“All That Necroses Is Not Toxic Epidermal Necrolysis”

Abstract

Toxic epidermal necrolysis (TEN) and cutaneous mucormycosis are dermatological emergencies. Both present with cutaneous necrosis that warrant prompt management, which is mutually exclusive. We report a case of TEN complicated by invasion of Apophysomyces variabilis species of Mucor that ended in a fatal outcome. A 45-year-old bipolar affective disorder patient developed itchy maculopapular rash due to carbamazepine. He was treated with 60 mg prednisolone from a local hospital without stopping the causal drug. Mucocutaneous examination revealed intact blisters at the periphery of eroded skin along with atypical target lesions on the face, trunk, and proximal extremities. Haemorrhagic crusting of lips, oral erosions, and mucoid exudates from eyes were noted. Deep ulcers with irregular borders covered with blackish eschar were noted on the trunk and both arms (Figure 1). In addition to stopping carbamazepine, he was treated with intravenous vancomycin for Staphylococcus aureus sepsis. High-dose intravenous immunoglobulin was also administered since he had new necrotic areas coming up. The erythema and atypical target lesions responded rapidly to the treatment, although deep necrotic ulcers persisted. Punch biopsy was taken from the margin of a necrotic ulcer, and he was put on empirical intravenous amphotericin-B. Histopathology showed features of toxic epidermal necrolysis with mucormycosis (Figure 2). Although there was initial improvement in ulcers, the patient developed septic encephalopathy on the fourth week of admission. Eventually, the patient died of multiorgan dysfunction syndrome. Polymerase chain reaction of the biopsy specimen was performed using panfungal primers ITS1 5′-TCCGTAGG-TGAACCTGCGG-3′ and ITS2 5′-GCTGCGTTCTTCATC-GATGC-3′ targeting the partial internal transcribed spacer region (ITS-1) of the nuclear ribosomal DNA. Subsequent sequencing of the amplicon was performed using the Big Dye Terminator Sequencing ready reaction kit in an automated ABI 3130 genetic analyzer (Applied Biosystems, Foster City, California). The sequence obtained showed 99% to 100% identity with A. variabilis in the NCBI database. In the current patient, the possibility of a necrotizing angioinvasive fungal infection was overlooked initially due Medical Letter 679827C MSXXX10.

Necrotizing fasciitis caused by Apophysomyces variabilis in an immunocompetent patient

“…There are few cases of A. variabilis infection reported in the literature, mostly form India [7] , [8] , [9] , [10] , [11] , [13] , [15] , [16] ( Table 1 ). The number of cases is likely to be underestimated because A. variabilis does not produce spores readily in traditional mycological culture media used in clinical laboratories, has special nutritional requirements, grows at high temperatures (37–42 °C) and after prolonged periods of incubation (7–10 days) [9] .…”

“… 1 45 Skin Torso and limbs Toxic epidermic necrosis. Without Death [11] 1 64 Skin Abdominal wall. Cutaneous zoster.…”

Mucormycosis caused by Apophysomyces species: An experience from a tertiary care hospital in Western India and systematic review of global cases

“…From literature search and meticulous study selection process, 89 studies were included in this systematic review with data retrieved from additional 250 cases of mucormycosis due to Apophysomyces species 5,9–96 (Figure 1). The worldwide distribution of reported cases of mucormycosis due to Apophysomyces species is shown in Figure 2.…”

Case Report: Gestational Melioidosis through Perinatal Transmission

“…7,8 In the literature, there are few neonatal melioidosis reports. 4,[9][10][11][12] Newborns can be infected through vertical transmission (transplacentally or in the birth canal), during breastfeeding 13 and by postpartum exposure, 6,10,14 especially in cases of contamination of the umbilical cord due to unsterile instruments. 15 In this case, given that the samples collected at birth were negative, we consider that vertical transmission occurred through the birth canal.…”