We are currently going through the second wave of the COVID 19 pandemic. While the first wave gripped us with fear and anxiety, the second wave caught us unaware, surprised and pushed us on the back foot. Huge masses were infected by the virus, to the extent that our limitations in almost all the spheres of life were exposed shamelessly. Amid this COVID 19 pandemic in India, there emerged a rare but deadly fungal infection called mucormycosis, which further broke our healthcare system and challenged our inadequacies. .By now,many of us know what this fungal disease is all about. Though there is a decline in the cases of mucormycosis secondary to decline in COVID 19 numbers, it is not the end yet. Being an aggressive disease, the challenge that most doctors faced while treating mucormycosis was to catch the disease early in its course. This requires a very high degree of suspicion among the treating doctors as well as adequate awareness amongst the general population about the disease.Mucormycosis explainedMucormycosis is not a new disease. Also commonly known as black fungus, mucormycosis is caused by a group ofmoulds called mucormycetes. According to one population-based study in India, the pre-COVID incidence of this disease was 14 to 18 cases per one lakh people in the Intensive Care Unit (not more than a few hundred cases annually). Since the second wave of COVID 19 disease, India has recorded more than 40,000 cases to date.There is no particular timeline for the development of post COVID mucormycosis though a majority of the cases are seen between the 2nd and 3rc1 week of COVID 19 infection. In people with very high blood sugar levels, aggressive mucormycosis is seen even during the 1st week of active COVID infection. Delayed post COVID mucormycosis cases have been witnessed even after 4 weeks of COVID infection.Risk factorsIncreased infections of mucormycosis are observed in COVID affected people who have:•\tDiabetes with uncontrolled blood sugar levels•\tPrediabetes with fluctuating blood sugar levels•\tCancer•\tUndergone organ transplantation•\tChronic kidney and liver disease•\tDecreased immunity due to any other diseaseSymptomsIn most cases, mucormycosis primarily infects the nose, paranasal sinuses (the area near the cheekbones, besides theupper nose and behind the nose) and teeth. Less commonly, it can cause primary infection in the lungs, intestine and skin.The nasal mucormycosis spreads aggressively to involve the eyes and the brain; hence it is calledrhino-orbito-cerebral mucormycosis. Some of its symptoms are:•\tCold, nasal stuffiness, nasal dryness - these are very early symptoms and are often missed.•\tFacial pain, pain around the eyes and numbness over the face - these symptoms suggest inflammation of the nerves surrounding the sinuses or the nerve involvement in itself. These symptoms, when persistent, should never be ignored and medical attention should be sought without delay.•\tTooth pain, a loose tooth and swollen gums•\tNasal crusting, blackish discolouration of nasal turbinates•\tEye pain, redness of the eyes•\tDrooping of eyelids, inability to move the eyes in any or all directions, double vision - these symptoms suggest that the disease has spread to the eye and are ominous symptoms•\tDiminution of vision, loss of vision•\tBlackish discolouration of gums, palate•\tA brain stroke, seizures - this occurs when the disease has spread to the brain or has involved one of the blood vessels supplying the brain.DiagnosisPost-COVID people who have high blood sugar levels and have any of the above symptoms should undergo ENT, Eye and Dental examination. Biopsy from the suspected sites of involvement, nasal endoscopy, and contrast MRVCT scans are important to establish the diagnosis of mucormycosis and plan the treatment.Prevention•\tIf a person has Diabetes, he or she should make sure that their blood sugar levels remain in the normal range. High blood sugar levels are an important risk for mucormycosis.•\tIf a person does not know whether he or she has Diabetes then they should get their sugar levels checked during and after the COVID infection. If the levels are increased then one should seek appropriate medical advice from a diabetologist or an endocrinologist.•\tSteroids are wonder drugs in experienced hands and are found to be useful in saving lives in COVID disease but when used indiscriminately, they can wreak havoc. Do not self-medicate with steroids. Take them only under close consultation with specialist doctors.•\tMaintain good hygiene during and after COVID infection. Take regular baths, change clothes every day even when hospitalized.•\tMaintain a good and balanced diet.Avoid sugars during and after COVID infection.•\tSaltwater nasal washes and Jalneti can help wash away the fungal debris.•\tSeek medical advice from a specialist doctor in case of any suspicion of mucormycosis symptoms.TreatmentMucor causes necrosis (death) of the infected tissue by blocking the surrounding blood vessels (angioinvasion). Hence, early surgical debridement (removal) of the dead tissue is very important for successful treatment by medicines. At the same time, antifungal medicine active against mucor must be started as soon as possible to kill the microscopic fungus spreading through the blood vessels.The common antifungal medicines used for treating mucormycosis are Amphotericin B, Posaconazole, Isavuconazole and Caspofungin. Of these, Amphotericin B is the most effective medicine. The commonly available forms of Amphotericin B are lyophilised (freeze dry) form, lipid emulsions and liposomal form. While lyophilised form and lipid emulsions cost less, they are toxic to the kidneys. The liposomal form is comparatively safe for the kidneys but is expensive. After the initial 2 to 4 weeks course of Amphotericin B, Posaconazole or Isavuconazole can be given for the next 2 to 3 months to clear the fungus completely from the body.SurgeryTheoretically, a very early case may not require surgical debridement. But this is a rare possibility. Given the aggressive nature of the fungus as well as its tendency to cause tissue death by blocking the blood vessels, it becomes imperative that the fungus-infected dead tissue be removed aggressively by surgical debridement so that the medicine can act effectively to remove the remaining microscopic fungus in the body.Indications of complete recoveryThough it is very difficult to access the endpoint of the treatment, resolution of the symptoms and decrease in inflammatory markers such as CRP (C-reactive protein) and ESR forms the important guidelines of successful treatment. Follow-up MRI scans can be helpful to assess disease resolution but it is difficult to differentiate between active disease and post-surgical inflammation effectively. Periodic nasal endoscopy can be helpful to assess the disease activity during the treatment.Hence, improvement in the general condition of the patient, resolution of the symptoms and decrease in the inflammatory markers will guide the successful completion of the treatment.To concludeMucormycosis was always present in the Pre-COVID period, hence depending upon the mutations in the COVID virus and the severity of the disease that it may cause, it is very much possible that we may see a resurgence in mucormycosis cases in the future waves of COVID infection. There's no substitute for maintaining good health, immunity, hygiene and more importantly blood sugar levels, to protect us. Prompt medical advice when in suspicion can help in early diagnosis and treatment, which can save many lives.