Black fungus/Mucormycosis -A post covid oral complication

• Mucormycosis, also known as Black Fungus, is a serious but rare fungal infection caused by a group of invasive infections caused by filamentous fungi of the Mucoraceae family, which is live throughout the environment. 

• The fungi responsible for these infections are found in different environmental niches like soil, decaying vegetables, bread, and even dust.

•  Mucormycosis fungus is not a new disease, but the severity of it is more dangerous when Covid patients develop this disease.

• Black fungus is a misnomer... the colour of fungus is not black but because of decreased blood supply in the affected area causing necrosis.., it may give a feeling that the area has become black, that is why the name has come.
• Mortality rate is 50%.

Causes

It is caused by filamentous fungi.

Kingdom	Fungi
Subphylum	Mucoromycotina
Order	Mucorales
Family	Mucoraceae
Genera (Frequency of infection)	Rhizopus	47%
	Mucor	18%
	Cunningghamella	7%
	Apophysomyces	5%
	Lictheimia	5%
	Saksenaea	5%
	Rhizomucor	4%

MAJOR ROUTE OF INFECTION

 Inhalation
 Ingestion
 Traumatic inoculation

Risk factor

Mucormycosis is a rare infection. The infection is more common among people with

weakened immune system.

• Uncontrolled Diabetes/Ketoacidosis
• Neutropenia Patients(low white blood cells)
• Immunocompromised:-Hiv/AIDS/Cancer or on chemotherapy, Chronic kidney disease, Organ transplant.
• Increased serum Iron
• Chronic Corticosteroid treatment
• Skin trauma
• Post covid-19(patients on steroids, ventilators, misuse of steroids)

Types 

1. Rhino-cerebral
2. Pulmonary
3. Disseminated
4. Cutaneous/Soft tissue
5. Gastro-Intestinal 

 symptoms

Common symptoms:

• Unilateral Headache
  
• Unilateral Facial pain
• Pain in region of sinusis
• Unilateral Numbness in face
• Nasal congestion
• one side nose obstructions (difficulty in breathing)
• Unilateral swelling of eyes or check
• Black dry crusts in the nose or cheek
• Foul-smelling blood-tinged  Nasal discharge
• Double vision(diplopia), Blurred vision,loss of vision,Ptosis
• Restriction or loss of eye moment
• Neurological symptoms
• Fever, cough, chest pain
• Abdominal pain, Vomiting

Dental findings:

1. 

   Necrosis of hard palate 

   Loosening of the tooth
2. Dental pain
3. Halitosis
4. Pus discharge from the mouth(intraoral draining sinuses)
5. Exposed palatal bone
6. Ulceration and blackening of the mucosa
7. Mobility of maxilla
   

Pathophysiology

 Angioinvasion
 Vessel thrombosis

 Ischemia
 Tissue necrosis

Pathogenesis of mucormycosis

Is mucormycosis contagious?

No. Mucormycosis can’t spread between people or between people and animals.

Mucormycosis /Black fungus and covid 19

• Mucormycosis has been reported in many states in India in recovered patients with covid 19.

• The infection may occur during covid 19 infection or a few weeks after recovery from covid 19.

• Many states in India have declared mucormycosis an epidemic.

• Covid 19 disease itself is associated with leucopenia and may lead to immune compromise caused by an impaired immune response

• Steroids are being used in covid 19 patients to reduce inflammation in the lungs. This may lead to an increase in blood sugar levels in diabetics as well as non-diabetics.

• Misuse of steroids during this second wave of covid 19 can also be contributing factor for mucormycosis.

• The coexistence of covid 19 infections with high blood sugar levels and immunosuppressive treatments would expectedly increase the incidence and severity of mucormycosis.

• Rhino Orbital cerebral mucormycosis(ROCM) is being reported in covid 19 patients.

• It starts with Paranasal inhalation f spores and the formation of coenocytic hyphae, Then proliferate in the sinuses and can find their way t the orbit either through direct invasin r via nasolacrimal duct. It can gain access to the brain either via spread from the orbital apex, cavernous sinus, through cribriform plate r through blood vessels.

Pathogenesis of Mucermycosis in covid19 patients

Diagnosis

• Medical history, symptoms, physical examinations
• Nose endoscopy
• Tissue biopsy
• Laboratory test(culture sampling, histopathological): Characteristic feature being an aseptate hyphal element that branch at right angles)
• CT scan  with contrast/ MRI of your lungs, sinuses, or other parts of your body, depending on the location of the suspected infection

Treatment

The key to a predictable treatment outcome is early detection and early treatment.

Multidisciplinary approach: ENT surgeon, oral and maxillofacial surgeon, Ophthalmologist, Neurologist, Microbiologist, Internal medicine specialist.

1. The mild form can be corrected merely by antifungal medicine called Amphotericin B.
2. The moderate form could involve some areas of the sinus, nose, throat, and upper jaw which would require surgical intervention.
3. The severe form of the disease could involve the eyeball leading to blindness, or encroach the cavernous sinus leading to death.

Treatment of Mucormycosis/black fungus

Role of Dentist

• Early detection
• Dual role in clearance surgery as well as post mucormycosis reconstruction.
• Dental rehabilitation
• Resection of involved jawbones.
• Reconstruction