What are common locations of Black fungus ?

What are the common locations of Black fungus: Do you know?

1-Introduction:

• Now a days a common term “Black fungus” is very  popular across the globe, specially in India.
• It is very common in those patients, who are either suffering  or recovered from covid-19.
• It is a rare kind of fungal infection affecting 1 in 10,00000 people, with overall mortality rate around 50 percent.
• This deadly fungal infection is growing very rapidly in susceptible patients in India.
• Over the last 10 years, doctors have not  seen enough cases of black fungus in India.
• In last 30 days, thousands of black fungus cases have been reported in India.
• It consumes a lot of resources especially during this pandemic right now in India, where healthcare assets are extended at limit.

What are the common locations of mucormycosis (Black fungus): Do you know?

2-What is Mucormycosis (Black fungus):

• Mucormycosis (also known as zygomycetes) is a serious but unusual fungal infection caused by a group of molds (a type of fungal thread) called mucormycetes.
• It comes under the scientific  biological category popularly known as mucorales.
• The most common types that are responsible for mucormycosis are Rhizopus and  Mucor species.
• Such type of these fungi of mucormycosis typically occur in person, who have health problems or get medicines, that lower the body’s ability to fight against  germs and sickness.
• Though the common cause of mucormycosis is usually a fungal infection, but some of the other causes are: Fungal spore containing water and food, poor hygiene, humidity and poor ventilation
• These types of infection are sometimes more difficult to diagnose due to the location of the flare-up site. What are the common locations of Black fungus

How does someone get mucormycosis?

• Person  get mucormycosis, when they come in contact with the fungal spores  present in the environment.
• If someone inhales spores from the air, infection spreads through sinus and lungs in the body.
• Mucormycosis can also develop on the skin, when fungus enters the skin through a cut, burn, scrape, or any skin trauma.

Where Mucormycosis Comes From?

• There are  the group of fungi that cause mucormycosis, are present everywhere in  the environment, mainly in soil.
• They are found near decaying organic matter, such as leaves, animal dung  and compost piles.
• These fungi  are more common in soil than in air during the summer. Their numbers again decrease in winter or spring.
• Most people usually  come in contact with these minute fungal spores every day therefore, it is s practically impossible to completely avoid coming in contact with these fungal spres.
• These fungi are not dangerous to most of the people.
• But  for those  person, who have weakened immune systems, these  spores can cause an infection in the lungs or sinuses.
• Now these spores can spread to other parts of the body with breathing. What are the common locations of Black fungus

 3-Types of Mucormycosis

There are 4 types of mucormycosis–

(A)-COVID-19 associted mucormycosis (CAM)  Black fungus.

Patient with covid-19 infected/or discharged usually show such type of mucormycosis.

It includes mainly two types-

(a)–Rhino-orbto-cerebral-mucormycosis (ROCM)

This type of infection occurs in  the sinuses that can spread to the brain.

This mucormycosis is most common in people with uncontrolled diabetes and in people who have had a history of kidney transplant. 

(b)-Pulmonary (Lung) mucormycosis 

This is the most common type of mucormycosis present in person with cancer and in people, who  had history of an organ transplant or a stem cell transplant.

(B)Gastro-intestinal mucormycosis

This is common among young children than adults, especially seen in premature and low birth weight infants less than 1 month of age.

These babies have history of use of antibiotics, surgery, or medications that lesser the body’s ability to fight against germs and sickness. 

(C) Cutaneous (Skin) mucormycosis

As the name itself indicates, this type occurs, when the fungi enter the body through a break in the skin (for example, a burn, after surgery, or other type of skin trauma).

This type of mucormycosis is usually  common among those people, who do not have weakened immune systems.

(D)Disseminated mucormycosis 

This mucormycosis occurs when the infection spreads through the bloodstream to affect another part of the body.

Most commonly affects the brain, but also can affect other organs such as the, heart,  skin, and spleen.

Which are common locations of mucormycosis (Black fungus): Do you know?

4-Symotoms of black fungus

The symptoms of mucormycosis depend on location in the body, where the fungus is growing.

What are the common locations of Black fungus ?

(A) Symptoms of COVID-19 associted mucormycosis (CAM) 

(A-1)-Symptoms of Rhino-orbito-cerebral  mucormycosis (ROCM) include:

• Initially presents with nasal blockade or sinus congestion.
•  Bloody or brown/black nasal discharge and local pain.
• Black lesions (that’s why called as black fungus) present  over nasal bridge or upper inside of mouth that rapidly become very severe.
• Pain,numbness and one-sided facial swelling.
• Pain around eye usually, associated with headache.
• Fever, blurred vision (diminished eyesight), skin lesions, thrombosis and necrosis (a type of tissue death).

