What Is Black Fungus and Why Is It Surging in India?

As India faces a rising death toll from a second COVID wave, the country is also experiencing an increase in a fungal infection called mucormycosis, or "black fungus." According to the BBC, India has reported over 8,800 black fungus cases, and the Indian government recently declared black fungus an epidemic.

What Is Black Fungus?

Mucormycosis, also called black fungus, is a fungal infection that is caused by exposure to mold that lives in soil. It’s common to come into contact with these fungal spores because it’s found in dust, dirt, and rotting leaves.

You have a high chance of coming into contact with the fungus, but your chances of developing an infection are low if you have a strong immune system.

The Centers for Disease Control and Prevention (CDC) says the United States has about 1.7 black fungus cases per million; however, the number can vary because there is no national surveillance for tracking fungal infections.

Common symptoms for black fungus include:

• Inflammation
• Redness
• Swelling
• Foul smell
• Double vision
• Severe headaches
• Fever

People with facial mucormycosis typically develop swelling around the face or lip area, which can look like:

• Fever ulcerations
• Nose swelling
• Edema
• Redness around the nose and eyes
• Symptoms of severe sinusitis

People with symptoms of an infection with black fungus will need to see their healthcare provider as soon as possible. They usually need to have a biopsy or CT scan to determine if a black fungal infection is present.

Who Is Most At Risk for Black Fungus Infection?

Nitin Desai, MD, CEO and CMO of COVID PreCheck, says the risk for black fungus infection is higher in people who are immunocompromised or who have open wounds.

Desai tells Verywell about an outbreak of mucormycosis during the 2011 tornado in Joplin, Missouri. “After the tornado, dirt and soil were all turned upside down, and people had cuts and bruises on them," recalls Desai. "People were found with mucormycosis after the tornado because people had lacerations and wounds here and there.”

Organ Transplant Recipients

Desai says that one reason people who have had an organ transplant are at risk for black fungus is that they usually need to be on steroid medication for life, putting them in a constant state of suppressed immunity.

“People with stem cell transplant, kidney transplant, or liver transplant are on immunocompromised medication to prevent the rejection of the organ," says Desai. "So, they're prone [to infection]"

The CDC reported that mucormycosis was the third most frequent fungal infection in people with stem cell transplants and made up 2% of invasive fungal diseases observed in people with solid organ transplants.

People Using IV Drugs

Drug use is also linked to black fungus infection. “IV drug users are prone to mucormycosis parties because they can be immunocompromised and are injecting dirty needles that then inject the fungus into them," says Desai.

People Who Are Malnourished

Malnourishment can affect how well the immune system responds to infections In fact, Desai says that malnourishment is a growing problem in poorer sectors of India and could be one of the many contributing factors to rising black fungus infections.

Is Black Fungus Deadly?

The CDC reports a 54% mortality rate for black fungus infection, though the number fluctuates based on the site of infection, any underlying health conditions a person has, and the type of fungus.

“A typical mortality rate with rhino orbital cerebral mucormycosis is anywhere from 25% to 60%," says Desai. "If you have pulmonary mucormycosis, which I do not see a lot of reports in India, but if you have COPD, chronic asthma, or another lung condition, then you can develop the same fungus mucormycosis pulmonary variant with a mortality rate as high as 87%."

Complications and Treatment

The good news is black fungus infection is treatable—but only if it's diagnosed in time. Desai says that a lot of patients have infections in their sinuses or around their nose, but that "the problem happens when the blood drains from those areas, they go into the brain because they're just right there."

If mucormycosis invades the frontal lobe of the brain, it can cause symptoms of psychosis and disorganized speech. The infection also destroys tissue, erodes bone, and produces inflammation.

Debridment and Antibiotics

Treating mucormycosis can be complicated. When the fungal infection has taken hold, surgeons have to remove dead or infected brain tissue surgically. “The treatment is very drastic," says Desai. "Doctors will have to debride you and clean out every tissue inch by inch around the mucormycosis and get rid of all the dead tissue.”

