People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

Mucormycosis- A Case Report

Tushar Phulambrikar, Sanjana Moses, Tanvi Dosi

Department of Oral Medicine and Radiology, Sri Aurobindo College of Dentistry, Indore

ABSTRACT:

Mucormycosis, an aggressive and opportunistic fungal infection caused by Rhizopus sp., Mucor, and

Lichtheimia, poses a significant challenge in the post-COVID era. Previously considered a rare

occurrence, mucormycosis has witnessed a surge in cases, particularly affecting the nose, paranasal

sinuses, and cerebral tissue. These fungal pathogens exhibit a destructive behaviour, eroding small

blood vessels and leading to thrombosis, ischemia, and tissue necrosis. Patients with compromised

systemic health, such as diabetes mellitus, leukemia, and immunosuppressive therapy, are particularly

susceptible to this infection due to impaired immunity.

The various clinical manifestations of mucormycosis are categorized into rhinocerebral, pulmonary,

cutaneous, gastrointestinal, and disseminated forms. Within the rhinocerebral form, subdivisions based

on the affected tissues further refine the classification like rhino-orbital, rhino-sino-orbital, rhino-

orbito-cerebral.

Fungal culture remains a cornerstone for identifying the causative organism, while magnetic resonance

imaging is the gold standard for radiological evaluation, offering detailed imaging of the affected

regions. Computed tomography scans also play a crucial role in the diagnostic pathway.

With dental practitioners encountering an increasing number of mucormycosis cases, Cone Beam

Computed Tomography has emerged as a valuable diagnostic tool. Recent advancements have led to the

development of diagnostic criteria based on CBCT findings, aiding in the accurate and timely diagnosis

of mucormycosis. We report a case of mucormycosis affecting maxilla highlighting the importance of

CBCT in addition to conventional diagnostic methods thereby improving its management and clinical

outcome.

KEYWORDS: mucormycosis; COVID-19; CBCT.

Address for correspondence : Dr Tushar Phulambrikar, HOD, Department of Oral Medicine and Radiology, Sri Aurobindo College of

Dentistry, Indore-Ujjain Highway, Indore-453555 (Madhya Pradesh)

E-mail: drtushar@hotmail.com

Submitted: 15.06.2023, Accepted: 19.06.2023, Published: 26.06.2023

INTRODUCTION:

Mucormycosis is an opportunistic fulminant

fungal infection caused by Rhizopus sp., which most

commonly affects nose, paranasal sinuses and cerebral

tissues. Rhizopus along with mucor and lichtheimia

account for about 70 - 80 % of all cases of

mucormycosis. These fungi have the tendency to erode

and invade small blood vessels and lead to thrombosis,

ischemia and tissue necrosis[1]. It is known to occur in

patients with compromised systemic health as in

diabetes mellitus, leukemia, prolonged corticosteroid

therapy, chronic renal failure, antineoplastic therapy,

immunosuppressive therapy, deferoxamine therapy,

protein calorie malnutrition owing to the impaired

immunity in these patients[2]. Mucormycosis is

categorized into rhinocerebral (most common form),

pulmonary, cutaneous, gastrointestinal and

disseminated. Rhinocerebral form can be further

subdivided depending on the tissues affected as- rhino-

nasal or rhino-maxillary, rhino-orbital, rhino-cerebro-

orbital[3].

Diagnosis is based on the history, clinical

Access this article online

presentation and investigations. Fungal culture is done

This is an open access journal, and articles are distributed under

the terms of the Creative Commons Attribution-Non Commercial

ShareALike 4.0 License, which allows others to remix, tweak, and build

upon the work non-commercially, as long as appropriate credit is given

and the new creations are licensed under the identical terms.

For reprints contact: editor.pjsr@peoplesuniversity.edu.in

How to cite this article: Phulambrikar T, et al.: Mucormycosis- A Case

Report. PJSR. 2023;16(1):69-73.

Quick Response Code:

Website:

www.pjsr.org

DOI:

doi.org/10.5281/zenodo.8077203

Case Report

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

Phulambrikar T et al. Mucormycosis

Figure 1: Intraoral clinical presentation showing enlarged gingiva and palatal changes in the region of 16, 17.

to visualize the causative organism and the gold

standard in radiological evaluation is Magnetic

Resonance Imaging (MRI), followed by Computed

Tomography (CT) scan[4].

