International Journal of Oral & Maxillofacial Pathology. 2012;3(1):86-90 ISSN 2231 – 2250

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Case Report

Palatal Perforation Resulted by Rhinocerebral Mucormycosis: A Case Report

Guruprasad R, Som Datt Gupta, Arpit Jain


Mucormycosis is a rare, opportunistic and potentially lethal fungal infection caused by saprobic organism of the class zygomycetes. Common predisposing factors for this disease include diabetes mellitus and immunosuppression. The most common reported form of the disease is rhinocerebral mucormycosis, which is characterized by progressive fungal invasion of the paranasal sinuses, hard palate, orbit, and brain. The fungi invade the wall of blood vessels, producing thrombosis and ischemia. Oral manifestations can be the early signs of rhinocerebral form. Early diagnosis and management is therefore paramount importance for the survival of the patients. Here we present a case report of 70 year old diabetic male patient who presented with a perforation in the palate, nasal discharge, periorbital cellulitis, and facial pain. Detailed clinical, radiographic, biochemical, histopathological examinations revealed a diagnosis of rhinocerebral mucormycosis.

Key words: Mycoses;Zygomycosis;Mucormycosis;Mucorales;Palatal Perforations;Fungal

Infections,Rhinocerebral;Fungal Eye Infections.

Guruprasad R, Som Datt Gupta, Arpit Jain. Palatal Perforation Resulted by Rhinocerebral Mucormycosis: A Case Report. International Journal of Oral & Maxillofacial Pathology; 2012:3(1):86-90. ©International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved.

Received on: 28/12/2011 Accepted on: 28/03/2012


Mucormycosis is the term for infection caused by fungi of the order mucorales.1 It is also known as zygomycosis or
phycomycosis. It is a rare opportunistic infection caused by fungi that are commonly found in soil and among decaying vegetation. Paultauf in 1885 described the first case of this uncommon disease in
human beings.2 It is an aggressive and often fatal disease which occurs mainly in people with immune disorders, uncontrolled diabetes, malnutrition, and severe burns. It involves the rhino-facial-cranial area, lungs,
gastrointestinal tract, skin, and less
commonly other organs, but can also present as disseminated form.3 The rhinomaxillary form of the disease is a subdivision of rhinocerebral form.4 The infection begins in the nose and paranasal sinuses due to inhalation of fungal spores. The infection can spread to orbital and
intracranial structures either by direct invasion or through the blood vessels. The fungus invades the arteries leading to thrombosis that subsequently causes
necrosis of hard and soft tissue.5 The most common symptoms of rhinomaxillary form include proptosis, loss of vision, nasal
discharge, sinusitis, and palatal necrosis.4 It mimics malignancies and various other
entities like midline lethal granuloma,
gumma, Wegener’s granulomatosis,
aspergillosis and other systemic mycosis.5
So it should be carefully differentiated and managed at the earliest for the better prognosis.
Here we present a case report of 70 year old diabetic male patient who presented with a perforation in the palate, nasal discharge, periorbital cellulitis, and facial pain, which was diagnosed as rhinocerebral mucormycosis after detailed clinical, radiographic, biochemical and histopathological examinations.

Case report

A 70 year old male patient visited to the Department of Oral Medicine and Radiology with the complaint of pain in upper left back teeth and left cheek region since five months. He also complained of pus discharge from left ear and inability to open the left eye since four months; ulcer on left side of palate since 3 months and dark colored nasal discharge since one month. Patient gave history that he accidentally fell on soil while he was doing agricultural work about six months back. It resulted in a wound on the left side of his face, which was managed by a local physician. Past medical history revealed that the patient was diabetic and hypertensive since 20 years and was not under regular medical care. General physical examination revealed altered gait

©2012 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited . All Rights Reserved

