What’s the link between COVID-19 and black fungus?

• Mucormycosis, or black fungus, is a rare but serious infection that requires medication or removal surgery.
• SARS-CoV-2 infection and COVID-19 treatment make the immune system vulnerable to other infections, including black fungus.
• With the rise in black fungus cases, India faces a shortage of treatments in the face of two epidemics.

India has been facing high rates of COVID-19, with more than 27 million confirmed cases since January 2020. Also, the World Health Organization (WHO) recently announced that the B.1.617 variant of the SARS-CoV-2 virus in India is a “variant of global concern.”

Some scientists believe that severe COVID-19 could potentially weaken the body’s immune response. This could lead to increased vulnerability to other infections, especially for people who are immunocompromised.

Of particular concern is an infection called mucormycosis, commonly referred to as black fungus. In India, 90 people who recovered from COVID-19 died from mucormycosis, and there are calls by India’s health authorities to declare a mucormycosis epidemic.

What is black fungus?

Mucormycosis is a rare type of fungal infection that occurs through exposure to fungi called mucormycetes. These fungi commonly occur in the environment, particularly in leaves, soil, compost, and animal dung. Mucormycetes can enter the body through breathing, inhaling, and exposed wounds in the skin.

There are different types of mucormycosis, including rhinocerebral (sinus and brain), pulmonary (lung), gastrointestinal, and cutaneous (skin) mucormycosis.

Respiratory-related symptoms include:

• cough
• fever
• headache
• chest pain
• nasal or sinus congestion and pain
• shortness of breath

Skin-related symptoms, which can occur in and spread to any part of the body, include:

• blackened skin tissue
• redness, swelling, tenderness
• blisters
• ulcers

Mucormycosis is not contagious, and most people who come in contact with the fungi do not develop an infection. However, people with severely weakened immune systems are at increased risk of mucormycosis. This includes people with:

• diabetes
• cancer
• HIV
• skin injury
• surgery

Doctors can treat the infection by administering antifungal medication or performing surgery to remove the affected area. If left untreated, mucormycosis can be fatal, with a mortality rate of 54%, according to the Centers for Disease Control and Prevention (CDC).

COVID-19 and mucormycosis

Higher rates of mucormycosis cases in India are due to a combination of factors. For instance, more than 30 million people in India have a diabetes diagnosis. Despite this, the number of cases of mucormycosis before the COVID-19 pandemic was relatively low, although prevalence was rising.

Since the start of the COVID-19 pandemic, however, there has been a dramatic increase. Dr. Arvinder Singh Soin, a pioneering surgeon in Delhi, notes that he has “seen more cases of black fungus in the past week than we normally treat in 2 years.”

COVID-19 leads to a weakened immune system, preventing the body from effectively protecting against infection. As a result, individuals recovering from COVID-19 are at risk for mucormycosis.

Christopher Coleman, assistant professor of infection immunology at the University of Nottingham in the United Kingdom, told Medical News Today:

“The virus, as part of its replication cycle, suppresses the immune system, so the immune system cannot clear other bacteria or fungi. The most famous example of this is HIV, of course, which causes long-term immune suppression. But, other viruses do this on a much shorter timescale — i.e., the immune system is only slightly suppressed for a few days or weeks while the virus is there.”

Steroid treatments for COVID-19 may also act to suppress the body’s immune response, contributing to these increased mucormycosis infection rates.

“In this case,” explained Coleman, “there seems to be a suggestion that steroids may be playing a role — in that they are suppressing normal immune responses and allowing a fungus to invade.”

In addition, oxygen support for people with severe COVID-19 can cause drying of the nasal cavity and further increase the risk of infection.

On May 19, the state of Rajasthan declared a mucormycosis epidemic. In the city of Surat, 8 out of 40 COVID-19 survivors who developed mucormycosis in the eye lost their eyesight.

The state of Maharashtra reported over 2,000 recent cases of mucormycosis, with 8 resulting in death. The state’s health minister, Rajesh Tope, announced that they will be creating special wards and launching an awareness campaign to spread awareness about the disease.

Next steps for treatment

It is difficult to determine the best course of action to simultaneously address both of these epidemics. Coleman raises some questions that experts need to address moving forward:

“Can the people be treated with an antifungal at the same time?” and “Is there a way to lower the COVID-19 treatment dose and still be effective while not suppressing the immune system enough to allow the fungus in?”

The combined risks of COVID-19 and mucormycosis raise challenging issues and require careful coordination of patient care and treatment.

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