Vitamin A Deficiency, COVID-19, and Rhino-Orbital Mucormycosis (Black Fungus): An Analytical Perspective.

Mucormycosis is a rare but serious opportunistic fungal disease characterized by rhino-orbito-cerebral and pulmonary involvement. It is mainly seen in people with secondary immunosuppression, isolated vitamin A deficiency, measles, and AIDS patients. It showed a rise during the second wave of the COVID-19 epidemic in the spring of 2021 in India, especially in diabetic COVID-19 patients. Vitamin A deficiency is known to cause nutritional immunodeficiency and hence leading the way to increased opportunistic fungal, bacterial, and viral infections. In the eye, it causes keratitis, night blindness, xerophthalmia, conjunctivitis, Bitot spots, keratomalacia, and retinopathy. It also causes decreased tear secretion and deterioration of the anatomical/physiological defense barrier of the eye. The negative impact of vitamin A deficiency has been previously demonstrated in measles, AIDS, and COVID-19. We think that mucormycosis in COVID-19 might be rendered by vitamin A deficiency and that vitamin A supplementation may have preventive and therapeutic values against mucormycosis and other ocular symptoms associated with COVID-19. However, any vitamin A treatment regimen needs to be based on laboratory and clinical data and supervised by medical professionals.

Rhino-Orbito-Cerebral Mucormycosis—The Bane of the ‘Black Fungus'

Rhino-orbito-cerebral mucormycosis (ROCM) is an infection of the nasal passages and orbit caused by ubiquitous fungi of the order Mucorales. These fungi are known to affect patients with phagocyte and neutrophil dysfunction. Patients with uncontrolled diabetes, solid-organ, haematological malignancies and organ transplant recipients on immunosuppressive therapy are especially susceptible. The disease is being seen with alarming frequency in patients with COVID-19 infection or those who have recently recovered from it. Poor glycaemic control due to the indiscriminate use of steroids has been strongly implicated. Patients present with periocular pain, oedema, numbness or skin discoloration along with symptoms of the nasal blockade. Direct microscopy of a deep nasal swab taken from the involved mucosa reveals broad aseptate or pauci-septate fungal hyphae, clinching the diagnosis. CT scan of the paranasal sinuses and orbit would reveal a hyperdense lesion involving the nasal turbinates and sinuses with extension into the orbit. Lack of contrast enhancement indicates necrosis of the tissues. The treatment involves administration of systemic antifungals (Amphotericin B, Posaconazole and isavuconazole) and aggressive surgical debridement of involved tissues. In spite of all measures, the mortality rate is about 46% in these patients. Strict diabetic control and judicious prescription and monitoring of systemic steroids in the setting of COVID-19 infection, keeping a high index of suspicion with early detection of the disease can go a long way in improving the prognosis. © The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021.

Effect of nurse-led intervention on knowledge and preventive behavior of diabetic pregnant women regarding COVID-19 associated mucromycosis infection in mid-delta region of Egypt.

BACKGROUND: Black fungus (mycoses) is an opportunistic invasive infection that predominantly occurred among immunosuppressed persons. It has been recently detected in COVID-19 patients. The pregnant diabetic woman is susceptible to such infections and needs recognition for protection. This study aimed to evaluate the effect of the nurse-led intervention on the knowledge and preventive practice of diabetic pregnant women regarding fungal mycosis during the COVID-19 pandemic. METHOD: This quasi-experimental study was conducted at maternal health care centers in Shebin El-Kom, Menoufia Governorate, Egypt. The study recruited 73 diabetic pregnant women through a systematic random sampling of pregnant women attending the maternity clinic during the period of the study. A structured interview questionnaire was used to measure their knowledge regarding Mucormycosis and COVID-19 manifestations. The preventive practices were assessed through an observational checklist of hygienic practice, insulin administration, and blood glucose monitoring for the prevention of Mucormycosis infection. RESULTS: The study revealed a statistically significant increment in the participants' knowledge, preventive practice, personal hygiene, and diabetes self-care scores (9.56 ± 1.75 ,3.6 ± 1.18, 3.18 ± 1.29 post-intervention) comparable to (6.19 ± 1.66, 1.97 ± 1.35, 0.89 ± 1.38 pre-intervention) respectively. There was a significant improvement in the overall COVID-19 protective score against Mucormycosis (from 2.66 ± 1.74 to 4.53 ± 1.43). CONCLUSION: Nursing educational sessions had a positive effect on pregnant women's awareness and preventive behavior. Hence, it is recommended to integrate nurse-led intervention targeting the preventive practice against COVID-19-associated Mucormycosis infection (CAM) as routine services for diabetic pregnant women during antenatal care.

