Mucormycosis of the mandible

Mucormycosis of the Mandible and Tongue: A Systematic Scoping Review

AIM

Mucormycosis is a rare human infection associated with Mucorales, a group of filamentous moulds found in different environmental niches. Its oral manifestations may occur in the mandible and tongue despite being rare. We aimed to systematically review the data on clinical manifestations, risk factors, diagnostic approaches, treatment options, and outcomes of mandibular and tongue mucormycosis.

METHODS

An electronic search of articles published between January 1975 and November 2022 in PubMed, Web of Science, and EMBASE databases was performed. A total of 22 articles met the inclusion criteria and reported 27 cases of oral mucormycosis in total.

RESULTS

Fourteen patients had mandibular mucormycosis signs unrelated to COVID-19 infection, 6 had SARS-CoV-2-related mandibular mucormycosis, and 6 had manifestations in the tongue. All published case reports during the COVID-19 pandemic were from India. Patient ages ranged from 4 months old to 82 years, and most patients had important comorbidities, such as blood dyscrasias related to immune deficiency and uncontrolled type 2 diabetes mellitus. The signs and symptoms of mandibular and tongue mucormycosis varied from dental pain, loose teeth, and nonhealing sockets to dysphagia and paraesthesia of the lip. Some patients also reported trismus, draining sinus tract, and facial pain. The diagnosis of oral mucormycosis was based on a combination of clinical, radiographic, and histopathologic findings by demonstrating fungal hyphae in tissue specimens. In most cases, mucormycosis was managed with systemic amphotericin B, strict glycaemic control, and aggressive surgical debridement of infected tissue, minimising the progression of the fungal infection and thus improving the survival rate. In some cases, combined antifungal therapy, antibiotic therapy, and chlorhexidine mouthwashes were used successfully.

CONCLUSIONS

Recognition of the signs and symptoms by oral care providers is pertinent for the early diagnosis and treatment of tongue and mandibular mucormycosis, and providers should be aware of the possibility of this opportunistic fungal infection in patients with COVID-19. A multidisciplinary approach is recommended for the management of this lethal infection.

A Novel Classification System for Oral Cavity Mucormycosis: a Hospital Based Cross-Sectional Study

Background

Rhino-oculo-cerebral Mucormycosis (ROCM) is a well-known complication post-COVID-19 infection. The extension of this disease into the oral cavity is a grey area with no proper protocol for management of the same in the existing literature. Based on our experience in the management of oral extension, this study aims to propose a protocol to treat these cases.

Aim

To derive a classification for the surgeon from retrospectively collected data of 53 operated cases of oral Mucormycosis.

Settings and Design

Hospital record-based cross-sectional study; evaluation of the previously treated 53 cases of oral extension of post-COVID-19 Rhino-oculo-cerebral Mucormycosis in the duration between May 2021 to August 2021. Follow-up for a period of 1 year.

Methods and Material

Based on the preoperative data, 4 parameters were taken -Tooth tenderness, Tooth mobility, Palatal perforation, and Radiological findings. A clinical-radiological classification system was derived based on the intraoperative data from the OT notes and the preoperative findings corresponding to the 4 parameters.

Statistical Analysis

The statistical analysis was done using SPSS for windows version 20 software (SPSS Inc., Chicago, IL, USA).

Results

Totally 220 cases of ROCM were recorded in our institute. Of this, 53 patients were treated for ROCM extending into the oral cavity. In 27 patients, we were able to achieve primary closure. In 26 patients, there was oro-antral communication after removal of the palate. Based on this data, we derived a protocol that may be used by the treating surgeon to manage oral cavity cases of ROCM, so that aggressive tissue resection may be avoided unnecessarily.

Conclusion

This protocol will help the treating surgeon to have a clearer outlook on treating this disease.

A retrospective analysis for the management of oromaxillofacial invasive mucormycosis and systematic literature review

PURPOSE

Mucormycosis is a type of fatal infectious disease, rarely involved in the oromaxillofacial region. This study aimed to describe a series of 7 cases with oromaxillofacial mucormycosis and to discuss the epidemiology, clinical features, and treatment algorithm thereof.

METHODOLOGY

Seven patients in the author's affiliation have been treated. They were assessed and presented as per their diagnostic criteria, surgical approach, and mortality rates. Reported cases of mucormycosis originally happened in craniomaxillofacial region were synthesized through a systematic review so as to better discuss its pathogenesis, epidemiology, and management.

