A fatal case of rhinocerebral mucormycosis of the jaw after dental extractions and review of literature

Oral Manifestations of Mucormycosis: A Systematic Review

Mucormycosis is a rare, opportunistic, and emerging fungal infection that can rapidly develop into a severe, highly fatal clinical picture. In most cases, it is caused by fungi of the order Mucorales, which are usually avirulent but become pathogenic when the host's immune system is compromised. This systematic review was conducted according to PRISMA guidelines. The databases searched included PubMed, Scopus, and Web of Science. We chose articles that analyzed the oral manifestations of patients with mucormycosis, were published between 2018 and 2023, and met our search terms. The risk of bias in the articles was assessed using the CARE guideline for case reports and STROBE for a cross-sectional study. After the selection process, 20 articles were included in this review, all containing information about the different oral manifestations presented by people with mucormycosis. The most common oral manifestations are mainly bone exposures and oral ulcers, halitosis, pus discharge, gingival thickening, and periodontitis. However, despite the importance of recognizing these oral manifestations in the early stages of mucormycotic infection, providing early treatment, and reducing the high mortality rate of the infection, more studies are needed.

Part 1: Mucormycosis: Prevalence, Risk Factors, Clinical Features and Diagnosis

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.

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.

Early CT and MRI signs of invasive fungal sinusitis complicating COVID-19 infection: case report

Background

Corticosteroids are usually prescribed for severe cases with SARS-CoV-2 (COVID-19). Despite their importance to decrease patients’ mortality, they can cause serious side effects like fulminant fungal infection that can damage lungs or invade the sinuses then rapidly spread to the orbit and even intra-cranially. Unless early diagnosed and properly managed, patients can lose their vision or die from cavernous sinus thrombosis or other intracranial complications.

Case presentation

A 71-year-old diabetic male patient presented with dry cough, fever, and dyspnea for 6 days. PCR test for COVID-19 was ordered and declared positive. The oxygen saturation on day 7 started to decline to reach 90%. Eight ampules of intra-muscular dexamethasone were prescribed. The patient’s dyspnea improved, and the oxygen saturation reached 94% by day 13. Oral prednisone was prescribed in a withdrawal protocol. Unfortunately, on day 15, the patient complained of mild left-sided cheek swelling and noticeably dropped left angle of mouth. Neurological consultation suspected facial palsy and asked for brain MRI examination. Limited lower cuts of the MRI study that covered the left maxillary antrum revealed mild fullness of the pre-maxillary fat planes with mucosal thickening. Complimentary dedicated MRI and CT cuts over the left maxillary sinus showed localized signs of invasive fungal sinusitis without orbital or intracranial complications. The patient received antifungal therapy even before evident endoscopic findings appeared. He underwent endoscopic debridement few days after and he had an excellent outcome without any progression or significant morbidities.

Conclusion

Early CT/MRI radiological signs of invasive fungal sinusitis that complicated COVID-19 infection aid in the diagnosis and proper timely management of this fatal disease.

Rhino-Orbito-Cerebral Mucormycosis: An Audit

This study aims at identifying the predisposing factors, clinical and radiological features that dictated the treatment outcome of Rhino-orbito-cerebral mucormycosis (ROCM). This is a retrospective observational study. Medical records of 39 patients with ROCM proven by fungal smear or histopathology (HPE), admitted in Sri Ramachandra Institute of Higher Education and Research from Jan 2015 to Dec 2019 were reviewed and audited. The mean age of the patients was 52.6 years and they were predominantly men (76.9%). There is a statistically significant association between uncontrolled diabetes and increasing severity of the disease in this study and an important cause of mortality. Fungal smear and HPE plays a crucial role in diagnosis. Radiological evaluation helps in identifying the extent of spread and in this study 31% of patients had intraorbital and 20% had intracranial extension. In-hospital mortality was 13%. Our results showed better outcome when combined medical and surgical intervention was undertaken. Rhino-orbito-cerebral Mucormycosis is a rapidly spreading invasive fungal infection with significant mortality and morbidity. Early diagnosis and proactive surgical and medical intervention is crucial for better outcome. Hence the clinician should be highly alert to certain subtle clinical signs and radiological features in a diabetic patients for improving the treatment outcomes and avoiding potentially fatal complications.

