Abstract Background and Aim: Mucormycosis is an aggressive and life-threating fungal infection that affects patients with uncontrolled diabetes mellitus (DM) or compromised immune system. The most common symptom of rhinocerebral mucormycosis is sinusitis, and if the infection spreads beyond the sinus, more severe symptoms such as blindness, seizure, and death may occur. Case Presentation: We describe a case of rhinocerebral mucormycosis successfully treated in an 11-year-old boy with uncontrolled DM and neglected sinusitis with sudden blindness. Conclusion: Patients with poorly controlled or insulin-dependent DM who experience periods of ketoacidosis are more likely to develop mucormycosis. Therefore, correct diagnosis and timely referral of patients greatly affect the prognosis of the disease and the treatment process. Key Words: Blindness; Diabetes Mellitus; Mucormycosis; Sinusitis |
In the head and neck area, Mucorales cause extensive damage by invading the blood vessels, and creating embolism and necrosis, which, if not diagnosed promptly, can lead to disease progression and invasion to vital structures and result in ultimate death of the patient.[5] Rhizopus arizus is the most common type of Mucorales that causes mucormycosis. This microorganism normally grows on the soil and various decaying organic materials, and releases many spores into the air that are inhaled by humans. In healthy people, the microorganism is cleared byphagocytes, and is not pathogenic.[6]
Numerous risk factors have been reported for susceptibility to mucormycosis; among which, DM is the most common.[2-4] Patients with poorly controlled DM or type I DM (insulin-dependent type) that experience periods of ketoacidosis are more likely to develop the disease. Ketoacidosis increases the serum iron level by inhibiting the binding of iron to transferrin. Iron promotes the growth of the fungi. On the other hand, patients with DM suffer from functional defects of phagocytes; thus, they are more prone to mucormycosis than healthy people. Therefore, it seems that blood sugar control is an important factor in controlling the disease and also preventing the occurrence of mucormycosis.[7-9]
The disease affects several different organs, among which, the oral cavity, sinuses, and orbits are the most commonly affected areas in rhiniorbital form. The situation would be more life-threatening in diabetic patients.[4] Since the rhinocerebral type is sometimes not diagnosed early in diabetic patients (due to the presence of nonspecific symptoms), and the disease progresses widely, the algorithm mentioned in the "International Guideline for Clinical Mycology in Europe" should be considered for correct diagnosis and appropriate treatment planning.[9,10] This algorithm contains diagnostic and therapeutic steps for patients with mucormycosis. For an initial diagnosis, complications such as sinusitis, orbital apex syndrome, and development of a single oral ulcer in the palatal area developed in a diabetic patient may be considered as symptoms of the disease.
According to the guideline, these symptoms are classified as warning signs. Therefore, dentists can play an important role in preventing the progression of disease by quickly diagnosing and referring such patients after examining and discovering such lesions in the head and neck area. The next step is to request additional imaging of the head and neck region to examine the affected areas and confirm the initial diagnosis, and also for use as a guide for definitive treatment. After clinical examination and imaging, to confirm the initial diagnosis, a smear cytology, culture, and biopsy of the affected site would be the next steps. On histopathological examination, fungal hyphae are typically seen in a broad non-septate form with a right-angle branch.[7-9] The treatment protocol for mucormycosis includes a combination of medication and surgery based on the area involved and the severity of the involvement. In the present case, after the initial steps to diagnose mucormycosis, due to the large area of involvement, the ultimate treatment for the patient was total maxillectomy and tracheostomy, and both left and right maxillary sinuses were totally
debrided. For antifungal treatment, amphotericin B is the first line treatment for mucormycosis, but due to its nephrotoxicity, it is recommended to evaluate the patient's renal function (especially in type I DM) before its administration.[9,10]
Conclusion
Patients with mucormycosis experience several complications after treatment following deformity due to fungal infection or surgery; therefore, correct diagnosis based on clinical and histopathological findings and timely referral of patients can greatly affect the prognosis of the disease and the treatment process.
Rights and permissions | |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |