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Year : 2022  |  Volume : 15  |  Issue : 7  |  Page : 110-113  

Isolated Involvement of Palatine Tonsil by COVID-19–Associated Mucormycosis

Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission28-Jul-2021
Date of Decision30-Oct-2021
Date of Acceptance30-Dec-2021
Date of Web Publication16-Mar-2022

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_628_21

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The novel coronavirus disease 2019 (COVID-19) is highly contagious and rapidly spreading all over the world. COVID-19 patients might present with higher susceptibility to fungal co-infection. Mucormycosis is a life-threatening fungal disease characterized by vascular invasion by hyphae, leading to thrombosis and necrosis. Currently, COVID-19–associated mucormycosis (CAM) is creating a threat to patient's life in the community and is considered a fatal clinical entity in the Indian subcontinent. Mucormycosis is emerging as a matter of concern in COVID-19 patients with poorly controlled diabetes mellitus and other comorbidities as risk factors. Here, a 48-year-old man previously admitted to the COVID hospital due to severe acute respiratory syndrome coronavirus 2 infection presented with foreign body sensation and was later diagnosed with primary mucormycosis at the palatine tonsils. Early diagnosis and prompt treatment with surgery followed by liposomal amphotericin B are essential for the successful management of the CAM.

Keywords: Coronavirus disease 2019, liposomal amphotericin B, mucormycosis, palatine tonsils

How to cite this article:
Swain SK. Isolated Involvement of Palatine Tonsil by COVID-19–Associated Mucormycosis. Med J DY Patil Vidyapeeth 2022;15, Suppl S1:110-3

How to cite this URL:
Swain SK. Isolated Involvement of Palatine Tonsil by COVID-19–Associated Mucormycosis. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Sep 29];15, Suppl S1:110-3. Available from: https://www.mjdrdypv.org/text.asp?2022/15/7/110/339734

  Introduction Top

Mucormycosis is a fulminant infection caused by fungi belonging to the order Mucorales of the class Zygomycetes.[1] These fungi are ubiquitous saprophytes commonly seen in soil, decomposed vegetation, and healthy digestive and respiratory tracts.[2] The Rhizopus species (approximately 44%) and Mucor species (approximately 15%) are most commonly identified in mucormycosis.[1] Currently, mucormycosis is found in coronavirus disease 2019 (COVID-19) patients which is increasing the fatality to the patients' life. COVID-19 is a rapidly spreading infection affecting all age groups of patients.[2] There are several treatment options available for COVID-19 infections; however, none except systemic corticosteroids have been shown to improve the survival of the patients. Unfortunately, the widespread use of corticosteroids in the current COVID-19 pandemic can result in secondary bacterial or fungal infections. Invasive mucormycosis complicating the course of COVID-19 patients is widely recognized and fatal in the outcome.[2] Clinical presentations, histopathological examination, direct microscopy, and culture of the clinical samples are important to get confirmation of the diagnosis.[3] Early diagnosis and prompt treatment with surgical debridement followed by administration of liposomal amphotericin B are key for preventing this fatal clinical entity. COVID-19–associated mucormycosis (CAM) is less frequently described in the literature. The isolated palatine tonsils by CAM are an extremely rare clinical entity. The purpose of this case report is to highlight and alert clinicians of an extremely rare presentation of the CAM involving isolated palatine tonsils.

  Case Report Top

A 48-year-old man attended the outpatient department of otorhinolaryngology with the complaints of throat pain and foreign body sensation in the throat for 10 days. He was discharged from COVID hospital because of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection 15 days back. He had no history of any systemic diseases such as diabetes mellitus and hypertension. He received remdesivir and systemic corticosteroids during his hospital stay. On examination, there was an enlarged and blackish appearance of the palatine tonsils [Figure 1]. No other parts of the oropharynx are affected by such blackish lesions. Indirect laryngoscopy showed normal larynx and hypopharynx. Throat swab was taken immediately from palatine tonsils anticipating the increasing number of mucormycosis of COVID-19 patients in the Indian subcontinent and sent for KOH staining. KOH preparation from the throat swab showed broad, ribbon-like, aseptate hyphae under a fluorescent microscope, which confirmed mucormycosis. Computed tomography of the nose and paranasal sinuses showed no opacification anywhere of the nose and paranasal sinuses. Magnetic resonance imaging (MRI) of the orbits and brain showed no abnormality. A routine blood test showed elevated blood glucose levels without ketoacidosis. The blood glucose level was corrected after consultation with an endocrinologist. Then, the patient underwent bilateral tonsillectomy, and tonsillar tissue was sent for histopathological examination. After tonsillectomy, the patient was administered with liposomal amphotericin B. Histopathology report showed broad nonseptate hyphae with 90° branchings [Figure 2]. The patient was administered with the parenteral infusion of amphotericin B (1–1.5 mg/kg/day) and a total dose of 3 g in 6 weeks.
Figure 1: Oropharyngeal examination showing blackish appearance of bilateral palatine tonsils

