By Aanya Shah, Troy High School, Troy, Michigan, USA
The COVID-19 pandemic has been responsible for a widespread loss of human life and continues to present unprecedented challenges to public health and medical professionals globally. India, the second-most populous country in the world, is witnessing a devastating new variant of COVID-19 that is spreading rampantly, resulting in high death tolls. Adding to the woes, a new health crisis frequently being diagnosed in COVID-19 patients and survivors, called Mucormycosis, commonly known as “Black Fungus,” has emerged.
On May 9th, an advisory was issued by the Indian Council of Medical Research, which called for better screening and awareness on the fungus (Thiagarajan, 2021). Since then, India has recorded almost 9,000 cases of Mucormycosis as of May 23rd, 2021 (Graham, 2021). The exact numbers of diagnoses are challenging to find, although one recent study published in the Journal of Fungi estimates the annual rate across India is around 140 cases per million people (Prakash & Chakrabarti, 2021). With a mortality rate of over 54%, Mucormycosis is a lingering threat to the aging and diabetic population in many countries globally (Centers for Disease Control and Prevention, 2021). The common symptoms presented in patients with Mucormycosis include sinusitis, one-sided facial swelling and pain, chest pain, fever, skin lesions on the inside of the mouth or nasal bridge, breathing difficulties and coughing (Centers for Disease Control and Prevention, 2020). CT scan, MRI, and laboratory tests are used to diagnose the severity of the disease. This fatal infection is caused by mucormycetes, a group of molds belonging to the order Mucorales (Centers for Disease Control and Prevention, 2021). There are five major clinical forms of Mucormycosis:
Rhinocerebral (affecting the sinus and brain)
Pulmonary (affecting the lungs)
The above two are contracted through inhalation of mold spores
Cutaneous
Enters through macerated skin (cut, scrape, burn, or other skin wounds)
Gastrointestinal
Enters host through ingested contaminated foods
Disseminated
Travels through the bloodstream
Mucormycetes mold is found most commonly in soil, including compost, animal dung, and decaying vegetation (Centers for Disease Control and Prevention, 2020). Black Fungus is not contagious, as there is no evidence of spread from contact between humans and animals.
The Black Fungus is known to target immunocompromised individuals. COVID-19 affected patients treated with systemic glucocorticoids (Singh et al., 2021, p. S1874), diabetic patients (Prakash & Chakrabarti, 2021), and organ transplant/iron overload patients (National Organization for Rare Disorders, 2018), are a few of the susceptible risk groups for Mucormycosis.
Research has indicated that the correlation between COVID-19 patients and severe Mucormycosis is owed to systemic glucocorticoids, known colloquially as steroids. Steroids such as dexamethasone, prednisone and methylprednisolone serve to reduce lung inflammation and control excess damage, and thus play a necessary role in treatment of critically ill COVID-19 patients (National Institutes of Health, 2020).
However, prolonged steroid administration reduces immunity and causes elevation of blood sugar levels in both diabetic and non-diabetic COVID-19 patients, often making patients susceptible to secondary bacterial and fungal infections. The drop in immunity combined with excessive sugar levels is a thriving environment for Mucormycosis invasion, thus being one of the factors contributing to the rise in Black Fungus infections among the affected patients (Singh et al., 2021, pp. S1884-1885).
The most common underlying factor in patients who have contracted Mucormycosis is diabetes mellitus. An observational study involving consecutive individuals diagnosed with Mucormycosis across 12 centers in India shows diabetes mellitus as the most common predisposing factor where 342 patients out of 465 (73.5%) were affected by Black Fungus. However, India is not the only country with prominence in Mucormycosis amongst diabetic patients. Mexico recorded 72% of Mucormycosis patients with diabetes mellitus, in Iran a staggering 75%, and in the USA, 52% (Prakash & Chakrabarti, 2021).
Transplant patients and those with iron overload syndromes (conditions resulting in an excess of deposition of iron in tissues) are also predisposed to Mucormycosis. In patients with metabolic conditions resulting in high iron levels, the Mucorales fungi scavenge on this surplus of iron.
Figure 1. “Distribution (%) of healthcare-associated mucormycosis risk factors recorded in 169 cases” (Rammaert et al., 2021, p. S46).
Treatment for Mucormycosis involves surgical debridement of infected tissue coupled with a long course of the antifungal drug, Amphotericin-B. In the absence of response or for those who cannot tolerate Amphotericin-B, drugs like Posaconazole and Isavuconazole are used (National Organization for Rare Disorders, 2018).
Although there are treatment options for the fungus, the cost of the medicines and procedures limits treating the fatal disease. At the Gandhi Institute, professor of medicine, S. P. Kalantri, states, “One-day therapy costs 30,000 rupees (about $410), a catastrophic health expenditure for 99 percent of Indians” (McKenna, 2021). Dr. Tanu Singhal, an infectious disease specialist from Mumbai states, “The overall treatment costs, including the surgeries, go up to 40,00,000 Indian rupees ($54,452) to 50,00,000 Indian rupees ($68,065)” (Shelar, 2021). Prolonged antifungal therapy and surgical intervention are expensive, and therefore, patients in many developing countries struggle to access treatment.
Additionally, drug scarcity has augmented the rise in infections and patient fatalities, compounding pressure on the health system. Differing cultural beliefs amongst countries have further increased the risk of acquiring the infection, such as smearing urine and cow dung on their bodies, an action some Indians perform to “boost immunity.”
Challenges within India are broadly emblematic of the challenges faced by other countries in terms of poor hygiene, high diabetic rates, steroid overuse, inadequate sanitation, and a lack of diagnosis of fungal diseases. By analyzing India's situation, medical professionals in other countries can prepare for other health issues and prevent future outbreaks by studying the pathology and common symptoms to prevent misdiagnosis and by harnessing newfound information. Crystallizing the salience of acceptable hygiene, monitoring and controlling blood glucose levels following COVID-19 treatment, and judicious use of steroids only for severe COVID-19 patients is pertinent in preventing the transmission of fungal diseases, given the severity of Mucormycosis.
Ultimately, the prevalence of this pandemic and its devastating effects on the human population globally has provided the impetus to construct this report, which aims to emphasize Mucormycosis and its effects, symptoms, treatments, and the challenges faced by developing countries in eliminating the catastrophic infection. The outbreak in India has shed light on the need for awareness and additional research on fungal infections.
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