Covid survivors in India are getting infected by black fungus. According to the Union Health Ministry the this fungal infection mainly affects people who are on medication and whose immune system is not recovered totally to fight pathogens in the environment. Fungal spores inhaled from air could be fatal if not taken care.

Central Government of India has released guidelines for public to create awareness and to help those who are recovering from Covid infection. The guidelines were prepared by the health ministry and Indian Council of Medical Research.

Sign and symptoms of mucormycosis/black fungus

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

What are the predispositions

• Uncontrolled diabetes mellitus
• Immunosuppression by steroids
• Prolonged ICU stays
• Co-morbidities – post-transplant/malignancy
• Voriconazole therapy

What should you do?

• Control hyperglycemia
• Monitor blood glucose level after COVID-19 recovery and also in diabetics
• Use steroid judiciously – correct timing, correct dose and duration
• Use clean, sterile water for humidifiers during oxygen therapy
• Use antibiotics/antifungals judiciously

What should you not do?

• Do not miss warning signs and symptoms
• Do not consider all the cases with a blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators
• Do not hesitate to seek aggressive investigations, as appropriate (KOH staining & microscopy, culture, MALDITOF), for detecting fungal aetiology
• Do not lose crucial time to initiate treatment for mucormycosis

How to prevent mucormycosis/black fungus?

• Use masks if you are visiting dusty construction sites
• Wear shoes, long trousers, long sleeve shirts and gloves while handling soil (gardening), moss or manure
• Maintain personal hygiene, including thorough scrub bath

When to suspect the fatal infection? (in COVID-19 patients, diabetics or immunosuppressed individuals)

• Sinusitis – nasal blockage or congestion, nasal discharge (blackish/bloody), local pain on the cheekbone or one-sided facial pain, numbness or swelling
• Blackish discolouration over the 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, haemoptysis, worsening of respiratory symptoms

How to manage mucormycosis?

• Control diabetes and diabetic ketoacidosis
• Reduce steroids (if the patient is still on) with the aim to discontinue rapidly
• Discontinue immunomodulating drugs
• No antifungal prophylaxis needed
• Extensive Surgical Debridement – to remove all necrotic materials

What is the medical treatment for mucormycosis?

• Install peripherally inserted central catheter (PICC line)
• Maintain adequate systemic hydration
• Infuse normal saline IV before Amphotericin B infusion
• Antifungal therapy, for at least 4-6 weeks (follow guidelines)
• Monitor patients clinically and with radio-imaging for response and to detect disease progression

Whom should you consult?

• Microbiologist
• Internal Medicine Specialist
• Intensivist Neurologist
• ENT Specialist
• Ophthalmologist
• Dentist Surgeon (maxillofacial/plastic)
• Biochemist

Guidelines Issued by: https://www.icmr.gov.in/: Indian Council of Medical Research, Govt of India

Image credit: CDC.gov, Netmed India, BBC