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Fakhruddin KS, Matsubara VH, Warnakulasuriya S, Tilakaratne WM, Ngo HC, Samaranayake LP. Mucormycosis of the Mandible and Tongue: A Systematic Scoping Review. Int Dent J 2024; 74:454-472. [PMID: 38143163 PMCID: PMC11123561 DOI: 10.1016/j.identj.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 12/26/2023] Open
Abstract
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.
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Affiliation(s)
- Kausar Sadia Fakhruddin
- Department of Preventive and Restorative Dentistry, University of Sharjah, Sharjah, United Arab Emirates
| | | | | | | | - Hien Chi Ngo
- Dental School, University of Western Australia, Perth, Western Australia, Australia
| | - Lakshman P Samaranayake
- Faculty of Dentistry, The University of Hong Kong, Hong Kong. Special Administrative Region, China.
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Repetto M, González-Quintanilla D, Alarcón A, Cordero E, Quiñones P, Argandoña J, Melian A, Lazo D, Mardones M, Cortés J, Córdova LA. Early diagnosis and aggressive surgical resection matters to cure rhinocerebral mucormycosis: Six case reports. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024:101898. [PMID: 38702012 DOI: 10.1016/j.jormas.2024.101898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 05/06/2024]
Abstract
Rhino-cerebral mucormycosis (RM) is a rare and opportunistic fungal infection observed in immune-compromised patients and metabolic imbalances such as Diabetes Mellitus. RM rapidly infiltrates blood vessels, leading to vascular thrombosis, subsequent tissue necrosis, and high mortality rates (23.6-60%). Due to its fast advancement, RM is a life-threatening condition requiring accurate clinical decisions by the medical and surgical teams. Based on the report of six cases, we emphasize the need for an early diagnosis and starting antifungal pharmacological therapy at the slightest suspicion of RM. Moreover, the restitution of metabolic balance and aggressive surgical debridement are vital steps to control RM, reducing the possibility of fatal outcomes.
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Affiliation(s)
- Maximiliano Repetto
- Department of Oral and Maxillofacial Surgery, Hospital Hernán Henriquez Aravena, Manuel Montt 115, Temuco, Chile
| | - David González-Quintanilla
- Doctorate Program in Dental Sciences. School of Dentistry, Universidad de Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; School of Health Sciences, Dentistry, Universidad Viña del Mar, Diego Portales 90, Viña del Mar, Chile
| | - Ana Alarcón
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; Department of Oral and Maxillofacial Surgery, Hospital San Borja Arriarán, Santiago, Chile. Av. Santa Rosa 1234, Santiago, Chile
| | - Erita Cordero
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; Department of Oral and Maxillofacial Surgery, Hospital San Borja Arriarán, Santiago, Chile. Av. Santa Rosa 1234, Santiago, Chile
| | - Patricio Quiñones
- Department of Oral and Maxillofacial Surgery, Hospital San Juan de Dios, Av. Portales 3239, Santiago, Chile; Department of Oral and Maxillofacial Surgery, Clínica Alemana, Av Vitacura 5951, Vitacura, Chile
| | - Juan Argandoña
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; Department of Oral and Maxillofacial Surgery, Hospital San Juan de Dios, Av. Portales 3239, Santiago, Chile
| | - Andrés Melian
- Department of Oral and Maxillofacial Surgery, Hospital San José, San José 1196, Independencia, Chile
| | - Diego Lazo
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; Department of Oral and Maxillofacial Surgery, Hospital San José, San José 1196, Independencia, Chile
| | - Marcelo Mardones
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; Department of Oral and Maxillofacial Surgery, Hospital San José, San José 1196, Independencia, Chile
| | - Juan Cortés
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; Department of Oral and Maxillofacial Surgery, Hospital San Borja Arriarán, Santiago, Chile. Av. Santa Rosa 1234, Santiago, Chile
| | - Luis A Córdova
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile; Craniofacial Research Lab, Faculty of Dentistry, Universidad Andrés Bello, Santiago, Chile. Echaurren 277, Santiago, Chile; IMPACT, Center of Interventional Medicine for Precision and Advanced Cellular Therapy, Santiago, Chile. Av. Mons. Álvaro del Portillo 12455, Las Condes, Santiago, Chile.
