COVID AFTER EFFECT: MUCOR MYCOSIS ANIL K KHAWARE ADVOCATE

 

 

COVID AFTER EFFECT: MUCOR MYCOSIS

ANIL K KHAWARE

ADVOCATE

The Covid -19 is quite an enigma, so it seems. The more you delve into it and start assuming victory over the virus, it turns turtle and yet again take further spin to deceive the mankind. It comes out with novelty with impunity and renewed vigour and still with much vengeance. It seems the Covid Virus takes meticulous note of the prospective remedy undertaken in this regard by expert and has the penchant to come out with top spin or ace to hoax us. People are perplexed. No, I am not discussing the mutant variants, that is already delved in much detail before. It is “Mucor Mycosis”, known as Black Fungus and the disease that it causes is known as Black Fungal Disease. The disease is believed to surface after recovery of covid patient and as soon as the covid patient feels that the worst is over, the adjunct in the name of Mucor Mycosis surfaces in some cases. Though, not relatively, in large numbers, still, the numbers are enough to attract attention to the mystery and necessitating a fresh look in the whole episode.

Mucor mycosis (previously called zygomycosis) is a serious but rare fungal disease caused by a group of molds called Mucormycetes. The disease, as illustrated above, is stated to surface after recovery of patients from Covid-19 and as the victim would start resurrecting himself in life, then, in some cases comes the nightmare- Black fungus disease. The hyphal fungi is generally hyaline and in group it is called hyphae and together they are called mycelium. In plants and animals it causes variety of diseases, though, the fungi like yeast (Saccharomyces cerevisiae)  has role in industrial production and biotechnology. The cause and chemistry of black fungus disease thus needs surgical analysis in the above backdrop.

 

MOLDS ARE COSMOPOLITAN IN DISTRIBUTION

These molds are ubiquitous in the environment and mainly  affect people who have health problems or take medicines that lower the body's ability to fight pathogens and sickness. Even as India reels under the second wave of Covid-19, Doctors at Delhi-based Sir Ganga Ram Hospital (SGRH) have again reported multiple cases of deadly fungal infection Mucor mycosis amongst the patients who had recovered from COVID-19 and was recuperating from COVID. In fact, during the first Covid wave, last year also, the black fungus disease was reported, but probably its intensity was not as high then to cause attention. The black fungal infection, triggered by Covid-19, last year caused many of the patients lose their eyesight. This time the intensity is more.

The Covid-19 patients with weak immunity are more prone to this black fungal Mucor mycosis disease. The black fungal infection, triggered by Covid-19, is reported to have lost eye sight and even eyes were to be removed in cases where the pathogen caused further entry into sinuses and if it leads to brain it may cause death of the patient.

USE OF STEROIDS

In Covid-19 treatment, life-saving steroids and medicines which incidentally suppress immunity are used. Steroids are chemicals and like hormones and made in human body naturally. Steroids are designed to reduce inflammation. They are also known as corticosteroids. These are chemicals readily fight inflammation and in fact immune system in activated in such a way so as to reduce inflammation. However, on the flip side as the steroids stop or slow the immune system  process, which may be causing inflammation. However, the immune system also takes a beat to negate the onslaught in the process. In addition, if one diabetic Covid-19 patient is on oxygen support, then he or she gets exposed to the humidifier. This increases the chance of the fungal infection. In order to minimize the effect of black fungus, blood sugar level has to be controlled and steroids if and when used should be used judiciously. The humidifier, if the Covid-19 patient is on oxygen support, should have clean water and that overall cleanliness of the covid-19 patient should be maintained. Further, if there is any new oral ulcer, it has to be treated immediately.

Use of steroids in treatment of corona virus infection and the fact that many Covid-19 patients have diabetes as co-morbidity could be one of the reasons for this rise in black fungus cases again. Covid-19 infected patients with weak immunity are more prone to this deadly infection. Use of Steroids increases sugar and suppresses immunity and therefore such patients shall be prone to be infected with Mucor mycosis.

WHEN MUCOR MYCOSIS SETS IN

According to the CDC (Centre for Diseases Control and Prevention), this is a rare, but critical fungal infection. These molds are present naturally in the environment. However, it affects humans, when the body’s immunity system has been weakened and it is vulnerable. It affects the lungs and the sinuses following inhalation of fungal spores from the air. It is also believed that the fungus might also enter the body through the outlet such as open wounds or cuts.

