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Mucormycosis: The 'black Fungus' Maiming Covid Patients In India

By Soutik BiswasIndia correspondent

Mucor mould is found in soil, plants, manure and decaying fruits

On Saturday morning, Dr Akshay Nair, a Mumbai-based eye surgeon, was waiting to operate on a 25-year-old woman who had recovered from a bout of Covid-19 three weeks ago.

Inside the surgery, an ear, nose and throat specialist was already at work on the patient, a diabetic.

He had inserted a tube in her nose and was removing tissues infected with mucormycosis, a rare but dangerous fungal infection. This aggressive infection affects the nose, eye and sometimes the brain.

After his colleague finished, Dr Nair would carry out a three hour procedure to remove the patient's eye.

"I will be removing her eye to save her life. That's how this disease works," Dr Nair told me.

Even as a deadly second wave of Covid-19 ravages India, doctors are now reporting a rash of cases involving a rare infection - also called the "black fungus" - among recovering and recovered Covid-19 patients.

What is mucormycosis?

Mucormycosis is a very rare infection. It is caused by exposure to mucor mould which is commonly found in soil, plants, manure, and decaying fruits and vegetables. "It is ubiquitous and found in soil and air and even in the nose and mucus of healthy people," says Dr Nair.

It affects the sinuses, the brain and the lungs and can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS.

Doctors believe mucormycosis, which has an overall mortality rate of 50%, may be being triggered by the use of steroids, a life-saving treatment for severe and critically ill Covid-19 patients.

Steroids reduce inflammation in the lungs for Covid-19 and appear to help stop some of the damage that can happen when the body's immune system goes into overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic Covid-19 patients.

It's thought that this drop in immunity could be triggering these cases of mucormycosis.

Steroids are an essential life-saving drug for Covid patients

"Diabetes lowers the body's immune defences, coronavirus exacerbates it, and then steroids which help fight Covid-19 act like fuel to the fire," says Dr Nair.

Dr Nair - who works in three hospitals in Mumbai, one of the worst-hit cities in the second wave - says he has already seen some 40 patients suffering from the fungal infection in April. Many of them were diabetics who had recovered from Covid-19 at home. Eleven of them had to have an eye surgically removed.

Between December and February, just six of his colleagues in five cities - Mumbai, Bangalore, Hyderabad, Delhi and Pune - reported 58 cases of the infection. Most of the patients contracted it between 12 to 15 days after recovery from Covid-19.

Mumbai's busy Sion Hospital has reported 24 cases of the fungal infection in the past two months, up from six cases a year, according to Dr Renuka Bradoo, head of the hospital's ear, nose and throat wing.

Eleven of them had to lose an eye, and six of them died. Most of her patients are middle-aged diabetics who were struck down by the fungus two weeks after recovering from Covid-19. "We are already seeing two to three cases a week here. It's a nightmare inside a pandemic," she told me.

In the southern city of Bangalore, Dr Raghuraj Hegde, an eye surgeon, tells a similar story. He has seen 19 cases of mucormycosis in the past two weeks, most of them young patients. "Some were so sick that we couldn't even operate on them."

Doctors say they are surprised by the severity and the frequency of this fungal infection during the second wave, compared to some cases during the first wave last year.

Dr Nair says he has come across not more than 10 cases in Mumbai in the past two years. "This year is something different," he says.

In Bangalore, Dr Hegde had never seen more than one or two cases a year in over a decade of practice.

Mumbai is one of the worst affected cities in India's second wave

Patients suffering from the fungal infection typically have symptoms of stuffy and bleeding nose; swelling of and pain in the eye; drooping of eyelids; and blurred and finally, loss of vision. There could be black patches of skin around the nose.

Doctors say most of their patients arrive late, when they are already losing vision, and doctors have to surgically remove the eye to stop the infection from reaching the brain.

In some cases, doctors in India say, patients have lost their vision in both eyes. And in rare cases, doctors have to surgically remove the jaw bone in order to stop the disease from spreading.

An anti-fungal intravenous injection which costs 3,500 rupees ($48) a dose and has to be administered every day for up to eight weeks is the only drug effective against the disease.

One way to stall the possibility of the fungal infection was to make sure that Covid-19 patients - both in treatment and after recovery - were being administered the right dose and duration of steroids, says Dr Rahul Baxi, a Mumbai-based diabetologist.

