ENT specialists and ophthalmologists in the city have begun to see cases of the very aggressive, invasive fungal condition of mucormycosis in patients cured of COVID-19 in the city.
Mucormycosis, as per the Centers for Disease Control, is a serious but rare fungal infection caused by a group of molds called mucormycetes. People with a compromised immune system can get mucormycosis when they come in contact with the fungal spores in the environment.
“There is a sudden and alarming increase in the occurrence of invasive rhino-orbito-cerebral mucormycosis in patients who have recovered from COVID recently,” says Mohan Kameswaran, Chief Surgeon and Director, Madras ENT Research Foundation (MERF). “What is perhaps new and worrisome is the sudden increase in the invasive form of the sinus variant which involves the orbit leading to blindness and at times, the brain leading to stroke and death.”
It was a rare occurrence in the past, seen mostly in people with uncontrolled diabetes mellitus, and in immune-compromised patients, he says.
Most major ENT departments in the country have noticed a 10-20 fold increase in the number of cases since the start of second wave of COVID-19, according to Dr. Kameswaran. For example at MERF, which used to see about 10 patients a year before the pandemic, it is now receiving 5 – 10 patients a day. Almost all of them have recovered from COVID within the last two to four weeks. About a third of them had lost their vision at the time of presentation, he says.
Toxic anti-dote
Ravi Ramalingam, senior ENT surgeon and Managing Director, KKR ENT Hospital here, says he saw two patients last week while the norm was one in two or three years. “When people come to the hospital, it is already in a fulminant stage, they are very sick. It is treated with the anti-fungal amphotericin B, which is affordable, but is so toxic that we need to go in for more sophisticated options, that are also expensive. It costs up to ₹5,000-₹6,000 a vial, and treatment typically lasts a few weeks.”
Dr. Kameswaran says an additional worry is reported shortage of these anti-fungal agents at the national level. “It is like a serpent moving through the sinus passages and occupying the entire area, impacting the entire face,” says Mohan Rajan, senior ophthalmologist of Rajan Eye Care. He saw two cases during the first wave, and this year, already there have been three cases.
This opportunistic infection seems to have multiple causative factors, and what all doctors are underlining repeatedly post COVID-19 is: indiscriminate use of high dose of steroids in COVID-19 patients, sometimes even in minimally symptomatic patients. This leads the blood sugar levels to spike rendering them vulnerable to mucormycosis. Dr. Kameswaran says the use of monoclonal agents like toclizumab may be contributory, besides the possible breach of sterile conditions that can lead to cross infections and hospital-acquired infections. “The question of COVID-19 infection itself predisposing to invasive fungal disease would need further studies but cannot be ruled out at this stage,” he adds.
“Steroids are a double-edged sword,” chimes in V. Mohan, senior diabetologist, Dr. Mohan’s Diabetes Specialties Centre.
“In some instances in COVID, they are a life saver, but in diabetics, they substantially raise blood sugar levels.” However, if it is identified and treated early, and aggressively, patients can be helped. His advice is to regularly monitor blood sugar levels among diabetics treated with steroids.
Sankara Nethralaya recently released a pamphlet to warn patients of possible mucormycosis infection. It has asked patients to watch out for stuffy nose, bloody, brown or black discharge from the nose, facial pain, numbness, swelling, and blackish colouration of skin. Apart from these, double vision, redness and bulging of the eyes are also signs.
