Primary Cutaneous Mucormycosis in a Trauma Patient with Morel-Lavallée Lesion.

Mucormycosis is an aggressive fungal infection caused by zygomycetes from the order of Mucorales. Immunocompromised patients or patients with comorbidities are susceptible to this infection. There are many forms of mucormycosis such as rhino-orbito-cerebral, cutaneous, gastrointestinal, and pulmonary. Cutaneous mucormycosis is rare in trauma patients with no comorbidities. Morel-Lavallée lesions are rare degloving injuries in trauma patients. We report a case of cutaneous mucormycosis in a trauma patient with the Morel-Lavallée lesions.

INTRODUCTION

Mucormycosis is an aggressive fungal infection caused by zygomycetes.[12] Immunosuppression or coexistence of multiple comorbidities such as diabetes mellitus, renal or hepatic dysfunction, deferoxamine therapy, chemotherapy, hematological malignancies, long-term steroids therapy, infectious diseases, such as HIV, tuberculosis, and extensive burns., increase susceptibility to this infection.[3456] Cutaneous mucormycosis is rare in trauma patients, and the clinical spectrum varies from mild chronic infection to severe multisystem involvement. The Morel-Lavallée lesions are rare post-traumatic degloving injuries deep to the subcutaneous plane and contain hemolymph and necrotic fat. We report a case of cutaneous mucormycosis in a young female with polytrauma secondary to extensive necrosis of Morel-Lavallée lesions.

CASE REPORT

A 22-year-old female patient was referred to our trauma center after a few days of admission in a private hospital following a railway accident. Surgical procedures performed during admission in the private hospital were a below-knee amputation and interlocking nail in the bilateral femur. She was being managed conservatively for open book pelvic bone fracture and extensive Morel-Lavallée lesions over the left flank. The patient was conscious and oriented with stable hemodynamic parameters on arrival to the trauma center; heart rate of 90/min, blood pressure of 110/70 mm Hg, and respiratory rate of 20/min. During her hospitalization despite regular dressing and the use of iv antibiotics injection meropenem and injection vancomycin, she developed features of sepsis.[7] Surgical debridement of the Morel-Lavallée lesion was planned on day 5 of admission under general anesthesia. The extensive necrotic area extending from left 12th rib to left thigh was debrided which left the pelvic bone exposed [Figure 1]. Intraoperatively, the patient developed hypotension and required inotropic support. The patient was shifted to the Intensive Care Unit (ICU) where she was managed for persistent hypotension requiring higher inotropic support, high-grade fever (41°C), and rising total leukocyte count (30,000/ml). On the postoperative day 3, black foul smelling necrotic areas were seen on the surface of the wound over the left flank with cottony bread mold lesions on the edges of the lesion. Immediate surgical debridement was planned. Intraoperative finding included extensive muscle necrosis in areas where peritoneum was breached, and bowel was exposed [Figure 2]. Tissue for fungal culture and sensitivity was sent. Histopathological examination showed the presence of nonseptate irregular hyphae of class zygomycetes. A provisional diagnosis of mucormycosis was made, and liposomal amphotericin B (5mg/kg) was immediately started for fungal sepsis. Later, the fungal culture grew strains of Rhizopus oryzae, thus confirming the presence of invasive mucormycosis. However, the patient died on day 6 of ICU admission of severe septic shock.

Figure 1

Intra-operative photograph of the left flank showing granulation tissue over the abdominal muscles following surgical debridement on the Iintensive Care Unit day 1

Figure 2

Intra-operative photograph of the left flank showing extensive gangrenous necrosis, exposed peritoneum, and colonies of mucormycosis on the Intensive Care Unit day 3

DISCUSSION

Cutaneous mucormycosis has been rarely documented in trauma patients and members of genus Rhizopus are most commonly implicated.[8] Contamination of the traumatized tissue with soil is the most likely mode of entry of Rhizopus. In open wounds, it has a cottony, bread mold appearance.[89] The most fatal form is phycomycotic gangrenous cellulitis which characteristically appears as a central blackened necrotic eschar surrounded by reddish-purple soft-tissue induration.[10]

Diagnosis of cutaneous mucormycosis is made by culture or biopsy. A potassium hydroxide preparation of the biopsy reveals nonseptate, thick-walled hyphae with right angle branching. Hyphae can also be seen on tissue sections on hematoxylin-eosin and Gomori's methenamine silver stain.[11] Hallmark of mucormycosis is a vascular invasion with thrombosis of vessels and necrosis of surrounding tissue.[12]

The most common form of mucormycosis is rhino-orbito-cerebral mucormycosis (44%–49%) followed by cutaneous mucormycosis (10%–19%), pulmonary mucormycosis (10%–11%), disseminated mucormycosis (6%–11%), gastrointestinal (2%–11%), and other rare forms.[131415] Although commonly associated with immunocompromised conditions, cutaneous mucormycosis is reported to occur in patients with no underlying immune deficiency. Local predisposing factors such as trauma, burns, and needle-stick play a major role.[1617] In the 1970s, there was a large outbreak of cutaneous mucormycosis secondary to use of infected Elastoplast bandages.[111218] Aggressive surgical debridement remains the cornerstone of management, amputation of the affected limb may also be required.[1219] Intravenous (IV) amphotericin B (1 to 1.5 mg/kg/day) is the anti-fungal of choice, and the liposomal preparation is advised if the patient develops renal toxicity.[20] Ketoconazole, itraconazole, and fluconazole have no sensitivity to Mucorales.[21] Posaconazole has shown good in vitro sensitivity against Rhizopus, mucor, and other zygomycetes.[22] Hyperbaric oxygen therapy has been reported to be beneficial.[23]

Prognosis of post-traumatic mucormycosis is poor. Cocanour et al. have reported 30% mortality.[8] However, in the largest case series, mortality from disseminated mucormycosis was found to be 83%.[24] More recently mortality rates between 26% and 43% have been reported.[2526] The patient had extensive cutaneous mucormycosis over the trunk reaching up to the peritoneum with bowel segment exposed and thus could not be saved.

CONCLUSION

We conclude that post-traumatic mucormycosis is a rare and underdiagnosed condition. Key to successful treatment is a high index of suspicion, aggressive debridement, early amputation, and administration of IV amphotericin B.

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Conflicts of interest

There are no conflicts of interest.