Post-COVID mucormycosis in presentation of periodontal abscess

ABSTRACT

COVID-19 pandemic has traumatized deep inside in minds and lives of human beings. Those who have survived are at risk of many post-COVID complications; mucormycosis being one of the most common as well as morbid infections. Mucormycosis is also known as black fungus, it is a life-threatening opportunistic fungal infection. Inoculation occurs by inhalation of spores in nose, paranasal air sinuses and in lungs. Mucormycosis is often associated in patients with compromised immunity and it presents with characteristic black necrotic eschar and necrosis. Disease affecting the facial region possess a challenge because it often disseminates with sino-orbital and cranial involvement at the time of diagnosis. Dental practice occasionally encounters unusual and subtle symptoms with non-pathognomonic clinical signs of several fatal diseases which may pretend like a common oral disease. Hence, the key knowledge to oral and primary care physicians and its precise application is necessary for the early diagnosis of such fatal infections to prevent untoward consequences in this COVID era. This article presents a case of mucormycosis with chief complaint of pain and swelling in right front tooth region, which mimicked as periodontal abscess in a patient, leading to delay in the diagnosis possess greater challenges during the treatment.

Introduction

In India, COVID-19 started with first case on 27^th January 2020 followed by 2^nd and 3^rd wave and still there is an apprehension of 4^th wave. According to WHO reports, incidence rate of mucormycosis globally varies from 0.005 to 1.7 per million population.[1] In India, the prevalence of mucormycosis is estimated as 140 per million population.[2,3] After candidiasis and aspergillosis, mucormycosis is the third invasive mould in order of importance in the class Zygomycetes.[4] The emergence of the new fungal epidemic in the country was due to injudicious use of corticosteroids, overdosage of drugs and panic condition among COVID-19 patients.[5] Pre-existing medical history of diabetes or any other debilitating disease makes that individual more susceptible to mucormycosis.[4] Successful management of this fulminant infection requires early recognition and diagnosis of the disease and aggressive medical and surgical interventions to prevent the high morbidity and mortality associated with the disease process.[6] Failure in same results in huge disfigurement and even can lead to death of the patient. This paper discusses importance of vigilant diagnosis in case report of a patient who was provisionally diagnosed as periodontal abscess but its final diagnosis came out to be mucormycosis involving right-side maxillary sinus, hence posing greater challenges within the diagnosis and treatment. The patient was successfully managed by comprehensive approach by a team of dentists of various specialities.

Case History

A 48-year-old male patient reported to the outpatient department with a chief complaint of pain and swelling in the right maxillary front tooth region. The patient gave history of hospitalization and received treatment for COVID-19 and discharged 1 month back. On examination, there was an extraoral swelling over the right lip area, extending mediolaterally from lateral aspect of nose to the corner of the mouth with mild obliteration of nasolabial fold [Figure 1a]. On palpation, the swelling was mild tender in nature without palpable lymph node. Eye movements were normal, pupils were reactive to stimuli, and nasal twang in voice was noticed. On intraoral examination class 3 mobility wrt teeth 12 and 13, mild vestibular tenderness with soft fluctuant swelling was found [Figure 1b]. A panoramic imaging showed advanced supporting bone loss around teeth 12 and 13. Keen observation of the same revealed ill-defined radiolucency in the right maxillary anterior alveolar bone extending up to the floor of the right maxillary sinus suggesting its involvement [Figure 2]. A provisional diagnosis of periodontal abscess wrt 12 and 13 was made.

Figure 1.

(a) Extraoral photograph of patient showing mild swelling in middle third of face. (b) Intraoral photograph showing abscess wrt teeth 12 and 13

Figure 2.

