Lecturer,
Department of Community Health Nursing, Holy Family Institute of Nursing
Education, Mumbai, Maharashtra, India
ABSTRACT:
Black
fungus is also known as Mucormycosis, and it is occasional but threatening
infection. Black fungus is caused by getting into exposure with fungus spores
in the surroundings. It can also form in the skin after the fungus enters
through a cut, scrape, burn, or another type of skin trauma. Fungi live in the
environment, particularly in soil and decaying organic matter such as leaves,
compost piles, rotten wood, particularly in soil, compost, and animal dung.
This fungal infection is caused by a type of mould known as 'mucromycetes’. It should be noted that this rare fungal
infection affects persons who have health issues or who use drugs that weaken
the body's ability to fight the infections. There are different types of
mucormycosis Trusted Source, including rhino cerebral (sinus and brain),
pulmonary (lung), gastrointestinal, and cutaneous (skin) mucormycosis. The
COVID-19 generates a sudden change in the interior environment of the host for
the fungus, and the medical treatment administered unknowingly promotes fungal
development. COVID-19 causes harm to the airway mucosa and blood vessels. It
also causes a rise in serum iron, which is required for the fungus to grow.
Broad-spectrum antibiotics not only kill potentially harmful bacteria but also
beneficial commensals. Although antifungals such as Voriconazole prevent
Aspergillosis, Mucor survives and grows due to a lack of resistance. Long-term
ventilation decreases immunity, and there is conjecture that the humidifier
water that is delivered along with the oxygen transfers the fungus. It is
ubiquitous and found in soil and air and even in the nose and mucus of healthy
people. It affects the sinuses, the brain and the lungs and can be
life-threatening in diabetic or severely immunocompromised individuals, such as
cancer patients or people with HIV/AIDS. Doctors believe mucormycosis, which
has an overall mortality rate of 50%, may be being triggered by the use of
steroids, a life-saving treatment for severe and critically ill Covid-19
patients. Steroids reduce inflammation in the lungs for Covid-19 and appear to
help stop some of the damage that can happen when the body's immune system goes
into overdrive to fight off coronavirus. But they also reduce immunity and push
up blood sugar levels in both diabetics and non-diabetic Covid-19 patients.
It’s thought that this drop in immunity could be triggering these cases of mucormycosis.
KEYWORDS:
Mucormycosis, Outburst.
INTRODUCTION:
Mucormycosis
is a rare type of fungal infection that occurs through exposure to fungi called
mucormycetes. Mucormycetes can enter the body through breathing, inhaling, and
exposed wounds in the skin. Mucormycosis is a rare but serious fungal
infection. While the cases of this infection were relatively less, the Covid-19
outbreak has given a boost to the spread of this infection. It is commonly
known as black fungus, the infection is now detected among Covid-19 patients
across India. With a significant increase in fungal infection cases, the
government has mandated that all states have to report suspected and confirmed
cases of mucormycosis to the Integrated Disease Surveillance Programme (IDSP).
Now let’s take a look at what this infection is and why it is caused more
frequently among Covid-19 patients. The infection is rare, but once a person is
infected, the fungus manifests in the skin or can affect the brain or lungs,
many cases of this infection have been reported in Covid-19 patients1.
PREVALENCE:
Statistics
suggest that there are over 12,000 cases of infection and many more which may
be unreported. On May 26, 2021, there were 11,717 confirmed cases of
mucormycosis in India, which has more people Trusted Source living with
diabetes than any other country in the world, except China. Without immediate
treatment with an antifungal medication and a surgery to remove necrotic
tissue, mucormycosis is often fatal. Before the pandemic, the Centers for
Disease Control and Prevention (CDC) reported an overall mortality rate of
54%Trusted Source. A 2021 systematic review of all COVID-19-related cases
published in the scientific literature found 101 cases: 82 of them in India and
19 from the rest of the world. Among these cases, 31% were fatal report that
around 60% of all the cases occurred during an active SARS-CoV-2 infection and
that 40% occurred after recovery. In total, 80% of the patients had diabetes,
and 76% had been treated with corticosteroids2.
RISK FACTORS:
People
who fall into the following categories are more likely to develop black fungus:
Uncontrolled
diabetes, diabetic ketoacidosis, and diabetics taking steroids or tocilizumab.
