Mucormycosis or Black Fungus - Cause, Transmission, Symptoms, Types, Diagnosis, Treatment and Prevention

Mucormycosis also known as Black Fungus. 

Mucormycosis (previously called zygomycosis) is a rare but serious angio-invasive infection caused by a group of fungi called mucormycetes. 

Spores of these ubiquitous fungi (commonly found in soil, fallen leaves, compost, animal dung and air) can be inhaled and then infect the lungs, sinuses, and extend into the brain and eyes. Less often, infection may develop when the spores enter the body through a cut or an open wound. 

Mucormycosis is not a contagious disease, it cannot be spread from one person to another.  

Mucormycosis mainly affects people who are immunocompromised, or patients already infected with other diseases. High risk groups include people with diabetes (especially diabetic ketoacidosis), solid organ transplantation, neutropenia (low neutrophils, a type of white blood cells), long-term systemic corticosteroid use, and iron overload (hemochromatosis). The risk is high for people living with HIV, and those using immunomodulating drugs, including the anti-fungal voriconazole in some high-risk groups. 

Clinical presentation is classified according to the organ involvement. It can be rhino-orbital cerebral, pulmonary, cutaneous, gastrointestinal, or disseminated. 

Mucormycosis is an aggressive, life-threatening infection requiring prompt diagnosis and early treatment. Treatment usually consists of antifungal medications and surgery. 

COVID-19 Associated Mucormycosis

Fungal infections, including mucormycosis, aspergillosis and invasive candidiasis, have been reported in patients with severe COVID-19 or those recovering from the disease and have been associated with severe illness and death. 

India has reported a recent surge in mucormycosis cases. Prevention of COVID-19 associated mucormycosis needs to focus on aiming for better glycaemic control in COVID-19 patients and monitoring the use of systemic corticosteroids in treating severe cases. 

Outpatient use of systemic corticosteroids/other immunomodulating drugs for mild or moderate patients with COVID-19 should be avoided. Health care facilities need to strengthen their infection prevention and control (IPC) programmes to prevent healthcare-associated outbreaks.

Disease Burden

The incidence rate of mucormycosis globally varies from 0.005 to 1.7 per million population.

In India, prevalence of mucormycosis is estimated as 140 per million population, which is about 80 times higher than the prevalence in developed countries.

In a systemic review and meta-analysis of 851 cases reports published in 2018, death was reported in 389/851 (46%) patients. Case fatality was observed to be highest among patients with disseminated mucormycosis (68%) and lowest in those with cutaneous disease (31%).

Following the surge of COVID-19 associated mucormycosis and the Government of India directive, several states in India made mucormycosis a notifiable disease in May 2021. This will provide better insights into the disease burden, population characteristic, risk factors, clinical spectrum and outcomes of these patients.

Current trends indicate that the surge is higher in those with pre-existing diabetes, those on systemic corticosteroids, and is being observed in both people with COVID-19, and those recovering from the disease. 

Transmission of Mucormycosis Black Fungus

It is not contagious and does not spread by contact of person to person.

This fungus is found in the environment. Transmission occurs through inhalation, inoculation, or ingestion of spores from the environment.

Although most cases are sporadic, healthcare-associated outbreaks have been linked to adhesive bandages, wooden tongue depressors, hospital linens, negative pressure rooms, water leaks, poor air filtration, non-sterile medical devices, and building construction.

It most commonly affects the sinuses or the lungs after inhaling fungal spores from the air. In such cases, it may spread to brain and eyes.

It may also occur on the skin after a cut, burn, or other type of skin injury gets infected.

Symptoms of Mucormycosis Black Fungus

The symptoms of mucormycosis depend on where in the body the fungus is growing. The most common presentation is a sinus infection (sinusitis) that is accompanied by nasal congestion, nasal discharge, and sinus pain. A fever and headache may also occur.

Type of Mucormycosis

Diagnosis of Mucormycosis Black Fungus

Early recognition, diagnosis and prompt administration of appropriate antifungal treatment and surgical debridement (as needed) are important for improving outcomes for patients with mucormycosis. 

Diagnostic methods include biopsy and fungal staining (KOH mount), which remains the mainstay of laboratory diagnosis. Facilities where fungal culture and susceptibility testing are available can help to confirm the species of mucormycosis. Treatment initiation, however, should not wait for fungal culture results. 

Imaging tests such as a CT scan of lungs, sinuses, or other parts of body, depending on the location of the suspected infection, may also be used to support the diagnosis.

