H5N1

Fungal disease spiked during Covid pandemic and pathogens spreading due to climate crisis, WHO says

Via The Guardian: Fungal disease spiked during Covid pandemic and pathogens spreading due to climate crisis, WHO says. Excerpt:

Health-threatening fungi are spreading in geographic range due to climate change, while some fungal diseases spiked during the Covid-19 pandemic, according to authors of a newly released World Health Organization report. 

On Tuesday the WHO published its first ever list of fungal priority pathogens, cataloguing 19 organisms that experts identified as being of the greatest threat to public health.  

“Currently, fungal infections receive less than 1.5% of all infectious disease research funding,” the report found, suggesting the true health burden of fungi is unknown, while “most treatment guidelines are informed by limited evidence and expert opinion”.

The WHO’s assistant director general of antimicrobial resistance, Dr Hanan Balkhy, said in a statement: “Emerging from the shadows of the bacterial antimicrobial resistance pandemic, invasive fungal diseases are growing ever more resistant to treatments, becoming an ever more pressing public health concern worldwide.”  

Dr Justin Beardsley, of the University of Sydney Infectious Diseases Institute, who led a group commissioned by the WHO, said historical research underspending was out of step with the “huge burden of disease” of fungal infections.  

“They’re causing as many deaths as tuberculosis, and more than malaria,” he said.  

The report, which involved more than 400 mycology experts and a review of more than 6,000 research papers, ranked fungal pathogens based on public health impact and risk of resistance to antifungal drugs.  

Of the 19 fungi included, four were identified as being of “critical” priority. These included Aspergillus fumigatus and Candida albicans – the two most common fungal pathogens globally – as well as Cryptococcus neoformans, which is a leading cause of death in people with HIV.  

Aspergillus fumigatus mainly affects the lungs, while Candida albicans is the most common cause of thrush – and invasive infections in vulnerable patients have high mortality rates.  

Infection rates of both pathogens rose in many countries during the Covid-19 pandemic. “We suddenly had a bunch of patients who were getting really sick, coming in with lung damage, being in intensive care and having immune-suppressing medications, and so we saw a spike in the rates of these infections,” Beardsley said.  

“Aspergillus fumigatus has got its own disease state called Covid-associated pulmonary aspergillosis.”  

The fourth critical priority pathogen, Candida auris, grows as a yeast and was first discovered in humans in 2009.  

“It just didn’t exist before then,” Beardsley said.  

“It literally appeared all over the world at the same time, and we’re still trying to work out why and how.”

Outbreak of mucormycosis in coronavirus disease patients, Pune, India

Via Emerging Infectious Diseases: Outbreak of Mucormycosis in Coronavirus Disease Patients, Pune, India. The abstract:

We provide an overview of the epidemiology and clinical course of mucormycosis in the coronavirus disease (COVID-19) pandemic era. 

We conducted a retrospective chart review of 178 patients with clinical or diagnostic, endoscopically or histopathologically confirmed rhino-sino-orbital or cerebral mucormycosis after COVID-19 treatment during the second wave of COVID-19 in Pune, India. Median time to symptom onset from COVID-19 detection was 28 days. Moderate or severe COVID-19 was seen in 73% of patients and diabetes in 74.2%. A total of 52.8% received steroids. 

Eschar over or inside the nose was seen in 75%, but baseline clinical and laboratory parameters were mostly unremarkable. Bone penetration was present in ≈90% of cases, 30% had soft-tissue swelling of the pterygopalatine fossa and 7% had cavernous sinus thrombosis, and 60% had multifocal mucormycosis. Of the 178 study cases, 151 (85%) underwent surgical debridement. Twenty-six (15%) died, and 16 (62%) of those had multifocal mucormycosis.

Mucormycosis after COVID-19 in a patient with diabetes

Via The Lancet: Mucormycosis after COVID-19 in a patient with diabetes.

A 44-year-old man attended our hospital reporting reduced vision in his left eye. 10 days earlier he had been started on treatment with supplemental oxygen, intravenous antibiotics, and corticosteroids because of a moderately severe pneumonia caused by SARS-CoV-2. The patient explained that a blackish patch—extending from just below his left eye to the left side of his face to the level of his mouth—had also developed 2 days earlier. 

