Mucormycosis, or Black fungus as it is referred to in common parlance, is being reported in patients with COVID-19. It is a rare but serious fungal infection caused by a group of fungi called the mucormycetes. The overall mortality rate of mucormycosis is 50%. It is usually found in air and soil and in association with decaying organic matter, such as leaves, compost piles, and animal dung.

The Health Ministry and Indian Council of Medical Research (ICMR) have released an advisory for the screening, diagnosis and management of mucormycosis. According to the advisory, this fungal infection mainly affects individuals with impaired immunity. The predisposing factors are uncontrolled diabetes mellitus, steroids, prolonged intensive care, comorbidities, immunocompromised state (cancer or post transplant). The sinuses or lungs are commonly affected after inhaling fungal spores from the air. Skin can also be affected after a cut, burn, or other type of skin injury.

The advisory has defined the warning signs and symptoms, which include:

• Pain and redness around eyes and/or nose
• Fever
• Headache
• Coughing
• Shortness of breath
• Bloody vomits
• Altered mental status

A diagnosis of mucormycosis should be suspected in case of following clinical presentations:

• Sinusitis – nasal blockade or congestion, nasal discharge (blackish/bloody), local pain on the cheek bone
• One sided facial pain, numbness or swelling
• Blackish discoloration over bridge of nose/palate
• Toothache, loosening of teeth, jaw involvement
• Blurred or double vision with pain; fever, skin lesion; thrombosis & necrosis (eschar)
• Chest pain, pleural effusion, hemoptysis, worsening of respiratory symptoms

To prevent mucormycosis, the advisory recommends use of masks, especially in dusty construction sites, cover yourself well (wear shoes, long trousers, long sleeve shirts and gloves) when handling soil or manure and maintain personal hygiene. It further advocates monitoring of blood sugar in COVID patients after discharge as well as in patients with diabetes, judicious use of steroids/ antibiotics/antifungals and use of clean and sterile water for humidifiers.

Mucormycosis needs urgent attention and is best managed by a team of specialists comprising of a microbiologist, internal medicine specialist, intensivist, neurologist, ENT specialist, ophthalmologist, dentist, surgeon (maxillofacial/plastic) and biochemist.

Mucormycosis can be managed by controlling blood sugar levels (and ketoacidosis in diabetic patients), reducing steroids, stopping immunomodulating drugs and extensive surgical debridement to remove all necrotic materials. The advisory further recommends putting in a peripherally inserted central catheter, maintaining adequate systemic hydration, normal saline infusion and antifungal therapy for at least 4-6 weeks. The patient should be carefully monitored both clinically and with radio-imaging to evaluate response to treatment and to check if the disease is progressing.

The advisory cautions to stay alert for the warning signs and symptoms. Not all cases, especially in immunosuppressed and COVID-19 patients, with blocked nose should be thought of as having bacterial sinusitis.  Investigate for fungal etiology and start treatment at the earliest.

(Source: ICMR, Evidence based advisory in the times of Covid-19, Screening, diagnosis and management.

https://www.icmr.gov.in/pdf/covid/techdoc/Mucormycosis_ADVISORY_FROM_ICMR_In_COVID19_time.pdf, May 09, 2021)

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA