Mucormycosis or Zygomycosis is a very rare Fungal infection which is seen in patients who are immunocompromised or people who have low immunity. Now seen in COVID-19 or Coronavirus affected or recovering patients due to their reduced Immunity. The Mucor mold as they call it, is found commonly in soil, plants, manure, decaying fruits, vegetables, etc. It is actually found even in the nose of healthy individuals as well. But in 99% of the cases in normal healthy human beings, our immunity tends to fight it off without letting it grow, but in case of Immunocompromised patients, the body is not in a position to fight or kill the Fungal infection and that is why it can spread.

Why is Mucormycosis or Black Fungus infection being seen commonly in COVID-19 patients?

As we have read earlier that it affects patients who are immunocompromised, in case of COVID, the use of Corticosteroids is recommended to control the Cytokine Storm in COVID patients (which is life saving in this scenario). Along with reducing systemic inflammation, reduce exudative fluid in lung tissue, reduces further alveolar damage this helping in managing hypoxia.

So let us look at the factors why COVID patients are more susceptible to Mucormycosis infection.

Mucormycosis or Black Fungus

Source: Wikepedia

  1. Excessive Use of Corticosteroids
  2. Uncontrolled Diabetes
  3. Unhygienic Oxygen Cylinders
  4. Humidifier not being cleaned regularly can be a breeding ground for Fungal growth
  5. Ventilators not being sterilized properly
  6. COVID Recovering patients with low immunity and uncontrolled Diabetes being exposed to potential sources of Fungal spores
  7. Patients undergoing Cancer therapy, HIV AIDS patients, Organ Transplant patients
  8. Increase in Zinc supplements has alsobeen linked to Mucormycosis growth

In the case of COVID 19 – Uncontrolled Diabetes reduces the immune defense of the body and Coronavirus exacerbates it, with the use of Steroids which is a life saving drug in case of COVID-19 making the perfect environment for the growth of Mucormycosis. In recent studies it is seen that the incidence of Black Fungus infection is not just restricted to Uncontrolled Diabetes patients but also in non-diabetic and patients who have not used any Steroid.

“The analysis of notified disease cases by the Health and Family Welfare Department revealed that of the total of 188 mucormycosis patients reported in the state during May 19-26, at least 40 (21.28 per cent) were non-Covid cases, 55 (29.25 per cent) of non-steroid use, and 67 (35.64 per cent) patients had never received life-saving gas prior to the onset of black fungus.e maximum of 154 cases, which accounts for 81.91 per cent, were found to be suffering from diabetes, 56 (29.79 per cent) with immuno-compromised status, and 47 (25 per cent) patients were with comorbidities.”

Why Mucormycosis and not other Fungal infections?

This is a question which can come into your head – it is due to the following factors, Low Oxygen, high iron levels, diabetes, immunosuppression etc. give a favorable environment for the growth of Mucor mycosis.

ROCM – Rhino Orbital Cerebral Mucormycosis is what is commonly being seen in COVID recovered patients, as the Nasal, Orbital and Cerebral regions are being involved.

Symptoms of Mucormycosis:

As Mucormycosis affects various parts of the body, the symptoms vary depending on where the Fungus grows and which region of the body it affects. As we have seen in the post earlier, Mucormycosis can affect the Oral Cavity, Nasal Sinuses and Brain, Pulmonary or Lung, Cutaneous or Skin, Gastrointestinal and Disseminated type.

Symptoms of Oral Mucormycosis:

  1. Bad Breath
  2. Redness and swelling of Gums
  3. Pus discharge from Gums
  4. Loosening of Teeth (Upper or Maxillary teeth in most cases)
  5. Ulceration or Discoloration of the Palate

Oral manifestations of Mucormycosis or Black Fungus

Symptoms of Rhinocerebral Mucormycosis:

As Rhinocerebral means, involving the Sinus and Brain, the symptoms are as follows

  • Headache
  • One Sided Facial Swelling
  • Nasal Congestion or Sinus Congestion
  • Black lesion on Nasal bridge
  • Red to Black lesion on the palate which spreads rapidly
  • Fever

Symptoms of Rhino-Orbital Mucormycosis:

  • Opthalmoplegia: Paralysis of the muscles supporting the eye, which leads to inability to move the eye ball, either one side or both.
  • Ptosis: Drooping Eyelid or inability to open the eye
  • Proptosis: Protruision of the eyeball out of the socket
  • Visual Loss
  • Chemosis
  • Nasal Discharge
  • Abducens nerve palsy
  • palatal necrosis
  • Hemiparesis
  • Eye Lid gangrene (extreme cases)

Symptoms of Pulmonary or Lung Mucormycosis: This is when the Fungus grows in the Lungs.

  • Fever
  • Cough
  • Shortness of Breath
  • Chest pain

Cutaneous or skin Mucormycosis:

  • Ulcers or Blisters on the surface of the skin
  • The infected area might turn black in color
  • Excessive redness in the region with Pain and warmth
  • Swelling is seen restricted around the lesion

Gastrointestinal Mucormycosis:

  • Nausea and Vomiting
  • Pain in the abdomen
  • Gastrointestinal bleeding

Diagnosis of Mucormycosis:

  1. KOH Test – to determine if the infection seen is caused due to Fungus
  2. CBCT – PNS
  3. MRI
  4. Endoscopy
  5. Blood Investigations

Treatment of Mucormycosis:

With Mucormycosis being a serious Fungal Infection, it should be treated with Anti-Fungal medication in the early stages – Amphotericing B, Isavuconazole or posaconazole.

  • Intravenous route – All three Amphotericin B, posaconazole, isavuconazole.
  • Oral route – posaconazole, isavuconazole.

Along with the medication, Mucormycosis infection needs surgical intervention as well, the infected tissue needs to cut off or excised. By removing the infected tissue we are preventing further spread of the infection and along with IV Antifungal therapy you are most likely to recover.

Death due to Mucormycosis is a possibility depending on the extent and spread of the Fungal infection.

References:

Role of Corticosteroids in COVID-19 treatment

Mucormycosis – CDC