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Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 94-97

The onset of mucormycosis amidst COVID-19 crises in India: A systematic analysis

Central Research Laboratory, Institute of Dental Sciences, Siksha “O” Anusandhan (Deemed to be) University, Bhubaneswar, Odisha, India

Date of Submission10-May-2022
Date of Decision30-May-2022
Date of Acceptance14-Jul-2022
Date of Web Publication2-Sep-2022

Correspondence Address:
Shakti Rath
Central Research Laboratory, Institute of Dental Sciences, Siksha “O” Anusandhan (Deemed to be) University, Bhubaneswar, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jigims.jigims_22_22

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A descriptive analysis of the “Mucormycosis” or “black fungus infection” surge in India is given in this article. Amidst the pool of deadly COVID-19 crises and when India is suffering its second wave, another dangerous but rare fungal infection of mucormycosis is rising. This study analyses the occurrence and prevalence of black fungus infection between India and other countries with a higher or similar COVID-19 infection peak. This study also identifies that mucormycosis is a more significant problem in India than in any other country.

Keywords: Black fungus infection, COVID-19, mucormycosis, opportunistic infection, systematic analysis

How to cite this article:
Rath S. The onset of mucormycosis amidst COVID-19 crises in India: A systematic analysis. J Indira Gandhi Inst Med Sci 2022;8:94-7

How to cite this URL:
Rath S. The onset of mucormycosis amidst COVID-19 crises in India: A systematic analysis. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2023 Mar 27];8:94-7. Available from: http://www.jigims.co.in/text.asp?2022/8/2/94/355316

  Introduction Top

As almost the entire world faces devastating COVID-19 crises, another deadly infection is on the rise. There are nearly 167,011,807 total cumulative cases, and the death toll peaks up to 3,472,068 total cumulative deaths globally, as identified by the World Health Organization (WHO) as of May 24, 2021.[1] India has even recorded its highest COVID-19 death in the second wave reporting an average of 307,231 deaths and 26,948,874 cases till May 25, 2021.[1] The deadly coronavirus infection is also associated with a variety of fungal and bacterial infections. There is evidence from different world regions that the deadly coronavirus leads to rare infections such as mucormycosis or black fungus, pulmonary aspergillosis, and pneumonia-like conditions.[2] Mucormycosis is one of the most widely increasing fungal infections, especially in India, which also puts the actual death toll questionable. There is evidence that proves that India is the most sufferer of “black fungus” these days even after receiving COVID-19 treatment, which is hardly seen in any other country of the world, which also puts a question on the medical guideline issued by the Ministry of Health and Family Welfare, by the Government of India for the treatment of COVID-19 patients. Although there has been a mucormycosis advisory from the Indian Council of Medical Research (ICMR), less or no effort has been put into the treatment guidelines.[2]

Over 11,000 cases of mucormycosis have been reported during the second wave of COVID-19 infections in different states of India. The studies conducted at various tertiary health-care centers in other parts of India show that patients develop an infection during COVID-19 treatment. The centers have also reported for disease control that the most at risk are the people already infected with COVID-19, diabetes, especially diabetic ketoacidosis, cancer patients, organ transplant patients, and other immunocompromised hosts.[3],[4] While observing the cases and deaths toll of the entire world during the second wave of COVID-19, India has the second-highest number of points after the United Nations despite mucormycosis being an arising major cause of death in India which is not the case in the U.S so far makes India real death toll questionable.[1],[3],[4]

The rising cases of COVID-19 infection across the globe have been increasing the burden on individual nations. [Figure 1] shows the cumulative number of cases and deaths per 100,000 population among the top 20 COVID-19 countries as categorized by the WHO. The figure suggests fewer deaths in India during the second wave but most experts believe it is far higher than the official statistics [Figure 2] and [Figure 3].[1]
Figure 1: Total cumulative number of cases and deaths per 100,000 population among the top 20 COVID-19 countries. Source: WHO Author's representation. WHO: World Health Organization

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Figure 2: Newly reported cases in the past 7 days/100,000 population in the top 20 countries of the world. Source: WHO Author's conceptualization. WHO: World Health Organization

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Figure 3: Newly deaths have been reported in the past few days/100,000 population in the top 20 countries of the world. Source: WHO Author's conceptualization. WHO: World Health Organization

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As the coronavirus infection rises and the severity of the disease also changes with time from mild to severe, this change in pattern is due to the quick mutation of coronavirus. The condition can also be life-threatening, leading to pneumonia. Many bacterial and fungal infections are also rising and are associated with the preexisting diseased condition or can also be acquired in a hospital setting through person-to-person transmission or surface transmission. The increasing of cases this week has been considered one of the most critical situations as it is the time of the second wave of COVID-19 infection for most regions.[5],[6],[7]

