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Ajdari A, Zolfagharypoor A, Firouzifar M, Akbarpour M. Rhinocerebral mucormycosis in immunocompetent patients: a case report and review of literature. Infection 2024; 52:673-684. [PMID: 38153685 DOI: 10.1007/s15010-023-02147-z] [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: 10/04/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
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.
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Affiliation(s)
- Atra Ajdari
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Azin Zolfagharypoor
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Firouzifar
- Otolaryngology-Head and Neck Surgery, Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Maliheh Akbarpour
- Otorhinolaryngology Research Center, Department of Otolaryngology and Head and Neck Surgery, Amiralmomenin Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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Celis-Aguilar E, Burgos-Páez A, Villanueva-Ramos N, Solórzano-Barrón J, De La Mora-Fernández A, Manjarrez-Velázquez J, Verdiales-Lugo S, Escobar-Aispuro L, Becerril P, Valdez-Flores A, Merino-Ramírez FJ, Caballero-Rodríguez CB. An Emergent Entity: Indolent Mucormycosis of the Paranasal Sinuses. A Multicenter Study. Int Arch Otorhinolaryngol 2018; 23:92-100. [PMID: 30647791 PMCID: PMC6331311 DOI: 10.1055/s-0038-1667005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 05/23/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction
Indolent or chronic mucormycosis is a rare entity that affects both immunosuppressed and immunocompetent individuals. Additionally, its clinical evolution is nonspecific and there is no standardized treatment for this condition.
Objective
To describe the clinical characteristics and management of patients with indolent mucormycosis.
Methods
In the project of study with chart review in the Interinstitutional secondary care centers, patients with evidence of indolent mucormycosis, defined as pathological confirmation of nasal/paranasal sinus mucormycosis for more than 1 month, were included. All patients underwent complete laboratory workup, imaging studies, surgical treatment and adequate follow-up. No evidence of disease status was defined when patient had subsequent biopsies with no evidence of mucormycosis.
Results
We included seven patients, three female and four male subjects. The mean age was 53.14 years. Four patients were immunosuppressed and three immunocompetent. Among the immunosuppressed patients three had diabetes and one had dermatomyositis. The symptoms were nonspecific: facial pain/headache, mucoid discharge and cacosmia were the ones most frequently reported. Maxillary sinus involvement was present in all patients. Two immunosuppressed subjects received amphotericin. Posaconazole was the only treatment in one immunosuppressed patient. All immunocompetent patients had single paranasal sinus disease and received only surgical treatment. All patients are alive and free of disease.
Conclusion
Indolent mucormycosis is a new and emerging clinical entity in immunosuppressed and immunocompetent patients. Single paranasal sinus disease is a frequent presentation and should not be overlooked as a differential diagnosis in these patients. Immunocompetent patients should only be treated surgically.
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Affiliation(s)
- Erika Celis-Aguilar
- Department of Otolaryngology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS) de la Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - Alan Burgos-Páez
- Department of Otolaryngology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS) de la Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - Nadia Villanueva-Ramos
- Department of Otolaryngology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS) de la Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - José Solórzano-Barrón
- Department of Otolaryngology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS) de la Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - Alma De La Mora-Fernández
- Department of Otolaryngology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS) de la Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | | | - Sergio Verdiales-Lugo
- Department of Otolaryngology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS) de la Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - Lucero Escobar-Aispuro
- Department of Otolaryngology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS) de la Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - Perla Becerril
- Department of Otolaryngology, General Hospital Regional No. 1 "Ignacio García Téllez" del IMSS, Mérida, Yucatán, México
| | - Ana Valdez-Flores
- Department of Pathology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS), Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - Francisco Javier Merino-Ramírez
- Department of Pathology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS), Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
| | - Carmen Beatriz Caballero-Rodríguez
- Department of Pathology, Centro de Investigación y Docencia en Ciencias de la Salud (CIDOCS), Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, México
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Indolent mucormycosis of the paranasal sinus in immunocompetent patients: are antifungal drugs needed? The Journal of Laryngology & Otology 2013; 127:872-5. [PMID: 23941886 DOI: 10.1017/s0022215113001795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To report the clinical characteristics and treatment outcomes of indolent paranasal mucormycosis in immunocompetent individuals. MATERIALS AND METHODS A retrospective review of four immunocompetent patients with indolent mucormycosis of the paranasal sinus managed by endoscopic sinus surgery only was performed. One year of regular follow up comprised angled endoscopy and repeated paranasal sinus computed tomography three months after surgery. RESULTS Clinical symptoms were non-specific. Pre-operative paranasal sinus computed tomography showed opacification of the unilateral maxillary sinus with focal calcification but without bony destruction or extension to the orbit or cranium. All patients underwent endoscopic sinus surgery without administration of antifungal agents. There was no recurrence on regular clinical and radiological follow up. CONCLUSION For indolent paranasal mucormycosis in immunocompetent patients, endoscopic sinus surgery can be the treatment of choice, and the administration of antifungal drugs may not be necessary.
