Journal of Global Infectious DiseasesOfficial Publishing of INDUSEM and OPUS 12 Foundation, Inc. Users online:935  
Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size     
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
 


 
MYCOLOGY MEDICINE Table of Contents   
Year : 2010  |  Volume : 2  |  Issue : 2  |  Page : 186-188
Elderly diabetic patient with surgical site mucormycosis extending to bowel


1 Infectious Diseases Clinic, "Vedanta" Institute of Medical Sciences; and Sterling Hospital, Ahmedabad, India
2 Sterling Hospital, Ahmedabad, India

Click here for correspondence address and email

Date of Web Publication30-Apr-2010
 

   Abstract 

Mucormycosis is rare in clinical practice. Most infections are acquired by inhalation; other portals of entry are traumatic implantation and ingestion in immunocompromised host. Mucormycosis is life threatening infection in immunocompromised host with variable moratlity ranging from 15 -81% depending upon site of infection. General treatment principles include early diagnosis, correction of underlying immunosuppression and metabolic disturbances, adequate surgical debridement along with amphotericin therapy. We describe surgical site mucormycosis extended to involve large bowel in elderly diabetic patient.

Keywords: Gastrointestinal mucormycosis, Intra-abdominal infection, Mucormycosis, Surgical site infection

How to cite this article:
Patel AK, Vora HJ, Patel KK, Patel B. Elderly diabetic patient with surgical site mucormycosis extending to bowel. J Global Infect Dis 2010;2:186-8

How to cite this URL:
Patel AK, Vora HJ, Patel KK, Patel B. Elderly diabetic patient with surgical site mucormycosis extending to bowel. J Global Infect Dis [serial online] 2010 [cited 2019 Jul 20];2:186-8. Available from: http://www.jgid.org/text.asp?2010/2/2/186/62877



   Introduction Top


Invasive infections caused by the Zygomycetes are well known to clinicians and now increasing in numbers. Within the class Zygomycetes, the order Mucorales contains the genera Rhizopus, Mucor, and Rhizomucor, which cause most cases of human infection. Mucormycosis is a life-threatening infection caused by fungi of the order Mucorales. These fungi are found in soil, in decaying vegetation, in manure, and on a variety of foodstuffs, including bread, fruits, and seeds. [1],[2],[3] Most infections are acquired by inhalation; traumatic implantation and ingestion also are portals of entry. [1],[2],[4] Risk factors for development of infection with the zygomycetes include poorly controlled diabetes mellitus, hematologic malignancies (especially with neutropenia), receipt of a solid-organ or hematopoietic stem cell transplant (HSCT), deferoxamine therapy for iron or aluminum overload states, burn wounds and corticosteroid therapy. [5],[6] The incidence of mucormycosis is increasing due to increase in hematopoietic stem cell transplant recipients and patients with hematological malignancies. Mucormycosis is usually acute and progressive, with mortality rates in the range of 70%-100%. Gastrointestinal (GI) mucormycosis is rare and fatal disease, mostly described in patients with malnutrition, infants with low birth weight, patients receiving peritoneal dialysis, abdominal trauma and patients with solid organ transplants. [6] The stomach, colon and ileum are the most commonly involved sites. As GI involvement with this infection is acute and rapidly fatal, it is often diagnosed postmortem. [6] We describe a case of post-surgical intestinal and surgical wound mucormycosis in patient with well-controlled diabetes mellitus.


