This will come as a surprise that the present COVID-19 pandemic, ranks 9th in the list of the largest known pandemics caused by an infectious disease. By the end of June 2021, there were around 180 million recorded cases and around 4 million deaths due to COVID-19, across the globe. Unlike the first half of the pandemic, when most of the cases came from the developed countries, it was not the same in the later half. Unfortunately, India contributed most of them, recording around 30 million cases and around 0.4 million deaths due to COVID-19.
The second wave of COVID-19 in India, within a span of 4 months, recorded twice the number of cases as recorded in the first wave over a year. The number of recorded fatalities were also almost doubled in the second wave. One of the major reasons for the increased mortality were uncontrolled diabetes and its complications like ketosis which increased susceptibility to opportunistic pathogens and various fungal infections.
As we learnt, the majority of people who caught the virus did not need hospitalization, and were managed at home with supportive care. However, in up to 15% of cases, COVID-19 had been severe and in around 5% of cases it has led to critical illness. The vast majority (around 98%) of people infected to date have survived.
Older people and people with pre-existing medical conditions (such as diabetes, heart disease and asthma) appear to be more vulnerable to becoming severely ill with the COVID-19 virus. When people with diabetes develop a viral infection, it can be harder to treat due to fluctuations in blood glucose levels and, possibly, the presence of diabetes complications, like ketosis.
There appear to be two reasons for this. Firstly, the immune system is compromised, making it harder to fight the virus and likely leading to a longer recovery period. Secondly, the virus may thrive in an environment of elevated blood glucose.
A growing number of studies have shown diabetes as an important risk factor affecting the clinical severity of a wide range of infections. Dysregulated immune cell populations and activity observed in diabetic patients play a critical role in aggravating the severity. Notably, diabetes is one of the comorbidities associated with morbidity and mortality of COVID-19. Late diabetes complications such as diabetic kidney disease and ischemic heart disease may complicate the situation for individuals with diabetes, making them frailer, and further increasing the severity of COVID-19 disease, leading to kidney or heart failure. Diabetes patients are more prone to acquiring selected types of (rare) infections due of alterations in cell-mediated immunity.
Mucormycosis (commonly referred as “black fungus”) is one such rare infection. It is caused by exposure to mucor mould which is commonly found in soil, plants, manure, and decaying fruits and vegetables. Since, it is ubiquitously found in soil and air and even in the nose and mucus of healthy people, its exposure is inevitable.
It affects the sinuses, the brain and the lungs and can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS. It has an overall mortality rate of 50%, being triggered by the use of steroids, a life-saving treatment for severe and critically ill COVID-19 patients.
Steroids reduce inflammation in the lungs for COVID-19 and appear to help stop some of the damage that can happen during the stage of cytokine storm, when the body's immune system goes into an overdrive to fight off coronavirus. But they also reduce immunity and push up blood sugar levels in both diabetics and non-diabetic COVID-19 patients. Diabetes lowers the body's immune defenses, coronavirus exacerbates it, and then steroids which help fight COVID -19 act like fuel to the fire. The rampant and injudicious use of steroids has led to deterioration of diabetes control, further declining the immune response and increasing the incidence of this rare fungal infection.
One way to stall the possibility of the fungal infection is to make sure that COVID -19 patients - both in treatment and after recovery - were being administered the right dose and duration of steroids. One must also make good efforts to keep their sugars under control and manage the complications related to diabetes. So, what should be done, if you have diabetes:
Pay extra attention to your glucose control. Regular monitoring can help avoid complications caused by high or low blood glucose.
If you do show flu-like symptoms (raised temperature, cough, difficulty breathing), it is important to consult a healthcare professional.
Any infection is going to raise your glucose levels and increase your need for fluids, so make sure you can access a sufficient supply of water.
Make sure you have a good supply of the diabetes medications you need. Think what you would need if you had to quarantine yourself for a few weeks.
Keep a regular schedule, avoiding overwork and having a good night's sleep.
Healthy nutrition is an essential component of diabetes management. It is therefore important for people with diabetes to eat a varied and balanced diet to keep their blood glucose levels stable and enhance their immune system. It is recommended to:
Give priority to foods with a low glycemic index such as vegetables, whole wheat pasta/noodles.
Avoid excessive consumption of fried foods
Limit consumption of foods high in sugar, carbohydrates and fat
Choose lean proteins (eg. fish, meat, eggs, milk, beans).
Eat green, leafy vegetables, fruits in two or three servings
When glucose is in your bloodstream, it needs help – a "key" – to get into its final destination where it's used, which is inside your body's cells (cells make up your body's tissues and organs). This help or "key" is insulin.
Insulin is a hormone made by your pancreas; an organ located behind your stomach. Your pancreas releases insulin into your bloodstream. Insulin acts as the “key” that unlocks the cell wall “door,” which allows glucose to enter your body’s cells. Glucose provides the “fuel” or energy tissues and organs need to properly function.
We come across many patients reluctant to start Insulin when prescribed by their doctor. They bear many misconceptions, apprehensions and uncertainties regarding Insulin. One should not doubt and fear Insulin, and should accept it as temporary measure to improve their diabetic control, when prescribed by their doctor as it is the fastest and the safest way to manage diabetes during and post steroid therapy.