COVID-Associated Mucormycosis in Case of Fibrous Dysplasia of Maxilla: Freeing 2 Birds With 1 Key

Introduction: India is one of the countries most affected by COVID-19. COVID-19-associated mucormycosis (CAM) has added to the woes of the already devastating effects of the virus. About 97.6% of cases in India presented with rhino-orbito-cerebral disease. Fibrous dysplasia (FD) is characterized by abnormal mixtures of fibrous and osseous elements leading to bony deformities and pathological fractures. Monostotic and polyostotic varieties have been described, with the latter being more common in children. The monostotic type of FD accounts for about 70% to 80% of FD, affecting the second and third decade. Method(s): We present a case of 44-year-old man with fibrous dysplasia of left maxilla with CAM, an angioinvasive fungal disease associated with high morbidity and mortality. As India and the entire world is struck by the COVID-19 pandemic, the use of corticosteroids has proven somewhat helpful in managing severe COVID infection. Evidence shows it has also led to CAM. Our patient was treated with radical surgical treatment of lesion with gross removal of all necrotic tissues from the sinuses along with antifungal treatment with amphotericin B. FD is a benign disorder characterized by replacement of normal bone with cellular fibrous connective tissue. Result(s): Our case presented with CAM of maxilla with palatal involvement requiring urgent surgical intervention and antifungal therapy. It incidentally happened to be a case of FD. Maxillectomy took care of the patient's FD as well. Conclusion(s): FD is a disorder characterized by dystrophy and bony metaplasia, and treatment depends on the zone of involvement. Early diagnosis and surgical intervention, with good antifungal therapy with strict glycemic control, are critical features to prevent its onslaught. Sometimes treatment of one condition can cure the others as well.

ANTIMICROBIAL PHOTODYNAMIC THERAPY: AN ALTERNATIVE FOR THE TREATMENT OF OSTEORADIONECROSIS

Introduction Osteoradionecrosis (ORN) is a side effect after head and neck radiotherapy (RT) that is difficult to control. Antimicrobial photodynamic therapy (aPDT) promotes bacterial lysis through photosensitization, aiming at stimulating the affected area, promoting healing of the oral mucosa. Methods We performed a retrospective cohort analysis of patients with head and neck cancer, treated with RT, who developed ORN after RT and who underwent the treatment with aPDT concomitant with irrigation with 0.12% chlorhexidine digluconate and surgical debridement. Results Thirty-six patients who had lesions by ORN in the mandible or maxilla, with a mean development time of 30.9 months, were included. Of them, 77.8% were male, with a median age of 58 years. All of them were diagnosed with malignant neoplasms of oral cavity and oropharyx that received local RT as part of cancer treatment. In 22 patients, chemotherapy was used as part of the treatment. The main etiologie of ORN was prosthetic trauma (61.2%). All patients underwent the proposed protocol and 75% of patients were successful in treatment with total healing of the affected area and presented with no symptoms. Conclusions The protocol used suggests successful healing of the area in 75% of cases. The others suffered some complication of the ORN, such as pathological fracture, oro-cutaneous fistula and bucosinusal fistula and 16.6% patients treatment were affected by the COVID-19 pandemic and had the continuity of treatment impaired, still maintaining, a chronic ORN.

wHY DOES IT ALWAYS HAVE to BE HEMOPHILIA FAULT?

Introduction: Hemophilia A is an X-linked bleeding disease caused by coagulation factor VIII (FVIII) deficiency. Clinical presentation include bleeding and their sequalae. Hemarthrosis are the most frequent bleeding manifestation and can lead to disabling hemophilic arthropathy. However, bleeding diathesis could also be unrelated to FVIII deficiency and other causes must be taken into consideration. Methods: Case presentation: A 54-year-old man affected by severe hemophilia A, with previous inhibitors eradicated with immune tolerance induction (ITI) and suffering from a disabling hemophilic arthropathy has been followed at our center since March 1988. After on demand treatment, he started regular prophylaxis in 2003. At 25 and 27 years-old he suffered pathological fractures to both femurs, presenting with pain and functional limitation in both cases. While the first fracture was caused by osteoporosis in abuse of steroids, the second one was related to bone localization of non-Hodgkin large cell malignant lymphoma, treated with chemo and radiotherapy plus autologous stem cells transplantation and currently in clinical remission. In April 2021, 20 days after second inoculation of COVID-19 vaccination (Pfizer®), the patient developed important mucosal and cutaneous bleeding, lasting more than a week despite recombinant FVIII infusion and for which he sought medical consult. Results: Blood count analyses revealed severe immune thrombocytopenia (Platelets 3000/mmc), requiring two lines of therapy (steroid plus intravenous immunoglobulin, followed by Rituximab), always under active FVIII prophylaxis. Further investigation for thrombocytopenia revealed that the cause is a chronic lymphatic leukemia clone in the bone marrow, currently not requiring active treatment. Discussion/Conclusion: The previous case highlights how alternative bleeding cause should be considered also in hemophilia patients and how crucial is physical examination: articular or bone pain can be related to typical hemarthrosis but also to bone damage of different nature. When a bleeding episode is refractory to usual therapy, particularly in patients with severe hemophilia and a previous history, inhibitors should always be suspected. However, especially if clinical presentation is unusual (as mucosal and cutaneous diathesis) a different source should be promptly investigated for lifesaving care.

Case series: experience of using external fixation as an adjunct in the management of mronj affecting the mandible

Introduction: External fixation was first described by Malgaigne and Rigaud in 1870 for use on long bones, then adapted for OMFS in 1934 and used for treating comminuted fractures. In recent times, popularity of external fixators has decreased with the use of mini-plates, often only used in major trauma, for example gunshot wounds. This is a case series of patients who have been treated by external fixation for medication related osteonecrosis (MRONJ) of the jaw and could be a fairly simple alternative to major reconstructive surgery in such cases. This method of treatment has been particularly useful during the Covid-19 pandemic as a non-aerosol generating procedure. Method: A single centre, retrospective study of 5 cases between December 2018 - December 2020. The MRONJ cases were graded using the AAOMS classification. All cases treated with external fixation of mandible were included. Pre-operative condition, medical history, treatment complications, pain management, length of treatment and follow-up results were recorded. Results: Of the 5 cases treated for MRONJ, 4 of these had pathological fractures. All were AAOMS stage 3. The mean duration of treatment was 78 days, with regular clinical reviews monitoring progress. Of these cases, 4 cases healed well with significant improvement or closure of intraoral and extra-oral wounds. Conclusions: In this small case series the technique has shown positive results;being well received by patients and allowing function while in situ. It allows treatment of pathological fractures as well as stabilising the mandible as a preventative measure whilst debriding severely atrophic mandibles.