In most of the people and in ordinary situation the fungi is not known to cause any harm. However, for such set of people, who have weakened immune systems, breathing in Mucor mycetis spores can cause an infection in the lungs or sinuses which can spread to other parts of the body, It is also assumed that Mucor mycosis is not contagious and hence, it cannot transmit between people and animals.  If the disease symptom are diagnosed early and prompt and appropriate antifungal treatment are administered, the likelihood of patients winning over it is high.

symptoms OF 'Black fungus INFECTION

The probable symptoms are as under:

(i)    Pain and redness around eyes and/or nose/swelling

(ii)   Fever & Headache

(iii)  Coughing & Shortness of breath

(iv)  Bloody vomits & Altered mental status

(v)   Attack on jaw

(vi)  Blackish discoloration over bridge of nose/palate

(vii)  Toothache, loosening of teeth, jaw involvement

(viii)   Blurred or double vision with pain; fever, skin lesion; thrombosis & necrosis

(ix)  Chest pain, pleural effusion, haemoptysis, worsening of respiratory symptoms

(x)   Sinusitis – nasal blockade or congestion, nasal discharge (blackish/bloody), local pain on the cheek bone One sided facial pain, numbness or swelling

What is required to be done

(i)    Control of hyperglycemia

(ii)   Monitor blood glucose level post-COVID-19 discharge and also in diabetics

(iii)  Use of steroid judiciously – correct timing, correct dose, and duration

(iv)  Use of clean, sterile water for humidifiers during oxygen therapy

(v)   Use antibiotics/anti fungals judiciously

CARE

(i)         It is commonly believed that Warning signs and symptoms should not be ignored. Moreover, it should not be assumed that all the cases with choked nose as cases of bacterial sinusitis, more particularly, relating to the issues of immune suppression and/or in a situation when COVID-19 patients are on immune modulators relates to black fungal disease.

(ii)          Aggressive investigations should be the norm for identifying and detecting fungal epidemiology and by adopting wholesome instruments and measures   such as (KOH staining & microscopy, culture etc

(iii)     Immediate recourse to the treatment is crucial tor Mucor mycosis.

 

How to protect from Mucor Mycitis

(i)    Use of masks

(ii)   Wearing shoes, long trousers, long sleeve shirts and gloves;  while handling soil (gardening), moss or manure

(iii)   Maintain personal hygiene, including thorough scrub bath

(iv)   The diabetic control

(v)   If patients is still on steroids , use of it should be reduced

(vi)  immune modulating drugs should be reduced

(vii)  antifungal prophylaxis  should not be used

(viii)   Advisory, if and when issued by the Government should be strictly adhered to.

In addition to this, proper medical treatment may be accessed, such as:

i) Installing peripherally inserted central catheter (PICC line)

ii) Maintaining adequate systemic hydration

iii) Infusing normal saline IV before Amphotericin B infusion

iv)  Antifungal therapy, for at least 4-6 weeks as per guideline

(iv)      Clinical  monitoring of patients and with radio-imaging for response and to detect disease progression may be necessary

The team which shall be of utmost importance shall comprise of Microbiologist, Internal Medicine Specialist, Neurologist, ENT Specialist, Ophthalmologist, Dentist Surgeon (maxillofacial/plastic), Biochemist

According to health experts, Mucor mycosis (previously called zygomycosis) has been a cause of disease and death in transplants, ICU, and immune deficient individuals for a long. However, it is a matter of serious concern that the cases of black fungal infections are on a rise in unsuspected Covid patients. In fact, Covid patients who have recovered from the virus are increasingly being pushed back into the ICUs due to Mucor mycosis. Last year, the black fungus or Mucor mycosis had caused high mortality with many patients suffering from loss of eyesight, removal of jawbones and nose.

What is Liquid Medical Oxygen?

The discussion will be incomplete, until Liquid Medical Oxygen is discussed at length, here. India is currently facing a medical oxygen shortage due to an unprecedented surge in COVID-19 cases. The supply of medical oxygen is extremely important for severe COVID-19 patients as one of the most common symptoms of the virus is shortness of breath and difficulty in breathing. One of the ways through which medical oxygen can be supplied is Liquid Medical Oxygen (LMO). Liquid Medical Oxygen is high purity oxygen used for medical treatment. It has been developed for use in the human body. Due to its low melting and boiling points, oxygen is in a gaseous state at room temperature. The liquification enables storage in larger volume and easier transportation.

 

 

How is Liquid Medical Oxygen (LMO) produced?

