|Year : 2016 | Volume
| Issue : 2 | Page : 85-88
Devastating posttraumatic primary cutaneous mucormycosis in a diabetic patient
Poongodi Lakshmi Santhana Kumarasamy
Department of Microbiology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India
|Date of Web Publication||18-May-2016|
Poongodi Lakshmi Santhana Kumarasamy
Department of Microbiology, Tirunelveli Medical College, Tirunelveli - 627 011, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Mucorales are saprophytic fungi causing mucormycosis, which is a life threatening infection manifested as rhinocerebral, pulmonary, gastrointestinal, cutaneous, and disseminated forms. The cutaneous form is further divided into primary and secondary forms. The major risk factors include uncontrolled diabetes mellitus with or without ketoacidosis, other forms of metabolic acidosis, and trauma. We report here a case of primary cutaneous mucormycosis caused by Rhizopus oryzae, in a diabetic after a road traffic accident.
Keywords: Diabetes, mucormycosis, trauma
|How to cite this article:|
Kumarasamy PL. Devastating posttraumatic primary cutaneous mucormycosis in a diabetic patient. J Sci Soc 2016;43:85-8
| Introduction|| |
Mucormycosis has a growing importance because of the increasing population of immunocompromised patients. It is a devastating infection with high morbidity and mortality rates. It generally refers to infections caused by fungi of the class Zygomycetes that consists of two orders - Mucorales and Entomophthorales and different genera such as Apophysomyces, Rhizopus, Rhizomucor, Absidia, Mucor, Cunninghamella, and Saksenaea. ,
Symptoms range from a skin infection around wounds to systemic multivisceral involvement. Rhizopus oryzae (R. oryzae) is the most common organism isolated from 70% of the patients with mucormycosis. The major risk factors for mucormycosis include uncontrolled diabetes mellitus with or without ketoacidosis, other forms of metabolic acidosis, corticosteroid therapy, organ or bone marrow transplantation, neutropenia, trauma, burns, insect bite, malignant hematologic disorders, malnutrition, prematurity, contaminated adhesive elastoplast dressings, chronic liver or renal failure, HIV, illicit intravenous drug use, and desferroxamine therapy in patients receiving dialysis.  The primary cutaneous form has a better prognosis than the deeply invasive form, but it is still associated with fatality and long-term morbidity if misdiagnosed. We report here a case of primary cutaneous mucormycosis caused by R. oryzae in a diabetic after a road traffic accident.
| Case report|| |
A 41-year-old male was admitted with multiple small injuries on the right foot sustained during a road traffic accident. He was a nonsmoker and nonalcoholic. He was not a known diabetic/hypertensive. He had fever with dyspnea at rest. His right foot was swollen with mild tenderness and right inguinal lymphadenopathy was present - blood pressure (BP): 160/100 mmHg, pulse: 113/min, body temperature: 101 ° F, blood oxygen level (SpO 2 ): 98%. CVS (S1, S2): Heard normally, RS: Normal vesicular breath sound on both sides, abdomen: Soft, no organomegaly.
Laboratory investigations revealed total cell count of 22,320/mm 3 , neutrophils 88.2%, lymphocytes 4%, monocytes 7.5%, eosinophils 0.1%, basophils 0.2%, red blood cell (RBC) count: 5.07 million/mm 3 , hemoglobin level: 16.4 gm/dL, hematocrit (HCT) level 47.4%, mean cell volume (MCV) 93.4 μm 3 , mean corpuscular hemoglobin (MCH) level: 32.3 pg, mean corpuscular hemoglobin concentration (MCHC) 34.6 g/dL, platelet count 5.9 lakhs/mm 3 , mean platelet volume (MPV) 9.3 mm 3 , red blood cell distribution width (RDW) 16.2%, blood sugar 205 mg/dL, urea 32.3 mg/dL, creatinine 1.9 mg/dL, total bilirubin 0.8 mg/dL, direct bilirubin 0.5 mg/dL, indirect bilirubin 0.3 mg/dL, cholesterol 94 mg/dL, pH 7.199, PCO 2 16.2 mmHg, PO 2 87 mmHg, HCO 3 6.2 mmol/L, serum electrolytes - Na + : 134 mEq/L, K + : 3.93 mEq/L, lactate dehydrogenase (LDH) 841.8 U/L; human immunodeficiency virus (HIV) antibodies (anti-HIV), hepatitis B serum antigen (HBsAg), and hepatitis C virus (HCV) antibodies (anti-HCV) were negative. Urine-albumin - trace, sugar - +++, deposit - occasional pus cells/high power field (HPF), protein - 36 mg/dL, creatinine - 20 mg/dL, acetone - negative.
He was diagnosed with recent-onset diabetes, systemic hypertension with mild renal failure probably prerenal due to sepsis with dehydration, severe metabolic acidosis, and compensatory respiratory alkalosis.
He was treated with insulin infusion, linezolid injection, meropenem injection, piperacillin-tazobactam injection, and metronidazole injection. Metabolic acidosis was corrected.
