Doctors are reporting a rise in cases of a rare black fungal infection, called Mucormycosis, among COVID-19 patients in India. The life-threatening infection often occurs in people with weak immune systems, such as severe diabetes. It can be fatal if left untreated.
Though there presently exists no study linking COVID-19 to mucormycosis, many doctors have observed that recent mucormycosis cases coming for treatment are those who recently recovered from COVID-19 and who have high blood sugar levels. The number of such cases have also sharply risen, they say. However, mucormycosis is not contagious, that is it does not spread from person to person.
The infection is caused by mucormyete molds, an organism present in the air, in leaves, piles of compost, soil and rotting wood. When exposed, the fungus can infect your central nervous system, eyes, sinuses, lungs, etc. But not everyone exposed to the fungus catches the infection.
Early symptoms of the infection include obstruction in the nose, swelling in the eye or cheeks, and black dry crusts in the nose, smelly black nasal discharge, face numbness, fever, cold, etc. If neglected, it can even spread to the eyes and then the brain, making it fatal. If it entered the body via a cut or bruise in the skin, it could show up as blackened skin tissue.
Typically, the infection overtakes the host when the latter is immunocompromised. That is why it is reported in persons with uncontrolled diabetes mellitus, HIV and cancer patients, those who had organ transplant, etc. Prior to COVID-19, most mucormycosis cases were reported in those with these conditions. The United States’ Centers for Disease Control and Prevention (CDC) estimated a yearly rate of 1.7 mucormycosis cases per 1 million population. The CDC also reported a mortality rate of 54% of mucormycosis cases.
However, since the pandemic, persons who have recovered from COVID-19 too have been contracting the disease. In fact, the Gujarat Health Department had in December issued an advisory to doctors and officials over the recent spurt of cases among COVID-19 patients.
Many of these cases are mucormycosis of the maxilla or upper jaw, which leads to the entire jaw detaching from the skull.
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“The infected person’s upper jaw comes off, just like a denture. They have to go for a primary reconstruction of the jaw if this happens,” says maxillofacial surgeon Dr M Veerabahu, president of the Association of Oral and Maxillofacial Surgeons of India (AOMSI).
The aggressive fungus is ‘angioinvasive’, which means it enters and blocks blood vessels and can cut off blood supply to the tissue. “When blood supply is cut off, the bone in the upper jaw dies. The dead bone then detaches from the live bone and comes out,” Dr Veerabahu explains. The fungus is found in the border of the dead and live bone and keeps killing off more bone by blocking blood, explains Dr Sonal Anchlia, Professor and Head of the Department of Maxillofacial Surgery at the Govt Dental College and Hospital, Ahmedabad.
“The infection is so aggressive that it spreads faster than cancer. In 15 days, it can spread from your mouth to eyes and within a month to the brain,” adds Dr Sonal.
Dr Sonal has been studying the mucormycosis patients coming to her hospital. Over the last four months, her team has been collecting data for further analysis. Their early results point to a specific pattern and frequency of cases.
“Pre-pandemic we were seeing one case a month. But over the last four months, we have been seeing two-three cases a day. I have been operating one case every single day for several weeks now,” she says.
Out of the 50 cases that the hospital has treated, nearly 46 had a history of COVID-19. “Many of them had come from rural areas and had not been tested. However, they too reported chest congestion and pneumonia like symptoms indicative of COVID-19,” she adds.
From Gujarat to Madurai, a spike in mucormycosis cases has been reported in the country. In December, 13 cases were reported in Delhi’s Sri Ganga Ram Hospital, where patients had loss of eyesight, removal of nose and jaw bone. Five deaths too were reported in Delhi.
Dr Sonal’s hospital has reported four-five deaths due to aggravated mucormycosis. Some of the patients had intracranial infection, meaning the fungus had spread to the brain.
“These are the cases coming to hospitals. But, you can only imagine the number of patients visiting ENT clinics thinking that the black crust inside their nose is just a minor infection. Even if the crust is removed from the nose, the fungus can spread aggressively if not completely removed,” Dr Sonal explains.
Speaking to TNM, Dr Veerabahu adds that the main trigger for the infection is not COVID-19 but suppressed immunity. The reasons for low immunity can be many.
“COVID-19 itself affects the immune system and has been found to alter the glucose metabolism in people. This is ideal ground for the fungus to take over, just like with diabetic patients who have low immunity and high sugar levels,” he adds. COVID-19 is known to damage lung cells through cytokine storms. To treat this, patients are put on steroids, which suppresses immunity and spikes blood sugar levels.
But other reasons too are reported. Over the lockdown months, several comorbid patients had access to regular medical care cut off. This includes cancer patients, those with severe diabetes, etc. Lack of proper medical care coupled with poor dental hygiene could be another trigger, Dr Veerabahu adds.
“I have seen patients with multiple cavities, bad odour, tartar on gums, mobile teeth come in infected with mucormycosis. Mostly, they have elevated blood sugar levels too,” he explains.
However, with COVID-19 patients, the pattern is unpredictable, say both Dr Sonal and Dr Veerabahu.
The fungal organism causing mucormycosis. Image credit: NCIB
“I had a 43-year-old patient with no comorbidities and perfect dental hygiene who came with mucormycosis. When we checked his sugar levels, it was over the roof. The thing is, most COVID-19 patients are unaware about the spike in their blood sugar levels,” Dr Veerabahu adds.
While earlier prognosis of patients with mucormycosis was predictable, with COVID-19 these cases have become more complicated. Some patients have died after being administered general anaesthesia. Some cases of acute renal failure following the procedure too have been reported. Certain patients do not react well to the Amphotericin B injection, a strong drug which can cause side effects and should only be used to treat potentially life-threatening fungal infections.
“Amphotericin is administered before and after the procedure. With some patients with severely affected lungs due to COVID-19 triggered cytokine storms, the Amphotericin B injection can have a serious impact,” Dr Sonal says.
Experts from three different disciplines – Maxillofacial surgery (upper jaw, cheek bones, etc.), Ophthalmology (eye) and Neurology (brain and central nervous system) – work together on advanced cases of mucormycosis. In case the infection has spread to the eye, ophthalmologists are roped in for treatment, which can even include removal of the eyeball in severe cases. In case it has spread to the brain, neurologists are roped in during the final stage of treatment.
For immunosuppressed patients particularly and others in general, it is important to maintain oral hygiene by brushing frequently, wearing fresh masks, etc.
“As a community, we don’t regularly visit the dentist. This is important to identify and avoid such potential infections. I would recommend a dental check-up once in six months,” Dr Veerabahu says. However, these measures only help to reduce the risk of infection.
Dr Sonal adds that checking blood sugar levels and keeping them in control is crucial, especially for COVID-19 recovered patients or those who experience COVID-19 symptoms such as pneumonia, etc.
If a person notices even a small indicator, like a tiny oral ulcer or discharge or any of the earlier listed symptoms, it is important to consult a doctor immediately, she says.