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3
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Bemquerer LM, de Arruda JAA, Costa FPD, Abreu LG, Macari S, Moreno A, Jardilino FDM, Travassos DV, Silva TA. Diagnosis and rehabilitation of an infant with palatal mucormycosis: A clinical report and systematic literature review. J Prosthet Dent 2024:S0022-3913(24)00200-2. [PMID: 38609762 DOI: 10.1016/j.prosdent.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 04/14/2024]
Abstract
STATEMENT OF PROBLEM Oral mucormycosis is uncommon in pediatric patients with hematolymphoid diseases. Prosthetic rehabilitation is challenging, and protocols are scarce in the literature. PURPOSE The purpose of this clinical report and systematic literature review of case reports and case series was to describe the clinicopathologic aspects of oral mucormycosis and the interim prosthetic rehabilitation of an affected infant. MATERIAL AND METHODS The clinical lesions were ulcerative and necrotic with underlying bone exposure that affected the hard palate. The affected area underwent surgical debridement, and histopathologic analysis was performed. A literature search in PubMed/MEDLINE, Embase, Scopus, and Web of Science up to October 2023 was performed. RESULTS The histopathological features were consistent with mucormycosis. Topical and systemic antifungals were prescribed. Tooth eruption was insufficient, and an acetate plate without clasp retention, but still with adequate retention, was fabricated. Articulatory, masticatory, and swallowing functions were restored, preventing the passage of food and fluids into the oroantral cavities. Twenty-five articles describing 26 patients with oral mucormycosis related to hematolymphoid disorders affecting the pediatric population were identified. None of the authors of these articles provided information about oral rehabilitation. CONCLUSIONS Early diagnosis and treatment are essential to increasing the chances of survival for infants affected by oral mucormycosis. Custom-made rehabilitation should be provided to restore oral function and improve the patient's general health.
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Affiliation(s)
- Larissa Marques Bemquerer
- Postgraduate Student, Department of Oral Surgery, Pathology, and Clinical Dentistry, School of Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - José Alcides Almeida de Arruda
- Postdoctoral Researcher, Department of Oral Diagnosis and Pathology, School of Dentistry, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Fernanda Pereira Delgado Costa
- Postgraduate Student, Multiprofessional Integrated Residency in Health, Clinics Hospital, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Lucas Guimarães Abreu
- Adjunct Professor, Department of Child and Adolescent Oral Health, School of Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Soraia Macari
- Adjunct Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Amália Moreno
- Adjunct Professor, Department of Oral Surgery, Pathology, and Clinical Dentistry, School of Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Francisca Daniele Moreira Jardilino
- Adjunct Professor, Department of Oral Surgery, Pathology, and Clinical Dentistry, School of Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Denise Vieira Travassos
- Associate Professor, Department of Social and Preventive Dentistry, School of Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Tarcília Aparecida Silva
- Full Professor, Department of Oral Surgery, Pathology, and Clinical Dentistry, School of Dentistry, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil.
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Lynch JP, Fishbein MC, Abtin F, Zhanel GG. Part 1: Mucormycosis: Prevalence, Risk Factors, Clinical Features and Diagnosis. Expert Rev Anti Infect Ther 2023. [PMID: 37262298 DOI: 10.1080/14787210.2023.2220964] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/30/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Mucormycosis (MCR) is caused by filamentous molds within the Class Zygomycetes and Order Mucorales. Infections can result from inhalation of spores into the nares, oropharynx or lungs, ingestion of contaminated food or water, or inoculation into disrupted skin or wounds. In developed countries, MCR occurs primarily in severely immunocompromised hosts. In contrast, in developing/low income countries, most cases of MCR occur in persons with poorly controlled diabetes mellitus and some cases in immunocompetent subjects following trauma. Mucormycosis exhibits a propensity to invade blood vessels, leading to thrombosis and infarction of tissue. Mortality rates associated with invasive MCR are high and can exceed 90% with disseminated disease. Mucormycosis can be classified as one of six forms: (1) rhino-orbital-cerebral mucormycosis (ROCM); (2) pulmonary; (3) cutaneous; (4) gastrointestinal or renal (5); disseminated; (6) uncommon (focal) sites. AREAS COVERED The authors discuss the prevalence, risk factors and clinical features of mucormycosis.A literature search of mucormycosis was performed via PubMed (up to November 2022), using the key words: invasive fungal infections; mold; mucormycosis; Mucorales; Zyzomyces; Zygomycosis; Rhizopus, diagnosis. EXPERT OPINION Mucormycosis occurs primarily in severely immunocompromised hosts. Mucormycosis can progress rapidly, and delay in initiating treatment by even a few days worsens outcomes.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Fereidoun Abtin
- Section of Radiology Cardiothoracic and Interventional, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, Max Rady College of Medicine, University of Manitoba
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Goel K, Dhillon J, Yadav V, Bhagat S, Aggarwal A. Post-Covid Isolated Mandibular Mucormycosis in a Patient with Chronic Kidney Disease: A Case Report. Indian J Otolaryngol Head Neck Surg 2023:1-6. [PMID: 37362119 PMCID: PMC10148609 DOI: 10.1007/s12070-023-03838-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/24/2023] [Indexed: 06/28/2023] Open
Abstract
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.
