‘Black fungus’ new scare in India as second COVID wave ebbs

India battles a new challenge in mucormycosis, a rare fungal disease with a high mortality rate commonly referred to as ‘black fungus’.

As a devastating second wave of COVID-19 ebbs with less than 100,000 new cases reported on Tuesday, India is now battling a new scare: Mucormycosis, commonly referred to as “black fungus”, is a rare fungal disease with a high mortality rate.

On Monday, Health Minister Harsh Vardhan said the country had more than 28,000 cases of fungal infection.

“From 28 states, we have some 28,252 cases of mucormycosis till now. Out of this, 86 percent, or 24,370 cases, have a history of COVID-19, and 62.3 percent, or 17,601, have a history of diabetes,” Vardhan said in a meeting with a group of federal ministers.

“The highest number of cases – 6,329 – have been recorded in Maharashtra, followed by Gujarat with 5,486, and then Madhya Pradesh, Uttar Pradesh, Rajasthan, Haryana, Karnataka, Delhi, and Andhra Pradesh,” he said.

What is black fungus?

Mucormycosis causes blackening or discoloration over the nose, blurred or double vision, chest pain, breathing difficulties, and coughing of blood. Coronavirus patients with diabetes and a weakened immune system are particularly prone to attack.

Pain and redness around the eyes or nose, fever, headache, coughing, shortness of breath, bloody vomit, and altered mental status are some of its symptoms.

Health experts say India’s poor air quality and excessive dust in cities, like Mumbai, make it easier for the fungi to thrive, terming the recent spike in cases a matter of “serious concern”.

“We and most mainstream hospitals have seen more mucormycosis cases in the past month than in the previous five years,” Dr. Arvinder Soin, chairman of the Medanta Liver Transplant Institute at Gurugram, said.

While black fungus has been found in India before, the current spike in infections is among people infected with COVID-19 and those who have recovered from the disease.

Dr. Sumit Mrig, who heads the ENT department at Max Smart Super Speciality Hospital in New Delhi, said they used to see one or two such cases in a week before the second wave of the pandemic.

“The numbers have drastically increased this time and at present, we are seeing five to six such patients on a daily basis,” Mrig said.

He said the outbreak has “put tremendous pressure on the health infrastructure”, especially on the availability of Liposomal Amphotericin-B, the last-line drug being used to treat black fungus and which he said is “suddenly in short supply in the country”.

“Apart from the high mortality associated with a disease which rapidly spreads from nose and sinuses to the eye and brain in a span of 24 to 48 hours, if treatment is not initiated on time, the patient can lose his eyesight. Once it involves the brain, the mortality is approximately 80 percent,” Mrig added.

How is the infection treated?

Liposomal Amphotericin-B is allocated to the states by the federal government based on the number of cases reported by them.

Several states have reported a shortage of vital drugs as Indian missions across the world scramble to secure supplies. India last week imposed curbs on the export of Amphotericin-B injections.

Opposition parties, including the Congress party, have questioned Prime Minister Narendra Modi over the handling of the black fungus scare.

“What is being done for Amphotericin B drug shortage? What is the procedure for getting this medicine to the patient?” Congress leader Rahul Gandhi asked in a tweet last week.

“Instead of giving treatment, why is the public getting bogged down in formalities by the government?” he posted.

Also last week, the Delhi High Court directed the federal government to form a policy on the distribution of Liposomal Amphotericin B drug.
The court also said the administration of the drug must be “prioritised” for those “with better chances of survival as also the younger generation, having promise of future over the older ones who have lived their lives”.

‘Steroids make things worse’

Medanta hospital’s Dr. Soin said that during the second wave of COVID, the fungal infection is affecting coronavirus patients three to six weeks after recovery, most commonly those who have uncontrolled diabetes or were treated with steroids.

“While steroids are life-saving for many patients with COVID, many cases could have been prevented if their diabetes was better controlled and steroid use was restricted,” he said.

Dr. Jayaprakash Muliyil, an epidemiologist at the Christian Medical College in the southern state of Tamil Nadu, said irregularity in attending diabetic patients is a likely cause of mucormycosis.

“When a patient is diabetic and is admitted to a ward, usually repeated blood sugar checking is done and doses of whatever required drug are adjusted to control it. But during COVID, these protocols are not fully followed in many hospitals. That could be one of the reasons,” he said.

“When blood sugar goes out of control and they [patients] are on steroids, that makes things worse.”

Experts suggest high-risk diabetics who have recovered from COVID-19 should be careful and any red flags should be immediately reported to an ENT surgeon.

“If we keep the sugar level of COVID-19 patients in control, I believe you won’t have this problem and we can do that.” Dr Muliyil said.