Rhinomaxillary mucormycosis in a kidney transplant patient

Clinical, Demographic, and Oral Presentations of COVID-19 Associated Mucormycosis from a Tertiary Care Hospital in India: A Cross-Sectional Study

Background

The black fungus, mucormycosis, is on the list of lethal complications reported in recent times in COVID patients.

Methodology

This cross-sectional study included all cases of post-COVID-19 mucormycosis. Patients' demographics, clinical presentations, and general health information were collected using a pre-designed form.

Results

The study included 171 participants with the mean (SD) age as 49 (10) years with the sex distribution as 71% (122/171) male and 29% (49/122) females. About half of the admitted patients (47%) were known cases of Diabetes Mellitus type II with a median (IQR) Glycosylated Haemoglobin (HbA1c) of 9.1% (7-11.1%). Only 28% (48/171) had received the first COVID vaccination, and 2.9% (5/171) were fully vaccinated with two doses. During COVID-19, 76% (130/171) required hospitalisation for a mean (SD) stay of 11 (6.4) days. Eighty percent of the patients (136/171) received steroids during therapy, while 87% (150/171) and 51% (88/171) received antibiotics and antivirals, respectively. Oxygen was administered to 71% of hospitalised patients (120/171), with 39.1% (47/120) receiving it for more than 7 days. About the development of the first symptoms of mucormycosis (headache, nasal congestion, black crusts in the nose, facial pain, swelling in cheeks and eyes, and loss of vision) after being diagnosed with COVID-19, 16% (28/171) reported it within 7 days, 75% (127/171) between 8 and 30th days and 9% (16/171) after a month. On examination, 20% of mucor patients had hard palate findings, eschars, fistulas, and perforations, 38% had periodontal abscesses, and 5% reported tenderness to percussion.

Conclusion

Generally, oral manifestations involved the palate and included varying degrees of mucosal discolouration, swelling, ulcers, superficial necrotic areas, and bone exposure and necrosis with dark eschars.

Post-COVID Mucormycosis Involving Mandible: A Rare Phenomenon

Mucormycosis is a fungal disease involving predominantly the paranasal sinuses and further spreading to the orbit and cerebral regions. It does rarely affect the pulmonary region and gastrointestinal regions. This disease is seen more in a very serious state, where the tissues undergo necrosis and cause huge morbidity and, in some cases, end up being fatal. The disease was common in individuals with an immune-compromised state, thus more commonly presenting in individuals with uncontrolled diabetes. The disease is usually acquired through coming into contact with spores of the fungus Mucormycetes through the nose, and the fungi invade the paranasal regions, colonize, and spread locally with angio-invasion and relying on host ferritin for survival, thereby causing tissue necrosis. The incidence of mucormycosis had increased considerably post-COVID-19 due to host immune factors. This fungus commonly spreads from paranasal regions to the cranial direction through orbit. The spread is rapid, thus needing early medical and surgical intervention. The spread of infection from the paranasal regions to the caudally placed mandible is very rarely seen. In this paper, we present three cases of mucormycosis spreading caudally and involving the mandibular regions.

Incidence of Mucormycosis in a Tertiary Care Hospital During Covid First Wave-A Retrospective Study

Rhino orbital cerebral mucormycosis is a medical emergency; though rare it's a life threatening infection in patients. It commonly occurs in immunocompromised patients due to various causes. A retrospective study was conducted in tertiary care centre wherein 30 non-covid, diabetic patients were treated for mucormycosis. All underwent intensive debridement and diabetic management along with antifungal- amphotericin. All the cases improved with aggressive therapy: medical and surgical. Early recognition and treatment is needed to prevent morbidity and mortality.

