After mucormycosis, Mumbai sees cases of aspergillosis
Amid rising concerns over mucormycosis cases in the city, doctors are observing growing cases of another invasive fungal infection—aspergillosis– among recovered Covid-19 patients. Doctors attribute it to unregulated usage of steroids among patients infected with the novel coronavirus in the second wave.
Mucormycosis is a serious, but rare fungal infection caused by a group of mould called mucormycetes. Similarly, aspergillosis is an infection caused by aspergillus, a common mould (a type of fungus) that lives indoors and outdoors. Doctors said aspergillosis that “mimics mucormycosis” spreads slowly, but also causes blindness, organ dysfunction, loss of body tissue and can reach the lungs of the patients. Healthy people breathe in aspergillus spores every day without getting sick due to high immunity. Taking this as a cue, currently many hospitals are routinely performing a nasal endoscopy for all in-house post Covid-19 patients with low immunity for early diagnosis of invasive fungal infections.
“There is a sudden and alarming increase in the occurrence of invasive aspergillosis. Those with a weakened immune system, having uncontrolled diabetes, organ transplant recipients, ones with certain types of blood cancer, and those taking steroids or having lung diseases are at a higher risk of developing health problems due to aspergillus,” said Dr Shalaka Dighe, ENT surgeon, Zen Multispeciality Hospital, Mumbai.
Civic-run hospitals like King Edward Memorial (KEM), Parel and Lokmanya Tilak General Hospital, also known as Sion hospital, also have patients with aspergillosis.
“We have got patients with either of the fungal infections or with co-infections of mucormycosis and aspergillosis. These fungi remain in the environment always. Earlier, we used to see these types of fungal infection among patients with immunosuppression like cancer, HIV, TB or organ transplant patients,” said Dr Hetal Marfatia, head of the ENT department, KEM hospital.
Dr Amol Patil, senior consultant, ENT and skull-base surgery at Nanavati Max Super Speciality Hospital, said the concept of white and black fungus is misleading. Fungi are mainly differentiated as invasive and non-invasive. “Both mucormycosis and aspergillosis are opportunistic invasive fungal infections, which means they affect people with a weakened immune system. If the infection gets detected at a later stage, both require debridement to remove dead tissues. This leads to loss of patients’ eyes, palate and nose. Mucormycosis is more aggressive than aspergillosis,” he said.
Mucormycosis commonly affects the nose and para-nasal sinuses and can very quickly spread to the eye and brain. Symptoms are nonspecific and include a blocked nose, bloody or foul smelling discharge from the nose, cheek swelling or pain, swelling of eyes, double vision, loose teeth and pain in the teeth. Invasive aspergillosis most commonly affects the lungs and causes cough with expectoration, blood in the sputum, fever and breathlessness. Involvement of the nose and sinuses results in symptoms similar to mucormycosis.
To rule out any confusion, doctors prefer doing fungal culture. “Patients with aspergillosis are usually treated with an antifungal drug called Voriconazole. But if any patient also has presence of mucor, Voriconazole can lead to a flare-up of mucormycosis. In such cases, we use a newer antifungal called Isavuconazole to treat these patients, as it works against both mucormycosis and aspergillosis,” said Dr Dighe.
Some states like Uttar Pradesh and Bihar are also reporting candidiasis fungus infection. “Candidiasis, which many people have foolishly named as ‘white fungus’, is harmless. It can be treated with normal antifungal medicines and ointments,” said Dr Patil.
Why the rise?
Covid-19 patients are often given high doses of steroids which compromises their immunity to fight fungal infections. This is as one of the primary reasons for the growth of fungal infection in the second wave of the pandemic.
Dr Lancelot Pinto, an epidemiologist sharing his views on the rising cases of fungal infection stated that there has been a widely held perception the second wave was caused by a virus that was more lethal than the first time around. This, coupled with the fear of a lack of hospital beds, the urgent need to control the infection, and the belief that sicker the patient, higher the dose of steroid should be, potentially could have nudged doctors to prescribing higher and prolonged doses of steroids.
