MUCORMYCOSIS OF THE HARD PALATE: A CASE REPORT

Bassam Y. Bany-yaseen, BDS*, Jaser Maita, BDS*, Talat Mneizel, BDS*

ABSTRACT

This is a case report of a 51-year-old female patient who presented to the surgical and prosthetic clinics at King Hussein
Medical Center with an extensive necrosis of the hard palate. A diagnosis of Mucormycosis was made. In this article, a
thorough discussion of the treatment and reconstruction of such a condition and revision of the literature is presented.

Key words: Mucormycosis, Palate, Necrosis, Obturator.

JRMS June 2006; 13(1): 61-63

Introduction
Mucormycosis is caused by a fungus of the order
Mucorales and is one of the most rapidly fatal fungal
infections known to man. Rhinocerebral mucormycosis
is the most common type and its extension to the orbit
and brain is quite usual. Location of mucormycosis on
the palate is a rare and late occurrence (1).
The usual predisposing factors are: diabetic
ketoacidosis, immunodepression, blood dyscrasia (2-7),
protein calorie malnutrition, iron overload with or
without the concomitant use of deferoxamine, solid
organ transplant reception (STOR), patients on steroids,
bone marrow transplant (BMT), and neutropenia.
Thrombosis and ischaemic necrosis are characteristic
features and contribute to local spread (3,6). Tissue
necrosis may result in ulceration or perforation of the
palate (8).
Early diagnosis and treatment of Mucormycosis is
extremely important. The diagnosis is confirmed by
histopathologic demonstration of the organism in
affected tissue. Identification of the specific order and
genus of the pathogen is possible only by morphologic
examination of growth from a successful culture of the
affected tissue (7). Control of underlying disease must be
established, metabolic abnormalities should be corrected,
and antifungal therapy with amphotericin-B combined
with surgical debridement of all necrotic tissues must be
performed (9).
This is a case of a localized palatal Mucormycosis,
which resulted in necrosis of most of the hard palate.
Combinations of both medical and surgical management
in addition to patient rehabilitation by construction of
obturator were performed.
*From the Department of Dentistry, King Hussein Medical Center, (KHMC), Amman-Jordan
The correspondence should be to Dr. B. Bany-Yaseen, P. O. Box 150602 Zerqa 13115 Jordan. E-mail: Bassam_bany@yahoo.com
Manuscript received November 6, 2003. Accepted May 6, 2004
Method
A 51-years old female, diabetic on hypoglycemic
agents patient was referred to oral and maxillofacial
surgery unit at King Hussein Medical Center (KHMC)
from a general practioner (GP) clinic. She was
complaining of foul oral smell associated with mild dull
pain of the upper jaw of 2 months duration. The patient
was admitted to the hospital. She was apyrexial and there
was no malaise. There was no facial swelling nor facial
numbness. There was no history of nasal obstruction.
Over the previous period, the patient was prescribed
different types of antibiotics and analgesics by different
GPs, but she did not get any benefit. On examination of
the lesion, it was found that there is a denuded necrotic
bone of the hard palate associated with a bad smell. The
patient was partially edentulous and the remaining teeth
were affected by periodontosis and gum recession. There
were heavy deposits of calculus and the oral hygiene was
bad.
Radiographic examination by means of taking
Water’s view showed clear sinuses without air-fluid
level. Haematological and urine analysis investigations
were done. The packed cell volume (haematocrit) was
38, fasting blood sugar was 231 mg/dL, ketone bodies
test was negative, serum creatinine and urea levels were
1.4 mg/dL and 25 mg/dL respectively, WBC count was
6000/mm, with increase of the percent of lymphocytes
(42.0%) and decrease of neutrophils (54.4%), and the
platelets count was 420000/mm. All the clotting tests
were within normal limits. There was no albumin or
glucose in the urine of the patient. The general condition
of the patient was stable. The differential diagnosis
included Mucoraceae infection (Mucor and Rhizopus),
actinomycosis, aspergillosis, ischaemic necrosis,
gummatous necrosis, and Wegener’s granuloma.
A medical consultation to her internist was made. The
medical records showed that the patient was suffering
from acute myelogenous leukemia before 2 years, was
treated by chemotherapeutic agents, and showed a good
response with complete remission. The patient was
shifted to crystalline insulin (10/10/5 units) 3 days before
surgery.
The decision was taken to manage the case by
combination of medical and surgical treatment. Before
surgery, all the remaining teeth were exposed to
intensive periodontal treatment such as scaling and root
planning. The patient was instructed about keeping her Fig. 1. The patient after surgery.
oral hygiene in a high standard. Amphotericin-B, dose
of: 1 mg/kg/day (80 mg/day, the cumulative dose was
about 2300 mg over 4 weeks) was given to the patient
one week before and 3 weeks after the surgical
operation. Debridement of the whole necrotic hard palate
was performed under local anesthesia with I. V.
sedation, using suitable surgical burs, chisels, and
osteotome. When the necrotic bone was removed, part of
the inferior portion of the medial wall of right and left
maxillary sinuses were opened. However, both sinuses
were free of infection. After bone removal, wet ribbon
gauze moistened with neomycin ointment was
introduced through the both nostrils of the nose to the
surgical field, filling the maxillary antrum, so as to
control the postoperative bleeding. The pack was
removed after 48 hours. On the day of surgery and 3
days after surgery, when the patient was kept NPO, Fig. 2. The patient is wearing an obturator.
replacement by parenteral fluid; glucose saline 1000 cc
/8 hours, added with 10 units of crystalline insulin and
20 meq of KCL. After 3 days of surgery, the parenteral
fluid was stopped and oral fluid and hypoglycemic
agents were started.
The excised bone was sent for histopathologic and
culture studies. The histopathologic report described the
specimen as a completely infected necrotic tissue with
multiple colonies of fungal hyphae, consistent with
Mucormycosis. Microbiological examination of the
specimen confirmed the diagnosis of Mucormycosis.
Figure 1 shows the shape of the hard palate 2 months
after surgery. Then the patient was referred to the
prosthetic clinic for construction of an obturator, as
could be seen in the Figures 2,3.

