Corona Daily 098: The Black Blinding Fungus

India’s BBC correspondent reports on his interaction with Dr Akshay Nair, an eye surgeon from Mumbai. Yesterday, Dr Nair operated on a 25 year old girl who had recovered from covid three weeks ago. She was diabetic. The ENT specialist had inserted a tube in her nose, and was trying to remove tissues infected with mucor, a rare but deadly fungus. In the three hour surgical procedure, in order to save her life, Dr Nair had to remove her eye.

In April, Dr Nair saw forty patients with mucormycosis. Eleven of them (28%) had to have an eye removed.

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Mucormycosis, informally known as the Black Fungus, usually infects the sinuses and via the eyes rapidly moves to the brain. Patients typically have a stuffy and bleeding nose, swelling of and pain in the eye, drooping of eyelids, blurred vision. Black patches of skin can form around the nose. Mucor can grow behind the eye, and compress the optic nerve.

Suddenly, Indian newspapers are filled with reports of black fungus patients from around the country. The numbers are small by Indian standards, but that was the case when coronavirus started. Awareness is useful before things get out of hand.

Dr Shailesh Kolhatkar is a practising head and neck cancer surgeon in Nagpur. During the last twenty years, he operated on just 11 patients with black fungus. In the last two months, he is performing three to four surgeries every day. Similar stories are happening in several states. The Gujarat government has set up a special ward for mucormycosis, and bought 5000 vials of the expensive injection Amphotericin B for Rs 3.12 crore ($450,000). It can happen at any age, but most common is 35-65 years.

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Diabetic patients are in the high risk category. Mucor attacks people with uncontrolled sugar.  It rarely happens to non-diabetic patients, unless their immunity is severely compromised by AIDS or cancer.

The main reason behind a black fungus infection is man-made. Covid patients are given dexamethasone or other medicines that suppress immunity. Steroids have a tendency to increase blood sugar levels even in non-diabetics.

If such patients are exposed to wet surfaces, the chances of mucormycosis grow. Some covid patients are put on oxygen support, which has a humidifier containing water. If the water leaks from the humidifier, or general hygiene is not good, the fungus has ideal conditions to infect.

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This is a fast-moving disease with high mortality. It takes only a few days for the fungus to reach the brain.

If detected early, an anti-fungal intravenous injection costing $50 has to be administered daily for eight weeks. The total cost of the treatment is beyond the budget of an average Indian.

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In terms of prevention, doctors say it is important to keep the sinuses open. That can be done by applying steam. Diabetic covid patients should watch their sugar levels. Hygiene is important. Oxygen cylinders when required must be clean. Humidity can increase the risk. Black fungus is an invasive disease.

The most important preventive measure is to focus on the use of steroids. Some covid patients graduating from WhatsApp University are themselves opting for steroids when not necessary. The general advice is not to take steroids for the first five-six days of covid infection. Steroids should never be given in mild cases. The doses and duration of life-saving steroids must correspond to the severity of covid.

The medical community in general is trained to offer strong medical interventions. In covid times, there is little opportunity for doctors to diagnose and treat each patient individually. Indian standards seem to be more relaxed than in America and Europe. Recognising this, the Indian medical body issued altered guidelines in April. They recommend reduced uses of steroids based on the covid severity.

Not only for covid, but for any disease if, god forbid, you or your loved ones land in a hospital, you must always insist on knowing what medicines are administered. That is a patient’s right. Even for patients in the ICUs, that right should not be surrendered.

If the cure for Covid makes the patient blind, the virus can’t really be blamed for that.

Ravi