Credit: Chauhan et al.

The patient was a known diabetic; he had no history of malignancy. 

On examination his temperature was 37°C, pulse was 84 beats per min, blood pressure was 118/82 mm Hg, and respiratory rate was 16 breaths per min; pulse oximetry showed an oxygen saturation of 96% on room air. The patient had exophthalmos, ophthalmoplegia, and chemosis of his left eye. Best corrected visual acuity was 20/20 in his right eye, but he reported no perception of light in his left eye. 

Laboratory investigations showed a random blood sugar concentration of 298 mg/dL (normal 140 or below), glycated haemoglobin A1c of 9·8% (normal 4–5·6), arterial blood pH 7·4 (normal 7·35–7·45), serum bicarbonate concentration 24 mEq/L (normal 23–30), and a mild neutropenia (1510 neutrophils per μL; normal 1800–6300). 

Examination of a potassium hydroxide mount of nasal scrapings showed broad, pauci-septate hyphae; and Sabouraud dextrose agar culture and lactophenol cotton blue mount were suggestive of Rhizopus arrhizus. 

Contrast-enhanced MRI showed non-enhancement of the bilateral middle and inferior turbinate: the characteristic so-called black turbinate sign. Contiguous extension of non-enhancing soft tissue into the left middle and ethmoidal air cells, with a breach in the cribriform plate to involve the basal frontal region was noted (figure). T2-hyperintense diffuse inflammatory changes were seen in the soft tissues of the left orbital region—involving the pre-septal, post-septal, and intraconal and extraconal compartments with orbital fat stranding. Heterogeneously enhancing soft-tissue inflammatory changes were noted on the left side of the face involving the premaxillary region, buccal fat pad, and infra-temporal fossa. Together—the clinical picture and the radiological findings—indicated mucormycosis. 

The patient was started on intravenous liposomal amphotericin B at a dose of 5 mg/kg per day; an insulin infusion was also continued because of persistent hyperglycaemia. Extensive debridement, a left total maxillectomy, and orbital exenteration were done under a general anaesthetic; however, the patient died 6 days later. 

During the second wave of the COVID-19 pandemic in India, an unprecedented surge in cases of mucormycosis was observed: immune dysregulation caused by the SARS-CoV-2 and the use of broad-spectrum antibiotics and corticosteroids—particularly in patients with poorly controlled diabetes with ketoacidosis—is likely to have contributed to the rise. 

COVID-19 followed by mucormycosis carries a very high mortality rate and timely detection, antifungal therapy, and aggressive surgical debridement remain key factors in the management.

COVID-19 creates conditions for emergence of 'superfungus' in Brazil

Via medicalexpress.com, a FAPESP report: COVID-19 creates conditions for emergence of 'superfungus' in Brazil. Excerpt:

Fully occupied intensive care units (ICUs). Physically and mentally exhausted health workers. Chaotically overcrowded hospitals. These and similar problems posed by the COVID-19 pandemic in Brazil have created ideal conditions for the emergence of Candida auris, a microorganism some are calling a "superfungus" because of the speed with which it has developed drug resistance. 

The first two cases were confirmed in December 2020 at a hospital in Salvador (state of Bahia, Northeast Brazil), and are described in the Journal of Fungi by a group of researchers led by Arnaldo Colombo, head of the Special Mycology Laboratory at the Federal University of São Paulo (UNIFESP). The study was supported by São Paulo Research Foundation—FAPESP. 

"Nine other C. auris patients have since been diagnosed at the same hospital, some colonized [with the fungus in their organism but not doing harm] and others infected," Colombo told. "No other cases have been reported in Brazil, but there are grounds for concern. We're monitoring the evolutionary characteristics of C. auris isolates from patients at the hospital in Salvador, and we've already found samples with reduced sensitivity to fluconazole and echinocandins. The latter belong to the main class of drugs used to treat invasive candidiasis." 

