Recurrence of Mucormycosis due to partial treatments

Dr. K. R. Meghanadh

During and after the second wave of COVID-19, India saw a sudden spike in mucormycosis cases. These days, the number of new black fungus cases has come down, but discharged patients are returning with recurrence of mucormycosis due to partial treatments.

Pre-Covid, the number of mucormycosis and aspergillosis (so-called white fungus) cases per annum were few. Sometimes in single digits. The percentage of doctors who had witnessed black fungus cases during their UG or PG (including ENT) is significantly less. Few UG medical books even mention mucormycosis. To treat black fungus cases efficiently, an ENT surgeon needs good experience with surgery and medications, which are very difficult to achieve due to the rarity of this disease. So, before COVID, there used to be a couple of ENT doctors who used to treat these cases. However, due to the rise in black fungus cases, many doctors started treating mucormycosis cases. In books, they mention multiple types of treatment modalities. Many doctors have just read this but do not have practical experience with it.

A balanced treatment with multiple medications and timely initiation of different medicines is required. The treatment must be tailored to the patient’s needs and individualized to avoid the relapse of mucor, which can be learned only by experience. Generalized and standardized treatment protocols are unlikely to give a high success rate of 90%.

Repeated surgical clearance and debridement of the fungus from the nose and adjacent structures is required. If incomplete, then success will be rare. Therefore, a combination of good surgeries and effective antifungal use judiciously is required to prevent fungus resistance and reduce the side effects of the medication.

In patients with multiple fungal infections, the modal treatment must also be with multiple antifungal drugs. While choosing the antifungal drugs in multiple drug therapy, one has to keep the profile of the side effects of the drugs in his mind because all the antifungal drugs can have a negative or positive interaction with the other drugs. For example, anti-acid syrup Digene can reduce the absorption of the Posaconazole drug. Similarly, some medications can enhance the action and toxicity of antifungals. If the doctor is not aware of these actions, there could be severe side effects of the drugs or the efficiency of the drugs might reduce. However, a doctor can make use of these actions positively. By adding one drug, a doctor can reduce the use of antifungals. For example, if we add Azithromycin to Posaconazole, Posaconazole’s efficiency will rise by 25 to 50 percent, so the Poscaconazole dose must be reduced. In a time frame with a scarcity of Posaconazole, Dr. K. R. Meghanadh reduced the dose of Posaconazole to 70%, added Azithromycin in his patients’ prescription, and managed all his 40 mucormycosis patients comfortably with the available medicines.

What led to this situation?

Please do not interpret this article as a criticism of ENT doctors whose patients had a relapse of mucormycosis. We must understand that mucormycosis is a stubborn and rare disease. Even for a patient with the best treatment under the best doctor, there will be a chance of recurrence. It is just a change in the percentage of the chance of relapse between experienced and non-experienced. Even the information and experience that most of the ENT doctors have are not sufficient.

Before COVID, if an ENT doctor without experience wanted to treat a mucormycosis to get experience without sending it to the experienced ones, that would be his/her selfishness. Now, post-COVID, all experienced doctors cannot accommodate all the cases present. If the doctor just left the patient because he had no practical experience, the patient’s disease will progress, and the patient can die within a few days. It is almost impossible to ask the patients to wait for an experienced doctor, as each patient's treatment will take 20 days to 40 days, and the chance of getting the bed is meager considering the time frame we have. If the patient keeps waiting for bed with an experienced doctor, he might die waiting, or the disease might spread to the brain. Mucormycosis doubles in a few hours based on the person's immunity, and it will not wait for some experienced doctor to come and treat it. So, doctors did what was best for the patients in that given time and scenario. All these situations are not because of wrong doctors or governance. It is just because of an unexpected terrible situation.

It is easy to blame than to accept the bitter truth.

Written by

Dr. K. R. Meghanadh