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Affiliation(s)
- Khushboo Goel
- Department of Otorhinolaryngology and Head & Neck Surgery, Government Medical College, Patiala, Punjab India
| | | | - Vishav Yadav
- Department of Otorhinolaryngology and Head & Neck Surgery, Government Medical College, Patiala, Punjab India
| | - Sanjeev Bhagat
- Department of Otorhinolaryngology and Head & Neck Surgery, Government Medical College, Patiala, Punjab India
| | - Ankita Aggarwal
- Department of Otorhinolaryngology and Head & Neck Surgery, Government Medical College, Patiala, Punjab India
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Li CX, Gong ZC, Pataer P, Shao B, Fang C. A retrospective analysis for the management of oromaxillofacial invasive mucormycosis and systematic literature review. BMC Oral Health 2023; 23:115. [PMID: 36810012 PMCID: PMC9942087 DOI: 10.1186/s12903-023-02823-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
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.
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Affiliation(s)
- Chen-xi Li
- grid.412631.3Department of Oral and Maxillofacial Oncology and Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology, Xinjiang Medical University, Stomatological Research Institute of Xinjiang Uygur Autonomous Region, No.137 Liyushan South Road, Ürümqi, 830054 People’s Republic of China ,grid.33199.310000 0004 0368 7223Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022 People’s Republic of China
| | - Zhong-cheng Gong
- grid.412631.3Department of Oral and Maxillofacial Oncology and Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology, Xinjiang Medical University, Stomatological Research Institute of Xinjiang Uygur Autonomous Region, No.137 Liyushan South Road, Ürümqi, 830054 People’s Republic of China
| | - Parekejiang Pataer
- grid.412631.3Department of Oral and Maxillofacial Oncology and Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology, Xinjiang Medical University, Stomatological Research Institute of Xinjiang Uygur Autonomous Region, No.137 Liyushan South Road, Ürümqi, 830054 People’s Republic of China
| | - Bo Shao
- grid.412631.3Department of Oral and Maxillofacial Oncology and Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology, Xinjiang Medical University, Stomatological Research Institute of Xinjiang Uygur Autonomous Region, No.137 Liyushan South Road, Ürümqi, 830054 People’s Republic of China
| | - Chang Fang
- grid.412631.3Department of Oral and Maxillofacial Oncology and Surgery, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology, Xinjiang Medical University, Stomatological Research Institute of Xinjiang Uygur Autonomous Region, No.137 Liyushan South Road, Ürümqi, 830054 People’s Republic of China
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Atypical presentations of fungal osteomyelitis during post COVID-19 outbreak – Case series. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY, MEDICINE, AND PATHOLOGY 2022; 34:622-627. [PMID: 35402152 PMCID: PMC8977445 DOI: 10.1016/j.ajoms.2022.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/06/2022] [Accepted: 03/11/2022] [Indexed: 11/20/2022]
Abstract
Introduction Mucormycosis and Aspergillosis are opportunistic fungal infections causing significant morbidity and mortality. Post the outbreak of COVID-19, these fungal osteomyelitis have seen a global rise with few atypical presentations noted. Case report Current case series reports three such atypical presentations of fungal osteomyelitis including mandibular fungal osteomyelitis in two patients, fungal osteomyelitis mimicking space infection in a middle aged male, and suspected mixed fungal osteomyelitis involving maxillary sinus. Aggressive surgical debridement was indicated along with institution of antifungal therapy (Liposomal Amphotericin B, and Posaconazole). The fungal osteomyelitis was successfully treated with surgical and medical management with no recurrence. Discussion The injudicious use of corticosteroids in COVID-19 patients along with their immunocompromised status increases their susceptibility to opportunistic fungal osteomyelitis. Prompt and aggressive surgical intervention along with antifungal therapy is important after diagnosing fungal osteomyelitis, as a delay could increase the mortality rate considerably.
