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Let’s ensure Black Fungus doesn’t follow Covid

01 Jun 2021

  • Lessons to be learnt from the Indian experience, for Sri Lanka

Last week, many states in India declared black fungus as an epidemic disease and by the end of the week the disease had affected over 12,000 people, mostly people who were infected with Covid-19 during the deadly second wave of the pandemic in India. Scientifically known as Mucormycosis, the Black fungus is an aggressive fungal infection which affects the eyes, nose, skin, even lungs, and the gastro-intestinal system. You can inhale the mold spores or come into contact with them in things like soil, rotting produce or bread, or compost piles.  Mucormycosis, even though it has been around for a long time, was not a common infection. However, it came into the limelight with the increasing number of cases being reported in India, which has been assumed to be associated with the Covid-19. Some of the people infected have had their lives completely altered for the treatment, with drastic measures such as the surgical removal of eyes and jaws to curb the spread of the fungal infection. The infection has also caused blindness in some cases.   Symptoms of Mucormycosis The symptoms caused by the black fungus depends on the area of infection. Infection of the skin shows areas of black/red ulcers and blisters with warmth of the skin in that particular area with associated swelling around the area and pain. Infection of the sinuses will cause nasal congestion, headache, and swelling of the face. When spread to the lungs it will cause shortness of breath, cough and fever. If the infection spreads to the gastro-intestinal system, it usually manifests as abdominal pain, nausea, vomiting, and bleeding from the intestines. Disseminated infection or spread of the infection throughout the body through the bloodstream occurs usually in severely ill and immunocompromised patients, and in this situation the infection has the potential to spread to organs like the spleen, heart, and also the brain, and cause alteration of mental state or even lead to a coma.   Risk factors This fungal infection is possible in anyone of any age, however, usually funguses infiltrate and infect those who have compromised immunity, such as those suffering from uncontrolled diabetes, HIV/AIDS, cancers, prolonged use of steroids, kidney disease etc. Other infections after a viral disease are common because viruses suppress immunity. For instance, post-viral bacterial infections are quite common. But such infections run the risk of becoming hardy and resistant to drugs. In Covid-19 the concurrent viral infection takes a toll on the immunity. Steroids are used in Covid-19 to reduce inflammation of the lungs caused by the immune response to the virus, and use of steroids in high doses are known to cause a drop in immunity and spikes in blood sugar, which opens up a window of opportunity for funguses such as mucormycosis to spread. It has been found in the reported cases of mucormycosis in India that most of them have been prescribed high doses of steroids to control the effects of Covid-19, and some of them have been self-medicating with steroids as well. Most of the reported cases had been diabetics. Along with the poor immunity, several other factors are considered as contributory to the spread of the black fungus, even though there’s no direct evidence linking it. It has been suspected that poor hygienic conditions and overcrowding of Covid treatment centers in India along with poor ventilation, the improper use of oxygen cylinders with unclean oxygen masks, and unpurified water. These were a common sight in India throughout the third wave. Another hypothesis claims that prolonged use of unclean masks has been a direct contributory factor for infection of Mucormycosis, however again there’s no direct evidence, however most of the cases reported from India had a history of poor self-hygiene and prolonged use of dirty masks.   Diagnosis and treatment There’s no single confirmatory test to diagnose mucormycosis, it is diagnosed by a combination of clinical history, examination with analysis of circumstances, and prevalent risk factors. If you have been around spoiled food, or overcrowded spaces with poor hygienic conditions, and if you have co-existing medical conditions which cause immunocompromisation, a case of mucormycosis may be suspected. Once a probable diagnosis is made, no delay is done in starting intravenous antifungal drugs in high doses. This aggressive management is required to control the spread of the infection. In some instances, surgical removal of certain body parts is considered in an effort to control the infection.   Complications of mucormycosis Complications of the black fungus depend on the place of infection. As mentioned earlier it has been reported of complications such as coma, blindness, and surgical removal of eyes and jaw bone to stem the spread. Other possible complications are blood clots or blood vessel blockage, nerve damage, and even death. The mortality rate of mucormycosis has been estimated to be as high as 54%, however the possibility of mortality also depends on the place and extent of infection.   How to prevent contracting mucormycosis? Main measure of prevention is to follow good hygienic practices such as maintaining good ventilation, avoiding overcrowding. Avoid sharing oxygen masks if admitted to a Covid center. Dispose surgical masks after use, they are not meant or made for continued use. KN95 masks can be washed and used several times but still not meant for prolonged use over months. If you have a condition such as diabetes or kidney disease, ensure your continued compliance to your drug regime and advice given by your doctor. Further ensure not to self-medicate yourself on a cocktail of drugs. If any concerns get medical advice immediately. Sri Lanka is currently fighting a raging third wave of Covid-19 and that is challenging as it is. We must ensure that we do not follow in India’s footsteps by adding mucormycosis to the burden on our healthcare system.    (The writer is a medical officer currently attached to a government hospital. His experience spans across the medical profession as a medical practitioner, and across the pharmaceutical and surgical equipment industry. He also possesses an MBA and a Diploma in Economics. Having represented his university rugby team in international tournaments, he also has a special interest in sports medicine)

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