Mucormycosis after open fracture injury

Bread mold osteomyelitis in the femur

Rhizopus osteomyelitis is an uncommon and often fatal infection that usually occurs in immunocompromised patients. The infection is commonly referred to as "bread mold." The usual course of treatment is Amphotericin B, debridement, and, if needed, amputation of the affected limb. This article details a rare case of postoperative Rhizopus osteomyelitis in an otherwise healthy patient. The patient originally presented at another institution for anterior cruciate ligament repair after a ski injury. Postoperatively, he developed clinical evidence of infection. He was referred to our institution with stiffness and swelling in the knee as well as weight loss and decreased range of motion. Fluid collection was visible on magnetic resonance imaging. Arthroscentesis was cultured for fungus and bacteria, and the fungal cultures were positive for Rhizopus species. An attempt at limb salvage was made. Debridement, use of a cement spacer loaded with Amphotericin B, systemic antifungal therapy, and 23 hyperbaric oxygen treatments were used to eradicate the disease. Four surgeries were needed to eradicate the disease, and 10 months after initial presentation, the patient had a distal femoral endoprosthesis placed in his leg. Laboratory tests returned to normal and frozen sections were negative for fungus. At 3-year follow-up, the patient reported a musculoskeletal functional score of 50% and had no evidence of recurrent infection.

Novel Use of a Swimming Pool Biocide in the Treatment of a Rare Fungal Mastoiditis

OBJECTIVE

To describe an extremely rare fungal mastoiditis caused by Lecythophora hoffmannii, its recalcitrant behavior to therapy, and eventual successful treatment with adjunctive therapy using polyhexamethylene biguanide (a common swimming pool biocide).

STUDY DESIGN

Case report and review of literature of human Lecythophora hoffmannii infections.

METHODS

Medline database was searched using the keywords Lecythophora and hoffmannii. All articles that described Lecythophora hoffmannii as the cause of human infection at any site were identified. Literature and patient's records were considered for complete data review and extraction.

RESULTS

We present the second known case in the literature of a human infection with Lecythophora hoffmannii. We also present the process to definitively identify and then to successfully eradicate this unusual fungal infection using polyhexamethylene biguanide as adjunctive treatment.

CONCLUSIONS

Successful treatment of a chronic Lecythophora hoffmannii fungal mastoiditis involved a combination of radical surgical removal of all apparent infected tissue along with local treatments with polyhexamethylene biguanide, a common swimming pool biocide agent under the brand name Baquacil (Avecia, Manchester, United Kingdom). Given the prolonged course of treatment, this report particularly stresses the importance of concurrent surgery combined with creative local antimicrobial therapy to eliminate an unusual fungal infection in an immunocompetent host.

Zygomycosis in HIV-positive patients: a review of the literature

The literature on zygomycotic infection in HIV-positive patients is reviewed. A total of 28 patients have been reported. The risk factor for HIV infection was known in 22 of these and was sexual transmission in only six patients and intravenous (i.v.) drug use in 16 (73%). In the latter group, it is likely that i.v. drug injection was the entry route of the zygomycotic infection. The most prevalent clinical presentations of zygomycosis in the i.v. drug-using HIV-positive patients were cerebral, cutaneoarticular and renal (accounting for 88% of presentations in total). These presentations were much less common (18%) in a cohort of 116 patients belonging to the conventional risk groups for zygomycosis (HIV negative and no i.v. drug use). The isolated cerebral localization is the typical presentation of zygomycosis in HIV-negative i.v. drug users.

Survival factors in rhino-orbital-cerebral mucormycosis

Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.

Wound zygomycosis (mucormycosis) in otherwise healthy adults

Two previously healthy men sustained trauma that caused extensive soft tissue damage together with soil contamination. Within three days, rapidly advancing necrosis was observed at the wound margins. Histologic examination revealed the presence of non-septate branching hyphae characteristic of Mucorales within tissues and in the lumen of blood vessels. In one case, the disease was unrecognized until widespread dissemination had taken place, and the patient died; in the other, a cure resulted from aggressive medical and surgical management. Infections due to Mucorales generally occur in immune-compromised hosts. In cases of extensive trauma, inoculation of devitalized tissues with soil may initiate infection by zygomycetes, even in persons whose immunologic status appears to be normal.

Opportunistic zygomycotic infections. A literature review

This is a literature review of 361 opportunistic fungal infections caused by the Zygomycetes. The clinical and laboratory diagnosis, pathogenesis, management, treatment, and outcome of infection are discussed. The Zygomycetes are a group of opportunistic fungi (orders Mucorales and Entomophthorales) which cause severe infections which may be fatal. Early clinical recognition, prompt diagnostic procedures, control of underlying disease and treatment with high doses of amphotericin B and aggressive surgery increases survival in an otherwise lethal infection.