Coronavirus was presumed to be the only leading villain in this daunting pandemic story, but now it has arrived with a deadlier and more complicated accomplice. Yes, it’s the black fungus! Not that we hadn’t seen and treated these cases before, but the numbers that are coming up these days are petrifying. The share of credit for the rise of this fungal infection has been attributed to Covid infection, but that’s not the complete story. Nearly every 4th person in India is having Covid infection at present, be it symptomatic or asymptomatic. Then why is everybody not succumbing to this black fungus? The reason is immunity!

Basically, Coronavirus has a cycle of 14 days, in which a strong immune reaction called the cytokine storm is produced on the 5-7th day. To combat this reaction, we need to suppress the immune system by giving steroids or immunomodulator drugs (like Tocilizumab). Now, these drugs are like a double-edged sword. If used judiciously, they can produce miracles; if not, they can be devastating. Patients who are taking these drugs without appropriate monitoring are in turn suppressing their immune system and thus making a gateway for fungal infections like Mucormycosis. Also, these immunosuppressant drugs tend to increase the sugar levels, decrease serum transferrin, and suppress the spleen which produces antibodies, especially in patients having co-morbidities like Diabetes and Renal failure or patients who have been on long term oxygen humidifiers or mechanical ventilation. Henceforth, freely available sugar and iron in the bloodstream is a dessert treat for this fungus!

Once the immunity level is down, the fungus enters via the bloodstream, mainly through the mouth, nose and eyes as this area of the face is rich in blood supply. Hence, the initial symptoms are dental pain, runny nose, nasal congestion, decrease in vision or eye movements, swelling around the eyes or severe frequent headaches. This fungus loves sugar-rich blood, and travels to all the terminal blood vessels and forms colonies there. Since the terminal vessels are supplying vital structures like eyes, brain, heart and kidney, these patients are falling in for blindness, heart attacks, kidney failure or blood clots in the brain leading to death.

The worst part here is ignorance! We are seeing a lot of patients on a daily basis who have early symptoms but are not seeking timely medical care. Instead, home remedies and quack treatments are initiated. Once the loss is significant, the fear of losing life is what is bringing them to the hospital, which is unfortunately too late for treatment. A simple eye checkup or a nasal endoscopy can pick these early signs up, and the fungus can be killed with just medications. Once the involvement is significant, hospital admission is warranted. Blood investigations, CT scan of Face and MRI of brain and Orbit are necessary. The cavities and sinuses need to be thoroughly debrided by an ENT surgeon, intravenous medications need to be administered, and systemic parameters (like sugar, blood pressure, electrolytes, kidney function) have to be monitored and maintained. If still no improvements, the eyeball along with structures in the orbit need to be removed (exenteration), which is mentally disturbing for the patient, relatives, and surgeon himself. If still not controlled, the fungus eventually chews up entire organs, which is mentally shattering to visualize. The mortality rate is as high as 30-40% in such cases, which is fearsome. Some of these images are so horrifying that health care workers are getting nightmares and are teary at bedtime. A team approach is obligatory for management, which includes ENT specialist, Ophthalmologist, Neurologist, Microbiologist, Radiologist, Internal Medicine/Intensivist, Psychiatrist and a Dentist.

Monitored Covid care, judicious use of steroids/immunosuppressant/antibiotic drugs, early detection and diagnosis of fungal infections, aggressive management and proper follow-ups are the keys to successful treatment. Hence, be rightly informed, seek proper medical advice and take adequate care. Mucormycosis is one such fungus that has come into the limelight recently, but there are plenty of others waiting in the queue. It’s a war, and this time it’s a colossal one, draining everyone physically, mentally and financially! We are all in it together, and it’s going to go a long way ahead!



Authors: Dr Dhaivat Shah, Dr Rinal Pandit

Department of Ophthalmology, Choithram Netralaya, Indore