Primary Cutaneous Zygomycosis in a Burns Patient: A Review

Abstract

Cutaneous zygomycosis is an uncommon but potentially fatal disease. An illustrative case is used to highlight the difficulties in managing these burns patients followed by a review of the literature with special emphasis on the surgical management and outcomes in these patients. English language articles were identified using the MEDLINE database from 1966 to 2006, using key words zygomycosis and mucormycosis. The set was limited to humans and cutaneous disease. All articles (n = 173) were reviewed with special consideration for articles (n = 28) post an extensive review of cutaneous zygomycosis in 1993 by Adam et al. Key clinical features, risk factors, microbiological diagnostics, medical and surgical treatment modalities, outcomes, and prognosis were extracted. In contrast to all overall zygomycosis, cutaneous zygomycosis is associated with immune competency in 50% of cases. Diagnosis remains difficult with extensive and sometimes multiple biopsies confirming the presence of a fungus. Although there are no randomized controlled trials on best care, documented treatment options providing survival benefits include antifungal therapy or surgical debridement. Multiple debridements are routine with amputation not an uncommon scenario. Infection may still progress, despite these aggressive measures. Treated patients with localized cutaneous zygomycosis still have a mortality rate of 31%. Cutaneous zygomycosis is an exceedingly difficult disease to manage with limited evidence to guide management. This review offers some insight to burns surgeons and other health professionals to help provide best practice for patients in the future.

Diagnosis and treatment of mucormycosis in patients with hematological malignancies: guidelines from the 3rd European Conference on Infections in Leukemia (ECIL 3)

“…Surgical debridement may have to be repeated and amputation in case of affected extremities may become necessary. 103,104 In a retrospective single-center analysis of mucormycosis in patients with mostly uncontrolled diabetes mellitus treated between 2000 and 2004, significantly higher survival rates were reported for patients treated with debridement surgery and AmB compared to antifungals alone (80% vs. 52%). 48 In addition to patients with rhino-orbito-cerebral disease, a survival benefit of a combined surgical intervention was also documented for 17 patients with cutaneous infection (91% vs. 80%).…”

Current Diagnosis and Management of Mucormycoses

“…Neonates are more likely to have disseminated disease (56% of cases), when compared with pediatric (13%) or adult (21%) patients [21]. The Mucorales have also been reported to cause cutaneous, cerebral and disseminated IFIs in intravenous drug users and cutaneous infection associated with trauma, severe burns, or recent surgical procedures [1,23]. These trauma-related cases are due to direct percutaneous inoculation of spores following tissue disruption, highlighting the importance of intact integument in host defense.…”

Mucormycosis and Entomophthoramycosis (Zygomycosis)

“…A large epidemic of cutaneous mucormycosis was reported in patients who had contaminated surgical dressings applied to their skin [78,79]. Cutaneous mucormycosis may also occur in burn patients [80].…”