Necrosis of maxilla, nasal, and frontal bone secondary to extensive rhino-cerebral mucormycosis

Reconstructive cranial surgery for invasive and non-responsive mucormycosis

The incidence of mucormycosis showed a sharp rise during the COVID-19 pandemic in vulnerable populations like people with diabetes. Here, we report a case of mucormycosis of the frontal and ethmoid sinuses in a man in his mid-50s with a background of diabetes mellitus and COVID-19 infection requiring steroids and oxygen support. The infection had remained persistent despite initial debridement by functional endoscopic sinus surgery of the anterior frontal sinus wall and re-exploration, followed by debridement using the brow incision. The patient had received an entire course of systemic antifungal therapy during the postoperative period. A bifrontal craniotomy, excision of the supraorbital ridge and complete removal of bilateral frontal sinuses managed the persistent fungal infection. The defect was reconstructed with a custom-made three-dimensional-printed MRI-compatible titanium cranioplasty mesh. The patient had no signs of infection on the 9-month follow-up.

Post Mucormycosis Frontal Bone Osteonecrosis: "A Road Less Traveled During the Pandemic"

BACKGROUND

Osteonecrosis in mucormycosis is a rare phenomenon and has been reported usually following trauma or in immunocompromised individuals. Osteonecrosis of skull as a complication of mucormycosis is a rare presentation, which makes the study ever so rare and interesting.

METHODS

Within 6 months, a total of 114 patients presented with mucormycosis as COVID-19 sequel, 60 of whom underwent form of endoscopic sinus debridement. Six of these 60 patients presented with frontal bone osteonecrosis and were included in the study. All 6 patients presented within a time period of 2-4 months' post FESS.

RESULTS

One of the 6 patients succumbed to her illness. Another patient presented with local recurrence after 3 months, for which she underwent resurgery and debridement. The other 4 patients showed gradual recovery and are without symptoms or radiologic progression at 6-month follow-up.

CONCLUSIONS

Osteonecrosis in mucormycosis is a rare phenomenon, and the 2 entities have rarely been reported together. The disease usually limits itself to the frontal bone only, and pathogenesis for spread is due to a vicious cycle of infection and ischemia. Prompt diagnosis via imaging, aggressive surgical debridement with a good antifungal cover, good patient compliance, and regular follow-up form the mainstay of treatment.

Outcomes of Open Fronto-Facial Resection for Fungal Osteomyelitis of Frontal Bone

INTRODUCTION

The second wave of coronavirus disease 2019 (COVID-19) led to the resurgence of opportunistic infections due to the injudicious use of steroids. Sinonasal mucormycosis was declared an epidemic in India during the pandemic. Mucormycosis was managed effectively by surgical debridement along with systemic amphotericin B. Currently, a resurgence of mucormycosis following initial treatment, in the form of fungal osteomyelitis of the frontal bone, is being seen in India.

METHODS

This prospective study included 10 patients with fungal osteomyelitis of the frontal bone due to mucormycosis. All patients underwent surgical debridement of the sequestrum and involucrum, with systemic antifungal pharmacotherapy.

RESULTS

The average duration of time until mucormycosis recurrence was 22 days following initial treatment (range 10-33 days). Patients presented with extracranial bossing following outer frontal cortex erosion (n=3), bicortical erosion (n=3), bifrontal involvement (n=2), dural involvement (n=3), and involvement of the brain parenchyma and prefrontal cortex (n=2). All cases underwent debridement of the entire sequestrous bone and involucrum until normal bone could be identified. The mean admission duration was 4 weeks (range 3-6 weeks). All treated patients are currently alive and without disease, confirmed by contrast-enhanced computed tomography.

CONCLUSION

Based on our experience, the successful treatment of fungal osteomyelitis due to mucormycosis requires a four-pronged approach: early detection, multidisciplinary management of comorbidities, surgical debridement of necrotic bone, and adequate systemic antifungal therapy.

Successful treatment of rhino-cerebral mucormycosis with dual antifungal therapy and minimal surgical debridement

The authors report the case of a 42-year-old female with history of type I diabetes mellitus and recent episode of diabetic ketoacidosis who presented with symptoms of epistaxis, gastrointestinal upset, hyperglycemia, confusion, and a cough. She was found to have rhino-cerebral mucormycosis with associated multi-focal strokes and a left internal carotid artery pseudoaneurysm. Her infection was successfully treated with dual-antifungal therapy consisting of liposomal amphotericin B and isavuconazole, and required only minimal surgical debridement.

Management of frontal sinus fungal osteomyelitis in the COVID 19 era: A case series

The aim of this study was to review different approaches and outcomes in the management of post-COVID-19 frontal sinus fungal osteomyelitis.

The study included 19 patients with frontal sinus fungal osteomyelitis. The main line of treatment was surgical debridement (sequestrectomy). Approaches included combined external and endoscopic approaches (n = 15) and pure endoscopic approaches (n = 4) according to the extent and accessibility of the sequestrum. Postoperative healing was satisfactory in all patients. All patients returned to their normal daily activity within 4–6 weeks, without residual or recurrent frontal sinus infection, osteomyelitis or need for revision procedures.

