Mandibular mucormycosis following SARS-CoV-2 infection - A case report and review of literature

Impact of COVID-19 Disease on the Development of Osteomyelitis of Jaws: A Systematic Review

Background/Objectives: Osteomyelitis is characterized by an inflammatory process affecting both bone and bone marrow, leading to cell death and the formation of bone sequestrum. Recent literature from the past five years has documented instances of osteomyelitis following infections of SARS-CoV-2. This systematic review explores the link between osteomyelitis of the jaw (OMJ) and COVID-19 infections. Methods: This review adhered to the PRISMA guidelines, systematically analyzing literature from 2020 to 2024 sourced from databases including Medline, Embase, Scopus, and Web of Science. PROSPERO ID: CRD42024526257. Results: The review selected 42 articles, detailing 201 cases of osteomyelitis of the jaw related to COVID-19 (COMJ). The demographic breakdown included 195 male (74.4%) and 67 female patients (25.6%), with a median age of 52.7 years, ranging from 24 to 71 years. A significant portion of COMJ patients (41.5%) were hospitalized due to COVID-19, and 58.5% received corticosteroid therapy. Diabetes mellitus was a common comorbidity among COMJ patients (65.1%). Most cases involved maxilla (182 cases; 90.5%), with nearly half showing sinus involvement (49.4%). The mandible was affected in 19 cases (9.5%). Mucormycosis and aspergillosis emerged as the predominant fungal infections, identified in 103 (51.2%) and 50 (24.9%) cases, respectively. Conclusions: Individuals with pre-existing health conditions such as diabetes mellitus who have been treated for COVID-19 are at an increased risk of developing OMJ, particularly maxillary fungal osteomyelitis. COMJ poses a significant diagnostic and therapeutic challenge for dental and maxillofacial professionals, who are often the first to encounter these cases.

Nintedanib-induced osteomyelitis of the jaw against the background of COVID-19 infection

PURPOSE

Various medications are administered to treat Coronavirus Disease 2019 (COVID-19) infection and prevent its complications. Some medicines have complications and long-term effects, which may mimic other conditions, making precise diagnosis difficult. This report aims to bring to light one such complication, medication-related osteonecrosis of the jaw (MRONJ), secondary to a commonly prescribed medication for preventing lung fibrosis post-COVID-19 infection.

METHOD

A 33-year-old male reported to our department with the typical clinical and radiological features of Mucormycosis of the upper jaw post-COVID-19 infection. However, on detailed evaluation of his history (controlled diabetic and short duration of steroid therapy) and review of the mycology staining, bacteriology, culture, and histopathological reports, we came to a negative diagnosis for Mucormycosis. The patient was, however, on treatment for the prevention of lung fibrosis with Nintedanib (tyrosine kinase inhibitor) 150 mg twice a day for one month.

RESULT

In the absence of predisposing factors and negative laboratory findings for mucormycosis, we arrived at a diagnosis of MRONJ, attributable to Nintedanib therapy given to prevent lung fibrosis post-COVID-19 infection.

CONCLUSION

The use of Nintedanib has recently increased due to the high incidence of lung fibrosis post-COVID-19 infection. However, Nintedanib should be considered a causative agent for osteonecrosis of the jaw in the absence of other obvious predisposing factors. Therefore, Nintedanib must be administered after a thorough consideration of risk factors.

Rhinocerebral mucormycosis in immunocompetent patients: a case report and review of literature

INTRODUCTION

Mucormycosis of the head and neck region is a rare but aggressive fungal infection that usually involves immunocompromised patients. More infrequently, this infection can also occur in people with no otherwise known underlying immunological deficit. This rarity usually causes a delay in diagnosis and may severely decrease the chance of survival in these patients. In this study, we present an extreme case of mucormycosis in an immunocompetent patient. By conducting a thorough review of the literature, we aim to increase our knowledge on this matter. Our goal is to improve diagnosis and start treatment at an earlier stage.

CASE PRESENTATION AND METHODS

Our patient was a 31-year-old man who presented with bilateral face numbness, neck pain, headache, and a necrotic palatal lesion 45 days after a dental root canal procedure. There was extensive involvement of facial and skull base bony and soft tissues. Through two debridement sessions and intravenous antifungal treatment, the patient was discharged with near-complete disease resolution. We identified 48 cases in the literature that matched our study criteria. We searched the current literature for proven cases of mucormycosis in the head and neck region who didn't have any underlying disease. We extracted their data and added the data of our patient. Then, we re-analyzed them using descriptive analysis, chi-square, and binary logistic regression to better understand the different factors for survival and disease burden in these patients.

