Disease A-Z – NICD

Mucormycosis Frequently Asked Questions

Koketso Matjane — Fri, 14 May 2021 11:22:39 +0000

What is mucormycosis or “black fungus”?

Mucormycosis is a rare but life-threatening opportunistic infection. This infection has been referred to as “black fungus” in media reports in 2021. Mucormycosis is caused by a group of fungi or moulds within the fungal Order Mucorales – the first part of the name of the infection “mucor-mycosis” is derived from the name of this group of fungi “Mucor-ales”. A fungus called Rhizopus within the Order Mucorales is the most common cause of mucormycosis. Mucormycosis most often affects the sinuses, eyes, brain and lungs and is a rapidly progressive disease. Depending on which body system is infected, between 30% to 100% of people will die, and survivors may have debilitating complications such as vision loss.

Who can get mucormycosis? Is COVID-19 a risk factor?

Mucormycosis mainly affects people with conditions that weaken the immune system. People with uncontrolled diabetes mellitus, those with lower than normal levels of white blood cells (neutropenia), those with cancers of the blood or bone marrow, those who undergo organ transplantation and those with traumatic injuries have a higher risk of developing mucormycosis.

Children with severe malnutrition can also develop a form of the disease affecting the gut. Medicines that weaken the immune system such as chemotherapy and corticosteroid therapy also increases risk of this disease. Corticosteroids are recommended for treatment of people with severe COVID-19 in hospital. In addition, diabetes mellitus predisposes patients to developing severe COVID-19 disease. As a result, patients with severe COVID-19 may have multiple risk factors for developing mucormycosis. During the COVID-19 pandemic, more than the usual number of people in some parts of the world (mainly India) have been diagnosed with mucormycosis due to a high prevalence of uncontrolled diabetes mellitus and severe COVID-19 infections.

How common is mucormycosis in South Africa?

Mucormycosis is fairly rare and is estimated to occur in 2 people per every million people in the world. Only about 100 people are estimated to be diagnosed with mucormycosis every year in South Africa. The number of cases has not increased despite the large HIV epidemic in South Africa. This may be because the immune (CD4) white blood cells which are depleted in patients living with HIV do not play a major role in fighting mucormycosis. However, people with advanced HIV disease (AIDS) may also have other immune system problems (for example, low levels of neutrophil white blood cells, poorly functioning white blood cells) or may need treatment with corticosteroids for other infections. A diagnosis of both COVID-19 and advanced HIV disease, similar to COVID-19 and diabetes, may possibly increase the risk of mucormycosis though this has not been established.

How is mucormycosis acquired?

The fungi that cause mucormycosis are found in decomposing material in the environment such as in spoilt food and soil. Construction sites may be a source of fungal spores due to disruption and dispersal of the spores in soil. People can get infected from breathing in fungal particles (spores) in the air – these lodge in the nasal passages, sinuses and lungs – and among people with very weak immune systems, the fungal spores transform into tubes called fungal hyphae which invade into tissue, blocking blood vessels and causing the surrounding tissues to die. People with open wounds from injuries may be infected directly from exposure to soil that contains the fungal spores. Some individuals who undergo surgery and other hospital procedures have acquired mucormycosis from contaminated medical equipment such as intravenous lines, adhesive bandages and the air in hospitals.

What are the signs and symptoms of mucormycosis?

Mucormycosis can affect several different parts of the body. The sinuses, nasal passages, eyes and brain (rhinocerebral mucormycosis) are most commonly affected, causing a one-sided headache, nasal or sinus congestion, facial swelling and toothache, as well as fever. As the disease progresses, visual disturbances and black spots on the bridge of the nose or inside the mouth may occur. The presence of blackened areas (caused by dead tissue) is the reason why the media has referred to this as “black fungus”. The lungs (pulmonary mucormycosis) can also be affected leading to cough, fever, difficulty breathing, chest pain and coughing up of blood. Less commonly, the gastrointestinal tract (abdominal pain, nausea and vomiting) and skin (blisters or ulcers which blacken over time) can be affected. Some patients with severe COVID-19 may develop symptoms of the rhinocerebral form of mucormycosis approximately a week or two after they have been discharged from hospital.