In the post COVID era, there has been a surge

of cases of mucormycosis which was a seldom

occurrence earlier[5]. As Dental practitioners, we

encountered a myriad of cases and evaluated them for

the signs and symptoms and conducted investigations,

in this case, Cone Beam Computed Tomography

(CBCT). The recent development of diagnostic criteria

based on CBCT findings aids in the diagnostic process.

We present a case of Mucormycosis affecting

maxilla in a diabetic patient with a history of COVID-

19. A 54 year old male patient reported to the

department of Oral Medicine and Radiology at Sri

Aurobindo College of Dentistry, with the chief

complaint of pain in the right side of his jaw since 7

days. The patient was apparently alright a week ago

when he started experiencing pain in the right quadrant

of maxilla which was dull, gnawing and continuous in

nature which aggravated on chewing. The patient's

medical history was significant for a recent COVID-19

i n f e c t i o n 3 m o n t h s a g o a c c o m p a n i e d b y

hospitalisation in the ICU for 10 days. Corticosteroids

along with antiviral drugs were administered to the

patient, after which he was discharged. His medical

history revealed that he had diabetes for 4 years and

was under medication. His foregoing reports were

suggestive of his blood sugar levels being consistently

>140 mg/dl.

On extra oral examination, there was no gross

facial asymmetry, no pain or tenderness on palpation.

The patient was evaluated for any sinus abnormality

through palpation which yielded a negative result. On

intra oral examination, swelling on the marginal and

attached gingiva was observed which was non

suppurative, fibrous and non tender on palpation and

gentle probing [Figure 1]. On further examination,

there was a diffuse slight tumescence on the right

posterior part of hard palate corresponding to the teeth

16 and 17 with mild tenderness on palpation and no pus

discharge. The teeth in the first quadrant had no

mobility, but examination of maxilla revealed the

presence of segmental mobility in the first quadrant.

Based on the history and clinical findings, a

provisional diagnosis of mucormycosis of the maxilla

was made and differentials included osteomyelitis,

chronic granulomatous infection, and deep fungal

infections.

A CBCT scan was advised and it indicated loss

of cortical plate in the region of the first quadrant. On

further perusal, the scan revealed an isodensity in the

lumen of right and left maxillary sinuses suggestive of

sinusitis. A radiographic diagnosis of Mucormycosis

involving maxillary arch and invasive fungal sinusitis

was made [Figure 2,3 & 4].

Phulambrikar T et al. Mucormycosis

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

hypoattenuation in the lumen of the maxillary sinus.

Figure 2: Shows an axial section of CBCT which depicts the loss of buccal cortical plate along with osteopenia in the region of 15, 16, 17.

Figure 3: Sagittal section of the scan gives an insight of the bone destruction. Figure 4: Axial section of the scan shows the isodensity or soft tissue

Figure 5: Post operative picture showing the sutured area of edentulous space Figure 6: Post operative OPG.

Diagnostic Criteria for Rhinomaxillary mucormycosis:

Involvement of at least one maxillary sinus

Osteolytic changes in maxillary alveolar bone

with or without involvement of other

mentioned bones

Presence or absence of dental findings

DISCUSSION:

M u c o r m y c o s i s i s a n o p p o r t u n i s t i c ,

angioinvasive and deep fungal infection affecting the

nasal cavity, paranasal sinuses, involving eye and

ultimately the brain. It most commonly affects

immunocompromised patients but healthy patients are

not an exception. Infection arises after inhalation

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

Phulambrikar T et al. Mucormycosis

through the nose and hence affects the nasal cavity and

then spreads to the surrounding tissues[1].

In 1855, Kurchenmeister described a case of

Mucormycosis in a patient of neoplastic lung on the

basis of its histoplasmology which was probably the

first authentic human case.

In 1876, Furbringer described pulmonary

mucormycosis for the first time which was caused by

Absidia.The first case in humans was reported in 1885

by Paultauf[2].The first publication was done by Gregory

et al, of the first observation of rhino-orbital cerebral

mucormycosis in 1943.The first report was by Harris in

1955 of the first known survivor[4].

