Mucormicosis Maxilar posterior, secundaria a una exodoncia: Reporte de un caso y revisión de la literatura / Posterior maxillary mucormycosis, secondary to an exodontics: A case report and literature review

RESUMEN: La Mucormicosis se describe como una infección fúngica de tipo oportunista y potencialmente mortal, reportándose en la literatura como la tercera en frecuencia, muy por detrás de la Candidiasis y Aspergilosis. Esta infección es causada por hongos de la familia de los Mucorales. Se presenta el caso de un hombre con Diabetes Mellitus II con un control metabólico deficiente, el cual posterior a una exodoncia, presenta una Mucormicosis Maxilar, presentando una etiología atípica y logrando ser confirmada posterior a biopsias y pruebas de cultivo, demostrando elementos del tipo Mucor. Se realizó una Maxilectomía parcial del lado afectado como tratamiento con una evolución favorable. Esta revisión destaca la importancia de la búsqueda activa basada en la semiología y la importancia de los exámenes complementarios, implicando lograr un correcto diagnóstico y pronóstico de la enfermedad.

ABSTRACT: Mucormycosis is described as an opportunistic and life-threatening fungal infection, being reported in the literature as the third in frequency, far behind candidiasis and aspergillosis. This infection is caused by fungi of the Mucorales family. We present the case of a man with Diabetes Mellitus II with poor metabolic control who, after an extraction, presents a Maxillary Mucormycosis, with an atypical etiology and confirmed after biopsies and culture tests, demonstrating elements of the Mucor type. A partial maxillectomy was performed on the affected side as a treatment with a favorable outcome. This review highlights the importance of active search based on semiology and of complementary examinations, implying a correct diagnosis and prognosis of the disease.

Intracranial actinomycosis of odontogenic origin masquerading as auto-immune orbital myositis: a fatal case and review of the literature.

BACKGROUND: Actinomycetes can rarely cause intracranial infection and may cause a variety of complications. We describe a fatal case of intracranial and intra-orbital actinomycosis of odontogenic origin with a unique presentation and route of dissemination. Also, we provide a review of the current literature. CASE PRESENTATION: A 58-year-old man presented with diplopia and progressive pain behind his left eye. Six weeks earlier he had undergone a dental extraction, followed by clindamycin treatment for a presumed maxillary infection. The diplopia responded to steroids but recurred after cessation. The diplopia was thought to result from myositis of the left medial rectus muscle, possibly related to a defect in the lamina papyracea. During exploration there was no abnormal tissue for biopsy. The medial wall was reconstructed and the myositis responded again to steroids. Within weeks a myositis on the right side occurred, with CT evidence of muscle swelling. Several months later he presented with right hemiparesis and dysarthria. Despite treatment the patient deteriorated, developed extensive intracranial hemorrhage, and died. Autopsy showed bacterial aggregates suggestive of actinomycotic meningoencephalitis with septic thromboembolism. Retrospectively, imaging studies showed abnormalities in the left infratemporal fossa and skull base and bilateral cavernous sinus. CONCLUSIONS: In conclusion, intracranial actinomycosis is difficult to diagnose, with potentially fatal outcome. An accurate diagnosis can often only be established by means of histology and biopsy should be performed whenever feasible. This is the first report of actinomycotic orbital involvement of odontogenic origin, presenting initially as bilateral orbital myositis rather than as orbital abscess. Infection from the upper left jaw extended to the left infratemporal fossa, skull base and meninges and subsequently to the cavernous sinus and the orbits.

Streptococcus chosunense sp. nov., Isolated from Human Postoperative Maxillary Cyst.

