ISSN: 2581-5989

PubMed - National Library of Medicine - ID: 101738774

International Journal of Dental Science and Innovative Research (IJDSIR)

IJDSIR : Dental Publication Service
Available Online at: www.ijdsir.com
Volume – 5, Issue – 2, March - 2022, Page No. : 411 - 415
Post covid mucormycosis of mandible
1
Dr. Bharati A Patil, Professor, Dept of Oral Medicine & Radiology, The Oxford Dental College, Bangalore-560068
Karnataka.
2
Dr. Yamuna Rani, Post Graduate Student, Dept of Oral Medicine & Radiology, The Oxford Dental College, Bangalore-
560068 Karnataka.
Corresponding Author: Dr. Yamuna Rani, Post Graduate Student, Dept of Oral Medicine & Radiology, The Oxford
Dental College, Bangalore-560068 Karnataka.
Citation of this Article: Dr. Bharati A Patil, Dr. Yamuna Rani, “Post covid mucormycosis of mandible”, IJDSIR- March
- 2022, Vol. – 5, Issue - 2, P. No. 411 – 415.
Copyright: © 2022, Dr. Yamuna Rani, et al. This is an open access journal and article distributed under the terms of the
creative commons attribution noncommercial License. Which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Type of Publication: Case Report
Conflicts of Interest: Nil
Abstract most often in diabetic and immunocompromised
Mucormycosis is a relatively uncommon opportunistic individuals. The COVID-19 associated mucormycosis
infection. It is a fulminant fungal infection that occurs has been reported globally. By 15th July 2021, a total of
most often in diabetic and immunocompromised 45,432 cases were reported. (Prakash and Chakrabarti,
individuals. A 57-year-old male patient who had 2021) in India. The estimated prevalence of
recovered from COVID pneumonia was diagnosed with mucormycosis was at alarming rate of nearly 70 times
Sino nasal mucurmycosis with involvement of the higher than the global data.1
mandible. The patient had a history of uncontrolled Based on anatomic localization Mucormycosis is
diabetes, hypertension and stroke. He was treated with classified as
sequestrectomy + saucerization of the mandible and B/L • Rhino cerebral mucormycosis
FESS + septoplasty under GA along with IV • Pulmonary mucormycosis
Amphotercin 1.5mg/kg and Inj Posaconazole 300mg for • Cutaneous mucormycosis
duration of 3weeks. The involvement of mandible • Gastrointestinal mucormycosis
sparing the maxilla was an interesting aspect of this case. • Disseminated mucormycosis
Keywords: Covid-19, Post Covid, Mandible, • Uncommon.
Mucormycosis Mucormycosis has a high mortality rate of 54% due to
Introduction its angioinvasive nature.
Mucormycosis is a relatively uncommon opportunistic
Page 411

Rhino cerebral mucormycosis is more common

infection. It is a fulminant fungal infection that occurs involving the maxillary region and accounts for around

Corresponding Author: Dr. Yamuna Rani, ijdsir, Volume – 5 Issue - 2, Page No. 411 - 415
Dr. Yamuna Rani, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

88% of the cases, whereas mucormycosis of mandibular

region is rare and only few cases have been reported till
date.2 Here we present a rare case of mandibular
mucormycosis sparing the maxilla.
Case report
A 57 yrs old male patient recovered from COVID
pneumonia reported to our department with chief
complaint of pain in lower right and left back tooth
region since 20 days.
His past medical history included diabetes, hypertension Fig 1: showing multiple sinus opening in the attached
and stroke. gingiva of mandible
During COVID treatment he was on oxygen 1lt/per The maxillary gingiva appeared normal on inspection &
minute for 15days, inj-Ptptaz (piperacillin/tazobactam) cervical abrasions were noted on the posterior teeth. In
4.5gm, inj-Remidesvir 200 on day 1 followed by 100 for the mandibular region the attached gingiva appeared
4 days, inj-Dexona (dexamethasone) 8mg, tab boggy with multiple sinus openings. On palpation the
Dabigatran110mg twice daily for 5days, tab Predmet mandibular attached gingiva was pebbly and pus
(methyl prednisolone) 8mg once daily for 5 days, tab discharge was present from the multiple sinus openings.
Vit. C 500mg thrice daily & tab Zinc 50mg once daily All the teeth were mobile and segmental mobility was
for 2 weeks. noticed.
After 3months of recovery from COVID with Since the patient had history of COVID & was treated
pneumonia he developed pain in the lower jaw for about with oxygen and remidesvir a provisional diagnosis of
20 days. The pain was sudden in onset, intermittent mucormycosis was considered with differential
severe & throbing in nature which lasted for 2 hrs and diagnosis of mandibular osteomyelitis and multiple
radiated to head and neck region. Pain was relieved on periodontal abscess.
medication. On investigation his FBS was 117mg/dl, PPBS-
On general physical examination the patient was found 314mg/dl, CRP- 67.96mg/l & D-Dimer- 243 and rest of
to be heavily built with normal gait. His random blood the haematology report was normal.
sugar was reported to be 157 mg/dl, his blood pressure Mycology, bacteriology culture report & Fungal culture
was 120/76 mmHg. report was negative, normal commensals & No growth
On extraoral examination bilateral submandibular lymph respectively.
nodes were palpable and tender.
412
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Dr. Yamuna Rani, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

Post operatively he was treated with IV Amphotericin

1.5Mg/kg, IV and Inj Posaconazole 300Mg for duration
of 3 weeks.