There are various methods through which LMO can be produced. The most common production method is the separation of oxygen in Air Separation Units (ASUs). ASUs are production plants that separate large volumes of gases. ASUs use a method known as the 'Fractional Distillation Method' to produce pure oxygen from atmospheric air. In the Fractional Distillation Method, the various gases constituting atmospheric air are separated into different components after cooling them into a liquid state. Liquid oxygen is then extracted from it. The atmospheric air is first cooled to -182 degree celsius. Oxygen liquifies at this point. Since, the boiling point of Nitrogen is -196 degree celsius, it remains in a gaseous state. The “Argon” is an inert gas and has a boiling point similar to that of oxygen (-186 degree celsius) and hence a significant amount of Argon liquifies along with Oxygen. The mixture of Oxygen and Argon thus produced is drained, decompressed and passed through a second low-pressure distillation vessel in order to separate the two gases. Ultimately, purified liquid oxygen is obtained using cryogenic containers. For ready references the chemical nature/properties of “Oxygen” and “Nitrogen” are described as under:

Nitrogen

Atomic number	7
Atomic Weight	14.0067
Melting point	−209.86 °C (−345.8 °F)
Boiling Point	−195.8 °C (−320.4 °F)
Density (1 atm, 0° C)	1.2506 grams/litre

 

Oxygen

Atomic Number	8
Atomic weight	15.9994
Melting point	−218.4 °C (−361.1 °F)
Boiling point	−183.0 °C (−297.4 °F)
Density (1 atm, 0 °C)	1.429 g/litre

 

In addition to the above sources of medical oxygen, there are also portable oxygen generators known as 'Oxygen Concentrators' that can be used at home. If a patient's oxygen saturation level is 94% or above, it still means there is sufficient oxygen in their body. Use of medical oxygen by these individuals can deprive someone whose saturation level is well below 90% or 80%. In fact, oxygen saturation levels of 92 or 93 should not be considered critical; instead, this level is only a buffer that enables the patient to reach the hospital on time.

 

INFECTION REORTED BEFORE & COVID CRISIS

The infection was reported last year in Gujarat’s Ahmedabad and Karnataka’s Bengaluru. In Ahmedabad, Mucor mycosis was reported in five patients who were all either suffering from Covid19 or had recovered from it. The Black Fungus infection or 'Mucor mycosis'  is a serious infection being detected in patients who are or have suffered from the Covid 19 virus. The disease often manifests in the skin and also affects the lungs and the brain. With a number of Mucor mycosis cases detected in Delhi, Maharashtra, and Gujarat, experts in the National Covid-19 task force has issued an evidence-based advisory on the disease.

The advisory from the government reveals that is a fungal infection that mainly affects people who are on medication that reduces their ability to fight environmental pathogens, informing that the infection might turn fatal if not provided proper treatment.  'Mucor mycosis' usually infects the sinuses or lungs of such people after fungal spores are inhaled from the air. 

The fungus finds its way among people hospitalized or recovering from Covid 19, with some requiring urgent surgery. Usually, Mucor mycetes do not pose a major threat to those with a healthy immune system.

It is also believed that black fungal infection inter alia may be also caused due to liquid oxygen (Medical oxygen) and as large quantity of it is inhaled by Covid patient for oxygenation, the production of liquid oxygen if not carried out in clean environment, the fungi may find its way in the liquid oxygen and finds is entry in the lungs of patients, which may be noticed after cure from COVID. Moreover, when in hospital, it is expected that care in oxygen should be such so as to insulate the patient from any such prospective infection and still further, the moment early symptoms are detected, rather than seeking discharge of patient after purported treatment and cure of patient, the treatment of black fungus should also be unveiled.

The responsibility of Government i.e state and the hospitals cannot be undermines, in case of any negligence. It is also to be understood that in the face of high number of COVID Patients and lack of oxygen in various hospitals. Many patients had unfortunately died. The level of care from Doctor who possibly worked under stress and for long hour also could not be immaculate.  Still, there cannot be any compromise with life of a person and inadequacies and negligence has to be accordingly dealt with.   

PLAUSIBLE TREATMENT

It is being said that the “overall mortality rate is around 50 per cent", but early identification and treatment can lead to a better outcome.

Early clinical suspicion on symptoms such as nose obstruction, swelling in the eye or cheeks, and black dry crusts in the nose should immediately prompt the conduct of a biopsy in the OPD and start of the antifungal therapy as early as possible.

The firm, Bharat Serums and Vaccines Limited, became the first company in India to receive the approval from Drug Controller General of India (DCGI) to use anti-fungal medication — Liposomal Amphotericin B or LAmB — as a medical intervention in patients of Mucor mycosis. According to Bharat Serums and Vaccines (BSV), the patients suffering from black fungus from progressing the stage of surgery. BSV is indigenously developing and manufacturing the formulation of Amphotericin B including Liposomal Amphotericin B and Lipid Complex Amphotericin B - the anti-fungal medications that have been recommended for use in life-threatening fungal infections such as Mucor mycosis. BSV, incidentally is the first Indian company having obtained regulatory approval of Liposomal Amphotericin B.

