Black Fungus

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ICMR issues Evidence-based advisory on "Black Fungus" in Covid-19 patients

What is "black fungus"?

Mucormycosis, colloquially known as "black fungus", is a fungal infection that mainly affects people who are on medication that reduces their ability to fight environmental pathogens.

Mucormycosis, if uncared for, may turn fatal. The sinuses or lungs of such individuals get affected after fungal spores are inhaled from the air.

Warning signs & symptoms

  1. Pain and redness around the eyes and nose
  2. Fever
  3. Headache
  4. Coughing
  5. Shortness of breath
  6. Bloody vomits
  7. Altered mental status

Major risk factors

  1. Uncontrolled diabetes mellitus
  2. Immunosuppression by steroids
  3. Prolonged ICU stay
  4. Co-morbidities- post-transplant /malignancy
  5. Voriconazole therapy
  6. In Covid-19 patients, diabetes or immuno-suppressed individuals

When to suspect?

  1. Sinusitis - nasal blockage or congestion, nasal discharge (blackish/bloody).
  2. Local pain on the cheekbone, one-sided facial pain, numbness, or swelling.
  3. Blackish discoloration over the bridge of the nose/palate.
  4. Toothache, loosening of teeth, jaw involvement Blurred or double vision with pain, fever, thrombosis, necrosis, skin lesion
  5. Chest pain, pleural effusion, hemoptysis, worsening of respiratory symptoms

Dos

  1. Control hyperglycemia
  2. Monitor blood glucose level post-Covid-19 discharge & also in diabetics
  3. Use steroid judiciously - correct timing, correct dose & duration
  4. Use clean, sterile water for humidifiers during oxygen therapy
  5. Use antibiotics/antifungals judiciously

Don'ts

  1. Don't miss warning signs & symptoms
  2. Don't consider all the cases with a blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or Covid-19 patients on immunomodulators
  3. Don't hesitate to seek aggressive investigations, as appropriate (KOH staining & microscopy, culture, MALDI-TOF), for detecting fungal etiology

How to manage?

  1. Control diabetes and diabetic ketoacidosis
  2. Reduce steroids (if the patient is still on) with the aim to discontinue rapidly
  3. Discontinue immunomodulating drugs
  4. No antifungal prophylaxis needed
  5. Extensive Surgical Debridement - to remove all necrotic materials

Medical Treatment

  1. Install peripherally inserted central catheter (PICC line)
  2. Maintain adequate systemic hydration
  3. Infuse normal saline IV before Amphotericin B infusion
  4. Antifungal therapy, for at least 4-6 weeks (follow guidelines)
  5. Monitor patients clinically & with radio-imaging for response & to detect disease progression

How to prevent Mucormycosis?

  1. Use masks if you are visiting dusty construction sites
  2. Wear shoes, long trousers, long sleeve shirts & gloves while handling soil (gardening), moss, or manure
  3. Maintain personal hygiene, including a thorough scrub bath

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