A A Bansalii

A Scalise

Adelmo Terenzi

Antonella Repetto

CS Cocanour

D Mackenzie

DH Marshall

E Dannaoui

E Jantunen

J Garbino

JA Ribes

Laura Marchesini

P Seguin

QN Sun

R Horre

Rita Belfiori

RN Greenberg

V Rickerts

WH Tiong

BMC Infectious Diseases

English

PubMed

Springer - Publisher Connector

BioMed CentralBMC Infectious Diseases
ssOpen AcceCase report
Absidia Corymbifera in an immune competent accident victim with 
multiple abdominal injuries: case report
Rita Belfiori1, Adelmo Terenzi*2, Laura Marchesini1 and Antonella Repetto3
Address: 1Intensive Care Unit, Perugia General Hospital, Monteluce, Perugia, Italy, 2Hematology and Clinical immunology Section. Dept. of 
Clinical and Experimental Medicine, University of Perugia, Italy and 3Microbiology Unit, Dept of Experimental Medicine and Biochemical 
Sciences, University of Perugia, Italy
Email: Rita Belfiori - contipg@libero.it; Adelmo Terenzi* - adterenzi@tiscali.it; Laura Marchesini - lauramarchesini@tiscali.it; 
Antonella Repetto - ar.mont.batt@libero.it
* Corresponding author    
Abstract
Background: We report a case of mucormycosis in a healthy 17-year-old accident victim with multiple
abdominal injuries which was caused by infection with Absidia Corymbifera, a ubiquitous saphrophyte in the ground.
Case presentation: The patient was admitted to hospital with massive abdominal trauma. During an 8-hour
emergency operation he received transfusions of compacted red blood cells, plasma, platelets and hemagel. He
developed a crush syndrome with acute renal failure, resolved with extra-corporeal dialysis and had to undergo
splenectomy because of spleen hematoma. As wound secretion and central venous catheter (CVC) blood cultures
and drainage fluid were positive for Enterococcus Faecium, Providentia Rettgeri, Hafnia Alvei and Candida Albicans,
tecoplanin, metronidazole, imipenem, and flucanozole were administered.
Although the CVC was changed high fever persisted and discharge continued from the large abdominal wound.
Repeated tampons in different sections and wound secretion smears were positive for A. corymbifera. Flucanozole
was stopped and liposomal amphotericin (Ambisome; 5 mg/Kg i.v.) given for over 3 months.
The patient improved; fever gradually disappeared. After 8 days, tampons and wound secretion smears were
negative for A. corymbifera. No other fungal infections developed. Drainage fluid was later positive for tecoplanin-
resistant E. faecium and Pseudomonas Aeroginosa responding only to meropenem and ciprofloxacin. Abdominal
computerized tomography visualized fluid accumulation around the iliac-femoral bypass. Abcess was ruled out
when scintigraphy showed no tracer uptake. The lesion was drained. Drainage fluid cultures were negative for
bacteria and fungi. Fluid accumulation gradually disappeared with prolonged antibiotic and antifungal therapy.
One year after the accident the patient is in good health, with normal quality of life.
Conclusion: Successful outcome was due to early, specific antifungal therapy, at sufficiently high dosage which
was prolonged for an adequate period of time. Early diagnosis of mucormycosis is essential for efficacious anti-
fungal treatment and prevention of irreversible spread of mucormycosis to vital organs. It presupposes awareness
that A. corymbifera infection can develop in healthy individuals who are stressed and traumatized through skin-
ground contact in accidents.
Published: 25 May 2007
BMC Infectious Diseases 2007, 7:46 doi:10.1186/1471-2334-7-46
Received: 5 October 2006
Accepted: 25 May 2007
This article is available from: http://www.biomedcentral.com/1471-2334/7/46
© 2007 Belfiori et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
BMC Infectious Diseases 2007, 7:46 http://www.biomedcentral.com/1471-2334/7/46Background
Absidia genus, a fungus belonging to the Mucorales group
of the Zygomycetes class, is an ubiquitous saphrophyte in
the ground which may cause zygomycosis. Although
those infections have occasionally been reported in
immune competent patients after accidents or trauma
involving contamination through skin-ground contact [1-
3], they usually occur in immune depressed hosts e.g.
patients undergoing chemotherapy for cancer or leukae-
mia, patients with poorly controlled diabetes, particularly