Mucormycosis in COVID-19 patients: predisposing factors, prevention and management

India is considered the diabetes capital of the world and has the highest burden of mucormycosis. Bacterial, viral and fungal co-infections are increasingly being reported in severe acute respiratory syndrome virus 2 (SARSCoV-2) infected patients. India is one of the worst affected countries during the second wave of the COVID-19 pandemic. This combination of diabetes mellitus, COVID-19 and mucormycosis has led to the drastic upsurge of COVID-19-associated mucormycosis (CAM) in India. Immunosuppression, iron disequilibrium, endothelial injury, ketoacidosis and hypoxia are some of the other COVID-19-related risk factors for CAM. There has been an increase in the proportion of mucormycosis affecting paranasal sinuses and central nervous system (CNS) in CAM compared to pre-COVID-19 literature due to the SARSCoV-2-related pathophysiological mechanisms, complications and treatment strategies. CAM is a medical and surgical emergency, and it can present with non-specific symptoms and signs initially resulting in diagnostic delay. High index of suspicion and regular screening for features of CAM are of paramount importance to prevent lethal consequences. Rapid action with a tripod approach consisting of withdrawal of immunomodulators, early antifungal therapy and extensive surgical debridement is considered the best possible treatment model. We review the published data to give a detailed account of the predisposing factors and their mechanisms, diagnostic work-up, treatment modalities and prevention strategies of CAM with special emphasis on CNS mucormycosis.

Chronic orbital and calvarial fungal infection with Apophysomyces variabilis in an immunocompetent patient

Apophysomyces is a rare fungal organism causing rhino-orbito-cerebral mycotic infections with high morbidity and mortality, typically in immunocompetent individuals. Several cases of Apophysomyces elegans orbital disease have been reported. Herein, we report a case of Apophysomyces variabilis infection involving the orbit, sinuses, and calvarium in an immunocompetent 74-year-old woman, with a review of the literature. Unlike prior cases of A. elegans classic rhino-orbito-cerebral infection, our case included diffuse calvarial lytic lesions and overlying soft tissue nodules, but without parenchymal intracranial involvement. There was radiographic and clinical evidence of infarction of the orbital contents and cavernous sinus thrombosis. Anastomoses between the superior orbital (ophthalmic) vein and diploic veins of the calvarium are believed to be primarily responsible for the unusual mode of spread on the extradural surface of the brain. Although the patient stabilized without definitive surgical intervention, her disease slowly and intermittently progressed for over a year after presentation, requiring multiple courses of antifungal treatment.

Severe falciparum malaria complicated by prolonged haemolysis and rhinomaxillary mucormycosis after parasite clearance: a case report

Background

Severe falciparum malaria may be complicated by prolonged haemolysis and recurrent fever after parasite clearance. However, their respective etiologies are unclear and challenging to diagnose. We report the first case of severe falciparum malaria followed by prolonged haemolytic anaemia and rhinomaxillary mucormycosis in a previously healthy adult male.

Case presentation

A 30-year old Bangladeshi man was admitted with severe falciparum malaria complicated by hyperlactataemia and haemoglobinuria. Prior to admission he was treated with intravenous quinine and upon admission received intravenous artesunate and empiric ceftriaxone. Thirty hours later the peripheral parasitaemia cleared with resolution of fever and haemoglobinuria. Despite parasite clearance, on day 3 the patient developed recurrent fever and acute haemolytic anaemia requiring seven blood transfusions over six days with no improvement of his haemoglobin or haemoglobinuria. On day 10, he was treated with high-dose dexamethasone and meropenem with discontinuation of the ceftriaxone. Two days later the haemoglobinuria resolved. Ceftriaxone-induced haemolysis was the suspected final diagnosis. On day 16, the patient had progressively worsening right-sided facial pain and swelling; a necrotic ulceration of the hard palate was observed. Rhinomaxillary mucormycosis was diagnosed supported by microscopy findings. The patient initially responded to treatment with urgent surgical debridement, itraconazole, followed by two weeks of amphotericin B deoxycholate, however was subsequently lost to follow up.

Conclusions

This case highlights the range of potential alternative aetiologies of acute, prolonged haemolysis and recurrent fever following parasite clearance in severe falciparum malaria. It emphasizes the importance of a high degree of suspicion for alternative causes of haemolysis in order to avoid unnecessary treatments, including blood transfusion and steroids. It is critical to consider and identify common invasive bacterial and rare opportunistic co-infections as a cause of fever in severe malaria patients remaining febrile after parasite clearance to promote antimicrobial stewardship and prompt emergency care.

