The Society for Promotion of Science of Science & Technology in India (SPSTI), jointly with Chandigarh Chapter of the National Academy of Sciences India (NASI), Chandigarh Chapter of the Indian National Science Academy (INSA) and Indian National Young Academy of Sciences (INYAS) with support from Haryana State Council for Science, Innovation and Technology, Government of Haryana have organized another series of Expository Lectures on current state of Covid pandemic to spread awareness on issues involved so as to enhance the confidence of the general public in facing this pandemic. The first lecture in this series was delivered by Dr. K.K. Talwar on “Covid-19 Pandemic: What have we learned”. The second lecture of the second series was conducted on May 27, 2021 at 5.30 pm through online mode on “Recent Epidemic of Covid Associated Mucormycosis”. The session was attended by more than 168 participants on the zoom and many on the Facebook page of SPSTI.
The session steered with opening remarks by Prof. Keya Dharamvir, General Secretary, SPSTI who welcomed the attendees and the speaker Prof. Arunaloke Chakrabarti. Prof. K.K. Bhasin gave a brief overview of the purpose and strategy of the lecture series. He also introduced the speaker Prof. Arunaloke Chakrabarti, Professor & Head, Medical Microbiology, PGIMER Chandigarh. He is currently the Vice-President of International Society for Human and Animal Mycology (ISHAM), President of Society for Indian Human and Animal Mycologists (SIHAM) and President of Indian Association of Medical Microbiologists.
There are several questions emerging in respect of Post Covid-19 pathological conditions due to Mucormycosis which is taking an epidemic form leading to many rumors among masses. Prof. Chakrabarti in his talk deliberated on facts and cleared myths associated with it. He began his lecture saying that calling Mucormycosis as black fungi is making mockery of scientific perception of our country. Mucormycosis and not a black fungi disease but occurs due to new mucorales, while black fungus is due to dematiaceous fungi, having melanin on its surface. He said the neglected discipline of fungi has been the first time recognized in India. He shared there have been 11717 reported cases of Mucormycosis, with 2800 from Gujrat and 119 from PGIMER, which has led fungal diseases to become a notable disease in India. He said mucorales are everywhere, ranging from ice packed Antarctica to hot geothermal soil, with certain species restricted geographically. Studies have shown indoor and outdoor mucorale spores are very high and with their prevalence is almost same in both air conditioner and non air conditioner rooms of hospitals. He explained Mucormycosis is classified on basis of anatomical localization like pulmonary Mucormycosis affects lungs, gastrointestinal Mucormycosis affects gut, etc. He shared disseminated Mucormycosis occur in individuals who are immunocompromised, rhino-orbital cerebral Mucormycosis is found in patients with uncontrolled diabetes, pulmonary Mucormycosis in haematological malignancies and transplant recipients who are on immunosuppressants, gastrointestinal in premature babies or in malnutrition adults, cutaneous Mucormycosis occur mostly after roadside accidents when contaminated soil gets into trauma wounds or in burns. In India, there have been incidences of uncontrolled diabetes and compliance to antidiabetic drugs is very poor. Quoting a study, shared 23% reported with Mucormycosis were unaware of underlying diabetes. Comparing data of India with other countries, he shared, there are 70% times higher incidences of Mucormycosis India, the prevalence of about 0.14 per 1000 in India. He shared uncontrolled diabetes overshadows all other risk factors and rhino-orbital-cerebral Mucormycosis being the most common clinical type observed in India. He also talked about number of increasing cases of gastrointestinal Mucormycosis cases and renal Mucormycosis cases where actual reasons for its occurrences are still unknown. He shared reports of all report of all reported causes of Mucormycosis in world and shared among these two thirds were from India, with uncontrolled diabetes and systemic corticosteroid as major predisposing factor. There are almost 75% cases of rhino-orbital-cerebral Mucormycosis cases with mortality rate was found to be as high as 50%, as most of these cases were reported late. He shared reports of review of 101 cases where 81% cases were from India with most of them being males nearly 78%. Among these 