Letter to Editor
Black fungus: Possible
causes of surge in cases in
the second pandemic in India
Dear Editor,
In India, as the second wave of COVID‑19 engulfed the entire
nation, another threat colloquially known as “Black Fungus”
imposed a new challenge to the medical world. In real sense,
black fungus is nothing, but an infection of mucormycetes
known as mucormycosis. This is the third most common cause
of invasive fungal infection next to Aspergillus and Candida
spp.[1] Rhizopus oryzae is the most common fungus, which is
responsible for approximately 60% of cases of mucormycosis.[2]
This is an opportunistic pathogen that is angioinvasive in nature.
Lesions appear as black spots in the nasal cavity, mouth and
throat and so named as “black fungus”. In early May of 2021,
a sudden increase in cases of mucormycosis was noted. Due to
the continuous rising of cases, the Union Health Ministry on
Thursday, 20 May 2021 urged the states to make mucormycosis,
a notifiable disease under the Epidemic Diseases Act 1897. There
were about 12,000 cases of mucormycosis up to 6 June 2021.[3]
Government of India stated on 8 June 2021 that the total cases
of mucormycosis were 28,252, of which 86% cases had a history
of COVID‑19 and 62.3% with a history of diabetes. Maharashtra
reported the maximum number of mucormycosis cases (6339)
followed by Gujarat (5486).[4] Mortality rate is 40%–80% but it
may vary upon different underlying conditions.[5]
There are several risk factors of mucormycosis such as diabetes
mellitus, haematological malignancy, organ transplant or stem
cell transplant patients, neutropenia, increased iron level,
deferoxamine.[6] In the current scenario of COVID‑19 pandemic,
diabetes is still the main predisposing factor of mucormycosis as
suggested by several studies as well.[2,5,7] Mucor utilises glucose
and so grows fast in excess blood glucose level.[8] Diabetes fulfils
this criterion. Another factor is that diabetes causes persistent
hyperglycaemia that is responsible for impaired chemotaxis
and phagocytosis of neutrophils. In addition to this, diabetic
ketoacidosis impairs the binding of iron to transferrin leading
to increase in free iron level which promotes fungal growth.[5]
Irrational use of corticosteroids is also a predisposing
factor for mucormycosis. Although the Ministry of Health
and Family Welfare (MoHFW) recommends intravenous
methylprednisolone/dexamethasone for moderate or severe
cases,[9] indiscriminate use or longer use may pose a problem
due to immunosuppression and by causing hyperglycaemia both
© 2021 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow 4322
in diabetic or non‑diabetic patient.[2,5,10] Furthermore, steroid
takes 4 weeks to wear off its effect, so patients treated with
steroids should protect themselves during this period and they
should avoid to visit damp and dusty area. If it is unavoidable,
they should wear three‑ply mask, gloves and fully cover legs and
arms. Furthermore, oxygen mask and canula should be sterile
and water used for oxygenation should be regularly checked for
patient on oxygen.
COVID‑19 causes sustained lymphopenia being reported in 85%
of cases.[11] So, there is decrease in number of T cells, CD4 cells
and CD8 cells. This decreased count of T cells makes a person
prone to fungal co‑infections. COVID‑19 also cause excessive
lung damage and alveolo‑interstitial pathology. It makes a
favourable chance of fungal infection.[12,13]
Kochi chapter of Indian Medical Association, experts suggested
that excessive steam inhalation may lead to mucomycosis. Data in
India reveal that 10%–20% of patients have mucormycosis due
to steam inhalation.[14] Nasal mucosa is very delicate structure
that may get damaged due to high temperature. Breached mucosa
affects protective escalatory function leading to invasive fungal
infection.
Some experts plead that use of industrial oxygen over medical
oxygen may be the culprit of fungal infection. Due to the sudden
rise of cases and decrease supply of medical oxygen, hospitals
were diverted to use of industrial oxygen. Medical oxygen
is highly purified. Before being used, it undergoes different
processes such as compression, filtration and purification.[15] Its
cylinders are cleaned and disinfected also. But these criteria are
not fulfilled by industrial oxygen. So, use of uncleaned industrial
oxygen may be a probable cause of the black fungus surge.
Mucormycosis should always be taken into consideration when
a patient at risk presents with unilateral facial swelling, proptosis,
facial pain or swelling. Diagnosis is based on combination of clinical
symptoms, radiological findings, histopathological examinations and
microbiological culture. Radiology is helpful for determination of
extent of disease. A combined approach is followed for treatment.
Patients with mucormycosis are undergone with exenteration
of affected part and administration of intravenous liposomal
amphotericin B (5‑10 mg/kg/day) along with blood sugar control.
It is utmost important to initiate treatment as the earliest because a
delay of 6 days may lead to doubling of mortality.[5]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 Letter to Editor
Shyam Kishor Kumar1,
Suprabha Chandran2,
Aroop Mohanty3,
Mithilesh Kumar Jha4
1
Department of Microbiology, All India Institute of
Medical Sciences, Deoghar, Jharkhand, 2Department of
Ophthalmology, Darbhanga Medical College, Laheriasarai,
Bihar, 3Department of Microbiology, All India Institute of
Medical Sciences, Gorakhpur, Uttar Pradesh, 4Department of
Microbiology, All India Institute of Medical Sciences, Patna,
Bihar, India
Address for correspondence: Dr. Suprabha Chandran,
Darbhanga Medical College, Laheriasarai, Bihar, India.
E‑mail: dr.suprabha04@gmail.com
References
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onset Diabetic Ketoacidosis and COVID‑19. Cureus
2021;13:e13163.
2. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in
COVID‑19: A systematic review of cases reported worldwide
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3. "Black fungus: India reports nearly 9,000 cases of
rare infection. BBC News (Internet). 06 June 2021.
Available from: https://www.bbc.com/news/
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Journal of Family Medicine and Primary Care 4323 Volume 10 : Issue 11 : November 2021
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Bhalla A, et al. Coronavirus disease (Covid‑19) associated
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12. Bhatt K, Agolli A, Patel MH, Garimella R, Devi M, Garcia E,
et al. High mortality co‑infections of COVID‑19 patients:
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13. Sarkar S, Gokhale T, Choudhury SS, Deb AK. COVID‑19 and
orbital mucormycosis. Indian J Ophthalmol 2021;69:1002‑4.
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leading to surge in black fungus cases? India Today (Internet).
23 May 2021. Available from: https://www.indiatoday.in/
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Received: 16‑06‑2021 Accepted: 10‑07‑2021
Published: 29-11-2021
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DOI:
10.4103/jfmpc.jfmpc_1183_21
How to cite this article: Kumar SK, Chandran S, Mohanty A, Jha MK.
Black fungus: Possible causes of surge in cases in the second pandemic
in India. J Family Med Prim Care 2021;10:4322-3.
© 2021 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow