Available via license: CC BY
Content may be subject to copyright.
Fungi
Journal of
Review
Necrotizing Mucormycosis of Wounds Following
Combat Injuries, Natural Disasters, Burns, and
Other Trauma
Thomas J. Walsh 1,*, Duane R. Hospenthal 2, Vidmantas Petraitis 3and
Dimitrios P. Kontoyiannis 4
1Departments of Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine of Cornell
University and New York Presbyterian Hospital, New York, NY 10065, USA
2Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at
San Antonio, San Antonio, TX 78229, USA
3Departments of Medicine, Weill Cornell Medicine of Cornell University, New York, NY 10065, USA
4Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston,
TX 77030, USA
*Correspondence: thw2003@med.cornell.edu; Tel.: +1-212-746-6320; Fax: +1-212-746-8852
Received: 1 April 2019; Accepted: 1 July 2019; Published: 4 July 2019
Abstract:
Necrotizing mucormycosis is a devastating complication of wounds incurred in the setting
of military (combat) injuries, natural disasters, burns, or other civilian trauma. Apophysomyces
species, Saksenaea species and Lichtheimia (formerly Absidia) species, although uncommon as causes
of sinopulmonary mucormycosis, are relatively frequent agents of trauma-related mucormycosis.
The pathogenesis of these infections likely involves a complex interaction among organism, impaired
innate host defenses, and biofilms related to traumatically implanted foreign materials. Effective
management depends upon timely diagnosis, thorough surgical debridement, and early initiation of
antifungal therapy.
Keywords: mucormycosis; antifungal therapy
1. Introduction
Fungi of the order Mucorales are increasingly recognized as important causes of necrotizing
wound infections in the setting of military (combat) injuries, burns, natural disaster-related, and
other civilian trauma [
1
–
7
]. As the literature on these infections is widely distributed into journals
across various disciplines, as well as lay press publications, we summarize herein the microbiology,
pathogenesis, epidemiology, diagnosis, and treatment of wound-associated mucormycosis.
2. Microbiology
While Rhizopus arrhizus is the most commonly reported cause of pulmonary, sino-orbital,
rhinocerebral, and disseminated mucormycosis, less commonly recognized species of Mucorales
are reported worldwide in associated with trauma-related disease. Apophysomyces species, Saksenaea
species and Lichtheimia (formerly Absidia)corymbifera, albeit uncommon causes of mucormycosis, are
relatively frequently reported agents of trauma-related infections (Table 1) [4,8–12].
J. Fungi 2019,5, 57; doi:10.3390/jof5030057 www.mdpi.com/journal/jof
J. Fungi 2019,5, 57 2 of 11
Table 1. Necrotizing Mucormycosis involving Wounds.
Reference Cause of Injury Number of
Patients Organisms Recovered (n) Location
Warkentien et al. 2015 [8] Combat-related injury 29 Mucor spp. (15), Saksenaea
vasiformis (5), Rhizopus spp. (1) Afghanistan
Paolino et al. 2012 [13] Combat-related injury 2 Mucor sp. (1), Absidia sp. (1) Afghanistan
Warkentien et al. 2012 [9] Combat-related injury 16 Mucor spp. (9), Saksenaea
vasiformis (6), Apophysomyces spp. (2) Afghanistan
Neblett Fanfair et al.
2011 [10]Tornado, 2011 13 Apophysomyces trapeziformis Joplin, Missouri
Maegele et al. 2006 [11] Tsunami, 2004 1 Apophysomyces elegans Southeast Asia
Andresen et al. 2005 [14] Tsunami, 2004 1 Apophysomyces elegans Sri Lanka
Snell et al. 2007 [12] Tsunami, 2004 1 Apophysomyces elegans Thailand
Kyriopoulos et al. 2015 [
15
]
Burn injuries and soft
tissue automotive
injury
6Rhizopus spp. (3), Rhizomucor spp. (3) Greece
Schaal et al. 2015 [16] Burn injuries 9 NS France
Christiaens et al. 2005 [17] Burn injuries 7 Absidia (currently Lichtheimia)
corymbifera Belgium
Lelievre et al. 2014 [7]
Civilian industrial,
agricultural, and
automotive injuries
16 Apophysomyces elegans complex,
Saksenaea vasiformis France
Kordy et al. 2004 [18] Automotive injury 1 Apophysomyces elegans Saudi Arabia
NS: not specified.
3. Pathogenesis
The pathogenesis of mucormycosis wound infections associated with trauma has not been well
characterized. Unlike the cutaneous and deep soft tissue infections that occur with mucormycosis
in immunocompromised patients, preponderance of patients sustaining traumatic mucormycosis
in the setting of military conflict, burns, and civilian trauma, such as that associated with natural
disasters and motor vehicle accidents, are immunocompetent. In the immunocompromised patient,
the absence of neutrophils, or immunoregulatory dysfunction, or diabetes mellitus clearly increased
the risk of locally invasive infection associated with incidental inoculation in skin and deep soft
tissue. By comparison, other host and microbiological variables are likely active in the pathogenesis
of infection in the immunocompetent patient. Both local and systemic immune impairment may be
active in the unique settings of trauma in the previously immunocompetent patient (Figure 1).
Leliefeld and colleagues [
19
] discuss in detail the impact of trauma-associated immunodysregulation
and impaired function of neutrophils. Among the multiple mechanisms of trauma-related immune
paralysis of neutrophils are impaired chemotaxis, dysfunctional pH control of phagolysosomes,
and autocrine or paracrine serine proteolytic cleavage by neutrophil-derived serine proteases and
downregulation of immune receptors (CXCR1, CXCR2, IL-2r, IL-6r, and complement receptors, including
C5a). Other mechanisms associated with trauma-associated immune paralysis include downregulation
of the neutrophil inflammatory response to microbial pathogens by host-tissue derived molecules with
damage-associated molecular patterns (DAMPS), such as ATP, uric acid, heat shock proteins, and
mitochondrial DNA, as well as release of functionally impaired circulating neutrophil populations
and suppression of adaptive immunity. Gupta et al. also describe a Th1/Th2 dysimmunoregulation
in patients with post-traumatic sepsis, wherein culture supernatant of T cells demonstrated elevated
levels of IL-4, IL-10, and TGF-
β
and low levels of IL-2and IFN-
γ
[
20
]. These patients also had a T-cell
immunophenotype of elevated T-regulatory cells and decreased Th17 cells. This immunodysregulation
of Th1/Th2 and Treg/Th17 may further contribute to the net immunosuppression of patients sustaining
trauma-associated mucormycosis.
J. Fungi 2019,5, 57 3 of 11
J. Fungi 2019, 5, x FOR PEER REVIEW 3 of 12
Figure 1. Pathogenesis of Wound Related Mucormycosis.
Leliefeld and colleagues [19] discuss in detail the impact of trauma-associated
immunodysregulation and impaired function of neutrophils. Among the multiple mechanisms of
trauma-related immune paralysis of neutrophils are impaired chemotaxis, dysfunctional pH control
of phagolysosomes, and autocrine or paracrine serine proteolytic cleavage by neutrophil-derived
serine proteases and downregulation of immune receptors (CXCR1, CXCR2, IL-2r, IL-6r, and
complement receptors, including C5a). Other mechanisms associated with trauma-associated
immune paralysis include downregulation of the neutrophil inflammatory response to microbial
pathogens by host-tissue derived molecules with damage-associated molecular patterns (DAMPS),
such as ATP, uric acid, heat shock proteins, and mitochondrial DNA, as well as release of functionally
impaired circulating neutrophil populations and suppression of adaptive immunity. Gupta et al also
describe a Th1/Th2 dysimmunoregulation in patients with post-traumatic sepsis, wherein culture
supernatant of T cells demonstrated elevated levels of IL-4, IL-10, and TGF- and low levels of IL-
2and IFN- [20]. These patients also had a T-cell immunophenotype of elevated T-regulatory cells
and decreased Th17 cells. This immunodysregulation of Th1/Th2 and Treg/Th17 may further
contribute to the net immunosuppression of patients sustaining trauma-associated mucormycosis.
We hypothesize that in the setting of military injuries, civilian trauma, or wounds sustained in
natural disaster, that there is a sequence of events that would include (1) direct injury to soft tissue
resulting in local necrosis, as well as impaired blood flow to damaged tissue, (2) traumatic inoculation
of foreign material, including soil, rocks, glass, and wood, contaminated with soil-borne Mucorales
forming a nidus for possible biofilm formation, (3) establishment of local infection by the Mucorales
fungus in deep tissue, and (4) possible synergistic interaction with bacteria and other fungi to
establish a necrotizing infection. Since tissue has been injured, either simultaneously or previously
from traumatic injury and impaired host inflammatory cells are unable to eradicate the organism, a
local infection is able to be established and become self-propagating as hyphal elements further
destroy local tissue, prevent capillary influx of white blood cells, and allow further proliferation of
organism.
Therapeutic intervention follows from this pathogenesis in that successful management would
include thorough and meticulous debridement of necrotic tissue, removal of foreign material, as well
as antifungal therapy.
Figure 1. Pathogenesis of Wound Related Mucormycosis.
We hypothesize that in the setting of military injuries, civilian trauma, or wounds sustained in
natural disaster, that there is a sequence of events that would include (1) direct injury to soft tissue
resulting in local necrosis, as well as impaired blood flow to damaged tissue, (2) traumatic inoculation
of foreign material, including soil, rocks, glass, and wood, contaminated with soil-borne Mucorales
forming a nidus for possible biofilm formation, (3) establishment of local infection by the Mucorales
fungus in deep tissue, and (4) possible synergistic interaction with bacteria and other fungi to establish a
necrotizing infection. Since tissue has been injured, either simultaneously or previously from traumatic
injury and impaired host inflammatory cells are unable to eradicate the organism, a local infection is
able to be established and become self-propagating as hyphal elements further destroy local tissue,
prevent capillary influx of white blood cells, and allow further proliferation of organism.
Therapeutic intervention follows from this pathogenesis in that successful management would
include thorough and meticulous debridement of necrotic tissue, removal of foreign material, as well
as antifungal therapy.
4. Epidemiology
4.1. Mucormycosis Following Combat-Related Injury
Combat-associated wounds complicated by invasive fungal infections (IFIs) are associated with
serious morbidity and excess mortality [
8
]. Early observations suggested that combat wound fungal
infections are more difficult to manage and had worse prognosis in comparison to non-fungal
combat-related injuries [
13
]. In order to better understand the role of military trauma-related invasive
fungal infections, particularly mucormycosis, several studies have examined the epidemiology, risk
factors, outcome, and management of combat-associated mycoses, including those caused by the
Mucorales. These include a series of studies of US military personnel who sustained serious injury in
Afghanistan [9,21].
Warkentien et al. of the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious
Disease Outcomes Study (TIDOS) group from the Walter Reed National Military Medical Center,
Uniformed Services University of the Health Sciences, San Antonio Military Medical Center, and
Landstuhl Regional Medical Center (Landstuhl, Germany) recently reviewed the impact of Mucorales
J. Fungi 2019,5, 57 4 of 11
and other invasive mould pathogens on clinical outcomes of polymicrobial traumatic wound
infections [
8
,
9
]. The investigators initially reported 37 cases of IFI in combat-related wounds using a
classification of proven (culture +histological evidence of angioinvasion, (n=20)), probable (culture +
nonvascular tissue invasion (n=4)), and possible (positive fungal culture without histopathological
documentation (n=13)). The data were collected from records of US military personnel who served in
Afghanistan. The following epidemiological and possible risk factors were common to most patients
with IFI: Blast injury during foot patrol, injury occurring in southern Afghanistan, lower extremity
amputation, and receipt of large volume blood transfusions [
22
,
23
]. Among the mould isolates,
Mucorales were cultured in 16 cases, Aspergillus spp. in 16, and Fusarium spp. in 9. Reflecting the soil
and environmental contamination of severely injured wounds, cultures yielded multiple species of
moulds in 10 (28%) of these cases. The median age of the patients with IFIs was 22.9 years and 100% were
male. All of the IFIs were associated with injuries sustained from blast injury. Traumatic amputations
of the lower extremity above or through the knee were the most common type of initial wounds.
These investigators then compared the potential differences in microbiological features and clinical
outcomes between wounds classified as IFIs (n=82) and as case-matched control non-IFIs (n=136).