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Haidry N, Bhavana K, Shivhare P, Kumar V, Vaidyanathan A. A Rare Case of Mandibular Mucormycosis in a Post-COVID-19 Patient. Cureus 2022; 14:e28216. [PMID: 36158405 PMCID: PMC9485010 DOI: 10.7759/cureus.28216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2022] [Indexed: 11/05/2022] Open
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Sharma A, Goel A. Mucormycosis: risk factors, diagnosis, treatments, and challenges during COVID-19 pandemic. Folia Microbiol (Praha) 2022; 67:363-387. [PMID: 35220559 PMCID: PMC8881997 DOI: 10.1007/s12223-021-00934-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Mucormycosis is a deadly opportunistic disease caused by a group of fungus named mucormycetes. Fungal spores are normally present in the environment and the immune system of the body prevents them from causing disease in a healthy immunocompetent individual. But when the defense mechanism of the body is compromised such as in the patients of diabetes mellites, neustropenia, organ transplantation recipients, and other immune-compromised states, these fungal spores invade our defense mechanism easily causing a severe systemic infection with approximately 45-80% of case fatality. In the present scenario, during the COVID-19 pandemic, patients are on immunosuppressive drugs, glucocorticoids, thus are at high risk of mucormycosis. Patients with diabetes mellitus are further getting a high chance of infection. Usually, the spores gain entry through our respiratory tract affecting the lungs and paranasal sinuses. Besides, they can also enter through damage into the skin or through the gastrointestinal route. This review article presents the current statistics, the causes of this infection in the human body, and its diagnosis with available recent therapies through recent databases collected from several clinics and agencies. The diagnosis and identification of the infection were made possible through various latest medical techniques such as computed tomography scans, direct microscopic observations, MALDI-TOF mass spectrometry, serology, molecular assay, and histopathology. Mucormycosis is so uncommon, no randomized controlled treatment studies have been conducted. The newer triazoles, posaconazole (POSA) and isavuconazole (ISAV) (the active component of the prodrug isavuconazonium sulfate) may be beneficial in patients who are refractory to or intolerant of Liposomal Amphotericin B. but due to lack of early diagnosis and aggressive surgical debridement or excision, the mortality rate remains high. In the course of COVID-19 treatments, there must be more vigilance and alertness are required from clinicians to evaluate these invasive fungal infections.
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Affiliation(s)
- Ayushi Sharma
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India
| | - Anjana Goel
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, 281 406, Mathura, UP, India.
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Ambereen A, Rahman SA, Rehman S, Zaidi K, Arif SH. Mandibular mucormycosis following SARS-CoV-2 infection - A case report and review of literature. CLINICAL INFECTION IN PRACTICE 2021; 12:100099. [PMID: 34568807 PMCID: PMC8450209 DOI: 10.1016/j.clinpr.2021.100099] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The second wave of COVID-19 pandemic has seen an unprecedented rise in the number of mucormycosis cases worldwide and in India particularly. This otherwise rare fungal infection has become an endemic among patients who have recovered from recent SARS-CoV-2 infection. Among the different types of mucormycosis, rhino-orbital-cerebral involvement has mainly been observed in the recent surge of cases. Very few cases of mucormycosis of mandible have been reported in literature and none in COVID-19 patients. We report a case of isolated mandibular mucormycosis in a COVID- 19 patient, with no other predisposing comorbidities.Case report.A 39 year old patient recently recovered from COVID-19 presented with typical symptoms of osteomyelitis which was confirmed using computed tomography of face. He underwent thorough debridement and curettage and tissue was sent for culture, special staining and biopsy. RESULT Diagnosis of mucormycosis was confirmed based on postoperative biopsy and special staining. He was further managed with complete course of appropriate antifungal therapy. CONCLUSION Mucormycosis is a fulminant and aggressive infection which requires prompt diagnosis and intervention. Early referral to a maxillofacial surgeon by physicians and general dental practitioners on seeing signs and symptoms of secondary fungal infections involving maxilla or mandible in patients with history of SARS-CoV-19 infection can improve prognosis.