Facial nerve paralysis: A case report of rare complication in uncontrolled diabetic patient with mucormycosis

Mucormycosis is a rare opportunistic aggressive and fatal infection caused by mucor fungus. Seven types of mucormycosis are identified based on the extension and involvement of the lesion, of which the rhino orbital mucormycosis is most common in the head and neck region. Although it is widely spread in nature, clinical cases are rare and observed only in immunocompromised patients and patients with uncontrolled diabetes mellitus. Early symptoms include fever, nasal ulceration or necrosis, periorbital edema or facial swelling, paresthesia and reduced vision. Involvement of cranial nerves although not common, facial nerve palsy is a rare finding. The infection may spread through cribriform plate to the brain resulting in extensive cerebellar infarctions. Timely diagnosis and early recognition of the signs and symptoms, correction of underlying medical disorders, and aggressive medical and surgical intervention are necessary for successful therapeutic outcome.

Uncommon opportunistic fungal infections of oral cavity: A review

The majority of opportunistic oral mucosal fungal infections are due to Candida albicans and Aspergillus fumigatus species. Mucor and Cryptococcus also have a major role in causing oral infections, whereas Geotrichum, Fusarium, Rhodotorula, Saccharomyces and Penicillium marneffei are uncommon pathogens in the oral cavity. The broad spectrum of clinical presentation includes pseudo-membranes, abscesses, ulcers, pustules and extensive tissue necrosis involving bone. This review discusses various uncommon opportunistic fungal infections affecting the oral cavity including their morphology, clinical features and diagnostic methods.

Presentation and outcome of rhino-orbital-cerebral mucormycosis in patients with diabetes

AIM

To report presentation and outcome of rhino-orbital-cerebral mucormycosis (ROCM) exclusively in patients with diabetes mellitus.

METHODS

Retrospective, non-comparative, interventional analysis of the medical records of 35 patients with ROCM among 22 316 patients with diabetes seen over the last 12 years.

RESULTS

A cohort of 23 men and 12 women with a mean (SD) age of 47.3 (14.4) years (range 18-70 years) was studied. Five patients had type 1 diabetes mellitus, 29 had type 2 diabetes mellitus, and one had secondary diabetes. Nine patients had ROCM as the first clinical manifestation of diabetes. The mean (SD) blood glucose at presentation was 20.6 (8.3) mmol/l (range 10.0 to 53.3 mmol/l) and 17 patients had ketosis/ketoacidosis. Ophthalmic symptoms and signs were pronounced: external ophthalmoplegia (89%), proptosis (83%), visual loss (80%), chemosis (74%), and eye lid gangrene (14%). Non-ophthalmic manifestations included sinusitis (100%), nasal discharge/ulceration (74%), infranuclear VI nerve palsy (46%), palatal necrosis (29%), cerebral lobe involvement (20%), and hemiparesis (17%). Computed tomography/magnetic resonance imaging showed involvement of paranasal sinuses in all patients with ethmoid (86%) and maxillary (80%) sinuses being most frequently involved. Orbital involvement was observed in 80% of patients with cavernous sinus thrombosis in 11%, and internal carotid occlusion and hydrocephalus in 3% each. All were treated with amphotericin B (3-3.5 g) and 26 (74%) patients underwent appropriate surgery. Twenty one patients (68%) survived with a mean (SD) follow up of 39.6 (34.1) months (range 10 months to 11 years). Factors related to poor survival included delay in diagnosis and treatment (p<0.05), facial and/or eye lid gangrene (p<0.05), hemiplegia (p<0.05), cerebral invasion by mucorales (p<0.05), and treatment with amphotericin B alone (p<0.05).

CONCLUSIONS

In patients with diabetes and ROCM, ROCM was the presenting manifestation in one fourth of the patients. Ophthalmic and extensive cerebral involvement predominated in the clinical picture. Delay in treatment due to late presentation and associated complications were major determinants of the survival outcome in these patients.

