Skip to main content

Post-Covid mucormycosis presenting as retropharyngeal abscess: a rare case report

Abstract

Background

Post-Covid retropharyngeal mucormycosis is a rare presentation, and no case has been reported in literature until date.

Case presentation

A-32-year-old female post Covid presented to our OPD with history of dysphagia and with a history of steroid intake. Radiology confirmed it as retropharyngeal abscess. Endoscopic-guided aspiration was done. HPE (histopathological examination) revealed classic broad aseptate hyphae of mucormycosis. Patient was managed conservatively with broad-spectrum antifungal.

Conclusion

Retropharyngeal mucormycosis is a rare entity in Covid era. Rapid diagnosis and management are needed to save life of an individual, or results could be fatal.

Background

Retropharyngeal abscess is a rare entity. It can also be potentially life-threatening. It is most commonly seen in children under the age of five but also seen in adults. Children less than 5 years of age have high propensity towards URTI (upper respiratory tract infection) which may lead to suppurative cervical lymphadenitis and eventually retropharyngeal abscess. In adults, trauma to posterior pharynx may result in retropharyngeal infection leading to abscess formation. Tubercular infection is the main cause of chronic retropharyngeal abscess. Treatment ranges from prolonged courses of intravenous antibiotics to surgical incision and drainage. Mucormycosis was described by Paltauf in 1885 [1]. It is a fungal infection mainly affecting immunocompromised patients and diabetics. Common varieties of mucormycosis are those involving the paranasal sinuses (39%), lungs (24%), skin (19%), brain (9%) and gastrointestinal system (7%) [2]. Cutaneous variety of mucormycosis is a rare entity. Once left untreated, it may become life-threatening due to involvement of critical structures. Mucormycosis is caused by a fungus of the order Mucorales. It is usually harmless to a healthy person but fatal in immunocompromised. Most common causative organism is Rhizopus species [3]. Diagnosis is made by histopathological examination, and it is treated by aggressive surgical debridement and appropriate systemic antifungal treatment. It is very rarely found in the retropharyngeal region, and such a case has not yet been reported in literature. We are reporting a case of post-Covid mucormycosis presenting as retropharyngeal abscess — a rare entity.

Case presentation

A 32-year-old female with history of steroid intake following Covid infection presented in the emergency department with dysphagia and odynophagia for the last 4 days. On examination, there was a mild swelling over the face with a minimal retropharyngeal bulge. Diagnostic nasal endoscopy and indirect laryngoscopy were unequivocal. She was a known diabetic with poor control and having HbA1c of 9.4. The WBC counts and serum creatinine levels were also elevated indicating an infective pathology. MRI imaging showed retropharyngeal abscess with no contrast uptake on T1 sequence (axial and sagittal) (Figs. 1, 2).

Fig. 1
figure 1

T1 contrast MRI image (Sagittal section) showing retropharyngeal abscess with no contrast uptake

Fig. 2
figure 2

T1 contrast MRI image (Axial section) showing retropharyngeal abscess with no contrast uptake

Endoscopic-guided aspiration of the abscess was done. Pus was sent for gene expert, KOH mount and HPE (histopathological examination). Gene expert denied the presence of Mycobacterium tuberculosis. HPE report showed broad, aseptate and obtuse angle branched fungal hyphae—suggestive of mucormycosis (Fig. 3) with angioinvasion (Fig. 4). The sputum for AFB stain was negative.

Fig. 3
figure 3

HPE image showing broad, aseptate and obtuse angle branched fungal hyphae—suggestive of mucormycosis

Fig. 4
figure 4

HPE image showing broad, aseptate and obtuse angle branched fungal hyphae with angioinvasion -suggestive of mucormycosis

A multidisciplinary team meeting was conducted with endocrinology and infection control departments. Consensus was reached to treat the patient conservatively with antifungal agents supplemented by broad-spectrum antibiotics. Ryles tube was placed for maintaining nutrition as the patient had difficulty in swallowing. The patient was also advised regular mouth gargles using hydrogen peroxide in 1:4 dilution along with povidone iodine 0.5% w/v 3–4 times a day.

Once the diagnosis of invasive mucormycosis involving retropharyngeal space was made, parenteral liposomal amphotericin B — 5 mg/kg/day along with broad-spectrum antibiotics, was started along with regular monitoring of serum electrolytes and kidney function tests [4]. A total dose of 5 g of liposomal amphotericin was given to the patient. Subsequently, the patient was weaned off the Ryle’s tube after 7 days of treatment and was allowed oral feeds. After a complete regimen of 5 g of liposomal amphotericin, the patient was discharged on 300 mg/day posaconazole for a period of 3 months with regular monitoring of liver function tests. After 1 month of the therapy, the patient was completely relieved of all the symptoms and was comfortably taking oral feeds. Patient was followed up with postoperative MRI. Controlling sugar, ferritin levels are the most important factor in prevention of mucormycosis in patient of Covid-19.