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Manjunatha BS, Das N, Sutariya RV, Ahmed T. Mucormycosis of the hard palate masquerading as carcinoma. Clin Pract 2012; 2:e28. [PMID: 24765427 PMCID: PMC3981330 DOI: 10.4081/cp.2012.e28] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 01/23/2012] [Accepted: 01/23/2012] [Indexed: 12/21/2022] Open
Abstract
A growing number of medically compromised patients are encountered by dentists in their practices. Opportunistic fungal infections such as mucormycosis usually occur in immunocompromised patients but can infect healthy individuals as well. Mucormycosis is an acute opportunistic, uncommon, frequently fatal fungal infection, caused by a saprophytic fungus that belongs to the class of phycomycetes. Among the clinical differential diagnosis we can consider squamous cell carcinoma. Such cases present as chronic ulcers with raised margins causing exposure of underlying bone. There is a close histopathological resemblance between mucormycosis and aspergillosis. Microscopically, aspergillosis has septate branching hyphae, which can be distinguished from mucormycotic hyphae by a smaller width and prominent acute angulations of branching hyphae. A definitive diagnosis of mucormycosis can be made by tissue biopsy that identifies the characteristic hyphae, by positive culture or both. The culture of diseased tissue may be negative and histopathologic examination is essential for early diagnosis. Mucormycosis was long regarded as a fatal infection with poor prognosis. However with early medical and surgical management survival rates are now thought to exceed 80%. In the present case, the fungus was identified by hematoxylin and eosin stain and confirmed by Grocott's silver methenamine special staining technique. Removal of the necrotic bone, which acted as a nidus of infection, was done. Post-operatively patient was advised an obturator to prevent oronasal regurgitation. Since mucormycosis occurs infrequently, it may pose a diagnostic and therapeutic dilemma for those who are not familiar with its clinical presentation.
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Affiliation(s)
| | - Nagarajappa Das
- Department of Oral and Maxillofacial Surgery, SJM Dental College and Hospital, India
| | - Rakesh V Sutariya
- Department of Oral Pathology and Microbiology, K.M. Shah Dental College & Hospital
| | - Tanveer Ahmed
- Department of Oral and Maxillofacial Surgery, SJM Dental College and Hospital, India
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Manjunatha BS, Das N, Sutariya RV, Ahmed T. Mucormycosis of the hard palate masquerading as carcinoma. Clin Pract 2012. [PMID: 24765427 DOI: 10.4081/cp.2012.e28.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A growing number of medically compromised patients are encountered by dentists in their practices. Opportunistic fungal infections such as mucormycosis usually occur in immunocompromised patients but can infect healthy individuals as well. Mucormycosis is an acute opportunistic, uncommon, frequently fatal fungal infection, caused by a saprophytic fungus that belongs to the class of phycomycetes. Among the clinical differential diagnosis we can consider squamous cell carcinoma. Such cases present as chronic ulcers with raised margins causing exposure of underlying bone. There is a close histopathological resemblance between mucormycosis and aspergillosis. Microscopically, aspergillosis has septate branching hyphae, which can be distinguished from mucormycotic hyphae by a smaller width and prominent acute angulations of branching hyphae. A definitive diagnosis of mucormycosis can be made by tissue biopsy that identifies the characteristic hyphae, by positive culture or both. The culture of diseased tissue may be negative and histopathologic examination is essential for early diagnosis. Mucormycosis was long regarded as a fatal infection with poor prognosis. However with early medical and surgical management survival rates are now thought to exceed 80%. In the present case, the fungus was identified by hematoxylin and eosin stain and confirmed by Grocott's silver methenamine special staining technique. Removal of the necrotic bone, which acted as a nidus of infection, was done. Post-operatively patient was advised an obturator to prevent oronasal regurgitation. Since mucormycosis occurs infrequently, it may pose a diagnostic and therapeutic dilemma for those who are not familiar with its clinical presentation.