A novel facultative anaerobic, non-spore forming, non-motile, and Gram-stain-positive coccus, designated strain ChDC B353T, was isolated from human postoperative maxillary cyst. The 16S ribosomal RNA gene (16S rDNA) sequence of the strain was most closely related to those of Streptococcus pseudopneumoniae ATCC BAA-960T (99.4%), Streptococcus mitis NCTC 12261T (99.3%), and Streptococcus pneumoniae NCTC 7465T (99.2%). The major fatty acids of the strain were C16:0 (43.2%) and C18:1 ω6c/C18:1 ω7c (20.2%). The genome of strain ChDC B353T was composed of 1,902,053 bps. The DNA G+C content of the strain was 40.2 mol%. Average nucleotide identity (ANI) values between strain ChDC B353T and S. pseudopneumoniae ATCC BAA-960T, S. mitis NCTC 12261T, and S. pneumoniae NCTC 7465T were 91.9%, 93.5%, and 91.3%, respectively. Genome-to-genome distance (GGD) values between strain ChDC B353T and S. pseudopneumoniae ATCC BAA-960T, S. mitis NCTC 12261T, or S. pneumoniae NCTC 7465T were 46.6% (44.0-49.2%), 53.2% (50.5-55.9%), and 46.0% (43.5-48.7%), respectively. The threshold values of ANI and GGD for species discrimination are 95-96% and 70%, respectively. These results reveal that strain ChDC B353T (= KCOM 1699T = JCM 33453T) is a novel species belonging to genus Streptococcus, for which a name of Streptococcus chosunense sp. nov. is proposed.

Prosthetic rehabilitation of a maxillary defect with a bone anchored prosthesis: A clinical report.

Mucormycosis is an opportunistic fungal infection that frequently infects sinuses, brain, or lungs and arises mostly in immunocompromised patients. Although its occurrence in the maxilla is rare, debridement and resection of the infected and necrotic area is often the best treatment but usually results in an extensive maxillary defect. Protocols for prosthetic obturation versus microvascular reconstruction have been established and used effectively in tertiary institutions for patients with such large defects. Aramany Class VI defects involving more than half of the palatal surface can be managed effectively by surgical reconstruction using microvascular free flaps as a platform for supporting bone-anchored prostheses. Providing fixed prostheses may offer advantages over a conventional obturator prosthesis in terms of hygiene, function, and esthetics. Nonetheless, fixed prostheses retained by endosseous implants in patients with reconstructive osteomyocutaneous flaps often require a sequential team approach by the surgeon and prosthodontist. This clinical report describes the reconstruction of a maxilla by using a scapular free flap with subsequent prosthetic rehabilitation in a patient with maxillary sinus infection secondary to mucormycosis.

Chronic non-healing ulcer of the oral cavity: tuberculosis or carcinoma?

OBJECTIVE: Tuberculosis is a chronic granulomatous lesion, which primarily has an affinity for the lungs. It can involve other sites like lymph nodes, kidney, oral cavity. Infection of the oral cavity by M. tuberculosis can be as a Primary infection or as a Secondary infection. Primary presentation of oral tuberculosis is in the form of the chronic non healing ulcer. A Primary infection or an Asymptomatic Secondary infection can impose a great diagnostic dilemma, as it may mimic neoplasia. Here we present a case of a 32-year-old asymptomatic female with secondary infection.

Complicaciones infecciosas severas del territorio maxilofacial: presentación de casos clínicos / Severe infectious complications of the maxillofacial territory: clinical cases presentation

RESUMEN: Las infecciones en el territorio maxilofacial, son cuadros frecuentes, de origen polimicrobiano, con manifestaciones clínicas muy variables y que están asociadas a múltiples vías de ingreso de los microorganismos al territorio. Un gran porcentaje de estas infecciones se origina en la cavidad oral, principalmente en lesiones bacterianas que sufren los dientes. La compleja anatomía de la cabeza y el cuello, permiten que muchas de estas infecciones se diseminen por espacios profundos, llegando a comprometer órganos o regiones anatómicas adyacentes, que pueden llevar a cuadros clínicos de alto riesgo vital. Los casos clínicos presentados en este artículo corresponden a pacientes tratados en el hospital San Juan de Dios a causa de procesos infecciosos del territorio maxilofacial, por equipos multidisciplinarios.