Modified coptisine derivatives as an inhibitor against pathogenic Rhizomucor miehei, Mycolicibacterium smegmatis (Black Fungus), Monkeypox, and Marburg virus by molecular docking and molecular dynamics simulation-based drug design approach.

During the second phase of SARS-CoV-2, an unknown fungal infection, identified as black fungus, was transmitted to numerous people among the hospitalized COVID-19 patients and increased the death rate. The black fungus is associated with the Mycolicibacterium smegmatis, Mucor lusitanicus, and Rhizomucor miehei microorganisms. At the same time, other pathogenic diseases, such as the Monkeypox virus and Marburg virus, impacted global health. Policymakers are concerned about these pathogens due to their severe pathogenic capabilities and rapid spread. However, no standard therapies are available to manage and treat those conditions. Since the coptisine has significant antimicrobial, antiviral, and antifungal properties; therefore, the current investigation has been designed by modifying coptisine to identify an effective drug molecule against Black fungus, Monkeypox, and Marburg virus. After designing the derivatives of coptisine, they have been optimized to get a stable molecular structure. These ligands were then subjected to molecular docking study against two vital proteins obtained from black fungal pathogens: Rhizomucor miehei (PDB ID: 4WTP) and Mycolicibacterium smegmatis (PDB ID 7D6X), and proteins found in Monkeypox virus (PDB ID: 4QWO) and Marburg virus (PDB ID 4OR8). Following molecular docking, other computational investigations, such as ADMET, QSAR, drug-likeness, quantum calculation and molecular dynamics, were also performed to determine their potentiality as antifungal and antiviral inhibitors. The docking score reported that they have strong affinities against Black fungus, Monkeypox virus, and Marburg virus. Then, the molecular dynamic simulation was conducted to determine their stability and durability in the physiological system with water at 100 ns, which documented that the mentioned drugs were stable over the simulated time. Thus, our in silico investigation provides a preliminary report that coptisine derivatives are safe and potentially effective against Black fungus, Monkeypox virus, and Marburg virus. Hence, coptisine derivatives may be a prospective candidate for developing drugs against Black fungus, Monkeypox and Marburg viruses.

Adverse Drug Reaction of Antifungals in the Management of Black Fungus: A Tertiary Care Centre Experience.

In India, COVID-19 has led to a surge in cases of a potentially fatal fungal infection called mucormycosis, popularly known as "black fungus." Intravenous amphotericin B is the only available drug for salvage therapy. Efforts to improve its therapeutic efficacy and decrease its nephrotoxicity have focussed on the reformulation of AmB in three new lipid formulations such amphotericin B lipid complex (Abelcet), amphotericin B colloidal dispersion (Amphotec), and liposomal amphotericin B (AmBisome). The aim of this study is (1) to evaluate the adverse drug reaction of various formulations of amphotericin B used for the treatment of rhinooculocerebralmucormycosis in Indian population. (2) to evaluate the adverse drug reaction of injectable form of posaconazole. This prospective observational study was done on a random sample of 110 patients who got admitted for the management of rhinooculocerebral mucormycosis in a tertiary care centre of middle india… The patients were assessed for the adverse reactions following the administration of various antifungal medication and the findings were analysed. All the 110 patients had received two forms of Amphotericin B (liposomal Amphotericin B and Amphotericin B lipid complex) and Posaconazole injection. 60 patients had received all three forms of Amphotericin B. Out of the 110 patients who received Liposomal amphotericin B, only 2 patients developed adverse drug reaction while in 110 patients who received Amphotericin B Lipid complex, 7 patients had adverse drug effects. Lyophilised amphotericin B had been administered to 60 patients in which 51 patients developed adverse drug reaction and in them one patient went to congestive cardiac failure. Injection posaconazole had been administered to 110 patients in which 72 patients developed drug reaction. In spite of its proven track record of Amphotericin B, its well-known side effects and toxicity will sometimes require discontinuation of therapy despite a life-threatening systemic fungal infection. Lipid formulations of AmB are better tolerated than AmB deoxycholate but infusional drug reactions have been reported in lipid formulation too. So improved strategies for the management of infusion related adverse events are required.

