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FAQ | What Is Mucormycosis? Is Steroid Overuse Behind its Rise?

Delhi hospitals have reported a rise in cases of mucor, a rare fungal infection, with the rise of COVID pandemic.

Updated
<div class="paragraphs"><p>Taking steroid based medicines in the early stages of COVID can do more harm than good.</p></div>
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In the last few weeks, along with COVID, India has also been seeing a parallel rise in cases a mysterious fungal infection, dubbed 'black fungal infection'.

This infection is particularly feared because of how rapidly it can escalate and lead to people losing their eyesight or even organ function.

But the 'black fungal infection' or mucormycosis isn't mysterious at all. It was just very rare. However, with the COVID pandemic, the number of people getting infected with mucor has gone up significantly.

Delhi's Sir Ganga Ram Hospital was one of the first to sound the alarm bells, followed by hospitals in Gujarat and Maharashtra.

In the last few months, the disease has seen an alarming rise in COVID recovered patients. So much so that the Union health minister, Dr Harsh Vardhan took to Twitter on Friday, 14 May, to advice people on the early detection and management of the infection.

What is Mucorcycosis? How does COVID cause it? And what do steroids have to do with it? FIT speaks to Dr Aparna Mahajan, Consultant, ENT, Fortis Hospital, Faridabad.

What is mucormycosis?

According to the US’s Center for Disease Control and Prevention (CDC), mucormycosis is a serious but rare fungal infection caused by a group of moulds called micromycetes.

"The fungus is freely present around us, but it needs a very specific kind of environment in someone's body for it to get an opportunity to cause an infection."
Dr Aparna Mahajan, Consultant, ENT, Fortis Hospital, Faridabad

"It is most commonly found in the nose, the sinuses, the eyes and the brain," she says. "Once it spreads to the brain, it can be very difficult to treat."

What makes the infection so dangerous?

“It is a type of lethal infection with a very high mortality rate,” she adds.

Speaking to FIT for a previous article, Dr Sumit Ray, a critical care specialist in Delhi, explained how the mortality rate in those infected with mucor is as high as almost 50-70 per cent.

“If the infection spreads beyond a point, it isn’t possible to save the patient,” says Dr Mahajan.

And what makes it even more dangerous is how fast it escalates.

“It behaves somewhat like cancer, but cancer would take at least a few months to have a lethal effect. This can lead to fatality within days or even hours.”
Dr Aparna Mahajan, Consultant, ENT, Fortis Hospital, Faridabad
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In spite of it being so dangerous, it wasn't considered particularly alarming until recently.

"It used to be a very rare disease," says Dr Mahajan. "In a high volume centre, we would only get to see about one case in a span of 3 or 4 years."

If mucor is rare, why is it spreading so rapidly now?

"Earlier severely immunocompromised patients, like cancer patients, people with uncontrolled diabetes, transplant recipients who are on immunosuppressant therapy, were susceptible to it, but now with COVID, it has become very very frequent."
Dr Aparna Mahajan, Consultant, ENT, Fortis Hospital, Faridabad

According to Dr Mahajan, this causal link can be because of the following reasons.

  • Covid virus per se creates an environment that makes it easy for the fungus to grow.

  • It has to do with the decrease in the immune response of a COVID patient.

But even then, the infection in COVID patients was largely restricted to people with severe diabetes, cancer, or those on immunosuppressants for other illnesses.

Dr Mahajan explains that the reason for mucormycosis spreading rapidly now, in otherwise healthy COVID patients, is the indiscriminate use of steroids.

Are steroids behind the spike in mucor cases?

Steroids, especially when used in high doses or over a long period of time can lead to mucormycosis.

This is because "steroids can also reduce our immunity, and have the tendency to increase blood sugar levels, even in nondiabetics. They can also create the ideal environment that allows the infection to spread," explains Dr Mahajan.

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In a recent press conference, Dr Randeep Guleria, Director, AIIMS, spoke of the harm that steroids can do if taken in the early stages of COVID.

