Mucormycosis: Before and after COVID-19

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Even before the pandemic, the prevalence of black fungi in India accounted for 70 percent of the global prevalence. According to health experts, the estimated prevalence in India before this pandemic was about 14 cases per 100,000 population.

Last year, COVID-19 shocked India. This year, it focused on mucormycosis. Mucor disease, also known as black fungus, is a rare and serious fungal infection caused by a fungus named Mucor. It is said that humans may touch the pores of black bacteria that exist in the environment. According to health experts, the disease is not new, but it was caused by COVID-19 because steroids were used to treat patients with comorbidities who suffer from COVID-19.

“The opportunistic infection mucormycosis is caused by uncontrolled diabetes, indiscriminate steroid use, and immunosuppressive drugs such as tocilizumab and trauma. Patients with COVID have a weakened immune system, many of which Steroids are being given to regulate the excess immune system. COVID patients are more susceptible to this infection as a result of these variables. It is an opportunistic fungus in the nose, sinuses, eyes and brain. It is an infectious disease and is called Rhino Orbito Cerebral Mucormycosis (ROCM), “said Dr. Syed Asghar Hussain Naqvi, Head of Clinical Services at Agarwal’s Eye Hospital in Terrangana.

Sharing a similar view with Dr. Naqvi, Dr. Ashutosh Kumar Singh, a senior consultant at Sharp Sight Eye Hospitals, said that mycosis affects the nose, sinuses, and orbits of patients who are taking immunosuppressive drugs or who have no control over diabetes. He also said that it is a rare fungal infection that usually affects.

“COVID-19 caused mucormycosis due to the widespread use of steroids in these patients. Other factors that trigger this infection are dysfunctional blood cells and acute reactions in COVID patients. Rising (such as ferritin). Even before the pandemic, the prevalence of steroids in India accounted for 70% of the global prevalence. The estimated prevalence in India before this pandemic is There were about 14 cases per 100,000 population, “he explained.

As an ophthalmologist, Dr. Kasu Reddy, Chief Surgeon, Founder and Mentor, and Co-Chair MaxiVision Eye Hospitals’ exposure to mucormycosis is a real-life condition and is ROCM. That is, it affects the nose, eyes, and brain.

He states: “Mucormycosis has co-existed with us from the beginning, along with spoilage substances and bacteria that exist around us in the soil, but it is common compared to other parts of the world. It is more common in India because of unsanitary conditions, and also because diabetes is a major risk factor for the same thing. In the current COVID-19 condition, the virus itself causes hyperglycemia, or diabetes. COVID-19 treatment requires steroids that add fuel to the fire. COVID viruses that cause diabetes, COVID treatments that require steroids, and steroids that re-induce hyperglycemia reduce immunity. And causes mucormycosis. “

He also emphasized that “diabetes has always been one of the most common risk factors for developing zygomycosis, even before the COVID-19 pandemic.”

Impact and treatment

According to Dr. Lady, the effects of mucormycosis are the removal of all parts of the inside of the nose, including the septum, and the eyes, from mild symptoms such as black nose, bleeding and secretions from the nose, swelling and protruding eyes. It can be anything up to the removal of.

“Mucormycosis infections are rare and not contagious. Nevertheless, in the current pandemic, this condition is far more by doctors due to the sudden surge in cases and the debilitating surgical treatment. Unlike COVID-19, the mortality rate is as high as about 54%, and the distribution of mortality is 31.8% for ROCM, 21.2% for dissemination, 17.8% for lung, 14.8% for gastrointestinal, and renal. 4.5% for cases and 4.5% for skin, “he notified.

Dr. Naqvi revealed that COVID-19 is damaging the retina.

“In COVID patients, in addition to vascular occlusion, there is an incidence of local inflammation (called retinitis). ROCM can be life-threatening if not responded on time. In proven cases , Liposomal amphotericin B is the first line of management. Even if the Mucor disease infection affects the eyes, it can be treated with drugs or surgery. In many severe cases, it is a life-saving measure. A combined approach by amphotericin surgeons and ophthalmologists is needed to extensively debleed man’s resection of infected nasal passages, sinuses and orbits. “

In addition, Dr. Lady said there are two types of treatment for zygomycosis: medical treatment and surgical treatment.