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Affiliation(s)
- Aafiya Ambereen
- axillofacial Surgery Dr ZA Dental College Aligarh Muslim University, Indi
| | - Sajjad A Rahman
- axillofacial Surgery Dr ZA Dental College Aligarh Muslim University, Indi
| | - Suhailur Rehman
- Department of Pathology JN Medical College Aligarh Muslim University, India
| | - Kamran Zaidi
- axillofacial Surgery Dr ZA Dental College Aligarh Muslim University, Indi
| | - S H Arif
- Department of Pathology JN Medical College Aligarh Muslim University, India
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Dos Santos RLO, Elchin CB, Guiguer-Pinto VA, Vasconcelos DDM, Ferreira MD, Dias RB, Sugaya NN, Paula CR, Coto NP. Diagnosis, treatment and maxillofacial rehabilitation in rhinocerebral mucormycosis patient: A case report and review of the literature. J Mycol Med 2021; 32:101211. [PMID: 34763149 DOI: 10.1016/j.mycmed.2021.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 09/22/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022]
Abstract
Mucormycosis is an aggressive, rare and opportunistic infectious disease, with a high mortality rate. Etiologic agents are filamentous fungi, and infection among humans normally occurs through spore inhalation. A 61-year-old male individual, presenting left eye amaurosis, dark epistaxis, hyperalgesia and malodor underwent clinical examination, which detected ulcerative lesion and wide bone exposure in the hard palate and alveolar ridge. Direct microbiological examination, microbiological culture and lesion biopsy were performed. Non-septate smooth fungal hyphae forming right angles with each other were observed through the direct microbiological examination. Microbiological culture revealed fast-growing fungal colonies with cottony texture, identified as Rhizopus sp. Histopathological examination exhibited necrosis areas, intense mononuclear inflammatory infiltrate and bulky hyphae, thus concluding the mucormycosis diagnosis. Amphotericin B antifungal therapy and surgical intervention were adopted as treatment. The patient was then rehabilitated with maxillofacial prosthesis, subsequently to the healing of the surgical wound.
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Affiliation(s)
| | - Cintia Baena Elchin
- Department of Maxillofacial Surgery, Prosthetics and Traumatology, School of Dentistry - University of São Paulo, Av. Lineu Prestes, São Paulo 2227, Brazil
| | - Vítor Ancheschi Guiguer-Pinto
- Department of Maxillofacial Surgery, Prosthetics and Traumatology, School of Dentistry - University of São Paulo, Av. Lineu Prestes, São Paulo 2227, Brazil
| | | | - Maurício Domingues Ferreira
- Department of Dermatology, School of Medicine - University of São Paulo, Av. Dr. Arnaldo, São Paulo 455, Brazil
| | - Reinaldo Brito Dias
- Department of Maxillofacial Surgery, Prosthetics and Traumatology, School of Dentistry - University of São Paulo, Av. Lineu Prestes, São Paulo 2227, Brazil
| | - Norberto Nobuo Sugaya
- Department of Stomatology, School of Dentistry - University of São Paulo, Av. Lineu Prestes, São Paulo 2227, Brazil
| | - Claudete Rodrigues Paula
- Department of Stomatology, School of Dentistry - University of São Paulo, Av. Lineu Prestes, São Paulo 2227, Brazil
| | - Neide Pena Coto
- Department of Maxillofacial Surgery, Prosthetics and Traumatology, School of Dentistry - University of São Paulo, Av. Lineu Prestes, São Paulo 2227, Brazil
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Dasukil S, Boyina KK, Sarkar S, Hallur V, Nayak A, Mishra AK, Aswathi KV, Preetam C, Parida PK. Management of Covid Associated Mucormycosis of Mandible: A Mountain Beneath a Molehill-A Lesson Learnt. Indian J Otolaryngol Head Neck Surg 2021; 74:3481-3484. [PMID: 34667749 PMCID: PMC8517559 DOI: 10.1007/s12070-021-02925-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 11/18/2022] Open
Abstract
The opportunistic infection of post-Covid associated mucormycosis has been reported globally; however, it has reached alarming proportions in India. Mucormycosis of the mandibular region is rare, and only a few cases have been reported to date. Covid associated mucormycosis has not been reported in the literature before, and we are the first to report them. We report two patients who presented with tooth loosening with pus discharge a few weeks following recovery from Covid infection. After tooth extraction adjacent necrotic bony specimen was sent for calcofluor potassium hydroxide mount, which was found positive for broad pauciseptate hyphae. Although CT scan imaging demonstrated the involvement of a mandible segment, we found a much more extensive involvement in both cases during resection. There was intramedullary spread of the mucormycosis throughout the inferior alveolar canal, with pus discharge and foul odor. The management of covid associated mandibular mucormycosis consists of surgical debridement with antifungal therapy and control of the underlying disease. It became challenging because the radiological extent of the disease was different from the definite clinical extension of the lesion found during surgery. The authors recommend surgeons adopt a flexible approach during surgery to plan resection depending on the clinical judgment and not rely entirely on CT scans. And the reconstruction of the mandible will follow as per the extent of excision.
