COVID-19 and Black Fungus: What Is Mucormycosis? Mucormycosis: The 'black fungus' maiming Covid patients in India
Mucor viewed through a microscope showing dark spherical spores. Photo: T. Rajamani, VINSTROM
Many people recovering from COVID-19 have of late been afflicted by black fungus – or mucormycosis – disease. The fungus invades the sinus and makes its way into the intraorbital and intracranial regions. If its progression is not checked early, 50-80% of patients could die.
On Saturday morning, Dr Akshay Nair, a Mumbai-based eye surgeon, was waiting to operate on a 25-year-old woman who had recovered from a bout of Covid-19 three weeks ago.
Inside the surgery, an ear, nose and throat specialist was already at work on the patient, a diabetic.
He had inserted a tube in her nose and was removing tissues infected with mucormycosis, a rare but dangerous fungal infection. This aggressive infection affects the nose, eye and sometimes the brain.
What is mucormycosis?
Mucormycosis is a very rare infection. It is caused by exposure to mucor mould which is commonly found in soil, plants, manure, and decaying fruits and vegetables. "It is ubiquitous and found in soil and air and even in the nose and mucus of healthy people," says Dr Nair.
It affects the sinuses, the brain and the lungs and can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS.
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Doctors believe mucormycosis, which has an overall mortality rate of 50%, may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients.
Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients.
It's thought that this drop in immunity could be triggering these cases of mucormycosis.
After his colleague finished, Dr Nair would carry out a three hour procedure to remove the patient's eye.
"I will be removing her eye to save her life. That's how this disease works," Dr Nair told me.
Even as a deadly second wave of Covid-19 ravages India, doctors are now reporting a rash of cases involving a rare infection - also called the "black fungus" - among recovering and recovered Covid-19 patients.
Both authors are plant biologists interested in fungi. When we first heard of mucormycosis sometime last year, from reports from Europe, it rang a bell.
People experience fungi most often in their kitchens, when fruits rot or the bread turns moldy. Fungi evolved 400 million years ago and play an important role on Earth. They have helped plants move from their aquatic habitats to land, and still help them obtain minerals from the soil. Fungi decompose organic litter and recycle the nutrients locked up in the leaves and wood.
Some of them have also evolved to become plant pathogens: they infect plants, multiply and disperse to other plants, leaving destruction in their wake. The great Irish famine of 1845 that left a million people dead was the work of the fungus Phytophthora infestans, which wiped out the country’s staple potato crop.
While fungal diseases are common among plants, only a very small fraction of them assail humans. One reason is that animals, including humans, have evolved intricate immune systems.
However, when the immune system has been breached by another illness, fungi that are otherwise harmless take advantage and invade human tissues. These are called opportunistic infections. Even so, unlike their pathogenic bacterial counterparts, fungi rarely cause life-threatening diseases. A few fungi, like the Candida yeast, can sometimes kick off a serious infection. Candida lives on the skin and inside the mouth, throat and vagina of healthy persons without causing any problems. But if the host’s body has been weakened by another disease or drugs, it can cause oral thrush, diaper rash and vaginal infections.
The Mucoralean fungi are even less problematic. They include the genuses of Mucor and Rhizopus. These are ubiquitous molds occurring in the soil, compost, animal dung, rotting wood and plant material. You may have seen them as the black growth on old fruits and bread. Mucoralean fungi are generally the first colonisers of dead or decaying plant material. They rapidly utilise the limited amount of simple carbohydrates available before other fungi show up for the more complex carbohydrates, such as cellulose.
Like most fungi, Mucor produces millions of microscopic spherical, dark-hued structures called spores, which are dispersed in air. When the spores land on moist surfaces, like soil or plant material, they begin to germinate and produce thread like structures called mycelia. The mycelia branch out and feed on sugars in their surroundings and grow.
