Dr. Koralla Raja Meghanadh
Mucormycosis / black fungus infection
Updated: Feb 22
Introduction | Causes | Treatment | Precautions | Symptoms | Diagnosis | Myths | Relation to COVID-19
What is mucormycosis black fungus infection?
Mucormycosis, known as black fungus, is a fulminant fungal infection. It occurs only when a person's immune system is compromised.
Organ transplant patients, cancer patients, those with immune deficiencies, long-term steroid users, and uncontrolled diabetics are at risk for this infection.
COVID-19 patients also have a higher risk of getting black fungus. The risk gets higher when a person has one of the above conditions.
Treatable when found early, but harder to treat if found late. To prevent this disease we can control diabetes, as it is the most common cause of the disease.
How do we get black fungus?
Mucor is a fungus that causes this disease.
Mucor develops on dead matter and is black in color. 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 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.
Treatment of mucormycosis
Treatment of mucormycosis requires a combination of surgical removal of infected tissues and antifungal medication to stop the growth of fungus in the body.
Treatment for this disease can go on for 15 to 40 days, depending on the diagnosis's timing and the patient's immunity.
Typically the survival rate is 90% if identified early only.
The earlier you start treatment, the earlier you recover, and the chances of recovery are higher.
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.
Black fungus in late stages
If you identify late-stage, most doctors don't see a point in the treatment as, most likely, the fungus will attack the brain bringing down survival chances to as low as 5%.
It will unnecessarily create pain and financial loss for the patient and give the patient and his family unnecessary hope.
The author says he doesn't take in patients with 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 the sinuses in a few days and the eyes and jawbone 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 painkillers - the first symptom observed
Black nasal discharge
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 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 are 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 speed of 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 of the above five conditions, the possibility of having 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 the eyes to detect mucormycosis, or a person with mucormycosis will have red eyes or swelling in the eyes. There were 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. 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 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."
What is the first symptom of black fungus?
The first symptom of black fungus is severe pain in the cheekbone, eye, teeth, or head, which regular painkillers cannot relieve. This symptom is crucial for identifying the infection, as it is mandatory and appears during a critical stage. Starting treatment promptly during this stage increases the likelihood of the person's survival.
Can you get mucormycosis at home?
Yes, we can get mucormycosis at home.
Mucormycosis is caused by a fungus called mucor, which is present everywhere in our environment and enters our bodies daily. However, our immune systems are capable of fighting the fungus easily.
It can only affect us when our immunity weakens. To know who can get black fungus, click here.
How fast does mucormycosis spread?
Mucormycosis has the potential to spread super fast through the blood vessels, causing the fungal load to double within a matter of hours. The rate of spread may vary depending on the patient's immune system strength.
What triggers mucormycosis?
Mucormycosis, or black fungus, is triggered when our immunity is compromised.
The fungus responsible for the infection is Mucor, which is found everywhere and enters our bodies daily. However, as long as our immune system is functioning correctly, it can fight off the fungus. It can only attack us when our immunity is weak.
To check out the list of patients "who can get black fungus," click here.
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