   Case Top


A 75-year-old male was referred with history of abdominal surgery for ischemic bowels following mesenteric arterial insufficiency before 11 days. Patient was hypertensive and diabetic since eight years receiving oral hypoglycemic agents, which were changed to insulin before operation. During his post operative course he had prolong ileus and abdomen was re-explored on the postoperative day 4. Ileal resection was carried out with ileostomy and mucus fistulae. He had persistent ileus and fever following re-exploration. Swab from surgical wound grew E. coli (ESBL strain), which was treated with appropriate antibiotics according to microbiological reports. Infectious disease consultant's opinion was taken on postoperative day 9, for persistent fever and intraabdominal infection. On examination surgical site showed black margins with surrounding erythematous area and skin wall edema. Patient was febrile with tachycardia, toxic look and requiring ventilatory support. His blood investigations showed polymorphonuclear leukocytosis (WBC counts 18850/cmm, 88% Polymorphs, 08% Lymphocytes, 02% eosinophil and 02% monocytes, platelet counts 2,62,000/cmm), while his liver functions and renal functions including electrolytes were normal and diabetes was controlled with insulin administration. His HbA1c on admission was 5.4. No past history of prolong immunosuppressive treatment and he was HIV nonreactive. Patient was advised third surgery. Intraoperative findings revealed extensive involvement of rectus sheath, cecum, ascending colon as shown in [Figure 1]. A skin biopsy was performed and tissue culture was sent. The complete resected part of colon was sent for histopathologic examination and tissue culture. The biopsy as well as tissue culture revealed extensive involvement of abdominal wall around surgical site and that of colon with mucormycosis [Figure 2]. Patient was treated with right hemicolectomy and resection of involved anterior abdominal wall along with amphotericin B deoxycholate infusion 1mg/kg/day and Meropenem 1gm q8h. Patient also received supportive care and antibiotic dosage were adjusted during the illness course according to creatinine clearance. Patient died on 8 th day after last surgery with ongoing sepsis following intra-abdominal infection.


   Discussion Top


The most common manifestation of mucormycosis is rhino-cerebral form. [5] Most affected patients are diabetics, especially poorly controlled with ketoacidosis, patients on immunosuppressive treatment, desferioxime treatment and HIV and patients with malignancies. [6] Skin and soft tissue nosocomial infection has been described in hospital settings with mucormycosis. [7] These outbreaks/ sporadic cases have been linked with contaminated bandages, adhesive tapes, [8] needles, and tongue depressors used to construct splints for intravenous and arterial cannulation sites. [9],[10]

Intact mucosal and endothelial barriers serve as structural defense mechanism and prevent tissue invasion and angioinvasion by Zygomycetes. Primary cutaneous zygomycosis is seen in relation to disruption of skin integrity mainly in immunocompromised patients, patients who have burns or severe soft tissue trauma (road traffic accident), and very premature neonates; it has been reported rarely in patients who have apparently normal skin. [11] Cutaneous zygomycosis typically starts as erythema and induration of the skin at a puncture site and progresses to necrosis. Extension to the subcutaneous tissue or bone is common in patients who have delayed or ineffectively treated cutaneous zygomycosis. Necrotizing fasciitis has been reported in cases of cutaneous zygomycosis and carries an extremely poor prognosis.

Gastrointestinal involvement with zygomycosis is rare and usually presents as necrotizing enterocolitis in premature neonates and a mass like appendiceal or ileal lesion in neutropenic patients. [1,12] Peritonitis due to mucormycosis has been rarely described in patients undergoing CAPD. [13],[14],[15] These infections are very rare. Diagnosis of gastrointestinal zygomycosis usually is delayed, because the nonspecific presentation requires a high degree of suspicion.

Our case developed rare gastrointestinal involvement from abdominal wall infection which is not so rare for following possible reasons in addition to immunocompromised state:

  1. Mucormycosis was not suspected and diagnosed with second surgery and hence patient has not received appropriate surgical debridement and amphotericin B therapy,
  2. Swab culture from surgical site is insufficient diagnostic tool for mucormycosis which obviously grew only E. coli only. We should bear in mind that the possibility of mycotic infection including mucormycosis in abdominal wall infection after operation in immunocomprimised state and start appropriate antifungal therapy as soon as possible.


Diagnosis can be made through visualization of broad, aseptate, 90Ί branching, ribbon like mucor hyphae in skin biopsy histopathological examination and culture in Sabouraud dextrose agar. [6] The disease site and host factors are key determinants of prognosis for zygomycosis. Successful treatment of zygomycosis largely depends on early diagnosis, correction or reversal of the underlying predisposing factors, adequate surgical resection/ debridement of infected tissue, and rapid initiation of effective systemic antifungal therapy in form of Amphotericin B. [6],[16]


   Conclusion Top


In suspected surgical site fungal infection, skin biopsy from surgical wound along with culture is an important part of diagnostic work up. Surgeons should not solely rely on swab culture from surgical wound for diagnosis of surgical site infection, especially when edges of wound showed areas of necrosis with/ without vasculitis. Early diagnosis and prompt surgical debridement along with appropriate antifungal treatment can improve prognosis of patient with surgical site mucormycosis.

