2. ACKNOWLEDGEMENT
I WOULD LIKE TO EXPRESSMY SPECIAL THANKS AND SINCERE GRATITUDE TO
THE DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY
FOR ALLOWING THIS PROJECT TO BE COMPLETED
FIRSTLY, I WOULD LIKE TO THANK DR.NAGARAJU KAMARTHI SIR, HEAD OF DEPARTMENT, ORAL
MEDICINE AND RADIOLOGY,FOR HIS PERCEPTIVENESS ANS UNDERSTANDING THROUGH OUT THE
COURSE OF THIS PROJECT.
I WOULD LIKE TO EXPRESS MY GRATITUDE AND SINCERE THANKS TO MY GUIDE, DR.SWATI GUPTA MAM,
FOR THE OPPOURTUNITY TO EXAMINE THE PATIENTS AND LEARN VISUAL CONNECT AND SUPPORT,
ENCOURAGEMENT AND MOTIVATIONAL IN ALL PHASES PF COMPLETION OF THIS CASE.
I WOULD ALSO LIKE TO THANK DR.SANGEETA MALIK MA’AM,DR.SUMIT GOEL SIR,DR.ABHINAV SHARMA
SIR, DR.KHUSHBOO BHALLA MA’AM,DR.ISHA MAHESHWARI MA’AM FOR THEIR NEVER ENDING
SUPPORT AND GUIDANCE.
I WOULD LIKE TO EXTEND MY THANK TO THE PATIENT FOR HELPING AND COOPERATING THROUGH
OUT THE MAKING OF THIS CASE.
3. CERTIFICATE BY
HEAD OF DEPARTMENT
ORAL MEDICINE AN RADIOLOGY
THIS IS TO CERTIFY THAT THE SPECIAL CASE ENTITLED
“MUCORMYCOSIS”
IS A GENUINE WORK OF
PRAGYA RATHORE, BATCH 2018,
HE HAS BEEN AWARDED _ GRADE
DR.NAGARAJU K.
PROFESSOR AND HEAD OF DEPARTMENT
ORAL MEDICINE AND RADIOLOGY
4. CERTIFICATE BY THE
GUIDE
I HERE BY CERTIFY THAT THE SPECIAL CASE ENTITLED
“MUCORMYCOSIS”
HAS BEEN SATISFACTORILY COMPLETED BY
PRAGYA RATHORE,BATCH 2018
DR.SWATI GUPTA
PROFESSOR
DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY
8. HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3-4 months back then she noticed
exposed bone in her upper tooth region. Patient also gave history of fluid
regurgitation from nose 6 months back. Patient gave positive history of covid
19 on April, 2021 for which she had to stay in hospital for 10 days. She was
given face mask oxygen ventilation for 10 days. Patient also gave history of low
dull pain in upper tooth region since 4-5 months. No medication is taken for
pain.
9. PERSONAL HISTORY
MEDICAL HISTORY- Patient gave history of hypertension – since 10 years on medication
(telmisartan).
History of cataract in right eye.
History of hyperglycemia on medication metformin).
DENTAL HISTORY- Patient gave history of an amalgam restoration in 38.
PERSONAL HABIT- Patient gave the history of COVID 19 April,2012.
STRESS- nothing significant.
SOCIAL HISTORY- Nothing significant.
FAMILY HISTRY-Nothing significant.
ORAL HYGIENE- FAIR.
10. GENERAL EXAMINATION
GAIT- normal CLUBBING- absent
BUILT- mesomorphic CYANOSIS- absent
HEIGHT-149 cm PULSE RATE- 78 beats per minute
WEIGHT- 64 kilograms BLOOD PRESSURE- 160/90 mm of hg
ICTERUS- absent RESPIRATORY RATE- 18 breath per minute
PALLOR- absent PIGMENTATION- absent
11. LOCAL EXAMINATION
EXTRA ORAL EXAMINATION
FACIAL SYMMETRY- bilateral symmetry evident
TEMPOROMANDIBULAR JOINT-
• MOUTH OPENING- adequate mouth opening
• INSPECTION- no asymmetry, no swelling and ulceration ,no deflection and deviation evident.
• PALPATION- tenderness absent.
• AUSCULTATION- no abnormal sound heard.
MUSCLE OF MASTICATION- non tender.
SALIVARY GLANDS – no abnormality detected
SINUSES- non tender , trans-illumination positive
LYMPH NODES- non tender , non palpable
12. LOCAL EXAMINATION
INTRA-ORAL EXAMINATION
SOFT TISSUE EXAMINATION
BUCCAL MUCOSA- No abnormality detected.
