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Krishingner GA, Forouzandeh M, Rodríguez JA, Ashouri K, Motaparthi K, Whiles BB. Successful Management of Angioinvasive Deep Fungal Infections of the Penis: A Multidisciplinary Approach with Intraoperative Frozen Margins. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e939971. [PMID: 37782653 PMCID: PMC10556538 DOI: 10.12659/ajcr.939971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/16/2023] [Accepted: 06/15/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Mucormycosis, a cause of opportunistic infections in immunocompromised patients, is rarely identified in the penis. The literature often describes drastic surgical interventions or rapid patient demise, with scant mention of surgical management specifics. The objective of this report is to detail our experience with this unique infection and highlight the utility of intraoperative frozen margins during surgical management. CASE REPORT Herein, we describe successful treatment of a 55-year-old man with biopsy-proven B-cell acute lymphoblastic leukemia (B-ALL) undergoing Hyper-CVAD (Cyclophosphamide, Vincristine, Adriamycin, and Dexamethasone) therapy who initially presented with an asymptomatic violaceous lesion of the penis. Differential diagnoses ranged from infectious, vasculogenic, and pharmacologic in nature. Ultimately, a punch biopsy tissue culture confirmed angioinvasive fungal infection with Rhizopus and Fusarium species. Initial debridement combined with intravenous antifungal therapy was unsuccessful. However, partial penectomy with use of intraoperative frozen margins, a 5-week course of antifungal therapy, and continued B-ALL treatment allowed effective and lasting resolution of the infection, with partial penile preservation. CONCLUSIONS This case supports a multidisciplinary approach as the primary treatment for penile angioinvasive fungal infections. This includes treatment of the underlying immunocompromising condition, appropriate intravenous antifungal therapy, and urgent operative debridement. This report highlights the importance of utilizing intraoperative frozen sections to ensure negative margins and to optimize overall tissue sparing in this anatomically sensitive area.
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Affiliation(s)
| | | | - José A. Rodríguez
- Department of Infectious Disease, University of Florida, Gainesville, FL, USA
| | - Kenan Ashouri
- Department of Urology, University of Florida, Gainesville, FL, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida, Gainesville, FL, USA
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Breakthrough Penile Mucormycosis in a Patient With Acute Myelogenous Leukemia on Posaconazole Prophylaxis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Creta M, Sica A, Napolitano L, Celentano G, La Rocca R, Capece M, Calogero A, Califano G, Vanni L, Mangiapia F, Arcaniolo D, Spirito L, Fusco F, De Sio M, Imbimbo C, Mirone V, Sagnelli C, Longo N. Fournier's Gangrene in Patients with Oncohematological Diseases: A Systematic Review of Published Cases. Healthcare (Basel) 2021; 9:healthcare9091123. [PMID: 34574898 PMCID: PMC8469850 DOI: 10.3390/healthcare9091123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Patients suffering from hematological malignancies are at increased risk of Fournier's gangrene (FG) due to immunosuppression caused by the disease itself or by disease-related treatments. A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in June 2021. We included full papers that met the following criteria: original research, human studies, and describing clinical presentation, treatment, and outcomes of FG in patients with oncohematological diseases. We identified 35 papers published from 1983 to 2021 involving 44 patients (34 males, 8 females) aged between 4 days and 83 years. The most common malignant hematological disorders were acute myeloid leukemia (n = 21) and acute lymphocytic leukemia (n = 9). In 10 patients FG represented the first presentation of hematological malignancy. Scrotum (n= 27) and perineum (n = 11) were the sites most commonly involved. Pseudomonas aeruginosa (n = 21) and Escherichia coli (n = 6) were the most commonly isolated microorganisms. Surgery was performed in 39 patients. Vacuum-assisted closure and hyperbaric oxygen therapy were adopted in 4 and in 3 patients, respectively. Recovery was achieved in 30 patients. FG-related mortality was observed in 11 patients. FG should be carefully considered in patients with oncohematological diseases.
