Zygomycotic infection of the neonatal upper extremity

Deep Fungal Infections of the Upper Extremity - A Review

Deep fungal infections are rare in the upper extremity. Vessel and nerve infection, synovitis, tenosynovitis, myofasciitis, arthritis and osteomyelitis have been discovered in literature. Treatment in most cases includes surgical procedure and antifungal agent use. Amputation is the final, most devastating for patient's functionality, solution. Intravenous antifungal drugs, frequently followed by oral administration, are important ancillary agents both for the initial treatment and the prevention of recurrence. We therefore performed a review of the current literature, in order to assemble the dispersed results of different studies and clarify the various aspects of upper extremity fungal infections.

Necrotizing fasciitis in neonates: A case report and review of literature

Early recognition and treatment of necrotizing fasciitis reduce mortality rate which is 24.1% among neonates. Antibiotics and debridement are common treatments. Hyperbaric oxygen and negative pressure wound healing show potential but need further investigation.

Gangrenous Necrotizing Cutaneous Mucormycosis in an Immunocompetent Neonate: A Case Report from Oman

We describe a case of progressive cutaneous mucormycosis, which caused gangrenous necrotizing fasciitis, in an immunocompetent neonate from Oman. Extensive wound contamination and a favorable environment for the growth of Mucorales were the predisposing factors. Early aggressive management including frequent wound debridement, targeted pharmacotherapy with liposomal amphotericin B and supportive care is pivotal for improved outcomes.

Zygomycosis in neonates: an uncommon but life-threatening infection

We systematically reviewed all published cases of zygomycosis, an increasingly important infection with high mortality, in neonates. We searched PubMed and individual references for English publications of single cases or case series of neonatal (0 to 1 month) zygomycosis. Cases were included if they fulfilled prespecified criteria. Fifty-nine cases were published through July 2007. Most of the infants (77%) were premature. The most common sites of zygomycosis were gastrointestinal (54%) and cutaneous (36%) diseases. This pattern differs from sinopulmonary and rhinocerebral patterns of older children. Fifty-six percent of cases were diagnosed by histology only and 44% by histology and culture. RHIZOPUS spp. were isolated from 18/25 (72%) cases. Thirty-seven percent of patients received no antifungal therapy. Thirty-two (54%) neonates underwent surgery with (39%) or without (15%) antifungal agents. Overall mortality was 64%. A higher fraction of neonates treated with amphotericin B and surgery survived than those who received no therapy (70% versus 5%). Zygomycosis is a life-threatening infection in neonates with a distinct pattern of gastrointestinal and cutaneous involvement and high mortality. Combination of amphotericin B and surgery was common management strategy in survivors.

Neonatal cutaneous fungal infections

PURPOSE OF REVIEW

Cutaneous fungal infections are not uncommon in newborns and are seen in premature or otherwise immunocompromised neonates as well as in healthy full-term neonates. Healthy newborns can develop clinical manifestations as a result of infection with Candida species or as a result of skin colonization with Malassezia species; cutaneous infection with other fungal pathogens is rare. Immunocompromised and premature neonates, however, are susceptible to infection with opportunistic pathogens and are also at higher risk for invasive infection with common pathogens such as Candida. This review discusses the fungal species associated with cutaneous fungal infection in neonates, emphasizes the relevant clinical features, and also reviews the use of newer antifungal agents, including lipid-associated amphotericin B, voriconazole, and caspofungin.

RECENT FINDINGS

Neonatal cutaneous infections with opportunistic fungal pathogens, including Aspergillus and the Zygomycetes, have been reported with increasing frequency as advances in neonatal care have improved the survival rate in very low birthweight neonates. Although these infections are frequently fatal, survival in some neonates has been reported with the use of aggressive surgical debridement and systemic antifungal therapy. Newer antifungal agents, including voriconazole and caspofungin, show promise in the treatment of potentially fatal fungal infections in neonates.

SUMMARY

Cutaneous fungal infections in neonates range from generally benign conditions such as congenital candidiasis and neonatal cephalic pustulosis to potentially fatal infections with opportunistic pathogens in very low birthweight or immunocompromised neonates. The prompt recognition and appropriate treatment of cutaneous fungal disease in neonates is critical to the prevention of adverse outcomes.

Life-threatening cutaneous conditions in neonates

One of the major medical concerns in neonates is their vulnerability to life-threatening complications. Early diagnosis of potentially serious medical conditions is essential in prevention of such complication by prompt administration of appropriate treatments. Recognition of cutaneous manifestations of potentially fatal diseases may assist a clinician in management of newborns. To overview the full spectrum of this category of conditions, Medline search was performed for cases of cutaneous manifestations associated with mortality during the first month of live that were published in the English language literature since 1977. This is a concise review of the clinical aspects of most of the potentially life-threatening disorders in neonates divided by basic morphology of their cutaneous manifestations.

Fungal infection in the very low birthweight infant

PURPOSE OF REVIEW

Fungal infections are prevalent in very low birthweight (<1500 g) infants and are associated with significant morbidity and mortality. A better understanding of the adherence factors, molecular diagnostics and risk factors for invasive fungal infection are important in treatment and prevention.

RECENT FINDINGS

Animal studies have demonstrated that Candida readily adheres to apical microvilli and the junctions between enterocytes. Although antibiotics facilitate colonization, dissemination occurs with immunosuppression. The INT1 gene is associated with enhanced colonization and dissemination in these animal models. Dissemination is probably caused by yeast cell adherence and invasion, whereas tissue injury may be related to filamentous formation. Polymerase chain reaction techniques have demonstrated promise in neonatal patients and may not only detect bloodstream infection, but fungal infection at other sites. At the time of fungal sepsis, less than 28 weeks' gestation, thrombocytopenia, and previous exposure to broad-spectrum antibiotics continue to be risk factors for infection. Empiric therapy is still being defined and investigated. Fluconazole prophylaxis should be strongly considered in the most immature infants.

SUMMARY

Preventative strategies against fungal colonization and infection are critical in high-risk very low birthweight infants. Also promising is the ability of molecular diagnostics to detect infection earlier, allowing for prompt treatment, including central venous catheter removal. Identifying the highest risk very low birthweight infants for prophylaxis and empiric therapy may lead to better outcomes. Multicenter clinical trials of fluconazole prophylaxis to confirm its safety and efficacy, and of empiric treatment to test safety and outcomes are urgently needed.