“The use of corticosteroids, for a prolonged duration, and in high doses could be contributory (in fungal growth), especially among patients with uncontrolled diabetes, immunosuppressive conditions such as chronic liver disease, kidney disease, and malignancies,” he said.
Dr Ajay Doiphode, president, Association of Otolaryngologists (AOI), Mumbai Branch, said Tocilizumab, another immunosuppressive medication that is given to Covid-19 patients is also associated with invasive fungal infections.
Abhay Pandey, national president of All Food and Drug Licence Holder Foundation (AFDLHF), said when there was a severe shortage of oxygen for Covid-19 patients in April, many companies producing industrial oxygen (not for human consumption) were forced to produce medicinal oxygen without proper quality check.
“There is a possibility that the fungus which remains in the environment may have gotten inside the patients through this sub-standard and polluted oxygen,” said Pandey who has also written a letter to the state health ministry regarding it.
Dr Pinto said “There has been speculation around the quality of oxygen, the use of zinc supplements, excessive steam inhalation as being contributory, but these should be considered speculative unless proven.”
“It is known that fungus thrive more in moist and damp environments so tropical countries are witnessing more cases of fungal infection. As these molds remain in the environment, it is essential that patients even after recovery maintain proper hygiene and keep wearing masks,” said Dr Patil.
Doctors suggest patients remain more vigilant, monitor their blood sugar levels, look for red flags like eye pain, swelling of the eyes and cheek, nose block, cheek pain, and abnormal discharge from the nose.
Infected in a week of discharge
Sunil Kanal, 62, a resident of Chembur was diagnosed with Covid-19 on April 5. He was admitted to a private hospital on April 9. After 21 days of hospital stay, he was discharged on April 30. But despite repeated requests of his family, the hospital refused to do a CT scan during discharge. Within eight days of discharge, he started having fever which made the family members curious.
“I had read about mucormycosis, so I immediately took him to an ENT for a general check-up. Later, he was diagnosed with a similar fungal infection, aspergillosis, which by then had spread to his lungs through his nose and throat,” said Roshan Kanal 38, his son who has already spent around ₹6 lakh on his Covid-19 treatment.
Now, the patient is undergoing treatment at Zen Multispeciality Hospital, Chembur.
Dr Shalaka Dighe, ENT Surgeon, the treating doctor, said, “At present, we are treating him with an antifungal medicine—Isavuconazole. We are trying to optimise his infected lungs before we can decide on operating upon him. Due to his health condition, we can’t even operate on his infected nose as we can’t put him on general anesthesia. We will do his CT scan in the next two days, depending on the result, we will take the final decision.”
THE FUNGAL INFECTIONS
Both mucormycosis and Aspergillosis are opportunistic fungal infections. They affect people with a weakened immune system.
The spores of mucor and aspergillus are found in the environment.
Inhalation of these spores normally does not have any harmful effects. The body’s immune system destroys them. However, it results in serious infections in immunocompromised patients such as those with uncontrolled diabetes, organ transplant recipients, patients with blood cancer and Covid-19.
Mucormycosis commonly affects the nose and paranasal sinuses and can very quickly spread to the eye and brain. Symptoms are nonspecific and include a blocked nose, bloody or foul smelling discharge from the nose, cheek swelling or pain, eye swelling, double vision, loose teeth, pain in the teeth.
Invasive aspergillosis most commonly affects the lungs and causes cough with expectoration, blood in the sputum, fever and breathlessness. Involvement of the nose and sinuses results in symptoms similar to mucormycosis.
Aspergillosis spreads slower than mucormycosis. Mucormycosis is more aggressive than Aspergillosis.
Aspergillosis is normally treated with Voriconazole. Mucormycosis is treated with Liposomal Amphotericin B/ Amphotericin B.
The differentiation of fungus as black and white is not scientifically correct, doctors said.