If Covid-19 is not treated in a hygienic environment, reduced immunity during the recovery can lead to the black fungus, putting even more pressure on the already overworked medical infrastructure

In the last month or so many cases attributed to black fungus have been reported, signalling that such cases are on the rise and a Covid-19 related complication resulting in many deaths. Last week, 52 Covid survivors died due to black fungus in Maharashtra alone, and many such cases are being reported from various parts of the country, including Delhi.

Usually, fungal diseases are common among plants, only a very small fraction of them affect humans—and the reason for it is that humans have an evolved immune system. In the eventuality where, due to other maladies, in recent times due to Covid-19 treatment by administration of steroids that results in the weakened immune system, the fungi that are otherwise harmless take advantage and attack human tissues.

Even the doctors are not safe. Dr Sanjay Pande, 58, a radiologist for the last 25 years tested positive for Covid, and, as part of the treatment, had to be administered oxygen. A few days later, he developed a fungal infection that spread from his throat to the eyes—lost one eye—and then to parts of the brain. Last heard he was in a critical state, and chances of survival were fairly grim.

AIIMS Director,  Dr Randeep Guleria, explains that the black fungus or mucormycosis, is not new but “a major cause” behind the large numbers of new infections is due to “the misuse of steroids” and this fungus “can affect the face, infecting nose, orbit of the eye, or brain, which can cause even loss of vision. It can also spread to the lungs.” He informed that fungal infection is frequent in the patients who are diabetic, Covid positive and are being administered steroids-which also contributes to the rise of blood sugar and weakening of the immune system.

According to an advisory issued by the Indian Council of Medical Research (ICMR), the risk of black fungus increases in Covid-19 patients if they suffer from uncontrolled diabetes, use weakening of immune system due to use of steroids, prolonged stay in ICU or hospital, co-morbidities like post organ transplant or cancer to mention a few.

Use of unclean oxygen cylinders and unhygienic conditions in the hospital is seen as a contributing factor, therefore, Dr Guleria stresses “the paramount importance that protocols of infection control practices are followed at hospitals.” Or in other words, the air in hospitals, particularly in the Covid wards, be checked and prevent the presence of spores—a reproductive cell capable of developing into a new individual without fusion with another reproductive cell, produced by bacteria, fungi, algae, and plants. It’s imperative that the humidifiers used during the administration of oxygen are sterile—there are reports of tap water being used for this purpose in some hospitals, especially in the smaller towns. It’s advisable for the Covid survivors to remain indoors until their immunity is strong enough.

The black fungus or mucormycosis manifests usually as skin infection in the air pockets located behind the forehead, nose, cheekbones, and in between the eyes and teeth, if unchecked, spread to eyes, lungs and brain—as is the case with Dr Sanjay Pande. Can manifest as any of these symptoms: fever, headache, reddish and swollen skin over nose, dark scabbing, eyes swelling, facial pain, diffuse abdominal pain to mention a few. Leads to blackening or discoloration over the nose—hence gets its popular name black fungus—results in blurred or double vision, chest pain, breathing difficulties and coughing of blood, in some cases—death. The drugs known to be most effective are Amphotericin B and Posaconazole – provided the infection is found early, which is usually not the case as there aren’t any reliable diagnostic features.

The detailed research paper, Challenges in the diagnosis and treatment of mucormycosis by A Skiada, C Lass-Floerl, N Klimko, A Ibrahim, E Roilides, G Petrikkos published in Medical Mycology in 2018, points that mucoraceous fungi are resistant to most antifungals in vitro (Latin for “within the glass” refers to what happens outside of a living organism), including voriconazole (is an antifungal medication used to treat a number of fungal infections). In addition, black fungus is “characterized by extensive angioinvasion (tumor masses within arteries or veins) that leads to vessel thrombosis (when blood clots block your blood vessels) and tissue necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply).

The research paper calls for a “multimodal approach” for the successful management of black fungus that includes “reversal or discontinuation of underlying predisposing factors, if possible. The key is early detection and administration of active antifungal agents and therapeutic interventions “may help” to preventing progressive tissue invasion and its devastating sequelae (a condition which is the consequence of a previous disease or injury), minimizing the effect of disfiguring corrective surgery, and improving outcome and survival.   The next stage is “complete removal of all infected tissues” and the use of various adjunctive therapies like “rapid correction of metabolic abnormalities..uncontrolled diabetes.” Also, “immunosuppressive drugs should be tapered quickly and to the lowest possible dose.”

Despite continuing efforts for a better understanding of the pathogenesis or the manner of development of a disease, early diagnosis and aggressive treatment of mucormycosis, the mortality rate of the disease remains high. Dr Sanjay Pande has lost an eye—as the removal of the affected part is the only option. If the black fungus spreads in the brain, the chances of survival are very slim. And the cost of treatment is very high, as the black fungus has to be removed surgically. “In a private hospital the costs could cost Rs 50,000 per day—it could take weeks,” says a resident doctor in Safdarjung Hospital “and the situation in many government hospitals are not particularly hygienic.”

One thing is clear: if Covid-19 is not treated in a hygienic environment, black fungus is a likely outcome.