International Journal of Research and Review www.ijrrjournal.com E-ISSN: 2349-9788; P-ISSN: 2454-2237

Case Report

Mucormycosis of Middle - An Incidental Finding

Dr. Avni Gupta1, Dr. Hoogar M.B.2, Dr. Reeta Dhar3, Dr. Atul Jain4, Dr. Deesha Bhemat1

1Senior Post-Graduate Student, 2Associate Professor, 3Professor, 4Assistant Professor, Department of Pathology, M.G.M’s Medical College, Kamothe, Navi Mumbai

Corresponding Author: Avni Gupta

ABSTRACT

Mucormycosis is a saprophytic fungal , commonly affecting the paranasal sinuses. An aggressive invasive form of infection is common in people with uncontrolled diabetes and in individuals with immunocompromised state. Most of the reported cases of otomycosis by mucor are of invasive disease in people with long history of diabetes mellitus. Thecase presented here as mucormycosis of middle ear cavity was diagnosed incidentally in a healthy nondiabetic woman while performing tympanoplasty as part of management of chronic suppurative media. Keywords: Chronic suppurative , Mucormycosis, Otomycosis, Tympanoplasty

INTRODUCTION osteomyelitis, peritonitis, and Sinonasal region is often the site of pyelonephritis. Mucormycosis of the middle many common , albeit infections ear is a very rare clinical entity. [3] There is by unusual microbial agents such as fungi only one reported case of mucormycosis of are highly uncommon. Fungal infections middle ear and mastoid region in a have been known to occur in sinonasal nondiabetic person, who was treated by region sporadically in patients predisposed radical mastoidectomy. [1] The case of to certain immunocompromised states, not mucormycosis of the middle ear in a middle necessary having immunosuppression. aged lady being presented here was an Among fungi Mucormycosis and incidental finding presenting in a unusual infections are found to be manner in a patient who was undergoing relative more commonly causing of tympanoplasty for chronic suppurative otitis the nasal cavity. Both mucormycosis and media. are seen mostly in patients suffering from debilitating chronic illnesses CASE REPORT and diabetic mellitus. [1] Infections by these A 45-year-old woman presented to fungi in patients with diabetes mellitus and OPD of a tertiary care hospital with history other chronic debilitating conditions of profuse, recurrent, mucopurulent clinically manifest in five major forms: discharge from left ear since 8 months.She Rhinoorbitocerebral, pulmonary, did not have any history of systemic disseminated, cutaneous, and illnesses including diabetes mellitus. Middle gastrointestinal. [2] Nevertheless, these fungi ear cavity was completely cleared while are known to cause less common forms of conducting tympanoplasty with residual mucormycosis like endocarditis,

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tissue after scraping sent for structures were broad, aseptate with histopathological examination. frequent branching at almost right angles [Figure 1,2]. Sections stained with special HISTOPATHOLOGY stains for fungi such as Histopathological examination of the Gomori’smethanamine silver stain and specimen revealed fibrocollagenous tissue Periodic Acid Schiff stain displayed diffuse showing mild to marked oedema with sparse positivity for branching fungi which were to focally dense infiltration by composed of predominantly non-septate predominantly mononuclear inflammatory hyphae [Figure 3,4], thus the cells. At places, the oedematous histopathological features being suggestive fibrocollagenous tissue showed plenty of of mucormycosis. No granulomatous fungal hyphae in multiple clumps with was evident in the sections admixed spore-like structures. The hyphal studied.

Figure 1 & 2 – 40 x magnification; H&E stain showing aseptate fungal hyphae Figure 3– 40 x magnification; GMS stain Figure 4- 40x magnification; PAS stain

DISCUSSION species comprise fungi belonging to the Otomycosis is uncommon in healthy order which include mucor, individuals, though it is often found to be rhizopus, rhizomucor, absidia, associated with some occupations such as apophysomyces, cunninghamella, and deep sea divers, farmers, horticulturists and saksenea. Mucor are essentially saprophytes agro-industries. Mucormycosis is the found in the soil and decaying organic commonest form of otomycosis caused by matter. [4] They gain access into the middle mucor species of , a common upper ear from the nasopharynx via Eustachian respiratory commensal in patients with tube or through a perforated tympanic immunocompromised states. The mucor membrane. Mucormycosis characteristically

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manifests in immunocompromised hosts existing conditions such as chronic suffering from chronic debilitating suppurative inflammation as in the case conditions such as diabetes, hematological being presented here. Though it is malignancy, neutropenia, organ diagnosed as incidental finding, the clinical transplantation, deferoxamine therapy, and management and outcome of such clinical people on immunosuppressive therapy with conditions such as tympanoplasty in the corticosteroids. Interestingly, human present case could have been complicated immunodeficiency virus (HIV) infection is had there not been any sampling of the certainly not a likely risk factor for lesion for histopathological examination or mucormycosis in the initial phases of had histopathological diagnosis been not infection. This could possibly be explained forthcoming in time. An eventful clinical by the fact that the defense against management of invasive mucormycosis is mucorales is provided mainly by the mandated by early diagnosis, successful neutrophils, which are not affected by HIV, management and regulation of underlying AIDS virus affects predominantly T risk factors, extensive surgical debridement lymphocytes. [4] Nonetheless, infection of necrosed tissue and antifungal therapy. mucor can be seen affecting imunocompetent people, though the REFERENCES incidence of such an infection is very rare. 1. Hazarika P, Ravikumar V, Nayak RG, [1,5] The most clinical manifestation or form Roa PS, Shivnanda PG. of mucormycosis is rhinoorbitocerebral, Rhinocerebralmucormycosis. Ear Nose Throat J. 1984;63:100–106 followed by cutaneous and pulmonary [6] [1] 2. Ribes JA, Vonover-Sams CL, Baker DJ. mucormycosis. Hazarika et al., in their Zygomycetes in human diseases. report of a case, opined that mucormycosis ClinMicrobiol Rev 2000;13:236-301. in the middle ear in a nondiabetic patient is 3. Petrikkos G, Skiada A, Lortholary O, noninvasive and may occur as indolent Roilides E, Walsh TJ, Kontoyiannis DP. infection which may coexist with chronic Epidemiology and clinical suppurative otitis media. The case presented manifestations of mucormycosis. Clin here is unique and unusual in that the patient Infect Dis 2012;54 Suppl 1:S23-34. did not have clinical history of previous 4. Prabhu RM, Patel R. Mucormycosis and fungal infections of the middle ear nor the entemophthoramycosis: A review of the patient was suspected of having clinical manifestations, diagnosis and treatment. ClinMicrobiol Infect 2004;10 mucormycosis of the ear as clinical Suppl 1:31-47. manifestations of the disease were 5. Solano T, Atkins B, Tambosis E, Mann apparently camouflaged by overwhelming S, Gottlieb T. Disseminated clinical manifestations of chronic mucormycosis due to suppurative otitis media. Saksenaeavasiformis in immunocompetent adult. Clin Infect Dis CONCLUSION 2000;30:942-3. Mucor infections of middle ear are 6. Sun HY, Singh N. Mucormycosis: Its very rare in healthy individuals, but when contemporary face and management they occur in hosts with preexisting strategies. Lancet Infect Dis 2011;11: infective lesions, the clinical diagnosis is 301-11. hampered by overwhelming features of pre-

How to cite this article: Gupta A, Hoogar MB, Dhar R et al. Mucormycosis of middle ear - an incidental finding. International Journal of Research and Review. 2017; 4(1):49-51.

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