RESULTS

Six patients had a primary metabolic disorder, and one immunocompromised patient had a history of aplastic anemia. The criteria for a positive diagnosis of invasive mucormycosis were based on clinical presentation of signs and symptoms, and a biopsy for microbiological culture and histopathologic analysis. Each patient used antifungal drugs and five of them also underwent surgical resection at the same time. Four patients died due to the unregulated spread of mucormycosis, and one patient died owing to her main disease.

CONCLUSIONS

Although uncommon in clinical practice setting, mucormycosis should be of great concern in oral and maxillofacial surgery, due to the life-threatening possibility of this disease. The knowledge of early diagnosis and prompt treatment is of utmost importance for saving lives.

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.

Post-COVID Mucormycosis of Mandible: A Conundrum of Management

Mucormycosis is an acute invasive infection of paranasal sinuses, with the propensity to spread from paranasal sinuses to intra-orbital and cranium. It is usually associated with immunocompromised states like diabetes mellitus, hematological malignancies, long-term steroids, neutropenia, and other multiple systemic disorders. Mucormycosis cases had been upsurging following COVID-19 infection. Due to the rampant use of steroids, pulmonary involvement secondary to cytokine upsurge, and deranged blood sugar levels in diabetic patients, mucormycosis of paranasal sinuses and neighboring anatomical structures has occurred at an unprecedented rate. The isolated involvement of the mandible is infrequent, and very few cases have been reported in the literature. We report one such case of post-COVID-19 isolated mandibular mucormycosis and its management. Generally, surgical excision and reconstruction of defect followed by a course of broad-spectrum antifungals are described as the appropriate line of management for this condition. However, on the contrary, we followed conservative management as the sole treatment because of the various challenges concerning undesirable postoperative consequences and reducing morbidity for the patient.

Mucormycosis of Paranasal Sinuses of Odontogenic Origin Post COVID19 Infection: A Case Series

The Severe acute respiratory syndrome and the Middle East respiratory syndromes emerged in 2002 and 2012 respectively. Currently the world is witnessing a global pandemic caused by a novel coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS CoV- 2) causing the Coronavirus 2019 (COVID-19). Mucormycosis is a fungal infection primarily affecting individuals with an immunocompromised state like diabetes mellitus, malignancies etc. Patients who have or have had COVID-19 infection with pre-existing uncontrolled Type 2 Diabetes mellitus are presumably more vulnerable for emergence of fungal infections cases. This article presents a report of 6 cases with histopathological proven mucormycosis associated with COVID-19 and uncontrolled Diabetes mellitus.

Case of mucormycosis of mandible after self-extraction of teeth incidentally detected to have chronic granulomatous disease: Case report and literature review

Mucormycosis isolated to the mandible is a rare presentation occurring generally after dental procedures. The case we report presented with discharging sinuses over facial region with radiological appearance of isolated osteomyelitis of the mandible. The patient used to apply an addictive dental powder over his teeth leading to caries. Following this, he pulled out all his teeth, which probably led to his condition. Invasive sampling revealed mucormycosis. An extensive search for an underlying immunodeficiency revealed that the patient had chronic granulomatous disease (CGD). Despite a prolonged course of L-Amphotericin B, the patient continued to have intermittent pus discharge and surgical debridement and curettage was eventually required. The patient had a chronic course with minimal soft tissue involvement which initially did not raise the suspicion of mucormycosis. The main learning point is that an unusual invasive fungal infection in an otherwise healthy host can be the first symptom of an underlying primary immunodeficiency, like CGD. Invasive fungal infections in patients with CGD often have an indolent course.

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Mucormycosis isolated to the mandible is a rare presentation, occurring generally after dental procedures.

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Self-extraction of teeth as in our patient can result in isolated mucormycosis of the mandible.

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Isolated mucormycosis of the mandible can be a presenting symptom of chronic granulomatous disease.

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Combination of medical and surgical treatment is usually needed in mandibular mucormycosis.

Rhinocerebral Mucormycosis Among Diabetic Patients: An Emerging Trend

Mucormycosis is an acute necrotic fungal infection with a fulminant course. Earlier considered a rare entity, mucormycosis is being reported with increasing frequency in recent years, possibly due to the increase in immunocompromised population especially diabetic patients. We report three cases of rhinocerebral mucormycosis among poorly controlled diabetic patients. This article emphasizes the need for further awareness of this disease, early diagnosis, and treatment to counter this opportunistic infection.

