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CASE REPORT
Year : 2023 | Volume
: 12
| Issue : 1 | Page : 96-99
Mucormycosis as Post Coronavirus Disease Complication
Pradeep Koppolu1, Mohammed Malik Afroz2, Tahseen Ali Khan2, Amara Swapna Lingam2, Sajida Husna3, Mehnaaz Sultana Syeda4
1 Department of Preventive Dental Sciences, Dar Al Uloom University, Riyadh, Kingdom of Saudi Arabia
2 Department of Oral Surgery and Diagnostic Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Kingdom of Saudi Arabia
3 Department of Oral Pathology, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
4 Department of Dentistry, Central Security Hospital, Riyadh, Kingdom of Saudi Arabia
Correspondence Address:
Pradeep Koppolu
Department of Preventive Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijmy.ijmy_207_22
Mucormycosis is called as black fungus, which is caused by fungus belonged to Mucorales. If this fungus, effects healthy individuals it won't cause any serious complications, but it may cause life-threatening issues when Mucorales affects individuals who have low immunity. The mortality rate of black fungus is more than 50%, and it may also range till 100% if the individual is having any preexisting or chronic disease. This was the case of a 55-year-old male patient complaint of having generalized pain in the maxillary teeth bilaterally and suffering fullness in the maxillary sinus. To check on other possible diseases, doctors have conducted other diagnosis tests, and orthopantomogram revealed in the diagnosis that there was the presence of haziness in the left maxillary sinus, which looked like an incompletely formed soap bubble and additionally he diagnosed with coronavirus disease positive. Then, doctors suggested a chest computerized tomography (CT) along with head CT excluding the brain and further investigation of this case was given below in detail. The report reveals acute necrotizing suppurative sinusitis with dead bony tissue, soft-tissue necrosis with fungal infestation showing broad hyphae with right-angle branching suggestive of mucormycosis.
Keywords: COVID-19, coronavirus disease case, mucormycosis, mucormycosis treatment
Mucormycosis is a severe complication caused by a fungal infection; the fungus or fungi belongs to Mucorales. Mucormycosis is being called a black fungus. This infection usually does not pose any serious threat to health in the persons who have a healthy immune system; however, it can be dire and life-threatening in persons with suppressed or low immunity.[1]
The primary causes for mucormycosis include uncontrolled diabetes mellitus (DM), metabolic acidosis in other forms, bone marrow transplantation, usage of corticosteroids, individuals who are suffering from burns and trauma, malignant hematologic disorder, and neutropenia. The patients who are receiving treatment of hemodialysis and have undergone deferoxamine therapy are also more vulnerable to the severe infection.[2],[3],[4]
The overall mortality rate for mucormycosis was more than 50%, and it may also reach 100% for the patients who are suffering from disseminated and chronic disease or individuals who are suffering from persistent neutropenia.[3],[5] Furthermore, there are cases where higher chances of developing mucormycosis are observed in persons who lack phagocytes or having impaired phagocytic activity.
It is observed that neutrophils are more critical rather than T-lymphocytes in inhibiting fungal spore proliferation. Oxidative metabolites and the cationic peptides generated both mononuclear, as well as polymorphonuclear phagocytes of regular hosts will help to demolish Mucorales.[6],[7],[8]
The infection may arise by inhalation of spores, which are deposited in pulmonary alveoli. Thus, fungus protrudes into the arteries, thereby resulting in thrombosis. Not only thrombosis but also subsequent necrosis may arise in surrounding tissues. Significant signs and symptoms reported with mucormycosis are oral ulcerations, sinusitis, and facial cellulitis. However, based on some early symptoms, one can notice the infection such as unusual nasal discharge, bleeding or excessive dryness in the nose, facial swelling, particularly one-side, discoloration over nose or cheeks (black or reddish), bulge around eyes, blurred or reduced vision.
The severity of such disease might increase or double by the nature of the infection, poor prognosis or due to delay in diagnosis. Mucormycosis is diagnosed by examining the smear and histologic demonstration of tissue invasion by hyphae. Furthermore, to see mucosa thickening with patchy destruction of the antral walls in sinus infection can be examined by magnetic resonance imaging.