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Affiliation(s)
- Massimiliano Creta
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
- Correspondence: ; Tel./Fax: +39-081-7462-611
| | - Antonello Sica
- Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80123 Naples, Italy;
| | - Luigi Napolitano
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Giuseppe Celentano
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Roberto La Rocca
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Marco Capece
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Armando Calogero
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80130 Naples, Italy;
| | - Gianluigi Califano
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Luigi Vanni
- Department of Public Health, University of Naples Federico II, 80130 Naples, Italy;
| | - Francesco Mangiapia
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Davide Arcaniolo
- Department of Woman, Child and General and Specialized Surgery, Urology Unit, University of Campania Luigi Vanvitelli, 81100 Naples, Italy; (D.A.); (F.F.); (M.D.S.)
| | - Lorenzo Spirito
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Ferdinando Fusco
- Department of Woman, Child and General and Specialized Surgery, Urology Unit, University of Campania Luigi Vanvitelli, 81100 Naples, Italy; (D.A.); (F.F.); (M.D.S.)
| | - Marco De Sio
- Department of Woman, Child and General and Specialized Surgery, Urology Unit, University of Campania Luigi Vanvitelli, 81100 Naples, Italy; (D.A.); (F.F.); (M.D.S.)
| | - Ciro Imbimbo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Vincenzo Mirone
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy;
| | - Nicola Longo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80130 Naples, Italy; (L.N.); (G.C.); (R.L.R.); (M.C.); (G.C.); (F.M.); (L.S.); (C.I.); (V.M.); (N.L.)
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Auerbach J, Bornstein K, Ramzy M, Cabrera J, Montrief T, Long B. Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives. Open Access Emerg Med 2020; 12:353-364. [PMID: 33204184 PMCID: PMC7665443 DOI: 10.2147/oaem.s238699] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.
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Affiliation(s)
- Jonathan Auerbach
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kasha Bornstein
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mark Ramzy
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jorge Cabrera
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA
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Bezzant M, Lago K, Calvano T. Case report of penile Rhizopus arrhizus infection in an unexpected patient. Med Mycol Case Rep 2019; 26:16-18. [PMID: 31667053 PMCID: PMC6812002 DOI: 10.1016/j.mmcr.2019.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/30/2022] Open
Abstract
There are few reports of penile mucormycosis and even fewer in the absence of overt immune suppression. An eighty year old male with diabetes presents with penile mass. The pathology and culture demonstrated Rhizopus arrhizus. He was treated with surgery and liposomal amphotericin B. His therapy was stopped after pathology demonstrated clear surgical margins. His good outcome provides evidence that stopping antifungal therapy after achieving clear surgical margins is acceptable in patients without ongoing immunosuppression.
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Affiliation(s)
- Matthew Bezzant
- Internal Medicine Service, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Kathryn Lago
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Tatjana Calvano
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
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Yacoub A, Soni KK, Mojica L, Mai J, Morano J, Cruse CW, Sandin RL, Nanjappa S, Bohra C, Gajanan G, Greene JN. Primary Gangrenous Cutaneous Mold Infections in a Patient With Cancer and Neutropenia. Cancer Control 2017; 23:265-71. [PMID: 27556666 DOI: 10.1177/107327481602300309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Opportunistic fungal infections caused by Aspergillus and Candida followed by infections with Fusarium, Rhizopus, Mucor, and Alternaria species are an important cause of morbidity and mortality in patients with hematological malignancies. Cutaneous mucormycosis infections are rare, and the incidence, outcomes, and factors associated with survival in the setting of hematological malignancies are not clear. METHODS A literature search was conducted for all cases of primary cutaneous mold infections in patients with hematological malignancy, of which 50 cases were found. Our case of a patient with a hematological malignancy who sustained a cat bite that in turn caused a primary cutaneous mold infection is also included. RESULTS In the 51 cases identified, 66.7% were neutropenic upon presentation, and 54.9% were male with an average age of 32 years. Aspergillus species (33.3%) was the most cited followed by Rhizopus species (19.6%). Overall mortality rate was 29.4% and was observed more frequently in patients with neutropenia (60.0%) and without surgical intervention (73.3%). Survival rate was higher (35.3%) for cases utilizing both antifungal and surgical intervention. The antifungal agent with the highest survival rate was amphotericin B and its formulations (58.8%). CONCLUSIONS Neutropenia within hematological malignancies demonstrate a risk for developing severe cutaneous fungal infections, of which primary cutaneous mucormycosis can carry significant mortality. Combination antifungal therapy and surgical debridement appears to be associated with higher survival outcomes and warrants further investigation.
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Affiliation(s)
- Abraham Yacoub
- Department of Infectious Diseases and Tropical Medicine, Moffitt Cancer Center, Tampa, FL 33612, USA.
