What is mucormycosis black fungus infection? How do we get black fungus?
Mucormycosis, commonly known as black fungus infection, comes under fulminant fungal infection.
Mucormycosis or black fungus is curable only when detected in the early stages only.
Because a fulminant fungal infection is a type of fungal infection where the disease spreads in hours and days rapidly through the blood vessels.
It can double in a few hours, making it deadly.
Mucor is a fungus that causes this disease.
Mucor develops on dead matter and is black in colour. It thrives on decaying foods and dead organisms and is found in our atmosphere.
Mucor is found everywhere and enters our bodies daily, yet our immune systems are capable of combating it.
It can only impact us if our immunity is compromised. It can cause problems with the nose, sinuses, and other nearby structures.
Who can get black fungus?
Fulminant fungal infection can occur only when the immunity is deficient. Here is a list of patients who can get black fungus.
Organ transplant patients on immune suppressants
Cancer patients on anti-cancer drugs
Immune deficiency syndromes Eg: AIDS
Patients who are on steroids for months
Uncontrolled diabetic patients
Uncontrolled diabetes is generally the most common cause as it is the most common condition among the above-stated conditions.
Who can get black fungus if affected by COVID-19 ?
The chance of getting this disease increases when the above patients get COVID-19. Although most of the patients had diabetes, some had none of the underlying conditions other than COVID-19. A significant chunk of people didn't require any hospitalization or oxygen support. You can find more details in Mucormycosis after COVID section of this article.
Is mucormycosis or black fungus curable ? / Treatment of mucormycosis
Mucormycosis or black fungus is curable when identified in a very early stage. The earlier you diagnose, the earlier you recover. Treatment for this disease can go on for 15 to 40 days, depending on the timing of diagnosis and immunity of the patient. Typically the survival rate is 90% if identified early only. The treatment of mucormycosis must be started on suspicion to keep the survival rate high. Waiting for a few hours to confirm the tests can give the fungus time to double and change the person's fate.
If you identify in late-stage, most doctors don't see a point in the treatment as most likely fungus will attack the brain bringing down survival chances to as low as 5%. It will unnecessarily create pain and financial loss to the patient and give the patient and his family unnecessary hope. In fact, the author says he doesn't take in the patient who has fungus spread to both eyes or brain or multiple organs in the face. He believes that the recovery of such patients will be a miracle he has never witnessed personally or hasn't heard of the recovery to date from his colleagues and would rather leave them untreated and ask them to spend their last days with their loved ones. However, few books state a single-digit percentage chance of recovery. Dr. K. R. Meghanadh says it would involve the removal of multiple organs in the face and would leave a heartbreaking image of the loved ones to their family in their final days. The chance of survival is so low that it is not worth taking risks. This is Dr. K. R. Meghanadh's opinion as a doctor, but opinion could vary from doctor to doctor as it is a matter of choice.
Dr. K. R. Meghanadh has observed that COVID-19 patients were recovering a shade quicker when compared to patients before COVID-19. Unlike diabetes, cancer, or AIDS, recovery time in COVID-19 is less, and the patient's immunity gets better quickly.
Due to the shortage of expert ENT doctors in mucormycosis, Dr. K. R. Meghanath saw many recurrent cases. Treating recurrent cases is tougher than first-timers as the patient's body has already gone through the vigorous medication of powerful antifungal drugs. The body will be a bit more sensitive than the first time. Please read this article for more details.
Recurrence of Mucormycosis due to partial treatments
Why is it deadly?
Black fungus infection is a fulminant type of fungal infection that spreads through the blood vessels rapidly. It doubles up its presence every few hours. It spreads from the nose to sinuses in a few days and eyes and jaw bone in a couple of days. When it ultimately spreads to the brain, the survival chances are negligible, and a doctor might deny taking up the case. The speed, however, depends on the immune status of the patient. This is why doctors start antifungals on suspicion of the disease and do not wait for confirmation.
Precautions for black fungus
The most common underlying disease or reason for black fungus infection in patients irrespective of COVID-19 is due to diabetes. In fact, few metrics say that mucormycosis cases per million people in India are much higher than in the rest of the world. A major reason could be that India has a very high percentage of people who have diabetes, and the majority of them are uncontrolled. Controlling diabetes can help in reducing the changes in black fungus cases.
Precautions for COVID-19 patients
We can prevent this by controlling COVID-19 with antivirals like favipiravir or molnupiravir at the very early stage, which can help slow viral infection and decrease the viral load in the body thus trying to keep the immunity of the person intact.
N95 mask can block the black fungus seeds very effectively. Wearing an N95 mask during and continuing after a few weeks of the infection can exponentially reduce the mucormycosis risk. You must remove the mask only when necessary, i.e., eat or drink. People who can get black fungus must follow this when affected by COVID-19.
Mucormycosis fungal infection symptoms
• A very severe pain in the cheekbone, teeth, eye, or head, which cannot be relieved by regular pain killers - the first symptom observed
• Black nasal discharge
• Double vision
• Deterioration of eyesight
• Swelling of eye, nose, or cheek
• Watering of the eye
• redness of the eye
Mucormycosis or black fungus infection spreads rapidly compared to other fungal infections, and the same goes for symptoms. Most of the fungal sinus infection symptoms are similar. They appear to progress rapidly in black fungus.
How to diagnose mucormycosis?
