Mucormycosis due to Apophysomyces species complex- 25 years’ experience at a tertiary care hospital in southern India

Abstract

Apophysomyces elegans species complex is an important cause of cutaneous mucormycosis in India. However, majority of those cases are reported as case reports only. We desired to analyze our patients with Apophysomyces infection reported over 25 years (1992–2017) to understand the epidemiology, management, and outcome of the disease. During the study period 24 cases were reported, and the majority (95.8%) of them presented with necrotizing fasciitis following accidental/surgical/iatrogenic trauma. One patient presented with continuous ambulatory peritoneal dialysis (CAPD) related peritonitis. Healthcare related Apophysomyces infection was noted in 29.2% patients. In addition to trauma, comorbidities were noted in 37.5% patients (type 2diabetes mellitus-6, chronic alcoholism-2, and chronic kidney disease-1). Of the 24 isolates, 11 isolates starting from year 2014 were identified as Apophysomyces variabilis by molecular methods. Majority (95.8%) of the patients were managed surgically with or without amphotericin B deoxycholate therapy, while one patient was treated with amphotericin B deoxycholate alone. Among 24 patients, seven (29.1%) recovered, six (25%) patients could not afford antifungal management and left the hospital against medical advice, and 11 (45.9%) patients died.The present case series highlights that necrotizing fasciitis caused by A. variabilis is prevalent in India, and the disease may be healthcare related. Although diagnosis is not difficult, awareness among surgeons is still limited about the infection, leading to a delay in sending samples to the mycology laboratory. Apophysomyces infection must be considered in the differential diagnosis in apatient with progressive necrosis of a wound who is not responding to antibacterial therapy.

Necrotizing fasciitis caused by Apophysomyces variabilis in a burn patient

“…The patient left against medical advice before specific antifungal therapy could be instituted and eventually underwent below-knee amputation of the right leg at another city hospital a week later. Such devastating outcomes of Apophysomyces infection have also been reported by Pamidimukkala et al [12] and Al-Zaydani et al [23], thereby emphasizing the importance of early diagnosis and aggressive treatment in such cases.…”

“…was the causative agent in 60.5% of the patients with trauma as the underlying risk factor. The clinical presentation in 95.8% of the cases was primarily necrotizing fasciitis that developed within 7–10 days following trauma [12]. Rapid progression of Apophysomyces infection can be explained by angioinvasion and growth of fungus within the vascular lumen leading to thrombus formation and consequent ischemic necrosis [11].…”

“…The infection may also be acquired in healthcare settings (healthcare-associated mucormycosis). In one study, healthcare-related Apophysomyces infection accounted for 29.2% of the mucormycosis cases [12]. Such infections have been attributed to contaminated wound dressings, bandages, medical devices, procedures like intramuscular injection or due to operating room contamination [14,15].…”

Coronavirus Disease 2019–Associated Mucormycosis: Risk Factors and Mechanisms of Disease

“…Construction and renovation may increase airborne fungal spore load. A study from South India reported that 29% of cases due to Apophysomyces species were nosocomial in origin (32). In other studies, nosocomial origin of mucormycosis has been attributed to 9% of reported cases (11).…”

Pathogenesis and Pathology of COVID-Associated Mucormycosis: What Is New and Why

“…The most common etiologic agents are Rhizopus spp., Mucor spp., and Lichtheimia spp., followed by Rhizomucor spp., Cunninghamella spp., Apophysomyces spp., and Saksenaea spp. [ 1 , 9 , 11 ••, 12 •, 13 , 47 ]. In CAM, Rhizopus spp.…”