{"id":13542,"date":"2022-05-25T18:40:25","date_gmt":"2022-05-25T22:40:25","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/im-residency\/?page_id=13542"},"modified":"2022-05-26T10:34:30","modified_gmt":"2022-05-26T14:34:30","slug":"research-week-2022-michael-rossi-md","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/im-residency\/research-week-2022-michael-rossi-md\/","title":{"rendered":"Research Week 2022 – Michael Rossi, MD"},"content":{"rendered":"

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A rare case of chronic rhinocerebral mucormycosis following a dental procedure<\/strong><\/p>\n

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A 45 year old Puerto Rican male, with a history of well controlled Diabetes (a1c 6.2%) presented with several month history of persistent jaw pain.<\/p>\n

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The patient was in his usual state of health in Puerto Rico, until 4 months prior to admission, when he began to have tooth pain.\u00a0 He saw a dentist and underwent right upper molar extraction.\u00a0 However, the pain continued to progress, he had 6 more teeth removed, and was given a short antibiotic course. He obtained a second opinion, was diagnosed with a \u201cbone infection,\u201d underwent a maxillary graft procedure, and another short antibiotic course.\u00a0 The pain continued to progress, the remaining upper teeth became loose, and he began having bleeding and congestion of the right nares, and malodorous taste prompting him to present to our hospital in Boston.<\/p>\n

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On admission, exam showed exposed necrotic, tender bone of the right posterior maxilla: 3cm x 2cm in size. Basic laboratory evaluation was otherwise unremarkable.\u00a0 CT head\/neck was obtained, which showed extensive bone destructive changes of the maxillary alveolar ridge, hard palate, clivus, and right sphenoid bones, with pathologic right Le Fort I fracture. Multiple areas of bone dehiscence were seen including: along the middle cranial fossa and lateral right orbital wall, the posterior right lateral wall of the nasal cavity, the petrosal segment of the internal cerebral artery canal, and along the posterior clivus adjacent to the basilar artery. A subsequent MRI showed skull base involvement without intracerebral involvement.<\/p>\n

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The patient underwent extensive debridement including maxillary antrostomy, total ethmoidectomy, and maxillectomy with Otolaryngology and Oral and Maxillofacial surgery.\u00a0 Surgical cultures and pathology grew Klebsiella, several anaerobes, Actinomyces and Mucormycosis consistent with polymicrobial osteomyelitis and chronic rhinocerebral mucormycosis (CRM).\u00a0 \u00a0He was treated with Levofloxacin, Penicillin G, Metronidazole and Amphotericin B for 6 weeks and subsequently transitioned to Amoxicillin and Isavucanozium.\u00a0 The patient had 2 further debridements and biopsies. The first biopsy of the clivus showed persistent mucormycosis infection for which he continued treatment and the second biopsy, 17 months after initial presentation, did not show any residual fungus and the patient has since remained off anti-microbials.<\/p>\n

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Rhinocerebral mucormycosis is a life-threatening infection that requires prompt recognition and treatment, while CRM is a rarer, distinct and more indolent form.\u00a0 It appears more commonly in patients without the traditional risk factors of poorly controlled DM or other immunosuppressed states. Clinically, it is more likely to present over the course of weeks to months, and seems to bear a better prognosis. \u00a0This case illustrates the importance of consideration of CRM in patients who do not respond to initial sinusitis treatment and the need for appropriate surgical and anti-microbial management despite lack of traditional risk factors for mucormycosis.<\/p>\n

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Learning Points:<\/p>\n