Apophysomyces elegansas an agent of zygomycosis in a patient following trauma

Abstract

Apophysomyces elegans was isolated from the subcutaneous tissue, muscle and bone of a patient who had fallen from a height of 55 feet. Broad, sparsely septate hyphae were present in the tissue. Surgical debridement of wounds and amphotericin B treatment were not sufficient in controlling rapid tissue necrosis. Ultimately, amputation of the two affected limbs was necessary.Apophysomyces elegans is a member of the order Mucorales, one of two orders of the class Zygomycetes. Other genera comprising the order Mucorales include Rhizopus, Mucor, Absidia, Rhizomucor, Saksenaea, Cunninghamella and Syncephalastrum.Zygomycosis has been associated with metabolic acidosis, immunosuppression and trauma. The major forms of zygomycosis include rhinocerebral, pulmonary, gastrointestinal, central nervous system and cutaneous or wound infections [5]. A. elegans has been reported infrequently in the literature as a causative agent of zygomycosis. We discuss a patient who received severe trauma to the limbs which resulted in an opportunistic A. elegans infection. CASE HISTORYOn 30 January 1989, a 38-year-old Latin American male was painting a water tower in Dallas, Texas without using appropriate safety precautions and fell approximately 55 feet from the structure. His fall to the grass-covered ground resulted in multiple blunt force injuries (open and closed), some of which were contaminated with soil. At the scene, he was awake and alert; however, blood was present in the ears and nares.On admission to Parkland Memorial Hospital, the patient was diagnosed as having humerus, femur, tibia and fibula fractures. Debridement and repair of the fractures were performed and multiple antimicrobial agents, including nystatin, were administered.The patient was ventilator-dependent throughout the course of hospitalization. He remained febrile with spiking temperatures up to 39.9°C and continued to have an elevated white blood cell count which ranged from 11.1-29.4 × 103 cells #1-1. Fungal and bacterial infections developed in several wounds on the right arm and right leg. Amphotericin B was administered to the patient; however, on day 12, amputation of both limbs was necessary in order to control the rapid progression of tissue necrosis.Gross pathology of the tissue at surgery revealed fat necrosis with acute hemor-

Zygomycetes in Human Disease

“…Its distribution in tropical and subtropical climates is further suggested by the occurrence of human infections with this agent. Cases have been confirmed in Texas (207,258,342), Arizona (349,493), Florida (134,494), Illinois (145), Missouri (349), Mississippi (349), Oklahoma (316), India (76,77,85,256,284), Australia (93,415), Venezuela (66), Aruba (295), and Mexico (376).…”

“…Exudates may also be serous, with few inflammatory cells and little necrotic debris seen (316). Cases of cutaneous and subcutaneous A. elegans tend to be locally invasive into adjacent tissues, particularly fat (66,93,207,258,322,493), muscle (66,77,93,207,295,493), nerves (258,322), and bone (134,207,258,295,494). Necrotizing fasciitis (284,288,322,376) and renal and bladder infections with this agent have also been described (85,258,342).…”

“…Traumatic implantation of spores in dirt has been seen in a number of patients (6,9,66,77,93,171,178,207,210,276,280,309,342,350,453). Needlestick exposures have been implicated in zygomycotic infections occurring at the site of medicine injection (77,158,215,361,474), catheter insertion sites (160,234,237,262,332), injection sites for illicit drug use (7,163,189,205,365,401,426,465,476,514), and tattooing (357).…”

“…Infection with A. elegans is predominantly the result of the introduction of spore-containing soil or vegetation into traumatic wounds (6,66,134,207,288,316,322,342,376,493) or burns (93). In the two cases from Australia, the origin of infection was confirmed by culturing A. elegans from soil or dust samples at the site of exposure (93,415).…”

Posaconazole Treatment for Apophysomyces elegans Rhino-Orbital Zygomycosis following Trauma for a Male with Well-Controlled Diabetes

“…Over the last decade, zygomycosis caused by A. elegans has emerged as an important disease affecting immunocompetent hosts (19), especially following trauma (4,6,9). An environmental fungus, Apophysomyces is a member of the fungal class Zygomycetes, order Mucorales.…”