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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1769-1771  

Mucormycosis during Coronavirus Disease pandemic: A diagnosis we cannot afford to miss


1 Department of Oral and Maxillofacial Surgery, JKK Nattraja Dental College, Namakkal, Tamil Nadu, India
2 Department of Periodontics, JKK Nattraja Dental College, Namakkal, Tamil Nadu, India
3 Department of Conservative Dentistry and Endodontics, JKK Nattraja Dental College, Namakkal, Tamil Nadu, India
4 Department of Dental Surgery, PSG Institute of Medical Sciences, Coimbatore, Tamil Nadu, India
5 Department of Ophthalmology, Arasan Eye Hospital, Erode, Tamil Nadu, India

Date of Submission14-Jun-2021
Date of Acceptance16-Jun-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
Kaneesh Karthik Arthanari
Department of Oral and Maxillofacial Surgery, JKK Nattraja Dental College, Kumarapalayam, Namakkal, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.jpbs_444_21

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   Abstract 


Mucormycosis is a very aggressive, devastating opportunistic fungal infection commonly involving nasal, maxillary,orbital, and cerebral regions. In the second wave of the coronavirus disease 2019 (COVID-19) pandemic, a high frequency of mucormycosis infections has been seen because of the triad of COVID-19, systemic steroids, and preexisting diabetes mellitus. A patient might present with a simple mobile tooth/teeth with multiple gingival abscesses Necrotic bone could be seen in the palate. Blackish discoloration might be present in the oral mucosa. There might be extraoral swelling . If rhino-oculo cerebral mucormycosis is diagnosed, then there are two immediate treatment modalities to be followed. Both surgical and medical treatment are necessary. Surgical is thorough debridement of the necrotic tissue. To prevent the occurrence of mucormycosis, meticulous glycemic control and rational use of steroids and antibiotics for the shortest possible time with adequate attention toward the ventilators and tubing are necessary.

Keywords: COVID-19, dentistry, gingival abscesses, mucormycosis


How to cite this article:
Arthanari KK, Annamalai S, Thangavelu A, Palanivelu C, Suresh G, Anbuselvan S. Mucormycosis during Coronavirus Disease pandemic: A diagnosis we cannot afford to miss. J Pharm Bioall Sci 2021;13, Suppl S2:1769-71

How to cite this URL:
Arthanari KK, Annamalai S, Thangavelu A, Palanivelu C, Suresh G, Anbuselvan S. Mucormycosis during Coronavirus Disease pandemic: A diagnosis we cannot afford to miss. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Jun 26];13, Suppl S2:1769-71. Available from: https://www.jpbsonline.org/text.asp?2021/13/6/1769/330138



Mucormycosis is a very aggressive, devastating opportunistic fungal infection commonly involving nasal, maxillary,orbital, and cerebral regions. It is acquired primarily through inhalation of spores through the nasal route. It is a rapidly progressive fungal disorder and any delay in identification and management leads to high morbidity and mortality.

The fungus belongs to the order Mucorales and subphylum Mucormycotina and it is angioinvasive that causes occlusion of blood vessels, which leads to tissue necrosis. Other forms of clinical presentation are gastrointestinal, bone, and joint infection and pulmonary, cutaneous, and disseminated mucormycosis.

In the second wave of the coronavirus disease-2019 (COVID-19) pandemic, a high frequency of mucormycosis infections has been seen because of the triad of COVID-19, systemic steroids, and preexisting diabetes mellitus (DM). This could be due to any or all of the following reasons COVID 19 associated illness requiring high and prolonged steroid use leading to worsening of preexisting DM and immunosuppression; elevated ferritin leading to high iron load, acidosis, and endothelial damage and the use of multiple broad spectrum antibiotics to prevent or treat secondary infections.[1],[2] Since India has the second-highest number of COVID-19 cases,[3] the second-highest number of DM patients,[4] and the highest incidence of mucormycosis,[5] it is expected that mucormycosis will be seen in India in huge numbers, especially in COVID-19 patients.


   Predisposing Factors Top


  • Uncontrolled DM
  • Concurrent/recently treated COVID-19
  • Inappropriate use of steroids
  • High doses of steroids
  • Using for prolonged periods.
  • Immunocompromised individuals
  • Malignancy
  • Transplant recipients.
  • People under long-standing oxygen therapy
  • Prolonged intensive care unit (ICU) stays
  • People under mechanical ventilation
  • Prolonged use of broad-spectrum antibiotics
  • Nosocomial-contaminated dirty linen, ICU instruments, and materials - if not properly sterilized.



