Black Fungus : Complicated Challenges in Treatment

Bengaluru, 26 May(HS): The lives of the general public is already shattered by the hardships, pain and sorrow from the second wave of Covid-19 mutated viruses. As if these adverse conditions weren’t enough they are now challenged with the fear of Black fungus infections. The second wave has been successful enough in exposing the ill-equipped infrastructure, both in the public and private sector. The sudden demand in terms of admissions, beds, ventilators and if all the three are met, paucity of life-saving oxygen leading to deaths continue to haunt like never before.

In comparison to the catastrophic havoc created by the Covid-19 second wave, the number of Black fungus cases as of now appears to be minimal. At the same time what is alarming is these patients are those who were assumed to have recovered from the fatal Corona. It is also now being learnt the treatment with steroids added to comorbidity conditions has aggravated the situation.

Just like in the cases of both Covid-19 waves, the situation is no better across the country when it comes to treating Black fungus infections. Dr SR Narahari, Director Institute of Applied Dermatology(IAD), Kasargod in Kerala doesn’t mince words in admitting the conditions: In the past, it was rarely seen among people who were suffering from chronic low immunity (immunocompromised) and mainly confined to cancer wards. While India is beginning to show a decline in COVID 19, this new killer virus is rapidly emerging, resulting in horrific facial injuries and death.

Dr V Govindasamy, Senior Scientist, Division of Microbiology, ICAR-Indian Agricultural Research Institute, New Delhi opines: Mucor and Rhizopus- Black mold or bread mold usually is there everywhere… common food spoilage organism and opportunist fungal pathogen to human (similar to entomological terms Secondary pests and pest resurgence) spores are commonly present in the human body also. Under low immunity, the possibilities of people getting infected are more if one is not doing regular hygienic practices like bathing etc. Mucormycosis is not a new disease as it’s a well known but rare disease that existed earlier also. However, Antifungal drugs with high efficacy are available for 100% cure if it’s diagnosed at early infection stages. Similarly, there is nothing like any separate white fungus. it’s all about Candida, a yeast infection causing candidiasis, he adds.

Dr Arunima.S in the Final year Post-Graduate Department of ENT, Kempegowda Institute of Medical Sciences and Research Centre, Hospital, Bengaluru points out: Mucormycosis is caused by mucor and Rhizopus fungi. When we see a suspect case we look out for crusts in the nose. The ideal method of investigation is to do a diagnostic nasal endoscopy and take scrapings from the middle meatus region (that is where all the sinuses drain) and send for microbiological investigation…

…The initial test we do is KOH mount which is not definitive, but we get results in less than 24 hours. Black, aseptate fungi are suggestive of mucor. we also send the sinonasal tissue for fungal culture to determine its rate of growth. The definitive diagnosis is by histopathological examination. Meanwhile, we also get MRI with gadolinium contrast to know how much soft tissue has been invaded and plan for surgery…
.Surgical exploration and complete debridement is the key. The antifungals will not work on the dead and necrosed tissue. We do a procedure called functional endoscopic sinus surgery and clear out all the sinuses by means of a debride. If there is orbit involvement orbital exenteration has to be done.If the cheekbone is involved the bone has to be removed entirely. Similarly with the palate. An extensive debridement is necessary or else the mortality is close to 80%! she fears.

Prevention and Control in Wards: According to Dr Arunima S: It’s more common in diabetics, in neutropenic patients, patients on steroids and immunocompromised individuals. Such individuals have to be identified and monitored closely. Unhygienic mask handling and oxygen handling: masks have to be changed timely and cleaned. Water used in oxygen humidifier has to be changed daily and only distilled water is to be used…
Surface cleaning of covid wards with 1 per cent hypochlorite solution is required. Judicial use of steroids, control of blood sugars is essential. It’s equally important to watch out for warning signs-headache, nasal discharge, bleeding from the nose, decreased sensation over the cheek, loosening of teeth, orbital, pain, drooping of eyelids…

…For proper debridement, we require an instrument called microdebrider. If the tissues are not debrided completely it would be equivalent to making an easy way for the fungus to grow. Most of the times the fungus would have invaded beyond the nasal tissue and reached the brain. At that stage, we will require and expertise of a skull base surgeon or a neurologist, she explains in detail.

Expensive Antifungals and Surgery for a Toss: The biggest roadblock we are facing now is the antifungals. Patients require around 30-40 vials for the treatment while each vial cost around Seven Thousand. The cost of surgery in a good setting is also pretty costly. Isotonic saline nasal wash and betadine mouth gargle for all the inpatients and patients who have got discharged is a must, concludes Dr Arunima S.