The authors further evaluated the effect of the type of mould on clinical outcome [
24
,
25
]. IFIs were
predominantly secondary to fungi of the order Mucorales (35%), Aspergillus spp. (29%), and Fusarium
spp. (21%). Among the 29 wound IFIs caused by Mucorales, the most common genera were Mucor
spp. (n=15 (52%), Saksenaea vasiformis (n=5 (17%)),and Rhizopus spp (n=1 (3%)). The other species
of Mucorales were apparently not cultured or identified to species and may have been diagnosed
histologically as mucormycosis.
Wounds infected with a species of the Mucorales required longer median time for wound-closure
in comparison to those infected with a non-Mucorales fungal pathogen (17 days vs. 13 days (p<0.01)).
The study also found that the median time to wound-closure was significantly longer (p<0.001) for
IFIs (16 days) than that for the control non-IFIs with or without skin and soft tissue infections (12 and
9 days, respectively). IFI wounds were managed principally by delayed primary closure, full-thickness
skin graft, or split-thickness skin graft. Surgical amputations and revisions were more frequently
performed in IFI wounds (n=63 (77%)) than in non-IFI wounds (n=71 (52%)). Median duration
of antifungal therapy for mucormycosis was 31 days (IQR, 22–44 days). Given the broad range of
fungal pathogens causing these infections, when IFI was clinically or microbiologically suspected,
a combination of liposomal amphotericin B and voriconazole was empirically initiated for broad
antifungal spectrum, pending definitive identification. That voriconazole is added empirically may
contribute to the selection of increased virulence of isolates of Mucorales [26].
Rodriguez et al. [
27
] reinforced these principles of broad-spectrum combination therapy, with
liposomal amphotericin B and voriconazole pending microbiological diagnosis, that was used in
management of blast-related wounds suspected of having IFI during Operation Enduring Freedom
in Afghanistan. Post-operative local wound management included frequent debridement of necrotic
tissue, 0.025% Dakin’s solution-soaked kerlix dressing, and instillation vacuum dressings.
4.2. Mucormycosis Following Natural Disasters
Mucormycosis of deep soft tissues have occurred in victims with severe injuries caused by
tornadoes, hurricanes, tsunamis, and floods [
10
–
12
,
14
,
15
,
28
,
29
]. The organisms are inoculated following
penetrating injuries from wind or water borne debris that is driven into deep soft tissues, including
muscle, fascia, tendon, and bone.
On 22 May 2011, a catastrophic EF-5 (enhanced Fujito scale; 200 MPH +) rated multiple vortex
tornado devastated the community of Joplin, Missouri, USA, resulting in 13 tornado victims with serious
necrotizing cutaneous mucormycosis caused by Apophysomyces trapeziformis following lacerations and
penetrating injury from airborne material, including soil, gravel, wood, and glass [
10
]. Apophysomyces
trapeziformis was definitely identified by sequencing each isolate in the D1–D2 region of the gene
encoding 28S rRNA. Eleven patients suffered at least one fracture, 9 sustained blunt trauma, and 5
J. Fungi 2019,5, 57 5 of 11
had penetrating injury. Multivariate analysis found that necrotizing cutaneous mucormycosis was
associated with penetrating injury and increased numbers of wounds.
Five of these patients died. Apophysomyces spp. are well described as causes of trauma-related
musculoskeletal mucormycosis in immunocompetent hosts. However, Apophysomyces trapeziformis had
seldom been reported as an etiological agent. Whole-genome sequencing typing (WGST), which was
conducted on four isolates, demonstrated that these four isolates were separate individual strains.
Additional WGST analysis was conducted by Etienne and colleagues from the Centers for Diseases
Control (CDC) on 17 outbreak isolates and three control strains of Apophysomyces trapeziformis, as
well as two control isolates of Apophysomyces variabilis [
14
]. While three clusters of genotypically
related or identical isolates were discovered, multiple distinct isolates were also identified among
the infecting organisms. The isolates from Joplin were more closely related to each other than to the
control isolates, suggesting a local geographic lineage. However, there was no relation between the
isolates or genotypic cluster and location within the Joplin area. Given the extensive disruption of
soil by the massive tornado system, one could expect that elucidation of any such genotypic and local
geographic relationship would be confounded by the wide dispersal of organisms.
The devastating Indian Ocean tsunami of December 26, 2004, that killed more than 200,000 estimated
victims with yet another estimated 40,000 seriously wounded patients [
11
,
12
,
28
], inflicted infectious
wound complications, including trauma-associated mucormycosis, on multiple victims in Thailand, India,
Sri Lanka, and other countries. These infections ranged from multifocal cutaneous mucormycosis to
mucormycotic necrotizing fasciitis. Patients were described as having multiple large flap lacerations
measuring as large as 60 cm in greatest diameter, particularly of the lower extremities. Among these
patients, Maegele et al. reported two cases of a lethal combined infection of mucormycosis and Fusarium
spp. Apophysomyces elegans was recovered from one patient. Aspergillus fumigatus was also recovered
from one of two patients who later died. Other invasive fungal infections complicating this massive
tsunami included Cladophialophora bantiana soft tissue infection, Scedosporium apiospermum brain abscess,
and Aspergillus fumigatus brain abscess. In addition to these organisms, water-borne bacterial co-infection,
including those caused by Aeromonas hydrophila and Pseudomonas aeruginosa, may have also contributed to
the pathogenesis of these infections.
Among other cases of mucormycosis associated with natural disasters, Patiño et al. reported the
development of 8 cases of necrotizing soft tissue infection caused by Mucorales fungi following the
cataclysmic volcanic eruption of Armero, Colombia in 1985 that resulted in more than 23,000 deaths and
4500 wounded, where burns sustained from lava, pyroclastic flows, and other fires may have allowed
for inoculation from environmental pathogens [
15
,
29
]. Within the same issue, Patiño and colleagues
underscore the importance of assessing necrotizing fasciitis as a syndromic clinical entity caused by
many different pathogens, including Mucorales fungi. Emphasizing the importance of mucormycosis
in this tragic setting, among the 38 patients with necrotizing soft tissue infection observed by Patiño
and colleagues, 8 had mucormycosis. While overall mortality in patients with necrotizing fasciitis was
47.7%, it was 80% in those with mucormycosis. The authors emphasize the importance of assessing for
the presence of these organisms in necrotizing soft tissue infection associated with natural disaster.