He says he treated some 800 diabetic Covid-19 patients in the past year, and none of them contracted the fungal infection. "Doctors should take care of the sugar levels after the patients are discharged," Dr Baxi told me.

A senior government official says there is "no big outbreak". Yet it is difficult to say why a growing number of cases of mucormycosis are being reported from all over the country. "The strain of the virus appears to be virulent, sending blood sugars soaring to very high levels. And strangely, the fungal infection is affecting a lot of young people," says Dr Hegde.

His youngest patient last month was a 27-year-old man, who was not even a diabetic. "We had to operate on him during his second week of Covid-19 and remove his eye. It's pretty devastating."

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My 79p Hack 'kills Mould In 30 Minutes' – It's Great For Bathrooms Or Around Windows And You Can Get It From B&M

IS your house full of black mould after a cold and damp winter?

Have you tried every trick in the book to no avail?

Mould can be touch to removeCredit: Getty

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We may just have found the answer.

Experts from bathroom retailer Plumbworld have suggested using white vinegar.

They said: "Vinegar is a great option for killing mould.

"It may smell unpleasant, but it won't have the toxicity of bleach.

"Pour it straight onto the spores or use a spray bottle.

"Try mixing it with water with a ratio of 2:1, leave for 30 minutes before wiping."

Black mould is a fungus that grows in warm, wet conditions such as in the bathroom.

Mould can build up for a number of reasons, such as leaking pipes, poor insulation or if condensation is not wiped away after you've had a shower.

IIT-M Gives Free 3D-Printed Face Implants To Poor Patients Disfigured By Black Fungus

A collaboration between IIT Madras and Chennai-based startup ZorioX Innovation Labs, the #Right2Face initiative aims to help poor patients with face implants developed using indigenous 3D-printing technology.

In a heartening development, researchers at the Indian Institute of Technology, Madras (IIT-M), have developed 3D-printed face implants for patients suffering from Mucormycosis, a rare but deadly infection also known as Black Fungus.

This infection has been reported in patients suffering from uncontrolled diabetes, HIV/AIDS, and other medical conditions up to the very recent COVID-19.

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"These procedures involve the reconstruction of the nose, eyes, and other facial structures using a variety of techniques, such as skin grafts, tissue expansion, and microvascular surgery."

"These procedures can help restore the patient's appearance and function, allowing them to lead a more normal life. However, patient-specific implants and procedures are expensive, rendering them inaccessible for people from weaker sections," the release adds.

Speaking to The Better India, Dr Karthik Balaji, a maxillofacial surgeon and CEO of ZorioX recalls, "In college, I delved into exploring advanced techniques for replacing facial structures. Witnessing the complexities and limitations of existing methods fueled my determination to find a more efficient and patient-friendly approach."

He continues, "The integration of 3D printing technology emerged as a promising solution, offering precise and customised implants that streamline the reconstruction process, reduce surgical time, and alleviate the need for multiple procedures."

Explaining the process, he says, "In conventional reconstructive surgery, we take bones from legs, hips, or ribs and reconstruct the face. This has to be followed by a microvascular surgery which can take as long as 18 hours. To fix these bones, we use a plate that is going inside the body. As a medical researcher, I was working on finding ways to develop a plate in the shape of the facial bone, fix the problem, and avoid microvascular surgery, thus reducing the time taken for surgery."

Thankfully, 3D-printing technology came to be. With the introduction of 3D-printing technology, Dr Balaji claims that they have reduced surgical time from 18 hours to 2 hours.

"We don't use bones from another part of the body now. Instead, we will use this titanium 3D-printed implant which is biocompatible. Unlike conventional reconstructive surgery, which allows patients to eat only two years after, followed by another surgery; in employing 3D-printed implants, we only need one surgery and the patient can eat within a month. In other words, these 3D-printed implants allow patients to return to normal life a lot sooner," he explains.

The key differences between conventional reconstructive surgery and employing IIT-M's 3D-printed customised implants lie in precision, efficiency, and the overall patient experience.

Dr Balaji explains, "In conventional reconstructive surgery, the process often starts from surgical removal of facial bones and reconstruction of those defects with the use of bone grafting techniques; this adds complexity to the procedure and is highly technique-sensitive. Over these grafts, conventionally made implants must be placed and that incurs additional burden to the patient barring the procedure."