Treatment of Black Fungus Mucormycosis

Mucormycosis is difficult to treat. It may sometimes requires both intravenous antifungal therapy and surgical excision, thus necessitating a multidisciplinary team approach in a facility setting. 

Liposomal amphotericin B is the drug of choice and needs to be initiated early. Other antifungals like posaconazole, or isavuconazolehave also been described for treatment. 

The Directorate General of Health Services (DGHS) has released detailed guidelines on managing mucormycosis in COVID-19 in India. 

The overall prognosis depends on several factors, including the rapidity of diagnosis and treatment, the site of infection, and the patient’s underlying conditions and degree of immunosuppression. The overall case fatality is approximately 50%,  although early diagnosis and treatment lead to better outcomes.

Prevention from Black Fungus Mucormycosis

Prevention of COVID-associated mucormycosis needs to focus on addressing the underlying risk factors:

1. Aiming for better glycemic control in those with diabetes.
2. Appropriate use of systemic corticosteroids.
3. Prevention of unnecessary use of antibiotic, antifungal and other immunomodulators.
4. IPC measures at the facility level are essential toprevent the environmental spread of this pathogen. 

These include:

Sterilization and disinfection of the equipment used by multiple patients (tracheal tubes, ventilators), ventilation systems ( if there is poor ventilation in the hospital that can contribute to dampness and dust).

Proper wound management (bandage, tape, adhesives, including  tapes to secure medical devices such as endotracheal tubes, ostomy devices must be sterilized and changed regularly),proper line management in health facilities.

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Should I be concerned about SARS-CoV-2 changing ?

It is normal for viruses to change, but it is still something scientists follow closely because there can be important implications. All viruses, including SARS-CoV-2, the virus that causes COVID-19, change over time. So far hundreds of variations of this virus have been identified worldwide. WHO and partners have been following them closely since January 2020.

Should I be concerned about SARS-CoV-2 changing ?

Most changes have little to no impact on the virus’ properties. However, depending on where the changes are located in the virus’s genetic material, they may affect the virus’s properties, such as transmission (for example, it may spread more easily) or severity (for example, it may cause more severe disease).

Should I be concerned about SARS-CoV-2 changing ?

WHO and its international network of experts, are monitoring changes to the virus so that if significant  mutations are identified, WHO can report any modifications to interventions needed by countries and individuals to prevent the spread of that variant.  The current strategies and measures recommended by WHO continue to work against virus variants identified since the start of the pandemic.

Should I be concerned about SARS-CoV-2 changing ?

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What does it mean to say a covid-19 virus mutates or changes?

When a virus replicates or makes copies of itself, it sometimes changes a little bit. These changes are called “mutations.” A virus with one or several new mutations is  referred to as a “variant” of the original virus. 

What does it mean to say a covid-19 virus mutates or changes?

The more viruses circulate, the more they may change. These changes can occasionally result in a virus variant that is better adapted to its environment compared to the original virus. This process of changing and selection of successful variants is called “virus evolution.”

Some mutations can lead to changes in a virus’s characteristics, such as altered transmission (for example, it may spread more easily) or severity (for example, it may cause more severe disease).

What does it mean to say a covid-19 virus mutates or changes?

Some viruses change quickly and others more slowly. SARS-CoV-2, the virus which causes COVID-19, tends to change more slowly than others such as HIV or influenza viruses. This could in part be explained by the virus’s internal “proofreading mechanism” which can correct “mistakes” when it makes copies of itself. Scientists continue to study this mechanism to better understand how it works.

What does it mean to say a covid-19 virus mutates or changes?

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What is WHO doing to monitor and understand the changes in SARS-CoV-2?

Since the start of the outbreak, WHO has been working with a global network of expert laboratories around the world to support testing and better understanding of SARS-CoV-2, the virus that causes COVID-19.

Research groups have sequenced SARS-CoV-2 and shared these on public databases, including GISAID. This global collaboration allows scientists to better track the virus and how it is changing.

WHO’s global SARS-CoV-2 laboratory network includes a dedicated SARS-CoV-2 Virus Evolution Working Group, which aims to detect new mutations quickly and assess their possible impact.

WHO recommends that all countries increase the sequencing of SARS-CoV-2 viruses where possible and share sequence data internationally to help one another monitor and respond to the evolving pandemic. 

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How does SARS-CoV-2 change when it infects animals, and what are the implications?

