Amidst Deadly Covid-19, Black Fungus traumatize People like Never Before

Thanks to the callousness on the part of all state and Union Governments ignoring the warnings of health experts’ way back in October 2020, the second wave of Covid-19 mutated viruses are having their hay time. Although several attempts are being made on behalf of the governments, philanthropic persons/institutions and NGOs’ to rise to the occasion, the virus seems to be having the last laugh as of now.

Source: Indian Express

Added to such adverse scenario and as if the onslaught of Covid-19 pandemic isn’t enough to have its fatal toll, all of us are now facing a formidable challenge in the form of Black Fungus or known as Mucormycosis in medical terms.

Dr SR Narahari, Director Institute of Applied Dermatology (IAD), Kasargod district in Kerala found time between his hectic schedule to dwell with the current crisis in detail and his viewpoints about the subject in general.

He fears: Since the Central Government issued guidelines on controlling the black fungus; this disease is bound to scare the nation. It is called Mucormycosis in medical terms and is a common fungus grown over the kitchen bread and usually does no harm to otherwise healthy people. At the same time, whenever affected, 50 to 85% of patients die in a very short period while severe disabilities take over those who battle to survive...

...Since the fungus looks black under the microscope, it is called the black fungus. A precise diagnosis is possible only by culturing the sample by the microbiologists. In the past, it was rarely seen among people who were suffering from chronic low immunity (immunocompromised) and mainly confined to cancer wards. While India is beginning to show a decline in COVID 19, this new killer virus is rapidly emerging, resulting in horrific facial injuries and death, he fears.

Dr SR Narahari also points out the reasons for the alarming scare: The panic is because modern medicine can do very little to this disease. Even doctors, nurses and other health care workers would be mentally traumatized to see these patients dying so quickly. As mucormycosis invades blood vessels causing deep and wide injuries on the face, heroic surgical treatment on the affected area is often required. So, nasal, palate and maxillary bones will have to be cut open to remove the fungal heaps (called debridement). All bones below the eyes till the jaw should be removed, and if the patient survives, a prosthesis would have to be given......These long surgeries require a multi-disciplinary team to manage; ENT, Ophthalmology, Neurosurgeon, Physician, Maxillo-Facial Surgeon, Anaesthetist, Pathologist, microbiologists working together in a high technology surgical support facility. In addition, injection Amphotericin B and Posaconozole, costing per day may vary from 10,000 to 25,000. If the patient survives, six months of treatment is needed. Unfortunately, with a large population and meagre health infrastructure, our country is unlikely to be able to give the minimum treatment for this medical emergency, he wonders.

Talking about the catastrophic features of the dreaded fungus, Dr SR Narahari asserts: It is a killer fungus. It enters the body using any breach in skin or mucosa that means common sites are eyes, nose and mouth. It starts as a thick brownish spot around the nose, a black spot inside the nose or palate. The black spot on the palate is the late stage of the disease. The disease may initially look like red-eye and swollen eyelids. Patients may not be able to move eyeballs or complain of blurred vision, eye pain, or healthy-looking eyes but sudden vision loss......The retinal examination will show what is called a Cherry red spot in a white looking retina. There could be brown or bloody nasal discharge, foul smell, loss of teeth etc. Suddenly the disease eats up the optic nerve (loss of vision), invading cavities and sinuses around the nose, damaging the bones and eventually invading the brain and cause death, he explains.

Not just Eyes, Nose and Mouth: Technically named Rhino-Orbital-Cerebral Mucromycosis (ROCM). It can also infect the intestine, presenting as diarrhoea. When lungs get, infected patients may also present with blood-stained sputum. Mucormycosis is a medical emergency. 

The disease is rapidly fatal, and doctors begin treatments when the condition is suspected, even before all reports are made available. Although it occurs in patients with uncontrolled diabetes, dialysis patients, those on anti-cancer drugs, a sudden increase happened following COVID 19 disease.

In our defence system, immunity is in the form of three protective levels. When the enemy enters the body, macrophages kill them. If the enemy’s army is large, neutrophils and other white blood cells come along and try to prevent the infection......During viral infections, especially COVID 19, there is a functional alteration of neutrophils. Since fungus attacks in large numbers and COVID 19 patients' neutrophils are either low in number or have less ability to fight mucormycosis get proliferated immediately. Patients receiving additional steroids to combat corona in the hospital and receive a low nutrient diet during the hospitalization condition further worsens. The black fungus attacks in conditions where neutrophils of white blood cells are not functioning, that is, viral infections. So, despite the many AIDS patients we had two decades ago, the black fungus was not prevalent because of reducing white lymphocyte cell in HIV, observed Dr SR Narahari.

Surgeons with superb surgical skills can alone save patients: The fungus requires iron for its growth and has a particular liking for blood vessels and alveoli of the lungs. During COVID 19, low oxygen (hypoxia) causes respiratory failure. In uncontrolled diabetics, blood pH level is lowered (acidosis in medical terms), causing the release of iron from haemoglobin and other iron stores in the body. Free iron is the food for the black fungus, and they thrive in this environment, eating up tissues, bones and blood vessels. Hence the fungus quickly surrounds and invades the blood vessel stopping the blood supply to the area causing local necrosis (death) of the tissue. Dead skin looks black. Horrific injuries happen as fungus invades inside for more iron, and fungal heaps are seen in the sinus mucosal layer and nasal cavities. Drugs can not remove these heaps of fungal growth. Only Surgeons with super-surgical skills only can save the patients, he laments.

The black fungus usually resides in soil, and farmers and agricultural labourers are more prone to this infection. This may be the primary reason for the Prime Minister to trigger the warning. The fungus thrives on iron. Free iron is more in circulation post-COVID 19 recovery periods. The common habit of cleaning a day-old bread and pasting jam stored in open bottles is not advisable for patients recovering from COVID 19 and diabetic patients. Patients on oral steroids and long-standing diabetics in the recovery period of COVID should be careful by improving local hygiene and keeping indoors as per Government directions, he warns.

Low Priced Drugs in Plenty should be a Priority: The government has declared the disease as an epidemic as it quickly spreads and is likely to affect many people. The condition is expected to affect only immune-compromised people and diabetic patients recovering from COVID. Since many hospitals are now full of corona patients, it would be better not to touch other patients’ beds and clothes or touch their relatives......Although medicines can do little in this disease to save a small percentage of patients who get the black fungal infection, low-priced drugs are to be made available in plenty. Already the Central Government has permitted five Pharma companies to produce antifungal drug Amphotericin B liposomal injections. These companies already have significant capabilities: Natco pharma, Gufic Biosciences, Alembic Pharmaceuticals, Emcure Pharmaceuticals, and Lyca Pharmaceuticals. We have very skilled surgeons and young doctors are working without holiday for more than one year. Let us hope that we will contain the spread of fungus and treat them possibly, concludes Dr SR Narahari.

-Manohar Yadavatti