Is COVID leading to an upsurge in diabetes in Chennai?

Recovered patients are struggling under post COVID complications such as diabetes, mucormycosis and other medical issues. We spoke to three city doctors to understand more about these.

The world is still grappling with the onslaught of COVID-19, its aftermath and its impact on global health and economy. Even after more than a year since it first surfaced, there are several things that we do not know about COVID-19 yet. While it has claimed many lives, it is also true that innumerable people have come out of COVID-19. But in some cases, post COVID complications have proven to be complex, lingering, even debilitating ─ impacting the daily life of recovered patients. In extreme cases, post COVID illness has proved to be fatal.

Not only has this affliction altered the way the world and people work, but it has also created anxiety and panic among those who have recovered from COVID – will I ever be able to come out of its stranglehold? Is what I am feeling a Long COVID symptom? What signs should I look out for? How often should I follow up with my doctor?

We spoke to a few expert doctors in Chennai, who give us brief insights into what the lingering consequences following a COVID-19 infection could be and what trends in Chennai looks like.  

Post COVID complications reported in Chennai

Dr V Ramasubramanian,  Senior Consultant, Department of Infectious Diseases, Apollo Hospitals, Founder, The Capstone Clinic,  specialist in Infectious Diseases, adolescent and adult vaccinations and travel medicine.

Dr V Ramasubramanian,  Apollo Hospitals on post COVID complications in Chennai
Dr V Ramasubramanian, Apollo Hospitals

What does the trend in the second wave of COVID-19 in Chennai and Tamil Nadu look like?

Cases in Chennai and Tamil Nadu are dropping dramatically. In fact, the drop is pretty steep, both in terms of new cases, hospitalization and death, all of which are coming down significantly. Some other districts and two tier cities are also showing a decrease, but some districts are lagging behind.

The second wave of COVID-19 infections has been fierce in its intensity and spread. What are the post COVID complications that we are seeing, and are they persisting for a long time?

People who have recovered from COVID-19 can be categorised into three types:

  1. People who have had severe COVID-19 infection with severe pneumonia and damage to the lungs. Some of these patients may be left with persistent difficulties in breathing, especially during any exertion such as walking. This is because the lungs are damaged and scarred. People who have recovered from severe COVID-19 may be oxygen-dependent for some time and minimal exertion may bring on breathlessness, giddiness and other symptoms related to low oxygen levels due to the damaged lungs.
  2. People with the type of damage and disturbing symptoms, who come under the category called as ‘long haulers’ and have had prolonged COVID-19 lasting more than two weeks. The long-term symptoms include dry mouth, sleep disturbances, appetite issues, tightness of the chest, fatigue and lack of energy, joint pains, disturbed bowel movements and difficulties in concentration ─ what is called as brain fog or confusion.
  3. The third category includes people with psychological or mental health issues. A lot of people may end up with panic attacks or are paranoid about any instance of minimal cough that causes panic and suspicion that they have another COVID-19 attack. We have come across several other mental health issues too.

Read more: Understanding Long COVID: The much-needed long term care you must be aware of

How long should people who have recovered from COVID-19 be monitored by a doctor? What precautions should they take and how long should they monitor themselves?

Most people don’t require any monitoring by a doctor after they have recovered from the damage to their lungs. It may take a couple of weeks and they settle down very well after that. The follow-up is mainly recommended for people with psychological difficulties and stress, and has to be planned according to the individual’s need, based on the symptoms they have.

Those with substantial damage to their lungs and are oxygen dependent, have to be followed up periodically to decide how long they need  oxygen support, how frequently they should be monitored and whether they need steroids or other medicines to minimize lung damage. Most people who recover may have residual cough for a few weeks, other than that they don’t require follow up at all.

So, is it established now that the new variant which has affected thousands in India during the second wave is more aggressive in terms of transmission as well as severity? Does that have implications for lingering effects?