Patients taking immunosuppressant’s or receiving anticancer treatment, as well
as those suffering from a chronic debilitating illness Patients taking high
doses of steroids or tocilizumab for an extended period Cases of COVID-19
Severity Patients on oxygen who required nasal prongs, a mask, or a ventilator
support Patients who get COVID treatment within six weeks are more likely to
develop black fungus3.
SYMPTOMS:
The
symptoms of mucormycosis depend on where in the body the fungus is growing.
Symptoms of rhino cerebral (sinus and brain)
mucormycosis:
One-sided
facial swelling, Headache, Nasal or sinus congestion, Black lesions on nasal
bridge or upper inside of mouth that quickly become more severe, Fever.
Symptoms of pulmonary (lung) mucormycosis include:
Fever,
Cough, Chest pain, Shortness of breath,
Cutaneous (skin) mucormycosis:
Can
look like blisters or ulcers, and the infected area may turn black. Other
symptoms include pain, warmth, excessive redness, or swelling around a wound.
Symptoms of gastrointestinal mucormycosis include: Abdominal pain, Nausea and vomiting, gastrointestinal
bleeding, diarrhea
Disseminated mucormycosis:
Typically
occurs in people who are already sick from other medical conditions, so it can
be difficult to know which symptoms are related to mucormycosis. Patients with
disseminated infection in the brain can develop mental status changes or coma.
If
skin is infected, the affected area may appear blistered, red, or swollen. It
may turn black, feel warm, or be painful. Through blood, the infection can also
spread to other parts of body. This is referred to as disseminated black fungus
(mucormycosis). When this occurs, the fungus can attack organs such as spleen
and heart. In severe cases, patient may experience mental changes or fall into
a coma. It can even be fatal4.
PREVENTIONS OF BLACK FUNGUS:
Humidifier
cleaning and replacement (for those using Oxygen Concentrators) the humidifier
bottle should be sterilized with normal saline and refilled on a regular basis.
Masks should be disinfected regularly, and they should not be used for weeks.
Those who use steroids should also monitor their blood sugar levels. During the
COVID-19 therapy, mortified oxygen should be utilized Practicing good hygiene
and maintaining the cleanliness of their surroundings brushing and gargling
daily is extremely beneficial. If recovered from COVID, it is critical to wear
masks to prevent the infection from entering the body. Diabetics patients must
keep their diabetes under control and monitor their blood glucose levels these
must be monitored, especially after infection with Covid-19. Steroid use is to
be reduced, and immunomodulating drugs are to be discontinued5.
TREATMENT OF BLACK FUNGUS:
Mucormycosis
treatment must be fast and aggressive. The concern is due to the fact that by
the time even a presumptive diagnosis is made, the patient has often suffered
significant tissue damage which cannot be reversed. Most patients will need
surgical and medical treatment.
Most
infectious disease experts say that without aggressive surgical debridement of
the infected area, the patient is likely to die. Medicines play an important
role. Two main aims are sought simultaneously: antifungal drugs to slow or stop
the fungal spread and drugs to treat debilitating underlying diseases.
Amphotericin B (initially intravenous) is the usual drug of choice for
antifungal therapy. Posaconazole or isavuconazole can treat mucormycosis.
Patients may even require an intravenous antifungal procedure lasting 4 -6
weeks. Patients with underlying diseases like diabetes need to be in optimal
control of their diabetes. Patients normally on steroids or taking deferoxamine
(Desferal; used to remove excess iron from the body) are likely to have these
drugs stopped because they can increase the survival of fungi in the body.
Patients may need additional surgeries and usually need antifungal treatment
for an extended period (weeks to months) depending on the severity of the disease.
While
it is treated with antifungals, mucormycosis may eventually require surgery.
