With the world reeling from the effects of the unique coronavirus, a submicroscopic, enigmatically animated infectious particle, we now have to deal with another previously unknown opportunistic opponent, the so-called “Black fungus” infection, academically dubbed mucormycotic.
Rhino-orbito-cerebral mucormycotic is the most cruel and vicious expression (ROCM). With this in mind, we’ll take a look at a lesser-known organism: the fungus, and its relevance in these volatile and unpredictable times.
What is a fungus?
These are organisms that do not belong to the plant or animal kingdoms. They can be found in the soil, plants, decaying organic materials, water, air, and wet locations, as well as in humans and animals. They, together with bacteria, serve a crucial function in our environment by reducing organic matter into simpler forms for plant use. Household yeast, moulds, mushrooms, and a variety of other organisms are among them. There are approximately 1,44,000 fungi (plural for fungus), some of which are pathogenic to humans. Candida, Aspergillus, Cryptococcus, Histoplasma, Pneumocystis, and Mucoromycetes are the most prevalent.
What types of infection do these fungi cause?
In general, several types of fungus do not cause infections in humans, but opportunistic infections, which affect persons with compromised immune systems, can cause illness.
The following are examples of common fungal infections:
*Infections of the skin, such as ringworm
Infections of the nails
*Further cutaneous infections as a result of trauma,
*A cutaneous blemish that leads to fungal implantation and proliferation.
*Infections of the sinuses and lungs
*The fungi can also impact the gastrointestinal and renal systems, as well as produce a full-blown infection when they enter the circulation.
If the fungi are so common why is it that we rarely get infected by them?
“We keep these omnipresent germs at bay and remain infection-free thanks to our body’s defensive mechanisms, which are constantly and assiduously combating them. Once our immune system’s protection is lowered, these germs gain the upper hand and unleash nasty and often fatal illnesses.
Who is susceptible to fungal infections?
People with a weakened immune system are more prone to illness, as previously stated. Immune deficiency is caused by a variety of factors, including:
*Diabetes: The combination of high blood sugar and an acidic environment, as seen in diabetic ketoacidosis, is ideal for rapid growth of these organisms. Diabetes is also linked to a weakened immune system.
*Steroid medicine raises blood sugar levels and lowers the body’s immunological response.
*Blood cancers, which result in a faulty immune system once again.
*Immunosuppressive patients, such as organ transplant recipients and haematologic stem cell recipients.
*Patients using deferoxamine or who have an excess of iron.
What is ROCM or Black fungus infection?
Mucormycosis (formerly known as Zygomycosis) is a deadly but uncommon fungal infection caused by micromycetes, a type of mould. Molds of the order Mucorales induce rhino-orbital-cerebral-mucormycosis (ROCM). There are a few subgroups that are most typically engaged in this infection, including as Rhizopus, Mucor, and Rhizomucor. These fungi are angioinvasive, meaning they enter and damage the surrounding blood vessels, causing tissue necrosis and death. Molds can be found all throughout the environment, and their spores can be found in the air. They become trapped in the nasal cavity and the sinuses that surround it.
They ensconce themselves within the tissue once they’ve found a favourable environment. When the spores germinate, the hyphae (filamentous processes) enlarge and exude destructive fluids that destroy the host tissue while also feeding the quickly developing fungi. They damage the surrounding host tissue as they grow in the nasal cavity. The nasal cavity and sinuses’ bones are damaged. The hard palate, orbital bones, and skull base bones are among them. In the nasal cavity and oral cavity, black lumps can be detected. It may cause bulging of the eyes, discomfort, frozen eye movements, and blindness if it destroys the orbit and enters the eye socket.When it breaches the skull base and enters the cranial cavity, it plugs major arteries and venous lakes, resulting in life-threatening brain strokes and bleeding.
He went on to say that spores can penetrate deep into the respiratory system and become pleasantly embedded in the lung parenchyma (alveoli and bronchioles). The fungus multiply quickly in this environment, damaging lung tissue and jeopardizing blood oxygenation. It can then spread throughout the circulatory system, causing an existential crisis.
Is it contagious?
The disease is not contagious and doesn’t spread from one person to another.
Why is it occurring in COVID 19 patients?
Mucormycosis can develop at any time after a COVID-19 infection, whether while in the hospital or several days to weeks after release.
“The COVID-19 alters the internal environment of the host in a way that benefits the fungus, and the medical treatment unknowingly aids fungal growth. COVID-19 causes harm to the mucosa of the airways and blood vessels. It also causes a rise in serum iron, which is necessary for the fungus to thrive. Steroids, for example, raise blood sugar levels. Broad-spectrum antibiotics kill not just the potentially harmful bacteria, but also the beneficial microorganisms.
Aspergillosis is inhibited by antifungals such as Voriconazole, while Mucor is unaffected and thrives due to a lack of competition. Long-term ventilation lowers immunity, and it’s possible that the fungus is spread by humidifier water mixed with oxygen. All of these factors combine to create an ideal environment for the spread of mucormycotic.
