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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 3  |  Page : 184-186

Mucormycosis and COVID 19: From the desk of a periodontist


Department of Periodontics, Institute of Dental Sciences, Jammu, Jammu and Kashmir, India

Date of Submission10-Jun-2021
Date of Decision05-Jul-2021
Date of Acceptance16-Jul-2021
Date of Web Publication11-Aug-2021

Correspondence Address:
Malvika Singh
Department of Periodontics, Institute of Dental Sciences, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_54_21

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  Abstract 


Oral mucormycosis is not a new disease and is known to occur in patients with low immunity such as in uncontrolled diabetes, posttransplant, and some cancer treatments. A sudden surge has been reported in mucormycosis in cases with COVID-19. Although rare, serious complication of COVID-19. The aim of this article is to discuss the periodontal presentation of oral mucormycosis in patients who currently have or have recovered from COVID-19 infection. Although fatal sometime, its successful treatment lies in the early diagnosis and for periodontists are the first doctors to identify the same, they should remain vigilant in its diagnosis so that the same can be treated by a multidisciplinary medical approach and fatalities can be avoided.

Keywords: COVID-19 patients, dental professionals, oral mucormycosis, periodontist


How to cite this article:
Singh M. Mucormycosis and COVID 19: From the desk of a periodontist. Apollo Med 2021;18:184-6

How to cite this URL:
Singh M. Mucormycosis and COVID 19: From the desk of a periodontist. Apollo Med [serial online] 2021 [cited 2021 Dec 6];18:184-6. Available from: https://www.apollomedicine.org/text.asp?2021/18/3/184/323677




  Introduction Top


In human history, one of the most common diseases that we have faced has been fungal infection known by the name of mycosis. The majority of these are resultant of opportunistic conditions where the host resistance impairment allows the initiation and progression of pathogenic conditions through local colonization in the oral cavity. Their frequency increases with the increased use of immunosuppressive drugs and immunodeficiency viral infections.[1] As per the latest reports, there has been a significant increase in the number of cases of mucormycosis in COVID-19 patients during treatment in hospitals and after discharge in different parts of the country.[2]

Mucormycosis is a deep fungal infection due to fungi of the Mucorales species. These fungi are commonly nonpathogenic in the healthy person, but may become opportunistic pathogens in medically complex patients leading to high rates of morbidity and potential mortality.[3] The organisms may be recovered from the head-and-neck, nose, sinus, throat, and oral cavity, while the most common forms of infection are pulmonary and sinus. The infection may present as a local necrotic ulceration that can result in hematogenous spread leading to fulminant infection and death.

The disease was first described in 1876 when Fürbinger described in Germany a patient who died of cancer and in whom the right lung showed a hemorrhagic infarct with fungal hyphae and a few sporangia.[4] In 1885, Arnold Paltauf published the first case of disseminated mucormycosis, which he named mycosis mucorina.[5]

The aim of this review article is to discuss the presentation of oral mucormycosis in patients who currently have or have recovered from COVID-19 infection. Internet database Medline/PubMed search for the word “Oral mucormycosis” resulted in 185 articles, “Oral mucormycosis and oral health” showed 12 articles, “Oral mucormycosis, COVID-19 patients and periodontal tissues” revealed 0 article. Only highly relevant articles from manual and PubMed search in English language were considered for the present review article.

Mucormycosis and COVID-19: Why is there a concern?

Mucormycosis is not a new disease and is known to occur in patients with low immunity such as in uncontrolled diabetes, posttransplant, and some cancer treatments. It occurs particularly in COVID-19 patients who have recently recovered due to COVID-19 infections due to the fact that medications such as rampant overuse and irrational use of steroids, broad-spectrum antibiotics during the management of COVID-19 infection causes immunosuppression. Furthermore, overuse of steroids cause the development of new-onset of diabetes which again is a risk factor for oral mucormycosis. The COVID-19 infection itself is associated with leukopenia and may lead to immune compromise caused by impaired or inappropriate immune responses. mucormycosis infection may occur during COVID-19 infection, or after a few weeks of apparent recovery from it so dental professionals should ensure to take past medical history before initiating any dental treatment.

Time of presentation

It is generally variable but usually it is around 3rd week of onset of symptoms of COVID-19.

Oral signs and symptoms

  1. Facial pain, pain over sinuses in teeth, and gingival tissues
  2. Multiple abscesses in the gingival tissues
  3. Palatal ulcer
  4. Loosening of teeth
  5. Discoloration of palate
  6. Gangrenous inferior turbinates
  7. Paresthesia over half of face
  8. Blackish discoloration of the skin over nasolabial groove/alae nasi
  9. Periorbital swelling
  10. Other symptoms include: blurred or double vision with pain, fever, skin lesion worsening of respiratory symptoms, hemoptysis, chest pain, alteration of consciousness, and headache.



  Diagnosis Top


Clinical presentation of mucormycosis usually provides an invasive picture of perforation into bony areas. Cases have been documented with oroantral communication or perforation extending to facial tissues. Confirmation of clinical diagnosis requires microscopic examination of the biopsied tissue.[6] For a rapid presumptive diagnosis of mucormycosis, KOH wet mounts can be used for direct microscopy. It can be applied to all materials sent to the clinical laboratory. KOH when supplemented with fluorescent brighteners such as Blankophor and Calcofluor white, enhance the visualization of the characteristic fungal hyphae but requires a fluorescent microscope.

