Multiple Modality Treatment Regimen in an Aggressive Resistant Fungal Hand Infection: A Case Report

Abstract

Cutaneous fungal infections are a rare but significant complication associated with immunocompromised states. Lesions allowed to progress to disseminated fungemia are associated with a near 80% mortality rate. Treatment guidelines aimed at local control are vague, centering on wide local excision with systemic antifungal medications. We present the case of a 3-year-old female who, while receiving induction chemotherapy, developed a progressive Aspergillus flavus infection. Involvement included the distal palm and common and proper neurovascular bundles to two fingers. Initial treatments with serial debridement and topical Dakin's solution were unsuccessful in eliminating this fungal infection. A novel treatment using topical voriconazole mixed with Aquaphor® (Beiersdorf AG; Hamburg, Germany) was compounded in the hospital pharmacy to maintain a moist wound healing environment followed by the use of the Vacuum Assisted Closure (VAC®, Kinetic Concepts, San Antonio, TX). Significant improvement was noted within 4 days with this new dressing regimen. Topical voriconazole therapy followed by VAC allowed progressive healing and eventual closure with a split thickness skin graft. The wound was then durably closed, allowing critical chemotherapy to resume. No evidence of systemic fungemia developed, and her clinical recovery preceded laboratory evidence of immune system recovery. Fungal skin infections can be a threat to both life and limb in immunocompromised patients. The armamentarium available to combat this rare but difficult problem is imperfect. In certain infections not responsive to other therapies, the therapeutic regimen described herein should be considered if wide local excision carries significant functional morbidity.

Cutaneous mucormycosis secondary to penetrative trauma

“…The use of dilute acetic acid as a prophylactic wound dressing, in trauma patients that are at a high risk of mucormycosis, has been suggested yet further study is warranted to fully advocate its use [33]. Adjuvant hyperbaric oxygen therapy is as yet unproven, while use of negative pressure wound therapy has shown to be helpful and its use is actively encouraged [6,22,27] .…”

Quantification of Impurity-E in Voriconazole Powder for Solution for Infusion (200 mg/vial) by using High Performance Liquid Chromatography

“…Voriconazole is chemically (2R,3S)-2-(2, 4-difluorophenyl)-3-(5fluoro-4-pyrimidinyl)-1-(1H-1,2,4triazol-1-yl)-2-butanol. 1 Voriconazole is a used to treat serious fungal or yeast infections 2 , such as aspergillosis 3 (fungal infection in the lungs), candidemia (fungal infection into the blood) esophageal candidiasis 4 (candida esophagitis) or other fungal infections (infections in the skin, stomach, kidney, bladder or wounds). It inhibits the cytochrome P450 [5][6][7][8][9] (CYP)-dependent enzyme 14-alpha-sterol demethylase, thereby disrupting the cell membrane and halting fungal growth 10 .…”