ISSN 2231 – 2250 Rhinocerebral Mucormycosis..... 87

due to a chronic non-healing ulcer on the right foot (Fig 1a). Patient was lethargic and also had poor vision in the right eye.
Extraoral examination revealed facial asymmetry due to a swelling on the left side of face. Dark colored discharge from left nostril, swelling around periorbital area, proptosis and ptosis of eyelid with loss of vision in left eye were noted (Fig 1b). A solitary left submandibular lymphnode was palpable which was ovoid in shape, measuring about 1.5cm, firm in consistency, freely mobile and tender on palpation. Intraoral examination revealed a single ulcer on left side of hard palate measuring about
5cm in its greatest dimension, extending anteriorly from tooth #23 to posteriorly till tooth #26 and from palatal gingival margin laterally to medially till 0.5cm short of midline. It was roughly oval in shape with undermined edges and necrotic slough. The floor of ulcer was perforated on the anterior aspect and denuded yellowish grey bone was visible on the posterior region (Fig 1c). Surrounding area was inflamed and tooth
#26 and tooth #27 were tender on percussion. A provisional diagnosis of
palatal perforation secondary to deep fungal infection was given. In the differential diagnosis rhinocerebral mucormycosis, aspergillosis, mucoepidermoid carcinoma,
Wegener’s granulomatosis, tertiary syphilis
(gumma) and antral carcinoma were considered.
Paranasal sinus view demonstrated hyperdense left frontal and maxillary sinuses, cloudy sinuses without fluid levels, spotty destruction of bony walls of sinuses. Computed tomography examination revealed soft tissue mass of mixed attenuation value involving left cheek area. It was extending up to left orbit & left nasal cavity (Fig 2a), fungating mass involving left maxillary sinus eroding left orbital floor and involving left orbit, frontal sinus (Fig 2b) and optic nerve sheath. Also mucosal thickening, spotty bone destruction and sclerosis were seen. Right maxillary sinus was clear (Fig
2c). Fungating mass was involving left petrosal bone also. Chest radiograph was clear. Hematological and serological investigations revealed mild anemia (Hemoglobin - 9.5gm/dl), reduced RBC count (3.9 million/cubic millimeter), neutropenia (55%) and elevated fasting blood sugar (318 mg%). Ketone bodies were found in urine. Screening tests for syphilis (Venereal Disease Research Laboratory
test) and human immunodeficiency virus (Enzyme Linked Immunosorbent Assay) were negative. Examination of the cytosmear from the floor of ulcer revealed nonspecific inflammation. Culture was negative.
An incisional biopsy was done in the General Surgery Department which demonstrated aseptate hyphae, confirmed the diagnosis of mucormycosis (Fig 3a and
3b). The patient was referred to a superspecialty institute, where administration of intravenous Amphotericin B, surgical debridement of the involved area and enucleation of eye was advised. However the patient refused treatment due to personal apprehensions & got discharged against medical advice. He succumbed to the disease a month later.


The infection caused by fungi of the order mucorales is known as Mucormycosis (zygomycosis).1 Rhinocerebral mucormycosis is one of the most rapidly
progressive and lethal forms of fungal
infections in humans and usually begins in nose and paranasal sinuses.7 Mucormycosis infection in humans is usually acquired through airborn fungal spores, contamination
of traumatized tissue, ingestion and direct inoculation.8 In the present case organism might have got a portal of entry from soil
through traumatized facial wound.
The predisposing factors for mucormycosis are uncontrolled diabetes (particularly in patient having diabetes ketoacidosis {DKA}), malignancies such as lymphomas and leukemias, renal failure, organ transplant, long term corticosteroid and immunosuppressive therapy, cirrhosis, burns, protein energy malnutrition and
AIDS.6 In a series of 929 cases of mucormycosis by Roden et al9, diabetics most frequently presented with rhinocerebral involvement. Some studies showed 75% of mucormycosis cases associated with
DKA.8,10 The causative organism in most
cases is Rhizopus Oryzae.1 DKA disrupts iron binding of transferrin, resulting in increased proportion of unbound iron which may promote growth of fungus. Susceptibility of the patients with DKA to this
infection may be due to decreased neutrophil chemotaxis and phagocytosis.11
In addition, microangiopathy and atherosclerosis in diabetes compromise the vascularity of tissues leading to necrosis.

88 Guruprasad, et al ISSN 2231 - 2250

Figure 1: The chronic non-healing ulcer on the right foot (a). The extraoral photograph showing periorbital swelling (b) and Intraoral ulcer on the left side of hard palate with perforation may be


Figure 2: Coronal computed tomography showing soft tissue mass of mixed attenuation value involving left cheek area extending up to left orbit & left nasal cavity (a) involving left maxillary sinus extending up to left orbit and frontal sinus with erosion of left lower orbital rim (b). The axial CT showing involvement of optic nerve sheath (c).
Figure 3: The hematoxylin and eosin stained histopathological photomicrograph demonstrating fungi proliferation at 10X magnification (a) and aseptate hyphae at 40X magnification (b).
Patient with diabetes mellitus has various foot disorders such as ulceration, infection, and gangrene which are the leading causes of hospitalization. The most characteristic lesion of the diabetic foot is a mal perforating ulceration which is the major risk factors for lower-extremity amputation (approximately
Rhinocerebral mucormycosis usually has three stages. First, inhaled spores infect the
paranasal sinuses and necrotic lesions develop in the nasal mucosa and hard palate. Next, either direct spread of infection occurs through ethmoid sinuses or orbital infection develops via haematogenous route. Finally, infection invades the intracranial region through the cribriform plate or orbital apex. The spores invade the vascular structures and are multiplied in the elastic lamina of the arteries. Hyphae erode the endothelium of the vessel walls and then