Within the limitation of this case series, it seems that there is no need to adopt a new therapy regimen for treatment of frontal sinus fungal osteomyelitis because the conventional and well-known treatment approach combining surgery and antifungal drugs seems to work well. However, early, and adequate debridement and sequestrectomy is crucial. Furthermore, an open approach may be required according to the extent of osteomyelitis.

Epidemiology, clinical features, diagnosis and treatment of cerebral mucormycosis in diabetic patients: A systematic review of case reports and case series

BACKGROUND

Patients with diabetes are known as an important high-risk group for cerebral mucormycosis (CM).

METHOD

We conducted a structured search using PubMed/MEDLINE to collect both case reports and case series case (ie including at least two patients) onto CM in diabetic patient published between 2000 and March 2020.

RESULTS

Forty-five reports of individual cases and eighteen case series articles were included. India accounted for the largest share of reports with 37.7% and 38.8% of individual cases and case series, respectively. Mortality ranged from 0% to 100% in the case series. The overall mortality in the individual cases was 46.3%, and 64.2% of deaths were reported in patients with ketoacidosis diabetes. Facial swelling (53.3%), headache (44.4%), loss of vision (35.5%) and ophthalmoplegia (35.5%) were the most frequently reported clinical symptoms. In all patients except 4 (91.1%), CM was treated surgically; however, in many cases (42%), despite the use of surgery, death occurred. Amphotericin B deoxycholate (AMB) and lipid-based AMB (LAMB) were used as the first lines of treatment for all patients; however, posaconazole, echinocandins, hyperbaric oxygen therapy (HBOT) and deferasirox were used in combination for a number of patients. Posaconazole has been shown to have positive therapeutic effect; however, posaconazole, LAMB and HBOT are not commonly used in low-income and health-challenged countries.

CONCLUSION

Cerebral mucormycosis is a rapidly progressive infection in diabetic patients and carries immense morbidity despite early diagnosis and treatment. Low-income countries have had the highest number of reports of the disease in recent years, indicating the need to control diabetes in these countries.

Maxillary Fungal Osteomyelitis: A Review of Literature and Report of a Rare Case

Fungal osteomyelitis is a life-threatening and seldom seen opportunistic infection. It is commonly an affectation of the nose and paranasal sinuses within the orofacial region. It is an aggressive infection that needs to be addressed promptly to prevent fatal consequences. Here, we present a case of a 62-year-old female who presented with complaints of pain and pus discharge from the extraction socket of the left maxillary 23, 24, 25, 26 teeth. She had a history of uncontrolled diabetes mellitus. On further investigation, using diagnostic and Interventional aids, a final diagnosis of maxillary fungal osteomyelitis was made. The infective fungal agents were a mixture of Mucorales and Aspergillus species. A review of all literatures on the subject in the past 13 years using different search engines showed that craniofacial fungal infections with primary maxillary involvement are a rare phenomenon. The primary aim of reporting this case, therefore, is to highlight its rarity, presentation, management and most importantly the outcome of management.

Mucormycosis in immunocompetent patient resulting in extensive maxillary sequestration

Mucormycosis or zygomycosis, also called phycomycosis, is an uncommon, invasive, potentially lethal and an aggressive fungal infection of the order Mucorales that usually affects patients with alteration of their immunological system. From its initial description (Paltauf, 1885), this entity still has a high mortality. Imaging techniques are not usually diagnostic, and cultures are not totally reliable. Definitive diagnosis is exclusively obtained by means of histopathological examination. Early recognition and aggressive treatment are of paramount importance and have reduced the mortality and morbidity. We present here a case report of oral mucormycosis in a 32-year-old male, immunocompetent individual resulting in extensive maxillary sequestration.

Oral mucormycosis in an 18-month-old child: a rare case report with a literature review

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.

The caverno-apical triangle: anatomic-pathological considerations and pictorial review

BACKGROUND

The caverno-apical triangle (CAT) is defined from the components that define its contours: the cavernous sinus and the orbital apex. A wide range of pathologies arise from the space between the cavernous sinus and the orbital apex.

OBJECT

To better define radiologically this critical anatomic landmark and establish an organized approach for image analysis to help generate focused differential diagnoses and accurately characterize lesions found on imaging.

CONCLUSION

We have identified common imaging characteristics of frequently encountered lesions and divided them into specific categories to facilitate creation of logical and focused differential diagnoses.

Unilateral rhino-orbital-cerebral mucormycosis with contralateral endogenous fungal endophthalmitis

Rhino–orbital–cerebral mucormycosis (ROCM) is an uncommon but fatal fungal infection. We report a rare case of unilateral ROCM with ipsilateral central retinal artery occlusion and contralateral choroiditis, which later progressed to endogenous fungal endophthalmitis. The patient was successfully treated with sinuses debridement, systemic liposomal amphotericin B, and intravitreal amphotericin B. The endophthalmitis completely resolved with good vision, but the ROCM eye remained blind due to central retinal artery occlusion.