ABSTRACT: Infections in the maxillofacial territory are frequent cases of polymicrobial origin, with very variable clinical manifestations and are associated with multiple entering pathways of microorganisms in the territory. A large percentage of these infections originate in the oral cavity, mainly in bacterial lesions that undergo experienced by the teeth. The complex anatomy of the head and neck allows many of these infections to spread through deep spaces, leading to compromising adjacent organs or anatomical regions, which can lead to high-risk clinical conditions. The clinical cases presented in this article correspond to patients treated at the San Juan de Dios hospital because of infectious processes of the maxillofacial territory, by multidisciplinary teams.

Case of disseminated histoplasmosis in a HIV-infected patient revealed by nasal involvement with maxillary osteolysis.

BACKGROUND: Disseminated Histoplasmosis (DH) is a rare manifestation of Acquired Immune Deficiency Syndrome (AIDS) in European countries. Naso-maxillar osteolysis due to Histoplasma capsulatum var. capsulatum (Hcc) is unusual in endemic countries and has never been reported in European countries. Differential diagnoses such as malignant tumors, cocaine use, granulomatosis, vasculitis and infections are more frequently observed and could delay and/or bias the final diagnosis. CASE PRESENTATION: We report the case of an immunocompromised patient infected by Human Immunodeficiency Virus (HIV) with naso-maxillar histoplasmosis in a non-endemic country. Our aim is to describe the clinical presentation, the diagnostic and therapeutic issues. A 53-year-old woman, originated from Haiti, was admitted in 2016 for nasal deformation with alteration of general condition evolving for at least 6 months. HIV infection was diagnosed in 2006 and classified at AIDS stage in 2008 due to cytomegalovirus infection associated with pulmonary histoplasmosis. At admission, CD4 cell count was 9/mm3. Surgical biopsies were performed and ruled out differential or associated diagnoses. Mycological cultures identified Hcc and Blood Polymerase Chain Reaction (PCR) for Hcc was positive. The patient was given daily Amphothericin B liposomal infusion during 1 month. Hcc PCR became negative in the blood under treatment, and then oral switch by itraconazole was introduced. Antiretroviral treatment was reintroduced after a 3-week histoplasmosis treatment. Normalization of naso-maxillar mucosa enabled a palatal prosthesis. CONCLUSION: Naso-maxillar histoplasmosis is extremely rare; this is the first case ever reported in a non-endemic country. Differential diagnoses must be ruled out by conducting microbiologic tools and histological examinations on surgical biopsies. Early antifungal treatment should be initiated in order to prevent DH severe outcomes.

Epidemiology of Oral and Maxillofacial Infections.

Dental caries and periodontal disease are the most common dental infections and are constantly increasing worldwide. Distribution, occurrence of dental caries, gingivitis, periodontitis, odontogenic infections, antibiotic resistance, oral mucosal infections, and microbe-related oral cancer are important to understand the public impact and methods of controlling such disease. Distribution of human papilloma virus and human immunodeficiency virus -related oral cancers in the US population is presented.

Aspergillus in endodontic infection near the maxillary sinus / Aspergillus em infecções endodônticas próximas ao seio maxilar

ABSTRACT INTRODUCTION: Diseases of the maxillary sinus have been associated with dental roots near the maxillary sinus that have undergone endodontic treatment. OBJECTIVE: To investigate the presence of filamentous fungi in patients with dental roots near the maxillary sinus who had apical periodontitis treated endodontically, and to alert practitioners that this could be a possible avenue of contamination of the sinus in patients who develop maxillary sinus infection. METHODS: Cross-sectional study in 60 palatal roots of the first maxillary molars near the maxillary sinus, that underwent endodontic treatment for apical periodontitis. After removal of the filling material, dentin shavings were collected and placed in test tubes containing Sabouraud dextrose agar and chloramphenicol. The phenotype was determined by macroscopic and microscopic examination of the colonies. For polymerase chain reaction, the primers ITS-5 and ITS-4 were used. The sequences obtained were compared with those deposited at GenBank using the Basic Local Alignment Search Tool program. RESULTS: Filamentous fungi were isolated from 6 of 60 canals (10%):Aspergillus niger (6.7%), Aspergillus versicolor (1.6%), and Aspergillus fumigatus(1.6%). CONCLUSION: Root canals near the maxillary sinus with endodontic treatment and apical periodontitis may exhibit positive cultures for filamentous fungi. Interested professionals should be alert, because these microorganisms have pathogenic characteristics that can cause disease of odontogenic origin in the maxillary sinus.