According to WHO, the incidence rate of

mucormycosis globally varies from 0.005 to 1.7 per

million population in 2020[7]. A 10-year study from

Tamil Nadu showed an annual incidence of 18.4 cases

per year during 2005–2015[8]. Another study from Tamil

Nadu reported 9.5 cases per year during 2015–2019[8]. A

multicentre study across India reported 465 cases from

12 centres over 21 months; the study reported an annual

incidence of 22 cases per year, and an average of 38.8

cases for each participating centre[8]. Chakrabarti et al

showed an increasing trend of mucormycosis, with an

annual incidence of 12.9 cases per year during 1990–

1999, 35.6 cases per year during 2000–2004, and

50 cases per year during 2006–2007. The overall

numbers increased from 25 cases per year (1990–2007)

to 89 cases per year (2013–2015)[9]. Though invasive

aspergillosis is given importance among invasive

mould infections in intensive-care units (ICUs), a

multicentre s tudy in Indian ICUs reported

mucormycosis in a considerable (14%) number of

patients[9]. Without population-based estimates, it is

difficult to determine the exact incidence and

prevalence of mucormycosis in the Indian population.

The computational-model-based method estimated a

prevalence of 14 cases per 100,000 individuals in India.

In India, prevalence of mucormycosis is about 80 times

higher than the prevalence in developed countries[7].

In India, Diabetes mellitus has been the most

common risk factor linked with mucormycosis[9]. Other

causes include haematological malignancy and

chemotherapy, haematopoietic stem cells, and solid-

organ transplant recipients on immunosuppressive

therapy, with iron overload, on peritoneal dialysis,

extensive skin injury, human immunodeficiency virus

(HIV) infection, and voriconazole therapy[10].

Along with these, COVID-19 disease has a

propensity to cause extensive pulmonary disease and

subsequent alveolo-interstitial pathology. This by itself

may predispose to invasive fungal infections of the

airways including the sinuses and the lungs.

Furthermore, there is an alteration of the innate

immunity due to COVID-19-associated immune

dysregulation characterized by decreased T cells,

including CD4 and CD8 cells[11]. Other factors like

steroid administration, immunomodulating drugs like

tocilizumab, and high doses of Vitamin C, oxygen

therapy, and prolonged hospitalization predispose the

development of mucormycosis.

Initial clinical assessment calls for an

investigation; MRI being the modality of choice to

evaluate the extent of disease and prognostication. Next

in line being CT although it has been observed that

CBCT is one of the most underrated imaging modalities

in the early diagnosis of mucormycosis as evidenced by

the paucity of literature. As of late, CBCT has been

considered as the examination of choice in various

instances, since it gives high resolution imaging,

diagnostic consistency and risk benefit assessment[6].

In the case mentioned in this report, we

evaluated the patient through proper history, assessing

the clinical signs and symptoms, subjecting the patient

to available modality i.e. CBCT and applying the

diagnostic criteria based on CBCT findings to

formulate a diagnosis.

The clinical findings included gingival

enlargement, diffuse swelling involving hard palate and

segmental mobility. In severe cases, a necrosed

ulcerative area forms over the palate owing to the

thrombosis which eventually causes exposure of the

non-vital bone[10].

CBCT images show loss of cortical bone along

with obliteration of right and left maxillary sinus

suggestive of invasion of sinus lumen.

In cases where the infection has spread through

the other paranasal sinuses, ocular involvement takes

place through the thin lamina papyracea of the ethmoid

bone into the orbit resulting in rhino-sino-orbital

mucormycosis[10].

The treatment for mucormycosis infections

involves the utilization of Amphotericin B, which is the

initial FDA-approved drug for this purpose.

Amphoterecin B is available in different lipid

formulations, including liposomal preparation, lipid

complex, and colloidal dispersion. These formulations

enhance the effectiveness of the drug and improve its

administration to the affected areas, thereby assisting in

the treatment of mucormycosis infections, administered

in the dose of 10 mg/kg/day.[12] A dosage of 5mg/kg/day

is recommended in COVID-19 associated Mucormy-

cosis. An oral suspension of Posaconazole

800mg/24hrs in 2 divided doses is advised for 12-13

weeks[13].