  Microbiology and Pathogenicity Top

Mucormycosis is caused when healthy individuals inhale the spores and move to the pharynx with the help of cilia. In general, the polymorphonuclear cells and macrophages evade it in immunocompetent patients. However, in immunocompromised patients, the spores settle and germinate and sometimes disseminate to other organs from the lungs. It leads to cerebral rhino infections, pulmonary, cutaneous, gastrointestinal, and disseminated infections, and uncommon presentations of mucormycosis [Figure 4].[8],[9]
Figure 4: Pathophysiology of mucormycosis

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  Mucormycosis in India Top

This question has now become the headline of most news articles. The Hindu headlined it as “Mucormycosis not uncommon in India” as the epidemiology of mucormycosis in India is different from any other region of the world, not only in the COVID-19 surge. Numerous case studies have been conducted on the patients being treated with COVID-19 infection within several hospital premises, showing rarely occurring but life-threatening fungal infections such as mucormycosis.[10] The mucormycosis case is increasingly being observed in different regions of India and is also transmitted. Any other respiratory infection transmission occurs through the air. Mucormycosis usually stays in the environment and mainly in a humid climate. The existence of black fungus in India is due to climatic factors, as India has a hot and humid environment which increases the sustainability of mucormycosis. Uncontrolled diabetes is one of the reasons for mucormycosis, and such conditions are widely observed in North India. It has been reported in a study that some states in India, such as Gujarat and Maharashtra, have written 300 and 1500 cases of mucormycosis in the past few months, with 52 deaths so far. It has also been evident that mucormycosis is responsible for more than 50% of the total deaths due to COVID-19.[11] There is some common condition which increases the risk of mucormycosis among patients are described in [Figure 5].
Figure 5: Common conditions which increase the risk of mucormycosis in COVID patients

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The infection may evolve during a stay in the hospital, also known as hospital-acquired infection or nosocomial infection. One of the primary reasons doctors have accepted is that mucormycosis, which has a general death pace of half, might be being set off by the utilization of steroids and day-to-day management of critically infected COVID-19 patients. Steroids such as tocilizumab and dexamethasone reduce the lungs' intensification for coronavirus, which helps the patient breathe better and is one of the most accepted practices in COVID treatment. However, its use shoots up the blood glucose level in such patients, which acts as a substrate for fungus growth. In nondiabetic patients, the risk of mucormycosis is still less as the blood glucose level can be managed; however, in diabetic patients, the risk increases as they do not have the natural ability to control the glucose level. Hence, steroids boost glucose levels and compromise the immune system, which has already taken a hit due to COVID infection and exposed the patients to deadly fungal infections. There have been numerous reports where uncontrolled diabetes was a common reason, and treatment therapy with corticosteroids among those patients made them more susceptible to the disease. Various causes lead to mucormycosis infection.[12] It affects people with compromised immunity and depends significantly on the line of treatment. Moreover, India has a high prevalence of diabetic mellitus which acts as a risk factor. There is literature about rhinocerebral mucormycosis and pulmonary mucormycosis, which develops among patients with compromised immunity, especially people with uncontrolled diabetes mellitus, existing pneumonia, other chronic conditions, and COVID-19-positive patients who are already weak with their immune system. Several reviews published show mortality widely varied depending on the underlying condition, site of infection, and even type of fungus.[13],[14] The mortality rate resulting from a sinus infection is about 46%, pulmonary disease about 76%, and around 96% for disseminated mucormycosis. There is no such particular effect known so far.

  Need for Immediate Public Health Response Top

There is a need for immediate public health response as the disease of mucormycosis has already been declared an epidemic. Direct actions in the area should be taken before the situation goes beyond control. As this infection shows a variety of symptoms, categorized by ICMR and the Government of Health and Family Welfare, it usually affects the lungs of individuals after inhalation of fungal spores from the air. Some common symptoms include pain and redness observed around the eyes/nose, fever, chills and temperature, headache, coughing, shortness of breath, blood vomits, and inconsistent mental health status.[15] Public health interventions taken by the government should be immediate. First, aid actions need to be taken at the ground level, which will affect the functioning of the entire health-care system. Temporary measures should be taken to prevent complications among immunosuppressant and comorbid patients. There are no effective treatment strategies that have been noted till now. There is a need for a separate guideline for treating mucormycosis patients based on its symptoms, as it is a life-threatening infection. Although the clinicians are most aware, the prevalence of mucormycosis death in India is very high, demanding early detection tools for early diagnosis of the disease before it spreads throughout the nation or cross-boundary. This study requires immediate actions to be taken by the government.[16]