RESUMO Introdução: Doenças do seio maxilar têm sido associadas à raízes com tratamento endodôntico próximas ao seio maxilar. Objetivo: Investigar a presença de fungos filamentosos em raízes com tratamento endodôntico e lesão periapical, próximas ao seio maxilar, alertando para uma possível contaminação do seio maxilar por via odontogênica. Método: Estudo transversal em sessenta raízes palatinas de primeiros molares superiores próximas ao seio maxilar, com tratamento endodôntico e lesão periapical. Após remoção do material obturador, raspas de dentina foram coletadas e inseridas em tubos de ensaio contendo Agar Sabouraud Dextrose e Clorafenicol. O fenótipo foi determinado pela análise macroscópica e microscópica das colônias. Para o PCR utilizou-se iniciadores ITS-5 e ITS-4. As sequencias obtidas foram comparadas as disponíveis no GenBank utilizando Basic Local Alignment Search Tool. Resultados: Fungos filamentosos foram isolados de 6 dos 60 canais (10%):Aspergillus niger (6,7%), Aspergillus versicolor (1,6%) e Aspergillus fumigatus(1,6%). Conclusão: Raízes próximas ao seio maxilar com tratamento endodôntico e lesão periapical, podem apresentar cultura positiva para fungos filamentosos. Profissionais afins devem estar alerta, pois este micro-organismo possuem características de patogenicidade podendo causar doenças no seio maxilar de origem odontogênica.

[Pseudo-tumoral Aspergillus rhinosinusitis of dental origin]. / Sinusite aspergillaire d'origine dentaire dans sa forme pseudo-tumorale.

INTRODUCTION: Sinonasal aspergillosis is caused by the interaction between the sinonasal mucosa with a cosmopolite fungus (Aspergillus), it is on the increase, this is an infection whose evolution is unpredictable requiring early diagnosis and appropriate support. We report a case of Aspergillus rhinosinusitis of dental origin in pseudo-tumoral form with a review of the literature. CLINICAL CASE: A 31 years-old, women, consulted for a right nasal obstruction with purulent rhinorrhea after dental treatment. On examination, there was a bulge of the inner canthus of the right eye and a mass in the right nasal cavity. The CT scanner showed a process of the left naso-sinus cavity centered by calcic image density. The patient underwent a total excision of the mass endoscopically. Mycological and pathological examination concluded that the etiology was Aspergillus fumigatus. The patient had not received any antifungal treatment. The postoperative course was uneventful. The evolution was favourable with no recurrence after 9 months. DISCUSSION: Aspergillus rhinosinusitis of dental origin is usually due to the emergence of canalicular filling paste into the maxillary sinus through and oral cavity and sinus fistula, neglected it can progress to invasive pseudo-tumoral form. The clinical presentation is nonspecific and the diagnosis often involves imaging (scanner). Mycological and histological examinations are essential for diagnosis. The treatment is based on surgery sometimes associated with antifungal treatment.

Brain abscess potentially secondary to odontogenic infection: case report.

Odontogenic infections are rarely implicated in the causes of brain abscess formation. As such, there are very few reports of brain abscesses secondary to odontogenic infections in the literature. This is due partly to the relative rarity of brain abscesses but also to the difficulty in matching the causative organisms of a brain abscess to an odontogenic source. The authors report a case of a 50-year-old woman whose brain abscess may potentially have been secondary to an odontogenic infection. The patient's early diagnosis, supported by imaging and microbiologic assessment, along with early minicraniotomy and extraction of infected dentition followed by a course of cephalosporins and metronidazole, contributed to a successful outcome.

The predominant bacteria isolated from radicular cysts.