Modified Convolutional Neural Network Architecture with XGBoost for Mucormycosis Detection and compare performance with XGBoost

Patients with coronavirus illness 2019, especially those in India, are more likely to see an increase in rhino-orbital mucormycosis. A well-known risk factor during COVID-19 infection and mucormycosis is diabetes mellitus (DM). With roughly 0.15 instances per 1000 people, mucormycosis is almost 82 times more common in India than it is in Western nations. Additionally, this fungus expanded quickly across numerous states, leading some of them to designate this illness an epidemic. Finding a solution for this potentially fatal fungal infection requires the aid of modern technologies, including artificial intelligence and data learning. In this paper, we combine a modified convolutional learning neural network with an XGBoost classifier to propose a unique black fungus detection method. Under the right circumstances, the CNNXGB model is made simpler by lowering the no of attributes since it is not essential to re-adjust the weight values throughout a back propagation cycle. On testing data, the mean classification performance is 98.26%, far better than current approaches. © 2023 IEEE.

Mucormycosis Detection using Hybrid Convolutional Neural Network with Support Vector Machine and Compare the performance with Support Vector Machine

Based on the patient's underlying condition, mucormycosis, often known as a black fungus illness, is an uncommon but severe disease with a high fatality rate. The large second wave of the COVID-19 epidemic has presented a challenge for the Indian healthcare system from this life-threatening powerful threat. The fungus family Mucorales causes mucormycosis, which affects numerous bodily organs. This fungal opportunistic illness spreads quickly. Recently, this unusual fungus has been infecting covid sufferers in India at greater rates than before. In India, the frequency of this black fungus illness amongst covid-19 as well as post-covid-19 patients is now on the rise. Finding a solution for this potentially fatal fungal infection requires the aid of modern technologies, including artificial intelligence and data learning. In this article, we present a unique hybrid model for black fungus identification that combines support vector machine classifier and convolutional learning network. Under the proper circumstances, the CNNSVM model is made simpler by minimizing the amount of variables because it is not important to constantly the weighting factors in a back propagation cycle. Additionally, it was shown that the SVM classifier was the best merging equivalent when the CNN was employed as a feature extractor, offering the highest accuracy-related synergy effect. On testing data, the mean classification performance was 99.3%, which is a significant improvement over current techniques. © 2023 IEEE.

A Novel Deep Learning based Black Fungus Detection using the Bagging Ensemble with K-Nearest Neighbor

Machine learning is widely employed, and broadly speaking, scientists consider applying it everywhere. Around the same period, we can see that India has been devastated by the second corona wave. In a single day, more than 4 lakh instances arrive. Meanwhile, reports of the arrival of a new, fatal fungus called Mucormycosis emerged (Black fungus). Additionally, this fungus expanded quickly throughout numerous states, leading some of them to designate this illness an epidemic. People with weak immunity functions, including those who have had the corona virus and some of whom are still recovering, are more likely to get a black fungus infection since their bodies can't successfully fight it off. Bagging Ensemble with K-Nearest Neighbor is a modified machine learning approach that will be developed in this study (BKNN). The traditional methods, including K-Nearest Neighbor ensemble with bagging classification, are the basis for the suggested methodology. After the image processing techniques, including pre-processing and segmentation, were reviewed, the accuracy score for this classifier was 96.4 percent, which would have been the highest of all the findings. This paper described how machine learning was beneficial during the Corona era, much as it would be beneficial during epidemics like mucormycosis. The last section of this essay presents accurate, graphical evidence for all items addressed, along with explicit specifications. © 2022 IEEE.