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Affiliation(s)
| | | | - Saurav Sarkar
- Department of ENT and HNS, AIIMS, Bhubaneswar, India
| | | | - Anindya Nayak
- Department of ENT and HNS, AIIMS, Bhubaneswar, India
| | | | - K V Aswathi
- Department of ENT and HNS, AIIMS, Bhubaneswar, India
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Pałka Ł, Gaur V. The importance of mucormycosis infections on
example of Rhino Orbital Cerebral Mucormycosis. POSTEP HIG MED DOSW 2021. [DOI: 10.5604/01.3001.0014.8123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mucormycosis is an angioinvasive fungal infection, characterized by high morbidity and mortality
and is strongly dependent on the patient’s general health condition, initial site of infection,
and the time from diagnosis to treatment commencement. It has been reported that the
occurrence of mucormycosis has increased rapidly, also among immunocompetent patients.
Moreover, the rise in number is expected to continue. Among all clinical manifestations of
mucormycosis, the rhino-orbital-cerebral type (ROCM) is the most common. The aim of this
article is to increase the awareness of mucoral infections, especially ROCM, and to describe its
first symptoms, as proper treatment requires immediate surgical and medical intervention.
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Affiliation(s)
| | - Vivek Gaur
- Jaipur Dental College, Maharaj Vinayek Global University, Jaipur, India
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14
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Agarwal S, Anand A, Ranjan P, Meena VP, Ray A, Dutta R, Jadon RS, Vikram NK. Case of mucormycosis of mandible after self-extraction of teeth incidentally detected to have chronic granulomatous disease: Case report and literature review. Med Mycol Case Rep 2020; 28:55-59. [PMID: 32477856 PMCID: PMC7248539 DOI: 10.1016/j.mmcr.2020.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 01/19/2023] Open
Abstract
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. Mucormycosis isolated to the mandible is a rare presentation, occurring generally after dental procedures. Self-extraction of teeth as in our patient can result in isolated mucormycosis of the mandible. Isolated mucormycosis of the mandible can be a presenting symptom of chronic granulomatous disease. Combination of medical and surgical treatment is usually needed in mandibular mucormycosis.
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Affiliation(s)
- Shubham Agarwal
- Department of Medicine, All India Institute of Medical Science, New Delhi, 110029, India
| | - Abhishek Anand
- Department of Medicine, All India Institute of Medical Science, New Delhi, 110029, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Science, New Delhi, 110029, India
| | - Ved Prakash Meena
- Department of Medicine, All India Institute of Medical Science, New Delhi, 110029, India
| | - Animesh Ray
- Department of Medicine, All India Institute of Medical Science, New Delhi, 110029, India
| | - Rimlee Dutta
- Department of Pathology, All India Institute of Medical Science, New Delhi, India
| | - Ranveer Singh Jadon
- Department of Medicine, All India Institute of Medical Science, New Delhi, 110029, India
| | - Naval Kishore Vikram
- Department of Medicine, All India Institute of Medical Science, New Delhi, 110029, India
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15
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Athanasiadou KI, Athanasiadis DI, Constantinidis J, Anastasiou A, Roilides E, Papakonstantinou E. Successful treatment of rhinoorbital mucormycosis due to Rhizopus arrhizus with liposomal amphotericin B, posaconazole and surgical debridement in a child with neuroblastoma. Med Mycol Case Rep 2019; 25:10-14. [PMID: 31245270 PMCID: PMC6582074 DOI: 10.1016/j.mmcr.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/14/2019] [Accepted: 06/07/2019] [Indexed: 11/20/2022] Open
Abstract
Mucormycosis is a rare but potentially mortal opportunistic infection caused by Mucorales. We present a case of rhinoorbital mucormycosis in an 11-year old male with neuroblastoma successfully treated with aggressive surgical debridement and antifungal combination of liposomal amphotericin B and posaconazole. Our patient developed signs of paranasal sinus infection and culture of fine needle biopsy grew Rhizopus arrhizus. Prompt treatment and drastic surgical resection led to complete clinical and radiological recovery without evidence of mucormycosis relapse.
