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MUCORMYCOSIS (PHYCOMYCOSIS, ZYGOMYCOSIS). WHAT IS MUCORMYCOSIS? Mucormycosis is a rare opportunistic fungal infection, commonly seen in patients with immunocompromised conditions such as uncontrolled diabetes mellitus and leukaemias and COVID-19.. 

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MUCORMYCOSIS  (PHYCOMYCOSIS, ZYGOMYCOSIS)

WHAT IS MUCORMYCOSIS? Mucormycosis is a rare opportunistic fungal infection, commonly seen in patients with immunocompromised conditions such as uncontrolled diabetes mellitus and leukaemias and COVID-19.

CLINICAL FORMS. Rhinocerebral 01. (Most common) - characterised by progressive fungal invasion of the hard palate, paranasal sinuses, orbit, and brain. 

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(Most common) - characterised by progressive fungal invasion of the hard palate, paranasal sinuses, orbit, and brain

occurring at specific organ sites e.g. kidney and liver

Fig. 1: Vestibular mucormycosis and aspergillosis: the vestibular ulcerative lesion in the area of the teeth 25-27. 

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Fig. 1: Vestibular                                   mucormycosis and aspergillosis:  the vestibular ulcerative lesion in  the area  of the teeth 25-27

(Image courtesy for fig 22(A,B): Vanja VB et al. Oral Mucormycosis and Aspergillosis in the Patient with Acute Leukemia.Acta stomatol Croat.2019;53(3):274-277.)

SPREAD. Found in fruits, soil, dust, and manure. The infections spread from inhalation of spores through the nose or mouth, or sometimes through a skin laceration. Mucorales are ubiquitous moulds, profusely recovered from the decaying organic matter. Evidences from studies have revealed heavy mould spore counts in hospital air due to hot, humid environment in our tropical climate. It can be cultured from the oral cavity, nasal passages, throat and stools of healthy patients without a sign of disease.. 

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Found in fruits, soil, dust, and manure. The infections spread from inhalation of spores through the nose or mouth, or sometimes  through a skin laceration. Mucorales are ubiquitous moulds, profusely recovered from the decaying organic matter. Evidences from studies have revealed heavy mould spore counts in hospital air due to hot, humid environment in our tropical climate.  It can be cultured from the oral cavity, nasal passages, throat and stools of healthy patients   without a sign of disease.

SYMPTOMS. Symptoms of rhinocerebral (sinus and brain) mucormycosis include: One-sided facial swelling Headache Nasal or sinus congestion Black lesions on nasal bridge or upper inside of mouth that quickly become more severe Fever Symptoms of pulmonary (lung) mucormycosis include: Fever Cough Chest pain Shortness of breath. 

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Symptoms of rhinocerebral (sinus and brain) mucormycosis include: One-sided facial swelling Headache Nasal or sinus congestion Black lesions on nasal bridge or upper inside of mouth that quickly become more severe Fever Symptoms of pulmonary (lung) mucormycosis include: Fever Cough Chest pain Shortness of breath

Cutaneous (skin) mucormycosis can look like blisters or ulcers, and the infected area may turn black. Other symptoms include pain, warmth, excessive redness, or swelling around a wound. Symptoms of gastrointestinal mucormycosis include: Abdominal pain Nausea and vomiting Gastrointestinal bleeding. Disseminated mucormycosis typically occurs in people who are already sick from other medical conditions, so it can be difficult to know which symptoms are related to mucormycosis. Patients with disseminated infection in the brain can develop mental status changes or coma. References Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosisexternal icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S23-34. Lewis RE, Kontoyiannis DP. Epidemiology and treatment of mucormycosisexternal icon. Future Microbiol. 2013 Sep;8(9):1163-75. Spellberg B, Edwards Jr. J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and managementexternal icon. Clin Microbiol Rev. 2005 Jul;18(3):556-69. Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human diseaseexternal icon. Clin Microbiol Rev 2000; 13:236-301.. 

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Cutaneous (skin) mucormycosis  can look like blisters or ulcers, and the infected area may turn black.      Other symptoms include pain, warmth, excessive redness, or swelling around a wound. Symptoms of gastrointestinal mucormycosis include: Abdominal pain Nausea and vomiting Gastrointestinal bleeding. Disseminated mucormycosis  typically occurs in people who are already sick from other medical      conditions, so it can be difficult to know which symptoms are related to mucormycosis. Patients with      disseminated infection in the brain can develop mental status changes or coma. References Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP. Epidemiology and clinical manifestations of mucormycosisexternal icon. Clin Infect Dis. 2012 Feb;54 Suppl 1:S23-34. Lewis RE, Kontoyiannis DP. Epidemiology and treatment of mucormycosisexternal icon. Future Microbiol. 2013 Sep;8(9):1163-75. Spellberg B, Edwards Jr. J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation, and managementexternal icon. Clin Microbiol Rev. 2005 Jul;18(3):556-69. Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human diseaseexternal icon. Clin Microbiol Rev 2000; 13:236-301.

CLINICAL FEATURES. Malaise, headache, facial pain, swelling and low grade fever5. The disease initiates from nasal mucosa or palate and extends to the paranasal sinuses spreading through the surrounding vessels. Can involve the retro-orbital region by direct extension4. Proptosis, ptosis, pupillary dilatation, orbital cellulitis and loss of vision can occur with loss of function of cranial nerve III, IV, VI with orbital involvement5. In mucormycosis , the fungal hyphae start to attack local tissue. Direct penetration and growth through the wall of blood vessels are responsible for the propensity for thrombosis and tissue necrosis.. 

