Invasive Fungal Infections Secondary to Traumatic Injury

Abstract

Invasive fungal infection (IFI) is a rare but serious complication of traumatic injury. The purpose of this article is to review the epidemiology, natural history, mycology, risk factors, diagnosis, treatment, and outcomes associated with post-traumatic IFI in military and civilian populations. The epidemiology of post-traumatic IFI is poorly characterized, but incidence appears to be rising. Patients often suffer from severe injuries and require extensive medical interventions. Fungi belonging to the order Mucorales are responsible for most post-traumatic IFI in both civilian and military populations. Risk factors differ between these cohorts but include specific injury patterns and comorbidities. Diagnosis of post-traumatic IFI typically follows positive laboratory results in the appropriate clinical context. The gold standard of treatment is surgical debridement in addition to systemic antifungal therapy. Patients with post-traumatic IFI may be at greater risk of amputation, delays in wound healing, hospital complications, and death as compared to trauma patients who do not develop IFI. More research is needed to understand the factors surrounding the development and management of post-traumatic IFI to reduce the significant morbidity and mortality associated with this disease.

Mould Infections of Traumatic Wounds: A Brief Narrative Review

“…The reported incidence of post-traumatic mould infections among the general population is frequently unseparated from that of other types of mould infections, e.g., approximately 0.43-1.7 cases per million persons have been reported for mucormycosis [4,[15][16][17]. Nonetheless, two important factors should be necessarily considered when interpreting these epidemiological data: (1) owing to the difficulties of diagnosing mould infections outside specific contexts, there could be an underestimation of incidence in the general population [18]; (2) incidence and prevalence of post-traumatic mould infections are undoubtedly higher in specific populations at risk (e.g., soldiers) [4,10]. It is also worth mentioning that an important factor hampering the comparison of incidence and/or prevalence data across different studies, even when conducted in similar populations, is the frequent use of different denominators (e.g., person-time, number of patients, number of patient at risk, number of patients with wound infection) [18].…”

“…Up to 11.7% prevalence of post-traumatic mould infections was observed in injured soldiers admitted to intensive care units [21]. Of note, combat-related injuries, by their nature, involve young people without any other comorbidity and/or immunosuppression and are thus one of the best example of how traumatisms are a key predisposing factor for mould infections (by altering not only mechanical defences, but possibly also by prompting a local/systemic immunosuppressed status) [4,22,23]. Other factors, besides the occurrence of trauma itself, are also likely to increase the risk of wound mould infections in soldiers with injuries.…”

“…Other factors, besides the occurrence of trauma itself, are also likely to increase the risk of wound mould infections in soldiers with injuries. In geographical areas of military operations, temperate climate, dismounted status, blast injuries, above-knee amputations, massive blood transfusion, and use of broad-spectrum antibiotics have all been identified as possible risk factors for the development of mould infections in military personnel [4,9,24,25]. With regard to predisposing environmental conditions, people affected by natural disasters are at increased risk of both injuries and wound contamination [26,27].…”

“…and Fusarium spp. [4,20,24,33]. Reports of post-traumatic mould infections due to Mucorales are also predominant after burn-related trauma and natural disasters, although infections due to other moulds (e.g., Aspergillus spp., Scedosporium spp.)…”

“…Mould infections may also follow traumatic injuries, with direct fungal inoculum in the site of injury and subsequent angioinvasion, possibly resulting in vessel thrombosis and tissue necrosis [4,5]. In this regard, penetrating traumas are a well-known risk factor for mucormycosis, especially amongst soldiers during campaigns war, although mould infections may also be observed in civilians experiencing severe trauma [6][7][8].…”