Favorable outcome of amphotericin B treatment of zygomycotic necrotizing fascitis caused by Apophysomyces elegans

Abstract

A 45‐year‐old man was referred from a primary health care center to our hospital in November 2005 with features of necrotizing fascitis of the right shoulder and upper back. He had been admitted to the previous hospital following an injury, sustained in an accident, while driving a tractor. He was treated for fracture of the right clavicle followed by wound debridement of the right shoulder at the health center. Examination of the wound in our hospital revealed a large, 15 × 15 cm, raw area over the upper back, extending to the right upper arm and shoulder. The wound was grossly infected with slough and purulent discharge. The margin of the wound was indurated. No other abnormality was detected on general examination, except for the fracture of the clavicle. Laboratory investigation revealed a hemoglobin level of 7.5 g/dL and a total leukocyte count of 19,600/mm3, with a differential count of 82% polymorphs, 16% lymphocytes, and 2% eosinophils. The blood glucose was 80 mg%, blood urea 36 mg/dL, and serum creatinine 0.9 mg/dL. Culture of a sample of tissue from the wound yielded a mixture of Escherichia coli, which was sensitive to imipenem, cefoperazone/sulbactam, and amikacin, and resistant to ampicillin, gentamicin, cefazolin, cefotaxime, ticarcillin, ofloxacin, amoxyclavulanic acid, and ciprofloxacin, together with a multidrug‐resistant Pseudomonas aeruginosa, which was sensitive to imipenem only. As the patient had features of impending septicemia, he was managed with daily cleaning of the wound, with intravenous imipenem 500 mg eight hourly. Seven days later, the wound showed pockets of white cheesy material extruding out as strands. Microscopic examination of scrapings from this cheesy material showed broad aseptate hyphae suggestive of a zygomycete (Fig. 1). A culture of the tissue on Sabouraud's dextrose agar (SDA) yielded a white fluffy growth after 48 h of incubation at both 25 °C and 37 °C (Fig. 2a). The microscopic morphology of the fungus stained with lactophenol cotton blue revealed broad, ribbon‐like, aseptate hyphae. Sporulation was very poor on the routine SDA medium. Stimulation of sporulation was attempted on 1% water agar.1 After 1 week of incubation, sporulation occurred, and microscopy revealed a sporangiophore measuring around 200–300 µm in length, arising at right angles with a septate basal segment, or foot cell, as it is called. The sporangia were multispored, small (20–50 µm in diameter), typically pyriform in shape, and with hemispherical columellae. The apophysis was funnel shaped (Fig. 2b). The fungus was identified as A. elegans on the basis of these characteristic features. 1 Photomicrograph of 10% KOH mount showing broad aseptate hyphae together with tissue debris (magnification, ×400) 2 (a) Sabouraud's dextrose agar plate showing gray–white cottony growth completely filling the Petri dish. (b) Photomicrograph of lactophenol cotton blue mount showing funnel‐shaped apophyses with broad aseptate hyphae and thickened foot cell (magnification, ×400) After confirmation of the ...

Cutaneous zygomycosis

“…[2] included 176 cases (19%) of cutaneous zygomycosis. We searched PubMed for case reports of cutaneous zygomycosis published from 2004 through 2008 in English, selecting only articles describing cases in which the diagnosis had been confirmed by histology and/or culture, and identified 78 cases [3–65]. The large number of publications in recent years may reflect the greater awareness in the part of physicians of this infection, as well as publication bias, but there are also data which support an actual increase in the incidence of zygomycosis, mainly in patients with haematological malignancies [66].…”

“…Trauma in general is a major cause of zygomycosis, especially in immunocompetent patients. Besides the previously mentioned minor traumas, road traffic accidents [23,24,31,38,39] or crush injuries (by agricultural machines) [29] can lead to traumatic implantation of soil and subsequent zygomycosis. Zygomycosis has also been reported to occur as a result of injury in a natural disaster, such as the tsunami that struck Southeast Asia in 2004 [48] or the volcanic eruption which wiped out the town of Armero, Colombia in 1985 [71].…”

“…Any area of the skin can be affected by zygomycosis. Although the upper and lower extremities are more often involved, there have been reports of cutaneous zygomycosis of the scalp [28,70], face [6,7,17,27], breast [18], thorax [37], back [23], abdomen [22,36], gluteal area [47] and perineum [42].…”

Changing epidemiology of an emerging infection: zygomycosis

“…A few years later, this pathogen was found in a clinical case with a trauma injury and was also cultured from environmental samples [16]. Infections with Apophysomyces are mostly acquired in tropical and subtropical areas, and cases have been described from several states in the USA (Texas [17–21], Arizona [22–25], Florida [26,27], Mississippi [28], Oklahoma [29], Georgia [30] Minnesota [31], Alabama [32], South Carolina [33]), different regions in India [34–45], Venezuela [46], Colombia [47], Mexico [20,48], Australia [16], Saudi Arabia [49], and Kuwait [50]. A case described from The Netherlands was linked to a subtropical source in the Caribbean [51].…”

The Rise of an oppurtunistic infection called "Invasive zygomycosis"

“…[84] It usually carries a better prognosis than other forms of mucormycosis until the fungal reaches deeper into muscle, bone or fascia where it causes severe necrosis; the mortality rate then becomes very high. [85]…”