A Case Of Mucormycosis Of Thigh

Introduction:
Mucormycosis, previously known as Zygomycosis refers to infections caused by diverse fungal
organisms in the order Mucorales. Multiple organisms are implicated to cause Mucormycosis such
as, but not limited to, Rhizopus spp., Mucor spp. and Apophysomyces spp. Their presentations are
atypical, require longer duration to arrive at a clinching diagnosis, require prolonged intensive care
and have worse manifestations of sepsis with high mortality.

Though a rare entity seen in surgical practice. Most of these infections are rapidly progressive and
exhibit high mortality (~50%) even after active management; the mortality rates approach nearly
100% among patients with disseminated disease.3-6 The principal risk factors implicated in
mucormycosis include uncontrolled diabetes and diabetic ketoacidosis, prolonged steroid therapy,
persistent neutropaenia, desferoxamine therapy, haematological malignancies, illicit use of
intravenous drugs, autoimmune disorders, prophylaxis with voriconazole or echinocandins, and the
breach of cutaneous or mucous membrane barrier due to trauma, burns and surgical wounds.1, 2
However, it has also been described in patients with no underlying disease.1, 2

Mucormycosis is fast emerging fungal infection in India. In a meta‐analysis of all the zygomycosis
cases reported from India, Diwakar et al. describe an overall prevalence of ROC (58%), cutaneous
(14%), pulmonary (6%), disseminated (7%), gastrointestinal (7%) and isolated renal (7%).21

Here we describe an atypical case of soft tissue infection of thigh in a Type 2 diabetes mellitus
patient, who had a trivial prick injury. Fungal aetiology was found and patient required serial
extensive debridements. Here we describe the case in detail regarding the presentation, progression
of the disease with the difficulties faced in early diagnosis and management of the case.

Case presentation:
A 45 years old man, Farmer by occupation, from Thiruvallur District, Tamil Nadu. Came to the
General Surgery outpatient department of Saveetha Medical College and Hospital, Thandalam. He
presented to us with chief complaints of Swelling and skin discoloration over Left thigh region for a
period of 10 days. He gave a preceding history of trauma (a thorn prick injury acquired at work
fields) over the Left thigh region 10 days back. The injury progressed over the days from a small prick
injury to the present lesion. (Figure 1). He also gave history of fever for 4-5 days accompanied with
pain over the region and pus discharge from the site of lesion. He was a known case of Diabetes
mellitus for past 5 years and was on irregular medications.

On Clinical examination he was conscious, oriented, well-built and moderately-nourished. He was

febrile and haemodynamically stable. There was no peculiar finding on systemic examination. On
local examination of the left thigh an induration of size 15 x 15 cm is seen over the mid-thigh region.
There was blackish discoloration of the skin around the region. A discharging sinus can be seen over
the centre of the lesion, with active pus discharge. On palpation it was firm, non-fluctuant and local
warmth and tenderness was present.
He was admitted in the ward with the initial working diagnosis of Cellulitis of Left Thigh. Ultrasound
of Left thigh showed subcutaneous edema. Routine investigation were sent. Wound debridement
was done and patient was started on IV antibiotic therapy with Inj. Piptaz and Inj. Metro, (cultures
sent showed) and later due to rapid progression of disease and increasing counts, and fever spikes IV
antibiotics was stepped up to Inj. Imipenem. Inj. Human insultard was started to manage the blood
sugar levels. In view of the rapid progression of the disease with deteriorating condition of patient
serial extensive wound debridements were done both Intra operatively and in ward. Extensive
wound debridement was done until bleeding was noted, intra operatively on day 1 and day ? of
admission, Intra op fungal moulds were noticed around the edges and were removed. Tissue
samples were taken and sent for fungal culture and biopsy. Post operatively patient developed fever
which was managed conservatively. {total counts} .

Fungal cultures and biopsy showed Multiple branching hyphae.

Empirical IV antifungals – Amphotericin B and flucanozle alongside of proper local care and
dressings.

However, patient general condition rapidly deteriorated requiring ICU care and he died on ??

Discussion:
Cellulitis is often caused by gram positive cocci. Anaerobes are another cause for more severe and
aggressive forms of cellulitis. Approximately 50% of such infections are polymicrobial; the remainder
is caused by single organisms. Fungal aetilogy in cellulitis is as such very rarely seen.

Mucormycosis (previously called zygomycosis) is a serious but rare fungal infection caused by a
group of moulds called Mucormycetes. Fungi that most commonly cause mucormycosis are:
Rhizopus species, Mucor species, cunninghamella bertholletiae, Apophysomyces species, and
Lichtheimia (formerly Absidia) species [1]. Mucormycosis can affect nearly any part of the body, but
it most commonly affects the sinuses or the lungs in people who have weakened immune systems.
Based on anatomic localisation Mucormycosis can be classified into 6 common forms namely
1)Rhino cerebral, 2)Pulmonary, 3)Cutaneous, 4)Gastrointestinal 5)Disseminated and 6) uncommon
presentation [1].

Though a rare entity seen in surgical practice. Most of these infections are rapidly progressive and
exhibit high mortality (~50%) even after active management; the mortality rates approach nearly
100% among patients with disseminated disease.3-6 In a meta‐analysis of all the zygomycosis cases
reported from India, Diwakar et al. describe an overall prevalence of ROC (58%), cutaneous (14%),
pulmonary (6%), disseminated (7%), gastrointestinal (7%) and isolated renal (7%).21

Mucorales are ubiquitous fungi commonly found in soil and decaying matter. It mainly affects
individuals with immunocompromised states like uncontrolled diabetes and diabetic ketoacidosis,
prolonged steroid therapy, persistent neutropaenia, desferoxamine therapy, haematological
malignancies, illicit use of intravenous drugs, autoimmune disorders, prophylaxis with voriconazole
or echinocandins, and the breach of cutaneous or mucous membrane barrier due to trauma, burns
and surgical wounds.

Major route of infection is via inhalation of conida, other routes include ingestion and traumatic
inoculation. Cutaneous infections are usually associated with trauma, burns and surgical wounds.

Mucorales forms hyphae in and around blood vessels, they can invade the blood vessels producing
tissues infarction, necrosis and thrombosis. Neutrophils are key host defence against these fungi, the
individuals with neutropenia or neutrophil dysfunction (eg: Diabetic) are at higher risk of infection.
Conclusion:

References: