Necrotizing fasciitis caused by Apophysomyces variabilis in a burn patient

Abstract

The genus Apophysomyces belonging to the order Mucorales is increasingly being reported as a cause of mucormycosis in immunocompetent patients. We report a case of necrotizing fasciitis caused by Apophysomyces variabilis in a 52-year-old immunocompetent male who sustained thermal burn in his right leg following a road-traffic accident. There was rapidly progressive necrosis of skin, soft tissues and underlying muscles which required extensive surgical debridement. Microscopic examination of excised tissues revealed broad aseptate fungal hyphae. Fungal culture on Sabouraud dextrose agar (SDA) showed growth of a mucoraceous mould which was identified as A. variabilis based on characteristic microscopic morphology and internal transcribed spacer sequencing of the ribosomal DNA. The isolate was found to sporulate on SDA, a finding that was unique as Apophysomyces spp. does not usually sporulate on primary isolation medium used in mycology laboratories. The disease progressed as there was an initial assumption of bacterial infection and the fungus was isolated late in the course of the disease because of which no antifungal drug was added to the regime. The patient left against medical advice and eventually underwent below-knee amputation at another city hospital a week later. Infection due to A. variabilis should be considered as a differential diagnosis of rapidly progressive necrosis of skin and soft tissues in immunocompetent individuals as early diagnosis and management will prevent the disease progression and a possible amputation.

Apophysomyces variabilis as an emerging pathogen in Mainland China

“…Unlike other members of the order Mucorales, which most commonly occur in patients who are immunocompromised, poorly controlled diabetes, neutropenic or receiving desferroxamine, infection with A. variabilis frequently occurs in immunocompetent individuals. 20,28 Similar to previous studies, our patient had no underlying disease, therefore, traumatic implantation could be the reason for infection. As A. variabilis tends to invade vessels, cause vascular occlusion and induce ischemic tissue necrosis, our patient's condition deteriorated rapidly and ultimately died in one month.…”

“…26 Infection occurs predominantly by traumatic inoculation from contaminated soil or water. 20 The most common clinical manifestation is necrosis of the skin and subcutaneous soft tissues, 12 which progresses rapidly and has a mortality rate of up to 42%. 27 There are some cases of A. variabilis infection reported in the literature but have not yet been reported from mainland China.…”

“…mainly in India and sporadically in Japan, Australia, Colombia, United States and Saudi Arabia. [13][14][15][16][17][18][19][20][21][22][23][24] However, the disease has not yet been reported in China. Herein, we report the first case of necrotizing fasciitis caused by A. variabilis in an immunocompetent woman in China.…”

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“…Previous studies have shown the antifungal effect of organic extracts derived from plant sources and also has been shown that the effects of phytochemicals may vary depending on the type of solvent used. In accordance with the last, antifungal activity has been reported in polar compounds such as glycosylated flavonoids and saponins isolated from polar extracts 40,41 and in non-polar compounds, like terpenoids 42,43 . In the present study, antifungal activity of leaves of Carica papaya (papaya), Citrus limon (lemon), Psidium guajava (guava) and Acalypha indica (Indian nettle) were investigated by the disc diffusion method.…”

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.…”