Contracted COVID-19? Here's When You Should Start Worrying About Mucormycosis

Dr Mala V Kaneria speaks on COVID-19 risk of mucormycosis and white fungus: The second wave of COVID-19 pandemic has brought with it a massive surge in cases of another deadly disease. Over the last few weeks, we have been reading alarming reports regarding the rise in cases of “Black Fungus” or mucormycosis across various states in the country. On May 20, the Health Ministry of India made it mandatory for all states to report both suspected and confirmed cases of mucormycosis to the Integrated Disease Surveillance Programme. The states of Gujarat and Rajasthan have declared it an epidemic.

But despite constant reporting, many people are left with unanswered questions regarding the disease. Should all COVID-19 patients be wary of mucormycosis? How long is a COVID-19 patient susceptible to catching this infection, and what are the precautions we can take? And what about “white fungus” which also is being reported among COVID-19 patients? Is it deadlier than mucormycosis?

To find answers to these questions and many more, SheThePeople.TV reached out to Dr Mala V Kaneria, Professor and Unit Head, Department of Medicine at BYL Nair Ch. Hospital and Kasturba Hospital for Infectious Diseases, and Consultant, Infectious Diseases at Jaslok Hospital and Research Centre, Mumbai.

As per Dr Kaneria, she used to see one or two cases of mucormycosis in a year and those too were seen mainly in high-risk group people who were immunocompromised or had uncontrolled diabetes, any haematological malignancies or had undergone a bone marrow transplant.

So, why is India seeing so many cases of mucormycosis during the second wave of the pandemic? To this Dr Kaneria says, “Probably the reason is that the underlying comorbidity for mucormycosis and COVID-19 both is diabetes. Secondly, SARS-CoV-2, the virus which causes COVID-19, itself gives rise to some amount of hyperglycemia. Also, many COVID-19 patients are being treated with steroids and that too causes high blood sugar. Some patients are also being treated using Tocilizumab. All these give rise to high blood sugar.”

Another possibility Dr Kaneria points out is the increased Iron metabolism during COVID-19. “Mucor fungus requires Iron for growth and we are seeing Ferritin levels being very high in patients of mucormycosis. So, there is a rise in the number of cases of mucormycosis associated with COVID-19. Some patients have not received oxygen or steroids, and they too are coming with the presentation of mucormycosis."

Mucormycosis symptoms to watch out for:

• blackish or bloody discharge from the nose
• unilateral headache
• facial pain
• diminishing of vision

According to Dr Kaneria, the reason why people should worry is that mucormycosis is not some simple fungus. It can get into a patient’s para-nasal sinuses, causing fungal sinusitis. These sinuses are situated very close to our eyes. So from the nose, the infection can spread to the eyes and even to the brain. Therefore, this infection can be quite devastating. “The treatment for mucormycosis consists of surgical debridement of all the fungus. If the infection spreads to the eye, it may have to be removed surgically to prevent the spread of infection to the brain.”

It is not as if there are no medications available to treat mucormycosis, but as Dr Kaneria points out, the anti-fungal medications needed for treating this disease are extremely costly and toxic, and they have to be given for a prolonged period. Sometimes even six to eight weeks, or even longer, to eradicate the entire infection.

“So this infection is debilitating, disfiguring, extremely toxic and costly and it can be mentally very unnerving.”

When Do People Catch This  Infection

But is there a time frame, during which a COVID-19 patient is more susceptible to catching this fungal infection? When should patients and their caregivers watch out for signs of mucormycosis closely and when can they breathe a sigh of relief?

Dr Kaneria says that during the first wave, mucormycosis was thought to be related to post-COVID-19 period. But now, during the second wave, patients are presenting themselves with symptoms much earlier. Even as early as five to six days after the first onset of COVID-19 symptoms. “If a patient has fever or cough because of COVID-19 and they get admitted because of it, on day six or seven itself they can start complaining of unilateral headache or eye pain and be diagnosed with mucormycosis. So, a person can have active COVID-19 and mucormycosis at the same time or there can be a delay, of say, 10 to 15 days. But not more than that. So, the time frame concerning COVID-19 can be anything from five to six days to eight to 15 days."

