At least 29 ‘black fungus’ cases in AIIMS, Ganga Ram spark worry

New Delhi: Hospitals are recording a spike in cases of mucormycosis, a potentially deadly fungal infection, as the surge in Covid-19 cases has led many people to be prescribed steroids and immunomodulators, which leave some people vulnerable to other pathogens

New Delhi: Hospitals are recording a spike in cases of mucormycosis, a potentially deadly fungal infection, as the surge in Covid-19 cases has led many people to be prescribed steroids and immunomodulators, which leave some people vulnerable to other pathogens.

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Mucormycosis, also known as black fungus, has been seen among those who have uncontrolled diabetes, whose immunity is compromised or those who are given excessive steroids or immune-modulating drugs such as tocilizumab.

According to doctors, if left untreated, it may kill 80% of those infected. If not detected early, it affects the orbit of the eye and the mouth, resulting in people losing their vision or jaw during debridement — the process of removing dead tissue from an infection or wound.

At least 10 patients suspected to have contracted mucormycosis are currently admitted to the All India Institute of Medical Sciences (AIIMS). Doctors said the centre used to see only two such cases a month previously.

“We have 10 patients admitted in the ENT department who, we suspect, have mucormycosis. Now, we are seeing reports of opportunistic infections like mucormycosis from Gujarat and other areas where it (tocilizumab) was used a lot. Many Covid-19 patients either have underlying diabetes or their blood sugar levels became uncontrollable because of the steroids given for treatment. Some of them (Covid patients) also receive medicines, such as tocilizumab and itolizumab, which furthers the aggressive decline in the immune system. All this leads to a very high chance of opportunistic infections,” said Dr Randeep Guleria, director of AIIMS, in a webinar.

Dr Alok Thakar, head of the ENT department at AIIMS, said, “We are seeing a surge over the last week or so. The last time we saw a surge in mucormycosis cases was when Covid-19 cases increased but this time, the number of cases is greater. Since last year, we are treating probably three to four patients a month and now, we are treating four patients a day at times. For the last three days, we have been getting four to five patients a day.”

“It generally occurs a couple of weeks after the onset of Covid-19 infections. However, it is still rare even among Covid-19 patients ; very few who have recovered will get it,” said Thakar.

He said people should maintain basic hygiene after recovering from Covid-19 to ensure that they do not get any infections, stay away from soil, and also get their blood sugar levels tested.

Another 19 people with mucormycosis are admitted at Sir Ganga Ram Hospital, said Dr Ajay Swaroop, head of the ENT department at the hospital.

“Before Covid-19, I would have seen as many cases probably in five years. We get one patient with the fungal infection in three to four months; that too because we are a big tertiary-care facility. Now, we are hearing of patients in other city hospitals who have contracted mucormycosis and who want to move in here for treatment.”

The sudden increase has also resulted in a shortage of anti-fungal medicines used for treating the infection. “The anti-fungal drugs are not freely available and there is a shortage because the demand has gone up again,” said Dr Guleria.

Dr Swaroop said, “Although I don’t know the current situation about the drugs, but it stands to reason that if 35 people need it instead of the usual five, there will be a shortage. The lypholised (freeze-dried) drug that is slightly better and less toxic to other organs was anyway difficult to get.”

Black fungus infection numbers went up 2.5 times last year between September and December across 16 centres in the country, said Dr Arunaloke Chakrabarti, head of the department of microbiology at Post Graduate Institute of Medical Education & Research, Chandigarh. He is part of the Fungal Infection Study Forum and is one of the members who drafted the government advisory on mucormycosis. “It is likely to go up further this time; we are planning to conduct another study,” he said.

Chakrabarti added not much is known about whether the immune dysregulation caused by Covid-19 could be causing the secondary fungal infection but there are three known reasons for it.

“One, uncontrolled sugar in Covid-19 patients; nearly 7 to 20% of Covid-19 patients who have diabetes may be at risk of contracting the infection (mucormycosis). Two, for those without diabetes, high use of steroids may lead to poor glycemic control after Covid-19, thereby leading to the fungal infection. Three, the ferritin levels go up during a Covid-19 infection. Ferritin is known to contain iron which is a good food for mucormycosis,” said Dr Chakrabarti.

The study done by his team found the infection usually happens 18 days after the onset of Covid-19. “So people should look out for pain in left or right side of the face, nasal blockage, nasal discharge, especially black discharge. Loosening of teeth has also been seen this time among Gujarat patients. If a diagnosis is delayed and the infection enters the eye orbit, it causes double vision, blurring, or protrusion of the eye. It can also cause ulcers in the palate of the mouth,” he said.