Combined mucormycosis and aspergillosis of the oro-sinonasal region in a patient affected by Castleman disease

One case of aspergillosis and mucormycosis occurring in a patient with stage-IV Castleman disease was investigated. The patient, who had undergone polychemotherapy and was in otherwise good general condition, without lymphadenopathies or imbalance of the immune system, presented with a palatal ulceration that progressively involved the palatal mucosa and bone, the paranasal sinuses and the orbit. Repeated cultural examinations were always negative. He had undergone multiple cytological smears of the inflammatory infiltration and biopsies of both the oral and nasal mucosa, which resulted in extensive necrotic debris and suppurative inflammation, and, on the very last biopsy, fungal hyphae, spores and conidia were also detected. These were large, branching, mostly non-septate hyphae, associated with conidiophores and conidia, the latter appearing dark brown to black in the histological preparations. Following the diagnosis of combined mucormycosis and aspergillosis, the patient underwent prolonged topic and systemic antibiotic treatment that resulted curative. Mucormycosis usually is a fatal complication of head and neck or systemic disorders, leading to severe immune suppression. Nevertheless, early diagnosis may be achieved using a combination of special stains and may lead to effective antibiotic treatment and cure of the patient, even if associated with other opportunistic infections, such as aspergillosis.

Lung cancer, proptosis, and decreased vision

A 48-year-old man presented to the emergency department with a 3-day history of decreased vision in a painful proptotic right eye. The patient was being treated with chemotherapy and radiation for non-small cell lung carcinoma. Examination showed visual acuity of hand motions, decreased motility, and an afferent pupillary defect on the right, consistent with an orbital apex syndrome. Neuroimaging revealed "dirty" orbital fat and no paranasal sinus disease. Orbital biopsy initially showed only fibrosis; however, on subsequent biopsies, nonseptate hyphae later identified as mucormycosis was recovered. The patient survived with exenteration and systemic amphotericin B.

Problems and abnormalities found on routine clinical head and neck examination

During the initial examination of a patient, the orthodontist may encounter various findings that will, for the most part, be normal or variants of normal. Most pathological conditions encountered will be derived from structures normally found in the anatomic locations examined. Knowledge of the anatomy and common pathological entities based on location can prove helpful when abnormalities are encountered. This article describes anatomic locations and their contents in and around the oral cavity and discusses pathological processes commonly encountered in these locations. Syndromes involved with various abnormalities also are briefly mentioned. The intent of this article is to give the clinician a working knowledge of commonly occurring pathological entities.

Infections in solid-organ transplant recipients

Solid-organ transplantation is a therapeutic option for many human diseases. Infections are a major complication of solid-organ transplantation. All candidates should undergo a thorough infectious-disease screening prior to transplantation. There are three time frames, influenced by surgical factors, the level of immunosuppression, and environmental exposures, during which infections of specific types most frequently occur posttransplantation. Most infections during the first month are related to surgical complications. Opportunistic infections typically occur from the second to the sixth month. During the late posttransplant period (beyond 6 months), transplantation recipients suffer from the same infections seen in the general community. Opportunistic bacterial infections seen in transplant recipients include those caused by Legionella spp., Nocardia spp., Salmonella spp., and Listeria monocytogenes. Cytomegalovirus is the most common cause of viral infections. Herpes simplex virus, varicella-zoster virus, Epstein-Barr virus and others are also significant pathogens. Fungal infections, caused by both yeasts and mycelial fungi, are associated with the highest mortality rates. Mycobacterial, pneumocystis, and parasitic diseases may also occur.

A review of oral fungal infections and appropriate therapy

Dental health care providers must recognize oral fungal pathogens that often are markers for early signs of immune deterioration. After accurate identification, appropriate therapy can be initiated. Predisposing factors for development of oral fungal infections, identification of oral fungal infections, treatment options and their relative costs are reviewed.

Survival factors in rhino-orbital-cerebral mucormycosis

Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.

Mucormycosis of the oral cavity

Mucormycosis (phycomycosis, zygomycosis) is an acute opportunistic infection caused by a saprophytic fungus found in soil, bread molds, and decaying fruits and vegetables. Numerous predisposing risk factors are associated with mucormycosis, although most cases have been reported in poorly controlled diabetics or in patients with hematologic malignant conditions. This report presents two cases of oral mucormycosis. One case occurred in the maxilla in a patient with well-controlled diabetes. The other involved the mandible and overlying gingiva in a patient with acute myelogenous leukemia. A review of the literature concerning oral mucormycosis is also presented.

Orofacial mucormycosis

Two cases of orofacial mucormycosis are reported. The first patient represents the typical progression of rhinocerebral mucormycosis with infiltration of the sinuses, the orbit, and the brain. The second patient had a tumorous maxillary lesion resembling fibrous dysplasia clinically and radiographically. Microscopically, the fungal infection in case 2 was associated with new bone formation. The significance of this phenomenon is discussed, and the importance of early diagnosis and possible treatment regimens are highlighted.