Black Fungus Classification using Adaboost with SVM-based classifier and Compare accuracy with Support Vector Machine

India recognize a severe public health issue in addition to the COVID-19 outbreak and the growing percentage of patients with related mucormycosis from 2021. An uncommon condition known as mucormycosis is brought on by fungus in the family Mucorales. Mucormycosis is a fairly uncommon illness that is caused by common environmental moulds that may be found in soil and decomposing organic materials. Spores develop into hyphae in a susceptible individual, which subsequently infect nearby tissue, including blood vessels, leading to hemorrhagic infarction. Doctors have offered many hypotheses on this. The issue is if black fungus is present in other countries given how uncontrolled it is growing in India. Patients in India with weakened immune systems are more susceptible to illnesses other than corona virus infection. The revised machine learning strategy which will be created in this work is Adaboost with an Support Vector Machine-based classifier (ASVM). Due of the difficulties in learning SVM and the differential in variety as well as efficiency over straightforward SVM classifiers, ASVM classifier is frequently believed to violate the Boosting principle. The Adaboost classifier used in the study gradually replaces SVM as the primary classifier when the weight value of the training sample changes. On testing data, the mean accuracy of the classification was 97.1%, which was much higher than that of SVM classifiers without Adaboost. © 2022 IEEE.

Deep Network Analysis and Prediction of Ophthalmic Disorders

Everybody, around the globe, is aware that their kids, relatives, and family are suffering from the pandemic COVID-19. S everal people are still facing post-COVID-19 issues. During COVID-19's second wave, mucormycosis, sometimes known as "black fungus, " plagued people, especially those who had previously been infected with the virus. The clinical manifestations of mucormycosis are quite varied, the disease affects the skin, subcutaneous fatty tissue, and visceral organs such as the eyes and brain. This paper surveys the Mucormycosis-affected eye diseases due to post-COVID-19 complications and leverages the Machine learning model to differentiate it from other eye diseases. COVID-19-associated Mucormycosis carries a very high mortality rate and timely detection that can assist people in starting therapy at an early stage of the disease, increasing their chances of recovery. Though it was evaluated for a specific disease (COVID-19-associated mucormycosis) we ended up developing a framework that can detect other eye diseases. Thus, the goal of this research is to distinguish Mucormycosis from other eye diseases such as Bulging Eyes, Cataracts, Crossed Eyes, Glaucoma, and Uveitis. This study implies Deep learning techniques with a Convolutional Neural Network based on the TensorFlow and Keras model to detect and make use of computer vision to accurately classify eye diseases. We achieved a precision of 70% in this study by developing a webpage using the trained model for an eye diseases evaluation. © 2022 IEEE

Critical Review of Covid-19 Associated Mucormycosis of Nose and Paranasal Sinuses in A Tertiary Care Hospital in Ongole, Andhra Pradesh

