It was April 20, when Covid patient Ahmad Azeem was admitted to Hakeem Abdul Hameed Centenary Hospital when his oxygen levels fell. There, he started having difficulty in swallowing food and liquids, even after taking hot water, and doing the complete course of Azithromycin.
"So, I just took a photo of my mouth and was surprised to see a white layer. When I showed the photo to a doctor friend, he said it was white fungus and put me on a 10-day course of Itraconazole, Clotrin Mouth Paint for application and Betadine for gargling. Within four days, I got relief but I completed the course. The doctor told me that it could have become serious if the infection had entered my respiratory tract," says Azeem, PRO, Jamia Milia Islamia.
In the Covid-19 saga, after dropping oxygen levels the focus has now shifted to the white, black and yellow fungal infections being reported in COVID and COVID-recovered patients. Experts attribute these fungi to the high amount of steroids administered to COVID patients.
"Hospitals are very careful with administering the right quantity of steroids, but doctors in the semi-urban areas are not specialists and are unaware about the right dosage. They are giving 80mg dosages without knowing the intensity of the problem. India also has the trend of hand-me-down prescription. If a family member is taking one medicine, the others will have the same without consulting a doctor," says a medical expert, choosing to stay anonymous.
While all three fungi are different, experts say, the names black, white and yellow are misnomers (inaccurate) because there are other fungi also in the same three colours.
In India, a high number of Mucormycosis (black fungus) cases are being reported as it is a hot tropical country, which becomes the ideal environment for these spores present in the air to grow. But the spores don’t cause infection in immunocompetent people, say experts.
Dr Amitabh Malik, Chief, ENT, Paras Hospital, Gurugram, says, "Black Fungus is a rare fungal infection, but a serious condition. Mostly diabetic patients, who are being given steroids, are at risk. Steroids are essential to control the inflammation in lungs but at the same time they take a toll on the patient’s immunity and increase the blood sugar levels in both diabetics and non-diabetic patients alike."
Black fungus is a dematiaceous (brown-pigmented) fungi where the cell wall turns black. The expert says, "The term black fungus is used for mucorails that are of six-seven types. Of these, rhizopus is the most common. Rhino-orbital cerebral is most common, and for this one to happen diabetes or hyperglycemia are the most important risk factors. Another is pulmonary Mucormycosis for which the risk factors are transplant and haematological malignancies, for Cutaneous Mucormycosis risk factors are trauma and burns, and for GI Mucormycosis, the risk factors are malnutrition and prematurity."
Experts say mortality is 60 per cent if Mucormycosis is sino-nasal or orbital, and if it goes to the brain, then mortality is close to 80 per cent. Dr Pankaj Aggarwal, MD Homoeopathy and Director Aggarwal Homoeo Clinic, adds, "Anyone using unwashed masks, and is immunocompromised or diabetic, is at risk. Our breath makes the mask moist, which becomes a potentially sound place for the fungus to grow."
Symptoms associated with mucormycosis are headache, facial pain, nasal congestion, loss of vision or eye pain, swelling of the cheeks and eyes, and black crust in the nose. "Recently, we operated on two patients in their 30s who were not diabetics, but developed Mucormycosis because their blood sugars were not monitored when they were on steroids. The fungus is treated surgically (debridement) to remove all dead and infected tissue and undergo a course of antifungal therapy," adds Dr Malik.
Antifungals called Isavuconazole and Posaconazole are used in the treatment if a patient can’t tolerate Amphotericin B, informs Dr Shashank Vashist, ENT, Columbia Asia Hospital, Palam Vihar, Gurugram.
"Both are available as injections as well as oral medications, but one should not take these medications without prescription," suggests Dr Vashist. "Hyperbaric oxygen is also used in the treatment of Mucormycosis. Fungi, especially mucorails, decrease when hyperbaric oxygen is given," adds the medical expert.
White Fungus belongs to the family of Candida. "The disease is not contagious, but these moulds can be easily inhaled by a patient, which can spread to vital organs and cause complications," notes Dr Malik.
White and Black fungi are similar as they originate from outside sources Mucor and Piedra. As compared to black fungus, fewer cases of white fungus have been detected.While white fungus was initially not viewed as dangerous, on Thursday, Delhi’s Ganga Ram Hospital reported a rare kind of white fungus that had spread throughout the intestine of a woman.
This one is the most dangerous of the three fungi emerging in COVID patients. "It begins internally, unlike others where symptoms are visible, which often leads to a delay in its diagnosis. This characteristic of yellow fungus makes it very difficult to manage," observes Malik.
Yellow fungus, says Dr Aggarwal, is rarely seen in humans and usually occurs in lizards. But it is the most dangerous of all as it can damage the internal organs of immunocompromised patients. Weight and appetite loss, lethargy are the common symptoms.
If not detected in time, these become severe and lead to pus leakage, sunken eyes, organ failure, slow healing of wounds and necrosis. Dr Aggarwal claims that all three can occur at the same time depending on how immunocompromised the person is.
Experts say such cases didn’t appear in the first wave because steroids were not listed in the initial guidelines. But in today's scenario, its over-the-counter availability should not be discontinued. Doctors also caution that whether someone contracted COVID-19 in the first or second wave, if one is immunocompromised, the chances of getting infected are high and they must stay in touch with their doctor.