  Conclusion Top

This study provides a comprehensive insight into the issue of mucormycosis happening in India. This study also gives sufficient evidence to justify that mucormycosis infection in India is higher than in any other country. It highlights the need for action among immunocompromised individuals in the country. There is a need to increase the efficiency of the health information system in India, which is one of the basic needs before we land on another epidemic, as it has already been declared an epidemic in 4 states of India. It should be considered, and guideline changes should be initiated at the very ground level by considering the severity of the infection and the universal health coverage framework. This study intends to motivate the initiation of proper planning of health-care guidelines for treating the disease. This study will enable policymakers to properly allocate scars resources based on the emergency need as the situation demands.

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Conflicts of interest

There are no conflicts of interest.

  References Top

WHO Coronavirus (COVID-19) Dashboard. Available from: https://covid19.who.int/. [Last accessed on 2020 May 25].  Back to cited text no. 1
Sharma S, Grover M, Bhargava S, Samdani S, Kataria T. Post coronavirus disease mucormycosis: A deadly addition to the pandemic spectrum. J Laryngol Otol 2021;135:442-7.  Back to cited text no. 2
Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, et al. Coronavirus disease (COVID-19) associated mucormycosis (CAM): Case report and systematic review of literature. Mycopathologia 2021;186:289-98.  Back to cited text no. 3
Khatri A, Chang KM, Berlinrut I, Wallach F. Mucormycosis after Coronavirus disease 2019 infection in a heart transplant recipient - Case report and review of literature. J Mycol Med 2021;31:101125.  Back to cited text no. 4
Lotfi M, Hamblin MR, Rezaei N. COVID-19: Transmission, prevention, and potential therapeutic opportunities. Clin Chim Acta 2020;508:254-66.  Back to cited text no. 5
Islam MS, Rahman KM, Sun Y, Qureshi MO, Abdi I, Chughtai AA, et al. Current knowledge of COVID-19 and infection prevention and control strategies in healthcare settings: A global analysis. Infect Control Hosp Epidemiol 2020;41:1196-206.  Back to cited text no. 6
Mahalmani VM, Mahendru D, Semwal A, Kaur S, Kaur H, Sarma P, et al. COVID-19 pandemic: A review based on current evidence. Indian J Pharmacol 2020;52:117-29.  Back to cited text no. 7
  [Full text]  
Spellberg B, Edwards J Jr., Ibrahim A. Novel perspectives on mucormycosis: Pathophysiology, presentation, and management. Clin Microbiol Rev 2005;18:556-69.  Back to cited text no. 8
Ibrahim AS, Spellberg B, Walsh TJ, Kontoyiannis DP. Pathogenesis of mucormycosis. Clin Infect Dis 2012;54 Suppl 1:S16-22.  Back to cited text no. 9
Saldanha M, Reddy R, Vincent MJ. Title of the article: Paranasal mucormycosis in COVID-19 patient. Indian J Otolaryngol Head Neck Surg 2021;1-4.  Back to cited text no. 10
Maini A, Tomar G, Khanna D, Kini Y, Mehta H, Bhagyasree V. Sino-orbital mucormycosis in a COVID-19 patient: A case report. Int J Surg Case Rep 2021;82:105957.  Back to cited text no. 11
Moorthy A, Gaikwad R, Krishna S, Hegde R, Tripathi KK, Kale PG, et al. SARS-CoV-2, uncontrolled diabetes and corticosteroids - An unholy trinity in invasive fungal infections of the maxillofacial region? A retrospective, multi-centric analysis. J Maxillofac Oral Surg 2021;20:418-25.  Back to cited text no. 12
Dexamethasone/methylprednisolone/prednisolone: Rhino-orbital-cerebral mucormycosis and off-label use: 5 case reports. React Wkly 2021;1843:137-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892756/. [Last accessed on 2021 May 21].  Back to cited text no. 13
Skiada A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and diagnosis of mucormycosis: An update. J Fungi (Basel) 2020;6:E265.  Back to cited text no. 14
Skiada A, Lass-Floerl C, Klimko N, Ibrahim A, Roilides E, Petrikkos G. Challenges in the diagnosis and treatment of mucormycosis. Med Mycol 2018;56:93-101.  Back to cited text no. 15
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