PURPOSE: To detect predominant bacteria associated with radicular cysts and discuss in light of the literature. MATERIAL AND METHODS: Clinical materials were obtained from 35 radicular cysts by aspiration. Cultures were made from clinical materials by modern laboratory techniques, they underwent microbiologic analysis. RESULTS: The following are microorganisms isolated from cultures: Streptococcus milleri Group (SMG) (23.8%) [Streptococcus constellatus (19.1%) and Streptococcus anginosus (4.7%)], Streptococcus sanguis (14.3%), Streptococcus mitis (4.7%), Streptococcus cremoris (4.7%), Peptostreptococcus pevotii (4.7%), Prevotella buccae (4.7%), Prevotella intermedia (4.7%), Actinomyces meyeri (4.7%), Actinomyces viscosus (4.7%), Propionibacterium propionicum (4.7%), Bacteroides capillosus (4.7%), Staphylococcus hominis (4.7%), Rothia denticariosa (4.7%), Gemella haemolysans (4.7%), and Fusobacterium nucleatum (4.7%). CONCLUSIONS: Results of this study demonstrated that radicular cysts show a great variety of anaerobic and facultative anaerobic bacterial flora. It was observed that all isolated microorganisms were the types commonly found in oral flora. Although no specific microorganism was found, Streptococcus spp. bacteria (47.5%) - especially SMG (23.8%) - were predominantly found in the microorganisms isolated. Furthermore, radicular cysts might be polymicrobial originated. Although radicular cyst is an inflammatory cyst, some radicular cyst fluids might be sterile.

Closure of large palatal defect using a tongue flap.

The aim of this study is to report the effectiveness of a tongue flap for covering a large hard and soft tissue defect following cleft of the palate. A young patient diagnosed with acute lymphoblastic leukemia underwent a surgical reconstruction of the cleft palate by Le Fort I osteotomy and palatal closure utilizing a tongue flap. The flap provided sound and lasting closure after the surgery, and the patient successfully healed. Our goal is to present this unique case and highlight how postoperative results were good, safe, and predictable. We also hope to show that tongue transplantation as flap for hard and soft tissue reconstruction represents a valuable option in reconstruction, given the proper circumstances.

Porphyromonas gingivalis infection-associated periodontal bone resorption is dependent on receptor activator of NF-κB ligand.

Porphyromonas gingivalis is one of the oral microorganisms associated with human chronic periodontitis. The purpose of this study is to determine the role of the receptor activator of nuclear factor-κB ligand (RANKL) in P. gingivalis infection-associated periodontal bone resorption. Inbred female Rowett rats were infected orally on four consecutive days (days 0 to 3) with 1 × 10(9) P. gingivalis bacteria (strain ATCC 33277). Separate groups of rats also received an injection of anti-RANKL antibody, osteoprotegerin fusion protein (OPG-Fc), or a control fusion protein (L6-Fc) into gingival papillae in addition to P. gingivalis infection. Robust serum IgG and salivary IgA antibody (P < 0.01) and T cell proliferation (P < 0.05) responses to P. gingivalis were detected at day 7 and peaked at day 28 in P. gingivalis-infected rats. Both the concentration of soluble RANKL (sRANKL) in rat gingival tissues (P < 0.01) and periodontal bone resorption (P < 0.05) were significantly elevated at day 28 in the P. gingivalis-infected group compared to levels in the uninfected group. Correspondingly, RANKL-expressing T and B cells in rat gingival tissues were significantly increased at day 28 in the P. gingivalis-infected group compared to the levels in the uninfected group (P < 0.01). Injection of anti-RANKL antibody (P < 0.05) or OPG-Fc (P < 0.01), but not L6-Fc, into rat gingival papillae after P. gingivalis infection resulted in significantly reduced periodontal bone resorption. This study suggests that P. gingivalis infection-associated periodontal bone resorption is RANKL dependent and is accompanied by increased local infiltration of RANKL-expressing T and B cells.

[Bisphosphonate related osteonecrosis of the jaw and infection with Actinomyces]. / Osteonecrosis maxilar asociada a bisfosfonatos e infección por Actinomyces.

