Mucormycosis, a
serious fungal infection but otherwise rare, has been observed in a number of
Covid-19 patients recently. While there is no major outbreak, the national
Covid task force has issued an advisory.
Mucormycosis is caused by mucormycetes that
generally attacks a diabetic person with low immunity. For a year, even
normally healthy patients are reporting this infection post Covid.
A rare but serious fungal infection, known as mucormycosis and
colloquially as “black fungus”, is being detected relatively frequently
among Covid-19 patients
in some states. The disease often manifests in the skin and also affects the
lungs and the brain. With a number of mucormycosis cases detected in
Delhi, Maharashtra and Gujarat, experts in the national Covid-19 task force on
Sunday issued an evidence-based advisory on the disease.
What is the disease?
Although rare, it is a serious infection. It is caused by a group of
moulds known as mucormycetes present naturally in the environment. It mainly
affects people who are on medication for health problems that reduces their
ability to fight environmental pathogens, say experts from the Covid-19 task
force task force.
Sinuses or lungs of such individuals get affected after they inhale
fungal spores from the air. Doctors in some states have noted a rise in cases
of mucormycosis among people hospitalized or recovering from Covid 19, with
some requiring urgent surgery. Usually, mucormycetes does not pose a major
threat to those with a healthy immune system.
What happens when one contracts it?
Warning signs include pain and redness around the eyes or nose, with
fever, headache, coughing, shortness of breath, bloody vomits, and altered
mental status. According to the advisory, infection with mucormycetes should be
suspected when there is:
* Sinusitis — nasal
blockade or congestion, nasal discharge (blackish/bloody);
* Local pain on the cheek bone, one-sided
facial pain, numbness or swelling;
* Blackish discoloration over bridge of
nose/palate;
* Loosening of teeth, jaw involvement;
* Blurred or double vision with pain;
* Thrombosis, necrosis, skin lesion;
* Chest pain, pleural effusion, worsening of
respiratory symptoms.
Experts advise that one should not count all cases of blocked nose as
cases of bacterial sinusitis, particularly in the context of immunosuppression
and/or Covid-19 patients on immunomodulators. Do not hesitate to seek
aggressive investigations for detecting fungal infection, they advise.
What’s the treatment?
While it is treated with antifungals, mucormycosis may
eventually require surgery. Doctors have said that it is of utmost importance
to control diabetes, reduce steroid use, and discontinue immunomodulating
drugs. To maintain adequate systemic hydration, the treatment includes infusion
of normal saline (IV) before infusion of amphotericin B and antifungal therapy,
for at least 4-6 weeks.
Experts in the task force have stressed the need to control
hyperglycemia , and monitor blood glucose level after discharge following
Covid-19 treatment, and also in diabetics. One should use steroids judiciously
— correct timing, correct dose and duration are important.
Management of Covid patients with mucormycosis is a team effort
involving microbiologists, internal medicine specialists, intensivist
neurologist, ENT specialists, ophthalmologists, dentists, surgeons
(maxillofacial/plastic) and others.
Life after surgery for mucormycosis
Mucormycosis can lead to loss of the upper jaw and sometimes even the
eye. “Patients would need to come to terms with loss of function due to a
missing jaw — difficulty with chewing, swallowing, facial aesthetics and loss
of self-esteem, doctors say. Be it the eye or upper jaw, these can be replaced
with appropriate artificial substitutes or prostheses. While prosthetic
replacement of the missing facial structures can commence once the patient
stabilises after surgery, doctors it is important to reassure him about the
availability of such interventions instead of leaving him to panic with the
sudden unforeseen loss, augmenting a post-Covid stress disorder which is
already a reality,” said Dr B Srinivasan, a maxillofacial prosthodontist.
“Prosthetic reconstruction can be effected after surgery, but interim solutions
should be planned even before surgery of the jaws for better long-term
outcomes. Prosthetic reconstruction can ensure that the cure is not more
dreadful than the disease itself,” he said.
How can one prevent it?
One should remember that it is a rare disease. However, some groups
of people are more vulnerable than others. What predisposes patients is uncontrolled
diabetes mellitus, immunosuppression by steroids, prolonged ICU stay, and comorbidities —
post transplant/malignancy, voriconazole therapy.
Experts advise that you use masks if you are visiting dusty
construction sites. Wear shoes, long trousers, long-sleeved shirts and gloves
while handling soil (gardening), moss or manure. Maintain personal hygiene
including a thorough scrub bath.
How frequently are cases being detected?
While cases are on the rise, there has been no major outbreak. Niti
Aayog member (health) Dr V K Paul said at a media briefing that there has been
no major outbreak and they were monitoring cases being reported.
In Maharashtra, Dr Tatyarao Lahane, head of the Directorate of
Medical Education and Research, has said that cases of mucormycosis are on the
rise. “Traditionally we see a case every few months, usually in very poorly controlled
diabetic and immunocompromised patients,” said Dr Parikshit Gogate, consulting
ophthalmologist at Ruby Hall Clinic, Pune. “But in the past 2 to 3 weeks, I
have seen almost 25-30 of them, mostly in Ruby Hall, some in D Y Patil
Hospital.”
Mucormycosis developing
in post Covid-19 setting breaks the back of a patient’s family that is barely recovering
from this viral infection, infectious diseases consultant in Pune Dr Rajeev
Soman wrote in the Journal of Association of Physicians of India in January
this year.
Dr Soman is one of the expert members who drafted the advisory as
part of the national Covid-19 task force. The also task force includes Dr
Arunaloke Chakraborti, Head of the Department of Medical Microbiology,
PGIMER, Chandigarh;
Dr Atul Patel, infectious diseases specialist, Ahmedabad; and several others.
Patients most vulnerable to mucormycosis are those who have been
treated with steroids and other drugs for Covid 19 to reduce inflammation.
Efforts are underway to collect data for large studies being done by the Fungal
Infections Study Forum and Clinical infectious Diseases Society, Dr Soman said.
What is mucormycosis?
Mucormycosis, commonly called black fungus, is a rare but serious
fungal infection caused by a kind of fungus called mucormycete, which is
abundant in the environment. It mainly affects people who have health problems
or take medicines that lower the body’s ability to fight germs and sickness.
Symptoms
These include pain and redness around eyes and/or nose, fever,
headache, coughing, shortness of breath, bloody vomits, and altered mental
status. Warning signs can include toothache, loosening of teeth, blurred or
double vision with pain.
Who is vulnerable?
Vulnerable groups include people who have health problems or take
medicines that lower the body’s ability to fight germs and sickness. These
include those with diabetes, cancer, or those who have
had an organ transplant.
Prevention
Use masks if you are visiting dusty construction sites. Wear shoes,
long trousers, long-sleeved shirts and gloves while gardening. Maintain
personal hygiene including a thorough scrub bath.
Diagnosis
It depends on the location of the suspected infection. A sample of
fluid from your respiratory system may be collected for testing in the lab;
otherwise a tissue biopsy or a CT scan of your lungs, sinuses etc may be
conducted.
Treatment
Mucormycosis needs to be treated with prescription antifungal
medicine. In some cases, it can require surgery; it can lead to eventual loss
of the upper jaw and sometimes even an eye.
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