The new variant is called, ‘Variant of concern’ because of its transmissibility. We know definitely that the new variant in India is more transmissible. However there is no proof whether it causes severe disease or not. Yet, it is probable that it may cause disease in the young who have no comorbidities.

Certain strains of the virus may not respond to the monoclonal antibodies which we give for mild infection to prevent people from progressing into severe disease. And also with respect to vaccine, the efficacy may be lesser for certain strains. But even if the vaccine is able to give 30% protection, it is better than zero. So vaccination is strongly recommended and may eventually play a role in ending the pandemic.

Considering the huge impact of the new variant that has wreaked havoc during the second wave, what would your advice be, over and above the usual precautions that are advocated to prevent COVID-19?

Let us all accept that COVID-19 is here to stay. We need to accept that vaccines are the best defence we have with respect to both transmission of COVID-19 and to minimise the severity of the illness as well as to conserve our health resources. This means that you take the vaccine not only for yourself but also for the entire society and the country. All of us need to take the covid vaccine in spite of the side effects, which are very negligible, at the earliest available opportunity. Masking and maintaining social distance must be continued diligently because even young people have vulnerable family members and seniors at home who need to be protected.

The Link Between COVID-19 and Diabetes

Padmashri Dr V Mohan, Chairman and Chief of Diabetology at Dr Mohan’s Diabetes Specialities Centre, President and Director of the Madras Diabetes Research Foundation , Author of ‘Making Excellence a Habit’

Dr V Mohan, President and Director of the Madras Diabetes Research Foundation on post COVID diabetes
Dr V Mohan, President and Director of the Madras Diabetes Research Foundation

Why has the focus on diabetes increased since COVID-19 struck? What are the long-term complications of COVID-19, especially among diabetics?

A few months after the COVID-19 pandemic struck humanity, people realised that not everyone with COVID-19 recovered fully even if they had tested negative after treatment. In some people vague symptoms and/or some complications seem to persist for weeks and even for months. These include anxiety, depression, fear, palpitation, chest pain, tightness of chest, nerve pulling, tingling sensation in the extremities etc.

It was also seen that COVID-19 affects diabetics in several ways. Indeed, there seems to be a bidirectional relationship between COVID-19 and diabetes. While it is well known that uncontrolled diabetes can lead to poor outcomes in those with   COVID-19, and may also lead to increased morbidity and mortality, COVID-19 can also cause diabetes. This can happen due to the following reasons:

1) Due to stress, anxiety and depression, many people tend to develop diabetes, hypertension and heart disease. It is well known that when one is under stress, hormones like adrenaline, non-adrenaline and cortisol are markedly increased. These hormones are called ‘counter regulatory hormones’ as they oppose the action of insulin. Hence, both insulin secretion as well as insulin resistance can increase, thus leading to diabetes. This is called ‘stress induced diabetes’. Sometimes after the stress is over, or with stress reduction measures (like yoga, pranayama, deep breathing etc.) or psychological treatment or after the use of antidepressant drugs, the diabetes may reverse.

2) Due to the frequent lockdowns, many people found it difficult to exercise. Overall, physical activity has decreased markedly. There were also a lot of people who started binge eating. Sometimes supply of fresh vegetables and fruits were also interrupted, leading to excess carbohydrate consumption. All these have resulted in weight gain and as we know obesity is a well-known risk factor for diabetes. So, this is the second mechanism by which COVID-19 can lead to diabetes.

3) During treatment for COVID-19, especially in those who are seriously ill and admitted to the ICU, use of steroids, especially in high doses, can be a life-saving measure. Unfortunately, the use of steroids in such doses can unmask latent diabetes and in those with prediabetes, can lead to overt expression of diabetes. Many instances of steroid-induced diabetes are being reported. I have seen that in many of these patients, once the steroids are stopped, the sugar levels settle down. However in others, the diabetes may continue even after steroids are withdrawn.