Fig 2: OPG The OPG showed normal anatomical

landmarks with angular bone loss irt
18,17,16,12,11,22,23,26,27,28,36,37,38,46,47, and 48 Fig 4: showing post treatment photo
Histopathology report
Histopathological report showed scattered broad,
aseptate, hyaline fungal hyphae with wide angle
branching resembling Mucorales against a necrotic
background. Other section studied showed tissue lined
by stratified squamous epithelium with underlying
chronic inflammatory cell infiltrates, suppuration and
haemorrhage suggestive of bone invasion with fungal
elements - morphology representing mucormycosis.
Fig 3: Showing CBCT images of mandible. The fungal elements were identified on routine H and E
CBCT revealed irregular osteolytic lesions involving sections. The tissue sections were subjected to additional
mandibular dentoalveolar region causing erosion with histochemical stains - PAS to highlight the fungal
loss of normal architecture of the bone. Irregular outline elements.
of alveolar sockets with exaggerated disruption in the Final diagnosis was given as Sino nasal and Mandibular
buccal & lingual cortical plates was evident around Mucormycosis.
posterior teeth bilaterally with furcation bone loss. Discussion
The patient was referred to a higher centre for Mucormycosis is a rare life threatening black fungal
management, where he underwent MRI infection in patients recovered from COVID-19.3 A
Of Brain, Orbits & PNS which showed subtle T2 complex interplay of factors, including pre-existing
hypertense signal changes at right cavernous sinus with diseases, such as diabetes mellitus, previous respiratory
post contrast enhancement. PNS and Calvaria appeared pathology, use of immunosuppressive therapy, the risk
normal and working diagnosis of Sino nasal of hospital-acquired infections, and systemic immune
Mucormycosis with involvement of mandible was given. alterations of
Patient underwent sequestrectomy + sauce ration of COVID-19 infection itself may lead to secondary
413

mandible + B/L FESS + Septoplasty’s under GA. infections, which are increasingly being recognized in
view of their impact on morbidity and mortality.3
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Dr. Yamuna Rani, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

Given the mortality rate of both COVID-19 and addition to zinc supplementation being a fungal growth
mucormycosis we must pay heed to diagnose this fungal promoter.6
infection at initial stage. It is recommended that post For any patient who received oxygen support during
COVID-19 patients are enquired about having any their hospital stay, it becomes essential to observe any
dental problems and any patients with symptoms must black pigmentation in their nostrils or mouth. Even the
be treated on urgent basis.4 slightest colour change or pigmentation should be
There are specific pathophysiologic features of COVID- reported immediately without neglect. Sanitization of the
19 that may permit secondary fungal infections, oxygen supply system in hospitals is also an area of
including a propensity to cause extensive pulmonary concern.7
disease & the subsequent alveolo-interstitial pathology The health ministry in its advisory has instructed the
that may enhance the risk of invasive fungal infections, hospitals to provide a pamphlet of mucormycosis related
second the immune dysregulation associated with symptoms, cure and preventive measures along with the
C0VID-19 with reduced numbers of T lymphocytes, discharge papers (ICMR,2021).7
CD4 +T & CD8+T cells may alter innate immunity.3 In the case of hospitalised COVID-19 patients,
Hyperglycaemia stimulates fungal proliferation and the especially aging people and those with severe symptoms
diabetic reduction in chemotaxis and phagocytic who require a ventilator, corticosteroids are given in an
efficiency permit these otherwise innocuous organisms attempt to alleviate some of the symptoms. However,
to thrive in acid-rich environment.1 Diabetic patients steroids are known to lower immunity and raise blood
have impaired defence mechanism along with increased sugar levels, and they tend to increase clotting factors
level of iron in tissues. Iron free environment is essential and fibrinogen concentrations in patients.
for proper innate and acquired immune response. Any This situation provides an opportunity for pathogens to
excess of iron (iron overload) would lead to direct evade the human immune system and infect the host.
damage to natural Défense system & an increase in According to a recent study, the number of cases of
5
fungal virulence. mucormycosis (also known as zygomycosis, black
The National Institute of health recommended the use of fungus) have increased in COVID-19 patients who are
dexamethasone (6mg/day for a maximum of 10 days) in either hospitalised or have recovered.
patients who are ventilated or require supplemental It is a potentially lethal infection occurring primarily in
oxygen but not in milder cases. The guidelines immunocompromised patients particularly in those with
specifically mention the risk of developing a secondary diabetes mellitus.6
infection.3 Timely intervention and recognising the fatal infection at
There are several hypotheses as to what else may an early stage will potentially reduce the mortality and
contribute to mucormycosis infections. Some are morbidity rate in mucormycosis cases.
unlikely, such as the use of industrial oxygen or Conclusion
ventilation systems, age-related immune complications It is imperative for health professionals to be on the
414

and non-sterile water, whilst others believe that steam lookout for mucormycosis in COVID-19 patients,
inhalation may play a role by impacting the mucosa, in particularly those with diabetes, aging people, and those
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Dr. Yamuna Rani, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

with multiple sinus drainage. India has contributed to

almost 70% of the global cases of mucormycosis since
the emergence of COVID-19. The rise in mucormycosis
in India reflects the triumvirate of diabetes, widespread
corticosteroid and oxygen use. All steps should be taken
cautiously in order to maintain optimal blood glucose
levels, and with sensible assessment-based corticosteroid
usage.6 Successful management of mucormycosis largely
depends on early diagnosis, reversal of underlying
predisposing factors, prompt and ideally broad surgical
debridement of infected tissue and rapid administration
of systemic antifungal therapy.5
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