Severe filamentous fungal infections after widespread tissue damage due to traumatic injury: Six cases and review of the literature

Abstract

We describe 6 cases of severe filamentous fungal infections after widespread tissue damage due to traumatic injury in previously healthy people. Additionally, we report 69 cases from an exhaustive 20-y review of the literature to investigate the epidemiological and clinical features, the prognosis and the therapeutic management of these post-traumatic severe filamentous fungal infections. Traffic (41%) and farm accidents (25%) were the main causes of injury, which involved either the limbs only (41%) or multiple sites (41%). Necrosis was the main symptom (60%) and Mucorales (72%) and Aspergillus (11%) were the 2 most frequent fungi causing infection. These infections required substantial surgical debridement or amputation (96%) associated with aggressive antifungal therapy (81%), depending on the responsible fungi. This study underlines the need for early, repeated and systematic mycological wound samples to guide and adapt surgical and antifungal management in these filamentous fungal infections.

Risk Factors Associated with Invasive Fungal Infections in Combat Trauma

“…observed in earlier case investigations of combat casualties who ultimately developed IFI [9][10][11][12][14][15][16]. Trauma-associated IFI cases within civilian populations are associated primarily with traffic or agricultural accidents and natural disasters [2,3,[6][7][8] and are characterized generally by penetrating wounds contaminated with environmental debris. An analysis of 75 patients diagnosed with IFI following a traumatic injury sustained during a traffic accident, agricultural accident, or natural disaster, reported that 100% of the cases occurred in a soil environment.…”

“…Delays may result from the lag time between the collection of specimens for culture and histopathologic analysis and receipt of results, a lack of understanding of risk factors for developing IFI, or slow recognition of an uncommon disease that can present similarly to other types of wound infections. Early diagnosis and prompt surgical and medical treatment are crucial components for favorable patient outcomes [3,6,7,10]. Although some clinicians have suggested prescribing antifungals at the first indication of a suspected IFI, others are hesitant without culture or histopathological IFI confirmation because of the potential hepatic and nephrotoxicity of the antifungal agents [13].…”

“…L ocally invasive fungal infections (IFI) are an insidious complication related to trauma characterized by high morbidity and mortality rates ranging from 11 to 38% [1][2][3][4][5][6][7][8]. Recently, combat trauma-associated IFI has emerged as a serious military health concern [9][10][11][12].…”

Saksenaea erythrospora Infection following Combat Trauma

“…Human infection with this mucoraceous mold is typically seen after trauma, including burns, and is associated with contamination with soil (4,5,7,9,10,11). Severe infection following penetrating trauma with contamination with soil is commonly associated with members of (5,11). Soft-tissue infection is the most common manifestation of mucormycosis due to Saksenaea, and the majority of patients have been previously healthy and without preexisting immune compromise (5,8).…”

“…S. vasiformis has been recovered from soil and diseased humans and animals. Human infection with this mucoraceous mold is typically seen after trauma, including burns, and is associated with contamination with soil (4,5,7,9,10,11). Severe infection following penetrating trauma with contamination with soil is commonly associated with members of (5,11).…”