 
   References Top

1.Ribes J, Vanover-Sams C, Baker D. Zygomycetes in human disease. Clin Microbiol Rev 2000;13:236-301.  Back to cited text no. 1      
2.Sugar AM. Agents of mucormycosis and related species. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 5 th ed. Philadelphia: Churchill Livingstone; 2000. p. 2685-95.  Back to cited text no. 2      
3.Yeung CK, Cheng VC, Lie AK, Yuen KY. Invasive disease due to Mucorales a case report and review of the literature. Hong Kong Med J 2001;7:180-8.  Back to cited text no. 3      
4.Chakrabarti A, Das A, Sharma A, Panda N, Das S, Gupta KL, et al. Ten years' experience in zygomycosis at a tertiary care centre in India. J Infect 2001;42:261-6.  Back to cited text no. 4      
5.Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis 2005;41:634-53.  Back to cited text no. 5      
6.Kontoyiannis DP, Lewis RE. Invasive zygomycosis: update on pathogenesis, clinical manifestations, and management. Infect Dis Clin North Am 2006;20:581-607.  Back to cited text no. 6      
7.Robledo-Ogazσn F, Lizaola-Pιrez B, Mier-Giraud F, Bojalil-Durαn L. Abdominal wall infection due to Mucormycosis. Case report. Cir Cir 2007;75:465-9.   Back to cited text no. 7      
8.Mead JH, Lupton GP, Dillavou CL, Odom RB. Cutaneous Rhizopus infection. Occurrence as a postoperative complication associated with an elasticized adhesive dressing. JAMA 1979;242:272-4.   Back to cited text no. 8      
9.Mitchell SJ, Gray J, Morgan ME, Hocking MD, Durbin GM. Nosocomial infection with Rhizopus icrosporus in preterm infants: association with wooden tongue depressors. Lancet 1996;348:441-3.  Back to cited text no. 9      
10.Baraia J, Muρoz P, Bernaldo de Quirσs JC, Bouza E. Cutaneous mucormycosis in a heart transplant patient associated with a peripheral catheter. Eur J Clin Microbiol Infect Dis 1995;14:813-5.   Back to cited text no. 10      
11.Andresen D, Donaldson A, Choo L, Knox A, Klaassen M, Ursic C, et al. Multifocal cutaneous mucormycosis complicating polymicrobial wound infections in a tsunami survivor from Sri Lanka. Lancet 2005;365:876-8.   Back to cited text no. 11      
12.Park YS, Lee JD, Kim TH, Joo YH, Lee JH, Lee TS, et al. Gastric mucormycosis. Gastrointest Endosc 2002;56:904-5.   Back to cited text no. 12      
13.Branton MH, Johnson SC, Brooke JD, Hasbargen JA. Peritonitis due to Rhizopus in a patient undergoing continuous ambulatory peritoneal dialysis. Rev Infect Dis 1991;13:19-21.  Back to cited text no. 13      
14.Nannini EC, Paphitou NI, Ostrosky-Zeichner L. Peritonitis due to Aspergillus and zygomycetes in patients undergoing peritoneal dialysis: report of 2 cases and review of the literature. Diagn Microbiol Infect Dis 2003;46:49-54.   Back to cited text no. 14      
15.Fergie JE, Fitzwater DS, Einstein P, Leggiadro RJ. Mucor peritonitis associated with acute peritoneal dialysis. Pediatr Infect Dis J 1992;11:498-500.   Back to cited text no. 15      
16.Jimιnez C, Lumbreras C, Aguado JM, Loinaz C, Paseiro G, Andrιs A, Morales JM, Sαnchez G, Garcνa I, del Palacio A, Moreno E. Successful treatment of mucor infection after liver or pancreas-kidney transplantation. Transplantation 2002;73:476-80.  Back to cited text no. 16      

Top
Correspondence Address:
Atul K Patel
Infectious Diseases Clinic, "Vedanta" Institute of Medical Sciences; and Sterling Hospital, Ahmedabad
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.62877

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 Primary Cutaneous Zygomycosis in India
Robin Kaushik
Indian Journal of Surgery. 2012; 74(6): 468
[Pubmed] | [DOI]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case
    Discussion
    Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed2318    
    Printed146    
    Emailed1    
    PDF Downloaded73    
    Comments [Add]    
    Cited by others 1    

Recommend this journal

Sitemap | What's New | Feedback | Copyright and Disclaimer | Contact Us
2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008