Dr. GOUNSIA AMIN

Abstract

Mucormycosis (formerly known as zygomycosis) is a severe but rare fungal infection caused by a group of molds called mucormycetes. These moulds live all around the environment. Mucormycosis primarily affects people who have health issues or are taking drugs that reduce the body's ability to fight germs and disease. Mucormycosis is a life-threatening infection that occurs in patients who are immuno-comprised because of diabetic mellitus, diabetic ketoacidosis, neutropenia, organ transplantation, and/or increased serum levels of available iron, cancer, chronic kidney disease. It most commonly affects the sinuses or the lungs after inhaling fungal spores from the air. It can also occur on the skin after a cut, burn or other kind of skin lesion. The most common etiological agent of mucormycosis is Rhizopus oryzae and is responsible for 70% of all cases of mucormycosis. The overall mortality rate of mucormycosis remains> 50%, and it approaches to 100% among patients with disseminated disease and those with persistent neutropenia.

Introduction

Mucormycosis is an aggressive, invasive and potentially devasting opportunistic fungal infection first described by Paultauf in 1885. It is a rare infection caused by an organism that belong to a group of fungi called mucormycotonia at one time these fungi were called as zygomycota, but this scientific name has been recently changed. The most commen genera are Absidia, Rhizomucor, Rhizopus, and Mucor. The genus Mucor contains several species including amphiborum, circinelloides, hiemelis, incidus, racemosus, and ramosissimus. Mucormycosis is caused by “bread mold fungi” of the green Mucor, Absidia, Rhizopus and cunning Lamella.  It is normally fungi found in the soil, plants, compost piles, rotten wood as well as decomposing fruits and vegetables.

According to the World health organisation and centre for disease and control prevention, it is not a contagious disease, it cannot be spread from one person to another. According to the Indian Ministry of Health, it begins as a skin infection and progress up to nose, cheek bones and between the eyes and tooth. In addition, it spreads to the eyes, lungs and even to the brain, causing redness or discolouration of the nose, blurred vision and double vision, among others. In extreme cases it can involve loss of the jaw and eyes.

Mucormycosis manifests in seven predominant clinical forms:-

• Pulmonary,
• Rhinocerebral,
• Cutaneous’
• Gastrointestinal,
• CNS,
• Disseminated, and
• Rarely miscellaneous (mainly found in the bone, kidney, cardiac, mediastinum, oral).

Infection Risk

Biologically-targeted therapies are those designed to act on a therapeutic target considered significant in the pathogenic process of the disease. In recent years, an increasing repertoire of agents has changed the landscape of therapies for acute leukemias. As experience with these targeted drugs becomes available, there is growing evidence of increased association between certain agents and susceptibility to infection, while for others there is no clear correlation with infection risk. Infection due to mucormycosis is essentially limited to patients with haematological, malignancies (mainly AML), and haemopoietic stem cell transplantation, solid organ malignancies and solid organ transplantation, diabetes mellitus and diabetes keto acidosis, corticosteroid therapy and rheumatic disease, iron overload and deferoxamine, prolonged use of voriconazole, HIV or AIDS, Chronic Renal Insufficiency, malnutrition and severe burns.

Mortality Rate

The prognosis for mucormycosis is rather depressing with mortality rates ranging from 25 to 80 per cent depending on the organs involved. The overall mortality rate of mucormycosis remains > 50%, and it approaches to 100% among patients with disseminated disease and those with persistent neutropenia. Mortality rates are high even when aggressive surgical procedures have been carried out.

Histopathologically

Histologically, it appears as a non- septate, ribbon like hyphae, which branch at right angles. Round or ovoid sporangia are also frequently seen in tissue section. It shows variable amount of necrosis. The fungus has an apparent predilection for blood vessels. It can penetrate their walls and there by produces thrombosis. A special stain like “Grocott’s silver meth amine stain” may use to confirm the diagnosis. Samples are taken from sputum bronchoalveolar lavage (BAL), biopsy of Para nasal sinuses. On culture it appears as cotton candy appearance.

Here we present the case pain with swelling right side of face having complicacy of diabetes mellitus and chronic kidney disease. Using KOH examination and fungal culture, we establish a rapid and accurate diagnosis. Then we extend our examination upto surguicaldebridment of maxiliary sinus. Prompt treatment of this infection was to prevent extention of this disease to the oral mucous cavity.

Treatment

Mucormycosis is a severe infection that requires treatment with prescribed anti fungals, usually amphotericin B, posaconazole or isavuconazole. These drugs are administered via the vein (amphotericin B, posaconazole, isavuconazole) or the mouth (posaconazole, isavuconazole). Other medications, including fluconazole, voriconazole and echinocandins, are not effective against fungi that cause mucormycosis. Often, mucormycosis requires surgical intervention to cut infected tissue.

(Author is Post Graduate Student Shree Bankey Bihari Dental College. Email Id: gousiaamin786@gmail.com)