4.3. Mucormycosis Following Burn Injuries
Mucormycosis of burn wounds has been known for more than one-half century to be associated
with a high mortality and severe morbidity. Devauchelle et al. recently reviewed the epidemiology
of mucormycosis in burn patients [
5
]. They identified 7 case series, 3 outbreaks and 25 case reports
containing infected patients. Mortality in this review ranged from 29–100%. Kyriopoulos and
colleagues from Athens, Greece reported six cases of trauma-associated mucormycosis with review of
literature. Among these newly reported patients, severe thermal burns were present in 3 [
16
]. The other
three patients suffered severe soft tissue trauma due to traffic vehicular accidents. Total body surface
area of burns ranged from 45–71%. Rhizopus and Rhizomucor species were recovered in all patients.
Bacterial co-infection with Staphylococcus aureus,Pseudomonas aeruginosa,Stenotrophomonas maltophilia,
J. Fungi 2019,5, 57 6 of 11
Acinetobacter baumannii, and Proteus mirabilis was identified. The authors observed that the frequency
of mucormycosis in their center from 2005 to 2014 among 477 adult patients was 0.63%, which they
further noted was consistent with that of Schaal et al., who reported an incidence of 0.5% in a French
military burn center [
17
,
30
]. Use of contaminated bandages in the burn unit was the reason for an
outbreak of Absidia corymbifera infection in 2005, according to Christiaens et al. [
31
]. Kyriopoulos et al.
describe that their treatment protocol for suspected mould infections of burn wounds stipulates rapid
diagnosis and extensive surgical debridement accompanied by amphotericin B in treatment of cases of
mucormycosis [16].
4.4. Mucormycosis Following Civilian Industrial, Agricultural, and Automotive Injuries
In addition to military (combat) injuries, burns, and natural disasters injuries as predisposing
factors for necrotizing mucormycosis, injuries associated with civilian industrial, agricultural, and
automotive/vehicular accidents also pose a threat for these serious infections. Lelievre, representing
the French Mycosis Study Group, published a study of posttraumatic mucormycosis [
7
]. Cases of
posttraumatic mucormycosis were identified and reviewed from the database of the nationwide French
study known as “RetroZygo” [
32
]. The RetroZygo study included 101 cases of proven and probable
mucormycosis. Among these cases were 16 with posttraumatic mucormycosis.
Posttraumatic mucormycosis in these patients was seldom associated with underlying diseases
(e.g., diabetes or malignancy) in comparison to other forms of mucormycosis. The preponderance of
cutaneous mucormycosis occurred in posttraumatic mucormycosis (87%) vs. other forms of mucormycosis
(7%). As these infections were localized to the skin and soft tissue and occurred in a trauma-related clinical
setting, an early diagnosis was readily established. Among the causes of mucormycosis, Apophysomyces
elegans complex and Saksenaea vasiformis were recovered more frequently from posttraumatic wounds
than from other types of mucormycosis. More patients (94%) underwent surgery for posttraumatic
mucormycosis than did those with other forms (48%). Survival at day 90 was greater in posttraumatic
mucormycosis (88%) in comparison to that of other types of mucormycosis (48%).
Among the 122 cases that were identified from a systematic review of literature, traffic injuries,
domestic accidents, natural disasters, and farm accidents constituted the most common events predisposing
to civilian posttraumatic mucormycosis. Dissemination from traumatic mucormycosis seldom occurred
(9%). Apophysomyces elegans complex and Lichtheimia (formerly Absidia) spp. were the two most common
species recovered from these cases of civilian posttraumatic mucormycosis. Lichtheimia corymbifera has
long been associated with post-traumatic necrotizing mucormycosis. Apophysomyces elegans complex was
also a common organism recovered from wounds of posttraumatic mucormycosis.
4.5. Trauma-Related Mucormycosis in Children
Most patients reported with trauma-associated mucormycosis are adults. Little is known about
trauma-associated mucormycosis in pediatric patients. Kordy and colleagues reported the development
of severe deep soft tissue mucormycosis caused by Apophysomyces elegans in an otherwise healthy
child who sustained a traumatic avulsion injury of her latissimus dorsi [
18
]. The traumatic inoculation
occurred in Saudi Arabia in the setting of the child being thrown from an automobile during a motor
vehicle accident and tearing the deep soft tissue in the soil where she had landed. The child was
treated successfully with surgical debridement and systemically administered liposomal amphotericin
B. This report further underscores the role of Apophysomyces spp. in trauma associated necrotizing
mucormycosis and highlights the need for a high index of awareness of in both pediatric and
adult patients.
4.6. Trauma-Related Osteoarticular Mucormycosis
While any of the previously mentioned settings may inflict trauma-related osteoarticular mucormycosis,
the preponderance of literature addresses deep soft tissue infections. Little has been written about
trauma-related osteoarticular mucormycosis. A systematic review of osteoarticular mucormycosis by the
J. Fungi 2019,5, 57 7 of 11
International Osteoarticular Mycoses Consortium from 1978 to 2014 [
33
] found that among 34 patients,
seven (21%) suffered trauma as the predisposing factor. Among these 7 patients with trauma, the
long bones were infected with direct inoculation as the mechanism of infection. By comparison,
hematogenous dissemination is the most common mechanism in immunocompromised patients.
Despite the complexity of osteoarticular mucormycosis, a combined therapeutic approach of surgical
debridement and amphotericin B resulted in a favorable outcome in 82%.
5. Principles of Management
Strategies of management of trauma-related mucormycosis follow fundamental principles of
diagnosis, empirical antifungal therapy for suspected infection, extensive surgical debridement of
necrotic tissue, definitive antifungal therapy for documented disease, topical therapy, and reversal of
underlying metabolic or immune-impaired conditions.
5.1. Microbiological Diagnosis
A heightened clinical suspicion at the time of wound assessment and a rapid laboratory diagnosis
are essential in the management of trauma-related necrotizing mucormycosis [
34
]. Direct examination of
calcofluor wet mounts of tissue samples under fluorescent microscopy may rapidly identify organisms
while cultures are pending [
35
]. Histological sections may further confirm the presence of characteristic
broad, sparsely septated, or non-septated hyphae. The presence of angioinvasion further confirms a
histological diagnosis.
