The Black Death or Mucormycosis – A new concern in the COVID pandemic

Article written by :drChandramouli
Dr Chandramouli Bhattacharya,
MD (Tropical Medicine), MRCP (Ireland),
Consultant in Tropical & General Medicine with Infectious Diseases
Peerless Hospital

We are more than a year into the Covid 19 pandemic in India and we have just been pushed to the brink of complete collapse of the healthcare system when we were hit by the second wave of the pandemic. All the horror stories we had come to associate with New York, London and Lombardy during the early part of the pandemic suddenly became our own reality. I can safely say that at no point in living memory has the entire world population faced what we have faced. We have seen enormous numbers of people becoming sick and a lot of them dying. We have seen shortages in PPE, in hospital beds, oxygen supply, ventilators and finally vaccines and medication. As if all of this was not enough the unsuspecting public has also been brought face to face with another health threat bearing a name that makes an association with an even older scourge of humanity—the bubonic plague—which in its time was called “the Black Death”.

What we are talking about of course is the Black Fungus. I would like to start out by saying that the nomenclature that the media has come up with is unique and inaccurate. There is something called a ‘black fungus’ but that is an organism called Cladophialophorabantiana and not Mucormycosis which is what we are talking about. To the best of my (very limited) knowledge mucormycosis was never called black fungus prior to now.

This is an infection caused by any member of a group of fungi that belong to the order Mucorales. It is actually Rhizopus spp. which is the commonest organism cultured followed by Mucor. They are characterised under the microscope by the presence of “ribbon-like large, aseptate hyphae”. The main way that infection is acquired is by inhalation of spores from environmental sources though inoculation during trauma and ingestion (for gastrointestinal disease) have also been documented. Mucormycosis is primarily a disease of the immunocompromised—poorly controlled diabetes mellitus is the most common predisposing factor. Other people at risk are people on steroids or other immunosupressants for a prolonged period of time (commonly transplant recipients), those with cancer who are receiving chemotherapy. Less common risk factors are renal failure, malnutrition and HIV infection.

It is a disease that is relatively well recognised in India which probably has something to do with the fact that we are the Diabetes capital of the world. Places like Gujarat and Maharashtra have always reported Mucormycosis and it is definitely not something new. What is unprecedented however is the scale of the problem and this is where Covid 19 has helped create the “perfect storm”. We have thousands of patients admitted in hospitals where infection control practices are often rudimentary and these people who may already be diabetic are being given moderate to high doses of corticosteroids for prolonged periods of time often without achieving optimum blood sugar control. It is the huge number of people who are being exposed to these risk factors that has led to the explosion in the number of cases. Add to that the fact that doctors as well as the general public have become so much more aware of the disease which ensures that fewer cases are missed.

The commonest form of Mucormycosis is the rhinocerebral form which involves the nose, sinuses, mouth, orbits and can spread to the brain. This is the classical form which the medical fraternity has always had some knowledge of. The other less common areas of involvement are the lungs, the gastrointestinal tract, the kidneys, the bone and the skin. There is also a disseminated form. Symptoms are non-specific though the rhinocerbral form is easier to recognise as it presents with headache, nasal discharge, mouth or facial pain or facial swelling. Early recognition is key as treatment outcomes are heavily dependant on early initiation of treatment which is almost always a combination of antifungal drugs and radical surgery.

Though this is a serious condition with high mortality it is really not something the general public needs to be worried about. In the absence of penetrating trauma it is almost impossible to have the disease in the absence of significant levels of immunocompromise or grossly uncontrolled blood sugar. The only preventive measure that is worth anything is trying to achieve tight control of blood sugar—that is something which should be happening anyway. It is not contagious and so does not spread from person to person. The spores are present in the environment and we all inhale these spores. It is only when our immune system is incapable of handling these spores that we can actually develop the disease.

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