Black fungus or Mucormycosis: Costly mistakes in COVID-19 treatment lead to new challenges

A rare fungal infection called Mucormycosis (black fungus) has suddenly surged in India, in patients suffering or recovering from COVID-19. Unfortunately, it is a highly dangerous infection, killing between 46-96 percent (one could say >50 percent) of patients, depending on its severity. Mucormycosis or black fungus is caused by a mold called Mucormycetes, which typically lives in soil, plants or decaying organic matter. If you’re into gardening or outdoor activities, you could carry it from outdoors to indoors. However, it is found indoors as well, think of the black fungal outgrowth in spoiled bread or the fuzzy white mold that grows in fruits which later turns into deep grey. The black fungus also grows in the condensation lines and drip pans of air conditioners. In short, it has always been everywhere around us. However, it is on extremely rare occasions that it should affect people whose immune system is compromised like uncontrolled diabetic patients or on steroid or cancer patients on chemotherapy. In the last 10 years, only a handful of patients have been reported in India. Last week, all of a sudden,  thousands of cases of black fungus have been reported in patients suffering or recovering from COVID-19. Why is it so? To put things in context –

• Millions of patients in India suffering from diabetes or on steroid or cancer patients are admitted to hospital in India every year but no one gets this infection.
• Millions all over the world are getting infected with COVID, are diabetic, are put on steroids and their immune system is compromised but is not getting black fungus.

Then why is there a sudden surge of Mucormycosis among COVID patients in India only? The first mistake The root cause of this is the completely unhygienic and dirty way of delivering oxygen to patients in many places in India combined with the indiscriminate use of steroids in the treatment of COVID. Firstly, medical oxygen (as opposed to industrial oxygen) is a highly purified version that is more than 99.5 percengt pure by preparing its through repeated steps of compression, filtration and purification. The cylinders in which the liquid oxygen is stored, transported and used are rigorously cleaned and disinfected. Secondly, oxygen, especially when administered to patients at high flow, requires humidification. This is done by passing it through a container filled with sterile water. The water itself must be sterilized and changed frequently as per protocol. If the water is not sterile, it is potentially a source of black fungus infection! (Especially if high flow oxygen is given over a long period.) On the other hand, if oxygen is given without humidification, it will dry the mucous membrane and damage the inner lining of the lungs. It will also make the sputum or secretion very thick to clear out. Both of these have created havoc among patients. The second mistake The use of steroids in the treatment of COVID-19 has to happen at the right time. Steroids are only effective to fight the effects of COVID, not the virus directly. It is dangerous and harmful if given early when the virus is replicating. This will reduce body immunity and facilitate further replication of viruses. Giving steroids unnecessarily or early to a diabetic patient will raise their sugar level to a high level predisposing them to further risk of increase in severity of COVID as well as predisposing them to the ill effects of black fungus. The third mistake While it is a good initiative to ramp up the production of medicine (Amphotericin B ) to treat black fungus, we must understand that this disease kills between 46-96 percent of people, once infected. However, the bitter truth is that Amphoterin B is very toxic. The real solution is to enforce quality control and compliance for production, storage (in cylinder) and delivery (sterile water, clean system of oxygen) as well as stop indiscriminate use of steroids to minimise this new enemy. The solution to bad body odor is a good shower, not expensive perfume. The author is vice chairman and managing director, chief consultant for Cardiovascular Thoracic Surgery at the Asian Heart Institute in Mumbai.