Fig. 3. The obturator (fitting surface).

Discussion
Mucormycosis is an infection that is caused by
several species of the orders of the Mucorales and
Entomophthorales. The agents most commonly involved
are Rhizopus, Mucor, and Absidia. Less often species
from Rhizomucor, Cunninghamella, and Mortierella are
involved (10). Infection arises through inhalation of
spores, and contamination of traumatized tissue,
ingestion and direct inoculation (11). In this case, the
cause of Mucormycosis was most probably due to direct
inoculation from the adjacent infected teeth. However,
the medical condition of the patient, such as acute
myelogenous leukemia, diabetes mellitus, and
chemotherapeutic agents, certainly were the predisposing
factors.
Mucormycosis is an opportunistic infection associated
with debilitation and is recognized as a secondary
disease occurrence in cancer patients, especially those
with malignant lymphomas. It is also common in
patients with diabetes mellitus, especially those with
diabetes ketoacidosis. 75% of patients with
Rhinocerebral form of Mucormycosis have ketoacidosis.
Immunocompromised patients are prone to develop this
infection, as are patients with burns, open wounds, or a
medical regimen of steroids and chemotherapeutics
antimetabolites (12-15). This is consistent with this case
that the patient is under debilitating diseases; acute
myelogenous leukemia and diabetes mellitus, and the
patient was exposed to several medications including
chemotherapeutic agents and corticosteroid.
Rehabilitation (closure of the oronasal and/or
oroantral fistulae) can be done surgically or by
construction of a prosthetic appliance. Since the general
medical condition of patient is fit, surgery is better and
permanent management. Surgical option can be done
using different techniques such as double reversing z-
plasty, vomer flap, Von Langenbeck’s operation,
Wardill-Kilner-Veau operation and lingual flap, either
with or without bone graft (16). We opted the prosthetic
appliance than surgery because it was easier to perform
and less traumatic to the patient.
Conclusion
Control and prevention of opportunistic fungal
infection in patients suffering from debilitating diseases,
such as diabetic ketoacidosis, immunodepression, blood
dyscrasia, protein-calorie malnutrition, iron overload
with or without the concomitant use of deferoxamine,
solid organ transplant reciption, patients on steroids,
bone marrow transplant, and neutropenia, is very
important. Once Mucormycosis infection diagnosed in
debilitated patients, it must be treated promptly, without
any delay, by different modalities, medically and
surgically. The great advantage in this case was early
diagnosis and early management; that the lesion was
localized and did not have the opportunity to spread to
the adjacent tissues such as maxillary sinuses, ethmoid
or sphenoid bones, etc.
Preoperative consultation of a plastic surgeon and
ENT specialist is useful in proper management of the
lesion and proper reconstruction of the hard palate. If
surgery was done, and a defect left in either function
and/or esthetic, the patient-rehabilitation is essential, by
either surgery or by construction a suitable prosthesis.
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