Discussion

Retropharyngeal space is posterior to the pharynx and oesophagus. Its extent is from the base of the skull to the thoracocervical junction. The main component of the retropharyngeal space is areolar fat. There are two spaces between the visceral (buccopharyngeal) and prevertebral fascia which are subdivided by a thin membrane known as the alar fascia. The anterior space is the “true” retropharyngeal space, described in this article, while the posterior one is called danger space. If there is any infection in the danger space, it can lead to mediastinitis; hence, it is called “danger space”. As the retropharyngeal abscess progressively increases in size, it results in gradual upper airway obstruction. If left unattended and untreated, it can eventually lead to asphyxiation. Mortality in these patients can also occur from sepsis [5]. Mucormycosis is a life-threatening invasive fungal infection. It primarily targets immunocompromised individuals with an impaired neutrophilic response. Factors increasing susceptibility are uncontrolled diabetes mellitus, acquired immunodeficiency syndrome, iatrogenic immunosuppression and haematological malignancies, and also those patients who have undergone organ transplantation [6]. The presence of hyphal invasion of sinus tissue is a characteristic feature of mucormycosis [7, 8]. Clinical presentation of rhinocerebral mucormycosis is similar to complicated sinusitis. Atypical features like nasal blockade, crusting, proptosis, facial pain and oedema, ptosis, chemosis and even ophthalmoplegia, with headache and fever, may present. If there is intracranial extension of the disease, various neurological signs and symptoms like headache and vomiting can manifest [9, 10]. A common presentation is a black eschar which is often seen in the nasal cavity or over the hard palate region [11, 12]. The histopathological picture may present as mycotic infiltration of blood vessels. There may be vasculitis with thrombosis, tissue infarction, haemorrhage and acute neutrophilic infiltration [13, 14]. Intra-orbital and intracranial complications up to 50–80 per cent cases are noticed with improper treatment [15]. Even after aggressive medical and surgical intervention, there may be intracranial extension and ultimately mortality [16]. Surprisingly, there has been a sudden surge of mucormycosis patients in Covid era.

Interplay of multiple factors including diabetes mellitus, respiratory illness, immunosuppressive therapy, hospital-acquired infection and systemic immune alterations by Covid-19 infection may cause secondary infections [17, 18]. Covid-19 patients have reported an overexpression of inflammatory cytokines. They have an impaired cell-mediated immunity with decreased cluster of differentiation (CD) 4- and 8-positive T-helper (CD4+ T and CD8+ T) cell counts. This impairment in immunity favours susceptibility to fungal coinfections [19,20,21]. Excessive steroid usage in the management of Covid-19 also suppresses immunity, thus favouring opportunistic fungal infections to colonize [22].

Complications associated with retropharyngeal abscess include airway obstruction, bronchial erosion, mediastinitis, sepsis, acute respiratory distress syndrome, cranial nerve palsies, oesophageal perforation, erosion into the carotid artery or jugular vein and meningoencephalitis, so it is mandatory to intervene as quickly as possible in terms of medical (antifungal with broad-spectrum antibiotics) and surgical therapy (incision and drainage, debridement).

Conclusion

Retropharyngeal abscess in association with post-Covid mucormycosis is a rare and life-threatening condition. Uncontrolled diabetes and abrupt use of steroids are two of the main factors aggravating the illness, and therefore, strict monitoring of sugar levels should be done. Once infected, early surgical intervention and intravenous antifungal treatment along with broad-spectrum antibiotics are the keystones of management.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Paltauf A (1885) Mycosis mucorina. Archivfu¨rpathologischeAnatomie und Physiologie und fu¨rklinischeMedicin 102(3):543–564

    Google Scholar 

  2. Petrikkos G, Skiada A, Lortholary O, Roilides E, Walsh TJ, Kontoyiannis DP (2012) Epidemiology and clinical manifestations of mucormycosis. Clin Infect Dis 54(suppl_1):S23–S34

    Article  Google Scholar 

  3. Baldin C, Ibrahim AS (2017) Molecular mechanisms of mucormycosis— the bitter and the sweet. PLoS Pathog 13(8):e1006408. https://doi.org/10.1371/journal.ppat.1006408

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. Cornely OA, Arikan-Akdagli S, Dannaoui E, Groll AH, Lagrou K, Chakrabarti A et al (2014) ESCMID_ and ECMM_ joint clinical guidelines for the diagnosis and management of Mucormycosis 2013. Clin Microbiol Infect 20:5–26

    CAS  Article  Google Scholar 

  5. Argintaru N, Carr D (2017) Retropharyngeal abscess: a subtle presentation of a deep space neck infection. J Emerg Med 53(4):568–569