Background: Mucormycosis is a fungal infection caused by filaments of Mucoraceae which invades blood vessels culminating in a lethal opportunistic infection. During the second wave of COVID-19, all over India a spurt of increased reporting of Mucoraecea infection was experienced. Compromised individual immunity system was suspected. Its early diagnosis and suitable surgical intervention were essential to decrease morbidity and mortality. Aim of the Study: To study the demography, clinical features, risk factors, laboratory investigations, and radiological findings of patients with mucormycosis and to evaluate the clinical outcomes in each case. Materials: A cross sectional study from the Department of ENT of Government Medical College Hospital, Ongole;350 COVID-19 RT-PCR positive patients presented with clinical symptoms and signs of Mucormycosis between February 2021 and February 2022 were analyzed. All age groups and genders were included. Mucormycosis proved on microscopic examination of the aspirate or histopathologies of tissue specimens were included. Clinical findings, risk factors, comorbidities, outcome of the disease, biochemical and hematological investigations, radiological signs, nature of fungal elements isolated, treatment instituted were noted. Surgical procedures included were Functional Endoscopic sinus surgery, extended Endoscopic sinus surgery, Medial maxillectomy, ethmoidectomy, Sphenoid exploration, frontal sinusotomy, Orbital exenteration and Skull base surgeries. Antifungal treatment consisted of administration of liposomal Amphotericin B and posaconazole. Result(s): 350 patients included in this study;268/350 (76.57%) males and 82/350 (23.42%) females with a male to female ratio of 3.26:1. 211 (60.28%) patients living in rural areas and 139 (39.71%) living in the urban areas. 324 (92.57%) patients were positive for COVID-19 (RT-PCR) test and 26 patients were negative. There were 233 (66.57%) patients who were obese with more than 30 BMI index and 117 (33.42%) who were with less than 30 BMI index. 299 (85.42%) patients were diabetic and 51 (14.57%) patients were non diabetic. Vaccination was taken 188 (53.71%) of the patients and not taken by 162 (46.28%) of the patients. Mortality rate was 09/350 (02.57%). It was observed that the variables such as Living area, COVID-19 (RT-OCR) test positivity, obesity, Diabetes mellitus and usage of steroids were significantly associated with Mucormycosis in this study. Conclusion(s): Mucormycosis was found to be common in males, from the rural areas. Other significant risk factors for Mucormycosis were COVID-19 (RT-OCR) test positivity, obesity, Diabetes mellitus and usage of steroids. The most common clinical symptoms and signs among were nasal obstruction with noisy breathing, blood stained nasal discharge, headache, periorbital swelling, reduced vision, Ptosis, external ophthalmoplegia, and facial pains were common. Surgical management reduced the morbidity and mortality of Mucormycosis in this study.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

COVID-19-associated rhino-orbital mucormycosis (CAROM)—a case report

BackgroundThere has been a rapid rise in the number of COVID-19-associated rhino-orbital mucormycosis (CAROM) cases especially in South Asian countries, to an extent that it has been considered an epidemic among the COVID-19 patients in India. As of May 13, 2021, 101 CAROM cases have been reported, of which 82 cases were from India and 19 from the rest of the world. On the other hand, pulmonary mucormycosis associated with COVID-19 has a much lesser reported incidence of only 7% of the total COVID-19-associated mucormycosis cases (Singh AK, Singh R, Joshi SR, Misra A, Diab Metab Syndr: Clin Res Rev, 2021). This case report attempts to familiarize the health care professionals and radiologists with the imaging findings that should alarm for follow-up and treatment in the lines of CAROM.Case presentationRhino-orbital mucormycosis (ROM) is a manifestation of mucormycosis that is thought to be acquired by inhalation of fungal spores into the paranasal sinuses. Here, we describe a 55-year-old male, post COVID-19 status with long standing diabetes who received steroids and ventilator therapy for the management of the viral infection. Post discharge from the COVID-19 isolation ICU, the patient complained of grayish discharge from the right nostril and was readmitted to the hospital for the nasal discharge. After thorough radiological and pathological investigation, the patient was diagnosed with CAROM and managed.ConclusionUncontrolled diabetes and imprudent use of steroids are both contributing factors in the increased number of CAROM cases. Our report emphasizes on the radiological aspect of CAROM and reinforces the importance of follow-up imaging in post COVID-19 infection cases with a strong suspicion of opportunistic infections.

SMART MEDIAIRGUARD™ (A Proactive Solution to Monitor and Control Infection Risks in Healthcare Facilities)

Purpose: Poor Hospital Indoor Air Quality is known to affect health leading to many diseases. To control infections, apart from clinical safety, care pathway, indoor air quality is also monitored. Considering the coronavirus outbreak and its extended disease incidences like Black fungus, it becomes important to proactively initiate preventive and mitigation strategies. Concept & Design: SMART MEDIAIRGUARDTM is an IoT integrated device that measures and monitors hospital Indoor Air Quality on a real time basis and give alerts when any measured parameter is abnormal. Findings: 1. IoT cloud supports an evidenced based decision. 2. Real time monitoring and alert encourages a proactive mode of practice, ensuring reduced hospital acquired infections and increased patient safety. The Originality value: In comparison to the prevailing technology, SMART MEDIAIRGUARDTM is a unique affordable device with precision, accuracy, enhanced safety and comfort. IoT integration complements a proactively monitored and controlled indoor environment on a real time basis for healthy indoor air. © 2023 DMICS.

