What's Up Doc? What's up with the black fungus I saw on TV in COVID patients in India?
A: Mucorales is a ubiquitous fungus found in decaying vegetation and soil, whose spores can become airborne. So this fungus can get almost anywhere. 'Microwave syndrome' is difficult to evaluate and poorly understood  Usually, Mucorales does not cause any problems; our bodys defense mechanisms prevent it from causing disease. However, in certain patients, such as those whose immune systems are compromised (whether from a disease or from a medication used to treat a condition, such as immune suppressants in organ transplant patients or chemotherapy treatments for certain cancers), diabetics, people treated with certain medications (deferoxamine, which is used to lower/chelate iron for certain patients is a key example), and others, Mucorales can cause an active infection, called mucormycosis. This is the case in certain COVID patients (at least partly because the infection itself weakens their immune system, and possibly also because some of the COVID treatments may also compromise their bodys ability to fight off the Mucorales). Mucormycosis is thankfully a rare infection (the exact incidence of it is not known), but there has certainly been a spike in cases in COVID patients, particularly in India. It may cause disease in multiple ways:  Rhino-orbital disease: here the fungus invades the sinuses after it is inhaled, potentially spreading from the sinuses to the eyes, brain, or other adjacent structures. Sinus involvement is the most common clinical presentation of mucormycosis. The symptoms start with sinusitis-type symptoms (runny nose, congestion, sinus pain, fever, headache, and/or other sinusitis symptoms), and then may progress to facial swelling, eye involvement, and/or other complications. Pulmonary (lung) disease: here the inhaled fungus causes pneumonia, with typical symptoms such as shortness of breath, cough, fever, etc. Since COVID infection itself may cause pneumonia, a high index of suspicion must be maintained to identify that there is a mucormycosis pneumonia (possibly in addition to a COVID pneumonia). Gastrointestinal (GI) disease: the ubiquitous fungus may be ingested, causing GI symptoms of abdominal pain, changes in stool, vomiting (even vomiting blood) and/or other symptoms. Skin disease: if the fungal infection invades the skin the symptoms may start with an inflammatory response (redness, pain, irritation, etc. ), then potentially become ischemic symptoms with the skin turning black and becoming necrotic (localized death of the affected tissue). Other disease: the fungus can also cause infection/disease in the kidneys, the brain, and potentially other organ systems, and can even become disseminated (spread throughout the entire body). The diagnosis of mucormycosis can be challenging. The first step is to have clinical suspicion, with certain imaging (for example direct visualization of the sinuses with an endoscopic evaluation, and/or utilizing a CT scan) used to increase this suspicion. Then analyzing samples of affected tissue (either by taking fluid from the affected site, such as sputum from the lung, and/or from taking a biopsy specimen) to identify the presence of invasive Mucorales may be indicated. Even with a reasonably early diagnosis, the prognosis for patients with mucormycosis is poor. For example, overall mortality of rhino-orbital disease is as high as 60 percent and pulmonary disease carries a mortality rate as high as 90 percent, as does disseminated disease. Even skin involvement, which overall has the best prognosis, still carries a mortality rate of as high as 15 percent. Therefore, treatment approaches are usually very aggressive to give the patient their best opportunity of survival. Friend's arm is paralyzed after a night of heavy drinking  The initial treatment for mucormycosis typically involves surgery to debride/remove the affected tissue, trying to get clean margins (that is remove all the affected tissue leaving behind only tissue with no invasion from the fungus). Depending on the tissue involved, there may be limitations to how aggressively this can be done. For example, someone with diffuse fungal pneumonia would not be able to have the affected tissue, i.e., their lungs, removed. Surgery is followed by aggressive treatment with antifungal medications to treat any residual disease. However, side effects and possibly other complications from these medications (for example, amphotericin B, one medication used to treat fungal infections, can affect kidney function as well as possibly cause other complications) can complicate this phase of treatment. Thankfully, only a small percentage of COVID patients develop complications from this "black fungus." As you can see from the discussion above, this is a very concerning complication, with high mortality even with aggressive treatments. This is yet another reason to avoid getting COVID, so please, if you have not yet been vaccinated, go get the vaccine as soon as possible. Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com