if ketoacidosis is present, those with iron accumulation,
those undergoing chelant therapy, haemodialysis or pro-
longed steroid therapy, patients who are positive for
human immunodeficiency virus (HIV) or who have suf-
fered severe, extensive burns [4-6]. Symptoms range from
a skin infection around wounds to systemic multi-visceral
involvement. Zygomycetes infection is confirmed by
hyphae in tampon cultures that are refractory to antibiotic
therapy and by wound secretion positivity at microscopy.
Histology is not always positive for Absidia Corymbifera
[4]. Here we report a case of mucormycosis in an appar-
ently immune competent accident victim with multiple
abdominal injuries.
Case presentation
A healthy 17-year-old Caucasian male weighing 70 Kilo-
grams was infected with Absidia Corymbifera after suffering
major abdominal injuries in an accident with agricultural
machinery. The patient was admitted to hospital with
multiple abdominal muscle lacerations and soil contami-
nation of the abdominal wall, haemorrhage from the
right internal iliac artery, multiple vein lacerations, contu-
sions and obstruction of the right external iliac artery at
the iliac-femoral junction, superficial femoral vein lacera-
tion, ruptured intestine and colon, fractured pelvis with
bone detachment, right retroperitoneal hematoma and
haemorrhagic shock.
In an 8-hour emergency operation surgeons constructed
an external iliac-right common femoral artery bypass,
inserted ligature of the right hypogastric artery, sutured
iliac-femoral vein lacerations, resectioned the small intes-
tine and left colon and sutured lacerations in the rectum,
right abdomen and psoas. During surgery the patient
received transfusions of 11 units of compacted red blood
cells, 9 units of plasma, 10 units of platelets and 9 litres of
hemagel.
After surgery the patient was admitted to the Intensive
Care Unit (ICU) because of marked hypothermia and low
blood pressure. Blood tests showed: white blood cells 10
× 109/L; haemoglobin12.4 g/dl; platelets: 124 × 109/L;
prothrombin: 55%; partial thromboplastin time: 39.7 sec;
International Normalized Ratio = 2; fibrinogen 195 mg/
dl. Blood chemistry indicated nitrogen 33 mg/dl; creati-
nine 11 mg/L; creatinine clearance 100 ml/min; proteins
3.9 g/dl; albumin 1.7 g/dl; aspartate aminotransferase 101
UI/L; alamine aminotransferase 36 UI/L; creatine phos-
phokinase (CPK) 8436 UI/L; lactic dehydrogenase (LDH)
930 UI/L; myoglobin >500 ng/ml; normal electrolyte bal-
ance; glucose 90 mg/dl; lactate 43.1 mg/dl (normal range
5.7–22). The patient was HIV negative. As drainage fluid
was positive for Enterococcus Faecium, Providentia Rettgeri,
Hafnia Alvei and Candida Albicans, tecoplanin (6 mg/Kg
i.v. once daily), metronidazole (7.5 mg/Kg i.v. daily 4
times daily) imipenem (10 mg/Kg i.v. thrice daily) and
flucanozole (8 mg/Kg i.v. once daily) were administered.
Twelve hours after admission to the ICU he developed a
crush syndrome with acute renal failure requiring imme-
diate extra-corporeal dialysis. Dosages of all drugs were
adjusted to renal function.
Day +3
Severe acute renal failure was partially resolved. No urina-
tion; creatinine 57 mg/L; clearance 4.30 ml/min; CPK
95700 IU/L (normal value < 190 UI/L); myoglobulin
>500 UI/L; LDH 4733 IU/L. Potassium 7.1 mEq/L. Four
days later extracorporeal dialysis was stopped.
Day +4
The patient underwent splenectomy because of spleen
hematoma with peritoneal bleeding. 800 ml blood were
removed.
Day +6
Surgical wound secretion resulted positive for A corymbif-
era, E. faecium, P Rettgeri, H. alvei and C. albicans. Wound
secretion and CVC blood cultures were positive for C. albi-
cans. A. corymbifera positivity was considered accidental
contamination due to residual soil traces.
Day + 10
Although the CVC had been changed very high fever per-
sisted. The patient was affected by vomiting and confu-
sion. Discharge continued from the large, hyperemic,
foul-smelling, abdominal wound. Surgeons drained
abcess fluid from the right abdominal wall. Cultures of
abcess fluid and drainage, as well as wound secretion
smears, were positive for A. corymbifera (figs 1, 2 and 3).
Growth was observed in mycetes medium and confirmed
in Saburaud agar where greyish-white, woolly, flock-like