Dr Murugaiyan Amirthalingam, associate professor at the Department of Metallurgical and Materials Engineering, IIT-Madras explains, "On the contrary, our 3D-printed custom implants offer a more tailored and precise solution. The implants are created based on detailed scans of the patient's anatomy ensuring an exact fit, post-removal of facial bones. This level of customisation not only enhances the aesthetic outcome but also contributes to a more efficient surgical process. The use of 3D printing technology allows for intricate designs that match the patient's unique facial features, resulting in improved functionality."

As Dr Amirthalingam goes on to explain, "The motivation behind developing 3D-printed face implants stemmed from the challenges faced in conventional techniques of facial reconstruction. We have developed a methodology for the use of 3D printing to design and manufacture unique custom-designed components for various biomedical and engineering applications. When the COVID-19 pandemic arose and the number of black fungus cases increased, surgeons approached us with possible solutions to develop patient-specific implants using 3D printing. We could immediately help them as the technology was already developed in our lab."

When Dr Balaji and his colleagues started these procedures initially, they had to import the [3D-printed] implants from the Netherlands or the United States. "The cost of a single implant was around Rs 24 lakh. Working with various engineering institutions, we developed the requisite facilities and software to develop these implants, and IIT-Madras began helping us manufacture them. After bringing all the necessary facilities to India, the cost of the implant fell from Rs 24 lakh to Rs 8 lakh," he says.

How does it work?

Dr Amirthalingam says, "Using unique in-house algorithms, a patient's MRI/CT data is converted to printable CAD (computer-aided design) format, and custom implants are printed from medical-grade titanium using an indigenously-built laser powder bed facility in IIT-M. Extensive research activities are already being carried out in IIT Madras to commercialise this technology for printing patient-specific implants in stainless steel, Ti-6Al-4V, and Co-Cr-Mo alloys."

Interestingly, the IIT-Madras team can print the implant exactly to match the patient's face.

"What sets our approach apart is the ability to custom-design and print implants that precisely match a patient's unique facial anatomy. Traditionally, reconstructive surgeons rely on pre-fabricated implants, which are akin to off-the-rack clothing. They might fit somewhat, but rarely perfectly, and also require additional alterations to patients' bone structures. 3D printing allows us to become bespoke craftsmen, crafting implants that are the exact size and shape of the missing facial bone. We use CT scans or MRIs of the patient directly to create a detailed 3D digital model of the patient's face. Think of it as a high-resolution picture, but instead of just depth, it captures the intricate contours and internal structures of the missing bone," he says.

Next comes the magic of CAD. "Our skilled research scholars and Zoriox team take the medical image data and, using specialised algorithms, transform it into a digital blueprint for the implant. This blueprint, called a CAD STL (stereolithography) file, essentially tells the 3D printer exactly how to build the implant, layer by layer, mimicking the patient's unique facial features," he says.

"Once the CAD STL file is ready, the 3D printer takes centre stage. Imagine a high-tech sculpting machine that uses medical-grade titanium powder to meticulously build the implant, following the precise instructions in the CAD STL file. Layer by layer, the missing bone structure comes to life, perfectly customised for the patient," he adds.

A significant hurdle was the initial capital expenditure cost associated with acquiring and implementing 3D printing technology. Another challenge involved ensuring a reliable supply of titanium, the chosen material for the implants. Most medical grade 3D-printable titanium powders were imported which increased the cost of the implants manyfold.

"We had then collaborated with an Indian supplier to help produce medical-grade titanium powders. Extensive testing was carried out in our lab to qualify the raw material produced by the Indian vendor for medical implant production," explains Dr Amirthalingam.

"Subsequently, careful resource planning helped secure a consistent procurement of high-quality, biocompatible titanium suitable for facial implants. Establishing accurate parameters for 3D printing was a crucial step in achieving the desired precision. Our team of experts in additive manufacturing fine-tuned the printing parameters, ensuring that the implants met stringent quality standards and conformed precisely to the patient's anatomy," he adds.

But as Dr Balaji explains, "No project like this is complete without the invaluable input of the surgeons. Their extensive experience and meticulous feedback guided every step of the process, from initial design to post-operative care. This synergistic collaboration between engineers, designers, and surgeons was the cornerstone of our success."