Doctors have said that it is of utmost importance to control diabetes, reduce
steroid use, and discontinue immunomodulating drugs. To maintain adequate
systemic hydration, the treatment includes infusion of normal saline (IV)
before infusion of amphotericin B and antifungal therapy, for at least 4-6
Do's and Don’ts to reduce the risk of Black fungus
infection (mucormycosis):
|
Do's
|
Don’ts
|
|
Control hyperglycemia
|
Do not ignore warning signs
and symptoms
|
|
Monitor blood glucose levels
after COVID-19 administration, as well as in diabetics
|
Don’t consider that all cases
of the blocked nose are caused by bacterial sinusitis, particularly in
immunocompromised patients or COVID-19 patients on
immunomodulators.
|
|
Steroids should be used with
caution: Correct
timing, doses, and duration
|
For detecting fungal etiology,
do not be afraid to conduct aggressive
investigations (KOH staining
and microscopy, culture, MALDI-TOF)
|
|
Use sterile and clean water in
humidifiers during
oxygen therapy
|
Do not spend much time before
starting treatment for
mucormycosis.
|
|
Use antibiotics/ antifungals
carefully
|
|
CONCLUSION:
Although
rare, it is a serious infection. It is caused by a group of moulds known as
mucormycetes present naturally in the environment. It mainly affects people who
are on medication for health problems that reduces weeks. Experts in the task
force have stressed the need to control hyperglycemia, and monitor blood
glucose level after discharge following Covid-19 treatment, and also in
diabetics. One should use steroids judiciously — correct timing, correct dose
and duration are important6.
LIFE AFTER SURGERY FOR MUCORMYCOSIS:
Mucormycosis
can lead to loss of the upper jaw and sometimes even the eye. “Patients would
need to come to terms with loss of function due to a missing jaw — difficulty
with chewing, swallowing, facial aesthetics and loss of self-esteem, doctors
say. Be it the eye or upper jaw, these can be replaced with appropriate
artificial substitutes or prostheses. While prosthetic replacement of the
missing facial structures can commence once the patient stabilises after surgery,
doctors it is important to reassure him about the availability of such
interventions instead of leaving him to panic with the sudden unforeseen loss,
augmenting a post-Covid stress disorder which is already a reality Prosthetic
reconstruction can be effected after surgery, but interim solutions should be
planned even before surgery of the jaws for better long-term outcomes.
Prosthetic reconstruction can ensure that the cure is not more dreadful than
the disease itself, he said.7
their
ability to fight environmental pathogens, say experts from the Covid-19 task
force. Sinuses or lungs of such individuals get affected after they inhale
fungal spores from the air. Doctors in some states have noted a rise in cases
of mucormycosis among people hospitalized or recovering from Covid 19, with
some requiring urgent surgery. Usually, mucormycetes does not pose a major
threat to those with a healthy immune system. Warning signs include pain and
redness around the eyes or nose, with fever, headache, coughing, shortness of
breath, bloody vomits, and altered mental status. particularly in the context
of immunosuppression and/or Covid-19 patients on immunomodulators. Do not
hesitate to seek aggressive investigations for detecting fungal infection
REFERENCE:
1.
Centre Asks States to Make Black
Fungus Infections a Notifiable Disease available from
https://science.thewire.in/health/centre-
asks-states-to-make-black-fungal-infections-a-notifiable-disease cited on 21-05-21
2.
James Kingsland, Black fungus' and
COVID-19: Myths and facts available from https://www.medicalnewstoday.com/articles/black- fungus-and-covid-19-myths-and-factscited 04-6-2021
3.
Covid treatment guidelines available
from https://www.covid19treatmentguidelines.nih.gov/critical- care/oxygenation-and-ventilation cited on 17-12-2021
4.
Kristeen Cherney, available from https://www.healthline.com/health/mucormycosis cited on 18-10- 2017
5.
Black fungus infection available fromhttps://www.medicoverhospitals.in/blog/black-fungus
6.
Black fungus treatment available from https://www.mpnrc.org/black-fungal-disease-infection-symptoms- cause-treatment-news/ cited on 09-02021
7.
Life after surgery for mucormycosis
available from https://www.medloops.in/post/black-fungus-in-covid-19-patients- what-is-mucormycosis-symptoms-and-treatment/cited 20-5-2021
Received on 22.06.2021 Modified
on 05.07.2021
Accepted on 13.07.2021 ©A&V Publications All right reserved
Asian J. Nursing
Education and Research. 2021; 11(4):591-593.
DOI:
10.52711/2349-2996.2021.00137