Rare ‘black fungus’ epidemic has followed India’s COVID-19 crisis

AHMEDABAD, INDIA >> In the stifling, tightly packed medical ward at Civil Hospital, the ear, nose and throat specialist moved briskly from one bed to the next, shining a flashlight into one patient’s mouth, examining another’s X-rays.

The specialist, Dr. Bela Prajapati, oversees treatment for nearly 400 patients with mucormycosis, a rare and often deadly fungal disease that has exploded across India on the coattails of the coronavirus pandemic. Unprepared for this spring’s devastating COVID-19 second wave, many of India’s hospitals took desperate steps to save lives — steps that may have opened the door to yet another deadly disease.

“The pandemic has precipitated an epidemic,” Prajapati said.

In three weeks, the number of cases of the disease — known by the misnomer “black fungus,” because it is found on dead tissue — shot up to more than 30,000 from negligible levels. States have recorded more than 2,100 deaths, according to news reports. The federal health ministry in New Delhi, which is tracking nationwide cases to allot scarce and expensive antifungal medicine, has not released a fatalities figure.

The coronavirus pandemic has drawn stark lines between rich nations and poor, and the mucormycosis epidemic in India stands as the latest manifestation. During the second wave, which struck India in April, its creaky, underfunded medical system lacked beds, oxygen and other necessities as infections and deaths soared.

The mucormycosis epidemic adds even more urgency to the difficult task of protecting India’s 1.4 billion people. Only a small fraction have been vaccinated against the coronavirus, and they remain vulnerable to a third wave and the consequences that could follow.

“Mucormycosis will tail off and go back to baseline as the COVID cases subside,” said Dr. Dileep Mavalankar, an epidemiologist. “But it may come back in the third wave unless we

find out why it is happening.”

Many doctors in India think they know why. The bone-and-tissue-eating fungus can attack the gastrointestinal tract, the lungs, the skin and the sinuses, where it often spreads to the eye socket and the brain if left untreated. Treatment for the disease involves complex, often disfiguring surgery and an uncommon and expensive drug, contributing to a mortality rate above 50%.

Mucormycosis is not passed from person to person. It develops from commonplace spores that sometimes build up in homes and hospitals. Doctors believe India’s crowded hospitals, and their dire lack of medical oxygen, left the fungus an opening.

Without enough oxygen to go around, doctors in many places injected patients with steroids, a standard treatment for doctors battling COVID globally. They can reduce inflammation in the lungs and help COVID patients breathe more easily.

Many doctors prescribed steroids in quantities and for durations that far exceed World Health Organization recommendations, said Arunaloke Chakrabarti, a microbiologist and co-author of a study examining the causes of India’s mucormycosis outbreak. Those steroids may have compromised patient immune systems and made COVID-19 patients more susceptible to fungal spores.

The steroids may have also dangerously increased blood sugar levels, leaving people with diabetes vulnerable to mucormycosis. It could also increase the chance of blood clots, leading to malnourished tissue, which the “fungus attacks,” Prajapati said.

According to the health ministry, about four out of five mucormycosis patients have had COVID-19. More than half have diabetes.