Clinical details:
38 years old female
Diabetic on poor glycemic control
Complaints:
Ulcerative lesion of right side of hard palate - 2 years
Devitalization of upper premolars - 6 months
On examination:
Nasal cavity - Whitish mass seen inside the right nasal cavity. The mass was insensitive to touch and cheesy.
Floor of right nasal cavity found to be eroded.
Oral cavity - Slough covered lesion seen in the right side of hard palate. On probing there was no bone palpable
through the slough.
Investigations:
Biopsy from the lesion was reported as mucormycosis.
These fungi can be seen as large number of aseptate ribbon like hyphae with right / obtuse angle branching in necrotic tissue.
Imaging:
Ct scan showing heterodense mass occupying the right maxillary sinus with destruction of its medial wall.
The mass could be seen extending to the right nasal cavity with destruction of the floor of right nasal cavity.
Discussion:
Synonyms include - zygomycosis / phycomycosis
Two main types of mucor mycosis infections occur in humans. They are superficial and visceral.
Superficial mucormycosis involves external ear, fingers and skin commonly.
The visceral form could be Gastrointestinal, rhinocerebral, pulmonary or disseminated.
Visceral forms of mucor infections are common in diabetics and immune compromised individuals.
Among these visceral types the rhinocerebral type is the most common. This is due to the fact that the
nasal mucosa is normally colonized by mucor. Rhinocerebral mucor mycosis can be subclassified into two types.
They include:
Type I - Rhino orbito cerebral. This form is highly fatal
Type II - Rhinomaxillary form. This form is not fatal. This case belongs to type II category.
Mucor infections has a strong prediliction to involve blood vessels, nerves and lymphatics. Invasion of arteries causes
avascular necrosis of the infected area.
Mucor is known to thrive in acidic and glucose rich medium, which is common in a diabetic. Hyperglycemia also impairs
neutrophil chemotaxis thereby reducing immunity.
In addition increased availability of micronutrients like iron in diabetics increase the pathogenecity of the organism.
Management:
Is by wound debridment.
Control of diabetes.
Administration of amphoteracin B.
Surgical video clipping:
Partial maxillectomy was performed in this patient.