Black fungus cases during covid

1. ORAL MANIFESTATION OF
MUCORMYCOSIS
PRESENTED BY:-
DR GOUNSIA AMIN
POST GRADUATE STUDENT
SHREE BANKEY BIHARI DENTAL COLLEGE
GHAZIABAD
UNDER THE GUIDANCE OF:-
DR SAMAN ISHRAT
HEAD OF DEPARTMENT
DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY
SBBDC GHAZIABAD.
.

2. Oral Manifestation of MUCORMYCOSIS
CASE I
.

3. .
OPD NO.:- 218286
CHIEF COMPLAINT:-
PAIN AND SWELLING ON RIGHT SIDE OF FACE
WITH BLACKISH COLOUR ON RIGHT SIDE OF
FACE ESPECIALLY BELOW EYE AND NOSE SINCE
1O DAYS.

4. ‘
HISTORY OF PRESENT ILLNESS:-
Patient was all right before 10 days when she
started with cold and nasal congestion along
with headache. Patient developed swelling
and pain on right side of face with blackish
colour below eye and side of nose which was
progressive and incidious in nature.
• On Examination:-
Tenderness around frontal sinus and right
maxillary sinus with periorbital swelling and
blackish area below orbit and side of nose.

5. .
• On Investigation:-
CBC:-
Haemoglobin:- 10.8
TLC:- 24.5
NEUTROPHILL:- 8.8
LYMPHOCYTE:- 5
PLT:- 389
• ON CECT :- SOFT TISSUE OPICIFICATION OF RIGHT MAXILLARY
SINUS WITH OBTURATION OF RIGHT EYE.
• KOH and FUNGAL CULTURE:-
POSITIVE FOR THIN SEPTATE ALONG WITH BROAD ASEPTATE HYPHAE
WITH RIGHT ANGLED.
FUNGAL CULTURE:- BROAD HYPHAE SUGGESTIVE OF
ZYGOMYCETESGROWN ON CULTURE.

6. CASE IInd
.

7. .
• OPD NO. :- 1841072
• CHIEF COMPLAINT:- PAIN AND SWELLING ON
RIGHT SIDE OF FACE WITH NASAL
CONGESTION AND HEADACHE SINCE 5 DAYS.

8. .
• HISTORY OF PRESENT ILLNESS:-
Patient was apparantly well before 5 days when she
started with nasal congestion and headache.
Patient developed swelling on right side of face
and eye which was incidious and progressive in
nature.
• On Examination:-
Tenderness around frontal sinus and right maxillary
sinus with periorbital swelling with decreased
sensitiveness on right side of face..

9. .
• On Investigation:-
CBC:-
Haemoglobin:- 5.6
NEUTROPHILL:- 4.0
• ON NCCT :- Mild DNS and sinusitis.
• KOH and FUNGAL CULTURE:-
BROAD ASEPTATE HYPHAE WITH RIGHT ANGLED.
FUNGAL CULTURE:- BROAD HYPHAE SUGGESTIVE OF ZYGOMYCETESGROWN ON CULTURE.
• ON HISTOPATHOLOGY:-
Debridment tissue of maxillary sinus.
ON GROSS EXAMINATION:-
Multiple grey brown tissue pieces all together of 4*4mm
ON MICROSCOPIC EXAMINATION:-
BONY TISSUE FRAGMENTS WITH EXTENSIVE ULCERATIVE COVERED WITH ACUTE INFLAMATORY
INFILLITRATE WITH EPITHILIOD CELL GRANULOMAS AND FUNGAL HYPHAE MORPHOLOGICALLY
CONSISTENT OF MUCORMYCOSIS.

10. .
• On the basis of these evidence and the
diagnosis of mucormycosis was made.
• Both the patients were diagnosed and treated
according to the ICMR guidelines:-
Control Diabetes and Diabetes ketoacidosis.
Reduce steriods.
No antifungal prophylaxis needed.
Excessive surgical debridement needed to
remove necrotic tissue.

11. MUCORMYCOSIS
• Also called as Zygomycosis, Phycomycosis.
• Oral Mucormycosis is an opportunistic fungal infection
caused by “bread mold fungi”of the green Mucor,
Absidia, Rhizopus and cunninghamella.
• Mucormycosis is an emerging angioinvasive infection
caused by the ubiquitous filmentous fungi of the
Mucorales order of the class of Zygomycetes.
• Third most common invasive mycosis in order of
importance after Candidiasis and Aspergillosia.
REFERENCE:- BURKET’S ORAL MEDICINE ELEVENTH EDITION
CLINICAL INFECTIOUS DISEASES,VOLUME 54, ISSUE SUPPL_1, FEBRUARY
2012, PAGES S23-S34

12. PRE-DISPOSING CONDITION
A)
• HEMOTOLOGICAL MALIGNANCY(MAINLY AML) AND
HEMOTOPOIETIC STEM CELL TRANSPLANTATION.
B)
• SOLID ORGAN MALIGANCIES AND SOLID ORGAN
TRANSPLANTATION.
C)
• DIABETES MELLITUS AND DIABETES KETOACIDOSIS
D)
• CORTICOSTERIOD USE AND RHEUMATIC DISEASES.
REFERENCE:-INDIAN JOURNAL OF DENTAL RESEARCH