Desai says that one of his colleagues who is an ear, nose, and throat (ENT) surgeon in India is performing endoscopic procedures to treat infections that have spread to the brain.

“They are putting an endoscope in the nose to enter the sinuses, which sit in the cavities in the skull bone," says Desai. "They basically dig out and take all the necrotic bone tissue, clean out the brain, and then flush it with antifungals.”

After debridement, patients usually receive intravenous amphotericin B, which comes with serious side effects that last for weeks.

“This is a bad situation if you have either pulmonary or rhino orbital cerebral mucormycosis," says Desai. Not only is the treatment drastic, but it also carries a high mortality risk. Even if a person survives the initial treatment, Desai says that "there's a lot of operative intervention with repeat debridement to remove necrotic tissue," and a person "may end up on an IV antifungal medication for weeks.”

Lasting Neurological Symptoms

For some patients, the neurological complications of a black fungus infection can lead to long-term health complications, such as vision problems. Desai says that this can happen because some of the muscles or nerves (like the optic nerve ) that are involved in eye movement can be affected by inflammation in the muscles nearby.

Desai says that when those neuromuscular tissues are damaged, it can lead to "a series of health issues, including double vision, squinted eyes, droopy eyelids, headaches, and a foul smell.”

Plus, surgical debridement to remove the dead tissue may cause irritation and permanent (though accidental) brain damage.

India’s Second Wave of COVID and Rising Black Fungus Infections

The COVID-19 pandemic has left many people around the world with weakened immune systems—the ideal conditions for the black fungus looking for a new host. India is currently at the center of that perfect storm.

According to the World Health Organization, India has reported over 27 million cases with more than 300,000 deaths as of May 26. However, Desai says that since census statistics tend not to be up to date, the numbers are probably much higher.

“You only know what you measure, and India is not measuring the entire population," says Desai. "In some rural areas or poor communities where hospital facilities and access are limited, they might not be able to diagnose cases. So, the reporting of data in India is unfortunately skewed because you are not catching everything.”

The Links Between COVID and Black Fungus

According to Desai, there is no direct scientific evidence that the SARS-CoV-2 virus itself is causing black fungus infections. It's more likely that the black fungus cases in India are connected to two main factors:

• The overuse of steroids such as dexamethasone to treat COVID-19 symptoms.
• Widespread infection in people who are already immunosuppressed, including people with diabetes (particularly uncontrolled diabetes).

Diabetes

According to Desai, India has been dealing with a diabetic epidemic for at least two decades—about 40% of the population in India has diabetes.

“People are walking around with uncontrolled diabetes, and then steroids are given to them, making diabetes worse, [and] which makes them more immunocompromised," says Desai. "So, you have a double whammy, you have uncontrolled diabetics thrown on steroids or other immunosuppressants.”

A recent study published in “Diabetes & Metabolic Syndrome: Clinical Research & Reviews” found that 80% of black fungus cases involved patients with diabetes. About 76.3% of cases occurred in patients who were given steroids to treat COVID-19.

Steroid Use

Steroid treatments have become a mainstay of COVID-19 treatment because of the prolonged inflammation and cytokine storm the virus induces in the body. There are specific indications for using steroids, but Desai says that the surge of COVID-19 cases has led to the overprescribing of steroids and other immunosuppressants without proper supervision.

“In India, the first reaction of general practitioners and regular doctors for COVID positive patients is to throw them on steroids," says Desai. "The practicing pattern is to give them anything and everything they can.”

Will COVID Vaccines Help?

Being fully vaccinated with one of the approved COVID-19 vaccines can make you less likely to get black fungus because you’re less likely to get severely sick from COVID. Avoiding the virus means that you won't need to receive steroid treatment or immunosuppressive therapy—both of which put you in an immunocompromised state, as would getting sick with COVID in the first place.

Desai says that because social distancing and face mask-wearing are not always popular or feasible, given India's crowded communities and population size, the country will have to rely heavily on immunization for controlling cases of COVID and black fungus infections.

According to vaccine data reported by the New York Times, about 3.1% of India’s population is currently fully vaccinated.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.