Orthopantomograph (OPG) showing radiolucency wrt teeth 12 and 13

Based on examination and observation, the following specific key points were also noted—Nasal twang, COVID history of 1 month back, bony changes in the floor of maxillary sinus. The patient was advised for a magnetic resonance imaging (MRI). MRI scan revealed mucosal thickening with T2 hypointense components and non-enhancement of involved mucosa/soft tissue suggestive of fungal aetiology in the right maxillary sinus and hyper density of the maxillary antrum [Figure 3]. After thorough investigation and evaluation of the patient’s medical history, clinical features and radiological findings, it was suspected as a case of post-COVID mucormycosis and expert opinion was obtained from the Oral and Maxillofacial Department. Extraction of hopeless teeth, that is, 12 and 13, was done, followed by curettage of socket and curetted sample was sent for histopathological analysis.

Figure 3.

Magnetic resonance imaging (MRI) scan (a) coronal view, (b) axial view showing soft tissue opacification in the right maxillary sinus with mucosal thickening

Microscopic findings revealed the areas of necrosis with thick-walled broad non-septate fungal hyphae of mucor. Condensed acute and chronic inflammatory cells and few epithelioid cell granulomas along with multinucleated giant cells were also found [Figure 4]. The presence of hyphae confirmed by the potassium hydroxide (KOH) staining. The periodic acid–Schiff staining confirmed the presence of right-angled hyphae which confirmed the presence of mucormycosis[7] [Figure 4].

Figure 4.

Histopathological report showing non-septate hyphae

The confirmatory diagnosis of mucormycosis involving the right maxillary sinus was made and the patient was hospitalized immediately. Liposomal amphotericin B in a dosage of 5 mg/kg was administered intravenously for a week. Subsequently, surgical entry to the right maxillary sinus was made through extracted socket, fluid was drained, and sinus was cleaned. Subsequently formed oroantral communication was treated with primary closure and healing was normal. The excisional biopsy reconfirmed mucormycosis infection. No recurrence was noticed after 6 months of patient follow-up.

Discussion

Supportive care, corticosteroids and remedial drugs are often used and most preferred treatment options in COVID-19 era. Due to the frequent and injudicious use of steroids, these patients became more susceptible to invasive opportunistic infections. Interplay of various factors, such as comorbidities (like diabetes mellitus), use of immunosuppressive therapy, risk of hospital-acquired infections and alteration of immune system by COVID-19, has increased chances for coinfections, superinfection and opportunistic infection.[4] Mucormycosis has evolved as one of the most common as well as morbid post-COVID complications. The mortality rate varied depending on underlying patient condition, type of fungus and body site.[8] The rhinoorbitocerebral form is of particular significance to the oral clinician as it can manifest in the orofacial region. Some of the common oral manifestations of mucormycosis in post-COVID patient are palatal swelling, palatal abscess, ulcerations, mucosal discoloration, osteomyelitis, etc., At most primitive-level sub-centre and primary healthcare centres serve as 1^st contact point between village community and primary healthcare system; hence, primary care physicians can be the first clinician to suspect an infection and play a critical role in diagnosing rhinomaxillary or rhino–cerebral mucormycosis as it involves facial tissues, palate, alveolar bone and mandibular bone.

Imaging possesses great help in the diagnosis of rhinoorbitalcerebral mucormycosis as it helps in assessing the extent of disease, identifying complications and for surgical planning.[9] In present case, orthopantomogram (OPG) findings illustrate minor bony changes in the floor of the right maxillary sinus, further correlated with patient’s clinical findings, and then, the patient was sent for MRI and histological examination. Delay in early intervention may lead to wide spread of infection to surrounding bones causing necrosis, infiltration into eye, retromaxillary space, brain and can even lead to death of patient. The management and outcome of mucormycosis depends on early diagnosis, immediate administration of antifungal therapy, control of risk factors and surgical debridement.

Conclusion

Mucormycosis should always be considered as one of the differential diagnoses in COVID era, since it is an aggressive fulminant invasive fungal infection that causes extensive damage in a very short time interval. Therefore, early and vigilant diagnosis, appropriate interventions in collaboration with multidisciplinary teams can significantly reduce morbidity and mortality associated with mucormycosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.