Black fungus in Assam: State govt issues SOP to contain spread of infection

GUWAHATI: With the rapid increase in COVID-19 cases in India, the country is now also fighting with black fungus also known as mucormycosis, which is a complication caused by a fungal infection.

A large number of cases of black fungus have been identified from various parts of the world, with the possibility of a rise in the number of such cases in the near future. As a result, the health ministry has urged states to list "Black Fungus" under the "Epidemic Diseases Act," a rare but potentially fatal infection.

Following this, an annexure containing the SOP for screening, diagnosis, and management of MUCOR MYCOSIS in COVID patients, as well as an advisory for the same, has been issued by the Assam government for the containment of the further spread of Mucormycosis (Black Fungus) in the state with immediate effect.

The advisory first explained what exactly black fungus is.

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What is mucormycosis (black fungus)?

Mucormycosis is a rare serious fungal infection caused by the fungus Mucor. People get mucormycosis by coming in contact with its spores in the environment. It can also develop in the skin after the fungus enters the skin through a cut, abrasion, burn, or other types of skin trauma.

Following is the SOP for screening, diagnosis, and management of mucormycosis in COVID patients:

Pre-disposing factors (It can develop in patients):

• With uncontrolled diabetes mellitus especially diabetic ketoacidosis.
• Immunosuppressed patients (post-transplant malignancy, injudicious use of a high dose of steroids, Etolizumab/Tocilizumab
• Prolonged ICU stay
• People with HIV
• Malnutrition
• Trauma including bum

When to suspect?

If people having predisposing factors mentioned above develop:

• Nasal blockage
• pain over cheekbone eyes
• blood-stained or blackish nasal discharge
• congestion or redness and swelling of eyes and nose
• difficulty in vision e.g. blurred vision, painful eye movement, double vision and blindness
• Headache and fever
• seizures
• altered mental state
• Cough and blood-stained sputum
• shortness of breath with worsening respiratory problem
• Toothache, loosening of teeth & jaw involvement
• Redness, blackish discoloration in the skin with necrosis.

COVID patients in Home isolation:

Patients who have comorbid conditions like Diabetes Mellitus, on immune suppressant drugs, renal transplant patients, or those or steroids for medical cause need to observe the following warning symptoms:

• Facial Pain/ Cheek pain, Bloody & foul-smelling nasal discharge, Nasal stuffiness, Eye Symptoms like — Eyelid oedema, redness in the eye, any visual disturbance.
• Community in general: Use masks if you are visiting a dusty construction site, Wear shoes, long trousers, long sleeve shirts & gloves while handling soil (Gardening), moss, or manure Maintain personal hygiene including a thorough scrub bath, and Seek immediate medical attention in case of developing any or combination of symptoms

COVID patients in hospital:

• Better control of blood sugar during COVID with or without steroids
• Use steroids judiciously observing correct timing, correct doe & correct duration
• Use clean, sterile water for humidifiers during the oxygen therapy
• Use antibiotics/anti-fungus judiciously

How to diagnose?

• A high index of clinical suspicion with special reference to pre-disposing factors
• Scrapping of the affected skin and examination with KOH preparation
• Nasal swab for fungal budding hyphae
• Fungal culture & skin biopsy
• Blood investigation – CBC, LFT, KFT, Electrolytes, Blood sugar (fasting, PP, HBA1C)
• Imaging – CT scan/MRI of the brain, PNS and chest
• The investigation related to pre-existing diseases.

Mucormycosis is often identified as a result of inadequate humidifier maintenance. As a result, strict adherence to the following SOP is required:

• Using purified or sterile water at all times.
• Never drink tap water that hasn't been boiled or mineral water that hasn't been filtered.
• Fill up to about 10 mm below the maximum fill line
• Make sure the water level does not fall below the minimum fill line.
• The water level should be tested twice a day and topped up as required.
• The humidifier's water should be changed on a daily basis.
• Before reusing a humidifier, it should be washed in mild soapy water, rinsed with clean water, and dried in the air.
• Both humidifier components should be soaked in a mild antiseptic solution for 30 minutes once a week (for the same patient) and between patients, rinsed with clean water, and dried in the air.

"Surgical debridement to remove all necrotic material, by ENT and Ophthalmology team," the advisory added.

It needs to mention that Assam reported its first black fungus case on May 18.

A 27-year-old patient who was admitted to a private hospital in Guwahati after being tested positive for the black fungal infection the very next day morning the patient died.

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