Mucormycosis: risk factors, diagnosis, treatments, and challenges during COVID-19 pandemic

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.

Diagnosis, treatment and maxillofacial rehabilitation in rhinocerebral mucormycosis patient: A case report and review of the literature

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.

Rhino-orbital mucormycosis during steroid therapy in COVID-19 patients: A case report

Purpose:

To report two cases of COVID-19 under treatment with a corticosteroid; in one case rhino-orbitocerebral mucormycosis and in another one rhino-orbital mucormycosis developed.

Case presentation:

A 40-year old woman and a 54-year old man with severe COVID-19 underwent corticosteroid therapy for immune-related lung injuries. The first case presented with a bilateral visual loss and complete ophthalmoplegia of the right eye. The second case presented with vision loss, proptosis, orbital inflammation, and complete ophthalmoplegia on the left side. Histopathologic, nasal endoscopic examinations, and radiologic findings confirmed mucormycosis in both patients. The patients denied orbital exenteration and were managed with systemic amphotericin B and daily endoscopic sinus debridement and irrigation with diluted amphotericin B. Because of the intracranial space involvement, the first case died. The second case was successfully managed surgically and medically.

Conclusion:

Rhino-orbital/cerebral mucormycosis may be developed in COVID-19 patients under treatment with corticosteroid, and requires prompt diagnosis and management.

Orbital Apex Syndrome due to Orbital Mucormycosis after Teeth Infection: A Successful Case Report

Rhino-orbital-cerebral mucormycosis is a severe and rapidly progressive fungal infection associated with low survival rates. Early diagnosis and proper management are mandatory. We report the case of a 20-year-old female with diabetic ketoacidosis and teeth infection, who presented with sudden orbital apex syndrome. Several surgical procedures were necessary to provide a definite histopathological diagnosis of the fungal infection. Ultimately, given the progressive aggravation of the infection and the ineffectiveness of antifungal and antibiotic agents, an orbital exenteration was performed. A mycobacteriological examination revealed a polymicrobial culture with Mucorales. One year after the initial presentation, the patient is alive and with a good general health condition.

Postextraction Mucormycosis in Immunocompromised-Patient Management and Review of Literature

PURPOSE

Mucormycosis is an uncommon aggressive, opportunistic infection that can produce widespread orofacial tissue necrosis. This primarily affects immunocompromised individuals. It is the deadliest and most rapidly progressing type of human-affecting fungal infection. The aim of the study is to investigate the diagnostic criteria and treatment approach in 10 cases of mucormycosis in the author's institute from 2008 to 2019. Moreover, a review of the English literature presents all cases of mucormycosis after tooth extraction.

MATERIALS AND METHODS

Ten patients at our institute have been treated. They were evaluated and discussed as per their diagnostic criteria, surgical treatment, and mortality rates.

RESULTS

All 10 immunocompromised patients had a primary hematologic malignancy. The criteria for a positive diagnosis were clinical symptoms and a biopsy for microbiological culture and histologic analysis. Each patient was subjected to vigorous surgical resection and underwent antifungal treatment. Seven patients died because of their main disease. Owing to the unregulated spread of mucormycosis, 2 patients died. Four cases were diagnosed after maxillary tooth extraction.

CONCLUSIONS

The most important factor for patient survival tends to be the management of the underlying disease with early detection and active surgical and antifungal action. Four of 10 cases diagnosed with mucormycosis appeared after tooth extraction, a relatively high number compared with the literature. Therefore, it is the dental profession's obligation to be familiar with the possibility of the potentially severe and possibly fatal complication.