Deployment of PCR or other molecular diagnostic systems for laboratory diagnosis of
wound-associated mucormycosis could complement conventional microbiological methods and
guide pathogen-directed antifungal therapy. Rapid molecular diagnostic tools have been developed
that may further aid in the diagnosis of necrotizing mucormycosis for those healthcare facilities with
clinical laboratories that are resourced with dedicated assays and technologist support. Pioneering work
by Kasai and colleagues developed a rapid PCR-based platform that identified several genera (Rhizopus,
Mucor,Rhizomucor, and Cunninghamella species) within the Mucorales in plasma, bronchoalveolar lavage
fluid, and tissue of rabbits with experimental invasive pulmonary mucormycosis [
36
]. The primers
and probe sequences used in these assays helped in developing several subsequent PCR systems for
diagnosis of mucormycosis. Millon et al. studied quantitative PCR assays detecting Mucor/Rhizopus,
Rhizomucor, and Lichtheimia (formerly Absidia) in a retrospective multicenter study [
37
]. The investigators
found that 36 (81%) of 44 patients had
≥
PCR-positive serum sample. The first positive PCR
sample was identified in a median of 9 days before a conventional microbiological or histological
diagnosis. The investigators also found that quantification of DNA loads in serum correlated with
therapeutic response.
In a combined retrospective and prospective study of 77 burn victims, Legrand and colleagues
identified 8 patients with wound related mucormycosis by plasma qPCR in a screening protocol of
samples collected twice weekly [
38
]. Underscoring its utility in early diagnosis, qPCR identified
the presence of wound-associated mucormycosis for a median of 11 days before a conventional
diagnosis using standard microbiological or histological tools. Moreover, there was a trend toward
improved survival in patients for whom pre-emptive was initiated following a molecular diagnosis of
wound-associated mucormycosis.
Fr
é
alle et al. investigated the possible role of non-sterile bandages used to secure sterile gauze
and strips in contact with burn wounds in the Burn Unit of the University Hospital of Lille, France in
order to determine their relationship to outbreaks of infections caused by Lichtheimia (formerly Absidia)
spp. in March 2014 and July 2016, as well as in individual cases in November 2013 and July 2016.
Real-time PCR, and Lichtheimia species-specific qPCR detected Lichtheimia ramosa,Lichtheimia ornata,
and Lichtheimia corymbifera in crepe bandages and elasticized bandages [
39
]. The authors underscore the
value of qPCR in molecular epidemiological investigations, the potential role of non-sterile bandages
J. Fungi 2019,5, 57 8 of 11
as a source of cutaneous mucormycosis in burn patients, and the need for sterile bandages in managing
these wounds.
5.2. Surgical Management and Antifungal Therapy
As trauma-related mucormycosis is an uncommon infection, there are no controlled studies to
guide management. Nonetheless, the experience from the medical command caring for servicemen
with trauma-related mucormycosis provides the largest body of collective experience in management
of this devastating infection [
27
]. The approaches outlined by Rodriguez et al. that are grounded
in direct battlefield experience during Operation Enduring Freedom maintain that aggressive and
frequent surgical debridement with topical antifungal therapy, such as Dakin’s solution, was the
principal therapy for management of invasive fungal infections, including mucormycosis, in war
wounds. When there is a strong suspicion of IFI, initial antifungal therapy consists of liposomal
amphotericin B and an intravenously administered triazole, voriconazole or posaconazole. Following
a diagnosis of mucormycosis, therapy was consolidated with liposomal amphotericin B.
As a guide to resection of tissue, one of the serious challenges is the need to repeatedly resect
necrotic tissue resulting in larger wounds. Defining clear margins is essential in limiting resection of
viable tissue while receiving infected margins. We have observed that wound margins may appear
clinically and histologically intact while still having viable organisms present. We therefore have used
a system of intraoperative assessment of resected tissue margins sent by the surgical team to the clinical
microbiology laboratory for fluorescent microscopy using calcofluor wet mounts [40,41].
There are, of course, many variables that must be individualized for each patient. These include
the extent, timing, and repeating of debridement, the duration of systemic therapy, use of oral agents,
role of adjunct hyperbaric oxygen, repair of major tissue defects, and the timing of skin grafting.
6. Future Directions
Considerably more work is needed in understanding the pathogenesis, diagnosis and treatment
of trauma associated mucormycosis. Appropriate immunocompetent animal models are paramount to
understanding the pathogenesis and treatment of these infections. Understanding the environmental
microbiology of trauma associated mucormycosis is important to addressing the role of non-Rhizopus
species, such as Lichtheimia corymbifera, Saksenaea and Apophysomyces spp. Development of new
rapid molecular tools, especially at point of care in a trauma setting would be highly beneficial in
guiding therapy [
42
–
48
]. Development of new approaches for topical therapy, as well as discovery
of novel antifungal agents with the potential for synergistic combinations with licensed compounds
may improve therapeutic outcome, especially in eradicating residual fungi that are not removed by
debridement or other surgical interventions [
49
,
50
]. Further study of the newer antifungal agents,
such as posaconazole and isavuconazole, are merited [
51
]. Finally, the potential for novel tissue
regenerative systems offers potential new approaches in management of the wounds associated with
trauma-related mucormycosis.
Acknowledgments:
T.J.W. was supported for this work as the Henry Schueler Foundation Scholar in Mucormycosis
by the Henry Schueler 41 & 9 Foundation.
Conflicts of Interest:
D.P.K. acknowledges the Texas 4000 Distinguished Professorship for Cancer Research and
the NIH-NCI Cancer Center CORE Support grant no. 16672. D.P.K. reports research support from Astellas Pharma
and honoraria for lectures from Merck & Co., Gilead, and United Medical. He has served as a consultant for
Astellas Pharma, Cidara, Amplyx, and Mayne, and on the advisory board of Merck & Co. He also reports fees
from consultancy and board membership from Pfizer, Astellas, and Schering. T.J.W. has received grants for
experimental and clinical antimicrobial pharmacology and therapeutics to his institution from Allergan, Amplyx,
Astellas, Lediant, Medicines Company, Merck, Scynexis, Viosera, and Tetraphase and has served as consultant
to Amplyx, Astellas, Allergan, ContraFect, Gilead, Lediant, Medicines Company, Merck, Methylgene, Pfizer,
and Scynexis.