How is mucormycosis diagnosed?

A tissue sample is essential for diagnosis of mucormycosis. A sample can be collected by doing a procedure called a tissue biopsy or a bronchoalveolar lavage (lung fluid collection in the case of pulmonary mucormycosis). Tissue can also be collected at emergency surgery. Samples are processed immediately because mucormycosis is a medical emergency. Frozen tissue sections can be examined in the operating theatre and samples are also sent to the microbiology and histopathology laboratories for urgent microscopic examination. Fungal culture is often performed but these results are only available after a day or two. Radiological imaging, such as CT and MRI scans, may be useful for visualising areas of suspected mucormycosis, but will not provide a definitive diagnosis.

How is mucormycosis treated?

Mucormycosis is urgently treated with an antifungal medicine called amphotericin B and immediate surgical intervention involving the removal of any necrotic or dead tissue from the infected areas. It is also important to treat the underlying condition, e.g. poorly controlled diabetes mellitus, and taper drugs, such as corticosteroids, which may have weakened the immune system and contributed to the development of mucormycosis.

Where can I find more information?

Medical/clinical related queries: NICD Hotline +27 82 883 9920 (for use by healthcare professionals only).

Results and laboratory inquiries: NICD Specimen Receiving Laboratory: +27 11 386 6404.

Guideline document: https://life-slides-and-videos.s3.eu-west-2.amazonaws.com/LIFE+guidelines/Cornley-mucor-guidelines.pdf

INFLUENZA FREQUENTLY ASKED QUESTIONS

Koketso Matjane — Wed, 12 May 2021 13:46:58 +0000

What is influenza?

Influenza, also known as “flu” is an acute respiratory illness caused by an infection of the respiratory tract with the influenza virus. There are two types of influenza viruses that commonly infect humans namely A and B. The flu viruses are typically in circulation before the winter months in South Africa with an average start of the flu season in the first week of June, although this varies.

Are there different types of influenza?

The influenza virus has two main types in humans: A and B. Influenza A is classified into different subtypes influenza A(H1N1)pdm09 and A(H3N2). Influenza A(H1N1)pdm09, which has colloquially been called “swine flu”, is the human influenza strain that emerged globally in 2009. This strain behaves like any other strain of seasonal influenza and infected patients should be treated like any other seasonal influenza case. There are no specific public health interventions required for patients or contacts of patients infected with influenza A (H1N1)pdm09. The term “swine flu” should not be used, because this term refers to influenza in pigs.

How is influenza transmitted?

The virus is spread from person to person. It can be passed from infected people to other people through inhalation of infected respiratory droplets from sneezing, coughing or talking. A person can also be infected by touching contaminated objects or surfaces that the flu virus is on and then touching their mouth, eyes or nose. People who are infected with influenza can prevent spread by doing the following:

Covering their mouth when coughing with a tissue or cough into the elbow
Wearing a cloth mask
Washing their hands frequently with soap and water or cleaning hands using an alcohol-based sanitiser
Staying at home and trying to keep a distance from others

What are the signs and symptoms of influenza in humans?

The most common symptoms in infected patients are sudden onset of fever, muscle pains and body aches, dry cough, sore throat, runny nose, feeling tired or unwell and headache. The symptoms develop anywhere from 1 to 4 days after infection and last for 2 to 7 days. For the majority of people, the symptoms commonly resolve without treatment. Complicated influenza infections can cause serious illness and in some cases death. Severely ill patients with influenza should be admitted to the hospital. The commonest complication of influenza is pneumonia.

Who is at most risk for influenza?

Influenza infection resulting in mild illness is most common in children of school-going age between 5 and 15 years. Influenza can also cause severe illness and the following groups of people are at the highest risk of severe illness: children aged <5 years, adults aged 65 years or older, pregnant women, those who are obese (BMI ≥40) and those with chronic health conditions such as chronic heart disease, chronic lung disease (e.g. TB), kidney, liver, blood or metabolic diseases (e.g. diabetes), or weakened immune systems (e.g. HIV infection).