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causes necrosis, thrombus and infarcts.13
Present case was in final stage.
In the present case the thrombosis of internal maxillary artery or descending palatine artery caused by mucormycotic infection as well as chronic diabetes might have caused necrosis and denudation of underlining bone ultimately perforating the palate. The present case demonstrated almost all the clinical and radiographic features (Table 1) in addition the patient who complaint of yellow colored discharge from ear, which may be due to the involvement of petrosal bone.

Clinical Features



Blood-tinged nasal discharge

Facial pain

Perinasal swelling


Black, necrotic crusting of septum and Perforation of turbinates

Oral ulcers with areas of bony denudation

Nodular thickening of sinus lining

Cloudy sinuses without fluid levels

Spotty destruction of sinus bony wall

Table 1: Summary of clinical and radiological findings of mucormycosis.
On the bases of clinical features mucormycosis may assume the presentation of malignancy, syphilis, tuberculosis, Wegener’s granulomatosis, aspergillosis, and other systemic mycosis5. This
aggressive disease should be carefully differentiated from other destructive lesions which occur in the same area. Early diagnosis and management is important for better prognosis.

Author Affiliations

1. Dr.Guruprasad R, Professor, Department of Oral Medicine and Radiology, People’s College of Dental Science & Research Center, Bhanpur, Bhopal, 2. Dr.Som Datt Gupta, Professor & Head, Department of Oral Medicine and Radiology, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab, 3. Dr.Arpit Jain, Postgraduate student, Department of Oral Medicine and Radiology, People’s College of Dental Science & Research Center. Bhanpur, Bhopal, MP, India.


We would like to thank all the staff members of Department of Oral Medicine and Radiology for their support and cooperation.


1. Cagatay AA, Oncu SS, Calangu SS, Yildirmak TT, Ozsut HH, Eraksoy HH. Rhinocerebral mucormycosis treated with 32 gran liposomal amphotericin b and incomplete surgery: a case report. BMC Infectious Disease 2001;1:22.
2. Garg R, Gupta VV, Ashok L.
Rhinomaxillary mucormycosis; A palatal ulcer. Cont Clin Dent 2011;2(2):119-23.
3. Cheema SA, Amin F. Five cases of rhinocerebral mucormycosis. Br J Oral Maxillofac Surg 2007;45:161-62.
4. Woo SB, Greenberg MS. Ulcerative, vesicular and bullous lesions in Greenberg MS, Glick M, Jonathan AS.


deferential diagnosis applied equally well in
Burket’s Oral Medicine. 11
Ed, New
our case because diabetes is the most common underlying cause of fungal infections. A negative culture was obtained in the study, however it does not rule out
infections.14,15 Diagnosis was made by biopsy of infected tissue.
Successful treatment of mucormycosis is based on three principles. First, any accompanying diseases should be kept under control. Second, necrotic tissues should be aggressively debrided or infected tissues should be resected. Lastly, medical treatment with antimycotic agents should be
carried out.13


An interesting case report of palatal perforation resulted by rhinocerebral mucormycosis in 70 year old uncontrolled diabetic male individual is described. This
Delhi, India: BC Decker: 2008. p74.
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8. Reddy SS, Rakesh N, Jatti D, Lanjekar A, Bijjal S. Rhino cerebral mucormycosis. a report of two cases and review of literature. J Clin Exp Dent.

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13. Turunc T, Demiroglu YZ, Aliskan H, Colakoglu S, Arslan H. Eleven cases of mucormycosis with atypical clinical manifestations in diabetic patients. Diab Res Clin Prac 2008;82:203-8.
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Mucormycosis presenting as palatal perforation. Indian J Dent Res.2006;
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Corresponding Author Dr. GuruPrasad R, Professor,

Department of Oral Medicine and Radiology, People’s College of Dental Science and Research Center,

Bhanpur, Bhopal, MP, India. Ph: +91- 8109678707,


Source of Support: Nil, Conflict of Interest: None Declared.


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