The histopathological examination of tissue shows broad, nonseptate type of hyphae with the pathognomonic nature of hyphae branching at right angles. The hyphae will be observed with a deeper connective tissue invasion. The special staining method, Grocott-Gomori methenamine silver stain helps in confirmation of the nonseptate hyphae. A thorough clinical examination of the oral cavity in invasive lesions is recommended to achieve a clinical diagnosis, since not all the cases with mucormycosis will show the classical diagnostic interpretation in imaging:

  1. Noncontrast computerized tomography of paranasal sinuses to see bony erosion
  2. High-resolution computerized tomography chest shows ≥10 nodules, reverse halo sign, and computerized tomography (CT) bronchus sign
  3. CT angiography
  4. Magnetic resonance imaging (MRI) brain for better delineation of the central nervous system (CNS) involvement.


CT is 100% sensitive and 78% specific in the diagnosis of sinonasal mycosis. Both contrast-enhanced CT scans and CE MRI of the paranasal sinuses are helpful for early diagnosis of mucormycosis.

Histopathological examination remains the gold standard in the diagnosis of oral mucormycosis.

Differential diagnosis

It should be made with aspergillosis in which the filaments would be septed and bound by acute angles.


  Management Top


Both medication and surgical management strategies are employed in mucormycosis cases. Patients should be advised to control diabetes and diabetic ketoacidosis. If the patient is still on the use of steroids and immunomodulating drugs, same should be reduced with the aim to discontinue the same which should be done after consulting the concerned medical practitioner.

Medications include

They should initiate Amphotericin B therapy on time and should ensure that the patient has controlled of blood glucose while attending the dental clinic for treatment.

  1. Liposomal Amphotericin B initial dose of 5 mg/kg body weight (10 mg/kg body wt. in case of CNS involvement) as the treatment of choice and has to be continued till a favorable response is achieved and disease is stabilized which may take several weeks following which step down to oral posaconazole (300 mg delayed-release tablets twice a day for 1 day followed by 300 mg daily) or isavuconazole (200 mg 1 tablet 3 times daily for 2 days followed by 200 mg daily) can be done
  2. Conventional Amphotericin B (deoxycholate) in the dose 1–1.5 mg/kg may be used if liposomal form is not available and renal functions and serum electrolytes are within normal limits.[2]


Following which, extensive surgical debridement should be used to remove all necrotic materials such as affected gingiva, tooth, and palatal ulcer.


  Prevention Top


Periodontists should ensure past medical history is taken before initiation of dental treatment and be vigilant regarding oral signs and symptoms of mucormycosis. They should immediately consult the medical team in case of any suspicion as one may have to initiate therapy in relevant cases even before diagnosis is made. Doctors should be advised to use steroids and antibiotics judiciously i.e. correct evidence-based dose, right timing, and for recommended duration. They should initiate Amphotericin B therapy on time and should ensure that the patient has controlled of blood glucose while attending the dental clinic for treatment.

Periodontists should counsel the patients recovered from COVID-19 infection, to keep them informed about all of their comorbidities such as diabetes, hypertension, heart disease, and any malignancy, and should tell the doctor about all medicines being taken, especially if under medication with immunosuppressant drugs for any immune-related disorder/disease. They are also advised to use masks and maintain personal hygiene and immediately inform the doctor if they develop signs and symptoms of oral mucormycosis during or after their dental treatment.


  Conclusion Top


Oral mucormycosis is not a new fungal infection and has been diagnosed and responsibly treated by the periodontists for long; however, with the surge of COVID-19 infection causing immunosuppression in the patients, their number has risen sharply. Although fatal sometimes when treated late, its successful treatment lies in early diagnosis. Since dental professionals are perhaps the first doctors to identify signs and symptoms, they should remain vigilant in its diagnosis so that the same can be treated and fatalities can be avoided.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Richardson M, Lass-Flörl C. Changing epidemiology of systemic fungal infections. Clin Microbiol Infect 2008;14 Suppl 4:5-24.  Back to cited text no. 1
    
2.
Guideline for Management of Mucormycosis in Covid – 19 Patients. Available from: https://www.dghs.gov.in/WriteReadData/News/202105171119301555988MucormycosismanagementinCovid-19.pdf. [Last accessed on 2021 Apr 09].  Back to cited text no. 2
    
3.
McDermott NE, Barrett J, Hipp J, Merino MJ, Richard Lee CC, Waterman P, et al. Successful treatment of periodontal mucormycosis: Report of a case and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e64-9.  Back to cited text no. 3
    
4.
Fürbringer P. Observations on pulmonary mycosis in humans. J Virchows Arch 1986;66:330-65.  Back to cited text no. 4
    
5.
Paltauf A. A contribution to the knowledge of human beings Fadenpiltzer disease. J Virchows Arch Pathol Anat 1885;102:543-64.  Back to cited text no. 5
    
6.
Reddy S, Kumar K, Sekhar C, Reddy R. Oral mucormycosis: Need for early diagnosis!! J Dr NTR Uni Health Sci 2014;3:145-7.  Back to cited text no. 6
    




 

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Abstract
Introduction
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