Mucormycosis, past and present: a comprehensive review.

Mucormycosis is an emerging opportunistic angioinvasive fungal infection. Predisposing factors such as diabetes, neutropenia, long-term corticosteroid therapy, solid organ transplantation and immunosuppression contribute to its occurrence. This disease was not of significant concern prior to the COVID-19 pandemic, but gained prominence due to infections in COVID-19 patients. Mucormycosis needs special attention and coordinated efforts of the scientific community and medical professionals to reduce morbidity and mortality. Here we present an overview of the epidemiology and prevalence of mucormycosis in the pre- and post-COVID-19 eras, the factors that contributed to the abrupt increase in COVID-19-associated mucormycosis (CAM), the actions taken by the regulatory agencies (including Code Mucor and CAM registry), the existing diagnostic tools and CAM management strategies.

The devastating effects of the COVID-19 pandemic have been further enhanced by various secondary illnesses, particularly opportunistic fungal infections such as mucormycosis. Mucormycosis or 'black fungus' primarily affects people with weakened immunity, those with medical conditions such as diabetes or cancer and those who use medications that reduce the body's capacity to resist infections and disease. The infection starts in the sinuses or the lungs after breathing in spores of the black fungus from the air. In just 2 months between 5 May and 12 July 2021, this uncommon but fatal fungal illness was responsible for 41,512 cases and 3554 fatalities in India alone. The government of India declared a mucormycosis epidemic in May 2021. The majority of such cases occurred during active SARS-CoV-2 outbreaks in India in 2021. Black fungus took over while the host defenses were compromised and the globe was preoccupied tackling the COVID-19 pandemic. Steroids prescribed in amounts and time spans that far exceeded WHO recommendations to manage severe COVID-19 cases, potentially weakened patients' immune systems, and raised blood sugar levels making them vulnerable to fungal invasion. Early diagnosis and treatment are the keys to a patient's survival. Simple means such as maintaining hygienic conditions, avoiding contact with an infected person, judiciously using steroid medications and antibiotics and properly managing high blood sugar can help protect an individual from black-fungus infection.

Surge of mucormycosis during the COVID-19 pandemic.

Patients with respiratory viral infections are more likely to develop co-infections leading to increased fatality. Mucormycosis is an epidemic amidst the COVID-19 pandemic that conveys a 'double threat' to the global health fraternity. Mucormycosis is caused by the Mucorales group of fungi and exhibits acute angioinvasion generally in immunocompromised patients. The most familiar foci of infections are sinuses (39%), lungs (24%), and skin tissues (19%) where the overall dissemination occurs in 23% of cases. The mortality rate in the case of disseminated mucormycosis is found to be 96%. Symptoms are mostly nonspecific and often resemble other common bacterial or fungal infections. Currently, COVID-19-associated mucormycosis (CAM) is being reported from a number of countries such as the USA, Turkey, France, Mexico, Iran, Austria, UK, Brazil, and Italy, while India is the hotspot for this deadly co-infection, accounting for approximately 28,252 cases up to June 8, 2021. It strikes patients within 12-18 days after COVID-19 recovery, and nearly 80% require surgery. Nevertheless, the mortality rate can reach 94% if the diagnosis is delayed or remains untreated. Sometimes COVID-19 is the sole predisposing factor for CAM. Therefore, this study may provide a comprehensive resource for clinicians and researchers dealing with fungal infections, intending to link the potential translational knowledge and prospective therapeutic challenges to counter this opportunistic pathogen.

Epidemiology, Risk Factors, Diagnosis and Treatment of Mucormycosis (Black Fungus): A Review.