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Affiliation(s)
- Kleoniki I. Athanasiadou
- Pediatric Oncology Department, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Dimitrios I. Athanasiadis
- Department of Surgery, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Region of Efkarpia, GR-564 03, Thessaloniki, Greece
| | - John Constantinidis
- Otorhinolaryngology Department, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Region of Efkarpia, GR-564 03, Thessaloniki, Greece
| | - Athanasia Anastasiou
- Department of Radiology, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Hippokration Hospital, Aristotle University School of Medicine, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
| | - Evgenia Papakonstantinou
- Pediatric Oncology Department, Hippokration Hospital, Konstantinoupoleos 49, GR-546 42, Thessaloniki, Greece
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16
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Cohen A, Shoukair FL, Korem M, Shaulov A, Casap N. Successful Mandibular Mucormycosis Treatment in the Severely Neutropenic Patient. J Oral Maxillofac Surg 2019; 77:1209.e1-1209.e12. [PMID: 30878590 DOI: 10.1016/j.joms.2019.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/05/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Mucormycosis is a rare opportunistic and aggressive deep fungal infection that predominantly affects immunocompromised patients, and its mortality rate has been reported as up to 80%. Typing of the infection is based mainly on clinical and anatomic presentations, with the most common being the rhinocerebral type. MATERIALS AND METHODS This report presents 3 patients with cancer who had successful treatment of mandibular mucormycosis. Chemotherapy was administered 13 to 30 days before diagnosis of the infection, resulting in neutropenia in all patients. Each case is thoroughly presented from initial admission through its diagnosis and treatment sequence. RESULTS Early surgical ablative treatment and antifungal treatment resulted in the resolution of infection in all patients. Absolute neutrophil count increased 7 to 8 days after surgical debridement. CONCLUSIONS Bringing patients to the post-neutropenic state tremendously increases their odds for survival.
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Affiliation(s)
- Adir Cohen
- Attending, Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah, Jerusalem, Israel
| | - Fady Louis Shoukair
- Resident, Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah, Jerusalem, Israel.
| | - Maya Korem
- Attending, Department of Clinical Microbiology, Faculty of Medicine, Hebrew University-Hadassah, Jerusalem, Israel
| | - Adir Shaulov
- Attending, Department of Hematology, Faculty of Medicine, Hebrew University-Hadassah, Jerusalem, Israel
| | - Nardy Casap
- Head, Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah, Jerusalem, Israel
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Abstract
Background Mucormycosis is one of the rapidly progressing and lethal form of fungal infection which involves the nose and paranasal sinuses of the head and the neck regions. Mucormycosis also remains a threat to patients with uncontrolled diabetes or other predisposing systemic conditions. It manifests as rhinocerebral, pulmonary, gastrointestinal, cutaneous or disseminated form. The underlying conditions can influence clinical presentation and often delay diagnosis, with resultant poor outcomes. Case Details We report a case of rhinocerebral mucormycosis in a 75 year-old diabetic patient with emphasise on diagnosis, treatment and survival options of patient from this potentially fatal fungal infection. Extra oral examination revealed mild non-tender swelling on the face, unable to see from left eye, impaired sense of smell, difficulty in speech and nasal stuffiness. Intra-oral examination showed necrosis of mucosa and underlying bone in relation to canine to the tuberosity area of the left vestibular region of the maxilla. Conclusion Timely diagnosis is critical to survival and minimization of morbidity. Institution of surgical and medical therapy is critical in maximizing the likelihood of good outcome.
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Affiliation(s)
- Richa Sahota
- Department of Oral Pathology, Rayat and Bahra Dental College and Hospital, Mohali
| | - Ramandeep Gambhir
- Department of Public Health Dentistry, Gian Sagar Dental College and Hospital, Rajpura
| | - Samir Anand
- Department of Periodontology, Rayat and Bahra Dental College and Hospital, Mohali
| | - Avani Dixit
- Department of Oral Medicine and Radiology, Swami Devi Dyal Dental College and Hospital, Golpura, Panchkula
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18
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McSpadden RP, Martin JR, Mehrotra S, Thorpe E. Mucormycosis Causing Ludwig Angina: A Unique Presentation. J Oral Maxillofac Surg 2016; 75:759-762. [PMID: 27875707 DOI: 10.1016/j.joms.2016.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/14/2016] [Accepted: 10/18/2016] [Indexed: 12/18/2022]
Abstract
Mucormycosis is a rare fungal infection with a yearly incidence of 1.7 cases per million in the United States. It usually occurs in patients with metabolic abnormalities or who are immunocompromised with prolonged neutropenia. However, it can also occur in patients without any underlying disease process. The treatment of choice is surgical debridement of necrotic tissue and systemic antifungal therapy, including amphotericin B. A dilemma for the surgeon when faced with head and neck mucormycosis is the morbidity of surgical debridement from both a functional and cosmetic standpoint. There have been multiple case reports of a form of cutaneous mucormycosis in the head and neck involving the oral mucosa and the mandible, but no reports in the literature of a fungal infection causing Ludwig angina. This report describes one such case. The morbid clinical implications of mucormycosis causing Ludwig angina become apparent when considering the defect caused by adequate surgical debridement.