Except for C. auris, fungi of the genus Candida are part of the human gut microbiota and cause problems only when there are imbalances in the organism, Colombo explained. These include infections such as vaginal yeast infection and thrush (oral candidiasis), often caused by C. albicans. 

In some cases, however, the fungus enters the bloodstream and causes a systemic infection known as candidemia, the most common form of invasive candidiasis, similar to bacterial sepsis. Invasion of the bloodstream and the immune system's exacerbated response to the pathogen can cause damage to several organs and even lead to death. According to scientific evidence, mortality among candidemia patients infected by C. auris can reach 60%. 

"The species quickly becomes resistant to multiple drugs and isn't very sensitive to the disinfectants used by hospitals and clinics," Colombo said. "As a result, it's able to persist in hospitals, where it colonizes health workers and ends up infecting patients with severe COVID-19 and other long-stay critical patients."

‘Black fungus’ is creating a whole other health emergency for Covid-stricken India

Via The Guardian: ‘Black fungus’ is creating a whole other health emergency for Covid-stricken India. Excerpt:

Covid-19 has killed millions around the world, but for some who are lucky enough to survive the infection, the nightmare is not over: adding insult to injury are deadly fungal infections that follow in the wake of the virus. Making matters worse, inequities that long predated the pandemic have left some countries without the capacity to combat these serious infections. 

In India, a fungal infection called mucormycosis has emerged in patients with Covid-19. This infection is caused by a group of fungi that are everywhere on the planet. In fact, all of us are probably inhaling spores of these fungi every day, but these are rapidly controlled by our immune systems. Rarely, our defences are breached, and the fungus takes hold, with devastating consequences. After establishing itself in the nose and sinuses, it begins to invade the tissue of the face, the jaw, the eyes and brain, blocking blood flow and causing tissue death. It is the black discoloration of dead tissue that conferred upon this mould its fearsome moniker in the Indian media: “the black fungus”.

Although the fungi are ubiquitous, mucormycosis is usually rare, and most specialists around the world will see fewer than a dozen cases in their entire careers. Even before the pandemic, rates of mucormycosis in India were estimated to be about 70 times higher than in the rest of the world. 

Even so, the tsunami of cases occurring in the wake of Covid-19 is of an unimaginable scale. More than 11,700 people were reported by a government minister to be receiving care for mucormycosis on 25 May. Two states, Maharashtra and Gujarat, have confirmed more than 5,500 cases. Whereas a large referral hospital in London might see three or four cases a year, some Indian hospitals are caring for more than 500 patients with mucormycosis right now. 

Mucormycosis cases in Covid-19 patients have also been linked to poorly controlled diabetes and therapeutic steroids, a triad of risk factors some have dubbed “the unholy trinity”. Although steroids can be lifesaving in Covid-19 patients needing supplemental oxygen, they are a double-edged sword: they weaken the immune system that normally keeps fungi we inhale at bay. 

Undisciplined prescribing is likely to be playing a major role in driving the epidemic: one study at 16 Indian hospitals found that nearly two in three steroid prescriptions for Covid-19 patients were inappropriate (they were either used in patients who weren’t sick enough to warrant them, or the dose was too high). Lack of access to oxygen may have resulted in doctors overcompensating by prescribing higher-than-recommended doses. 

Additionally, rates of diabetes have been increasing in India, and high blood sugars further weaken the immune system and increase the growth of fungi in the body. High blood sugars are also a well-known side-effect of steroids, particularly in diabetic or prediabetic patients, and overstretched healthcare workers have been unable to adequately monitor blood sugar levels of Covid-19 patients on crowded wards. 

The confluence of these risk factors, plus higher-than-average background rates of mucormycosis, high numbers of spores in both indoor and outdoor environments, and the lack of hospital infection-control resources (like efficient air particle filters in ICU rooms, standard in resource-rich settings to filter out airborne spores) have allowed the fungus to run amok.

Mucormycosis (Black Fungus) in COVID-19 patients—India—19 May 2021

EpiCore is a very interesting group of public-health professionals working as a a volunteer epidemic-intelligence group. It recently responded to a request for information on black fungus, and issued this report: Mucormycosis (Black Fungus) in COVID-19 patients—India—19 May 2021.

