Wednesday, June 15, 2011

Cluster of zygomycosis infections in Joplin, Missouri tornado victims

The CDC is working on this although I cannot find anything about it on their website. I did find this story from JEMS, an EMS news service:

In the aftermath of the Joplin tornado, some people injured in the storm developed a rare and sometimes fatal fungal infection so aggressive that it turned their tissue black and caused mold to grow inside their wounds.
Scientists say the unusually aggressive infection occurs when dirt or vegetation becomes embedded under the skin. In some cases, injuries that had been stitched up had to be reopened to clean out the contamination...
"To my knowledge, a cluster like this has not been reported before," said Dr. Benjamin Park, head of the CDC team that investigates fungal diseases. "This is a very rare fungus. And for people who do get the disease, it can be extremely severe."

Of the several patients reported, three have died. Since they had multiple injuries and medical problems it is not known the degree to which the mortality is attributable to the infections.

A few observations. Zygomycosis is a term which describes infections with a group of closely related molds. The terminology can be confusing, and despite changes in the taxonomic classification the older term has persisted. It is also known as mucormycosis, a term which clinicians usually think of as a life threatening necrotizing infection of the oropharynx and neighboring structures in patients with DKA (always be mindful of the nasopharynx in your H and P when you admit a patient with DKA!).

Even nasopharyngeal mucor is rare and wound infection is virtually unheard of though not unprecedented. And it's not just the mucor group. Other molds can cause necrotizing skin and soft tissue infections. I recall a critical care CME meeting years ago where we were given an unusual presentation by a mycologist. He presented case after case of these infections involving species of molds I had never heard of. A huge variety of species inhabit trees, grass and other plants. Many cases did not involve known trauma. In the typical case the supposedly immunocompetent patient presented with a funny “dermatitis” and was shuffled around among the ER, the PCP and a dermatologist. Many patients were treated with antibiotics and referral to a surgeon was too late. In virtually all cases the outcome was bad, with loss of life or limb. (Did these patients have some not yet described immune deficiency or were they just unlucky?). The speaker, not a clinician himself, thoroughly scolded doctors for not “thinking fungus.” I can't remember the names of any of the species but the adage “think fungus” was indelibly emblazoned in my hippocampus. These are very aggressive infections requiring prompt antifungal therapy and surgical debridement with an urgency not unlike that of necrotizing fasciitis.

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