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Successful Treatment of Cutaneous Mucormycosis in a Leukemic Patient. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2015. [DOI: 10.1097/ipc.0000000000000227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Perkins TA, Bieniek JM, Sumfest JM. Solitary Candida albicans Infection Causing Fournier Gangrene and Review of Fungal Etiologies. Rev Urol 2014; 16:95-98. [PMID: 25009452 PMCID: PMC4080857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Polymicrobial bacterial infections are commonly found in cases of Fournier gangrene (FG), although fungal growth may occur occasionally. Solitary fungal organisms causing FG have rarely been reported. The authors describe a case of an elderly man with a history of diabetes who presented with a necrotizing scrotal and perineal soft tissue infection. He underwent emergent surgical debridement with findings of diffuse urethral stricture disease and urinary extravasation requiring suprapubic tube placement. Candida albicans was found to be the single causative organism on culture, and the patient recovered well following antifungal treatment. Fungal infections should be considered as rare causes of necrotizing fasciitis and antifungal treatment considered in at-risk immunodeficient individuals.
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D’Arena G, Pietrantuono G, Buccino E, Pacifico G, Musto P. Fournier's Gangrene Complicating Hematologic Malignancies: a Case Report and Review of Licterature. Mediterr J Hematol Infect Dis 2013; 5:e2013067. [PMID: 24363882 PMCID: PMC3867231 DOI: 10.4084/mjhid.2013.067] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 10/08/2013] [Indexed: 12/11/2022] Open
Abstract
Fournier's gangrene (FG) is a rare but severe necrotizing fasciitis of the external genitalia that may complicate the clinical course of hematologic malignancies and sometimes may be the first sign of the disease. The clinical course of FG is very aggressive and the mortality is still high despite the improvement in its management. Early recognition of FG and prompt appropriate treatment with surgical debridement and administration of antibiotics are the cornerstone of the management of this very severe disease. A review of the scientific literature focusing on the topic of FG complicating hematologic disorders is reported.
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Affiliation(s)
- Giovanni D’Arena
- Onco-Hematology and Stem Cell Transplantation Unit, IRCCS “Centro di Riferimento Oncologico della Basilicata”, Rionero in Vulture (Pz), Italy
| | - Giuseppe Pietrantuono
- Onco-Hematology and Stem Cell Transplantation Unit, IRCCS “Centro di Riferimento Oncologico della Basilicata”, Rionero in Vulture (Pz), Italy
| | - Emilio Buccino
- Surgical Department, “S. Giovanni di Dio” Hospital, Melfi (Pz), Italy
| | | | - Pellegrino Musto
- Scientific Direction, IRCCS “Centro di Riferimento Oncologico della Basilicata”, Rionero in Vulture (Pz), Italy
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Ye B, Yu D, Zhang X, Shao K, Chen D, Wu D, Zhang Y, Zhou Y, Shen Y, Yu Q. Disseminated Rhizopus microsporus infection following allogeneic hematopoietic stem cell transplantation in a child with severe aplastic anemia. Transpl Infect Dis 2013; 15:E216-23. [PMID: 24119033 DOI: 10.1111/tid.12144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/31/2013] [Accepted: 07/05/2013] [Indexed: 11/30/2022]
Abstract
Disseminated Rhizopus microsporus infections are uncommon in children and are resistant to echinocandin and azole antifungal agents. We describe a child with severe aplastic anemia who developed disseminated R. microsporus infection following allogeneic hematopoietic stem cell transplantation. R. microsporus was identified microscopically in the hepatic drain culture and was confirmed on the basis of 18S rRNA and 28S rRNA sequence analyses. The patient was treated successfully with hepatic drainage and amphotericin B deoxycholate.
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Affiliation(s)
- B Ye
- Department of Hematology, The First Affiliated Hospital, Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
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Cutaneous Mucormycosis in a Diabetic Patient following Traditional Dressing. Case Rep Dermatol Med 2013; 2013:894927. [PMID: 23991340 PMCID: PMC3749590 DOI: 10.1155/2013/894927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 07/06/2013] [Indexed: 11/22/2022] Open
Abstract
Cutaneous mucormycosis is a rare manifestation of an aggressive fungal infection. Early diagnosis and treatment are vitally important in improving outcome. We report an unusual case presenting with progressive necrotizing fasciitis due to mucormycosis following trauma and dressing by man-made herbal agents.
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