What are the clinical features of mucormycosis infection? How do we diagnose them?
Mucormycosis is characterised by nasal obstruction, haemorrhage, and discharge. An unmistakable black eschar (slough or dead tissue) coated mass will be evident on endoscopic viewing of the nasal cavity, indicating the diagnosis. The palate may be damaged as the disease proceeds, as evidenced by a massive black necrotic mass visible when the mouth is opened. Proptosis (eyeball protrusion), lack of eyeball motions, and resultant double vision occur when the orbit is implicated. Eye pain, redness, and blindness are all possible outcomes. There will be strokes, haemorrhages, and even death if the brain is invaded due to blood vessel blockage.
Headaches, sleepiness, limb weakness, convulsions, and even death might occur in patients.
An MRI and CT scan of the nasal cavity, sinuses, and brain are performed based on clinical suspicion. These provide a clear image of the existence and extent of the lesion.
Clinical characteristics of lung mucormycosis are similar to COVID-19, including fever, cough, and shortness of breath, making clinical diagnosis challenging. Suspicion of fungal infection should be evaluated when a patient is not improving or was improving but is now deteriorating for no apparent reason. Additional lung abnormalities are revealed with a CT chest scan, which aids in diagnosis.
Can there be other fungal infections in COVID 19 patients?
Mucor has not created as much devastation in Western countries as it has in India. Other fungal infections, such as aspergillosis and candidiasis, have been found to be more common in COVID-19 patients. In clinical terms, fungus-caused lung infections are difficult to detect. The patient has a fever, cough, and shortness of breath, which are symptoms of COVID. As a result of the overlap, diagnostic problems arise. The doctor should be on the lookout for signs of fungal infection and have a low suspicion level, especially when a COVID-19 patient appears to be improving but then begins to have respiratory problems.Bronchopulmonary lavage and pathological examination for fungi are must in order to incorporate appropriate treatment.
How is ROCM treated?
It’s a multi-pronged strategy. Here, time is of the importance. An endoscopic examination of the nasal cavity can confirm a fungal lesion if a clinical and radiological diagnosis has been obtained. Surgical debulking should be done right away. The procedure may be invasive and disfiguring, but it is justified given the existential threat of leaving any remaining tissue behind. The entire nasal cavity should be scoured and any fungal or necrotic tissue removed. If the orbit is implicated, surgery as extreme as exenteration of the contents of the eye socket may be required. If the infection has progressed to the brain, intracranial decompression may be required. Surgical intervention should be undertaken a couple of hours after diagnosis.
Medical management with antifungal medicines, specifically injectable Liposomal amphotericin-B, must also be implemented. Amphotericin deoxycholate, in its older form, is extremely nephrotoxic. The liposomal cousin, on the other hand, is both safe and effective. If the patient is unable to tolerate amphotericin, parconazole tablets, suspension, and injectable formulations are available. Following many weeks of intravenous therapy, the patient is switched to oral parconazole sustained release tablets for several months, depending on the response. Isavuconazole is another medicine that can be used as a substitute. After the disease has been cleared clinically and radiologically, the drugs are withdrawn. During treatment, careful use of steroids (to keep blood sugar levels in check), antibiotics, and other antifungal medicines is required.
Are these infections life-threatening?
These illnesses are extremely deadly, and most people will die if they are not treated. The death rate varies between 25% and 90%. Once the infection has gone to the brain, the risk of death is extremely high. As a result, early detection and treatment are given a high priority.
How to prevent the occurrence of ROCM?
It is always preferable to prevent than than cure.
In the hospital,
*It is essential to maintain good hygiene and cleanliness. Mouthwash and povidone-iodine gargles should be used on a regular basis.
*When delivering oxygen, the water for humidification must be sterile, and the humidifier should not leak.
*With rigorous blood glucose management, steroid use should be limited to no more than is absolutely necessary.
*Unnecessary use of broad-spectrum antibiotics and antifungals should be avoided since they deplete the typical commensal flora, allowing unwelcome organisms to thrive due to a lack of competition.
After being released:
*Avoid going outside as much as possible.
*Blood sugar management
*At home, the environment must be clean, dust-free, and damp-free.
*Keep your mouth and nose clean.
*Always wear an N-95 mask when going out.
*Avoid working areas, fields, and grounds.
*Fungi can be found in abundance in soil and plants. As a result, gardening and working with soil should be avoided. Masks, rubber gloves, and boots must be worn if at all possible.
“If a patient suffers sinus headaches, facial pain, stuffy nose, bloody nasal discharge, blackish discoloration over nose or palate, eye pain, edoema, decreased vision or double vision, tooth pain, headache, convulsions, sleepiness, or limb weakness after receiving Covid, seek immediate medical attention.
“The significant take-home messages are that opportunistic fungal infections do occur in COVID-19 patients, that raising awareness among health care providers and the general public is critical, that early diagnosis and aggressive treatment are critical for improving outcomes in an otherwise dismal condition, and that working together we can surely win this battle against COVID 19 and mucormycosis,” says the author.