PALATAL MUCOSA-No abnormality detected.
GINGIVA- soft , edematous and pigmented gingiva.
generalized gingival recession present.
ALVEOLAR MUCOSA-.exposed bone in maxillary. Yellowish sloughing is seen
FLOOR OF MOUTH- no abnormality detected.
TONGUE- no abnormality detected.
SALIVA- nothing significant found.
13. LOCAL EXAMINATON
INTRA-ORAL EXAMINATION
HARD TISSUE EXAMINATION
OCCLUSION-
• MOLAR RELATIONSHIP- cannot be defined (because of absence of first molars)
• CANINE RELATIONSHIP- cannot be defined (because of absence of canine).
• CROWDING- no crowding evident.
• TRAUMA FROM OCCLUSION- absent
TOOTH WEAR PATTERN-
• ATTRITION - absent
• ABRASION – absent
• EROSION-absent
14. EXAMINATION OF AREA OF
INTEREST
INSPECTION- necrotic exposed bone visible wrt upper alveolar bone
including left maxillary tuberosity region. Oro antral communication present.
(confirmed by WATER HOLDING TEST).
PALPATION-lesion is non-scrapable, tenderness on right and left molar area.
15. On clinical examination :- necrotic exposed bone visible wrt including
left tuberosity region. Oro antral communication present which was confirmed
by water holding test.
Lesion is non-scrapable and tenderness is present on right and left molar area.
On radiographic examination Osteolytic changes are seen in maxillary alveolar
arch involving palatal bone.
16. (Lesion present on midline of palate
involving upper left alveolar ridge
including maxillary tuberosity).
17. PROVISIONAL DIAGNOSIS- MUCORMYCOSIS(fungal osteomyelitis of maxilla).
DIFFERENTIAL DIAGNOSIS- tubercular osteomyelitis,scc,Necrotizing
sialometaplasia, Osteoradionecrosis
.
INVESTIGATION- CBCT, OPG,PNS,BONE BIOPSY UNDER L.A., FUNGAL
CULTUR PLUS KOH MOUNT,ESR.
FINAL DIAGNOSIS- MUCORMYCOSIS.
PROGNOSIS- poor.
22. TREATMENT PLANNING :
1. EMERGENCY PHASE - Not required
2. NON SURGICAL PHASE - INJ AMPHOTERICIN 30 MG IN
500ML DS. FIRST 10ML TO BE GIVEN IN 1 HR REMAINING
490 ML TO BE GIVEN IN 4-5 HRS FOLLOWED BY 500ML NS
X 7DAYS.
TAB CEFUROXIME 500MG PIO TWICE DAILY.
TAB PANTOPRAZOLE 40 MG 1TAB BEFORE BREAKFAST
3days.
TAB METFORMIN 16M PO TWICE DAILY.
TAB DICLOFENAC SODIUM 75 MG PIO THRICE DAILY.
• TAB EMESET 4MG P/O THRICE DAILY.
• CAP AUTRIN 1 CAP P/O TWICE DAILY.
• SYP SUCRALFATE 3 TSF P/O THRICE DAILY Tal EMSET 4
3. SURGIAL PHASE – subtotal maxillectomy and surgical
debridement of involved sinuses (maxilary sinus and
sphenoidal sinus).
4. RESTORATIVE PHASE - Not required
5. MAINTENANCE PHASE- Patient is recalled after 7 days.
23. SUMMARY
• Patient Jayada 65 years female presented in department of OMR with chief
complaint of exposed bone in upper tooth region since 4-5 months. Patient was
apparently asymptomatic 3-4 months back then she noticed exposed bone in her
upper tooth region. Patient also gave history of fluid regurgitation from nose 6
months back. Patient gave positive history of covid 19 in year 2021 for which
she had to stay in hospital for 10 days. She was given face mask oxygen
ventilation for 10 days. Patient also gave history of low dull pain in upper tooth
region since 4-5 months. No medication is taken for pain.
25. MUCORMYCOSI
S
It is also called ‘phycomycosis' or 'zygomycosis”. It is
caused by saprobic organism of class Zygomycetes. It is
more common in patients with decreased resistance,
due to diseases like diabetes, tuberculosis, renal failure,
leukemia, cirrhosis and in severe burn cases. It begins
with inhalation of fungus by susceptible individual.
26. TYPES
Superficial: It involves external ear,
fingernails and skin.
Visceral
Pulmonary
Gastrointestinal
Rhinocerebral or rhinomaxillary form:
it is important with dental point of
view.