J. Fungi 2019,5, 57 9 of 11
References
1.
Roden, M.M.; Zaoutis, T.E.; Buchanan, W.L.; Knudsen, T.A.; Sarkisova, T.A.; Schaufele, R.L.; Sein, M.; Sein, T.;
Chiou, C.C.; Chu, J.H.; et al. Epidemiology and Outcome of Zygomycosis: A Review of 929 Reported Cases.
Clin. Infect. Dis. 2005,41, 634–653. [CrossRef] [PubMed]
2.
Petrikkos, G.; Lortholary, O.; Walsh, T.J.; Skiada, A.; Roilides, E.; Kontoyiannis, D.P. Epidemiology and
Clinical Manifestations of Mucormycosis. Clin. Infect. Dis.
2012
,54 (Suppl. 1), S23–S34. [CrossRef] [PubMed]
3.
Tribble, D.R.; Rodriguez, C.J. Combat-Related Invasive Fungal Wound Infections. Curr. Fungal Infect. Rep.
2014,8, 277–286. [CrossRef] [PubMed]
4.
Kronen, R.; Liang, S.Y.; Bochicchio, G.; Bochicchio, K.; Powderly, W.G.; Spec, A. Invasive Fungal Infections
Secondary to Traumatic Injury. Int. J. Infect. Dis. 2017,62, 102–111. [CrossRef] [PubMed]
5.
Devauchelle, P.; Jeanne, M.; Frealle, E. Mucormycosis in Burns Patients. J. Fungi
2019
,5, 25. [CrossRef]
[PubMed]
6.
Benedict, K.; Park, B.J. Invasive fungal infections after natural disasters. Emerg. Infect. Dis.
2014
,20, 349–355.
[CrossRef] [PubMed]
7.
Lelievre, L.; Garcia-Hermoso, D.; Abdoul, H.; Hivelin, M.; Chouaki, T.; Toubas, D.; Mamez, A.C.; Lantieri, L.;
Lortholary, O.; Lanternier, F.; et al. Posttraumatic mucormycosis: A nationwide study in France and review
of the literature. Medicine (Baltimore) 2014,93, 395–404. [CrossRef]
8.
Warkentien, T.E.; Shaikh, F.; Weintrob, A.C.; Rodriguez, C.J.; Murray, C.K.; Lloyd, B.A.; Ganesan, A.;
Aggarwal, D.; Carson, M.L.; Tribble, D.R.; et al. Impact of Mucorales and Other Invasive Molds on Clinical
Outcomes of Polymicrobial Traumatic Wound Infections. J. Clin. Microbiol. 2015,53, 2262–2270. [CrossRef]
9.
Warkentien, T.; Rodriguez, C.; Lloyd, B.; Wells, J.; Weintrob, A.; Dunne, J.R.; Ganesan, A.; Li, P.; Bradley, W.;
Gaskins, L.J.; et al. Invasive mold infections following combat-related injuries. Clin. Infect. Dis.
2012
,55,
1441–1449. [CrossRef]
10.
Neblett Fanfair, R.; Benedict, K.; Bos, J.; Bennett, S.D.; Lo, Y.C.; Adebanjo, T.; Etienne, K.; Deak, E.; Derado, G.;
Shieh, W.J.; et al. Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011. N. Engl.
J. Med. 2012,367, 2214–2225. [CrossRef]
11.
Maegele, M.; Gregor, S.; Yuecel, N.; Simanski, C.; Paffrath, T.; Rixen, D.; Heiss, M.M.; Rudroff, C.; Saad, S.;
Perbix, W.; et al. One year ago not business as usual: Wound management, infection and psychoemotional
control during tertiary medical care following the 2004 Tsunami disaster in southeast Asia. Crit. Care
2006
,
10, R50. [CrossRef] [PubMed]
12.
Snell, B.J.; Tavakoli, K. Necrotizing fasciitis caused by Apophysomyces elegans complicating soft-tissue and
pelvic injuries in a tsunami survivor from Thailand. Plast. Reconstr. Surg.
2007
,119, 448–449. [CrossRef]
[PubMed]
13.
Paolino, K.M.; Henry, J.A.; Hospenthal, D.R.; Wortmann, G.W.; Hartzell, J.D. Invasive fungal infections
following combat-related injury. Mil. Med. 2012,177, 681–685. [CrossRef] [PubMed]
14.
Etienne, K.A.; Gillece, J.; Hilsabeck, R.; Schupp, J.M.; Colman, R.; Lockhart, S.R.; Gade, L.; Thompson, E.H.;
Sutton, D.A.; Neblett-Fanfair, R.; et al. Whole genome sequence typing to investigate the Apophysomyces
outbreak following a tornado in Joplin, Missouri, 2011. PLoS ONE 2012,7, e49989. [CrossRef] [PubMed]
15.
Patiño, J.F.; Castro, D. Necrotizing lesions of soft tissues: A review. World J. Surg.
1991
,15, 235–239.
[CrossRef] [PubMed]
16.
Kyriopoulos, E.J.; Kyriakopoulos, A.; Karonidis, A.; Gravvanis, A.; Gamatsi, I.; Tsironis, C.; Tsoutsos, D. Burn
injuries and soft tissue traumas complicated by mucormycosis infection: A report of six cases and review of
the literature. Ann. Burns Fire Disasters 2015,28, 280–287. [PubMed]
17.
Schaal, J.-V.; Leclerc, T.; Pasquier, P.; Bargues, L. Epidemiology of fungal infection in burns: Therapeutic
implications. Burns 2012,38, 942–943. [CrossRef] [PubMed]
18.
Kordy, F.N.; Al-Mohsen, I.Z.; Hashem, F.; Almodovar, E.; Al Hajjar, S.; Walsh, T.J. Successful treatment of a
child with post-traumatic narcotizing fasciitis caused by Apophysomyces elegans: Case report and review of
literature. Pediatr. Infect. Dis. J. 2004,23, 877–879. [CrossRef]
19.
Leliefeld, P.H.; Wessels, C.M.; Leenen, L.P.; Koenderman, L.; Pillay, J. The role of neutrophils in immune
dysfunction during severe inflammation. Crit. Care 2016,20, 73. [CrossRef]
20.
Gupta, D.L.; Bhoi, S.; Mohan, T.; Galwnkar, S.; Rao, D.N. Th1Coexistence of Th1/Th2 and Th17/Treg
imbalances in patients with post traumatic sepsis. Cytokine 2016,88, 214–221. [CrossRef]
J. Fungi 2019,5, 57 10 of 11
21.
Weintrob, A.C.; Weisbrod, A.B.; Dunne, J.R.; Rodriguez, C.J.; Malone, D.; Lloyd, B.A.; Warkentien, T.E.;
Wells, J.; Murray, C.K.; Bradley, W.; et al. Combat trauma-associated invasive fungal wound infections:
epidemiology and clinical classification. Epidemiol. Infect. 2015,143, 214–224. [CrossRef] [PubMed]
22.
Tribble, D.R.; Rodriguez, C.J.; Weintrob, A.C.; Shaikh, F.; Aggarwal, D.; Carson, M.L.; Murray, C.K.; Masuoka, P.;
Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group. Environmental
Factors Related to Fungal Wound Contamination after Combat Trauma in Afghanistan, 2009–2011. Emerg. Infect. Dis.
2015,21, 1759–1769. [CrossRef] [PubMed]
23.
Rodriguez, C.J.; Weintrob, A.C.; Shah, J.; Malone, D.; Dunne, J.R.; Weisbrod, A.B.; Lloyd, B.A.; Warkentien, T.E.;
Murray, C.K.; Wilkins, K.; et al. Risk factors associated with invasive fungal infections in combat trauma.
Surg. Infect. (Larchmt) 2014,15, 521–526. [CrossRef] [PubMed]
24.
Lewandowski, L.R.; Weintrob, A.C.; Tribble, D.R.; Rodriguez, C.J.; Petfield, J.; Lloyd, B.A.; Murray, C.K.;
Stinner, D.; Aggarwal, D.; Shaikh, F.; et al. Early Complications and Outcomes in Combat Injury-Related
Invasive Fungal Wound Infections: A Case-Control Analysis. J. Orthop. Trauma
2016
,30, e93–e99. [CrossRef]
[PubMed]
25.
Rodriguez, C.; Weintrob, A.C.; Dunne, J.R.; Weisbrod, A.B.; Lloyd, B.; Warkentien, T.; Malone, D.; Wells, J.;
Murray, C.K.; Bradley, W.; et al. Clinical relevance of mold culture positivity with and without recurrent
wound necrosis following combat-related injuries. J. Trauma Acute Care Surg.
2014
,77, 769–773. [CrossRef]
[PubMed]
26.
Chamilos, G.; Lamaris, G.A.; Ben-Ami, R.; Lewis, R.E.; Samonis, G.; Kontoyiannis, D.P. Increased Virulence
of Zygomycetes Organisms Following Exposure to Voriconazole: A Study Involving Fly and Murine Models
of Zygomycosis. J. Infect. Dis. 2009,199, 1399–1406.
27.
Rodriguez, C.J.; Tribble, D.R.; Malone, D.L.; Murray, C.K.; Jessie, E.M.; Khan, M.; Fleming, M.E.; Potter, B.K.;
Gordon, W.T.; Shackelford, S.A. Treatment of Suspected Invasive Fungal Infection in War Wounds. Mil. Med.
2018,183 (Suppl. 2), 142–146. [CrossRef]
28.
Andresen, D.; Donaldson, A.; Choo, L.; Knox, A.; Klaassen, M.; Ursic, C.; Vonthethoff, L.; Krilis, S.; Konecny, P.
Multifocal cutaneous mucormycosis complicating polymicrobial wound infections in a tsunami survivor
from Sri Lanka. Lancet 2005,365, 876–878. [CrossRef]
29.
Patiño, J.F.; Castro, D.; Valencia, A.; Morales, P. Necrotizing soft tissue lesions after a volcanic cataclysm.
World J. Surg. 1991,15, 240–247. [CrossRef]
30.
Schaal, J.; Leclerc, T.; Soler, C.; Donat, N.; Cirrode, A.; Jault, P.; Bargues, L. Epidemiology of filamentous
fungal infections in burned patients: A French retrospective study. Burns 2015,41, 853–863. [CrossRef]
31.
Christiaens, G.; Hayette, M.P.; Jacquemin, D.; Melin, P.; Mutsers, J.; De Mol, P. An outbreak of Absidia
corymbifera infection associated with bandage contamination in a burns unit. J. Hosp. Infect.
2005
,61, 88.
[CrossRef] [PubMed]
32.
Dannaoui, E.; Morizot, G.; Elie, C.; Garcia-Hermoso, D.; Huerre, M.; Dromer, F.; Lortholary, O.; Lanternier, F.;
Bitar, D. A Global Analysis of Mucormycosis in France: The RetroZygo Study (2005–2007). Clin. Infect. Dis.
2012,54 (Suppl. 1), S35–S43.
33.
Taj-Aldeen, S.; Gamaletsou, M.N.; Rammaert, B.; Sipsas, N.V.; Zeller, V.; Roilides, E.; Kontoyiannis, D.P.;
Henry, M.; Petraitis, V.; Moriyama, B.; et al. Bone and joint infections caused by Mucormycetes: A challenging
osteoarticular mycosis of the 21st century. Med. Mycol. 2017,55, 691–704. [CrossRef] [PubMed]
34.
Lloyd, B.; Weintrob, A.C.; Rodriguez, C.; Dunne, J.R.; Weisbrod, A.B.; Hinkle, M.; Warkentien, T.; Murray, C.K.;
Oh, J.; Millar, E.V.; et al. Effect of Early Screening for Invasive Fungal Infections in U.S. Service Members
with Explosive Blast Injuries. Surg. Infect. 2014,15, 619–626. [CrossRef] [PubMed]
35.
Gamaletsou, M.N.; Hayden, R.T.; Walsh, T.J.; McGinnis, M.R.; Kontoyiannis, D.P. Early Clinical and Laboratory
Diagnosis of Invasive Pulmonary, Extrapulmonary, and Disseminated Mucormycosis (Zygomycosis).