4) The fourth mechanism is direct injury to the pancreatic beta cells by the SARS COV2 virus. This has however been proven in very few cases and is probably a rare cause of diabetes.

Read more: Why ‘family’ is key to detection and prevention of diabetes, the urban epidemic

What is the current trend that you find in the city in terms of COVID-induced diabetics?

Due to COVID-19 we are witnessing an increase in the number of people with new onset diabetes. We are also seeing people, whose sugars were well controlled earlier, developing severe, uncontrolled diabetes due to COVID-19. Also, during the lockdown, many people delayed their visit to the diabetes centre; this resulted in some patients unfortunately developing gangrene of the legs leading to amputation or other complications of diabetes. 

What precautions and monitoring would you suggest for diabetics post COVID-19 attack?

The most important thing that people with diabetes should remember is to keep it under good control. The latest threat which has been described in people with uncontrolled diabetes (and presumably due to large doses of steroids being used) is a serious fungus disease called Mucormycosis or Black Fungus. It is therefore abundantly clear that diabetes control assumes top priority.

With this in mind, I made a fervent plea to the nation to declare the month of June 2021 as the ‘Diabetes Control Month’. Many medical associations and several of my colleagues have responded positively to this plea and have taken up diabetes control measures in a big way.

I am sure that if adequate precautions like healthy diet, exercise, reducing stress, regular intake of medications, increased testing of the blood glucose, large-scale screening to detect undiagnosed diabetes and above all, seeing that everyone with diabetes keeps their sugar and Glycated haemoglobin (HbA1c) levels under good control, we can mitigate the serious side effects of   COVID-19,  including mucormycosis.

Black Fungus and COVID-19: Rhino Orbital Cerebral Mucormycosis (ROCM)

Dr Mohan Rajan , Chairman & Medical Director – Rajan Eye Care Hospital Pvt Ltd, Member Tamil Nadu State Government Panel for Mucormycosis 

Dr Mohan Rajan, Member, Tamil Nadu State Government Panel for Mucormycosis on black fungus post COVID complication
Dr Mohan Rajan, Member, Tamil Nadu State Government Panel for Mucormycosis

What is Mucormycosis or Black Fungus?  What does the present trend indicate as far as black fungus is concerned? Why is it a dangerous condition that affects mortality rates?

In the midst of this pandemic, we are facing a bigger issue of mucormycosis or Black Fungus.  So far, more than 28,000 people have been affected by mucormycosis in our country and Tamil Nadu has contributed to around 1100 Cases of mucormycosis. This number is expected to go up significantly in the near future. In essence, we are now facing a Mucormycosis epidemic in the midst of the Corona pandemic.

Mucormycosis (previously called zygomycosis) is a serious but rare fungal infection caused by a group of molds called mucormycetes. These molds live everywhere in the environment. Mucormycosis mainly affects people who have health problems or take medicines that lower the body’s ability to fight germs and sickness.

The fungus usually starts from the nose, then invades sinuses and then the eye and then goes into the brain resulting in fatality. That is why it is called Rhino Orbital Cerebral Mucormycosis (ROCM). It can be a threat to life if the fungus reaches the brain and it is enormously important to arrest it from spreading deep.

How did mucormycosis come to be associated with COVID-19, because we had never heard of such a spread earlier? What leads to this infection?

Mucormycosis can occur in people with uncontrolled sugar or those who are immuno-compromised, such as those who have had organ transplantation, those with HIV/AIDS and others who are on steroids for various conditions.

Following are the causes for mucormycosis, which are all closely associated with COVID-19:

  • Uncontrolled Diabetes Mellitus
  • Treated for COVID – 19 with corticosteroids
  • Treated for COVID – 19 with immunomodulators
  • Treated with Mechanical Ventilation for COVID-19
  • Long-Standing Oxygen therapy during COVID-19 treatment
  • The use of industrial oxygen, which is impure, has also been implicated as one of the reasons for mucormycosis.