Even if we have one symptom mentioned above, we must consult an expert ENT doctor who will conduct a nasal endoscopy. If the doctor finds a black material inside the nose, there is a high probability of having mucormycosis. A small sample of the black material is scraped and sent to culture and biopsy to prove the diagnosis. Still, the doctor will start the anti-fungal medication even before the culture results as a precautionary measure.
Mucormycosis black fungus infection treatment
If the disease has progressed, i.e., to multiple parts of the face, the surgeon might not see the point in treating and ask the patient to leave. Else, he will start the medication on doubt even before the biopsy report of the black dead skin in the nose comes, as the progression of the disease is very fast, and it might end up doubling before the report comes and the risk is not worth it.
There could be multiple surgeries to remove the fungus as the disease progresses. A surgeon, upon confirmation, must immediately remove every black bit in the body by the endoscopic or open method on confirmation. The surgery might include the removal of an eye or a jaw bone. After the surgery, a doctor gives medical treatment for 15 to 40 days. This treatment includes AmphotericinB DOC and posaconazole. Posaconazole is in tablet form but must be used under the guidance of a registered medical practitioner with experience. AmphotericinB DOC is offered in a graded dosage of around 1.5 grams in injection form. AmphotericinB DOC has many side effects like reducing potassium, calcium, and hemoglobin levels. Patients can often have fever, chills, vomiting sensation, and loose motions that need to be corrected by additional medication.
The recovery will depend on the patient's immunity, and there will be chances for recurrence of mucormycosis. The chance gets lower if the ENT surgeon is experienced in mucormycosis treatment.
Mucormycosis after COVID
The author was among a few ENT doctors in Andhra Pradesh and Telangana who treated mucormycosis black fungus infection cases before the COVID-19 pandemic. You cannot credit this to his talent or experience but to the rarity of this disease. Pre-COVID in more than 20 years, he has hardly seen five to ten cases per annum. So, only a few ENT doctors used to treat fulminant fungal infection cases. If every ENT doctor in the state or world wanted to treat mucormycosis, then no one would be an expert, and it is patients who would suffer the most. In India's first wave of COVID-19, he saw around 30 patients. During the second peak of COVID-19 in India, he saw a minimum of five patients daily despite the increase in ENT doctors treating mucormycosis. The author witnessed more than 500 cases and treated 170 patients during the COVID-19 second wave. The author was worried about seeing the alarming increase in mucormycosis patients due to the fungus progression and success rates. On May 9th, 2021, Dr. K. R. Meghanadh said,
"I am distraught about the horrors I have to see in future. I have removed five jawbones and two eyeballs in this one week. I declined 14 patients' treatment today as I don't see chances of recovery in them."
Omicron, thankfully didn't affect immunity as much as Delta and Alpha did. The hospitalization rate in Omicron cases was negligible, and most of the patients were admitted due to some other complications. In the third wave driven by the Omicron virus, Dr. K. R. Meghanadh didn't get any post-COVID mucormycosis.
COVID-19 attacks the immune system. When a patient has any one of the above five conditions, the possibility of getting mucormycosis post covid rises. But, we have observed that most of the mucormycosis patients who got post covid have diabetes. However, there were patients without the above conditions and only COVID-19, including two kids (2 and 8-year-old boys).
The doctor must give every antifungal injection like conventional Amphotericin-B in the form of an IV, which can take up to 8 hours for the dose. The hospital must give the antifungal dose only in the ICU, which has restricted the intake of mucormycosis-infected patients during the second wave of COVID-19 in Dr. K. R. Meghanadh's hospital. They can take only three patients per ICU bed, and they had no scope to compromise. Every patient will take from 20 to 40 days of treatment which made expert doctors reject many patients as taking extra patients would mean a compromise on both already admitted patients and patients being admitted. Keeping the disease progression in mind, they cannot wait for other patients' discharged to admit a new patient. So, ENT doctors who had minimal experience and knowledge of the shortage of time and beds with experts in mucormycosis had to take up these cases and it was the best choice to keep the patient alive in the given crisis. Although it knowingly meant a higher chance of recurrent mucormycosis for the patients admitted than the expert doctor.
Myths on black fungus infection
There is a lot of misconception in the public that we have to look for changes in eyes to detect mucormycosis or a person with mucormycosis will have red eyes or swelling in the eyes. There were even rumors that we needed to check our noses for black discharge. However, both of these are mucormycosis fungal infection symptoms. These are not the first symptoms, the first symptom is severe facial pain, and a patient must consult a doctor before these symptoms appear. Nasal discharge is an infrequent symptom.
During the second wave of COVID-19, many media and social media channels were behind why mucormycosis black fungus infection cases were only in the Indian subcontinent. This led to giving out many theories with the help of a few ENT doctors, few could have some weight, but most of them are false. This is because most doctors don't have prior experience with mucormycosis due to the rarity of the disease. In fact, the books they read might also be insufficient. The disease is so rare that witnessing a black fungus disease during the PG of an ENT doctor is super rare, and if the doctor is exposed to even one patient with this disease, he is considered lucky.
- There is a myth prevailing that steroid medication taken for COVID is the cause. Steroids taken for a few weeks do not impact the immunity to a considerable amount. So steroids taken for COVID treatment under an expert doctor for a few days will not tend to cause mucormycosis.
Oxygen has nothing to do with mucormycosis. Many media channels have reported that black fungus could be due to unhygienic oxygen pipes, cylinders, or the use of industrial oxygen. Check out our article "Don't link Mucormycosis / Black Fungus and Oxygen Cylinders."