27. Caused by: organisms of the subphylum Mucormycotina, including genera as Absidia,
Mucor, Rhizomucor, and Rhizopus
predisposing factors : uncontrolled diabetes (particularly in patients having ketoacidosis)
Other factors:malignancies such as lymphomas and leukemias, renal failure, organ
transplant, long-term corticosteroid and immunosuppressive therapy, (AIDS)
Patients on Anti-aspergillus drugs
Animal studies - increased virulence of Mucorales spp.following
voriconazole pre-exposure
Difficult to establish a causal relationship between voriconazole use and
development of mucormycosis
Increasing trend in pulmonary mucormycosis in patients receiving
antifungal agents with activity against aspergillosis but not
mucormycosis
30. HOW DOES THE INFECTION SPREAD-
• The fungi are found throughout the
environment. and most people breath during
inhaltion.
• They do not spread from person to person .
• In rare cases, skin usually only where a skin
injury.
• People with a weak immune system can
develop infection In the sinuses and lungs .
• Very rarely, it has been known to affect the
gastrointestinal.
31. Locations: Infections usually arise in lateral
wall of the nose and maxillary sinus; may
rapidly spread by arterial invasion to involve
the orbit, palate, maxillary alveolus and
ultimately the cavernous sinus and brain
through hematogenous spread and may
cause death
Symptoms: Ptosis, proptosis, nasal
obstruction, fever, swelling of cheek and
paresthesia of face can occur. Intracranial
involvement:
Intracranial involvement may be heralded
by cranial neuropathy, especially of the
trigeminal and facial nerves. There is
increased lethargy, progressive neurologic
deficit and ultimately death.
Artery involvement: Fungus invades artery
to cause fibrosis and ischemia of the
supplied area.
Nose: There is appearance of a reddish
black nasal turbinate and septum. Nasal
discharge caused by necrosis of nasal
turbinate.
32. Clinical features
COMMON IN MADIBLE THAN MAXILLA
WHY ?
•MANDIBLE IS LESS VASCULAR
•THICK CORTICAL PLATES
•LESS MEDULLARY BONE
• IN MANDIBLE IN DECREASING ORDER
BODY > ANTERIOR ARCH > ANGLE > RAMUS >condyle
But in this case it is seen in maxilla
33. ORAL
MANIFESTATIO
N
Site: Most common site involved is
maxillary sinus. Other sites which can
also be involved are palate, lip, alveolar
bone and gingiva.
Signs: Ulceration of palate may occur
due to necrosis and invasion of palatal
vessels. It is large and deep, causing
denudation of underlying bone (Fig.
29.3). Ulcer may be seen on gingiva,
lip and alveolar bone. Ulcer on palate
may appear black and necrotic.
Massive destruction: It can be seen
when the condition is not treated at
the earliest.
34. • RADIOGRAPHIC
FEATURES
Appearance: Paranasal sinus may reveal
mucoperiosteal thickening of the involved
sinus. With disease progression, there is
increased nodularity and soft tissue
thickening, usually mimics a tumor on
radiographical examination
CT scan features: CT scan is most helpful
for detecting the degree of bone destruction
and for evaluating disease extension into the
orbit and brain
35. Reverse Halo Sign
Focal area of GGO(ground glass opacity)
surrounded by ring of consolidation
-20 to 90% of pulmonary mucormycosis
Legouge C et al- 15 of 16 pts leukemia with
neutropenia
Lee et al- 54% with mucor and 6% with IPA
Even though these findings are not conclusive,
they may be used as indicators to start aggressive
diagnostic laboratory tests
36.
37. DIFFERENTIAL DIAGNOSIS
DIFFERENTIATING FEATURES
1 Tubercular osteomyelitis
history of swelling & pus discharge following extraction
Deep pain with malasie
H/o long standing fever
Teeth--lossen
Enlargment of dimension of bone
Trismus & dehydration
2 necrotizing sialometaplasia
The defect contained loose, yellow sloughing tissue
DEEP INTENSE PAIN
High intermittent fever
Clear identifiable cause.
38. 4squamous cell carcinoma
Indurated longer history resistance to therapy
Firm border
Swelling of jaw
Loosening of teeth
Difficulty in chewing
39. Microscopy
Direct microscopy-optical brighteners like
Blankophor and Calcofluor White
Hyphae are of variable width, non septate, irregular
ribbon like with wide angle bifurcations (90°)
Periodic acid-Schiff or Grocott Gomori's
methenamine silver staining - highlight fungal
hyphae
40. .