13. .
E)
• IRON OVERLOAD AND CHELATION THEARPY WITH
DEFEROXAMINE (DFO).
F)
• PROLONGED USE OF VORICONAZOLE.
G)
• HIV OR AIDS.
H)
• SEVERE BURNS.
I)
• CHRONIC RENAL INSUFFICIENCY.
REFERENCE:- INDIAN JOURNAL OF DENTAL RESEARCH

14. CLINICAL FORMS
 PULMONARY MUCORMYCOSIS
 RHINOCEREBRAL MUCORMYCOSIS
 CUTANEOUS MUCORMYCOSIS
 GASTROINTESTINAL MUCORMYCOSIS
 DISSEMINATED MUCORMYCOSIS
 CENTRAL NERVOUS SYSTEM
 UNCOMMON FORMS OF MUCORMYCOSIS (i.e bone, kidney,
cardiac, mediastinum)
REFERENCE:-CLINICAL MICROBIOLOGY AND INFECTION VOLUME25, ISSUE 1,
JANUARY 2019.

15. ORAL MANIFESTATION OF
MUCORMYCOSIS
Reference:- Doni BR,et al. Indian J DENT RES.2011.
• Usually in the palate where ischemic necrosis
of the mucoperiosteum with bony
denudation.
• Ulcers of mucormycosis have been reported
on the gingiva, lips, alveolar ridge, cheeks
tongue and mandible.
• It involves Rhino-cerebral Mucormycosis

16. RHINOCEREBRAL MUCORMYCOSIS
Common form of Mucormycosis in patients
with Diabetes Mellitus.
Also occur in patients with underlying
maligancies, recipients of haemopoietic stem
cell or solid organ transplant and individuals
with other risks.
Reference :- CLINICAL INFECTIOUS DISEASES,VOLUME 54, ISSUE SUPPL_1,
FEBRUARY 2012, PAGES S23-S34

17. DEVELOPMENT OF RHINOCEREBRAL
MUCORMYCOSIS
INHALATION OF FUNGAL SPORONIOSPORES
PARANASAL SINUSES
RAPIDLY EXTEND INTO ADJACENT TISSUES
INVADE INFERIORLY TO THE
PALATE
POSTERIORLY SHENOID SINUS
LATERALLY INTO THE CAVERNOUS
SINUS TO INVOLVE THE ORBIT
CRANIALLY TO THE BRAIN
CRANIUM INVADES THROUGH EITHER THE
ORBITAL APEX ON CRIBIFORM PALATE OF
THE ETHMOID BONE
UPON GEMINATION
Reference :- CLINICAL INFECTIOUS DISEASES,VOLUME 54, ISSUE SUPPL_1,
FEBRUARY 2012, PAGES S23-S34

18. INITIAL SYMPTOMS
• SINUSITIS
• PERIORBITAL CELLULITIS
• EYE and/or FACIAL PAIN
• FACIAL NUMBNESS FOLLOWED BY BLURRY
PAIN.
Reference :- CLINICAL INFECTIOUS DISEASES,VOLUME 54, ISSUE SUPPL_1,
FEBRUARY 2012, PAGES S23-S34

19. SYMPTOMS
• MULTIPLE CRANIAL NERVE PALASIES.
• UNILATERAL PERIORBITAL FACIAL PAIN.
• ORBITAL INFLAMMATION.
• EYELID EDEMA.
• BLEPHEROSIS.
• PROPTOSIS
• ACUTE OCCULAR MORTALITY CHANGES
• INTERNAL OR EXTERNAL OPTHALMOPLAGIA.
• HEADACHE.
• ACUTE VISION LOSS
Reference :- CLINICAL INFECTIOUS DISEASES,VOLUME 54, ISSUE SUPPL_1,
FEBRUARY 2012, PAGES S23-S34

20. .

21. SIGNS
• BLUE NECROTIC ESCHAR.
• FEVER IS VARIABLE AND MAY BE ABSENT IN
UPTO HALF OF CASES.
• WHITE BLOOD CELL COUNT IS TYPICALLY
ELEVATED AS LONG AS THE PATIENT HAS
FUNCTIONING BONE MARROW.
Reference :- CLINICAL INFECTIOUS DISEASES,VOLUME 54, ISSUE SUPPL_1, FEBRUARY
2012, PAGES S23-S34

22. DIAGNOSIS
• SAMPLES:- Sputum, bronchoalveolar lavage
(BAL), biopsy of paranasal sinuses.
• Direct exam:- Nonseptate, ribbon-like hyphae
which branch at right angles, sporangium.
• Culture:- SDA(cotton candy appearance).
Reference:- THE BLACK FUNGUS BOOK BY edinson salazar

23. INVESTIGATIONS
• CBC
• Grocott’s Silver Methenamine stain.
• Pre-operative contrast- enhance
Computed Tomography.
• Magnetic Resonance (MR) imaging and Contrast –
enhanced MRI.
• Surgical exploration with biopsy analysis in high
risk patients.
Reference :- CLINICAL INFECTIOUS DISEASES,VOLUME 54, ISSUE SUPPL_1,
FEBRUARY 2012, PAGES S23-S34

24. MANAGEMENT
• Detection of acidosis or other predisposing
feature.
• Antifungal thearpy using amphoterins.
• Surgical debridement of sinus and orbit.
• Hyperbaric oxygen treatment.
REFERENCE:- BURKET’S ORAL MEDICINE ELEVENTH EDITION