Context

As India is still reeling under the second wave of COVID-19 pandemic, Black, White and Yellow Fungus infections have brought along unending woes, pressuring the already stressed healthcare system. These fungal infections have been attributed to COVID-19 and led to prolonged morbidity and mortality in COVID-19 patients

Black Fungus

What is black fungus (Mucormycosis)?

• Mucormycosis, previously known as zygomycosis and sometimes called black fungus, is a serious fungal infection, generally in people with less ability to fight infection.
• Mucormycosis is a rare but serious infection that is caused by a group of moulds called mucormycetes.
• It mainly affects people who have health problems or take medicines that lower the body’s ability to fight germs and sickness.
• It reduces the ability to fight environmental pathogens.
• It can also happen on the skin after a burn, cut or other type of skin wound through which the fungus enters the skin. It can also affect the brain
• People having co-morbities, variconazole therapy, uncontrolled diabetes mellitus, immunosuppression by steroids or prolonged ICU stay can get predisposed to the fungal infection.

Types of Mucormycosis

• Sinuses and brain (rhinocerebral): Most common in people with poorly controlled diabetes and in people who have had a kidney transplant.
• Lungs (pulmonary): The most common type of mucormycosis in people with cancer and in people who have had an organ transplant or a stem cell transplant.
• Stomach and intestine (gastrointestinal): More common among young premature and low birth weight infants, who have had antibiotics, surgery, or medications that lower the body’s ability to fight infection.
• Skin (cutaneous): After a burn, or other skin injury, in people with leukaemia, poorly controlled diabetes, Graft-versus-host disease, HIV and intravenous drug use.
• Widespread (disseminated): When the infection spreads to other organs via the blood.

Symptoms of Mucormycosis

The symptoms of Black Fungus infection are:

For Brain Mucormycosis

1- One-sided facial swelling
2- Headache
3- Nasal or sinus congestion
4- Black lesions on nasal bridge or upper inside of the mouth
5- Fever

For Pulmonary Mucormycosis

1- Fever
2- Cough
3- Chest pain
4- Shortness of breath

For Gastrointestinal Mucormycosis

1- Abdominal pain
2- Nausea and vomiting
3- Gastrointestinal bleeding

Who are at risk of getting infected with Black Fungus?

1- Diabetes
2- Cancer
3- Organ transplant
4- Stem cell transplant
5- Neutropenia 
6- Long-term corticosteroid use
7- Hemochromatosis (excess of iron)
8- Skin injury due to surgery, burns, or wounds
9- Pre-maturity 
10- Low birth weight 

Where are these fungi found?

• Mucormycosis is caused by a group of molds called mucormycetes. It is naturally found in air, water and even food.
• It enters the body through fungal spores from the air or can also occur on skin after a cut, burn, or skin injury.

Mucormycosis affecting COVID-19 patients

• Patients who have high levels of diabetes are at a higher risk of contracting covid-19. When this occurs, they are treated with steroids which compromises their immunity.
• According to doctors, steroids can prove to be a trigger for mucormycosis. While steroids help in reducing inflammation in lungs they can decrease immunity and increase blood sugar levels in both diabetics and non-diabetic covid-19 patients alike.
• Medicines used in treating Covid-19 tend to bring down the count of lymphocytes.
• Lymphocytes are one of the three types of white blood cells whose job is to defend our body against disease-causing pathogens such as bacteria, viruses, and parasites.
• The reduced count of lymphocytes leads to a medical condition called lymphopenia, making way for opportunistic fungal infection in Covid-19 patients.

Treatment

• While it is treated with antifungals, mucormycosis may eventually require surgery.
• To maintain adequate systemic hydration, the treatment includes infusion of normal saline (IV) before infusion of amphotericin B and antifungal therapy, for at least 4-6 weeks.

Life after surgery for mucormycosis

• Mucormycosis can lead to loss of the upper jaw and sometimes even the eye.
• Be it the eye or upper jaw, these can be replaced with appropriate artificial substitutes or prostheses.

Yellow Fungus

• Yellow Fungus, dangerous than white or black fungus, is another fungal infection that has been attributed to COVID-19. Health experts say it is a fatal infection.
• Yellow Fungus is commonly found in reptiles.
• Yellow fungus initially develops by the presence of moulds (a type of fungi) in the environment. It may be present with unnecessary fatigue, rashes, burning sensation on skin etc.
• It may not start from the lungs but it invades internal organs of the body and affects the entire functioning.

Potential causes of yellow fungus

• Prolonged use of steroid.
• Contaminated environment.
• Uncontrolled diabetes.
• Unhygienic or dirty surroundings.
• Unhygienic habits.
• Lesser immunity.
• Co-morbidities.

Symptoms of Yellow Fungus

• Weight loss
• Reduced appetite
• Lethargy
• Pus leakage
• Sunken eyes
• Organ failure

Treatment

• Like mucormycosis, the treatment for yellow fungus is Amphoteracin-B injection

Prevention

• Keep your room, home and surroundings as clean as possible
• Remove stale food and fecal matter immediately to check bacterial and fungal growth.
• Keep the humidity of the room and home under check as excessive humidity promotes bacteria growth. Just like for Covid patients maintaining clean air flow inside the room and homes is necessary.
• Coronavirus positive patients must immediately start treatment so complications like yellow fungus do not develop.

White Fungus

• White Fungus or Candidiasis is a fungal infection caused by a yeast (a type of fungus) called Candida.
• Candida normally lives on the skin and inside the body, in places such as the mouth, throat, gut, and vagina, without causing any problems.
• Candida can cause infections if it grows out of control or if it enters deep into the body (for example, the bloodstream or internal organs like the kidney, heart, or brain).
• The most common species that causes infection is Candida albicans.
• Patients of white fungus show Covid-like symptoms but test negative; the infection can be diagnosed through CT-Scan or X-ray.

Cause

• This infection can be caused due to low immunity, or if people come in contact with things that contain these moulds like water, etc.
• Children and women are more at risk of contracting the fungal infection.
• Like the black fungus, white fungus is also more likely to afflict people with compromised immune systems, pre-existing medical conditions, AIDS, a recent kidney transplant or diabetes.

Symptoms

• People experience symptoms similar to Covid if it reaches the lungs such as chest infection, despite testing negative for the virus.
• White fungus affects the lungs as well as other parts of the body including the nails, skin, stomach, kidney, brain, private parts and mouth.

Diagnosis/Treatment

• CT scans or X-Rays can reveal the condition.
• Patients with the white fungus are currently being treated with known anti-fungal medication.

Prevention

• Special caution is required of moulds in water that can lead to infection.
• Proper sanitation is very important.

Way Forward

• Use of Steroids must be curbed down in the treatment of Covid to prevent low immunity in patients.
• The fungus must be dealt as a pandemic and not just a regular post Covid complication.
• All necessary medicines needed for the treatment of above mentioned Fungus must be made available in the hospital.
• Government should run awareness campaigns about these funguses as a preventive measure.