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

Phulambrikar T et al. Mucormycosis

Necrosis and thrombosis occurring during

mucormycosis can lead to inadequate delivery of

antifungal medications, making it crucial to consider

the removal of affected tissue as an essential aspect of

care for complete eradication of the infection. It is

important to acknowledge that predicting surgical

outcomes in mucormycosis cases is challenging due to

biases in patient selection. Reports have indicated that

surgical management in patients with rhino-orbito-

cerebral mucormycosis yields better results compared

to non-surgical treatment, enabling local control of the

infection.

CONCLUSION:

Early detection and aggressive management

are paramount in eradicating mucormycosis. Thorough

clinical assessment, meticulous patient history, and

comprehensive investigations are prerequisites for

accurate diagnosis. In settings with limited resources,

CBCT serves as an invaluable resource for visualizing

radiographic images. This case report underscores the

signiﬁcance of astute clinical and radiographic

examination in facilitating an early and expeditious

diagnosis of mucormycosis. By emphasizing the

pivotal role of these diagnostic approaches, healthcare

providers can augment their capacity to promptly

identify and treat mucormycosis, ultimately leading to

improved patient outcomes.

Financial Support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES:

1. Kauffman CA, Pappas PG, Sobel JD, Dismukes WE,

editors. Essentials of clinical mycology. 2nd, Edn.; New

York, NY: Springer; 2014.

2. Skiada A, Pavleas I, Drogari-Apiranthitou M.

Epidemiology and Diagnosis of Mucormycosis: An

Update. J Fungi (Basel). 2020 Nov 2;6(4):265.

3. Dilek A, Ozaras R, Ozkaya S, Sunbul M, Sen EI,

Leblebicioglu H. COVID-19-associated mucormycosis:

Case report and systematic review. Travel Med Infect

Dis. 2021;44:102148.

4. Patel A, Kaur H, Xess I, Michael JS, Savio J,

Rudramurthy S, et al. A multi-centre observational study

on the epidemiology, risk factors, management and

outcomes of mucormycosis in India. Clin. Microbiol.

Infect. 2020; 26:944.e9–944.e15.

5. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in

COVID-19: A systematic review of cases reported

worldwide and in India. Diabetes MetabSyndr

[Internet]. 2021;15(4):102146

6. Muley P, Garg R, Jambure R, Gupta VV, Mahesh KP,

Thind G. A New Diagnostic Criteria and Grading

System of Rhino-Maxillary Mucormycosis based on

Cone Beam Computed Tomographic Findings.

Contemp Clin Dent. 2023;14(1):52-56.

7. Manesh A, Rupali P, Sullivan MO, Mohanraj P, Rupa V,

George B, et al. Mucormycosis-A clinicoepidemio-

logical review of cases over 10 years. Mycoses.

2019;62:391–398. doi: 10.1111/myc.12897.

8. Priya P, Ganesan V, Rajendran T, Geni VG.

Mucormycosis in a Tertiary Care Center in South India:

A 4-Year Experience. Indian J. Crit. Care Med.

2020;24:168–171. doi: 10.5005/jp-journals-10071-

23387.

9. Chakrabarti A, Kaur H, Savio J, Rudramurthy SM, Patel

A, Shastri P, et al. Epidemiology and clinical outcomes

of invasive mould infections in Indian intensive care

units (FISF study) J Crit Care. 2019;51:64–70. doi:

10.1016/j.jcrc.2019.02.005.

10. Mohammadi F, Badri M, Safari S. et al. A case report of

rhino-facial mucormycosis in a non-diabetic patient

with COVID-19: a systematic review of literature and

current update. BMC Infect Dis. 2021; 21: 906.

11. Prakash H, Chakrabarti A. Epidemiology of

Mucormycosis in India. Microorganisms. 2021 Mar

4;9(3):523. doi: 10.3390/microorganisms9030523.

PMID: 33806386; PMCID: PMC8000977.

12. Sen M, Lahane S, Lahane TP, Parekh R, Honavar SG.

Mucor in a viral land:A tale of two pathogens. Indian J

Ophthalmol. 2021;69:244–52.

13. Rai S, Yadav S, Kumar D, Kumar V, Rattan V.

Management of rhinomaxillary mucormycosis with

Posaconazole in immunocompetent patients. J Oral

BiolCraniofac Res. 2016 Nov;6(Suppl 1):S5-S8. doi:

10.1016/j.jobcr.2016.10.005. Epub 2016 Oct 20. PMID:

27900242; PMCID: PMC5122804.