What is the relationship between Covid-19 and fungal infections in India?

Introduction

During the deadly second wave of coronavirus in India, we have seen a sudden rise in reported ‘black fungus’ cases. What is black fungus? How does Covid-19 cause fungal infections? And what can be done to prevent this from happening in the future?

How does Covid-19 cause fungal infections?
How does Covid-19 cause black fungus?
Covid-19 in India

Mucormycosis, popularly known as ‘black fungus’, is a rare fungal infection of the sinuses which is notoriously difficult to treat and can often be fatal. It is difficult to obtain up to date statistics on the number of infections or fatalities, especially from more rural areas. However, recent reports estimate ~28,000 cases of black fungus across India with some regions such as Maharashtra being heavily impacted with ~7,400 cases (1). On Sunday, India reported less than 60,000 new cases of Covid-19 for the first time in 80 days, showing the second wave has hopefully begun to subside. With more than 386,000 deaths to date (likely an underestimate) India has been severely impacted by Covid-19, particularly in the last 2 months. Raising awareness of co-morbidities, such as black fungus, could help to reduce the future death toll if there is a third wave in the still largely unvaccinated country.

What is black fungus?

Mucormycosis is caused by a group of molds. These infections do not spread from person to person but reside in the environment, commonly found in soil and associated with decaying organic matter such as animal waste. These fungi aren’t harmful to most people. Black fungus generally occurs in people with other health conditions or those who are taking drugs which effect the immune system. This is not a new infectious disease, but is on the rise and is linked to Covid-19 infection (discussed below).

How does Covid-19 cause fungal infections?
How does Covid-19 cause black fungus?
Covid-19 in India
Covid-19 associated fungal infections
Symtpoms;
  • Headache
  • Facial pain
  • Nasal congestion
  • Vision loss or pain in the eyes
  • Swelling in cheeks and eyes
  • Black crusts in the nose
Treating black fungus

Following infection, black fungus can spread through the nose and the eyes and if left untreated can reach the brain, which results in increased mortality. The fungus ‘eats’ the tissue and leads to tissue necrosis (a type of tissue death) which causes the tissue to turn black, giving the infection the name black fungus. Infected tissue needs to be surgically removed, which can result in disfiguration and even the removal of the eyes. Besides surgical removal, treatment involves intravenous anti-fungal drugs (usually amphotericin B, posaconazole, or isavuconazole) spanning 4-6 weeks.

With several states reporting a shortage of these anti-fungal drugs the Indian government has taken action, such as banning the export of Amphotericin-B (2).

What is white and yellow fungus?

Other fungal infections are potentially on the rise due to Covid-19 in India. White fungus is a fungal infection caused by the candida group of fungi and results in the formation of whitish membranes or discharge. Although commonly associated with mouth (thrush) or vaginal infections, it can attack other parts of the body such as the lungs, skin, nails and kidneys and can pose extra risk if it becomes systemic. However, generally white fungus is more easily treated and less fatal than black fungus (2).

There has also been one reported case of yellow fungus in India in a 45-year-old patient, the resident of Sanjay Nagar in Harsh Hospital. Yellow fungus infection begins in the body and so is harder to detect than black or white fungus. Yellow fungus is said to be more dangerous, however, it remains to be seen if cases of yellow fungus will increase.

What is causing the rise in fungal infections?

How does Covid-19 cause fungal infections?
How does Covid-19 cause black fungus?
Covid-19 in India
Covid-19 associated fungal infections

A study which investigated the rise in black fungus infections in India between Sep-Dec 2020 released an early draft of their results (3). Their results showed that uncontrolled diabetes and Covid-19 were the most common underlying diseases in black fungus patients. The black fungus mortality rate after 12 weeks was very high at 45.7%, showing the severity of this infection.

The study found that overuse of steroids during Covid-19 treatment was associated with black fungus infection. This could be due to the steroids affecting the patients immune system, leaving them susceptible to black fungus infection.

Reasons cited for increased black fungus infections (4);

  • Poor hygiene in overwhelmed hospitals
  • Lack of oxygen supply leading to increased use of steroid treatment with Covid-19 patients
  • Immunosuppressive effects of Covid-19 infection
  • Poor controlled diabetes following Covid-19 infection

What can we do to prevent another rise in cases during a third wave?

Unfortunately a third wave of Covid-19 is inevitable in India as restrictions ease. There will be fewer cases, hospitalizations and deaths the more people are vaccinated. This is clear looking at data from Israel, the UK and the US which have high vaccination rates. Limiting the use of steroids and providing oxygen to hospitals may also limit the rates of fungal infections. Additionally, use of masks, cleaning of your environment and maintaining good personal hygiene may all help reduce the spread of Covid-19 and the risk of developing black fungus. Black fungus is currently being reported in other countries and associated with Covid-19 infections (see map below) making research into preventing the spread of this fungus crucial to not only India, but to the world.

How does Covid-19 cause fungal infections?
How does Covid-19 cause black fungus?
Covid-19 in India
Covid-19 associated fungal infections
Black: India Red: Countries where COVID-19–associated mucormycosis has been detected.

References

  1. https://www.cbsnews.com/news/black-fungus-india-covid-19/
  2. https://www.dnaindia.com/health/report-black-fungus-vs-white-fungus-what-we-know-so-far-signs-symptoms-and-treatment-2891452
  3. https://wwwnc.cdc.gov/eid/article/27/9/21-0934_article
  4. https://www.bmj.com/content/373/bmj.n1238

Author

  • Tamizhini Loganathan completed a Master of Technology degree at SASTRA Deemed University. She has experience as Project Associate at IIT Madras. She is a passionate researcher. Major interests in Multi-omics, Cancer Biology, Bioinformatics and Computational Biology.

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