"Many people take high dose steroids in an early stage. This can lead to the virus replicating more rapidly. People with mild symptoms can end up developing severe viral pneumonia with the virus spreading in the lungs."
Dr Randeep Guleria, Director, AIIMS, New Delhi

Do all steroid based drugs pose a considerable risk of mucormycosis?

Not necessarily. The risk of developing mucormycosis is mainly with the use of systemic steroids.

Systemic steroids currently used to treat COVID that can cause mucorycosis if misused, include Dexamethasone and Methylprednisolone.

These drugs are also part of the guidelines issued by the government for the treatment of moderate COVID, and along with oxygen, remain one of the more effective treatment options for COVID. Dexamethasone has been found to be very effective in hospitalised patients with COVID-19 and respiratory failure who required therapy with supplemental oxygen or mechanical ventilation, in the Recovery Trials.

On the other hand, inhaled Budesonide, another corticosteroid recommended for the treatment of early COVID, does not pose such a threat.

This is because inhaled budesonide is not a systemic steroid. It is potent locally, and can cause local fungal infections (in the oral cavity) but isn't likely to cause mucormycosis.

"Budesonide can coat the lining of the respiratory tract and lead to superficial fungal infections. Mucor, on the other hand, affects the body in a systemic level. Mucor is not a superficial infection."
Dr Aparna Mahajan, Consultant, ENT, Fortis Hospital, Faridabad

"No reports have been found so far of inhaled budesonide causing mucormycosis," she adds.

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Should you, then, not take steroid based drugs for COVID treatment?

So far there is no cure for COVID, and there is no drug capable of killing the COVID virus.

The various steroids, in the meantime, have emerged as 'saviour drugs' capable of curbing the illness from turning severe, and have been used widely.

But having said that, experts have time and again recommended using steroids only in case of moderate illness. The same Recovery Trials also indicated that dexamethasone might increase mortality in hospitalised patients who were not receiving oxygen.

What should you keep in mind while taking steroid based medicines?

"Steroids should only be taken under a doctor's supervision," says Dr Mahajan.

“No individual should self-medicate with steroids. Steroids aren’t medicines to be taken without a doctor’s supervision."
Dr Aparna Mahajan, Consultant, ENT, Fortis Hospital, Faridabad
The timing and the duration of the steroids are very important, especially in the case of COVID.

"In the initial 5 to 7 days, steroids should not be given," says Dr Mahajan. "Even after then, the doctor should take that call based on the patient’s condition."

"Steroids should only added very judiciously to the treatment," she adds.

What are some warning signs to look out for?

According to the slides shared by Dr Harsh Vardhan, some early signs of mucormycosis include,

  • Redness in the eyes

  • Fever

  • Shortness of breath

  • Cough

  • Bloody vomit

  • Altered mental state

  • Headache

FAQ | What Is Mucormycosis? Is Steroid Overuse Behind its Rise?

(Photo: Twitter/ @drharshvardhan)

Apart from these, Dr Mahajan also mentions,

  • Any kind of facial swelling, especially around the eyes and cheeks

  • Runny nose

  • Nasal congestion

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"In case you notice any of these early clinical suspicion or symptoms, you should immediately prompt the conduct of a biopsy in the OPD and start of the antifungal therapy as early as possible."
Dr Manish Munjal, Senior ENT surgeon, Sir Ganga Ram Hospital

Dr Mahajan further warns against self-medicating with steroids saying "these warning symptoms can go unnoticed by patients if they are self medicating without a doctor's knowledge."

Is Mucormycosis treatable?

Yes, but the success rate, and the type of treatment will depend on a few factors.

For one, the stage at which the infection is will determine whether the patient can be saved or not.

"The course of the treatment will also vary depending on which organs are involved," explains Dr Mahajan. "It can require aggressive surgical debridement."

How can you effectively manage the infection?

Experts agree that early detection is the key to treating the infection successfully.

Dr Harsh Vardhan, in his Tweet, mentions some Dos and Dont's that can help diagnose and treat the disease at the earliest.

These include, not ignoring early warning signs, using steroids judiciously, and seeking medical help to detect and eliminate the infection at the earliest.

FAQ | What Is Mucormycosis? Is Steroid Overuse Behind its Rise?

(Photo: Twitter/@drharshvardhan)

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