Fungal spores measure one thousandth to one hundredth of a millimeter. The density of the spores – the number of spores per cubic metre of atmosphere – varies depending on the fungus, the location (vegetation and exposed earth) and season. In tropical areas like in India, spore counts are generally higher during the summer than during the monsoons. But compared to the 1,000-5,000 spores per cubic meter outdoors, the count inside homes is typically 100-250 only. Five to 10 species account for more than 90% of the total spore density in the air.
As it happens, hospitals are not free from these spores. A study in Tehran in 2014 suggested that hospital air could carry many opportunistic pathogenic fungi like Candida, Aspergillus, Penicillium and Rhizopus.
Patients suffering from the fungal infection typically have symptoms of stuffy and bleeding nose; swelling of and pain in the eye; drooping of eyelids; and blurred and finally, loss of vision. There could be black patches of skin around the nose.
Doctors say most of their patients arrive late, when they are already losing vision, and doctors have to surgically remove the eye to stop the infection from reaching the brain.
In some cases, doctors in India say, patients have lost their vision in both eyes. And in rare cases, doctors have to surgically remove the jaw bone in order to stop the disease from spreading.
An anti-fungal intravenous injection which costs 3,500 rupees ($48) a dose and has to be administered every day for up to eight weeks is the only drug effective against the disease.
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One way to stall the possibility of the fungal infection was to make sure that Covid-19 patients - both in treatment and after recovery - were being administered the right dose and duration of steroids, says Dr Rahul Baxi, a Mumbai-based diabetologist.
He says he treated some 800 diabetic Covid-19 patients in the past year, and none of them contracted the fungal infection. "Doctors should take care of the sugar levels after the patients are discharged," Dr Baxi told me.
A senior government official says there is "no big outbreak". Yet it is difficult to say why a growing number of cases of mucormycosis are being reported from all over the country. "The strain of the virus appears to be virulent, sending blood sugars soaring to very high levels. And strangely, the fungal infection is affecting a lot of young people," says Dr Hegde.
His youngest patient last month was a 27-year-old man, who was not even a diabetic. "We had to operate on him during his second week of Covid-19 and remove his eye. It's pretty devastating."
When a patient whose immune system has been compromised inhales Mucor spores, they may develop mucormycosis. This is a rare, non-contagious disease – but it can be debilitating or fatal if not treated quickly. The frequency of mucormycosis infections has increased in the last decade, principally because of the greater number of organ transplants. People who have received transplanted organs depend on immunosuppressant drugs to keep their bodies from rejecting the new organs, but in this state they are also predisposed to infection.
People suffering from COVID-19, HIV/AIDS and other viral diseases, congenital bone marrow disease, severe burns, cancers and untreated or irregularly treated diabetes have reduced immunity and are prone to developing mucormycosis. COVID-19 patients who have received steroids are particularly at risk because steroids suppress the immune system. This is why steroids should not be used unless absolutely necessary.
Experiments with rats and rabbits have found that the inhaled spores in healthy animals are quickly killed by white blood cells. But if the host’s immune response has been suppressed, the body produces fewer white blood cells. In this condition, the spores germinate and grow rapidly as thin, wire-like tubes that branch out and enter the blood vessels and kill them.
When Mucor attacks the sinuses, it spreads to the lungs, the brain and the central nervous system. Common symptoms of the resulting mucormycosis include fever, headache, reddish and swollen skin near the nose or eyes, facial pain, cough producing bloody or dark fluids, and shortness of breath. Doctors can diagnose it through a tissue biopsy and an X-ray scan of the lungs.
The two drugs most effective at treating mucormycosis are amphotericin B and posaconazole – provided the infection is found early. However, the latter is hard to do because we don’t know of a reliable diagnostic feature of mucormycosis.
This said, there are a few simple steps we can follow to lower our risk of contracting mucormycosis. The first is to educate society about the disease. Second: we must periodically sample the air in hospitals, especially in the critical care wards, to check for the presence of spores. Third: we must ensure that the humidifiers used during oxygen therapy are sterile. Fourth: recovering patients should be advised to remain indoors until they regain their natural strength and immunity. Fifth: patients engaged in farming or gardening should be advised to lay off from work until the storm has settled.
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