Soft-Tissue Fungal Infections: Surgical Management of 12 Immunocompromised Patients

Abstract

Isolated fungal soft-tissue infections are uncommon but may cause severe morbidity or mortality among transplant recipients and other immunosuppressed patients. Twelve immunocompromised patients illustrating three patterns of infection were treated recently at the Duke University Medical Center. These groups comprised (I) locally aggressive infections, (II) indolent infections, and (III) cutaneous manifestations of systemic infection. Patient diagnoses included organ transplant, leukemia, prematurity, chronic obstructive pulmonary disease, and rheumatoid arthritis. Time from immunosuppression to biopsy ranged from 5.5 to 31 weeks. Organisms included Aspergillus, Rhizopus, Fusarium, Paecilomyces, Exophiala, and Curvularia. Patients presented with necrotic ulcerations or nodules. Surgical treatment ranged from radical debridement to excisional biopsy to none. Antifungal chemotherapy also was employed in some cases. The mortality rate was 33 percent, two patients dying without evidence of fungal infection. Six of the eight survivors cleared their infections. Necrotic skin lesions with surrounding erythema in this population call for prompt examination, biopsy, and culture. Group I lesions mandate radical excision with rapid intraoperative microscopic control and systemic antifungal medication. Group II requires surgical control with or without antifungal therapy. Group III requires systemic antifungal therapy for metastatic infection. In our opinion, treatment of fungal soft-tissue infection should be tailored to infection type and requires a team approach of surgeon and expert infectious disease consultation.

AspergillusInfections in Transplant Recipients

“…An exception may be in patients with hematologic disorders in which neutropenia may be reversed. Successful treatment of primary cutaneous aspergillosis associated with neutropenia has been associated with reversal of neutropenia by use of granulocyte colony-stimulating factor (G-CSF) (115). Amphotericin preparations or voriconazole would be the preferred initial therapy.…”

“…Therapy was switched to caspofungin, with dramatic and sustained improvement. Numerous reports have demonstrated that postsurgical wound infection requires aggressive surgical intervention in addition to antifungal drugs for successful resolution (45,115). The surgery may be as aggressive as limb amputation or extensive debridement of the kind seen in cases of necrotizing fasciitis.…”

Morphologic Criteria for the Preliminary Identification ofFusarium, Paecilomyces, andAcremoniumSpecies by Histopathology

“…4,18 The accurate identification of Fusarium species, Paecilomyces lilacinus, and Acremonium species is of practical importance, because they often are resistant to several of the available antifungal agents. Selection of initial antifungal drug therapy and possible inclusion of surgical treatments may depend on the identity of the fungus, 21 " 23 and early specific antifungal therapy is more likely to lead to a positive clinical outcome. Definitive diagnosis of etiology in hyalohyphomycosis requires culture for the identification of the offending organism.…”

“…22 ' 23,34 Although culture remains the standard for identification of the causative agents of hyalohyphomycosis, presumptive identification of these fungi in histologic sections is of value for several reasons. Histology results can be obtained in less than 24 hours, whereas a preliminary culture identification may require several days.…”

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“…The therapy of localized fusariosis is important to prevent progression to disseminated fusariosis and includes surgical excision and systemic antifungal therapy. 6,10 However, the prompt treatment of disseminated fusariosis is unclear. 3 Fusarium species are resistant to most antifungal drugs.…”