LAW

The Disaster Management Act 2005 is currently in place and there is prescription to deal with the issue in hand. However, any wrong in the above context, if attributable on State could be dealt with under Article 226 of Constitution of India and by way of a writ petition. If State is found wanting, it may not only be censured by the High Courts, but necessary directions including payment of damages to the victims and their family could be passed. I may hasten to add, though, that the issue of damages shall, generally, be the domain of civil law, but writ courts, still, has the authority to pass comprehensive orders in apt cases, even in writ jurisdiction i.e extra-ordinary jurisdiction. Conversely, in law of torts, if wrong is attributable either on state or any private parties like private hospitals a civil suit for damages owing to negligence attributable against any of them or against them jointly and severally could be field and necessary orders could be passed.

Yet another aspect is negligence under Consumer Protection Act 2019. If negligence is found palpable against a hospital or Doctor or doctors, they will be amenable to the trap of Consumer Protection Act 2019.

It may be noted that the law of damages and negligence has to go a long way in Indian context and unlike common law, the finding out of liability index and granting of adequate damages is still far away. It is generally believed that a grave crime,  (wrong, even if seen from the perspective of law of torts) relating to Bhopal Gas Tragedy emanating from Methyl Isocynate (MIC) could not adequately compensate the peoples who have lost their life and many injured. In the case of COVID also, the situation in the country remained heart writhing and precious lives are lost. The moot point is whether they can be compensated?      

It shall be of significance in this context to refer to some judicial precedents:

(1) Rylands v Fletcher (1868) LR 3 HL 330 The law of “strict liability” was propounded in the case and law of torts was conceptualized, then and it was held that any wrongs committed by any agency even if evidence is not forthcoming, it will be construed as strict liability against the person. It was propounded in the backdrop that contractor had left a dugged mine unsealed when constructing a reservoir and it was later found that this was attributable on the contractor and he cannot escape from the liability.    The House of Lords affirmed their decision of courts of exchequer chamber and  the contractor was held guilty.

(2)    MC Mehta vs Union of India & Ors                   1987 SCR (1) 819; AIR 1987 965 Supreme Court

In the backdrop of Bhopal Gas Tragedy the case related to leakage of oleum gas from Shriram Food and Fertilisers Ltd. complex at Delhi. The chaos was resulted in Delhi. At that time One person died in the incident and few were hospitalized. The case laid down the principle of absolute liability and it was held that of any action or omission could be attributable on a defaulting party, the pleas such as Act of God or adopting reasonable caution  shall not be available to the perpetrator. The principles of Strict Liability enunciated in 1868 was thus amplified with a doctrine of absolute liability”.

The article 21 of Constitution of India ordains that everyone is entitled to “Right to Life” and that mean the life itself presupposes life with dignity. If contaminated oxygen is allowed to be produced that is the first stage of negligence, in fact, it is akin to criminal negligence. The oxygen when infused from the outlet of hospital and through pipeline to a patient, the same should also be checked of quality parameter. In Covid times such were the need that probably the hospital authorities might not even had time to quality check, as patients were dying. The responsibility ought to be fixed as a patient who reposes faith in a hospital or system cannot be treated so shabbily.

The effect of black fungus, particularly, if not detected early could be fatal as narrated. As regards law, if the instrumentality of state is found negligent and death or deformities is caused due to the negligence and that  had a direct bearing on the cause of illness, removal of eye or death, then instrumentality of state could not claim indifference and should be held liable. The production of medical oxygen and availability of it if compromised and administering that contaminated oxygen, if causes injury or death, the by virtue of a writ petition under Article 226 of Constitution of India , state could be sued and under the extra-ordinary jurisdiction a command could be issued to the state. Generally, no damages are contemplated in writ jurisdiction, but in apt cases, the high court could direct the state to pay compensation for the negligence. Similarly, a civil suit seeking damages/compensation could be filed against state for losses to body and life.

The hospital, if found guilty of administering contaminated oxygen in this context could also be sued for medical negligence before the Consumer Commission. The negligence shall be akin to grossest deficiency in service and the case shall be made out under the Consumer Protection Act 2019.

REMARK

It is indeed painful that in a developing country like India, as is evident in this Covid wave as well that a large number of people have breathed their last, though, life was bubbling in them, in some cases the death was the direct cause of lack of oxygen availability. These are the basic necessity and the citizen remained deprived of the life and right to life so to say owing to deficient action or inadequate action or omission on the part of  state. The life lost is irreversible and by no means the agony could be neutralized. The position and development of a nation shall be of no consequence, if basic necessity could not be afforded to a citizen. The Government of the days at both Centre and State levels whichever political spectrum they belong to shall have to share responsibility to the catastrophe which appears to have been accentuated due to lack of planning and action. There has been vast changes of late and government appears to have risen from slumber. The prompt action on the part of the government even a son today is of utmost necessity. I am sanguine that our country shall again rise to the occasion and better future awaits us.

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