Cardiac transplantation: dental considerations

The same basic principles of dental management of the immunocompromised patient apply to patients receiving cardiac transplants: preimmunosuppressive therapy examination and elimination of all existing and potential sources of infection; counseling regarding the importance of meticulous oral hygiene obviating further medical complications; and frequent oral health assessments for interception of emerging oral problems, maintenance, and reinforcement of good oral care. Dental practitioners familiar with the more numerous patients with renal transplants will find differing therapy complications secondary to immunosuppression and maintenance drug regimens. The dental approach to the candidate for a cardiac transplant will differ in degree of morbidity and complexity of delivering necessary oral care before transplantation.

Endoscopic surgery for mycotic and chronic recurring sinusitis

Chronic sinusitis and its complications are often caused or perpetuated by fungi. In Europe and North America Aspergillus species are the most common contaminants of the sinuses, with relatively few cases of mycoses caused by Mucor, Candida, Penicillium, Cladosporium, and Fusarium reported in the literature. Although Aspergillus and Mucor are mainly saprophytic, they may cause severe, potentially lethal complications. Consequently, therapy should include complete removal of the mycotic masses and prevention of reinfection. In nearly all cases in our experience, fungal diseases of the maxillary sinuses are secondary diseases, the pathologic conditions for which are created by chronic recurring sinusitis. Nasal endoscopy has shown that in most cases of recurring sinusitis, infection spreads from the nose into the larger sinuses, mostly from an infected anterior ethmoid. Maxillary and frontal sinuses are fully dependent on the pathophysiologic conditions in the anterior ethmoid because their ventilation and drainage pass through its complicated system of fissures and clefts into the middle nasal meatus. Endoscopic endonasal surgery of the diseased ethmoid is therefore an important element in our treatment schedule. Stenotic and/or chronically infected areas of the anterior ethmoid are identified by conventional or computed tomography. These areas then undergo endonasal operation under the guidance of rigid endoscopes. Diseased mucosa is removed, narrow or stenotic areas are widened, and the natural maxillary sinus ostium is enlarged. In many cases it is possible to remove all mycotic masses through this new window. Fenestration into the inferior nasal meatus is unnecessary with this method, and the sinus mucosa is usually left untouched. For follow-up treatment, instillations of antimycotic or antibiotic ointments are used. Even in cases of massive mucosal changes, the dependent sinuses, such as the frontal or maxillary sinuses, usually heal spontaneously after this procedure without having been treated directly. More than 140 patients with mycotic sinusitis, 48 of whom were studied and followed up for this paper, were treated by us during the last 8 years. The endoscopic surgical technique we have developed is described in detail.

Rhinocerebral mucormycosis: three case reports and subject review

Rhinocerebral mucormycosis (RCM) in the diabetic patient can be a particularly aggressive and devastating disease. The emergency physician will typically see patients with RCM in its earliest stages masquerading as a variety of other, less serious diseases. Early diagnosis is the key to a successful outcome. Three such cases seen in the emergency department are reviewed with attention to their initial clinical presentation and treatment. In addition, the historical, pathophysiologic, clinical, and therapeutic aspects of RCM are reviewed.

Dental care for patients with renal failure and renal transplants

Patients with renal failure have characteristic systemic and oral conditions that require special precautions during dental treatment. Drugs must be administered with caution and patients undergoing hemodialysis must receive special consideration. Both hemodialysis and transplant patients must be protected against infection. This is achieved by early, aggressive, and thorough dental treatment. Use of antibiotics during dental treatment is essential in transplant patients and is often necessary in hemodialysis patients to protect them against bacteremia. Bacterial endocarditis is a concern in patients with renal failure and with heart disease and, in these patients, antibiotic prophylaxis is essential. Hepatitis is often present in patients with renal failure, and precautions should be taken against its spread. Before dental treatment of patients with renal failure is begun, the dentist should consult the patient's physician regarding specific precautions. A treatment plan should be constructed which best restores the patient's dentition and protects from potentially severe infection of dental origin.