The TLDR: Hospitals are witnessing a surge in black fungal infections—which is claiming the lives of patients or often leaving them maimed and disfigured. We look at the latest horror of the second wave—and examine how poor medical protocols are triggering a secondary epidemic.

What is this fungal infection?

The mold: The medical term for it is Mucormycosis—and it is an invasive infection caused by a common class of molds called mucormycetes. They are found everywhere from soil, compost, manure, rotting wood or that black mold you see on old fruits and bread. Mucor produces millions of microscopic spores which are dispersed in air and replicate where they land—and the spore count is typically higher during summer. We often inhale these spores, but they are harmless if you are a healthy person—since our immune system can easily fight them off. 

The danger: But mucor can turn deadly for certain kinds of people, triggering Mucormycosis. One, a person whose immune system has been compromised. Two, someone who is on immunosuppressant drugs —which makes them more vulnerable to infections. Three, a person who has diabetes since higher blood sugar levels and more acidic blood creates a fertile environment for the fungi.

The effect: Here’s what happens when a person becomes infected as the spores enter through their nostrils:

“In such vulnerable patients, the spores germinate to form long tubular filaments that can grow into the sinuses, into the bone, and the blood stream. The symptoms of mucormycosis and progression of the infection can vary from person to person; they include a throbbing headache, fever, facial and nasal pain, blackish nasal discharge, loss of vision, toothache, loosening of teeth, swelling in the upper jaw, and sometimes face paralysis.”

And once it invades the sinuses, the fungus can spread to the lungs, the brain and the central nervous system. The chances of dying are higher than 50% if it crosses into the brain. Doctors often have to cut out the infected parts to save the patient’s life.

Point to note: The disease is initially painless and silent. So people often don’t know that something is wrong until it's too late.

What’s the connection to Covid?

Mucormycosis is an ‘opportunistic’ infection—i.e. it takes advantage of the weakened immune system of already ill patients. And the second wave has offered fertile ground for it to spread uncontrollably. There are two reasons why Covid patients in India are especially at risk:

One: Diabetes.

• We are the diabetes capital of the world. Around 77 million Indians are diabetic—including a whopping 28% of the urban population. 
• And people with diabetes are at the greatest risk of severe disease if they develop Covid. 
• As a result, they are also more likely to be prescribed steroids. These are used to suppress our immune system when the Covid infection triggers a ‘cytokine storm’—which is our body going into overdrive and attacking its own cells. 
• The combination of higher blood sugar levels, acidic blood plus a suppressed immune system is the perfect environment for the mucor spores. 
• Recent data shows that 94% of Covid patients with mucormycosis had diabetes, and it was poorly controlled in 67% of cases.

Two: Over the past week, a number of medical experts have raised the alarm over "overuse, misuse, and rampant use of steroids” in Covid patients in India. Examples of steroids used to treat Covid include tocilizumab and dexamethasone. Steroids not only suppress the immune system, they also may cause blood sugar levels to spike, which can be especially dangerous for patients with uncontrolled diabetes—who are already vulnerable to fungal infection.

Indian doctors are notorious for overprescribing strong medicines to treat mild diseases (See: rising levels of antibiotic resistance in India). And many take the same sledgehammer approach, especially in serious cases of Covid. Leading pulmonologist Lancelot Pinto says:

“We’ve seen people go crazy with steroid prescriptions...There’s a misperception among doctors that [the] more severe the [COVID-19] case, [the] higher the dose of steroids needed, which isn’t supported by any trial so far.”

Doctors also tend to prescribe steroids early to prevent more serious symptoms—which also means patients tend to stay on these drugs for a prolonged period of time. This again makes them more susceptible to fungal or bacterial infections. 

Point to note: The big worry is that the current wave of fungal infections will get worse: “The concern is that this is just the start…The infection typically begins to hit the body two to three weeks into the steroid therapy, and we might see the case numbers jump in the coming weeks.”

Why are doctors doing this?

The absence of proper medical guidelines. Typically, what drug to prescribe, when and in what strength is based on knowledge gleaned from medical trials—which form the basis of best practices. But our government guidelines are often outdated and not always based on sound evidence. Example: Plasma therapy—which has repeatedly been found ineffective in trials—was not removed from the list of recommended Covid treatments until this month! Another example: The government just approved the emergency use of 2-DG (2-deoxy-D-Glucose) without any sound clinical data to back that decision.  

Also this: When doctors are under pressure to avoid putting the patient on oxygen therapy or a ventilator—in the midst of extreme shortages—it is inevitable that they will prescribe aggressive drugs.

Point to note: AIIMS finally released its protocol for the treatment of mucormycosis. The national Covid task force unveiled its guidelines earlier this week. 

The bottomline: As Mallika Sekhar concludes in The Wire:

“[W]e need a credible and authoritative central medical body that makes pragmatic decisions and issues sensible guidelines. These guidelines should be available to practicing doctors at the touch of a button.

 

Such a body will ensure two things: doctors won’t feel pressured to use medicines that have no rationale, and doctors will be enabled to not prescribe medicines outside their therapeutic windows. And perhaps most of all, it will ensure they do no harm.”

Reading list

National Geographic, The Hindu and BBC News have the best reporting on the spread of the black fungal infection in Indian hospitals. New Indian Express has good reporting on how to prevent mucormycosis. Dr Malika Shekhar has an excellent op-ed in The Wire on the importance of medical guidelines.