Media quoting clinicians in India have been reporting that mucormycosis, a rare fungal infection, has been recently identified in several COVID-19 patients in the country. The disease has been increasingly documented in these patients in different areas including Pimpri-Chinchwad (YCMH) and Mumbai (Sion Hospital). One of the hypotheses is that some drugs used for COVID-19 treatment could play a role by reducing immunity and push up blood sugar levels in diabetics and non-diabetic patients and represent a risk factor for mucormycosis. 

An RFI has been sent to EpiCore members to collect details that could support the assessment of the risk for this condition in COVID-19 patients. 

The EpiCore network has confirmed the occurrence of these cases in India, informing about similar cases documented in other cities, as New Delhi. The network has provided additional details, professional opinions and sources for further information. 

It has been commented that the general feeling is that in India steroids may be often misused for the treatment of COVID-19 as prescribers tend using them virtually in all patients even though recovery trials have showed benefits in only a small subset of them: it is thought that the increase in mucormycosis cases could be related to the drop in immunity in these patients following extensive use of steroids. 

EpiCore network has also informed that there is a report available online that includes contributions, professional comments and updates in terms of new cases from several clinicians from all around the country, in addition to valid and updated useful details for diagnosis, treatment and prognosis purposes. These experts noted that cases have not been noted during the first wave (when steroids were not used as much as today) and that there are other possible risk factors that should be considered. 

For more details, please refer to the source below (see link) that include comments from clinicians from several cities (Bengaluru, Bhagalpur, Chennai, Delhi, Goa, Hyderabad, Indore, Lucknow, Maharashtra, Raipur, Ranchi and Vadodara). 

It should be also mentioned that media are reporting that a link between the fungal infection and cow dung use is currently being explored. 

The RFI has been supported with information available online and related to comments from local clinicians about this event. 

More information: 

Post-COVID Tsunami of Mucormycosis (May 10, 2021) 

https://cmeindia.in/post-covid-tsunami-of-black-fungus-mucormycosis/ 

Example of media reporting a possible link to cow dung (May 17, 2021) 

https://www.india.com/health/cow-dung-increases-chances-of-black-fungus-in-diabetic-and-covid-patients-say-doctors-4669763/

Covid-induced black fungus cases on rise in Maharashtra, Gujarat: How deadly is it?

Via the Times of India: Covid-induced black fungus cases on rise in Maha, Gujarat: How deadly is it? Excerpt:

New Delhi: At least eight COVID-19 patients have lost vision in one eye due to mucormycosis, a rare and deadly fungal infection which has a mortality rate of over 50%.

The cases of mucormycosis, also known as black fungus, are on the rise in Maharashtra and Gujarat during the second wave of the pandemic.

Dr. Tatyarao Lahane, who heads the Directorate of Medical Education and Research (DMER), told PTI that cases of mucormycosis are on the rise and 200 patients are being treated in Maharashtra alone.

Here's all you need to know about this deadly infection...

What is mucormycosis?

It is a type of serious fungal infection that occurs most often in people with weakened immunity from an illness or chronic health condition.

Niti Aayog Member (Health) V K Paul had said that mucormycosis is caused by a fungus named mucor, which is found on wet surfaces.

Why are Covid survivors vulnerable to the infection?

In pre-Covid times, the ‘black fungus’ mucormycosis used to be rare and seen mainly in immunocompromised people. However, after the pandemic, three factors have led to an exponential rise — Covid itself, diabetes and abuse of steroids that lower immunity.

Dr Lahane said the fungal disease is already known but the cases are increasing because of Covid-19 related complications, wherein the use of steroids elevates the sugar level in blood while some medicines result in suppression of immunity of patients.

"In such a scenario, the black fungus infects the patient easily and spreads. If the fungus reaches the brain of the infected person, it can prove fatal. In one such case, one of the eyes of a patient had to be removed permanently to save his life," he said.

He said that Covid-19 patients with co-morbidities are also vulnerable and can catch the infection early.

What are the symptoms caused by the infection?