“Medical treatment is hospitalization for IV injections of amphotericin B, and these drugs have side effects. The disease affects blood vessels, blocking the blood supply to tissues and killing them. It’s like a diabetic foot necrosis, the only treatment at that stage is surgery, and the surgery is called a wound resection of black dead tissue. If the nasal sinus is involved, it’s medium. Remove all black areas inside the nose, including the gap, and if it spreads to the eyes, we will do our best to save the eye and optic nerve, but when they are affected, the eyes and surrounding tissues are complete. This is called eye resection. “

Discriminating use of steroids is arguably one of the main reasons for the surge in black fungal infections, Dr. Lady said, while amphotericin B use is in a different situation than steroids, according to relevant medical authorities. He suggested that it is important to regulate treatment protocols. , And the availability of a drug in the current scenario is a much more serious problem than considering it as a regulated drug.

Dr. Singh also emphasized that steroids should be used with caution in COVID patients only after consulting a doctor. Dr. Naqvi advised in the same way.

“Wise and supervised use of steroids is essential to prevent zygomycosis. The life-saving drug amphotericin B should only be regulated, supplied and administered by authorized personnel,” Naqvi said. The doctor emphasized.

The states most affected by mucormycosis include Gujarat, Maharashtra, Andhra Pradesh, Madhya Pradesh and Telangana. A warm and moist climate favors the growth of such fungi, Dr. Singh said.

Can Mucormycosis be a Nosocomial Infection?

In Dr. Naqvi’s opinion, mucormycosis infection is determined by the patient’s immune status and source of infection.

“Contaminated oxygen and humidifiers can be a source of infection for people with a predisposition. Therefore, to prevent infection, the tubes should be replaced regularly and the oxygen humidifier should be filled with distilled water. “He said.

Dr. Singh said mucormycosis is usually found in uncontrolled diabetics, immune-compromised patients, and patients taking steroids. It cannot spread from patient to patient. Therefore, in most cases it is not a nosocomial infection.

“Some reports have observed that about 40-50% of COVID patients who develop black fungus do not take oxygen supplements during treatment. Therefore, oxygen alone cannot cause Mucor infection. “He pointed out.

Dr. Lady warned that mucormycosis is rare in a hospital environment, but should be suspected if a black lesion appears next to a postoperative wound.

“In such scenarios, direct histology, culture, and histopathology should be performed. Hospital outbreaks include plasters, ventilation systems, wooden tongue indenters, oxygen humidifiers, and stains during spraying. It can be caused by sterilized water, and the humidity of the ICU is too high. Therefore, sterilized water should be used for the humidifier and the filter of the ventilation system should be replaced frequently. Masks, especially disposable types, are important. All post-COVID patients should continue to wear the mask for a year, “he warned.

Mucormycosis after COVID

Dr. Naqvi recognizes the importance of taking a balanced and wise approach to drug use due to zygomycosis, which was less common before the COVID era, and found that mild fungi are also fatal. I warned that I might.

Dr. Lady also commented that increased awareness of mucormycosis will certainly change awareness of mucormycosis after the COVID-19 era. Therefore, people will come to the doctor early.

“I want to be more cautious after oxygenated inpatients, diabetics, and steroid patients are discharged. They are healthy to control diabetes and boost immunity. In addition, future steroid use is expected to be better monitored, “he said.

Dr. Singh said the incidence of mucormycosis should be significantly reduced after the second wave of COVID-19. The main reason that emerged in the first wave was improper use of steroids. Furthermore, because it is a rare disease in Japan, the production and inventory of amphotericin B was limited.

“I hope our country is well prepared for the 3rd COVID-19 wave and can save enough on black mold,” he jokingly said.

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