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Figure 2: Histopathology microphotograph showing broad nonseptate hyphae with 900 branching (Eosin stain, ×400)

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  Discussion Top

COVID-19 infection is a highly infectious and rapidly spreading disease of the respiratory tract caused by a novel virus, called SARS-CoV-2.[4] COVID-19 infections spread all over the world in a short period. The World Health Organization declared COVID-19 as a global pandemic on March 11, 2020.[5] Currently, fungal infection-like mucormycosis is rising in COVID-19 patients, resulting in a fatal outcome. Mucormycosis is an uncommon opportunistic fungal infection caused by organisms in the order Mucorales, and it is characterized by infarction and necrosis of the host tissue by the invasion of the blood vessels by hyphae.[6] Mucormycosis often affect immunocompromised patients with predisposing conditions, such as poorly controlled diabetes mellitus, organ transplantation, malignancy, neutropenia, iron overload, and prolonged steroid therapy.[7] The pathological hallmark for this opportunistic fungal infection is vascular invasion, leading to thrombosis and tissue necrosis.[7] Rhino-orbito-cerebral mucormycosis is the most common type of mucormycosis, accounting for one-third to one-half of all varieties of mucormycosis, and is most commonly (approximately 70%) associated with diabetes mellitus.[8] In case of severe COVID-19 infection, patients might present with markedly higher levels of inflammatory cytokines such as interleukin (IL)-2R, IL-6, IL-10, and tumor necrosis factor-alpha, associated with an impaired cell-mediated immune response which affect both CD4+ T and CD8+ T cells. Hence, these patients are more susceptible to fungal co-infections.[9]

The clinical manifestations of mucormycosis depend on the site of the disease. The majority of the patients with invasive mucormycosis are often under treatment with immunosuppressants or with underlying diseases such as diabetes mellitus and hematological malignancies or are transplant recipients. In the head and neck area, the most common forms of mucormycosis are rhino-orbital-cerebral infections.[10] In this case, the patient was presenting with throat pain and foreign body sensation in the throat. Although rare, mucormycosis of the oropharynx, particularly palatine tonsils, may occur as a result of the ingestion of the spores of the fungus. Cases of CAM affecting the isolated palatine tonsils are extremely rare. CAM can affect all age groups of patients with COVID-19 infections. Mucormycosis is a life-threatening infection and can manifest as a local or systemic invasion.

In our case, traditional risk factors were absent such as diabetes mellitus, transplantations, or hematological malignancies. In this case, the patient was taking systemic corticosteroids during the treatment period of COVID-19 infection. The development of mucormycosis in the palatine tonsils can probably be attributed to the use of glucocorticoids and suggests a need for its judicious use. Thus, the use of steroids in a mild case of COVID-19 infection (without hypoxemia) or administration of higher doses of glucocorticoids should be avoided. Some clinicians administer tocilizumab (recombinant humanized anti-IL-6 receptor monoclonal antibody) in severe COVID-19 infections. However, in the absence of a clear benefit, drugs targeting immunity of the body such as tocilizumab should be discouraged.[11]

Proper history taking, clinical examination, imaging, and microbiological confirmation are important components for the diagnosis of the suspected mucormycosis. In CAM, computed tomography scan is very useful to rule out any bone destruction. MR) of the brain and orbit is helpful to rule any involvement of the fungus of the brain, sinuses, and orbit.[12] In case of brain involvement, MRI shows multiple areas of infarction and ischemia which indicate invasive fungal lesions. Ophthalmological and neurological examinations should be done to rule out loss of vision and neurological involvement. Before surgical debridement, the swab is usually taken from infected tissue sent for KOH mount where it shows aseptate hyphae. In this case, KOH preparation from the throat swab showed broad, ribbon-like, aseptate hyphae under a fluorescent microscope, which confirmed mucormycosis. A biopsy is taken from infected tissue which shows a picture of mucormycosis with foci of nonseptate fungal hyphae with right angles' hyphae branches. The diagnosis of mucormycosis is confirmed by histopathological examination and fungal culture. The fungal culture is usually done with sabouraud dextrose agar(SDA) which shows mycelia growth, features of Rhizopus oryza.