59% were active COVID cases and 41% were post COVID with 80% of these having pre existing diabetes. Among these 76% cases were on having corticosteroid and with mortality of about 30%. Sharing an unpublished report from 16 centers conducted during September-December 2020 which showed 2.1 fold increase in Mucormycosis with mainly aged patient especially males, 62.7% of these cases had diabetes and almost 78% of these were on steroids. He shared, of these cases in 33% cases COVID-19 alone was the underlying disease and 79% of these were on steroids. In majority cases the Covid associated Mucormycosis was diagnosed with Mucormycosis after 8 days with median of 18 days, whereas most Covid patients are discharged from hospitals after 10 days. Hypoxia and inappropriate steroid use were found in 63% cases which is a significant cause. During the second wave people are not getting proper medical facilities including no oxygen, beds and increasing mortality. Of all the Covid cases almost 30% were diabetic which were not attended properly due to Covid all attention was focused on respiratory treatment. These patients were given steroids with more than recommended dose to save the patient. leading steroids as a major cause for Mucormycosis. The diabetic patients, use of steroids, pandemic and the environment have together play a significant role in increasing the cases of Mucormycosis.
Talking about the link between he focused on unrecognized diabetes cases in India, Covid affecting beta-cells of pancreas, steroids raising the blood sugar level and impair neutrophils migration and release of cortisol and adrenaline causing inflammation leading to free iron circulation in blood, causing hyper ferretinemic syndrome, which provide ground for mucor adhere and causing cell damage and epithelial penetration, leading to thrombus formation and which causes hypoxia and ischemia. He shared along with this immune dysregulation and can also be responsible for Mucormycosis.
He shared mucor are being present in atmosphere and we are exposed to them but do not get affected due to immunity but being infected with Covid, diabetes and being on high dosage of steroid initiates the cycle for mucor proliferation.
He suggested to diagnose rhino-orbital cerebral mucormycosis, a nasal endoscope is used and radioimaging can be used to know the extent of the disease. He also shared there are pulmonary causes of pulmonary mucormycosis which is different from Covid associate pulmonary aspergillus. but in nearly 5% of rhino-cerebral cases both mucormycosis and aspergillus has been observed. Early symptoms of rhino-orbital-cerebral mucormycosis include local pain in one side of the face, numbness in the face, nasal blockage and nasal discharge brown to black in color. in COVID patient jaw involvement has also been infected leading to loosening of teeth, and at later stage eye get involved leading to blurred or double vision, swelling in eye, necrosis and thrombosis. Symptoms of pulmonary mucormycosis are present in many other diseases also so it becomes difficult to identify.
He suggested to manage mucormycosis control diabetes, stop or reduce steroids and discontinue immunomodulators. extensive surgical debridement is needed as in pulmonary mucormycosis surgery is not feasible and antifungal drugs also do not reach these places, leading to high mortality. He also suggested certain drugs recommended for treatment of Covid associated mucormycosis followed by therapy for mucormycosis management.
He clarified mucors are not black fungi and are neither contagious. He shared antifungal prophylaxis and combination of antifungal therapy are not recommended and also enlisted certain drugs like voriconazole , fluconazole, etc, which are also not recommended.
He ended his session with certain questions for the scientific community to pursue like, in Covid -19 immune dysfunction is there any mucor-specific immunity disturbance and if the new Covid variant can cause more mucus-specific immunity disturbances. He raised questions about genetic susceptibility issues in Indian population and correlation between environmental isolated and patient isolates.
The session was much appreciated by the audience and followed with questions about mucors proliferation, drugs that can be used for treatment of mucormycosis, vaccination effecting predisposition towards mucormycosis, link between mucor and diabetes, reasons for mucormycosis in patients who were not on steroids, etc. Prof. R. K. Kohli thanked the speaker as well as the attendees.