Management of mucormycosis involves certain steps
Detection of acidosis or other predisposing factorsBy using amphotericin B performing antifungal therapySurgical debridement.[9] Case ReportThis case study explains a 55-year-old male patient who consulted a dentist with a complaint of having generalized pain in the maxillary teeth bilaterally and suffering fullness in the maxillary sinus. He also reported having a mild cough with no fever, no sputum, no shortness of breath, etc. Hence, the dentist went ahead and did an intraoral examination to find out the exact problem. The examination revealed a full complement of teeth and slight bleeding on probing, which is associated with mild gingivitis, no teeth mobility, and no localized pain to percussion.
To check on other possible diseases, an orthopantomogram was suggested so that the whole complement of maxillary teeth could be obtained. It was revealed in the diagnosis that there was the presence of haziness in the left maxillary sinus, which looked like an incompletely formed soap bubble. It was observed that the appearance did not arise from the teeth or alveolus but rather from the sinus wall or lining borders. Vitals such as patients' pulse rate fluctuated, and the respiratory rate decreased. Patient gave a history that the patient was coronavirus disease (COVID) positive 1 year ago and recovered. Additional investigation or treatment options were not considered as at the patient's primary visit, and a COVID test was also performed and diagnosed COVID positive. He was instantly referred to the higher center, and there the doctors (we) suggested a chest computerized tomography (CT) along with head CT excluding the brain.
The patient's chest CT revealed ground-glass opacities with smooth inter and intralobular septal thickening recorded in both the lung fields, primarily in peripheral sub-pleural distribution. At the same time, during this diagnosis process, patient's leukocyte count was gradually decreasing. Thereby, he started to suffer from breathlessness. Hence, he was immediately admitted to the hospital. During his hospital stay of 20 days, doctors observed a hard bony swelling on the left side of his upper face extending from the maxillary sinus region to the left lower eyelid and medially to the nasal turbinate and laterally till tragus of the ear. Hence, doctors suggested that a dental visit, investigation, and treatment will be continued or carry forward after performing a facial bone CT scan.
A facial bone CT scan revealed that soft-tissue mass was observed in the left sinus, resulting in erosion and expansion of mesial and superior walls. Furthermore, another small soft-tissue mass was being observed on the right maxillary sinus, except those other sinuses were quite clear.
During his hospital stay, although his condition was improved, the patient developed a black eroded lesion [Figure 1] which resembled the left side of the face and was observed in the mid-facial region. It is prolonged from left turbinate to left eye, which was utterly involved and extended laterally to a line drawn from the outer canthus of the eye and inferiorly to ala, which is the tragus line. The exact resemblance of the lesion appeared in black with clear denuded demarcation from adjacent normal skin.
Figure 1: Preoperative picture revealing the extent and appearance of the lesionIt has burrowed lining which was having an irregular border. However, there is no discharge or pain from the lesion. The patient underwent an reverse transcription polymerase chain reaction test again, and the report revealed he turned negative. The lesion was increasing day by day. Moreover, within 10 days of the period, there was a significant change in the lesion. Hence, he was suggested to operate immediately. While operating, doctors noticed that the left eye left maxilla and left maxillary sinus were completely occupied with denuded and dead tissue. Hence, doctors planned for extensive surgery, which involved losing a left eye and left nasal turbinate along with maxilla, which caused facial disfigurement [Figure 2].
Figure 2: Postsurgical picture showing fresh bleeding areas devoid of necrotic tissueIntervention after surgery was performed by a prosthetic and cosmetic surgeon, who will rectify and cover the lost anatomic structure in the face. Hence, the patient will feel confident and return to his routine and life at the earliest. After the surgery, the tissue specimen will be sent for further investigation to the pathology laboratory. The report reveals acute necrotizing suppurative sinusitis with dead bony tissue, soft-tissue necrosis with fungal infestation showing broad hyphae with right-angle branching suggestive of mucormycosis [Figure 3].