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Affiliation(s)
| | - Nagarajappa Das
- Department of Oral and Maxillofacial Surgery, SJM Dental College and Hospital, India
| | - Rakesh V Sutariya
- Department of Oral Pathology and Microbiology, K.M. Shah Dental College & Hospital
| | - Tanveer Ahmed
- Department of Oral and Maxillofacial Surgery, SJM Dental College and Hospital, India
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A case of rhinoorbital mucormycosis in a leukemic patient with a literature review from Turkey. Mycopathologia 2011; 172:397-405. [PMID: 21761152 DOI: 10.1007/s11046-011-9449-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 07/03/2011] [Indexed: 12/18/2022]
Abstract
Mucormycosis (Zygomycosis) is a rare, invasive, opportunistic fungal infection of the paranasal sinuses, caused by a fungus of the order Mucorales. We report a case of rhinoorbital mucormycosis caused by Rhizopus oryzae in an acute lymphoblastic leukemia patient and review the 79 Mucormycosis cases reported in the last decade from Turkey. In our case, the diagnosis was made with endoscopic appearance, computerized tomography of the paranasal sinuses, and culture of the surgical materials. Following aggressive surgical debridement and parenteral amphotericin B therapy, the patient recovered completely. In Turkish literature, rhinocerebral manifestations were the most common form of the mucormycosis (64 cases), followed by pulmonary form (6 cases). The most common risk factor was hematologic malignancies (32 cases) and diabetes mellitus (32 cases), similar to those reported from the rest of the world. The etiologic agents responsible for the review cases were Rhizopus sp., Mucor spp., Rhizomucor spp., Rhizopus oryzae, Mucor circinelloides, and Lichtheimia corymbifera. Although various treatment modalities were used, amphotericin B was the mainstay of therapy. Mortality rate was found to be 49.4% in review cases. It seems that strong clinical suspicion and early diagnosis, along with aggressive antifungal therapy and endoscopic sinus surgery, have great importance for better prognosis in mucormycosis.
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Kim DW, Heo ST, Jeon SY, Kim JY, Lim MH, Bae IG, Yang JW, Lee JS. Invasive paranasal mucormycosis with peripheral eosinophilia in an immunocompetent patient. Med Mycol 2010. [DOI: 10.3109/13693780903177790] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Bansal S, Grover G, Grover M, Gupta AK. Isolated sphenoid mucormycosis presenting as visual impairment: changing trends? Am J Otolaryngol 2010; 31:64-6. [PMID: 19944905 DOI: 10.1016/j.amjoto.2008.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Revised: 08/07/2008] [Accepted: 08/24/2008] [Indexed: 10/20/2022]
Abstract
Mucormycosis of the paranasal sinuses represents an important cause of morbidity and mortality in patients whose host defenses have been altered by primary disease or immunosuppressive therapy. The pattern of involvement by this fungus is changing with reports of mucormycosis occurring also in immunocompetent host. The involvement of isolated sphenoid sinus is rare. In the present case, the only presenting symptom was visual impairment. These changing trends in presentation, the extent, and the area of involvement are challenging for the otorhinolaryngologist, ophthalmologist, and neurosurgeon. High index of suspicion, prompt intervention, and aggressive therapy are required to reduce the morbidity and mortality associated with this disease.
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Elinav H, Zimhony O, Cohen MJ, Marcovich AL, Benenson S. Rhinocerebral mucormycosis in patients without predisposing medical conditions: a review of the literature. Clin Microbiol Infect 2009; 15:693-7. [PMID: 19624514 DOI: 10.1111/j.1469-0691.2009.02884.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Rhinocerebral mucormycosis is a rare disease, affecting almost exclusively patients with known predisposing conditions such as diabetes mellitus, immunocompromised status, haemochromatosis or major trauma. Subsequent to a case of rhinocerebral mucormycosis in a 78-year-old woman without any known risk factor, we reviewed the published English-language literature and found an additional 72 cases. Reviewing all the published case series of mucormycosis involving any site, the proportion of apparently normal hosts among cases of rhinocerebral mucormycosis was found to be 9.06% (95% confidence interval 6.7-11.8). These findings suggest that rhinocerebral mucormycosis in patients without known predisposing factors is more prevalent than was previously believed.
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Affiliation(s)
- H Elinav
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Park SK, Jung H, Kang MS. Localized bilateral paranasal mucormycosis: a case in an immunocompetent patient. Acta Otolaryngol 2006; 126:1339-41. [PMID: 17101598 DOI: 10.1080/00016480500316852] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Mucormycosis of the nasal cavity and paranasal sinuses is an uncommon opportunistic fungal infection, which often has an aggressive, life-threatening course. Patients who have this condition are generally diabetic or immunosuppressed. However, mucormycosis can also occur in immunocompetent individuals. The most effective treatment consists of reversal of the source of immunocompromise, immediate surgical debridement and administration of systemic amphotericin B. No consensus has been reached regarding the appropriate surgical treatment or the total dose of amphotericin B. We present the case of a patient suffering from localized bilateral paranasal mucormycosis who was treated by means of endoscopic sinus surgery and administration of systemic amphotericin B. We suggest that endoscopic sinus surgery is the choice of treatment for localized paranasal mucormycosis in an immunocompetent patient, and that the total dose of amphotericin B can be determined by the extent of disease and the postoperative endoscopic findings.
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Affiliation(s)
- Seong Kook Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Pusan Paik Hospital, Pusan, South Korea.
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Abstract
PURPOSE OF REVIEW Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed. RECENT FINDINGS There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death. SUMMARY Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.
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Affiliation(s)
- Patrick J Bradley
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital, Nottingham, UK.
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Paranasal Mucormycosis in a Patient With AIDS Presenting as a Palatal Mass. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2006. [DOI: 10.1097/01.idc.0000203895.77101.b2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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