Clin. Infect. Dis. 2012,54 (Suppl. 1), S55–S60.
36.
Kasai, M.; Harrington, S.M.; Francesconi, A.; Petraitis, V.; Petraitiene, R.; Schaufele, R.L.; Sein, T.; Cotton, M.P.;
Hughes, J.E.; Beveridge, M.G.; et al. Detection of molecular biomarkers for Rhizopus spp., Mucor spp., and
Cunninghamella spp. by quantitative PCR and melt curve analysis in plasma, bronchoalveolar lavage, and
lung tissue in experimental pulmonary zygomycosis. J. Clin. Microbiol.
2008
,46, 3690–3702. [CrossRef]
[PubMed]
J. Fungi 2019,5, 57 11 of 11
37.
Millon, L.; Herbrecht, R.; Grenouillet, F.; Morio, F.; Alanio, A.; Letscher-Bru, V.; Cassaing, S.; Chouaki, T.;
Kauffmann-Lacroix, C.; Poirier, P.; et al. Early diagnosis and monitoring of mucormycosis by detection
of circulating DNA in serum: retrospective analysis of 44 cases collected through the French Surveillance
Network of Invasive Fungal Infections (RESSIF). Clin. Microbiol. Infect. 2016,22, 810.e1–810.e8. [CrossRef]
38.
Legrand, M.; Gits-Muselli, M.; Boutin, L.; Garcia-Hermoso, D.; Maurel, V.; Soussi, S.; Benyamina, M.; Ferry, A.;
Chaussard, M.; Hamane, S.; et al. Detection of Circulating Mucorales DNA in Critically Ill Burn Patients:
Preliminary Report of a Screening Strategy for Early Diagnosis and Treatment. Clin. Infect. Dis.
2016
,63,
1312–1317. [CrossRef]
39.
Fr
é
alle, E.; Rocchi, S.; Bacus, M.; Bachelet, H.; Pasquesoone, L.; Tavernier, B.; Mathieu, D.; Millon, L.;
Jeanne, M. Real-time polymerase chain reaction detection of Lichtheimia species in bandages associated with
cutaneous mucormycosis in burn patients. J. Hosp. Infect. 2018,99, 68–74. [CrossRef]
40.
McDermott, N.E.; Shea, Y.R.; Walsh, T.J. Successful treatment of periodontal mucormycosis: Case report and
literature review. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodontol. 2010,109, e64–e69. [CrossRef]
41.
Downie, M.L.; AlGhounaim, M.; Davidge, K.M.; Yau, Y.; Walsh, T.J.; Pope, E.; Somers, G.R.; Waters, V.;
Robinson, L.A. Isolated cutaneous mucormycosis in a pediatric renal transplant recipient. Pediatr. Transplant.
2018,22, e13172. [CrossRef] [PubMed]
42.
Kontoyiannis, D.P.; Lewis, R.E.; Lotholary, O.; Spellberg, B.; Petrikkos, G.; Roillides, E.; Ibrahim, A.; Walsh, T.J.
Future Directions in Mucormycosis Research. Clin. Infect. Dis. 2012,54, S79–S85. [CrossRef] [PubMed]
43.
Walsh, T.J.; Skiada, A.; Cornely, O.A.; Roilides, E.; Ibrahim, A.; Zaoutis, T.; Groll, A.; Lortholary, O.;
Kontoyiannis, D.P.; Petrikkos, G. Development of new strategies for early diagnosis of mucormycosis from
bench to bedside. Mycoses 2014,57, 2–7. [CrossRef] [PubMed]
44.
Alanio, A.; Garcia-Hermoso, D.; Mercier-Delarue, S.; Lanternier, F.; Gits-Muselli, M.; Menotti, J.; Denis, B.;
Bergeron, A.; Legrand, M.; Lortholary, O.; et al. Molecular identification of Mucorales in human tissues:
Contribution of PCR electrospray-ionization mass spectrometry. Clin. Microbiol. Infect.
2015
,21, 594.e1–594.e5.
[CrossRef] [PubMed]
45.
Millon, L.; Scherer, E.; Rocchi, S.; Bellanger, A.-P. Molecular Strategies to Diagnose Mucormycosis. J. Fungi
2019,5, 24. [CrossRef] [PubMed]
46.
Baldin, C.; Soliman, S.S.M.; Jeon, H.H.; Alkhazraji, S.; Gebremariam, T.; Gu, Y.; Bruno, V.M.; Cornely, O.A.;
Leather, H.L.; Sugrue, M.W.; et al. PCR-Based Approach Targeting Mucorales-Specific Gene Family for
Diagnosis of Mucormycosis. J. Clin. Microbiol. 2018,56, e00746-18. [CrossRef] [PubMed]
47.
Dadwal, S.S.; Kontoyiannis, D.P. Recent advances in the molecular diagnosis of mucormycosis. Expert Rev.
Mol. Diagn. 2018,18, 845–854. [CrossRef]
48.
Walsh, T.J.; McCarthy, M.W. The expanding use of matrix-assisted laser desorption/ionization-time of flight
mass spectroscopy in the diagnosis of patients with mycotic diseases. Expert Rev. Mol. Diagn.
2019
,19,
241–248. [CrossRef]
49.
Di Pentima, M.C.; Chan, S.; Powell, J.; Napoli, J.A.; Walter, A.W.; Walsh, T.J. Topical amphotericin B in
combination with standard therapy for severe necrotizing skin and soft-tissue mucormycosis in an infant
with bilineal leukemia: case report and review. J. Pediatr. Hematol. Oncol. 2014,36, e468–e470. [CrossRef]
50.
McCarthy, M.W.; Kontoyiannis, D.P.; A Cornely, O.; Perfect, J.R.; Walsh, T.J. Novel Agents and Drug Targets
to Meet the Challenges of Resistant Fungi. J. Infect. Dis. 2017,216, S474–S483. [CrossRef]
51.
Thielen, B.K.; Barnes, A.M.T.; Sabin, A.P.; Huebner, B.; Nelson, S.; Wesenberg, E.; Hansen, G.T. Widespread
Lichtheimia Infection in a Patient with Extensive Burns: Opportunities for Novel Antifungal Agents.
Mycopathologia 2019,184, 121–128. [CrossRef] [PubMed]
©
2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).