RESULTS

49 patients were analyzed in this study. The mean age was 46.93 ± 15.75 (min 16 and max78 years old). The most prevalent subsite to be involved was the sino-nasal mucosa, followed by the surrounding soft tissues and the orbit. While both orbit and intracranial tissue involvement differed significantly between surviving and deceased patients, only intracranial tissue involvement could be used to predict survival. The overall survival rate was 91.8%.

CONCLUSION

Although very rare, mucormycosis can occur in immunocompetent patients. Physicians should consider mucormycosis when faced with refractory conditions and unusual symptoms such as exposed bones, facial numbness, headaches, and intractable pain. Complementary imaging (CT scan with or without MRI) and histopathological examination are critical for timely diagnosis or exclusion of this potentially fatal yet treatable disease.

Post-COVID mucormycosis osteomyelitis and its imaging manifestations in the North of Iran: case series

Mucormycosis is an invasive fungal infection that usually affects patients with immunocompromised conditions. In the context of the COVID-19 pandemic and the following corticosteroid therapy, mucormycosis prevalence has increased. The situation may be more complicated with some underlying diseases such as diabetes mellitus. In addition, due to the vicinity of maxillary bone to the nasal cavity and paranasal sinuses, which are the main routes for the infection to spread, dentists, maxillofacial radiologists, and surgeons may be the first to encounter these patients. Post-COVID mucormycosis osteomyelitis is one of the complications of this infection Bone destruction and the erosion or breach of cortical boundaries of the maxilla and the bone structures in the vicinity of paranasal sinuses are the most critical radiographic findings of post-covid osteomyelitis. Herein, there are some cases of post-covid mucormycosis osteomyelitis involving the maxillary and other facial bones.

Post-Covid Isolated Mandibular Mucormycosis in a Patient with Chronic Kidney Disease: A Case Report

Mucormycosis is an opportunistic fungal infection which was earlier seen only in immunocompromised patients. With the recent covid pandemic, there had been a drastic surge in cases of mucormycosis worldwide and especially in India. Here, we present an unusual case of biopsy proven invasive mandibular mucormycosis in a patient with chronic kidney disease and a history of COVID-19 infection. The patient was given low-dose amphotericin B and underwent surgical debridement with a successful outcome.

COVID-19 and Mucormycosis of Orofacial Region: A Scoping Review

During the second wave of coronavirus disease, or COVID-19, infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in the year 2021 around the globe, there is a surge in the number of cases of mucormycosis or "Black Fungus" that is directly/indirectly associated with COVID-19. In this review article, mucormycosis of the orofacial region has gained importance from the maximum published literature (45 articles) from various databases like PubMed, Google Scholar, Scopus, Web of Science, and Embase. Rhino-orbital cerebral mucormycosis (ROCM) is a fatal condition associated with COVID-19 among categories of mucormycosis such as pulmonary, oral, gastrointestinal, cutaneous, and disseminated. ROCM targets the maxillary sinus, also involving teeth of the maxilla, orbits, and ethmoidal sinus. These are of particular interest to dentists and oral pathologists for proper diagnosis and identification. Co-morbid conditions, especially diabetes mellitus type II, have to be monitored carefully in COVID-19 patients as they have a higher risk of developing mucormycosis. In this review article, various presentations of COVID-19-linked mucormycosis are mentioned having particular emphasis on pathogenesis, signs and symptoms, clinical presentation, various diagnostic modalities including histopathology, radiology like CT and MRI, serology, tissue culture, various laboratory investigations, treatment protocols, management with prognosis, and so on. Any suspected case of mucormycosis needs quick detection and treatment since it progresses quickly due to the destructive course of infection. Long-term follow-up along with proper care is a must to detect any kind of recurrence.

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.

Pathogenesis and Pathology of COVID-Associated Mucormycosis: What Is New and Why

Purpose of Review

There is global increase in the incidence of mucormycosis. However, a sudden increase in the COVID-associated mucormycosis (CAM) was noted, particularly in India, during the second wave of the COVID-19 pandemic. The interplay of factors involved in the pathogenesis is complex. In this review, the influence of pre-existing disease, exaggerated risk factors, altered milieu due to COVID-19 itself and the consequences of its treatment on the host pathogen interactions leading to the disease and morphology of the fungus will be highlighted.

