By Nishindra Kinjalk
The scourge of covid 19 has not been less of a nightmare, and now comes the addition of a deadly fungal infection— Mucormycosis.
Healthcare planners in India were sweating it out anticipating a plateau in covid 19 surge by mid -May, but the rapidly rising cases of this black fungus, on top of SARS CoV-2 infections, has lately opened a Pandora’s box.
According to a data recently presented at the All India Institute of Medical Sciences (AIIMS) Delhi, it was found that in the first wave, there were 15 cases of mucormycosis in the intense three months of covid-19; whereas the figure rose alarmingly during the second wave, with 60 cases reported in the last three weeks only.
India with 40 per cent of global burden of this disease, finds the alarming rate of 40-80 percent mortality. It is now posing a serious challenge for the doctors to handle it, as its management also necessitates a multidisciplinary approach.
It often needs the services of an ENT specialist, an eye surgeon, or even a neurosurgeon; or at times all of them in a team. The antifungal medicines for this condition too, are a group of drugs with serious concerns of kidney and cardiac toxicity.
A senior consultant in ENT at Fortis and Manipal Hospitals in Delhi, Dr Jayant Jaswal says, ” It’s catching up fast. More and more cases in complicated forms have come to our notice. The new strain of coronavirus seems to have done the trick.”
Dr Jaswal further says this is not only more infectious, it seems to play a big role in the genesis of myriad of complications this time.”
The triad of uncontrolled blood sugar, indiscriminate use of steroids and infection with SARS Co2 virus infection, is forerunner to mucormycosis, he adds.
What is making it a major health issue is that it is catching them also who have gone home after a successful management of covid -19 illness.
Once this disease sets in, it either damages lungs, or it goes to infect nasal sinuses and eyes. At times, infection creeps into the brain. Often a person otherwise looking healthy presents with pain in the eyes, pain around nose or severe headache. The downhill course of the illness is so rapid, that within a short span of 48 hours patient even may slip into a state of altered sensorium.
Dr Jaswal emphasizes that early diagnosis is the key to successful outcome in these cases.
Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial results that were published in February 2021 gave some sort of a licence to use steroids indiscriminately. However, the reports mention clearly about the hazards of unnecessary uses of steroid drugs.
According to senior resident doctor Dr Meghna Kinjalk, who is looking after covid patients at the largest covid hospital in Delhi— Lok Nayak Hospital (LNJP) — no one infected with coronaviruses or even otherwise, should start using oral or injectable steroids without consulting a senior clinician.
Patients in domiciliary care must ensure that they undertake good hygiene measures, especially the mouth and nose care. The basics of general hygiene, like washing hands and staying in well ventilated and less humid rooms can go a long way in preventing serious opportunistic infections, Dr Meghna adds.
“This fungus is in fact, not black. It is a group of molds, called mucormycetes. It exists freely in the environment, and infects whenever it finds a suitable host. This suitable host this time, is the covid 19 patient with persistently raised blood sugar levels along with weak immune status. There is no way through lab diagnostics to identify the fungal infections early”, says senior microbiologist Dr Krishna Nandan Prasad who is an associate professor at Katihar Medical College in Bihar.
However, a biopsy from the infected tissue can give specific diagnosis, but a clinician must not waste precious time awaiting these results. Clinician must have a high index of suspicion for mucormycosis in all the cases of covid 19, whether active, or during convalescence.
The KOH mount and the calcofluor stains of the skin or mucosal scrapings can be handy for quick diagnosis, but it needs expertise with experience on the part of a good lab, cautions Dr Prasad.
Indian Council of Medical Research (ICMR) and AIIMS Delhi have already issued guidelines about management of mucormycosis.
The population at high risk
Uncontrolled diabetes mellitus, prolonged use of steroids use, previous use of antifungal drug voriconazole, prolonged ICU/ hospital stay, cancer, organ transplant cases, skin injury, skin ulcers, malnutrition, neutropenia, excess iron in blood, HIV/AIDS, low birth weight babies, premature babies, and the active or recovered cases of coronavirus infections are all much at risk of contracting this fungal infection.
Typical ways of clinical presentation
- Abnormal black colour discharge or crusts in nose
- Any bleeding from nose
- Nasal blockade
- Eye pain
- Swelling around eyed/ nose
- Vision loss or double vision
- Inability to open the eyes
- Numbness or tingling on face
- Difficulty in opening of mouth
- Difficulty in chewing
- Pain and redness around eyes and/ or nose
- Increased coughing
- Vomiting with blood or brown vomitus
- Impaired mental status
There is no vaccine against this fungal infection. Prophylactic use of any antifungal or antibiotics has no role, rather it has a potential to harm the patient.
The present medicines— amphotericin, Posaconazole and isavuconazole— approved for this illness, are costly, and are to be used with proper monitoring to avoid serious toxicities. Usually, these medicines are to be taken for 4-6 weeks.
The sale of these medicines is strictly under statutory guidelines. Information pouring in from different corners indicates, there is a fresh spate in hoarding these drugs.
As of now, it appears the black marketing of oxygen concentrators, oxygen cylinders and remdesivir has taken a back seat, as India reports a drop in total number of active cases of covid -19 lately.
(Author is a senior consultant in internal medicine)