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Malaise, headache, facial pain, swelling and low grade fever5. The disease initiates from nasal mucosa or palate and extends to the paranasal sinuses spreading through the surrounding vessels. Can involve the retro-orbital region by direct  extension4. Proptosis, ptosis, pupillary dilatation, orbital cellulitis and loss of vision can occur with loss of  function of cranial nerve III, IV, VI with orbital involvement5. In mucormycosis , the fungal hyphae start to attack local tissue. Direct penetration and growth through the wall of blood vessels are responsible for the propensity for thrombosis and tissue necrosis.

RADIOLOGICAL PICTURE. Shows opacification of the paranasal sinuses without fluid level, thickening of the sinus mucosa and bone distraction of the sinus walls.. 

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Shows opacification of the paranasal sinuses without fluid level, thickening of the sinus mucosa and bone distraction of the sinus walls.

IMAGE COURTESY: https://radiopaedia.org/articles/sinonasal-mucormycosis

DIAGNOSIS. From tissue biopsy, clinical picture Histological picture : are characterised by extensive tissue necrosis and the presence of numerous, large (around 5–30 μm). These fungal hyphae are thin-walled, non-septate, branched at right angles and have a ribbon-like appearance.. 

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From tissue biopsy, clinical picture  Histological picture : are characterised by extensive tissue necrosis and the presence of numerous, large (around 5–30 μm). These fungal hyphae are thin-walled, non-septate, branched at right angles and have a ribbon-like appearance.

Photomicrograph from retro- molar region showing elongated, broad, non-septate branching hyphae within the tissue and the bone marrow space (Gomori methenamine silver nitrate stain, original magnification _400) (Image Courtesy: Abdulaziz A Bakathir. Mucormycosis of the Jaw after Dental Extractions: Two Case Reports.SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL DECEMBER 2006 VOL 6, NO. 2)

MANAGEMENT. Medical and surgical intervention. Treatment of underlying medical condition. Systemic antifungal agents: Amphotericin B, Liposomal Amphotericine B. Surgical: debridement of all infected and necrotic tissues. Radical resection, partial or total maxillectomy, mandibulectomy and orbital operation are required in some cases.. 

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Medical and surgical intervention. Treatment of underlying medical condition. Systemic antifungal agents:   Amphotericin B, Liposomal Amphotericine B. Surgical:  debridement of all infected and necrotic tissues. Radical resection, partial or total maxillectomy, mandibulectomy and orbital operation are required in some cases.

PROGNOSIS. In most cases, the prognosis is poor, mortality rates depending on its form and severity. In the rhinocerebral form, the mortality rate : 30% and 70%,Disseminated mucormycosis : up to 90%, Patients with AIDS : almost 100%.Possible complications include the partial loss of neurological function, blindness and clotting of brain or lung vessels.. 

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In most cases, the prognosis is poor, mortality rates depending on its form and severity. In the rhinocerebral form, the mortality rate : 30% and 70%,Disseminated mucormycosis : up to 90%, Patients with AIDS : almost 100%.Possible complications include the partial loss of neurological function, blindness and clotting of brain or lung vessels.

REFERENCES. 1.deShazo RD, O’Brien M, Chapin K, Soto-Aguilar M, Gardner L, Swain R. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg. 1997;123:1181– 1188. 2.Tryfon S, Stanopoulos I, Kakavelas E, Nikolaidous A, Kioumis I. Rhinocerebral Mucormycosis in a Patient with latent diabetes mellitus: A Case Report. J Oral Maxillofac Surg. 2002;60:328– 330. 3.Peterson KL, Wang M, Canalis RF. Rhinocerebral Mucormycosis: Evaluation of the Disease and Treatment Options. Laryngoscope. 1997;107:855– 861. 4.Sugar AM. Mucormycosis. Clin Infect Dis. 1992;14:126–129. 5.Taylor R, Shlkar G, Budson R, et al: Mucormycosis of the oral mucosa. Arch Dermatol 89:419, 1964. 6.Ribeiro NNF, Cousin GCS, Wilson GE, Butterworth DM, Woodwards RTM. Lethal invasive mucormycosis: Case report and recommendation for treatment. Int J Oral Maxillofac Surg.2001;30:156–159. 7.Rudramurthy SM, Singh G, Hallur V et al. High fungal spore burden with predominance of Aspergillus in hospital air of a tertiary care hospital in Chandigarh. Indian J Med Microbiol2016; 34:529-532.. 

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1.deShazo RD, O’Brien M, Chapin K, Soto-Aguilar M, Gardner L, Swain R. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg. 1997;123:1181– 1188. 2.Tryfon S, Stanopoulos I, Kakavelas E, Nikolaidous A, Kioumis I. Rhinocerebral Mucormycosis in a Patient with latent diabetes mellitus: A Case Report. J Oral Maxillofac Surg. 2002;60:328– 330. 3.Peterson KL, Wang M, Canalis RF. Rhinocerebral Mucormycosis: Evaluation of the Disease and Treatment Options. Laryngoscope. 1997;107:855– 861. 4.Sugar AM. Mucormycosis. Clin Infect Dis. 1992;14:126–129. 5.Taylor R, Shlkar G, Budson R, et al: Mucormycosis of the oral mucosa. Arch Dermatol 89:419, 1964. 6.Ribeiro NNF, Cousin GCS, Wilson GE, Butterworth DM, Woodwards RTM. Lethal invasive mucormycosis: Case report and recommendation for treatment. Int J Oral Maxillofac Surg.2001;30:156–159. 7.Rudramurthy SM, Singh G, Hallur V et al. High fungal spore burden with predominance of Aspergillus in hospital air of a tertiary care hospital in Chandigarh. Indian J Med Microbiol2016; 34:529-532.

MY NOTE 127 and a rare 2. The The : . fig are d Radu. 

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