Misuse of steroids

With the rising number of cases of this fungal infection, the reported indiscriminate use of steroids to treat coronavirus infection by medical practitioners has come under the scanner. AIIMS director Dr Randeep Guleria had warned against the misuse of steroids just last week.

Dr Kaneria says that while steroids have been shown to decrease mortality in COVID-19 cases, they are indicated only for patients who have hypoxia or low oxygen saturation and they should be used only after seven to eight days. During the first seven days, the body sees a phase of viral replication and at that time patients shouldn’t be given steroids as it is an immunosuppressant. “Unfortunately patients are getting steroids in a higher dose and they are getting it early on in the therapy, that is during the phase of viral replication and they are getting it for a prolonged period. Also, patients who are not hypoxic and have good oxygen saturation levels also getting steroids. Which is what is wrong. Steroids are like a double-edged sword, they have to be given at the right time for the right duration and the right indication.”

According to Dr Kaneria, misuse of steroids is adding to the problem as they cause high blood sugar, which is a risk factor for mucormycosis, and they are also immunosuppressants, leaving patients prone to several secondary bacterial and fungal infection.

How do you contract the fungal infection?

Many people have also been asking whether factors like humidity, or poor hygiene practices like wearing dirty masks, etc., also play a role in the contraction of the infection or not? Their role cannot be ruled out entirely, says Dr Kaneria, but that is not the sole factor. She says that it is a combination of many factors like the use of steroids, diabetes, COVID-induced high blood sugar levels and the iron metabolism play a role here. “A mask could probably play a small role which we are not very certain about, at this moment.”

The biggest precaution that COVID-19 patients need to take to avoid being infected with mucormycosis is controlling their blood sugar levels. Says Dr Kaneria, “Any patient who is diabetic, even if he doesn’t have COVID-19, should aggressively control his sugar. If COVID-19 patients have mild symptoms of COVID-19 and opt for home management, they should ensure that somehow their blood sugar remains in control. Secondly, they shouldn’t start steroids on their own. Even when their general practitioner suggests the use of steroids they need to ask whether it is indicated. Also, any reusable cloth masks they are using should be washed and dried thoroughly.”

Dr Kaneria further specifies that it is uncontrolled diabetes that is the main risk factor here. “Uncontrolled diabetes mellitus causes a condition known as diabetic ketoacidosis, which plays a significant role in the growth of mucormycosis in the body. Therefore, generally, patients who have uncontrolled sugar, which is on the higher side, are the ones who are prone.”

White Fungus

In Bihar’s Patna, some cases of “white fungus” or oral thrush have been reported last week. Is “white fungus” more dangerous than mucormycosis though? Dr Kaneria says that candida or what is being called “white fungus” is a fungal infection which is very common in critical patients who are in the ICU. If the patient is on a ventilator, has a prolonged ICU stay, have multiple lines (intravenous line, Foley’s catheter), has received high-end antibiotics, has uncontrolled diabetes, is receiving parenteral nutrition (feeding via tubes). These factors can give rise to candidiasis in any critical patient, not necessarily a COVID-19 patient.

“When a COVID-19 patient is critical and lands in the ICU, he has all these factors, which are common to non-COVID-19 patients as well. In addition to those factors what a COVID-19 patient has is lymphopenia (decreased levels of lymphocytes- a type of white blood cell, in the blood) and high blood sugar.” She adds that candidiasis or “white fungus” is only seen in critical patients of COVID-19 whereas mucormycosis is seen more in patients who have mild or moderate COVID-19 symptoms.
Says Dr Kaneria, “So since Candidemia (a candida bloodstream infection) is seen in ICU patients, it has higher mortality.” This implies that a patient with mild to moderate symptoms of COVID-19 needs to worry more about mucormycosis than a white fungal infection.