Fulminant mucormycosis involving paranasal sinuses: a rare case report

Mucormycosis is an opportunistic fulminant fungal infection, which has the ability to cause significant morbidity and frequently mortality in the susceptible patient. Common predisposing factors include diabetes mellitus and immunosuppression. The infection begins in the nose and paranasal sinuses due to inhalation of fungal spores. The fungus invades the arteries leading to thrombosis that subsequently causes necrosis of the tissue. The infection can spread to orbital and intracranial structures either by direct invasion or through the blood vessels. Here we describe a case of mucormycosis of maxillary antrum extending to ethmoidal and frontal sinus and also causing necrosis of left maxilla in an uncontrolled diabetic individual to emphasize early diagnosis and treatment of this fatal fungal infection.

Mucormycosis of mandible with unfavorable outcome

Mucormycosis is a fulminant fungal infection that occurs most often in diabetic and immunocompromised individuals. Our patient, with uncontrolled diabetes mellitus and multiple systemic disorders, developed postextraction mucormycosis of mandible, an extremely rare complication. An initial clinical and radiographic diagnosis of mandibular osteomyelitis was made and the lesion was treated medically and surgically with curettage and saucerisation. The specimen was sent for histopathological evaluation, which showed necrotic area containing broad aseptate fungal hyphae with right angle branching consistent with mucormycosis. The patient succumbed to multipleorgan failure secondary to septicemia. The disease is usually fatal with a poor survival rate; there is still paucity of literature on the definitive management of this disease involving the mandible. This paper emphasizes the need for correction of underlying immunodeficiency and early diagnosis with aggressive multimodality treatment approach to offer the best chance of survival.

A trifungal infection of the mandible: Case report and literature review

Orofacial fungal infections are occasionally seen in the immunocompromised patient. In this case, a patient with a relapse of an acute lymphoblastic leukemia (ALL) developed a fatal mandibular infection. This may be the first reported case of a trifungal infection with zygomycosis, aspergillosis, and candidiasis in the oral cavity and the fifth mandibular zygomycosis case. Epidemiology, diagnosis, treatment and prognosis of zygomycosis infection are reviewed, along with the 4 mandibular zygomycosis cases found in the English literature.

Cutaneous Mucormycosis of the Head and Neck with Parotid Gland Involvement: First report of a Case

Cutaneous mucormycosis is an uncommon, life-threatening, opportunistic fungal infection that is a distinctly different entity from the more frequent although still uncommon rhinocerebral form that is better known to otolaryngologists. We describe what to our knowledge is the only reported case of cutaneous mucormycosis of the face with parotid gland involvement, which occurred in a 56-year-old man. The diagnosis was established by tissue biopsy. The patient was treated with antifungal medications and wide local debridement, including a total parotidectomy with sacrifice of the inferior division of the facial nerve. At the 2-year follow-up, he remained free of disease. Familiarity with the risk factors associated with the development of cutaneous mucormycosis is critical to determining the need for early tissue biopsy to confirm the diagnosis. Generally favorable clinical outcomes are associated with prompt and aggressive medical and surgical therapy.

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 manifestations of the systemic mycoses

Aspergillosis, cryptococcosis and zygomycosis (mucormycosis) are overall the most common systemic mycoses but histoplasmosis is particularly endemic in parts of central USA and other areas worldwide. Orofacial lesions caused by systemic mycoses have rarely been reported in the past though they have been recorded particularly in outdoor workers from geographic areas with a high prevalence of infection and occasionally in immunocompromised individuals. Increasing world-wide travel, and the dramatic increase in numbers of immunocompromised persons, especially those with human immunodeficiency virus (HIV) disease, have been responsible for an increase in reports and other studies of orofacial disease in systemic mycoses and new opportunists are now being recognized. Those in Oral Medicine and Pathology must now be aware of the possibility of a systemic mycosis as the cause of chronic oral ulceration, chronic maxillary sinus infection, or bizarre mouth lesions, especially in patients with HIV disease, lymphoproliferative disorders, or diabetes mellitus, or in those who have been in endemic areas. Diagnosis and management should be undertaken in consultation with a physician with appropriate expertise, as pulmonary and other systemic infection may well be present. This paper reviews the eight main systemic mycoses.

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.