Mucormycosis in an immunocompetent patient.

Mucormycosis is a rare opportunistic fungal disease, causing infections of the upper and lower respiratory tract, commonly affecting the paranasal sinuses.[1] The fungi are large, with branching nonseptate hyphae.[2] They disrupt normal blood flow by invading into small blood vessels, resulting in infarction and extensive tissue necrosis.[1] Mucormycosis is usually noted in individuals with diabetic ketoacidosis and also in other conditions like bone marrow transplant patients, patients with AIDS, and those receiving systemic corticosteroid therapy, desferoxamine therapy, and cancer chemotherapy.[3] Mucormycosis has been rarely reported in apparently normal, immunocompetent individuals,[2] like our patient under consideration.

A 37-year-old male patient presented with the complaint of pain and pus discharge from extracted, nonhealing tooth socket in the left upper jaw. The tooth was extracted 1 month earlier for acute irreversible pulpitis.

The patient had a mild diffuse swelling over the left side of the face. Intraorally, blackish discoloration of the alveolar mucosa was noted in relation to maxillary premolar region on the left side. There was pus discharge and foul-smelling odor. He also had no history diabetes mellitus or HIV infection or prolonged corticosteroid therapy or any other medications.

Computerized tomographic imaging with serial and coronal sections of paranasal sinuses established the oroantral communication in the left premolar region, and also haziness was noted in the left maxillary sinus owing to accumulation of pus.

The lesion was explored and the necrotic bony sequestrum and sinus lining were removed and sent for histopathological examination.

HISTOPATHOLOGY

Necrotic tissue and debris with prominent stout, nonseptate fungal hyphae, some showing branching at acute angles or 90 degrees [Figures 1 and 2].

Figure 1

Shows necrotic debris and prominent stout, nonseptate fungal hyphae, some showing branching. The fungal hyphae are cut in different planes (H and E, × 100)

Figure 2

Shows branched nonseptate hyphae of mucormycosis (H and E, × 400)

Some fungal hyphae appear to be cut transversely along their diameter while sectioning [Figure 2].

Presence of inflammatory cells in the necrotic tissue [Figure 3].

Figure 3

Shows inflammatory cells interspersed between fungal hyphae and necrotic debris (H and E, × 400)

The bony sequestrum showed necrotic lamellar bone surrounded by multiple fungal hyphae [Figures 4 and 5].

Figure 4

Shows fungal hyphae adjacent to necrotic lamellar bone (H and E, × 400)

Figure 5

Grocott-Gomori methamine staining showing brown–black fungal hyphae in green background (× 100)

Grocott-Gomori methamine silver staining shows prominent fungal hyphae stained brown–black in green background [Figures 5 and 6].

Figure 6

Fungal hyphae adjacent to necrotic bone, confirmed by Grocott-Gomori methamine staining (× 400)

FINAL DIAGNOSIS

Based on the above histopathological features, the final diagnosis of mucormycosis was given.