Black, white and yellow fungus, a major challenge for health workers: AIIMS doc tells The Probe

After thousands of black fungus cases were reported across India, several white and yellow fungus infections have now emerged among Covid-19 recovered patients. The Probe’s Editor in Chief Prema Sridevi spoke to Prof Dr Kaushal Verma - associated with the Department of Dermatology and Venereology at AIIMS - on the challenges faced due to the sudden spurt of white and yellow fungus in Covid-19 patients.

Prema Sridevi: Since the last couple of days we have been speaking about how mucormycosis or black fungus has been wreaking havoc in the country. Several patients have been falling sick and there is also a dearth of the life saving drug Amphotericin-B. Just when the authorities have been trying to deal with this issue, we are now hearing cases related to white fungus. What exactly is white fungus? How is it different from black fungus?

Dr Kaushal Verma: Let us first talk about black fungus. Black fungus is not actually black. When the infection occurs, the skin turns dusky and it appears blackish when you look at it from the surface and it generally starts from the nasal cavity. People feel stuffiness in the nose; there may be some bloody discharge; they can have headache; they can have blurred vision and dizziness depending on where the fungus has reached. Black fungus is common in people who have been immune-suppressed. There are 3 major areas to be considered here: 1. Diabetes: India is called the diabetes capital of the world. Many people in India don’t even know that they have diabetes. 2. Covid-19: this causes immune suppression 3. Corticosteroids - those steroids used for the treatment of Covid-19. All these 3 factors have contributed to the increase in the number of black fungus cases. It’s not something that otherwise occurs in healthy individuals.

White fungus, on the other hand, is medically or technically called “candida”. We have this in the GI tract, oral cavity or the anal mucosa. It is also known as Aspergillosis.
White fungus - when the immune system becomes compromised then it becomes a pathogen and it manifests as a disease. Generally, it starts in the oral cavity as an oral thrush where there is a white deposit on the surface of the tongue. Sometimes it also occurs on the cheeks. Subsequently, if the person is severely immune-compromised then the infection can go to the food pipe and then it can even trickle down to the lungs or the intestines. So, the internal organ system which comes in contact with the external environment like the mouth, nose or genitals can get infected.

Prema Sridevi: We have seen several reports that say that white fungus is more dangerous than black fungus. Is it true?

Dr Kaushal Verma: Both black fungus and white fungus are dangerous in immune-compromised people. It is the immune suppression that makes the fungus dangerous. If you look at the treatment for both, I would say, mucormycosis or black fungus is more difficult to treat when compared to white fungus because when it comes to candida, there are more effective drugs that are available for treatment. In the case of black fungus, you need injectable drugs like Amphotericin-B, Posaconazole etc. White fungus can still be treated with conventional medicines but having said that in some cases of white fungus, you may still need to treat it with Amphotericin-B. If you protect yourself from Covid-19, if you don’t have diabetes and if you have a healthy lifestyle, you will not get any of these infections.

Prema Sridevi: Why are Covid-19 recovered patients more susceptible to white fungus infections?

Dr Kaushal Verma: That is because their immune system is compromised due to Covid-19. If some others have diabetes and it is aggravated because of Covid, then again there is further aggravation of diabetes because of the use of corticosteroids.

Prema Sridevi: What are the major symptoms of white fungus?

Dr Kaushal Verma: Patients complain of burning, irritation in the oral cavity, difficulty in swallowing and this is also associated with white deposits. In the genital area, some patients face irritation, itching and other associated symptoms. Some patients may also have difficulty in passing stools.

Prema Sridevi: Have you been treating a lot of patients with white fungus in recent times? Are these Covid-19 recovered patients?

Dr Kaushal Verma: Yes, I have been treating many such patients. These are mostly Covid-19 recovered patients who have recently been to hospitals or who have been treated for Covid-19 infections.

Prema Sridevi: Black fungus, we are told, is a race against time. Early detection and early treatment can only save patients. Is time also a very significant factor when it comes to white fungus?

Dr Kaushal Verma: Time is of utmost significance. The problem is not the fungus really. The problem is the immune suppression. So, if the immune system is compromised, if the suppression is more, the chances of getting the infection is more. Then the treatment will be longer and more difficult. Therefore, early detection is important. As soon as you feel the symptoms, you must consult a doctor and your treatment must immediately start and the treatment must be continued for as long as it is needed. Please do not discontinue the treatment unless you are specifically told to discontinue by your doctor.

Prema Sridevi: What are the causes for white fungus disease and what precautions need to be taken to protect oneself from white fungus?

Dr Kaushal Verma: The best action required here is to adopt Covid appropriate behaviour and prevent Covid-19. Wear masks, maintain social distancing, wash your hands at regular intervals, stay indoors etc. The second thing that needs to be kept in mind is, if you have diabetes, you need to control it and the third is maintain a healthy lifestyle. If you take care of these three things, you can easily prevent these infections.

Prema Sridevi: What is the line of treatment for white fungus and how affordable are these medicines for poor patients? For instance, in the case of black fungus Amphotericin-B is used for treatment but a single vial of this drug costs 7000 rupees and a patient needs at least 7 vials every day for 15 to 30 days depending on the severity of the disease. By the time the patient exits from a hospital, he or she would have spent at least 15 to 20 lakh rupees. Having said that, if you use an alternate medicine, it has a negative impact on the kidneys. What are the affordable alternatives for the poor when it comes to treatment of white fungus?

Dr Kaushal Verma: White fungus is relatively easier to treat when compared to black fungus. Only in some patients, we need to administer Amphotericin-B. Early detection, early intervention and early treatment is the key to the management of this disease.

Prema Sridevi: What about yellow fungus? We are now hearing about yellow fungus infections in Covid-19 recovered patients. How is this different from black and white fungus?

Dr Kaushal Verma: All these infections including yellow fungus are occurring in immunocompromised people. The line of the management is more or less the same because they belong to the same class of organisms or the same class of pathogens.

Prema Sridevi: What are the major challenges faced by health professionals like you when it comes to treatment of patients suffering from black, white and yellow fungus?

Dr Kaushal Verma: The treatment or the management is the biggest challenge. We call it a challenge because the patient's immune system is not adequately geared to combat these infections. These medicines are not very effective and it also takes a long time to take effect in the human body.

Prema Sridevi: Earlier, we were told that mucormycosis is a rare disease. Initially, we only saw a handful of cases but now there are thousands of cases across the country. In the days to come, what do you think, is there going to be a surge or you think there will be a downward trend when it comes to these fungal infections in Covid-19 or Covid recovered patients.

Dr Kaushal Verma: I think, since the number of cases are now on a steady decline and because the hospital admissions are also declining, the numbers of these infections will also come down. It totally depends on the numbers of Covid-19 patients. Once the number of patients, hospitalisations and ICU admissions reduces then the occurrence of these infections will also simultaneously reduce. We are hoping that things will get better in the future.