How is influenza diagnosed?

Influenza is normally a clinical diagnosis and not all patients require testing for diagnosis. Testing for diagnosis can be done to assist in the treatment and when there are a higher number of cases than expected to identify outbreaks. When testing is needed respiratory samples can be collected and these include nasopharyngeal or nasal swab, nasal wash or aspirate, throat swab and sputum.

How is influenza treated?

The majority of infected people will only need bed rest, adequate fluid intake and paracetamol to help with the fever or aches. The more severe cases may need antiviral drugs for influenza that can only be prescribed by a medical doctor. The drugs are ideally administered early (within 48 hours of the onset of symptoms) in the disease. Antiviral treatment may also be used for people at risk of severe influenza early in the infection. People at risk for severe influenza illness or complications should consult their doctor early in the illness.

How can influenza be prevented?

Influenza vaccination is the best way to prevent influenza infection. The influenza virus is constantly changing and vaccination for influenza has to be re-done every year. The vaccine is an inactivated virus that is not harmful and cannot cause flu infection. It only offers protection 2-3 weeks after administration. So ideally the flu vaccine should be done early (March/April each year) before the Flu season so that it has sufficient time to protect a person. However, it is never too late to vaccinate.

In 2021 with the circulation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) the virus that causes Coronavirus Disease 2019 (COVID-19) we recommend the influenza vaccine as it is likely that the 2 viruses will be circulating at the same time and the flu vaccine may help to decrease the burden on our healthcare system.

Groups recommended to receive influenza vaccination in 2021 include:

Healthcare workers
Persons aged ≥ 65 years
Persons with underlying chronic health conditions
HIV–infected adults
Pregnant women at any stage of pregnancy, or postpartum
Residents of old-age homes, chronic care and rehabilitation institutions
Persons aged 6 months to ≤18 years on long-term aspirin therapy
Children aged 6 months to 5 years and their household contacts or caregivers
Any persons wishing to minimise the risk of influenza acquisition.

What is the difference between the flu and COVID-19?

While influenza and COVID-19 are both contagious respiratory illnesses caused by viruses, the viruses that cause them are not the same. COVID-19 is caused by infection with a new coronavirus (called SARS-CoV-2), and flu is caused by infection with influenza viruses. Both viruses can cause mild to severe illness and present with similar symptoms including fever, cough, sore throat, shortness of breath, runny or blocked nose, muscle pains/body aches and fatigue. COVID-19, on the other hand, seems to spread more easily than flu and can result in a more serious illness in certain people. Other signs and symptoms of COVID-19, different from flu, may include a change in or loss of taste or smell. COVID-19 infected people can also take longer to show symptoms, and they can be contagious for longer periods. Since some flu and COVID-19 symptoms are similar, it may be difficult to differentiate between them based on symptoms alone, and laboratory testing may be needed to confirm a diagnosis.

Can I get flu and COVID-19 at the same time?

Yes, it is possible to have both the flu and COVID-19 at the same time if both viruses are circulating in the community. If you suspect that you have either of the diseases, it is recommended that you go to your doctor or clinic for further assessment.

Do I have to take the influenza vaccine if I have the SARS-CoV-2 vaccine or vice versa?

Yes. The influenza vaccine will protect you against influenza and the SARS-CoV-2 vaccine will protect you against COVID-19. A minimum of 14-days waiting period between the 2 vaccines is recommended.

Where can I find out more information

Guidelines and other useful resources are available on the NICD website.

Additional information on influenza is available on the following website references:

For the public:

U.S. Centers for Disease Control and Prevention (CDC):

World Health Organization Fact sheet on Influenza disease:

For healthcare workers:

Contact the NICD hotline (+27 82 883 9920) after hours and in emergency situations
NICD recommendations for the diagnosis, management, prevention and public health response are available here.