or a form of candidiasis. CDC defines candidiasis as an infection caused by a yeast (a type of fungus) called Candida. While basic forms of this infection is not deadly if treated on time (thrush in the mouth or vaginal infections), CDC explains that invasive candidiasis can be deadly.
CDC says on its website, "Invasive candidiasis is a serious infection that can affect the blood, heart, brain, eyes, bones, and other parts of the body. Candidemia, a bloodstream infection with Candida, is a common infection in hospitalised patients." CDC warns patients hospitalised for COVID-19 are at risk for healthcare-associated infections (HAIs), including candidemia.
Media reports in India claim that at least 4 cases of the white fungus infection have been detected in Patna, Bihar and that many more might be undiagnosed at this stage.
Who is at risk?
Like black fungus, invasive candidiasis also affects people with impaired immunity either from a pre-existing condition like diabetes, the long-term use of steroids or those who are hospitalised and under treatment.
What can individuals do to stay safe?
The most important step is to stay safe from COVID-19 by staying indoors, wearing masks, and maintaining social distance and sanitisation requirements. Since severe cases of COVID-19 require the use of steroids and possible lower immunity, getting the coronavirus infection automatically increases the risk of getting the deadly fungus infection.
For people with diabetes or cancer, and others whose immunity may be compromised due to long-term medication, organ or stem cell transplant, or surgery, staying safe from the fungal infection is just as important as staying safe from COVID-19.
Inputs from AFP, ANI