   Clinical Presentation Top


A patient might present with a simple mobile tooth/teeth with multiple gingival abscesses [Figure 1]. Necrotic bone could be seen in the palate. Blackish discoloration might be present in the oral mucosa. There might be extraoral swelling [Figure 2]. We should not misdiagnose it as simple periodontitis or cellulitis if the patient is/was COVID positive and diabetic and was given steroids. Strongly suspect mucormycosis and evaluate the patient or refer to a higher center. The patient might have other symptoms such as headache, myalgia, and fever and nasal symptoms such as nasal discharge often bloody, brownish, or blackish. Diminished vision or proptosis might be present. There could be altered sensorium in case of cerebral involvement.
Figure 1: Multiple gingival abscesses in a diabetic patient who was coronavirus disease positive before 15 days and was given steroids (Picture Courtesy – Dr. S. Sanjeev Kumar, Ambur)

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Figure 2: Extraoral swelling in a patient who is diabetic and was coronavirus disease positive before 20 days

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   Diagnosis Top


Clinically, there will be necrotic bone with blackish eschar. Computerized tomography and/or magnetic resonance imaging might show erosion of bone involving nasal, paranasal sinuses, maxilla, ethmoid, and base of the skull. KOH smear will show the presence of nonseptate, ribbon-like hyphae (at least 6–16 μm wide) with obliteration of the vessels. On histopathological examination, we could find angioinvasion, coagulation necrosis, hemorrhagic infarction, infiltration by neutrophils, and perineural invasion. Fungal culture done with routine media between 30°C and 37°C might show grayish–black or cotton-white colony.[6]


   Treatment Algorithm Top


If rhino–oculo cerebral mucormycosis is diagnosed, then there are two immediate treatment modalities to be followed. Both surgical treatment and medical treatment are necessary. Surgical is thorough debridement of the necrotic tissue. Functional endoscopic sinus surgery is done if there is nasal and paranasal sinus involvement without involving maxilla or palate or zygoma. If the maxilla is involved, then maxillectomy is done. If the orbit is involved, then orbital exenteration is done. If the frontal bone is involved, then debridement or cranialization is done. The osteomyelitic bone is removed and the necrotic tissue is debrided.

Medical treatment is with injection amphotericin B (1–1.5 mg/kg/day) or injection liposomal amphotericin B 5–10 mg/kg/day for 14–21 days.


   Conclusion Top


As the disease is known to be really very aggressive, mortality is generally >50%.[7] The mortality increases to an unbelievably high 80%, with an intracerebral involvement of the disease.[8] Larger studies are the need of the hour in mucormycosis in COVID-19 to know prognostic markers and outcomes.

Due to the rapid increase in cases of mucormycosis in COVID-19, there is an immense need to improve awareness among treating physicians and dentists about early diagnosis and treatment. There is marked variability in the frequency of mucormycosis cases reported in different regions in pre- and post-COVID times. A nationwide registry and larger studies could help in providing useful data. Abnormalities in the immune system in COVID-19, sensitivity patterns of fungus, and the reasons for the sudden surge in cases in the second wave of the pandemic need to be studied. To prevent the occurrence of mucormycosis, meticulous glycemic control, rational use of steroids and antibiotics for the shortest possible time with adequate attention toward the ventilators and tubing are necessary. The microbiologists should also monitor the ward, ICU, and hospital environment to account for fungal diseases and take regular swabs and culture them.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
John TM, Jacob CN, Kontoyiannis DP. When uncontrolled diabetesmellitus and severe COVID-19 converge: The perfect storm for mucormycosis. J Fungi (Basel) 2021;7:298.  Back to cited text no. 1
    
2.
Rubino F, Amiel SA, Zimmet P, Alberti G, Bornstein S, Eckel RH, et al. New-onset diabetes in COVID-19. N Engl J Med 2020;383:789-90.  Back to cited text no. 2
    
3.
WHO Coronavirus (COVID 19) Dashboard, Data Table Page 1. (https://covid19.who.int/)  Back to cited text no. 3
    
4.
Unnikrishnan R, Anjana R, Mohan V. Diabetes mellitus and its complications in India. Nat Rev Endocrinol 2016;12:357-70.  Back to cited text no. 4
    
5.
Prakash H, Chakrabarti A. Global Epidemiology of Mucormycosis. J Fungi (Basel) 2019;5:1.  Back to cited text no. 5
    
6.
Management Protocol for Mucormycosis AIIMS, Rishikesh. Multidisciplinary Mucor management team_Version 1.0_16.05.2021:7.  Back to cited text no. 6
    
7.
Patel A, Kaur H, Xess I, Michael JS, Savio J, Rudramurthy S, et al. A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India. Clin Microbiol Infect 2020;26:944.e9- 944.e15.  Back to cited text no. 7
    
8.
Cagnoni PJ. Liposomal amphotericin B versus conventional amphotericin B in the empirical treatment of persistently febrile neutropenic patients. J Antimicrob Chemother 2002;49 Suppl 1:81-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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