Mucormycosis: A rare entity with rising clinical presentation in immunocompromised hosts

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It is a case study of an immunocompromised patients affected by Mucormycosis which is - a profoundly mortal fungal infection.

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In order to restore the function, enhance the cosmetic appearance and quality of life of the patient, surgical intervention is often necessary to correct the various pathologies affecting the patients.

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This paper highlights the significance of prompt diagnosis and urgent treatment, especially among high-risk patients, of this potentially lethal phenomenon and the surgical procedure undertaken to remove the disease afecting the person and improve the patient's overall health.

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The management of our patient demonstrates the need for an early visual identification and diagnosis approach that is multidisciplinary, multi-factorial and multi-faceted.

Introduction

Mucormycosis is a rare, rapidly progressive and a fulminant, life-threatening, opportunistic infection. Although it most commonly manifests in diabetic patients, its presence in other immunologically compromised patients cannot be ruled out. Its etiology is saprophytic fungal organisms, with rhizopus being the most common causative organism. Clinically the disease is marked by a partial loss of neurological function and a progressive necrosis due to the invasion of the organisms into the blood vessels causing a lack of blood supply. The disease may progress to involve the cranium thereby increasing the mortality rate. The first line of management in mucormycosis is antifungal therapy which may extend and also include surgical management.

Presentation of case

Authors present here two patients with mucormycosis affecting the maxillofacial region, that were treated by including both medical and surgical lines of management.

Discussion

This report aims to highlight the importance of prompt diagnosis and urgent management of this potentially fatal phenomenon, particularly among high-risk individuals.

Conclusion

This case report intensifies the importance of considering mucormycosis as a possible diagnosis in spontaneous necrotic soft tissue lesions of the face, especially in an immunocompromised patient.

Epidemiology and Diagnosis of Mucormycosis: An Update

Mucormycosis is an angioinvasive fungal infection, due to fungi of the order Mucorales. Its incidence cannot be measured exactly, since there are few population-based studies, but multiple studies have shown that it is increasing. The prevalence of mucormycosis in India is about 80 times the prevalence in developed countries, being approximately 0.14 cases per 1000 population. Diabetes mellitus is the main underlying disease globally, especially in low and middle-income countries. In developed countries the most common underlying diseases are hematological malignancies and transplantation. Τhe epidemiology of mucormycosis is evolving as new immunomodulating agents are used in the treatment of cancer and autoimmune diseases, and as the modern diagnostic tools lead to the identification of previously uncommon genera/species such as Apophysomyces or Saksenaea complex. In addition, new risk factors are reported from Asia, including post-pulmonary tuberculosis and chronic kidney disease. New emerging species include Rhizopus homothallicus, Thamnostylum lucknowense, Mucor irregularis and Saksenaea erythrospora. Diagnosis of mucormycosis remains challenging. Clinical approach to diagnosis has a low sensitivity and specificity, it helps however in raising suspicion and prompting the initiation of laboratory testing. Histopathology, direct examination and culture remain essential tools, although the molecular methods are improving. The internal transcribed spacer (ITS) region is the most widely sequenced DNA region for fungi and it is recommended as a first-line method for species identification of Mucorales. New molecular platforms are being investigated and new fungal genetic targets are being explored. Molecular-based methods have gained acceptance for confirmation of the infection when applied on tissues. Methods on the detection of Mucorales DNA in blood have shown promising results for earlier and rapid diagnosis and could be used as screening tests in high-risk patients, but have to be validated in clinical studies. More, much needed, rapid methods that do not require invasive procedures, such as serology-based point-of-care, or metabolomics-based breath tests, are being developed and hopefully will be evaluated in the near future.

Orbital mucormycosis in immunocompetent children; review of risk factors, diagnosis, and treatment approach

BACKGROUND

Orbital mucormycosis is a rare but potentially severe and troublesome invasive fungal infection that could be occurred even in healthy individuals. The initial clinical presentation is similar to bacterial pre-septal or septal cellulitis, especially in early stages.

