The crushing second wave of Covid-19 in mid-2021 saw a sudden spurt in the dreaded mucormycosis, colloquially known as black fungus. India had reported more than 47,000 cases of mucormycosis in five months (May to September 2021), though the actual figures are likely to be much higher. The number of deaths due to black fungus, according to available statistics, stands at 3,129 and the majority of the cases were reported from the states of Maharashtra, Gujarat, Andhra Pradesh, Rajasthan and Karnataka.
Though considered to be a relatively rare fungal infection, its presence has long been detected in patients with a debilitated immune system such as those with uncontrolled diabetes, cancer patients on chemotherapy, etc. It is telling that despite the second wave being a global phenomenon, black fungus, which ravaged our communities, was found only in India. The prevalence of the Delta variant virus in uncontrolled diabetic patients who were put on a high dose of steroids and antibiotics to improve lung function and also to prevent hospitalisation (as beds were scarce and craving for oxygen was at its peak) were some of the factors that completely weakened the patients’ immune system. What ensued later was mucormycosis affecting the head and neck areas and in some cases, destroying them completely. In many patients, during the height of the wave, the infection had spread aggressively into the brain and thus had turned lethal. In most of them, the fungus was found to affect the upper jaw (maxilla) where initially, the patients complained of most of their teeth becoming loose in a span of a few weeks and subsequently their entire upper jaw got detached from the skull. This occurs because the blood supply to the bone of the upper jaw is cut off due to the fungus as a result of which, the bone dies and separates from the skull.
What is the treatment?
Ideally, a multi-disciplinary team is required to manage the damaging effect of mucormycosis. This includes an oral maxillofacial surgeon, otolaryngologist, ophthalmologist, neurosurgeon and physician.
Once the diagnosis is confirmed, a surgical debridement (removal of the dead bone or damaged tissue) of the infected area must be performed as soon as possible, or else there is a risk of the fungus spreading further to the head and neck region. When black fungus affects the upper jaw, the affected bone is resected along with the entire dental apparatus and this is followed by weeks of anti-fungal therapy. The real problem starts after the surgery as patients are unable to swallow, chew well, or speak with finesse as their upper jaw is missing and often, whatever they eat/drink gets regurgitated through the nose. Precisely why it is crucial for patients to approach trained surgeons who are specialists in handling these post-operative issues. For simple defects, an obturator with teeth made of acrylic would suffice; this seals the defects inside the oral cavity and helps the patients feed and speak well. For complex defects, rehabilitation with zygomatic implants or Patient-Specific Implants (PSI) using 3D printed models is ideal. Reconstructions may also involve using a bone from the leg (fibula) and reshaping it as a jaw. This can be done with absolute accuracy, thereby restoring the jaw to its complete form. These surgeries come as a relief to black fungus patients whose morale is often severely depleted and who go through phases of depression with many developing suicidal tendencies.
Need of the hour
Facial reconstruction, zygomatic implants and PSI are all expensive treatments and hence there are many patients out there suffering simply because they cannot afford the surgery/implants. The need of the hour is to provide insurance facilities for these treatment modalities so that more patients can opt for these high-end surgeries.
(The author is a consultant oral maxillofacial surgeon, oral oncologist and implantologist.)
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