Mucormycosis: As India struggles with Black Fungus, doctors say Methylene Blue can be a solution, demand detailed study on priority

Mold-tainted humidifier and oxygen piper are also to blame for cases of Black Fungus. (Photo Source: PTI)

Black Fungus: As India is in the middle of the second coronavirus wave, it is facing another challenge in the form of mucormycosis, commonly referred to as Black Fungus. The cases of mucormycosis in Covid-19 positive patients are on the rise and some states and Union Territories have already declared it an epidemic. There were cases of black during the first wave too, but experts believe that the rise in the number of Black Fungus cases this time is mainly because of unrestricted use of steroids during treatment, large population with poorly controlled diabetes, and use of industrial oxygen or oxygen concentrators in an unhygienic way in large number.

What Led To Sudden Rise In Cases of Mucormycosis Or Black Fungus?

The exponential surge in the number of coronavirus infections this year led to demand for medical oxygen far beyond the supply. Because of this, many people had to use industrial oxygen or oxygen concentrators.

According to Dr Ajay Mohan Agarwal – a senior physician with around three decades of experience – the sudden surge in black fungus cases seems to be because of the widespread use of industrial oxygen and humidifiers. He said that those under oxygen therapy in the intensive care unit (ICU) are more prone to Black Fungus infection.

Dr Agarwal said that sources of mucormycosis, commonly known as Black Fungus, are very widely available in our environment. “But they are saprophytes and humans usually never had any danger from them, except when the immunity of a person is very low for whatever reasons. For example, when a patient is on steroids, has uncontrolled diabetes or some pathological conditions; it weakens the immune system. In these cases, mucormycosis can attack our body as an opportunistic infection.”

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“After the sudden crisis of medical oxygen, most patients had no option but to use industrial oxygen. Industrial oxygen is not the purest form and this might have caused a sudden spike in cases of Black Fungus. Secondly, most of the time we have found that instead of using distilled water, people are using tap water in the flow meters of the oxygen cylinders and oxygen concentrators, and therefore this fungus manages to reach inside our body through the contaminated water. Mold-tainted humidifier and oxygen piper are also to blame,” the doctor said.

What is Methylene Blue?

Methylene Blue (MB) has been used as an antiseptic to heal wounds for ages. Methylene Blue was initially used as an antimalarial drug and it has anti-fungal activity as it has the mechanism of redox reduction in mitochondria.

For the uninitiated, Methylene Blue was prescribed to Covid patients in sub-lingual and nebulized forms during the first wave by some doctors. Given its low cost, it was also thought to be a viable regime for developing countries like India in the treatment of symptomatic patients and as a prophylactic drug for the vulnerable population.

According to Dr Wasim Ghori -Mumbai- based Consultant Physician & Diabetologist and Fellow – Royal Society of Public Health, UK – Methylene Blue is used to treat methemoglobinemia, a condition in which the blood loses its ability to carry oxygen through the body.

“MB is fast-acting, has a strong anti-fibrotic action, and is considered an approved drug of choice for methemoglobinemia. Covid patients show resemblance to methemoglobinemia. Covid-19 causes silent hypoxia wherein patients despite having low oxygen saturation (SpO2) show no clinical symptoms of dyspnoea. These soon escalate to a cytokine storm and the patient goes into the irreversible phase of respiratory distress. Given the similarities in the clinical presentations, doctors started using it. However, they stopped prescribing MB for Covid treatment in absence of clinical trials and data proving the effectiveness of MB in the treatment of Covid-19.” Dr Ghori told Financial Express Online.

How Methylene Blue Can Prevent Mucormycosis Or Black Fungus?

Dr Ajay Mohan Agarwal said that a few drops of methylene blue in the humidifier, moisturizing jar, or concentrators through which oxygen passes can control almost all types of contamination, including mucormycosis, present in oxygen.

“Black fungus has now become epidemic and therefore it is very important to take all necessary measures to prevent it from spreading. We need to invent new methods based on our past experiences if want to control this disease.”

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Dr Agarwal believes that there are negligible chances that methylene blue used in the process can reach to lungs and cause any kind of harmful effect. “I am saying this because the concentration is so low that it won’t have any side effects. Also, I request the government to conduct trials at the earliest so that we can control the further spread of the disease.”

Echoing the same sentiments, Dr Raj Kumar Singh – principal virologist and former director of Indian Veterinary Research Institute (IVRI) – said that Methylene Blue has the mechanism to destroy mitochondria of fungus and therefore can help us in controlling mucormycosis or Black Fungus.

“Just like the human body, this black fungus too has mitochondria. Mitochondria are considered to be the powerhouse of any cell. Now, this Methylene Blue has the mechanism to destroy mitochondria and therefore it can help prevent the growth of fungus. So there is no doubt that Methylene Blue can help us in controlling mucormycosis or Black Fungus – which has now been declared an epidemic in several states. As a microbiologist, I can say this with surety. But then doctors need to study in what amount this Methylene Blue should be used. Based on my empirical knowledge, few drops should not be a concern. But I again repeat, a proper study should be done at the earliest so that it can be used to prevent the spread of this potentially fatal fungus,” the former director of IVRI said.

Dr Ghori said that Covid patients who are continuously on oxygen commonly face mucormycosis or Black Fungus which is thought to be prevented by adding Methylene Blue solution in the oxygen humidifier.

“Going by the theory of Hospital Acquired Infection of mucormycosis among Covid patients by opportunistic fungal spores, some hospital managements and clinicians are using dry oxygen and air purifiers, keeping a close watch on sugar levels, and using steroids judiciously. Dry oxygen is being used because water and moisture are some of the reasons behind mucormycosis. There are hospitals using Methylene Blue for oxygen humidifier bottles and isotonic saline nasal washes twice daily for all admitted Covid patients as well as keeping a strict vigil on the blood sugar level along with austere use of steroids.”

He too said that large clinical trials proving the effectiveness of Methylene Blue in the prevention and treatment of Mucormycosis Black Fungus is the way forward.

Commenting on doctors suggesting the use of Methylene Blue for preventing Mucormycosis, Dr Anant Bhan, a researcher in the fields of global health and health policy and former president of the International Association of Bioethics, told Financial Express Online that if a section of the medical community firmly believes that this medicine can help, a study should be done on priority.

“When individual doctors share their experiences, it’s anecdotal. This doesn’t qualify as evidence. Evidence has to come from high-quality studies of various randomized controlled trials. So if a section of the medical community firmly believes in something, the simple answer is to run a good quality study and demonstrate that. May be first at the lab level to understand what proportion of Methylene Blue can inhibit the growth of fungus. And then it should be tested clinically on priority,” said Dr Bhan.