(A-2)–Symptoms of lung mucormycosis include-

• Fever,cough

• Chest pain and shortness of breath
• Hemoptysis (blood in sputum)

(B) Symptoms of skin mucormycosis  looks like blisters or ulcers, and the infected area become turn black. What are the common locations of Black fungus

• Other symptoms include pain, raised temperature, excessive redness, or swelling around a wound.

(C)Symptoms of gastrointestinal mucormycosis include-

• Pain around stomach.
• Nausea and vomiting.
• Bleeding inside stomach.

(D)Disseminated mucormycosis 

• Since this type typically occurs in those people who are already ill from other medical conditions, so it can be very  difficult to know which symptoms are associated to mucormycosis.
• Patients with this type of disseminated infection in the brain can develop mental status changes, confusion or coma.

What are the common locations of mucormycosis (Black fungus): Do you know?

(5) How to diagnose mucormycosis?

What are the common locations of Black fungus

^{6-How to treat mucormycosis}

Treatments:

• There are number of specialist involved in the management of mucormycosis (black fungus).
• Team approach is required with infectious disease specialist, microbiologist, ENT (ear,nose,throat) specialist, neurologist, dentist, ophthalmologists, surgeons, radiologists etc.
• Management of mucormycosis may include several different methods.
• Once the condition is diagnosed, there are many things that doctors will try to rectify the problem, or reduce the symptoms.
• Early recognition, diagnosis, and timely administration of proper antifungal treatment are important for improving health in patients with mucormycosis. What are the common locations of Black fungus

^{Control of increased sugar (diabetes) is very important step in black fungus.}

^{Judicious use of steroids regarding-correct timing,dose and duration.}

^{If patient is still on steroids, try to reduce it,  with purpose to stop rapidly.}

^{Stop other  drugs, which are usually  used in weaked immune-system,like like Baricitinib, Tofacitinib.}

^{Doctor or nurse  might insert peripherally inserted central catheter (PICC line) or central venous catheter if necessary.}

^{Maintain adequate systemic hydration it means, proper water intake in the body should always maintained.}

What are the common locations of Black fungus

^{Antifungal therapy-}

^{Antifungal drugs are mainstay treatment in case of mucormycosis (black fungus).}

These  drugs are used to treat the infection and stop new growth.

Lipid formulations of amphotericin B are frequently used as first-line treatment for black fungus.

AMPHOTERICIN B

• Liposomal  Amphotericin B injection is  considered as preferred treatment
• While treating with amphotericin b injection, always monitor kidney function and potassium level in our body.
• Patients who are not showing response to amphotericin b injection, alternative medicines posaconazole, and isavuconazole (antifungal drugs) are also used for treatment of black fungus. What are the common locations of Black fungus ? One important thing about a drug voriconazole, that is used against  another fungus  Aspergillus.
• This drug voriconazole are not found useful in treatment for mucormycosis.
•  Even some reports say that, treatment with voriconazole may be associated with increased incidence of mucormycosis in some patients.
• Apart from these measures, surgical  resection(debridement) of infected tissue is usually necessary, mostly for rhinocerebral, cutaneous, and gastrointestinal mucormycosis.
• ^{In this surgery doctors, remove all necrotic (black,dead) material. Removal of eyeball is necessary in case eye is involved.}
• ^{In case of lung if lesion is particularly present in one lobe or localized, doctors usually remove it.}
• Whenever possible focus should be on strengthening the weak immune system of the body.
• The role of other treatment modality such as hyperbaric oxygen therapy is doubtful, but has been found useful in certain situations.

• Antiviral drugs (medicines used for viral infection in the body)  may also  be a option if no drugs currently available found useful for treatment of mucormycosis (black fungus).

• Drug treatments orally or injections are generally for a period of six weeks and can go on for upto 6 months.