CASE PRESENTATION

Herein, we describe the successful management of a series of five cases presenting with orbital mucormycosis in previously healthy children.

CONCLUSIONS

Orbital mucormycosis is extremely rare in healthy children and maybe life-threatening when diagnosis delayed given a similar clinical presentation with bacterial septal cellulitis. Intravenous antifungal therapy with amphotericin B and timely surgical drainage is live-saving.

Rhino-Orbito-Cerebral Mucormycosis in Diabetic Disease Mucormycosis in Diabetic Disease

The authors present their experience about clinical evidences that include patients with an untreated diabetes who developed rhino-orbito-cerebral mucormycosis (ROCM). They were treated with endoscopic sinus surgery and medical treatment with intravenous, intradural therapy, and sinus washes with amphotericin B. The ROCM is a disease with a rapid evolution and an increase in mortality rate, especially if the fungus enters the cranial cavity. Therefore, it would be necessary in all diabetic patients with sinus symptoms, headaches, visual changes, suspect a mucormycosis, and perform a careful radiology assessment and a nasal endoscopy. Often, despite an early diagnosis and rapid treatment for ROCM, it is not possible to stem the disease, which ends with the patient's death.

Mucormycosis Following Tooth Extraction in a Diabetic Patient: A Case Report

Mucormycosis is a rare, opportunistic fungal infection, which can progress acutely or subacutely in immunosuppressed patients. It is a devastating disease in patients with poorly controlled diabetes mellitus and immunocompromised conditions. It causes decaying and extensive lesions of the soft tissue caused by fungi belonging to the order of Mucorales and is often fatal. Due to its aggressive nature, early detection and prompt management are of great importance for a good prognosis. We report a case of mucormycosis post-dental extraction in a patient with uncontrolled diabetes mellitus.

A Guide to Investigating Suspected Outbreaks of Mucormycosis in Healthcare

This report serves as a guide for investigating mucormycosis infections in healthcare. We describe lessons learned from previous outbreaks and offer methods and tools that can aid in these investigations. We also offer suggestions for conducting environmental assessments, implementing infection control measures, and initiating surveillance to ensure that interventions were effective. While not all investigations of mucormycosis infections will identify a single source, all can potentially lead to improvements in infection control.

Rhinocerebral mucormycosis with dissemination to pontine area in a diabetic patient: Treatment and management

Rhinocerebral mucormycosis is a rapidly life-threatening disease caused by a fungal infection. Every diabetic patient with sinusitis symptoms, headache, and visual changes needs radiological approach and nasal endoscopy to rule out mucormycosis. The mortality rate is 50%-85%, despite an early diagnosis and a correct treatment.

Rhinocerebral mucormycosis, risk factors and the type of oral manifestations in patients referred to a University Hospital in Tabriz, Iran 2007-2017

Inadequate data are available on the global epidemiology of mucormycosis, mainly derived from the evaluation of specific population groups. Rhinocerebral mucormycosis is an invading and fatal mycosis, particularly among diabetic patients. In the present study, patients hospitalised in Imam Reza Hospital in Tabriz, from 2007 to 2017, were evaluated. The hospital information system (HIS) was used to collect the records of the patients. A total of 42 patients with a diagnosis of mucormycosis were included in the study, 40 cases (95%) of which had a diagnosis of the rhinocerebral form. Of these 40 patients, 21 (52.5%) and 19 (47.5%) were male and female, respectively. Seven cases (17.5%) of rhinocerebral mucormycosis were due to dental procedures. The most predisposing factor in the patients was diabetes with 36 (90%) cases. In our study, the role of tooth extraction in patients with uncontrolled diabetes was identified as an important factor. It may show the important role of dentists in preventing of the disease in diabetic patients.