SARS-CoV-2 spreads primarily through human-to-human transmission, but there is evidence of transmission between humans and animals. Several animals like mink, dogs, domestic cats, lions, tigers and raccoon dogs have tested positive for SARS-CoV-2 after contact with infected humans.

Covid-19

There have been reports of large animal outbreaks in mink farms in several countries. SARS-CoV-2 can change while infecting minks. It has been observed that these mink variants are able to transmit back into humans through close contact with the mink. Preliminary results suggest that the mink variants infecting humans appear to have the same properties as other variants of the SARS-CoV-2 virus.

Bat

Further research is needed to better understand whether these mink variants will cause sustained transmission among humans and could have a negative impact on countermeasures, such as vaccines. 

How does SARS-CoV-2 change when it infects animals, and what are the implications?

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What should staff do if they have Covid 19 symptoms?

If staff develop COVID-19 symptoms while at work, such as fever, dry cough or tiredness, they should immediately stop working, put on a medical mask and isolate in a suitable room while medical services are notified. Disposable tissues and an appropriate waste bin with a lid should be available in the designated isolation area while waiting for medical assessment or transfer to an assessment facility.

What should staff do if they have Covid 19 symptoms?

If staff develop symptoms while at home, they should stay at home and seek medical attention, following instructions from a health worker that will include a period of time for self-isolation away from others, including family members, according to local guidance.  The staff member should inform the management accordingly.

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Healthy diet For infants and young children during covid-19

Consuming a healthy diet throughout the life-course helps to prevent malnutrition in all its forms as well as a range of noncommunicable diseases (NCDs) and conditions. However, increased production of processed foods, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are now consuming more foods high in energy, fats, free sugars and salt/sodium, and many people do not eat enough fruit, vegetables and other dietary fibre such as whole grains.

Healthy diet For infants and young children during covid-19

The exact make-up of a diversified, balanced and healthy diet will vary depending on individual characteristics (e.g. age, gender, lifestyle and degree of physical activity), cultural context, locally available foods and dietary customs. However, the basic principles of what constitutes a healthy diet remain the same.

Diet

For infants and young children

In the first 2 years of a child’s life, optimal nutrition fosters healthy growth and improves cognitive development. It also reduces the risk of becoming overweight or obese and developing NCDs later in life.

Advice on a healthy diet for infants and children is similar to that for adults, but the following elements are also important:

• Infants should be breastfed exclusively during the first 6 months of life.
• Infants should be breastfed continuously until 2 years of age and beyond.
• From 6 months of age, breast milk should be complemented with a variety of adequate, safe and nutrient-dense foods. Salt and sugars should not be added to complementary foods.

Balance Diet

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How much take sugar in healthy diet

In both adults and children, the intake of free sugars should be reduced to less than 10% of total energy intake.  A reduction to less than 5% of total energy intake would provide additional health benefits.

Consuming free sugars increases the risk of dental caries (tooth decay). Excess calories from foods and drinks high in free sugars also contribute to unhealthy weight gain, which can lead to overweight and obesity. Recent evidence also shows that free sugars influence blood pressure and serum lipids, and suggests that a reduction in free sugars intake reduces risk factors for cardiovascular diseases.

How much take sugar in healthy diet 

Sugars intake can be reduced by:

• limiting the consumption of foods and drinks containing high amounts of sugars, such as sugary snacks, candies and sugar-sweetened beverages (i.e. all types of beverages containing free sugars – these include carbonated or non‐carbonated soft drinks, fruit or vegetable juices and drinks, liquid and powder concentrates, flavoured water, energy and sports drinks, ready‐to‐drink tea, ready‐to‐drink coffee and flavoured milk drinks); and

Fresh Fruit

• eating fresh fruit and raw vegetables as snacks instead of sugary snacks.

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How to promote healthy diets ?

Diet evolves over time, being influenced by many social and economic factors that interact in a complex manner to shape individual dietary patterns. These factors include income, food prices (which will affect the availability and affordability of healthy foods), individual preferences and beliefs, cultural traditions, and geographical and environmental aspects (including climate change). Therefore, promoting a healthy food environment – including food systems that promote a diversified, balanced and healthy diet – requires the involvement of multiple sectors and stakeholders, including government, and the public and private sectors.

