Green fungus’ Aspergillus now noticed in India: nearly triples mortality in severe Covid-19

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Aspergillus, dubbed the ‘green fungus’ in India, occurs in 13.5% of severely ill hospitalised patients with COVID-19, according to Woon Chong of Albany Medical Center, New York State. Only last week, 75 weeks into the pandemic, the first cases of ‘green fungus’ were described in India, probably indicative of many missed cases.

Chong and Neu reviewed 19 observational studies from across the world and found 1421 patients with CAPA (COVID-19- associated pulmonary aspergillosis). All were critically ill and most were ventilated. Some patients (12.5%) had additional risk factors for aspergillosis (leukaemia, transplantation etc). None of these series or patients were from India. Yet India has had at least 30 million COVID-19 cases and 390,000 deaths according to the Johns Hopkins Coronavirus Resource Center. In a review of mortality of CAPA (from Shreya Singh at the Postgraduate Institute of Medical Education and Research, Chandigarh, India), the risk of dying from CAPA was 2.8 times higher than a comparative group of severely ill patients with COVID-19.  Yet a handful of cases only are described from India. Why?

CAPA is a lung infection on top of severe coronavirus lung infection. The most sensitive diagnostic test is the detection of Aspergillus antigen from lung and airway samples – tests which the WHO recently listed as ‘Essential Diagnostics’. Blood tests for aspergillosis are not sensitive and besides only a few centres in India actually offer these tests. Growing the ‘green fungus’ is both slow and often negative.

Professor Denning, Chief Executive of the Global Action Fund for Fungal Infections and an expert on aspergillosis at the University of Manchester finds the lack of cases diagnosed in India as ‘concerning’. He went on to say:

“Awareness of CAPA was highlighted in 2020 by many experts, but this did not appear to translate to diagnostic preparedness for severe COVID in India. The explosion in cases of mucormycosis (so called Black Fungus) was unexpected but CAPA was expected, yet seemingly is still missed.”

Of the 390,000 COVOD-19 deaths recorded in India, how many can be attributed to CAPA?  Given the widespread use of corticosteroids, and ubiquitous nature of the green fungus Aspergillus, probably tens of thousands. Untreated aspergillosis is almost always fatal.

Links to papers