Rhino-Orbital Mucormycosis associated with COVID-19
Pooja M Khatri1, Manoj Mittal2, Javed S Chand3, Apoorva Bhardwaj4, Mitesh Khatri5
1Post-graduate student, Department of Periodontology, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India.
2Vice Chancellor, Dean, Prof and Head, Department of Periodontology, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India.
3Associate Professor, Department of Periodontology, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India.
4Reader, Department of Periodontology, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India.
5Consultant ENT, Head and Neck Surgeon, Amravati, Maharashtra, India.
Abstract
Coronavirus has been associated with different bacterial and fungal infections. Of late the cases of mucormycosis or black fungus are being reported in patients with a recent history of COVID-19, especially from India. Out of 28,252 Mucormycosis cases reported 86% of infections had a history of Covid-19 and 62.3% a history of diabetes.
A 75year old male diabetic patient was admitted to a tertiary care centre in a nearby hospital with a history of high- grade fever for 5 days, shortness of breath, and bodyache. Around the 20th day, the patient developed facial swelling
& pain on the left side of the face, numbness, and nasal congestion. On clinical examination, a palatal ulcer was observed on the left side of the hard palate, teeth mobility was seen. Nasal Endoscopy by ENT surgeon revealed black necrotic eschar involving Left middle turbinate & osteomeatal area. The patient’s glycated hemoglobin level was 7.5gm% Hb. The elevated level of CRP(70 mg/l) was seen. Smear for fungus (By KOH wet mount/ with lactophenol blue) showed thick non septate & branching hyphae highly suggestive of mucormycosis. It is a dire necessity to establish protocols for diagnosis and treatment of this fatal fungal disease. Immunosuppressant need to be used with caution to decrease the aggravation of such opportunistic infection.
Key Words: Infection, Nasal Endoscopy, Left middle turbinate
Introduction
Since 2020, COVID-19 has wreaked havoc over the entire world. To date, 180,272,776 confirmed cases of COVID-19, including 3,904,895 deaths, were reported to World Health Organization(WHO). [1] Coronavirus has been associated with different bacterial and fungal infections. [2] Of late the cases of mucormycosis or black fungus are being reported in patients with a recent history of COVID-19, especially from India.[3] Out of 28,252 Mucormycosis cases reported 86% of infections had a history of Covid-19 and 62.3% a history of diabetes. The main reason for this spread of mucormycosis can be attributed to the fact that Mucorales spores germinate in COVID- 19 patients as they have low levels of oxygen or high glucose (diabetes, new-onset hyperglycemia, steroid-induced hyperglycemia)or decreased phagocytic activity of white blood cells (WBC) due to immunosuppression combined with several other risk factors including prolonged hospitalization with or without mechanical ventilators.[3] It is thought that the new strain, known as “Delta” or B.1.617, is causing unprecedented damage to the beta cells in the pancreas, which produce insulin and regulate blood glucose levels, triggering sudden onset diabetes and soaring blood glucose levels in otherwise normal individuals. Mucormycosis, an uncommon but fatal infection caused by mold fungi of the genus Rhizopus, Mucor, Rhizomucor, Cunninghamella, and Absidia of Order- Mucorales, Class- Zygomycetes.[4] The second COVID-19 wave which severely hit India in 2021 saw a surge in mucormycosis cases in COVID cases. [5] The inception of Mucormycosis infection starts from the
nose and the paranasal sinuses.[6,7]From there, it can spread to orbital and intracranial structures either by direct invasion or through the blood vessels.[8,9] Later, the fungus invades arteries leading to thrombosis that subsequently causes necrosis of hard and soft tissues. [10] We present a case of mucormycosis in a diabetic patient recovering from COVID-19.