The infection typically starts growing from the nose, upper jaw and travels to the brain. Pain under the eyes, one-sided facial swelling, headache, fever, nasal or sinus congestion, black lesions on nasal bridge and partial vision loss are some of the common symptoms.

"Once it reaches the brain, it's almost a death sentence," a Mumbai-based doctor said.

Covid-induced black fungus cases reported in Delhi hospital

Via NDTV: Covid-Induced Black Fungus Cases Reported In Delhi Hospital. Excerpt:

New Delhi: Doctors at a leading private facility here are seeing a rise in the number of COVID-triggered mucormycisis cases, according to a statement from the hospital. 

Mucormycisis is a fungal infection triggered by COVID-19. Black fungus or mucormycosis has been a cause of disease and death of patients in transplants, ICUs and immunodeficient patients since long. 

According to Dr Manish Munjal, senior ENT surgeon at the Sir Ganga Ram Hospital, "We are seeing a rise again in this dangerous fungal infection triggered by COVID-19. In the last two days, we have admitted six cases of mucormycisis. Last year, this deadly infection caused a high mortality with many patients suffering from the loss of eyesight and the removal of the nose and the jaw bone." 

Dr Ajay Swaroop, the chairman of the ENT department at the hospital, said the use of steroids in the treatment of COVID-19 coupled with the fact that many coronavirus patients have diabetes could be one of the reasons for this rise in the number of black fungus cases again.

Two babies die after contracting infection at Glasgow hospital

Via The Guardian: Two babies die after contracting infection at Glasgow hospital. Excerpt:

Two premature babies have died after contracting a bloodstream infection at a Glasgow hospital, the third infection-control crisis to hit the city’s health service within two weeks.  

NHS Greater Glasgow and Clyde confirmed on Wednesday night that it was investigating three cases in the neonatal unit at the Princess Royal maternity hospital. It said the infection was “one of a number of contributing causes” in the deaths of two “extremely premature” babies, and that a third had required treatment and was in a stable condition. 

On Tuesday Scottish prosecutors confirmed they were investigating the deaths of two patients, a 10-year-old boy and a 73-year-old woman, who contracted an infection connected to pigeon droppings at Queen Elizabeth university hospital in Glasgow. Another patient at that hospital remains seriously ill after contracting a separate fungal infection called mucor.

Dr Barbara Weinhardt, an infection control doctor, said a number of measures had been taken at the Queen Elizabeth university hospital, including a deep clean, isolation and barrier nursing, safety briefings to all staff and infection control advice to all visitors.  

She said: “Our thoughts are with the families affected. Results have confirmed that the three cases of Staphylococcus aureus are linked and our investigations continue into how they are linked.”

Two dead after pigeon droppings infection at Glasgow hospital

Via The Guardian: Two dead after pigeon droppings infection at Glasgow hospital. Excerpt:

Two patients have died at a hospital after contracting a fungal infection linked to pigeon droppings. 

The individuals are thought have caught the airborne disease at the Queen Elizabeth University hospital in Glasgow after inhaling the fungus cryptococcus, typically found in soil and pigeon droppings. 

NHS Greater Glasgow and Clyde (NHSGGC), which runs the hospital, has launched an investigation into the outbreak. It said the likely source of the pigeon droppings was a non-public room, thought to contain machinery, which has now been cleaned. 

NHSGGC said “control measures” had been introduced, which is understood to mean equipment to filter the air in some parts of the hospital, and that some patients, including children, who may be vulnerable to the disease have received medication, which was proving effective.  

The health board said that the second patient who died was elderly and the death was due to an unrelated matter. It said it could not share further details of the case because of patient confidentiality. 

Teresa Inkster, NHSGGC lead consultant for infection control, said: “Cryptococcus lives in the environment throughout the world. It rarely causes infection in humans. People can become infected with it after breathing in the microscopic fungi, although most people who are exposed to it never get sick from it.”  

She said there had been no further cases since control measures were put in place. “We are continuing to monitor the air quality and these results are being analysed. It remains our priority to ensure a safe environment for patients and staff,” she added.