    Article  Google Scholar 

  6. DeShazo RD (1998) Fungal sinusitis. Am J Med Sci 316:39–44

    CAS  PubMed  Google Scholar 

  7. Ferguson BJ (2000) Definitions of fungal rhinosinusitis. Otolaryngol Clin N Am 33:227–235

    CAS  Article  Google Scholar 

  8. Chakrabarti A, Denning DW, Ferguson BJ, Ponikau J, Buzina W, Kita H et al (2009) Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope 119:1809–1818

    Article  Google Scholar 

  9. Scheckenbach K, Cornely O, Hoffmann TK, Engers R, Bier H, Chaker A et al (2010) Emerging therapeutic options in fulminant invasive rhinocerebralmucormycosis. Auris Nasus Larynx 37:322–328

    Article  Google Scholar 

  10. Vairaktaris E, Moschos MM, Vassiliou S, Baltatzis S, Kalimeras E, Avgoustidis D et al (2009) Orbital cellulitis, orbital subperiosteal and intraorbital abscess. Report of three cases and review of the literature. J Craniomaxillofac Surg 37:132–136

    Article  Google Scholar 

  11. Mohindra S, Mohindra S, Gupta R, Bakshi J, Gupta SK (2007) Rhinocerebralmucormycosis: the disease spectrum in 27 patients. Mycoses 50:290–296

    Article  Google Scholar 

  12. Munir N, Jones NS (2007) Rhinocerebralmucormycosis with orbital and intracranial extension: a case report and review of optimum management. J Laryngol Otol 121:192–195

    CAS  Article  Google Scholar 

  13. DeShazo RD, Chapin K, Swain RE (1997) Fungal sinusitis. N Engl J Med 337:254–259

    CAS  Article  Google Scholar 

  14. Abdel-Aziz M, Azab N (2021) Acute invasive fungal rhinosinusitis and coronavirus disease 2019. J Craniofac Surg 32(8):e827–e830. https://doi.org/10.1097/SCS.0000000000008231

    Article  PubMed  PubMed Central  Google Scholar 

  15. Gillespie MB, O’Malley BW (2000) An algorithmic approach to the diagnosis and management of invasive fungal rhinosinusitis in the immunocompromised patient. OtolaryngolClin North Am 33:323–334

    CAS  Article  Google Scholar 

  16. Ballester DG, González-García R, García CM, Ruiz-Laza L, Gil FM (2012) Mucormycosis of the head and neck: report of five cases with different presentations. J Craniomaxillofac Surg 40:584–591

    Article  Google Scholar 

  17. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y et al (2020) Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 395:507–513

    CAS  Article  Google Scholar 

  18. Abdel-Aziz M, Azab N, Abdel-Aziz NM, Abdel-Aziz DM (2022) Mucormycosis: a potential head and neck problem in COVID-19 patients. Laryngoscope Investig Otolaryngol 7(1):67–69. https://doi.org/10.1002/lio2.727

    Article  PubMed  PubMed Central  Google Scholar 

  19. Song G, Liang G, Liu W (2020) Fungal co-infections associated with globalCOVID-19 pandemic: a clinical and diagnostic perspective from China. Mycopathologia 185:599–606

    CAS  Article  Google Scholar 

  20. Yang X, Yu Y, Xu J, Shu H, Liu H, Wu Y et al (2020) Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 8:475–481

    CAS  Article  Google Scholar 

  21. Bakshi SS, Kalidoss VK (2021) COVID 19 infection and mucormycosis—a dangerously increasing combination. Egypt J Otolaryngol 37:53. https://doi.org/10.1186/s43163-021-00121-w

    Article  Google Scholar 

  22. Gangneux JP, Bougnoux ME, Dannaoui E, Cornet M, Ralph ZJ (2020) Invasive fungal diseases during COVID 19: we should be prepared. J Mycol Med 30:100971

    Article  Google Scholar 

Download references

Acknowledgements

Dr. Anupam Mishra, Professor of the ENT Department, KGMU, India

Funding

No funding has been taken from any associations.

Author information

Authors and Affiliations

Authors

Contributions

RJ, DA and ABS: concepts, design, literature search, clinical studies, data acquisition, manuscript preparation, manuscript editing, manuscript review and guarantor. VV, HPS and SK: literature search, manuscript editing, manuscript review and guarantor. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Rajat Jain.

Ethics declarations

Ethics approval and consent to participate

Ethical approval—“not applicable”. Written consent was taken from the participant to participate.

Consent for publication

Written informed consent for publication of the patient’s clinical details and clinical images was obtained from the patient.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Jain, R., Agarwal, D., Singh, A.B. et al. Post-Covid mucormycosis presenting as retropharyngeal abscess: a rare case report. Egypt J Otolaryngol 38, 83 (2022). https://doi.org/10.1186/s43163-022-00274-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s43163-022-00274-2

Keywords

  • Retropharyngeal
  • Mucormycosis
  • Covid era
  • Case report