colonies were observed 48 hours later. An antimicrogram-
mme indicated resistance to 5-fluorocytosine, flucanozole
and voriconazole and response to amphotericin B with a
low antimicrogramme index (0.016 μg/ml). Posacona-
zole was not tested as it was not available the hospital
pharmacy. Flucanozole was suspended and liposomal
amphotericin (Ambisome) started (5 mg/Kg i.v. for 40
days). Therapy was well tolerated.Page 2 of 5
(page number not for citation purposes)
BMC Infectious Diseases 2007, 7:46 http://www.biomedcentral.com/1471-2334/7/46Day + 15
The patient started to improve and fever gradually
dropped.
Day +18
Tampons and wound secretion smears were negative.
Blood cultures for C. albicans were also negative. No other
fungal infections developed.
Day +20
Drainage fluid was positive for E. faecium and Pseu-
domonas Aeroginosa. As E. faecium was resistant to teco-
planin and vancomycin, linezolid (10 mg/Kg i.v. twice
daily) and rifampycin (15 mg/Kg i. v. twice daily) were
administered. P. Aeroginosa responded only to mero-
penem (13 mg/Kg i.v. thrice daily) and ciprofloxacin (6.5
mg/Kg i.v. thrice daily). This combined antibiotic therapy
was continued until discharge from the ICU.
Day + 35
Abdominal computerized tomography visualized an area
of 12 × 5.5 cm fluid accumulation around the iliac-femo-
ral bypass. Abcess was ruled out when scintigraphy of
autologous radio-labelled leucocytes showed no tracer
uptake.
Given the risks of further surgery, the relatively complex
surgical technique that would be required, the patient's
25% loss of body weight despite parenteral nutrition with
2,500 calories daily and negative scintigraphy, it was
decided only to drain the lesion. Drainage fluid cultures
were negative for bacteria and fungi, confirming the valid-
ity of therapy. Fluid accumulation gradually disappeared
with prolonged antibiotic and antifungal therapy. (Figure
4 shows the patient's clinical course). After 75 days in the
ICU the patient was transferred to the Infectious Diseases
Unit where he continued anti-infectious treatment with
liposomal amphotericin B, linezolid and ciprofloxacin for
another two months. One year after the accident he is in
good health, with normal quality of life.
Discussion
The massive abdominal trauma could have facilitated
abdominal colonization by A. corymbifera. Systemic fac-
tors – acute renal failure, multiple fractures, soft tissue
destruction, haemorrhagic shock, transfusions, antibiotic
therapy, parenteral nutrition – undoubtedly stressed the
patient's immune status and facilitated fungal growth.
Mucor's marked affinity for blood vessels, determining
necrosis rather than abcess, probably accounts for our
negative scintigraphy. One may hypothesize the fluid was
fungal-related and that antifungal therapy and drainage
gradually eliminated it. Fever disappeared completely a
long time after cultures became negative because, in
patients with major abdominal injuries, bacterial abdom-
inal infections require prolonged therapy with specific
antibiotics
Microscopy (magnification × 100)Figure 2
Microscopy (magnification × 100). Abdominal fluid: A. corymb-
ifera growth in culture with sporangium and cone-shaped col-
umella.
A. corymbifera colony in wound secretion cultureFigure 1
A. corymbifera colony in wound secretion culture.Page 3 of 5
(page number not for citation purposes)
BMC Infectious Diseases 2007, 7:46 http://www.biomedcentral.com/1471-2334/7/46Cocanour et al., [7] reported 9 cases of skin mucormycosis
caused by contact with the ground following trauma.
Overall mortality is 30% which rises to 100% in cases of
cranial and brainstem trauma because of necrosis in soft
tissues adjacent to the brain and the ensuing encephalitis,
as is observed in cases of endoophthalmitis [8]. In these 9
patients abdominal involvement was not fatal. On the
other hand, Horre et al., [9] reported simultaneous infec-
tion with C. albicans and A. corymbifera in a healthy patient
who suffered multiple rib fractures, kidney, liver and pan-
creas rupture in a road accident. After surgery, the abdo-
men wall was infected with both fungi and, despite
amphotericin B therapy, the patient died of multi-organ
failure. Our young patient probably survived similar
infections because, apart from the spleen, his vital abdom-