Governments have a central role in creating a healthy food environment that enables people to adopt and maintain healthy dietary practices. Effective actions by policy-makers to create a healthy food environment include the following:

1.    Creating coherence in national policies and investment plans – including trade, food and agricultural policies – to promote a healthy diet and protect public health through:

• increasing incentives for producers and retailers to grow, use and sell fresh fruit and vegetables;
• reducing incentives for the food industry to continue or increase production of processed foods containing high levels of saturated fats, trans-fats, free sugars and salt/sodium;
• encouraging reformulation of food products to reduce the contents of saturated fats, trans-fats, free sugars and salt/sodium, with the goal of eliminating industrially-produced trans-fats;
• implementing the WHO recommendations on the marketing of foods and non-alcoholic beverages to children;

• establishing standards to foster healthy dietary practices through ensuring the availability of healthy, nutritious, safe and affordable foods in pre-schools, schools, other public institutions and the workplace;
• exploring regulatory and voluntary instruments (e.g. marketing regulations and nutrition labelling policies), and economic incentives or disincentives (e.g. taxation and subsidies) to promote a healthy diet; and
• encouraging transnational, national and local food services and catering outlets to improve the nutritional quality of their foods – ensuring the availability and affordability of healthy choices – and review portion sizes and pricing.

2.    Encouraging consumer demand for healthy foods and meals through:

• promoting consumer awareness of a healthy diet;
• developing school policies and programmes that encourage children to adopt and maintain a healthy diet;
• educating children, adolescents and adults about nutrition and healthy dietary practices;
• encouraging culinary skills, including in children through schools;
• supporting point-of-sale information, including through nutrition labelling that ensures accurate, standardized and comprehensible information on nutrient contents in foods (in line with the Codex Alimentarius Commission guidelines), with the addition of front-of-pack labelling to facilitate consumer understanding; and
• providing nutrition and dietary counselling at primary health-care facilities.

3.    Promoting appropriate infant and young child feeding practices through:

• implementing the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions;
• implementing policies and practices to promote protection of working mothers; and
• promoting, protecting and supporting breastfeeding in health services and the community, including through the Baby-friendly Hospital Initiative.

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Healthy diet for adult during Covid-19

Consuming a healthy diet throughout the life-course helps to prevent malnutrition in all its forms as well as a range of noncommunicable diseases (NCDs) and conditions. However, increased production of processed foods, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are now consuming more foods high in energy, fats, free sugars and salt/sodium, and many people do not eat enough fruit, vegetables and other dietary fibre such as whole grains.

Healthy diet for adult during Covid-19 

The exact make-up of a diversified, balanced and healthy diet will vary depending on individual characteristics (e.g. age, gender, lifestyle and degree of physical activity), cultural context, locally available foods and dietary customs. However, the basic principles of what constitutes a healthy diet remain the same.

Healthy diet for adult during Covid-19 

For adults

A healthy diet includes the following:

• Fruit, vegetables, legumes (e.g. lentils and beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat and brown rice).
• At least 400 g (i.e. five portions) of fruit and vegetables per day, excluding potatoes, sweet potatoes, cassava and other starchy roots.

Healthy diet for adult during Covid-19 

• Less than 10% of total energy intake from free sugars, which is equivalent to 50 g (or about 12 level teaspoons) for a person of healthy body weight consuming about 2000 calories per day, but ideally is less than 5% of total energy intake for additional health benefits. Free sugars are all sugars added to foods or drinks by the manufacturer, cook or consumer, as well as sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

Healthy diet for adult during Covid-19 

• Less than 30% of total energy intake from fats. Unsaturated fats (found in fish, avocado and nuts, and in sunflower, soybean, canola and olive oils) are preferable to saturated fats (found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard) and trans-fats of all kinds, including both industrially-produced trans-fats (found in baked and fried foods, and pre-packaged snacks and foods, such as frozen pizza, pies, cookies, biscuits, wafers, and cooking oils and spreads) and ruminant trans-fats (found in meat and dairy foods from ruminant animals, such as cows, sheep, goats and camels). It is suggested that the intake of saturated fats be reduced to less than 10% of total energy intake and trans-fats to less than 1% of total energy intake. In particular, industrially-produced trans-fats are not part of a healthy diet and should be avoided.

Healthy diet for adult during Covid-19 

• Less than 5  g of salt (equivalent to about one teaspoon) per day.  Salt should be iodized.

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What causes of Mucormycosis or black fungus ?

Mucormycosis or black fungus is a complication caused by fungal infection. People catch mucormycosis by coming in contact with the fungal spores in the environment. It can also develop on the skin after the fungus enters the skin through a cut, scrape, burn, or other type of skin trauma.