The COVID-19 pandemic has shown an adverse effect worldwide, but in India, it has been observed during the second wave that people who recovered from COVID-19 infection developed a secondary infection because it grows in tandem with COVID-19 treatment. Meanwhile, news of a new deadly fungus has surfaced known as Mucormycosis (Black fungus). Mucormycosis is a fungal infection that invades the blood vessels and is caused by Mucormycetes, a group of fungi. Due to the post-pandemic effect of COVID-19 many fungal and bacterial diseases have affected the population. The reason behind the frequent development of opportunistic infections like mucormycosis is the use of steroids, oxygen masks, and antibiotics throughout the treatment of critically and severely ill patients with COVID-19. Inhaling filamentous fungi from the natural environment and a lack of supportive care units can be a risk factor for mucormycosis. It is usually found in people who are immunocompromised. Mucormycosis is more common in people with HIV/AIDS, COVID-19, congenital bone marrow disease, viral diseases, malignancies, severe burns, and irregularly or untreated and treated diabetes. This review emphasizes triggers that may precipitate mucormycosis related to corticosteroids, recent epidemiology, and incidence of mucormycosis. The infection was diagnosed and identified using a variety of cutting-edge medical techniques, including clinical diagnosis, histopathology, and serology. Many treatment methods, such as antifungal medications and therapies, have also been successfully used. The mortality rate, however, remains high due to an aggressive surgical excision or debridement and lack of early diagnosis.

Black fungus outbreak in India - A direct consequence of COVID-19 surge: A myth or reality.

The deadly second wave of COVID-19 has seen an unprecedented surge in mucormycosis associated mortality in India, overwhelming the heath authorities with challenges beyond measure. Also known as black fungus, this life-threatening fungal infection usually manifests in the nose, spreads to the eyes, and in some cases also to the brain. Immune suppression, pre-existing conditions, prolonged and indiscriminate use of steroids, and unhygienic environments are some of the widely recognized risk factors for contracting black fungus in individuals recovered from COVID-19. However, diagnosis of the infection remains insufficient due to the lack a holistic understanding of the possible risks, symptoms, and exposure pathways and therefore no definite protocol exists for managing this fatal infection. Here, we synthesize the current state of knowledge on black fungus outbreak in India and identify key gaps in its understanding with respect to potential risk factors leading to the widespread infection. We looked at 3354 black fungus cases in India, enlisting ailment history (particularly diabetes) and steroid usage in COVID-19 patients as the key factors responsible for exacerbating risks associated with the disease. However, we also press on the possibilities that other less studied non-traditional risk factors may also have a role in causing the infection. Black fungus is therefore a reality of COVID-19, with or without diabetes or steroid use needs to be investigated. We believe such a review is imperative for making informed decisions specially around timely diagnosis and channelizing efforts in controlling the spread of COVID-19 associated mucormycosis.

Management of post-COVID mucormycosis at a tertiary care center in Northern India

Purpose: Our study aims to compile data on the clinical presentation, pathological and radiological findings in cases of post-COVID mucormycosis, and present the management strategy used in our center. Methods: This is a retrospective cohort observational study based at a tertiary healthcare institution in Northern India. All COVID-positive patients presenting with clinical features of mucormycosis were included in the study. They underwent complete otorhinolaryngeal, medical, and ophthalmological examination after thorough history taking. Biochemical tests, biopsy and imaging studies were done for all the patients. The treatment strategy included a multidisciplinary team approach, that is, intravenous antifungals as well as surgical debridement of necrotic tissue via Modified Denker's approach or open maxillectomy, and orbital exenteration, if required. Patients were followed up for six months to look for recurrence. Results: Twenty-three patients were studied, out of which 14 were males and 9 were females. Pathological findings of 13 out of 15 patients, who underwent surgical debridement revealed mucormycosis as a causative agent, received Amphotericin. Aspergillus was found in two cases which received Voriconazole. Eleven out of 20 patients who were treated in our hospital survived. Three patients were lost to follow up. The average hospital stay of discharged patients was 14 days. Conclusion: Post-COVID mucormycosis was reported at an alarming rate after the second COVID wave in India especially after steroid therapies in diabetic patients. Thus a timely, aggressive, team approach using Modified Denkers or open maxillectomy along with proper intravenous antifungals is the key to survival in such patients. © 2023, The Author(s).