Culture-
Tissue swabs, sputum, or BAL cultures are usually non-diagnostic
Direct microscopy of bronchoalveolar lavage & transbronchial biopsy may increase
the yield
Rapid growth (3 to 7 days) on Sabouraud agar and potato dextrose agar incubated at
25°C to 30°C
Aggressive vertical growth toward the lid of the Petri dish – Lid lifters.
Specimens should be chopped not grounded
Histopathology-
Hyphae will be seen
Neutrophilic or granulomatous inflammation
Absent in a few cases - immunosuppressed patients.
Invasive disease is characterized by prominent infarctsand angioinvasion.
Perineural invasion may be present.
41. • TREATMENT
General principles
Early diagnosis (Chamilos et al.)
Early administration of active antifungal
agents
Reversal of underlying factors
Complete removal of all infected tissues
Primary Antifungal Therapy
Liposomal Amphotericin-B first line
recommended agent
Fluconazole, Voriconazole-No reliable activity,
Itraconazole - Absidia species
Posaconazole, Isuvaconazole can also be used
as first line therapy
Use of various adjunctive
42. Duration of Treatment
Highly individualized
Near normalization of radiograph, negative biopsy specimens
and cultures, recovery from immunosuppression
Azoles
Posaconazole 800mg/day in 2 or 4 divided doses - first
line (ESCMID/ECMM), Salvage therapy (ECIL-6)▸
Isuvaconazole (Cornely OA et al) - 200mg OD. But
VITAL study showed higher mortality rates and poor
response
• Surgery
Removal of necrotic tissue - Increases
penetration of antifungals
Lobectomy, Pneumonectomy or wedge
resection
Surrounding infected healthy-looking
tissues should be removed
Groll A et al. - Mortality reduced by 79%
43. Salvage Therapy
If disease is refractory or intolerance towards
previous antifungal therapy.
Posaconazole (A)
Polyenes + Posaconazole (B)
Lipid complex, liposomal, Colloidal dispersion
(8)
Polyenes + Caspofungin(C
• Adjunctive Therapies
Hyperbaric Oxygen - 100% O2 at 2atm pressure for 90
min twice a day (C)
Cytokine therapy in hematological malignancy GCSF(A),
Granulocyte transfusion +/- IF Ny (C)
Lovastatin
VT-1161(otesaconazole) - Inhibits fungal CYP51
Nivolumumab and IFNy
44. Iron chelators – Deferasirox
Deferasirox-A Bisome Therapy for Mucormycosis (DEFEAT Mucor) study▸
First randomized trial for any treatment of mucormycosis
45% (5) mortality at 30 days, 82 % (9) mortality at 90 days▸
Deferasirox cannot be recommended as part of an initial combination regimen for
the treatment of mucormycosis
Other than hematological malignancy -ESCMID/ECMM marginally
supports its use(C
Hematological malignancy - ECIL-6 and ESCMID/ECMM recommended
against its use
Liposomal Amphotericin B
2016 ECIL & ESCMID/ECMM liposomal form as first line
Can be given as 5mg/kg/day to 10mg/kg/day, if CNS involved
Surgery + Lip Amp B increases survival rates and cure rates.
Use of Amphotericin Deoxycholate is discouraged (ESCMID/ECMM)
ABLC can also be used- if no CNS involvement (B)
Alternate routes – ABLC aerolised with Respigard II nebulizer, Direct instillation
of Amphotericin B into pulmonary cavities or pleural space
45. Remove loose teeth & sequestra
Consider irrigating drains :Antibiotic impregnating Beads.
Caldwell luc operation ,adjunctive therapy,nanomedicine
Sequestrectomy, debridment,decortication,
Resection , Reconstruction.
If surgical excision of the maxilla was done, an acrylic plate was
given as a splint.
46. • Prophylaxis
• ESCMID/ECMM
Neutropenic or GvHD with
immunosuppressive outbreaks -
Posaconazole 600mg/day (C)
Surgery and Past h/o mucormycosis -
Strong recommendation
• Prognosis
• Overall mortality in pulmonary
mucormycosis-50-70 %, if disseminated
>90%
47. Conclusion
Early diagnosis means early treatment and leading to less mortality rates
Reversal of underlying factors, Surgery and Liposomal amphotericin B increases cure rates
Duration of treatment is highly individualized
Posaconazole, Isuvaconazole can also be tried
Salvage therapy in refractory or intolerant pts
Adjunctive therapies need to proved in large trials and standardized