Recent Findings

Hyperglycemia, acidosis, available free iron, lowered host defenses, and the fungal virulence factors promote the growth of Mucorales. There is a high background prevalence of diabetes mellitus (DM) in India. Uncontrolled or undiagnosed DM, COVID-19 itself, and inappropriate administration of corticosteroids in high doses and for prolonged periods result in hyperglycemia. Diabetic ketoacidosis (DKA) and metabolic acidosis due to hypoxia or renal failure contribute to acidic pH and dissociate bound iron from serum proteins. The host defenses are lowered due to COVID-19-induced immune dysregulation, hyperglycemia itself, and administration of corticosteroids and immune suppressants for the treatment of COVID-19. The altered metabolic milieu in the local microenvironment of nose and paranasal sinuses (PNS) promotes specific interaction of glucose-regulated protein-78 (GRP-78) on host cells with spore coat protein homologue (CotH 3) on Mucorales resulting in rhino-orbito-cerebral mucormycosis (ROCM) as the predominant clinical form in CAM. The pathology is extensive soft tissue involvement with angioinvasion and perineural invasion. Melanized hyphae and sporangia were seen on histopathology, which is unique to CAM. While many factors favor the growth of Mucorales in CAM, hyperglycemia, hyperferritinemia, and administration of hyperbaric oxygen result in reactive oxygen species (ROS) and inadequate humidification results in dehydration. Melanization is possibly the adaptive and protective mechanism of Mucorales to escape the unfavorable conditions due to the treatment of COVID-19.

Summary

High background prevalence of DM, inappropriate administration of corticosteroids and immune dysregulation due to COVID-19 favor the growth of Mucorales in CAM. Melanization of Mucorales hyphae and sporangia on histopathology probably represent adaptive and protective mechanism due to the treatment with hyperbaric oxygen with inadequate humidification as well as the metabolic alterations.

COVID-19-Associated Mucormycosis: A Matter of Concern Amid the SARS-CoV-2 Pandemic

Mucormycosis is an invasive fungal infection caused by fungi belonging to order Mucorales. Recently, with the increase in COVID-19 infections, mucormycosis infections have become a matter of concern globally, because of the high morbidity and mortality rates associated with them. Due to the association of mucormycosis with COVID-19 disease, it has been termed COVID-19-associated mucormycosis (CAM). In the present review, we focus on mucormycosis incidence, pathophysiology, risk factors, immune dysfunction, interactions of Mucorales with endothelial cells, and the possible role of iron in Mucorales growth. We review the limitations associated with current diagnostic procedures and the requirement for more specific, cost-effective, convenient, and sensitive assays, such as PCR-based assays and monoclonal antibody-based assays for the effective diagnosis of mucormycosis. We discuss the current treatment options involving antifungal drug therapies, adjunctive therapy, surgical treatment, and their limitations. We also review the importance of nutraceuticals-based therapy for the prevention as well as treatment of mucormycosis. Our review also highlights the need to explore the potential of novel immunotherapeutics, which include antibody-based therapy, cytokine-based therapy, and combination/synergistic antifungal therapy, as treatment options for mucormycosis. In summary, this review provides a complete overview of COVID-19-associated mucormycosis, addressing the current research gaps and future developments required in the field.

Mucormycosis, one month after recovery from COVID-19: A case report

Introduction

and importance: There are increasing case reports of mucormycosis in patient with coronavirus disease 2019 (Covid-19). Herein, we describe the case of mucormycosis after recovery from Covid-19.

Case presentation

The patient was a 73 years old woman with a history of chronic kidney disease, diabetes mellitus, hypertension, and dyslipidemia that referred to the emergency department with clinical presentation of Covid-19. On the third day of admission, the Covid-19 PCR test was negative, but the patient presented headache and pain in her upper jaw. Physical examination showed fever, erythema, and tenderness in the right cheek. Emergency biopsy and culture from sinus by subsection to mucormycosis conducted. and the diagnosis of mucormycosis was confirmed by the positive result of biopsy and culture. Despite anti-fungal treatment with Amphotericin B, patient developed severe diarrhea and became hemodynamically unstable. In the stool analysis, Strongyloides stercoralis was reported. Unfortunately, patient was expired on day thirty-two of this admission.

Clinical discussion

Mucormycosis is a dangerous infection, and its rapid diagnosis is so important. On the other hand, Covid-19 may associated with many nonspecific sign and symptoms. These finding may overlap with other infections.

In patients with prolonged mucormycosis infection, the development of strongyloidiasis should not be neglected. A single dose of ivermectin as strongyloidiasis prophylaxis should be given if the duration of the illness is prolonged.

Conclusion

Clinicians should consider mucormycosis and its complications after Covid-19 treatment in diabetic and immunocompromised patients.

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COVID-19 may be associated with bacterial or fungal co-infections.

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Nonspecific sign and symptoms of COVID-19, may overlap with other infections.

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Mucormycosis may occur following COVID-19, especially in patients with risk factors.

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We report a case of mucormycosis, one month after recovery from COVID-19 in a patient with poor diabetic control.