COVID-19 and Mucormycosis: A Black Fungus Disaster?

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been associated with a wide range of opportunistic bacterial and fungal infections. Recently, several cases of mucormycosis in people with COVID-19 have been increasingly reported worldwide, in particular in India. 1. To study the total prevalence of mucormycosis and other fungal species in patients' samples. 2. To elaborate on the associated underlying risk factors and their presentations with COVID-19. The study was conducted at the Department of Microbiology, Kalpana Chawla Government Medical College from April 2021 to July 2021 during the COVID-19 pandemic. Both outpatient and admitted cases were included in the study suspected of mucormycosis with underlying COVID-19 infection or post-recovery phase. In total, 906 nasal swab samples were collected at the time of the visit from suspected patients and were sent to the microbiology laboratory of our institute for processing. Both microscopic examinations by preparing a wet mount with KOH and lactophenol cotton blue stain and culture using Sabouraud's dextrose agar (SDA) were done. Subsequently, we analyzed the patient's clinical presentations at a hospital, associated comorbidities, site of mucormycosis infection, past history for use of steroids or oxygen therapy, admissions required, and its outcome in patients with COVID-19. In total, 906 nasal swabs from suspected cases of mucormycosis in people with COVID-19 were processed. In all, 451 (49.7%) fungal positivity was seen, out of which 239 (26.37%) were mucormycosis. Other fungi such as Candida (175, 19.3%), Aspergillus 28 (3.1%), Trichosporon (6, 0.66%) and Curvularia (0.11%) were also identified. Out of the total, 52 were mixed infections. The total percentage of patients having underlying active COVID-19 infection or in the post-recovery phase was 62%. Most cases (80%) were of rhino-orbital origin, 12% were Pulmonary and the rest 8% where no primary site of infection was confirmed. Among risk factors, pre-existing diabetes mellitus (DM), or acute hyperglycemia was present in 71% of cases. Corticosteroid intake was recorded in 68% of cases, chronic hepatitis infection in 4%, two cases of chronic kidney disease, and only one case with triple infection of COVID-19, underlying HIV, and pulmonary tuberculosis. Death from fungal infection was reported in 28.7% of the cases. Even with rapid diagnosis, treatment of underlying disease, and aggressive medical and surgical intervention, the management is often not effective, leading to an extension of the infection and ultimately death. So, early diagnosis and prompt management of this suspected new emerging fungal infection with COVID-19 should be considered.

Focusing COVID-19-associated mucormycosis: a major threat to immunocompromised COVID-19.

COVID-19 disease has been identified to cause remarkable increase of mucormycosis infection cases in India, with the majority of cases being observed in individuals recovering from COVID-19. Mucormycosis has emanated as an outcome of the recent COVID-19 pandemic outbreak as rapidly developing fatal illness which was acquired by Mucorales fungus which is a subcategory of molds known as mucormycetes. Mucormycosis is one of the serious, sporadic mycotic illnesses which is a great threat to immunocompromised COVID-19 patients and affects people of all ages, including children with COVID-19 infections. This is associated with tissue damaging property and, therefore, causes serious clinical complications and elevated death rate. The COVID-19-associated mucormycosis or "black fungus" are the terms used interchangeably. The rapid growth of tissue necrosis presenting as "rhino-orbital-cerebral, pulmonary, cutaneous, gastrointestinal, and disseminated disease" are various clinical forms of mucormycosis. The patient's prognosis and survival can be improved with proper surgeries using an endoscopic approach for local tissue protection in conjunction with course of appropriate conventional antifungal drug like Amphotericin-B and novel drugs like Rezafungin, encochleated Amphotericin B, Orolofim, and SCY-078 which have been explored in last few years. This review provides an overview of mucormycosis including its epidemiology, pathophysiology, risk factors, its clinical forms, and therapeutic approaches for disease management like antifungal therapy, surgical debridement, and iron chelators. The published patents and ongoing clinical trials related to mucormycosis have also been mentioned in this review.