A rare but serious fungal infection is appearing more frequently among COVID-19 patients in India as coronavirus cases soar to more than 350,000 per day, according to Johns Hopkins University data.
Mucormycosis, also known as “black fungus,” is caused by a group of molds called mucormycetes, which tend to live in soil and decaying organic matter, according to the Centers for Disease Control and Prevention. It’s a life-threatening infection with a mortality rate between 46% among people with sinus infections and 96% with spread disease.
In the past decade, doctors have seen only a handful of cases in India. But in the past month, they’re reporting tens of thousands of cases, said Dr. Bhakti Hansoti, associate professor in the department of emergency medicine and international health at the Johns Hopkins Bloomberg School of Public Health.
“We’ve seen this skyrocket in recent weeks,” she said. “It consumes a lot of resources especially during this pandemic right now in India where health care resources are stretched at the limit.”
The most common form of the infection seen among COVID-19 patients in India is rhinocerebral mucormycosis, an infection that starts in the sinuses and can spread to the brain. Symptoms include one-sided facial swelling, headache, nasal or sinus congestion, black lesions on the nasal bridge or upper inside of the mouth, and fever, according to the CDC.
Symptoms of mucormycosis tend to appear two to three weeks after COVID-19 infection, Hansoti said.
This type of mucormycosis occurs more frequently among patients with diabetes, which is why health experts say cases are spiking in India where one in six people have the chronic disease, according to the International Diabetes Federation Diabetes Atlas published in 2019.
“Diabetes is the No. 1 risk factor for this,” Hansoti said. Up to 75% of mucormycosis cases occur among COVID-19 patients with diabetes, she added, with as many as 45% undiagnosed until they show up to the hospital.
“The Indian population has a high prevalence of uncontrolled diabetes due to the lack of routine screening,” she said.
In addition to this risk factor, health experts say, immune-suppressing steroids prescribed to control inflammation from COVID-19 create an opportunity for fungal infections to take hold.
“That’s the goal of going on steroids, to turn down the volume on the immune system,” said Dr. Michael Angarone, associate professor of medicine at Northwestern Medicine.
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Many COVID-19 patients in India with breathing difficulties are being prescribed steroids as oxygen becomes a scarce resource, Hansoti said. Additionally, people therecan bypass doctors and obtain steroids through a pharmacy without a prescription.
“Some of it is the doctors throwing (steroids) at patients because there’s a critical need for oxygen,” she said. “And … the health system isn’t built to monitor and report across the country. You can go to any pharmacy in the mall and ask what you need.”
The structural integrity of the lungs also can be compromised by the coronavirus and ventilators, making it harder to fight off fungal infections, Angarone said.
“Once it starts to grow inside the lung, it becomes very difficult for our anti-fungal therapies,” Angarone said. “(Mucormycosis) infections to the lung tend to be harder to treat in that the anti-fungals that we have to use may not work as well as an anti-bacterial for bacteria.”
Fungal infections tend to be more aggressive and destructive, creating big cavities in the lungs, and can take up to weeks to treat, he said. In some instances, they can spread to the liver, brain and eyes.
Many patients in India haverequired surgery to stop the spread of infectionto the brain. In some cases, an eye has had to be removed, Hansoti said.
Fungal infections are cropping up not only in India but in Europe, South America and the United States, as well. However, instead of mucormycosis, which is less common outside of India, doctors are seeing cases of aspergillosis.
Aspergillosis is caused by aspergillus, a common mold that lives indoors and outdoors. According to the CDC, this type of fungal infection is not as life-threatening as mucormycosis. A 2018 study found the one-year survival for people who had invasive aspergillosis was 59%.
While they’re appearing more frequently in COVID-19 patients, fungal infections are still fairly rare in the U.S., Angarone says.
“As we really started looking at the numbers, it wasn’t as frequent as bacterial infections,” he said. “It’s still uncommon and we don’t know the true impact it’s going to have.”
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