Case Report
A 75year old male diabetic patient was admitted to a tertiary care centre in a nearby hospital with a history of high-grade fever for 5 days, shortness of breath, and bodyache. The patient’s nasopharyngeal swab was sent for an RT-PCR test and COVID-19 was confirmed. The patient was treated for COVID-19 in the hospital for 10 days and was discharged. Around the 20th day, the patient developed facial swelling & pain on the left side of the face, numbness, and nasal congestion. The patient was referred to the Department of Periodontology, Bhabha College of Dental Sciences, Bhopal for the same. On clinical examination, a palatal ulcer was observed on the left side of the hard palate (Figure 1), teeth mobility was seen.
Figure 1: Palatal ulcer on the left side of the palate
Nasal Endoscopy by ENT surgeon revealed black necrotic eschar involving Left middle turbinate &
osteomeatal area. (Figure 2)
Figure 2: Necrotic eschar involving left middle turbinate
The patient’s glycated hemoglobin level was 7.5gm% Hb. The elevated level of CRP(70 mg/l) was seen. Smear for fungus (By KOH wet mount/ with lactophenol blue) showed thick non septate &
branching hyphae highly suggestive of mucormycosis.
A computed tomography (CT) scan revealed double density sinuses due to the thickening of mucosa with hyperdense areas. Moderate mucosal thickening involving left maxillary sinus, ethmoidal sinus, effacement of osteomeatal unit & erosion of anterior maxilla and midpalatal region was observed.
(Figure 3)
Figure 3: Radiographic presentation of the case
Based on radiological and histopathological investigations, a final diagnosis of mucormycosis of the maxilla was given. Initially, conservative management was done with Intravenous Amphotericin B (5mg/kg/bw) and IV Cefuroxime was given.
Surgical debridement of necrotic bone involving left maxillary sinus, alveolar arch, ethmoid air cells, diseased necrotic/ dead tissue from the nasal cavity, and adjacent soft tissue was done (Figure 4) and sent for histopathological examination. (Figure 5)
Figure 4: Left maxillectomy showing blackish discoloration involving lateral nasal wall.
Figure 5: Specimen for HPE
The histological examination revealed that there were several thick-walled, irregularly branching nonseptate hyphae in the background of necrotic tissue at the periphery of the bony trabeculae.
Angioinvasion was seen. (Figure 6)
Figure 6: Histopathological view showing vascular invasion The excisional biopsy revealed similar histopathological findings as that of KOH mount.
Discussion
Mucormycosis is caused by fungi of the class zygomycetes.[10] Depending upon the anatomic site, mucormycosis can be divided into six clinical categories which are: rhino-orbito-cerebral (44%–
49%), followed by cutaneous (10%–19%), pulmonary (10%–11%), disseminated (6%–11%), gastrointestinal (2%–11%)and miscellaneous. [11,12]
The factors which predispose mucormycosis are uncontrolled diabetes, immunosuppressive therapy, leukemias, neutropenias.[13] Apart from this, mucormycosis can also be seen in patients with neutrophil dysfunction, hematopoietic stem cell transplantation, diabetic ketoacidosis, iron-overload, and HIV/AIDs. [14]
Uncontrolled diabetes mellitus is known to alter the immunologic response of an individual thus making them susceptible to infections because of decreased granulocyte phagocytic ability in addition to altered polymorphonuclear leukocyte response.[15]
Mucormycosis of the oral cavity can disseminate through one of the two ways:1) through inhalation, 2) through an open wound in the oral cavity.[16] If the mouth is involved, a black, necrotic eschar is found on the palate, and ischemic, necrotic turbines may be found in the nose. [17]
It is essential to diagnose the disease at an early stage to prevent the spread of the disease. Also, the first line of treatment would be to find the underlying cause and treat it conservatively followed by surgery. However, it is difficult to achieve when the patient is on steroid therapy for the treatment of COVID-19. The patient was administered Amphotericin B which acts as a fungistatic agent followed by surgery.
Conclusion
A rising number of mucormycosis cases have been linked to COVID-19. It is a dire necessity to establish protocols for diagnosis and treatment of this fatal fungal disease. Immunosuppressants need to be used with caution to decrease the aggravation of such opportunistic infection. Also, research needs to be amplified to study such opportunistic infections which occur after COVID-19.
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