ISLAMABAD: The hospital of the Mahatma Gandhi Institute of Medical Sciences, a medical school in the town of Sevagram in the Indian state of Maharashtra, has been taking in patients afflicted with COVID since May 2020. But in the middle of last month, something changed. Patients arrived with problems the physicians there had not yet seen in the pandemic: people were not only breathless and feverish yet had pain and pressure behind their cheekbones and around their eyes, foreign media reported.
Their cases were some of the earliest indications of a wave of illness that is now swamping India, an epidemic within the pandemic: infections with a rare group of fungi called mucormycetes. The infection they cause, mucormycosis—”black fungus,” colloquially—can infest the sinuses and bones of the face and invade the brain or cause patients to lose an eye. When it goes untreated—and treatment is prolonged and difficult—mucormycosis can kill up to half of those who contract it. There have been almost 12,000 cases of the infection in India during current COVID-19 wave, with most of them occurring in the western states of Maharashtra and Gujarat. A range of states across India have declared the outbreak black fungus an official epidemic. Friday alone, the government of Delhi reported 153 new cases. It is not contagious but its rapid rise in recent weeks has left doctors shocked. Dozens of hospitals across India have seen patients hit by the rare condition, which has a mortality rate of about 50 per cent. So far, 300 people have died as a result of the extremely rare condition, according foreign media. Early diagnosis and treatment, however, significantly improve survival chances.
Mucormycosis causes vital organs to rot, include the brain, lungs and sinuses. Some doctors have had to remove infected jaw bones, noses and eyes in order to save patients, namely to prevent the mucor from spreading to the brain.
Before the outbreak of the coronavirus pandemic, Mucormycosis was close to non-existent, with only a few known cases reported every year.
Mucormycosis is caused by exposure to mucor mould, which is commonly found in soil, air and even in the nose and mucus of humans. It spreads through the respiratory tract and erodes facial structures.
“It is a new challenge and things are looking bleak,” Ambrish Mithal, the chairman and head of the endocrinology and diabetes department at Max Healthcare, a chain of private hospitals across India, told media.
He explained that the fungal infection “preys on patients with weakened immune systems” and underlying conditions, particularly diabetes, and irrational usage of steroids.
Uncontrolled blood sugar can further put immunocompromised people at a higher risk of contracting the disease.
Health experts are worried that over-the-counter medication, including steroids, can increase the prevalence of mucormycosis. SK Pandey, a medical officer at Ram Manohar Lohia Hospital in Uttar Pradesh state’s Lucknow, warned that unqualified doctors were giving steroids to patients in many rural areas without giving a thought to whether they require it or not.
“This has led to increase in black fungus cases in smaller cities where the patient has not even been hospitalised,” he added.
These fungal infections arise after a COVID diagnosis, which seems to be a clue. A standard component of treatment for severe cases of COVID is high doses of corticosteroids, anti-inflammatory drugs that damp down the immune system’s overreaction to infection. Steroids save lives, but they simultaneously make a patient more vulnerable to attack by whatever bacteria or fungi are already in their body or hanging around their environment.
Identifying a case of mucormycosis early can be challenging. Unlike some other fungal infections, there are no blood-based tests that can detect it. Diagnosis requires doing a biopsy, examining the sample and sometimes following up with a CT scan—all of which imply the availability of specialty personnel to perform those tasks and advanced equipment to support them. In the under-resourced parts of India’s vast health care system, those cannot be guaranteed.
Even antifungal drugs are in short supply in India, according to news reports, and they may be unaffordable for most. There are relatively few categories of antifungals, and while some of them have been available for decades, newer versions that are less toxic to patients are expensive and scarce. For the preferred drug, “one-day therapy costs 30,000 rupees (PKR64,000), a catastrophic health expenditure for 99 percent of Indians,” Kalantri says. “The therapy often lasts for weeks and requires an intravenous infusion, admission to the hospital and close monitoring of the kidney function.”