Posttraumatic Mucormycosis

Abstract

Data on clinical, mycologic characteristics, and outcome of posttraumatic mucormycosis are scarce and often limited to case reports. From the French nationwide “RetroZygo” study, we compared posttraumatic mucormycosis cases with other forms of mucormycosis. We also reviewed reports of posttraumatic mucormycosis in the English-language literature from 1993 to 2013. We included all proven or probable cases for which underlying condition, route of infection, surgical and antifungal treatments, and outcome were detailed. From our cohort, posttraumatic mucormycosis (n = 16) differed significantly from other forms (n = 85) by rarity of underlying disease (31.2% vs 81%, p < 0.0001), frequency of cutaneous localization (87% vs 7%, p < 0.0001), short time before diagnosis (4.5 vs 21 d, p = 0.0002), species involved (Apophysomyces elegans complex and Saksenaea vasiformis), surgical requirement (93.7% vs 47%, p = 0.0006) and better survival (87.5% vs 47.6% at day 90, p = 0.03). We studied 122 cases of posttraumatic mucormycosis through our literature review. Most frequently reported traumas were traffic (37%), domestic accidents (15.1%), or natural disasters (13.4%). Mucormycosis occurred after extensive soft-tissue damage in 47.5% cases, with symptoms occurring a median of 9.5 days after trauma with necrosis being reported in 76.2% cases. Dissemination was found in 9% of patients, and bacterial coinfection in 41%. Nineteen percent of cases occurred in the Middle East or in India where Apophysomyces elegans complex was the predominant species recovered. Awareness of mucormycosis as a cause of posttrauma soft-tissue infection is warranted, especially in cases of soil-contaminated wounds. Survival is higher than in other forms of mucormycosis, but morbidity remains high.

Invasive Fungal Infections Secondary to Traumatic Injury

“…Demographically, IFI occurs over a wide range of ages, with the mean age in civilian trauma patients between 27 and 48 years (Table 1) (Neblett Fanfair et al, 2012;Fares et al, 2013;Moran et al, 2006a;Lelievre et al, 2014). This age distribution is roughly comparable to that of the general trauma population and reflects occupational age patterns (Heim et al, 2014;Alghnam et al, 2014;Allen et al, 2015).…”

“…Estimating temporal incidence trends is similarly challenging, and data is only available for post-traumatic mucormycosis, of which the frequency of published case reports has increased significantly between 1993 and 2013 (Lelievre et al, 2014). In an analysis of all-cause mucormycosis rates in French hospitals, overall IFI incidence, but not IFI in immunocompetent patients, increased between 1997 and 2006, suggesting that the rising incidence of post-traumatic mucormycosis may be attributed to an increasing proportion of immunocompromised individuals within this population.…”

“…In an analysis of all-cause mucormycosis rates in French hospitals, overall IFI incidence, but not IFI in immunocompetent patients, increased between 1997 and 2006, suggesting that the rising incidence of post-traumatic mucormycosis may be attributed to an increasing proportion of immunocompromised individuals within this population. Indeed, up to 25% of patients with post-traumatic IFI may be immunocompromised to some extent (Skiada et al, 2011;Lelievre et al, 2014).…”

Successful Treatment of Saksenaea sp. Osteomyelitis by Conservative Surgery and Intradiaphyseal Incorporation of Amphotericin B Cement Beads

“…M ucorales osteomyelitis still presents diagnostic and therapeutic challenges and is associated with high mortality rates despite a combined therapeutic strategy involving antifungal treatment and surgery (1). Members of the order Mucorales are present in soil and plant debris and could be responsible for osteoarticular mucormycosis as a consequence of contamination through disrupted cutaneous barriers after traumatic injury (2). Surgical management is classically aggressive and complicated, with poor functional outcomes or even amputation.…”

“…The phylogenetic analysis, which was based on the DNA sequences of three genes (internal transcribed spacer [ITS], large subunit [LSU], and translation elongation factor 1-alpha [TEF1-␣] genes) from the patient's strain, suggested evidence of the existence of a cryptic species in the genus Saksenaea. Human infections caused by Saksenaea species represent only 2% of reported mucormycosis cases and 9% of posttraumatic mucormycosis cases, behind other species such as Absidia, Apophysomyces, Rhizopus, and Mucor species (2,(7)(8)(9). However, this apparent low incidence may be partly explained by culture failure in routine mycological media, as this fungus needs nutritionally deficient medium or Czapek-Dox agar medium to sporulate (9).…”