by Dr. Amol Ghaisas, Maxillofacial Surgeon practicing in Mumbai
As the COVID pandemic is making all of us struggle in different ways, I would like to put some light on the recent blast in cases of post-COVID Mucormycosis.
Mucormycosis is a type of fungal infection caused by fungi in the order Mucorales. Airborne spores land on nasal/oral mucosa if immunologically incompetent spores are not contained by phagocytic response and gemination ensues.
The exact cause of post-COVID Mucormycosis is unknown but it may be because of immunosuppression caused by
- underlying systemic disease s/a DM
- High dose Steriods
- Drug-induced – remdesivir, toclizumab
- Or because of an increase in serum iron load seen because of inflammation due to cytokine storm in COVID cases.
It mostly affects maxilla but some mandibular cases are also being reported.
Signs and symptoms
- Mobility in teeth with or without periodontal abscess
- OpG may be completely normal
- Nasal discharge
- Palatal or nasal mucosa necrosis or black eschar
- Perforation in palatal mucosa
- Low-grade fever
Mucormycosis spread is rapid and can affect maxillary alveolus, maxillary sinus, orbit, and eventually, intracranial involvement can take place.
As it spreads upwards it can cause chemosis, proptosis, blindness, cavernous sinus thrombosis, cerebral ischemia, infarction, and death.
As toothaches or extraction can be associated with the onset of symptoms dentist should be extremely vigilant in diagnosing such cases. Thus history undertaking and prompt consultation play a vital role in early diagnosis.
It is best diagnosed by
- Fungal culture and biopsy/
- Endoscopic biopsy from sinus
MRI is favorable than CT scan to diagnose soft tissues and vascular structures
- Surgical debridement of the affected area
- Hemi / Total maxillectomy
- Debridement of maxillary sinus
- Orbital Excentration
- Endoscopic debridement of Ethmoid , Sphenoid sinus
Early Administration of antifungal agent
- Amphotericin B with strict monitoring of serum creatinine and urea as it highly nephrotoxic
Newer agents s/a liposomal or liyophillised amphotericinB preferred as it less nephrotoxic
Dosage is up to 5 mg/kg of body weight. Dose adjustments in view of raised creatinine are needed.
Mucormycosis is deadly and has mortality up to 50%. Without surgery, the mortality is 100%. Surgery also leads to facial deformity and subsequent rehabilitation procedures are needed. It will affect patients financially and emotionally to great extent.
Many maxillofacial surgeons throughout India are seeing a rise in mucormycosis cases. So early diagnosis plays a vital role
Also, all post COVID patients should get a regular dental checkup done and should be asked to wear clean masks and main oral hygiene by brushing thrice daily and using mouth wash on a regular basis.