Read more: From HCQ to Remdesivir to 2DG: Why COVID-19 treatment is likely to continue evolving

What are the symptoms of mucormycosis that we should be alert about and seek immediate treatment?

Symptoms to be noticed by people apart from other signs that can be identified only by medical professions include

  • Facial Pain, Sinus Headache, Stuffy Nose, Decreased Vision,
  • Bloody Nasal Discharge, Dental Pain, Facial Swelling, Facial Discoloration,

How can we prevent mucormycosis from happening?

Serious mucormycosis leads to a threat to life. Prevention is therefore better than cure. Mucormycosis can be prevented to a large extent by strict adherence to the following protocols:

  • Creating public awareness about  mucormycosis
  • Very close monitoring of post covid patients by health workers
  • Monitoring of Immuno-suppressed patients.
  • Giving importance to personal hygiene/ oral hygiene. Povidone iodine gargle by post covid    patients is helpful to keep mucormycosis at bay.
  • It is important for people to know and be alert to early symptoms and signs of mucormycosis like brownish tinged nasal discharge, stuffy nose, etc.
  • Blood sugar at the time of discharge should be noted and the patient guided to maintain sugar levels.
  • Home monitoring of patients for Diabetes Mellitus and other comorbidities is important.
  • Special attention and monitoring of post covid patients from lower socioeconomic status because they may not have awareness about the symptoms as well as the importance of maintaining personal hygiene, more importantly oral hygiene.
  •  Simple nasal examination by an ENT specialist ( nasal endoscopy) for all high-risk post covid patients

Why did we not see so many patients affected by mucormycosis during the first wave of covid last year?

There are many reasons:

  • In the second wave a greater number of sick patients required hospital admission as well as oxygen when compared to the first wave.
  • There has been rampant usage of steroids during the second wave when compared to the first. Eve self-medication by patients with steroids after consulting the Google Doctor!
  • Lack of proper control of Diabetes Mellitus.
  • Use of industrial oxygen with contaminated cylinders and contaminated nasal cannula as well as use of contaminated masks.
  • The mutant strain (Delta Variant) of COVID-19 probably affects the nasal mucosal immunity, making these patients more susceptible to mucormycosis infections.

How is mucormycosis treated?

Medical Management involves:

  • Induction with Liposomal Amphotericin B (L-AMB) 5 to 10 mg/kg/day for 2 weeks
  • Dual Therapy: L-AMB + Oral Posaconazole dose 300 mg OD for 2 weeks
  • Oral Posaconazole 300 mg BD for a further 2-4 weeks till clinical resolution and radiological stabilization

Surgical Management

  • Early Surgical Debridement of Sinuses  by an ENT surgeon  which involves removal of blood clots, crusts and secretions from the nasal and sinus cavities, a procedure that is usually performed under local anaesthesia.
  • FESS surgery where an ENT surgeon inserts an endoscope, a small tube with a camera attached, into the nasal cavity through a nostril to detect the extent of infection.
  • Transcutaneous retrobulbar injection of Amphotericin B 9TRAMB) 1ml of 3.5 mg/ml (select cases only) alternate days for 4-6 weeks.

Orbital Exenteration (Patients with extensive orbital involvement) which involves removal of the entire contents of the orbit.

Is it also true that COVID-19 affects the eyes in other ways?

COVID-19 can affect the front part of the eye causing conjunctivitis. Sometimes the back gets affected causing too, central retinal vein or artery occlusion. COVID-19 can also result in ocular myasthenia gravis (MG), which is a disease of the neuromuscular junction resulting in variability in eye muscle weakness and fatigability or it may cause optic neuritis, an inflammation of the optic nerve which can damage the nerve.

Another condition a COVID-19 patient may develop is Orbital cellulitis, which is an infection of the soft tissues and fat that hold the eye in its socket. This condition causes uncomfortable or painful symptoms and is a potentially dangerous condition.

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