He continued to have fever. His great toe showed gangrenous changes with discoloration and loss of sensation, cellulitis on dorsum of right foot was seen. The skin and soft tissue over the medial aspect of foot was discolored.
Under local anesthesia, right great toe was amputated through base of first metatarsal and the skin and soft tissue till the proximal part of foot was debrided. Pus swab from wound and blood were collected for culture. Insulin, antihypertensive, and the same antibiotics were continued.
The wound showed further rapid progression of necrosis. Pus swab collected from wound revealed no organism on direct gram stain and culture was reported as no growth, however, fungal sepsis was suspected clinically. He was started on liposomal amphotericin B, potassium chloride (KCl) injections, and the same antibiotics were continued.
Patient was clinically stable but sepsis and gangrene were spreading, plantar skin also became gangrenous. Blood culture was reported as no growth.
The patient was advised below knee amputation, but he was not willing for amputation.
Tissues were taken for microbiological examination. Direct grams stain revealed broad, aseptate hyphae [Figure 1].
Fungal culture from tissue-growth revealed the presence of R. oryzae [Figure 2] and [Figure 3], and it was further confirmed by the matrix-assisted laser desorption/ionization (MALDI) system.
Under general anesthesia, below knee amputation was done with circular flap, muscles and soft tissues were approximated, skin was left unsutured, and drain was kept in place.
Oral fluconazole was started in addition to amphotericin B injection.
His general condition improved.
The wound was cleaned and the skin edges at the stump were sutured.
After 2 weeks of treatment, he was discharged in good general condition; however, oral administration of antibiotics, antifungal drug, antidiabetic drug, and antihypertensive was continued and the patient advised for regular follow-up.
| Discussion|| |
Mucorales are saprophytic fungi characterized by broad, aseptate, and thick-walled hyphae found ubiquitous in the environment, particularly in the soil and decaying vegetable matter. Several clinical types have been recognized such as rhinocerebral, pulmonary, gastrointestinal, cutaneous, and disseminated forms. The cutaneous form is further divided into primary and secondary forms. 
Cutaneous disease may be locally invasive and can penetrate fascial compartments leading to invasion of surrounding subcutaneous fat, muscle, and bone.  It can present initially as erythematous papules or pustules but may rapidly evolve into necrotic ulcerations because this angiophilic pathogen often involves early invasion of blood vessels, vascular occlusion, infarction, and ischemia. It may resemble ecthyma gangrenosum. The most lethal form - gangrenous cellulitis - is characterized by central blackened necrotic eschar surrounded by reddish purple soft tissue induration.  In patients with open wounds, it produces a cottony, "bread mold" appearance. Invasion into blood vessels lead to a hematogenous spread and disseminated disease. 
Reduced neutrophil chemotaxis and defective alveolar macrophages in diabetes may allow the germination of spores. Acidosis temporarily disrupts the capacity of transferrin to bind iron in the serum, thereby reducing the fungistatic activity of serum. 
Rapidly progressive mucormycosis can occur even in healthy individuals following trauma. Hence, a high level of clinical suspicion is important in trauma patients, especially in case of open wounds and soft tissue injuries contaminated with soil. 
Definitive diagnosis is hard to establish and it often requires invasive procedures such as tissue biopsy by histology or culture.  Cultures of infected tissues are often negative, when it is positive, identification to species level is time-consuming and requires expertise. Further, no reliable serological or molecular tests are available. A sterile blood culture does not rule out the infection, and waiting for the fungal culture results may delay the institution of appropriate therapy.  The culture of discharge or exudate is not reliable for diagnosis.  False positivity is also common because of contamination at the time of sampling or in the laboratory by ubiquitous environmental spores.
Treatment of cutaneous mucormycosis requires a combined approach. Early and repeated surgical debridement of involved tissue is important and limb amputation is often required to control infection. Liposomal amphotericin B is the most reliable antifungal agent.  Resistance to amphotericin B has been reported. Azoles have no consistent activity against mucormycosis. But, newer azoles, such as posaconazole, are effective.  Hyperbaric oxygen has been used as auxiliary treatment in cutaneous and rhinocerebral forms. Reversing an acidic environment by systemic alkalization as in diabetic ketoacidosis can inhibit the fungal growth. Discontinuation of immunosuppressive agents, if any should also be considered. Immunomodulators may be used to augment host defense. Use of growth factors, such as granulocyte-macrophage colony-stimulating factor, can stimulate the phagocytic activity of neutrophils and proliferation of macrophages. 
This patient survived his injury but was left with a significant disability, losing right limb below knee. With ever-increasing incidents of trauma, more cases of soft tissue mucormycosis are being seen. Despite improvement in diagnostic modalities leading to early diagnoses and increasing therapeutic options, treatment of mucormycosis is still challenging. Hence, a high index of clinical suspicion of fungal infection and early aggressive treatment by a combination of surgery and antifungal therapy will save limbs and lives.
The author thank the treating surgeon for his suggestion and support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]