The key to effective treatment of the CAM is early diagnosis, elimination of predisposing factors, and aggressive surgical debridement and parenteral antifungal treatment such as liposomal amphotericin B.[13] Successful treatment of CAM requires rapid diagnosis, reversal of predisposing factors, urgent surgical debridement, and aggressive antifungal therapy. Surgical debridement is an essential component in the management of the CAM. Aggressive surgical excision of the necrotic tissue till getting a healthy margin with bleeding tissue is a must for effective treatment. This surgical excision enhances the penetration of the drug into the affected tissues. The standard medical treatment for mucormycosis is amphotericin B in a dose of 1.0–1.5 mg/kg/day for a period ranging from weeks to months based on clinical response.[14] The less toxic form of amphotericin B is available such as liposomal form, colloidal dispersible form, and lipid complex with fewer side effects.

  Conclusion Top

Mucormycosis is a fatal fungal infection resulting in angioinvasion by the hyphae, leading to thrombosis and necrosis of the tissue. Immunocompromised patients or patients taking systemic steroids or under any immunosuppressive drugs with COVID-19 infections are at greater risk of getting mucormycosis. Primary mucormycosis of the palatine tonsils in COVID-19 patients is extremely rare. Clinical suspicion and prompt treatment are important steps to achieve the cure of this disease. Clinicians should be careful of critically ill COVID-19 patients and must be aware of palatine tonsils involvement of the mucormycosis. Early diagnosis and timely treatment are required for CAM involving isolated palatine tonsils for improving the outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Zaoutis TE, Roilides E, Chiou CC, Buchanan WL, Knudsen TA, Sarkisova TA, et al. Zygomycosis in children: A systematic review and analysis of reported cases. Pediatr Infect Dis J 2007;26:723-7.  Back to cited text no. 1
Swain SK, Jena PP, Das S, Gupta A. COVID-19 Associated mucormycosis in head and neck region: Our experiences at a tertiary care teaching hospital of eastern India. Siriraj Med J 2021;28;73:423-8.  Back to cited text no. 2
Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health 2020;25:278-80.  Back to cited text no. 3
Swain SK, Jena PP. Clinical implications and future perspective of COVID-19 pandemic – A review. Int J Adv Med 2021;8:334-40.  Back to cited text no. 4
Swain SK, Acharya S, Sahajan N. Otorhinolaryngological manifestations in COVID-19 infections: An early indicator for isolating the positive cases. J Sci Soc 2020;47:63.  Back to cited text no. 5
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Swain SK. COVID-19 associated mucormycosis in head and neck region of pediatric patients: A life-threatening disease in current pandemic. Int J Contemp Pediatr 2021;8:1322-7.  Back to cited text no. 6
Neofytos D, Treadway S, Ostrander D, Alonso CD, Dierberg KL, Nussenblatt V, et al. Epidemiology, outcomes, and mortality predictors of invasive mold infections among transplant recipients: A 10-year, single-center experience. Transpl Infect Dis 2013;15:233-42.  Back to cited text no. 7
Swain SK, Lenka S, Das SR. Rhino-orbital mucormycosis – A dreaded clinical entity. Int J Cur Res Rev 2020;12:197-202.  Back to cited text no. 8
Song G, Liang G, Liu W. Fungal co-infections associated with global COVID-19 pandemic: A clinical and diagnostic perspective from China. Mycopathologia 2020;185:599-606.  Back to cited text no. 9
Swain SK, Sahu MC, Baisakh MR. Mucormycosis of the head and neck. Apollo Med 2018;15:6-10.  Back to cited text no. 10
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Kimmig LM, Wu D, Gold M, Pettit NN, Pitrak D, Mueller J, et al. IL-6 inhibition in critically ill COVID-19 patients is associated with increased secondary infections. Front Med (Lausanne) 2020;7:583897.  Back to cited text no. 11
Swain SK, Sahu MC, Banerjee A. Non-sinonasal isolated facio-orbital mucormycosis – A case report. J Mycol Med 2018;28:538-41.  Back to cited text no. 12
Swain SK, Behera IC, Mohanty JN. Mucormycosis in head-and-neck region – Our experiences at a tertiary care teaching hospital of Eastern India. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2019;3:58-62.  Back to cited text no. 13
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Lumbang WA, Caufield BA. Vesicular eruption on the arm of an infant. Dermatol Online J 2010;16:13.  Back to cited text no. 14


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