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Black Fungus - 7 things to know

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Author : Dr Deepak Garg

Here is the discussion I had with Dr Akshay Nair about Black Fungus. You can also watch the video at the end.

Dr Deepak Garg : Hi this is Dr Deepak Garg from Eye Solutions and today we have with us Dr Akshay Nair who's an oculoplasty specialist and he's going to be talking to us about Mucormycosis some of you may have heard him on BBC, Al Jazeera or the Times Now news channels talking about Mucormycosis and I would like to thank him for being here with us today to explain to our listeners more about the infection. So actually the first question addressed to you is we know a little bit about Mucormycosis. We want to know what it is and why are Covid19 patients more susceptible to it.

Dr Akshay Nair : So Mucormycosis is a very rare fungal infection. This typically is seen in patients who have a very weak immune system, such as patients who've got diabetes, patients who are on long term medications that can suppress your immune system like those who've had an organ transplant or even patients such as those with HIV AIDS. It's very unusual to have otherwise healthy patients land up with an infection like Mucormycosis which is why we are now seeing this in patients with covid19. We are finding that covid19 itself is weakening the local nasal immunity, it is causing diabetes in patients who otherwise don't have diabetes and in already those who are diabetic it can really increase the blood sugar to very high levels and therefore make them more susceptible to Mucormycosis. Mucormycosis typically starts in the nose and the spaces around the nose called the sinuses and from there it spreads around the eyes, involves the eyes, the vision and if not treated at this stage it can even spread into the brain.

Dr Deepak Garg : Okay what is the rate of infection that you have seen in the past few weeks or months and how is Mucor different in Covid patients and non Covid patients.

Dr Akshay Nair : That's a great question Dr Deepak. We're seeing Mucormycosis in very high rates. To give you an idea in the past couple of years I may have seen no more than 10 patients of Mucormycosis all put together but in the past four-five months alone we've seen more than 50 patients at a single hospital. So that's almost five times as many patients in a very short span of time. Also the other thing that we are seeing this time is Mucormycosis is being far more aggressive. Typically we won't see as many patients of Mucormycosis where the fungal infection has reached the eye or the brain but this time after covid we are seeing a lot more patients where the eye is involved.

Dr Deepak Garg : Okay, Akshay can you tell us, you know I have actually been asked this question even by some of my friends and patients, why are we seeing Mucormycosis only in india or why are we hearing reports of Mucormycosis only from india not from other countries. Does it have to do with us being the diabetic capital of the world.

Dr Akshay Nair : That's actually part of the answer but i think there is more to it than just diabetes. Interestingly the first case in medical literature of Mucormycosis after Covid19 came from the United States and speaking to some of my colleagues from iran they've also had a brief wave of Mucormycosis after Covid19. So it's not an isolated phenomenon in india but the scale at which we are seeing it is definitely unprecedented. As you said india is the diabetic capital of the world which means we have the highest number of patients who are diabetic. highest number of diabetic patients who are under treated which means they're not taking as much medicine as they should and also the highest number of undiagnosed diabetes. So when an infection like Covid comes along which medically is called as a diabetogenic infection which can increase the intensity of the diabetes or can cause non-diabetics to become diabetes in a small proportion, something like this can you know really change things because Mucormycosis typically is seen in uncontrolled diabetes. Another factor that is adding fuel to the fire here is the use of steroids. Now steroids are a life-saving group of drugs which have to be used in critical cases of covid in order to increase the survival but as a side effect steroids can raise your blood sugar level so some amount of indiscriminate use of steroids, some self-medication of steroids in addition to the diabetes which is not diagnosed and treated in time, all of these put together are the factors that make it just right for an opportunistic infection like Mucormycosis to show up.

Dr Deepak Garg : Excellent what are the misconceptions that you have come across in the past few weeks. I know I have received calls from patients thinking that they have Mucormycosis for the smallest of eye problems which they wouldn't have really paid attention to before but now having heard of so much Mucormycosis on the news, so many people think they have Mucormycosis. What are similar stories that you want to tell our listeners.

Dr Akshay Nair : I think the most common and the most important thing that people should know is that Mucormycosis is not a contagious disease. This does not spread from a person who already has the infection to someone who doesn't. The fungus mucour itself is present all around us. It's present in the air, in the dust, in the soil even on food that we may eat but a healthy person like you or me would automatically be able to fight this infection off. It's only when the local immunity in the nose and the general immunity of the body is reduced by say diabetes that is not controlled that it makes someone very very vulnerable. The other thing that i've heard is 'I get redness in my eyes do I have black fungus ?'. Something as simple as redness or watering of your eye is unlikely to be the first presenting sign of Mucormycosis.

Dr Deepak Garg : Speaking of diabetes, have you seen Mucormycosis patients in individuals who don't have diabetes.

Dr Akshay Nair : Deepak that's a great question because we're now analyzing the data that we've seen from so many patients over the past few months and we've just about begun putting the pieces together. There is a very small subset of patients who were known to be non-diabetic before they got Covid19 and after contracting and recovering from covid19 they are now found to be diabetic and it was unfortunate that by the time they realized that they were now diabetic, Mucormycosis had already infected and it was Mucormycosis that brought them to the hospital at which time diabetes was diagnosed. But I must stress that there is no need to panic because this really is a very very small subset of patients in whom we are seeing.

Dr Deepak Garg : Thanks, we already know that it's a deadly infection we know that the survival rate is around 50 or 60 % for this type of an infection and obviously that causes worry. Can you tell our listeners what should they be aware of or what are the symptoms that they should then seek an opinion from an ophthalmologist or from an oculoplasty specialist like yourself to rule out whether they have Mucormycosis or not.

