FACIAL SWELLING AND PALATAL ULCERATION IN ADIABETIC PATIENT Zuhal Tugsel, DDS, PhD, Bahar Sezer, DDS, PhD, and Taner Akalin, DDS, PhD, Izmir, Turkey EGE UNIVERSITY [ Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004 ; 98 : 630-6]

FACIAL SWELLING AND PALATAL ULCERATION IN A DIABETIC PATIENT

Zuhal Tugsel, DDS, PhD, Bahar Sezer, DDS, PhD, and Taner Akalin, DDS, PhD,Izmir, Turkey EGE UNIVERSITY[ Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004 ; 98 : 630-6]CONTENTS: Case report Differential diagnosis Discussion Conclusion ReferencesCASE REPORT:Demographic data: 64 yrs. / Male Chief complaint: left sided facial swelling , numbness in the infra orbital area, and pain in the maxillary left molar region On oral examination: Suspicious Palatal Ulcer.

That subsequently biopsied and diagnosed as consistent with lethal midline granuloma.3 3 cm Ragged ulcer was observed on hard palate that demonstrated a raised erythematous border and central 0.5 cm area of exposed bone In addition the maxillary left quadrant exhibited evidence of moderate to severe periodontitis.

Along with that there is a poorly defined area of induration was palpable and tongue mobility is restricted.4Medical history: Insulin dependent diabetes Mycotic pneumonia Fungal Pleuritis.In December 1994 that had been succefully treated with antibiotics. 5Radiographic analysis:Panoramic and Periapical radiographs - bony destruction consistent with chronic periodontitis in the maxillary left first and second molar teethPlain sinus films revealed Vague opacification of left maxillary sinus . But there is no bony destruction.Computerized Tomography:

Mucosal thickening of maxillaey sinusIndicated areas of mild erosion of the medial wall of the left maxillary sinus together with mucosal thickening and opacification of the left maxillary , sphenoid, ethmoid, and frontal sinuses.

7Diffential diagnosis: AspergillosisParacoccidiomycosisWegners granulomatosisSquamous cell carcinomaSyphilisTuberculosisZygomycosisSCC dyplastic epithelial cells with keratin pearlsSyphilis cockscrew like organisms.8Microscopic findings:

GOMORI- METHANAMINE SILVER NITRATE STAIN . Numerous large aseptate hyphae were observed within the fibrovascular conn. Tissue portion of the specimen together with microabscess formation and areas of necrosis. The hyphae are thin walled with focal bullous dilatations and non dichotomous, irregular, broad angled branching pattern.9Diagnosis: ZygomycosisManagement: Amphotericin-B iv [ 0.8 mg /kg/day]Left maxillectomy and orbital exenterationPatient placed on Itraconazole and dischargedThe dose was increased to 1mg/kg by day 3 of therapy. However the dosage needed to be reduced on day 5 owing to progressive increase in pt creatine levels11Discussion: Zygomycosis is an acute opportunistic infection.

Most common forms are Rizopus, Rizomucor, Mucor, Absida.

Infection usually result from inhalation of spores. 5 clinical forms of Zygomycosis - rhinocerebral - Pulmonary - Cutanious - GIT - Central nervous sysem.Pathogenisis:Inhalation of spores -> spores germinate -> form hyphae -> blood vessel [ invasion ] -> clot formation -> necrosis. Radiographically rhinocerebral Zygomycosis associated with thickening of the sinus mucosa, and destruction of the bony walls of the paranasal sinuses Histologically It is characterized by extensive tissue necrosis and Presence of numerous large fungal hyphae, Which are non septate and have a ribbon like appearance, with budding and non- dichomatous branching that tends to approximate 90 degree angles.16CONCLUSIONDespite aggressive therapy overall mortality rate is high. New strategies to prevent and treat mucormycosis is urgently needed REFERENCES:Bailey and scotts diagnostic microbiology 12th editionBrouk biology of microorganisms 9th editionPathogenesis of Mucormycosis Ashraf S. Ibrahim,Brad Spellberg,2,3Thomas J. Walsh,4and Dimitrios P. Kontoyiannis 5 Division of Infectious Diseases, Los Angeles Biomedical Research Institute at HarborUniversity of California at Lo