BACKGROUND AND OBJECTIVE: Bisphosphonate related osteonecrosis of the jaw (BRONJ) has raised considerable interest since its recent description. Its pathogenesis is not yet clarified; formerly it has been considered a non-infectious complication, but recent studies seem to implicate bacteria of the genus Actinomyces. The objective of this study is to analyze the cases of BRONJ in our institution. PATIENTS AND METHODS: Review of medical records of patients diagnosed of BRONJ in the Maxillofacial Surgery Unit of our hospital. RESULTS: We have found 11 cases of BRONJ in our hospital: 4 women taking oral alendronate or risendronate for osteoporosis and 7 cancer patients treated with intravenous zolendronic acid. All of them showed bone invasion by bacteria of the genus Actinomyces. Nine patients underwent prolonged treatment with amoxicillin with favourable clinical outcome in all of them, but 3 died of their malignancy. By contrast, one patient with beta-lactamic allergy and irregular treatment with erythromycin and tetracycline had a chronic evolution of the lesions. There was no information for other patient. CONCLUSIONS: Actinomyces play an important role in the development of BRONJ and specific antibiotic treatment improves the prognosis of this process.

Molecular profiling of oral microbiota in jawbone samples of bisphosphonate-related osteonecrosis of the jaw.

OBJECTIVE: Infection has been hypothesized as a contributing factor to bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ). The objective of this study was to determine the bacterial colonization of jawbone and identify the bacterial phylotypes associated with BRONJ. MATERIALS AND METHODS: Culture-independent 16S rRNA gene-based molecular techniques were used to determine and compare the total bacterial diversity in bone samples collected from 12 patients with cancer (six, BRONJ with history of BP; six, controls without BRONJ, no history of BP but have infection). RESULTS: Denaturing gradient gel electrophoresis profile and Dice coefficient displayed a statistically significant clustering of profiles, indicating different bacterial population in BRONJ subjects and control. The top three genera ranked among the BRONJ group were Streptococcus (29%), Eubacterium (9%), and Pseudoramibacter (8%), while in the control group were Parvimonas (17%), Streptococcus (15%), and Fusobacterium (15%). H&E sections of BRONJ bone revealed layers of bacteria along the surfaces and often are packed into the scalloped edges of the bone. CONCLUSION: This study using limited sample size indicated that the jawbone associated with BRONJ was heavily colonized by specific oral bacteria and there were apparent differences between the microbiota of BRONJ and controls.

Mucormycosis of the head and neck.

INTRODUCTION: Mucormycosis of the head and neck is a rare disease increasingly occurring in immunocompromised patients. We report on two cases with different outcomes. CASE REPORTS: A 63-year-old female presented with a recently developed deformation of her right cheek and nose combined with a loosening of the teeth. Further examination revealed mucormycosis of the maxilla. Hemimaxillectomy and secondary bony reconstruction with oral rehabilitation were performed. The second patient was a 54-year-old male who suffered from multiple myeloma. After receiving an allogeneic haematopoietic stem cell transplant, he developed a necrotizing infection of the right midface. Histopathological investigation confirmed the diagnosis of mucormycosis. The patient died one day after radical surgical resection. DISCUSSION: These two cases demonstrate the variability of mucormycosis. Although slow progression of the disease is possible, a high level of attentiveness and expedient treatment are necessary due to the high risk of a devastating course.

Identification and treatment of bisphosphonate-associated actinomycotic osteonecrosis of the jaws.

Osteonecrosis of the jaws (ONJ) is a condition characterized by necrotic exposed bone in the jaws of patients receiving intravenous or oral bisphosphonate therapy. A review of the medical and dental literature reveals that the pathoetiology of ONJ remains unknown and there is no established link that bisphosphonates are the primary cause of this bone pathology. However, there is clinical evidence that Actinomyces may play a critical role in the pathogenesis of bisphosphonate-associated ONJ. Identification and a prolonged course of oral antimicrobial therapy may lead to complete resolution of this actinomycotic osteonecrosis.