Dr Akshay Nair : So typically Mucormycosis like I mentioned, is something that starts in the nose. It begins in the nose and then goes into the sinuses. Sinuses are the spaces around the nose and from there it enters the eye or the orbit. The orbit is the space around the eye and then it spreads into the brain. So typically if you've got symptoms related to nasal stuffiness, nasal blockage, a foul smelling discharge from the nose, crusting that you can see at the nostrils, pain around the cheeks which is basically pain in the sinuses, pain in between the eyes or the forehead, facial swelling, this facial swelling is typically on one side of the face or any numbness on one side of the face. All of these are the early signs of Mucormycosis which can be treated with a ENT surgeon. An ENT surgeon can do a surgery known as a sinus debridement and with the right amount of drugs this can be treated but by the time it has reached the eye at which time you will present with symptoms of blurred vision, double vision or even loss of vision it's probably you know that stage where you probably have to undergo a surgery in the eye as well. So this can be detected and diagnosed early and definitely be treated if diagnosed in time.

Dr Deepak Garg : Now in terms of prevention is there anything that somebody can do to prevent getting infected with Mucormycosis.

Dr Akshay Nair : Right so like i said the the whole point is not to panic about something like Mucormycosis. We need to be calm and understand that only a small group of people are susceptible or vulnerable to this disease. This includes those who have recovered from covid19, those are already diabetic patients and those who've received any dose of steroids during the course of their covid19 infection. This group needs to be very alert of any of the symptoms that we discussed earlier and for those who've already recovered from Covid a good starting point would be to get a blood sugar test done. This can be done at home or at your nearest bloody pathology laboratory and just to get an idea if your blood sugar is under control because at the end of the day one thing that is common amongst all the Mucormycosis patients we have treated, is that they have a high blood sugar level.

Dr Deepak Garg : I think in summary what you're saying is your diabetes has to be under control and you have to be aware of the early symptoms and a combination of these two factors can help in detecting early Mucormycosis patients.

Dr Akshay Nair : Absolutely the best form of treatment for Mucormycosis is preventing it because once you have it it's a long course of treatment. It can be treated, we have to be aggressive and operate them but keeping safe and diagnosing early is the best thing that you can do and i'd also like to take this opportunity to tell all our viewers and patients that it is only in the faith in the science of vaccines that gives doctors like Dr Deepak and me the strength to work in these times so stay safe and make sure you get vaccinated when you get the chance.

Dr Deepak Garg : What are the treatment options for this infection. I also have read and we all have that there's a shortage of the drugs that have that are being used to treat Mucormycosis. Have you experienced this shortage in the treatment and what is the solution around this for patients.

Dr Akshay Nair : Right, so like we discussed when this infection is limited to the nose and the sinuses an ENT specialist or an ear nose throat doctor is the right person to treat it at that stage where they go into the sinuses and can do a clearing surgery called sinus debridement. Along with this controlling your diabetes and receiving the right amount of anti-fungal medicine which is called Amphotericin B is extremely important. You're right in saying that we are facing shortages of this drug. There have been some cases where even our patients have had to look high and low in order to get this medication. There are a couple of other drug alternatives like isavuconazole and posaconozole that we have resorted to tide over the temporary crisis but thankfully the supplies have started coming back and now our patients with Mucormycosis are receiving the drug.

Dr Deepak Garg : Perfect two more questions now. I have a question as to what if a doctor is not 100 sure whether the patient has Mucormycosis. Does he start treatment or does he closely observe the patient.

Dr Akshay Nair : So if if there are any signs and symptoms that you suspect it could be Mucormycosis your referring doctor should be an ENT doctor. You have to refer it to an ENT specialist. The way to diagnose Mucormycosis is a nasal swab much like how it is done for a Covid test. So your doctor will put in a swab probably put an endoscope in the nose and a quick swab is taken which is then checked under the microscope to confirm the diagnosis of Mucormycosis. Later on, scans can be done like an MRI scan of the brain, the eyes and the sinuses to confirm this disease and see how much it is spread.

Dr Deepak Garg : Perfect, okay finally we are now hearing about a white fungus, a yellow fungus and what are these, is it the same thing, is it something different and is it as deadly as Mucormycosis.

Dr Akshay Nair : Right, unfortunately in this state of panic we are seeing a lot of reports about yellow fungus and white fungus. Like you said these are names that are common names given by the media, by press and news which could possibly confuse the layman. Yellow fungus is usually referring to a disease called aspergillosis and white fungus is usually referring to candidiasis. Now both these fungal infections have been around since way before Covid 19 and they are likely to hang around till even after the current pandemic eases off. It's just that at this heightened state of awareness even if there are a few few reports of these fungal infections they tend to make the headlines. Right now the news isn't as worrying, the numbers aren't as high. So i would request everybody not to panic about these different colors and funguses and for the medical practitioners and doctors our main aim at this point in time remains Mucormycosis or what is called the black fungus so we'll stick to that and focus on that. Nothing else at this stage should worry people. They really shouldn't be losing their sleep over yellow and white fungus.

Dr Deepak Garg : Perfect thank you so much. In summary Mucormycosis is an infection that we don't want to get. It's happening in patients who've had Covid19, who are diabetic and have received steroids. You know the early symptoms, you know how important blood sugar control has become or has come to limelight because of this infection. We also know how it is treated. It's a treatment which is done by two specialities an ENT or a ear nose throat specialist and an ophthalmologist. We hope you find this video useful. Akshay, thank you so much for joining us today.

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