#Right2Face Initiative

Dr Amirthalingam, says, "Our collaboration with Zoriox began in 2021, driven by a shared vision to revolutionise maxillofacial [relating to jaws and face] implants through 3D printing technology."

As he explains, "Initially, our efforts focused on addressing key technical challenges associated with these novel implants namely:

Surface finish: Optimising the implant surface to promote tissue integration and minimise bacterial adhesion.

Machinability: Streamlining the manufacturing process for improved efficiency and cost reduction.

Osseointegration: Enhancing bone ingrowth and long-term implant stability."

Through collaborative research and development, they have made significant progress in these areas, paving the way for more reliable and functional 3D-printed implants.

As their technical advancements matured, the focus shifted to broader societal impact. In 2023, the effort blossomed into the Right2Face movement, driven by the following objectives:

Raising awareness: Educating the public and medical community about the transformative potential of 3D-printed maxillofacial implants.

Standards development: Contributing to the establishment of robust quality and safety standards for these innovative implants.

Material exploration: Researching and developing new biocompatible materials that further enhance implant performance and affordability.

Improved surgical outcomes: Collaborating with surgeons to refine surgical techniques and optimise patient outcomes with 3D-printed implants.

To save the lives of a patient, a lot of facial bones had to be removed. These patients are mostly breadwinners of the family and are now confined within four walls because of their facial deformity. The #Right2face movement is aimed to help these needy patients in association with oral and maxillofacial surgeons to restore their faces and "give them back their smile".

According to the press release, "IIT Madras researchers are also identifying patients who cannot afford costly imported implants and giving these implants free of cost under the campaign called #Right2Face."

This campaign was started by a group of maxillofacial surgeons including Dr Balaji last year. This group began by working with dental colleges where maxillofacial surgeries were done. They started working with state-funded dental colleges in Chennai, Cuddalore, and other such colleges in Tamil Nadu and Telangana where they would find patients from economically weaker sections who needed these implants.

"IIT-Madras also came to help us with this initiative. We also worked with local nonprofits to raise some funds for these cases. It began with two or three cases and then IIT-Madras came in to help us with the implants. Before these procedures, we conduct one-on-one interviews with these patients, following which we obtain a letter from their doctors saying that they cannot afford these procedures and need help. After this letter, we check the ration card of the patient (if it's available) to check their credibility and then we proceed with the implants," says Dr Balaji.

"As a commercial entity, we have completed almost 450 implants. Under #Right2Face where patients could not afford these procedures, we have done 47 cases and in about 18 cases or so patients were able to shell out some money but not enough to cover the procedure. Medical colleges are also helping us in waiving costs for patients," he adds.

One such beneficiary of this initiative is a 63-year-old vegetable vendor from Coimbatore who wishes to remain anonymous. Living with a wife and four daughters, things were okay till the first lockdown. Making matters worse, he tested positive for COVID-19 and was infected by black fungus.

"After the lockdown, I was affected by black fungus because of which doctors had to remove my upper jaw. Wanting to resume work after the lockdown, I heard about facial reconstruction surgery and a doctor in Madurai who could perform it. When I reached Madurai, I approached Dr S Suraj (a maxillofacial surgeon) for help," he recalls.

Dr Suraj then referred his case to the Zoriox team, and both sides agreed on developing 3D-printed patient-specific face implants.

"It [the procedure] was expensive, and I couldn't afford it. But under this [#Right2Face] initiative, they supplied the implant to me [free of cost]. Dr Suraj did the surgery, placed the implant inside, and reconstructed my upper jaw, and I got my denture within one month. Now, I can eat properly and carry on with my everyday routine. I'd like to sincerely thank Dr Suraj, Zoriox, and IIT-Madras for helping me, " he adds.

Looking ahead, they are planning to help as many as patients who require these face implants.

"Official data shows at least 60,000 people are suffering from post-black fungus facial deformities. We are approaching various corporations for CSR (Corporate Social Responsibility) funding and reaching out to other funding bodies. So far, we could manage using the existing funding from IIT Madras and CSR in-kind contributions from the hospitals. However, through The Better India, we are reaching out to your readers to support us," says Dr Balaji.

(Edited by Padmashree Pande; Images courtesy IIT-Madras and Dr Karthik Balaji/LinkedIn)

(If you want to contribute to this initiative, please click here.)

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