Mucormycosis

The disease is being detected among patients who are recovering or have recovered from COVID-19. Moreover, anyone who is diabetic and whose immune system is not functioning well needs to be on the guard against this.

black fungus

According to an advisory issued by the Indian Council of Medical Research, the following conditions in COVID-19 patients increase the risk of mucormycosis infection:

• Uncontrolled diabetes
• Weakening of immune system due to use of steroids
• Prolonged ICU/hospital stay
• Co-morbidities / post organ transplant / cancer
• Voriconazole therapy (used to treat serious fungal infections)

• 

  What causes of Mucormycosis or black fungus

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How mucormycosis or black fungus is related with COVID-19 ?

The disease is caused by a set of micro-organisms known as mucormycetes, which are present naturally in the environment, seen mostly in soil and in decaying organic matter like leaves, compost and piles.

mucormycosis

In normal course, our body’s immune system successfully fights such fungal infections. However, we know that COVID-19 affects our immune system. Moreover, the treatment of COVID-19 patients involves intake of drugs like dexamethasone, which suppress our immune system response. Due to these factors, COVID-19 patients face a renewed risk of failing the battle against attacks mounted by organisms such as mucormycetes.

Covid 19

In addition, COVID patients undergoing oxygen therapy in ICU, where humidifier is used, are prone to fungal infection because of exposure to moisture.

But this does not mean that every COVID patient will get infected by Mucormycosis. The disease is uncommon in those not having diabetes but can be fatal if not treated promptly. Chances of recovery depend upon early diagnosis and treatment.

black fungus

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How is black fungus treated ?

While the infection may just begin with a skin infection, it can spread to other parts of the body. Treatment involves surgically removing all dead and infected tissue. In some patients, this may result in loss of upper jaw or sometimes even the eye. 

Cure may also involve a 4-6 weeks course of intravenous anti-fungal therapy.  Since it affects various parts of the body, treatment requires a team of microbiologists, internal medicine specialists, intensivist neurologists, ENT specialists, ophthalmologists, dentists, surgeons and others.

How is black fungus treated ?

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What are the common symptoms of black fungus or Mucormycosis ?

Mucormycosis begins to manifest as skin infection in the air pockets located behind our forehead, nose, cheekbones, and in between the eyes and teeth. It then spreads to eyes, lungs and can even spread to the brain. It leads to blackening or discoloration over the nose, blurred or double vision, chest pain, breathing difficulties and coughing of blood.

 What are the common symptoms of black fungus or Mucormycosis ?

The Indian Council of Medical Research has advised that not all cases of blocked nose should be considered as cases of bacterial sinusitis, particularly during/after the treatment of Covid-19 patients. One must seek medical help for detecting fungal infection.  

 What are the common symptoms of black fungus or Mucormycosis ?

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How is black fungus related to COVID-19 ?

The disease is caused by a set of micro-organisms known as mucormycetes, which are present naturally in the environment, seen mostly in soil and in decaying organic matter like leaves, compost and piles.

In normal course, our body’s immune system successfully fights such fungal infections. However, we know that COVID-19 affects our immune system. Moreover, the treatment of COVID-19 patients involves intake of drugs like dexamethasone, which suppress our immune system response. Due to these factors, COVID-19 patients face a renewed risk of failing the battle against attacks mounted by organisms such as mucormycetes.

How is black fungus related to COVID-19 ?

In addition, COVID patients undergoing oxygen therapy in ICU, where humidifier is used, are prone to fungal infection because of exposure to moisture.

But this does not mean that every COVID patient will get infected by Mucormycosis. The disease is uncommon in those not having diabetes but can be fatal if not treated promptly. Chances of recovery depend upon early diagnosis and treatment.

How is black fungus related to COVID-19 ?

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Are there treatments for COVID-19?

Scientists around the world are working to find and develop treatments for COVID-19.

Optimal supportive care includes oxygen for severely ill patients and those who are at risk for severe disease and more advanced respiratory support such as ventilation for patients who are critically ill.

Dexamethasone is a corticosteroid that can help reduce the length of time on a ventilator and save lives of patients with severe and critical illness.   

Results from the WHO’s Solidarity Trial indicated that remdesivir, hydroxychloroquine, lopinavir/ritonavir and interferon regimens appear to have little or no effect on 28-day mortality or the in-hospital course of COVID-19 among hospitalized patients.

Hydroxychloroquine has not been shown to offer any benefit for treatment of COVID-19.

WHO does not recommend self-medication with any medicines, including antibiotics, as a prevention or cure for COVID-19. WHO is coordinating efforts to develop treatments for COVID-19 and will continue to provide new information as it becomes available.

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