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Affiliation(s)
- Ryan P McSpadden
- Resident, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL.
| | - James R Martin
- Resident, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL
| | - Swati Mehrotra
- Associate Professor, Department of Pathology, Loyola University Medical Center, Maywood, IL
| | - Eric Thorpe
- Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL
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Kalaskar RR, Kalaskar AR, Ganvir S. Oral mucormycosis in an 18-month-old child: a rare case report with a literature review. J Korean Assoc Oral Maxillofac Surg 2016; 42:105-10. [PMID: 27162751 PMCID: PMC4860375 DOI: 10.5125/jkaoms.2016.42.2.105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/21/2015] [Accepted: 07/22/2015] [Indexed: 12/16/2022] Open
Abstract
Oral mucormycosis is a fungal infection observed mainly in elderly immunocompromised patients. In rare instances, the disease occurs in healthy individuals and those patients that are below preschool age. Although this condition mainly involves the maxilla, it may also manifest in any part of the oral cavity based on the source of infection. Mucormycosis of the maxilla spreads rapidly, leading to necrosis of the palatal bone and palatal perforation. Such patients are usually rehabilitated using bone grafting or free flap surgeries. However, when surgeries are delayed, palatal prosthesis is an interim treatment modality that can prevent nasal regurgitation and aspiration of food or fluids. Palatal prostheses also help with mastication, speech, and swallowing. The present case describes a rare case of oral mucormycosis in an 18-month-old male involving the maxilla that was managed by palatal prosthesis.
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Affiliation(s)
- Ritesh Rambharos Kalaskar
- Department of Pedodontic & Preventive Dentistry, Government Dental College & Hospital, Nagpur, India
| | - Ashita Ritesh Kalaskar
- Department of Oral Diagnosis Medicine & Radiology, VSPM Dental College & Research Centre, Nagpur, India
| | - Sindhu Ganvir
- Department of Oral Pathology & Microbiology, Government Dental College & Hospital, Nagpur, India
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20
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Rhinocerebral zygomycosis with pansinusitis in a 14-year-old girl with type 1 diabetes: a case report and review of the literature. Ital J Pediatr 2013; 39:77. [PMID: 24325793 PMCID: PMC4029383 DOI: 10.1186/1824-7288-39-77] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/07/2013] [Indexed: 12/26/2022] Open
Abstract
Background Zygomycosis is a rare life-threatening fungal infection affecting mostly patients with predisposing conditions such as diabetes mellitus, immunodeficiency, haemochromatosis or major trauma. Methods We describe a case of rhinocerebral zygomycosis in a girl with type 1 diabetes and review previous published cases and treatment options. Results A 14-year-old girl with type 1 diabetes mellitus occurred with dental pain, facial swelling, ecchymosis and left eye decreased visual acuity, unresponsive to antibiotic therapy. The coltures of the sinusal mucosa were positive for fungal species belonging to the Zygomycetes. She performed antifungal therapy with posaconazole (POS) with a very slow improvement and a poor glycemic control, leading to blindness of the left eye. Conclusion Our report adds further awareness on rhinocerebral zygomycosis and emphasizes on urgent diagnosis and timely management of this potentially fatal fungal infection through an adequate treatment.
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Ebadi M, Alavi S, Ghojevand N, Aghdam MK, Yazdi MK, Zahiri A. Infantile splenorenopancreatic mucormycosis complicating neuroblastoma. Pediatr Int 2013; 55:e152-5. [PMID: 24330301 DOI: 10.1111/ped.12182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 07/01/2013] [Accepted: 07/03/2013] [Indexed: 11/28/2022]
Abstract
Herein is described the first case of an infant with neuroblastoma who developed isolated splenorenopancreatic mucormycosis. An 18-month-old boy with neuroblastoma who was on intensive chemotherapy was admitted with febrile neutropenia. On abdominal computed tomography, multiple hypodense lesions in the spleen with invasion to the upper pole of the left kidney were demonstrated. Enlargement of splenic lesions with a complete hypoechoic pattern replacing the whole spleen, consistent with splenic abscess were observed on serial ultrasound. On splenectomy the resected spleen appeared to be severely fragmented and necrotic. On pathology, massive infiltration of broad, non-septate hyphal fragments identified as Mucor with invasion to all blood vessels was seen. Histologically, a piece of the tail of the pancreas also showed involvement by the filamentous Mucor. The present case highlights the necessity of high index of suspicion in susceptible patients, early diagnosis and appropriate management in order to minimize the mortality rate.
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Affiliation(s)
- Maryam Ebadi
- Tehran University of Medical Sciences, Tehran, Iran
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