Figure 3: A ×40 image showing dead bony tissue, necrosis of soft tissue with fungal infestation showing broad hyphae with right angle branching of mucormycosis Discussion Mucorales fungi are commonly found in decaying organic substrates, and they are ubiquitous fungi that are isolated and noted as contaminants. The adverse effects and diseases caused by this fungus have been reported throughout the world. Usually, adverse effects of this fungus are associated with immunocompromising states such as patients who receive immunosuppressive therapy or suffering from cancer, individuals who are under deferoxamine therapy, diabetic patients, and neutropenic, etc.[10] In general, identifying mucormycosis disease is quite tricky in laboratory settings. A high index of suspicion is required, and an appropriate sample is essential, and it is required to test in the laboratory as a prerequisite to diagnose the mucormycosis disease. To isolate the fungus and to maintain it in the clinical lab is not an easy task, mainly because their poorly septate hyphae lose vital cytoplasm at the slightest manipulation.[11]
Apart from all the above issues, lab technicians' awareness, particularly microbiologists dealing with these types of fungus, is still low. When mucormycosis attacks an individual, adverse effects resemble jawbones, nose, central nervous system, lungs, sinuses, orbit, gastrointestinal tract, skin, joints, kidney, heart, and mediastinum. Rhino-orbital-cerebral mucormycosis (ROCM) is the most commonly seen variety; ROCM denotes the entire spectrum, which ranges from limited sino-nasal disease (sino-nasal tissue invasion), limited rhino-orbital disease (progression to orbits) to rhino-orbital-cerebral disease (central nervous system involvement).[12] However, the area of involvement may also alter because of underlying condition.
One clinical study conducted in 2019 nationwide multi-center study on 388 confirmed or suspected individuals of mucormycosis in India. These data are before COVID-19, in which 18% individuals had diabetic ketoacidosis, and 57% of individuals had uncontrolled DM.[13] Another study that was quite similar to the above study was that 465 cases of mucormycosis without COVID-19 recorded in India revealed that 67.7% of rhino-orbital presentation was observed and most commonly noted, followed by 13.3% of pulmonary and 10.5% of cutaneous type. The predisposing factors which are related to mucormycosis in Indians who are affected with 73.5% of DM, 9.0% of malignancy and 7.7% of organ transplantation.[14] Individuals who are suffering from DM have higher odds of contracting ROCM by 7.5-fold, which was elaborated in the Indian study, and this study was conducted before COVID-19 pandemic.[15]
Recently, a systematic review which was conducted until April 9, 2021, by John et al.[16] reported on 41 confirmed cases of mucormycosis in people who suffered from COVID-19, out of which 93% cases were reported as DM, and nearly 88% of individuals were receiving corticosteroids. These observations were consistent and coincide with Singh et al. study,[17] and in that study even larger case series of 101 mucormycosis cases were observed in which 95 were confirmed, and 6 cases are suspected in COVID-19, in which 80% cases had DM. Nearly two-third or even more (76.3%) have taken the corticosteroids.
Unfortunately, the significant increase in mycobacterial diseases should not be overlooked because there is insufficient information regarding the impact of the COVID-19 pandemic on mycobacterial laboratories.[18],[19],[20]
Finally, in collecting all the findings and results, there is a strong linkage or connection of mucormycosis, steroids and diabetes, in people who are suffering or suffered from COVID-19. However, with a history of undiagnosed or uncontrolled diabetes when patients with COVID-19 admitted in the hospital are administered with a heavy corticosteroid, which may increase the chances of his condition of attacking mucormycosis.
The coronavirus mainly affects one's immunity and deplete it to a hazardous level making one's infected with the virus more vulnerable to various diseases and illness. In this condition, spores of fungi usually present in our surroundings will take advantage and make gain damaging the person's health severely.
ConclusionThe environment and the pathogens are beyond our control since the start of the pandemic triggered by COVID-19. Further, various interactions in the people lead to less or suppressed immunity in the people who had a severe infection due to the virus. Hence, it is very critical to check the spread of the fungal infections described in the above case. Although they seem to be less prevalent and clinically absent, they are capable of deep tissue perfusion. They can cause severe damage to persons with compromised immunity even before the onset of symptoms.
Limitation of study
Postprosthesis picture could not be attached in the report as the patient moved to a different place and could not visit us.
Acknowledgment
The authors extend their appreciation to the Deanship of Postgraduate and Scientific Research at Dar Al Uloom University, Riyadh, KSA for their support for this project.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Self.
Conflicts of interest
There are no conflicts of interest.
References
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