AHMEDABAD, India – In the stuffy, crowded Civil Hospital ward, the ear, nose and throat specialist moved swiftly from bed to bed, shining a flashlight in a patient’s mouth and examining the other’s x-rays.
The specialist, Dr. Bela Prajapati, oversees the treatment of nearly 400 patients with mucormycosis, a rare and often fatal fungal disease that has exploded on the skirts of the coronavirus pandemic across India. Unprepared for the devastating second wave of Covid-19 this spring, many Indian hospitals took desperate steps to save lives – steps that may have opened the door to yet another deadly disease.
“The pandemic started an epidemic,” said Dr. Prajapati.
In three weeks, the number of cases of the disease – known under the misnomer “black fungus” because it is found on dead tissue – shot from negligible levels to more than 30,000. States have recorded more than 2,100 deaths, according to news reports. The Federal Ministry of Health in New Delhi, which is tracking nationwide cases to distribute scarce and expensive antifungal drugs, has not released a death toll.
The coronavirus pandemic has drawn strong lines between rich and poor nations, and the mucormycosis epidemic in India is the most recent manifestation. During the second wave, which struck India in April, creaky, underfunded The medical system lacked beds, oxygen, and other necessities as infections and deaths rose.
The mucormycosis epidemic makes the difficult task of protecting India’s 1.4 billion people even more pressing. Only a small fraction have been vaccinated against the coronavirus and they remain vulnerable to a third wave and its consequences.
“The mucormycosis will subside and return to baseline when the Covid cases subside,” said Dr. Dileep Mavalankar, an epidemiologist. “But it could come back in the third wave unless we find out why it happens.”
Many doctors in India think they know why. The bone- and tissue-eating fungus can affect the gastrointestinal tract, lungs, skin and sinuses, where, if left untreated, it often spreads to the eye socket and the brain. Treatment for the disease includes complex, often disfiguring surgery and a rare and expensive drug that contributes to a death rate of over 50 percent.
Mucormycosis is not passed on from person to person. It develops from everyday spores that sometimes accumulate in homes and hospitals. Doctors believe India’s overcrowded hospitals and their terrible lack of medical oxygen left an opening for the fungus.
Without enough oxygen to get around, doctors in many places injected patients with steroids, a standard treatment for doctors battling Covid around the world. They can reduce inflammation in the lungs and help Covid patients breathe easier.
Many doctors prescribed steroids in amounts and for durations that far exceeded the recommendations of the World Health Organization, said Arunaloke Chakrabarti, microbiologist and co-author of a study Investigating the causes of the mucormycosis outbreak in India. These steroids may have weakened patients’ immune systems and made Covid-19 patients more susceptible to fungal spores.
The steroids can also have dangerously elevated blood sugar levels, making people with diabetes susceptible to mucormycosis. It could also make blood clots more likely, leading to malnourished tissues that the fungus “attacks,” said Dr. Prajapati.
Desperate doctors may not have had the opportunity to ask patients if they had diabetes or other medical conditions before resorting to steroids.
“Doctors barely had time to manage patients,” said Dr. Chakrabarti. “You’ve all wondered how to take care of your respiratory system.”
According to the Ministry of Health, around four out of five mucormycosis patients have had Covid-19. More than half have diabetes.
Alok Kumar Chaudry, a 30-year-old engineer with surgical tape over his left eye and hooked up to an infusion line in the civil hospital, is one of those who have mucormycosis and who has had Covid for the first time.
He was studying for India’s state examination in New Delhi in April when the second wave hit. After testing positive for the coronavirus and scarce hospital beds, medication and oxygen, he jumped on a train to his older brother’s home in rural Gujarat. There, its oxygen levels dropped to a potentially fatal 54 percent.
After two weeks on oxygen support and steroids in a local hospital, he recovered from Covid-19 but developed acute left brain headache. Doctors thought steroids could have caused it and that it was going to go away.
“All of a sudden my left eye went blank,” said Mr. Chaudry.
An MRI showed mucormycosis. The doctors said they had to remove his eye.
He went to Ahmedabad Civil Hospital for a second opinion. Five specialists oversaw an operation to remove the dead tissue in his sinus tract. To clear the remaining infection, he was given a 15-day course of amphotericin B, an antifungal agent.
Dr. Chakrabarti said if Mr. Chaudry kept his eye he could still lose his life as surgeons couldn’t remove the thin layer of infection behind his eye without removing the eye itself.
“I’ve lost the eyesight in my left eye, my studies have suffered,” said Mr. Chaudry. “In any case, I want to know why Mucor was formed. If it is incorrect treatment, someone is responsible. If it’s the wrath of God what can I do? “
The study that Dr. Chakrabarti wrote down released this month from the U.S. Centers for Disease Control and Prevention said heavy steroid use, the association with diabetes, and unsanitary conditions in some hospitals had played a role.
Even before the pandemic, India had around 50 cases of mucormycosis a year, compared to an average of a single case every two years in the US and Western Europe. Environmental conditions play a role, as does the incidence of diabetes – India has more than twice as many people with the disease as the United States.
Mucormycosis usually affects people with diabetes in India who are either unaware of their condition or are not using insulin properly. But during the current outbreak, many patients had no history of diabetes. The common denominator was a steroid-treated Covid-19 infection, clinicians and researchers say.
In May, the Ahmedabad government declared mucormycosis an epidemic in Gujarat. Other states followed. Whether patients live or die often depends on how quickly they undergo debridement surgery that removes the fungus and then begins a two-week treatment with amphotericin B.
Prime Minister Narendra Modi, who is from Gujarat, described the fungal disease as a new “challenge” and said it was “important to create systems to address it”.
India makes small amounts of Amphotericin B, which is available for free in some public hospitals. However, because supplies are limited, India imports it from the United States, where it costs around $ 300 per vial. Each patient needs 60 to 100 vials. The American manufacturer Gilead Sciences donated around 200,000 vials.
Doctors use cheaper drugs that are just as effective but more toxic and pose a risk of kidney damage.
“This is a very painful decision,” said Dr. Atul Patel, an infectious disease specialist at the private Sterling Hospital in Ahmedabad, who has treated dozens of mucormycosis patients during the outbreak.
Dr. Another author on the study, Patel, said that Covid-19 patients with mild infections that they did not need were prescribed steroids, which in India are often prescribed for routine symptoms such as diarrhea or fever.
This was the case with a patient of Dr. Patel is the case, Ambaben Heerabhai Patel, 60, the matriarch of a farming family in rural Gujarat who pays about $ 700 a day in sterling for antifungal treatments and other services.
It’s a high price, but Ms. Patel had Dr. Patel – no relationship – consulted for previous health problems related to her diabetes. After back-to-back infections from Covid-19 and then mucormycosis, she didn’t want to take any risks.
When she arrived at the hospital on May 17 with a severe headache and numbness, Ms. Patel said from her private room at Sterling Hospital in early June that she was feeling well for the first time in more than a month.
From Dr. She said to Patel: “He is like my God.”