INTRODUCTION:

Mucormycosis is a fungal infection that commonly effects palate in the oral cavity. Mucormycosis is mainly caused by genera mucor, Absidia organisms. These fungi are commonly found in soil, decaying vegetables and fruits. Contact with these substances can be infectious leading to mucormycosis.

People with immunocompromised condition are prone to get mucormycosis as it’s an opportunistic infection¹. Mucormycosis is rare in people with adequate immune status. Mucormycosis infections cause vascular invasion, necrosis, ulceration and perforation of the palate in later stages.

This case report presents a case of mucormycosis in an immunocompetent patient with no underlying immunocompromised condition.

CASE REPORT:

A 48-year-old female patient had reported to the department of Oral and Maxillofacial Surgery, College of Dental Science and Hospital, Rau, Indore with a chief complaint of difficulty in mouth opening with pain in upper left jaw region since 20 days.

Patient gave a history of extraction of upper left 2^nd and 3^rd molar teeth 20 days back due to decay. This was followed by pain and swelling which increased with time. After this bone necrosis was seen around the extraction area.

Medical history was non-contributory. Patient was moderately built well nourished. Local examination showed restricted mouth opening with no extra oral swelling.

Intra oral examination showed ulcerated fungating lesion on the palatal left side region not involving the midline. Upper left canine premolars and 1^st molars were grade II mobile.

There was no bleeding on probing. Lesion was bluish black to whitish red in appearance.

Paraesthesia was observed on left infraorbital region. Visual acuity and pupillary reaction to light were normal.

C.T Scan findings revealed the lesion extending on to the left maxillary sinus, nasal cavity, and ethmoidal sinus. The orbital rim was found to be intact.Aletred bony architecture was seen in OPG.

Endoscopy of nose was performed which reported nasal mucosa congested, crust was present on the nasal floor. All other investigations were within normal limits. Biopsy was obtained with patients consent and sent for histopathological examination.

Need for surgery was explained to the patient and duly written consent was obtained. Injection fluconazole 150 mg once daily was started. This drug was continued for next 3 weeks post-operative period.

Partial maxillectomy was done initially followed by excision of maxillary sinus lining. Secondary reconstruction was done with temporalis myofacial flap. An implant supported prosthesis was fabricated for the patient after 2-3 months. Follow up for 6-12 months was done and patient was found to be stable.

1. NECROSED LEFT MAXILLA

2. PARTIAL

MAXILLECTOMY:

3. EXCISED MAXLLA

4.TEMPORALIS MYOFACIAL FLAP

5. POST-OP 1 MONTH

DISCUSSION:

Mucormycosis is a common name given to several different diseases caused by fungi of the order Mucorales².

Mucormycosis was first described by Paltauf in 1885. He coined the term Mycosis Mucorina which subsequently became mucormycosis ³.

Mucormycosis is an opportunistic fungal infection usually seen in immunocompromised patients, but can effect healthy individuals as well ⁴.

Predisposing factors include uncontrolled diabetes, malignancies as lymphomas, long term steroid therapy, leading to immunocompromised condition, renal failure, autoimmune disorders and others⁵.

Mucormycosis spreads via airborne route (inhalation) or ingestion of food which is contaminated with spores via soil and water. These spores penetrate the deeper tissues and cause infection in immunocompromised patients.

In immunocompetent patient’s phagocytes kill the spores of Mucorales by generating various oxidative metabolites⁶. But in some cases, spores are highly virulent and present in large numbers. In such circumstances, these spores colonize the area and spread all over extensively causing infection before they can be managed especially in immunocompromised person.

Clinically, in initial conditions, tissues show erythema, oedema, and slight tenderness. With time lesion gets blackish due to necrosis, as blood vessels in that area get thrombosed due to involvement of vessels in that area by the lesion.

Palatal mucormycosis is commonly seen due to direct extension of disease from the maxillary sinus. Other clinical features include pain, ulceration, bone loss, necrosis, and palatal perforations.

Various other lesions which mimic mucormycosis and which need to be included in list of differential diagnosis of mucormycosis include, osteomyelitis, other fungal infections, herpes zoster, traumatic nectrotizing sialometaplasia and others.

CONCLUSION:

Mainstay of antifungal therapy for treating mucormycosis is systemic Amphotericin B, highest possible dose being 1 mg/kg/day⁷. But newer drug Fluconazole was used in this case as first line of treatment along with Surgical Debridement, Reconstruction and Rehabilitation as successful treatment with no side effects and no complications. Mucormycosis is a rapidly progressing aggressive opportunistic fungal infection which can prove to be fatal if not treated well in time. Early, correct diagnosis and adequate management with preventive measures will help treat mucormycosis the best successful way.

REFERENCES:

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Received on 01.08.2019 Modified on 18.08.2019

Res. J. Pharmacology and Pharmacodynamics.2019; 11(3): 89-91.

DOI: 10.5958/2321-5836.2019.00015.6