7-Risk factors to develop mucormycosis

• Mucormycosis is a very serious fungal infection which can affect humans, pets, and domestic animals.
•  The most common place where this illness can occur, is in people with weakened immune systems such as the old person. It is also prevalent in those who are undergoing chemotherapy.
• Though, this disease can also affect those  people, who do not have such type of  conditions, and is present in both animals and people. What are the common locations of Black fungus

• Mucormycosis (black fungus) is rare illness, but it’s more common among person, who have health problems or take medicines that lesser the body’s ability to fight against germs and sickness.
• There are certain groups of people who  are more likely to get mucormycosis. These groups are-
• Person, whose sugar level is not  controlled (Uncontrolled Diabetes).
• Cancer patients.
•  Patients who is on organ transplant or stem cell transplant.
• Low number of white blood cells-neutropenia (white blood cells are responsible for body’s defence). What are the common locations of Black fungus
• Those patients who are taking steroids for very long time.
• Patients who are mainly taking drugs by injections for long time.
• If patients are inside ICU(intensive care unit) , for very long time.
• Any patients taking treatment for ungal infection and he/she is on voriconazole medicine.
•  There are too much iron in the body ( as in case of iron overload).
• Any type of skin injury due to, burns, wounds or surgery.
• New born baby who has low birth weight and born before 9 months (Prematurity and low birthweight).
• These babies are more likely to develop for neonatal gastrointestinal mucormycosis. What are the common locations of Black fungus

8-Prevention of black fungus

How can I lower the risk of mucormycosis?

Early diagnosis and treatment in any fungal infection are very important to prevent any further infection.

For person who have weakened immune systems, there are a number of ways to lower the chances of developing mucormycosis.

• Uncontrolled diabetes is major cause. So sugar control is very important during management of Covid- 19 patients.
• Keep protect yourself from the environment. 
•  But, It is important to note here, despite being recommended  these actions are  have not been confirmed to prevent mucormycosis.
• Try to avoid those areas with a lot of dust like construction or mine sites.
• If any person is not able to avoid these areas and important to go there, he/she should wear an N95 respirator (a type of face mask).
• Keep away from direct contact with water-damaged buildings and flood water after natural disasters like hurricanes and cyclones.
•  Try to avoid those  activities that involve close contact to dust or soil, such as gardening or yard work.
• If any how this is not possible, try to wear shoes, long-sleeved shirt and  long pants specially during outdoor activities such as visiting wooded areas, gardening or storage area.
•  Make a habit of wearing gloves when handling materials such as moss soil,dung or manure.
•  With the help of scrub bath try to maintain personal hygiene.
• In case of skin injury, clean well with soap and water, as a result it  reduces the chances of developing a skin infection especially when exposed to dust or soil.
• Universal masking and social distancing reduces exposure to fungal spores (mucorales). 
• Steroids should be used judiciously.
• During discharge of the patients, advice about early symptoms of mucormycosis.

what are common locations of mucormycosis (Black fungus): Do you know?

9- Some Misconceptions regarding mucormycosis

• Misconception-1 Mucorales are black fungi.
• Truth- Mucorales are not black fungi. Black fungi are different category of fungi having melanin in the cellwall.
• Misconception- 2  Mucormycosis is contagious.
• Truth – Mucormycosis  is not contagious. Mucormycosis can’t spread between people or between people and animals.
• Misconception-3 Mucormycosis spread by humidifier and oxygenation
• Truth-Mucormycosis is not spread by oxygenation, humidifier and water. The fungi remain in the indoor and outdoor environment. The spores enter the respiratory tract with the help of air.
• Misconception-4 Antifungal prophylaxis (prevention of illness) is needed for mucormycosis.
• Truth- No antifungal prophylaxix is recommended (not much evidence currently).

10-Conclusion:

• This black fungus is life threatening disease. It has infected many covid-19 patients, including those who have recovered.
• It’s difficult to avoid breathing in fungal spores because the fungi that cause mucormycosis are common in the environment. There is no vaccine available to prevent mucormycosis.
• Although it is not yet classified as outbreak despite,  number of cases continue to grow.
• On 22 May 2021, Uttar Pradesh (U.P) State in India,  declared black fungus (mucormycosis) as a “notified disease” due to increasing cases.
• Mucormycosis, if not treated properly for may turn fatal.
• All cases of mucormycosis should be treated as medical and surgical emergency.
• The overall prognosis depends on several factors, including the rapidity of diagnosis and treatment, the site of infection,  patient’s underlying conditions and status of immunity.
• The overall mortality rate is nearly 50%, but early detection and treatment can lead to better outcomes.
• Contact immediately your doctor, if you have symptoms that you think are related to mucormycosis or black fungus.

Take home message

• Don’t miss warning signs and symptoms of black fungus (mucormycosis)
• Don’t consider all the cases with blocked nose as cases of bacterial sinusitis, mostly in the context of weak immune system in  covid 19 patients.

And last and most important-

• Don’t lose crucial time to initiate treatment for mucormycosis (black fungus).