inal organs were injured less severely in the accident.
In A. corymbifera infection amphotercin B is more effica-
cious in vitro and in vivo than voriconazole or itracona-
zole [10,11]. Posaconazole, which is also efficacious in
vivo and in vitro [11], has been successfully administered
in cases of amphotericin B intolerance [12], as salvage
therapy for zygomycosis [13] and, in combination with
amphotericin B, as therapy for disseminated infection
[14]. Consequently, treatment of choice for A. corymbifera
infection is early therapy with amphotocerin B alone or in
combination with posaconazole, together with surgical
asportation of necrotic tissue to remove the infected area
Clinical course and microbiological culturesFigure 4
Clinical course and microbiological cultures. • Blood cultures: positive for C. albicans. ■ Tampons and abdominal drainage fluid: 
positive for A. corymbifera.  Negative blood cultures.  Tampons and abdominal drainage fluid: negative for A. corymbifera.
Microscopy (magnification × 100)Figure 3
Microscopy (magnification × 100). A. corymbifera : Typical 
broad non-separate hyphae showing right-angled branching.Page 4 of 5
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[15]. As our patient had been affected by acute renal fail-
ure we opted for liposomal amphotercin B which ensured
prolonged treatment at a sufficient dosage and no organ
toxicity. We also preferred drainage to any further surgery.
Conclusion
In this patient with concomitant A. corymbifera and C. albi-
cans infections, successful outcome was due to early, spe-
cific antifungal therapy at sufficiently high dosage which
was prolonged for an adequate period of time. Early diag-
nosis using wound secretion cultures and smears is essen-
tial if anti-fungal treatment is to be efficacious and prevent
irreversible spread of Zygomycetes to vital organs. It pre-
supposes awareness that A. corymbifera infection is not
restricted to immune compromised hosts but can develop
in healthy individuals who are stressed and traumatized
through skin-ground contact in accidents.
Abbreviations
CVC = Central Venous Catheter
ICU = Intensive Care Unit
CPK = Creatinine Phosphokinase
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
Rita Belfiori took care of the patient in the ICU and drew
up the first draft of the report, Adelmo Terenzi, consultant
haematologist, made a substantial contribution to analy-
sis and interpretation of clinical and microbiological data
and revised the manuscript critically Laura Marchesini
took care of the patient in the ICU and drew up the figures
Antonella Repetto carried out all microbiological studies
and collected all microbiological data
Acknowledgements
Written consent was obtained from the patient for the publication of study. 
The authors would like to thank Dr Geraldine Anne Boyd, University of 
Perugia, Italy for her help in drafting this paper in English. This study was 
unfunded.
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Pre-publication history
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Absidia Corymbiferain an immune competent accident victim with multiple abdominal injuries: case report

Crossref

Absidia post traumatic infection: successful treatment with posaconazole.

Al Zeerah BF: Post traumatic corneal mucormycosis caused by Absidia Corymbifera. Ophhalmology

De Hoo Ruchel R, Schaal KP: Wound infection due to Absidia Corymbifera and Candida Albicans with fatal outcome. Med Mycol

Fisher RP: Mucormycosis in trauma patients.

JR: In vitro activities of posaconazole, itraconazole, voriconazole, amphoterin B and fluconazole against clinical isolates of zygomycetes. Antimicrob Agents Chemother

JustNubling G: Successful treatment of disseminated mucormycosis with a combination of liposomal amphotericin B and posaconazole in a patient with acute myeloid leukaemia. Mycosis

Meningitis caused by Absidia Corymbifera.

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Post traumatic course complicated by cutaneous infection with Absidia corymbifera.

Post-ttraumatic and post-surgical Absidia Corymbifera infection in a young healthy man. Plast Reconstr Aesthet Surg

Scalose G: Infection due to Absidia Corymbifera in a patient with massive crush trauma of the food.

Vanover Sams CA, Backer DJ: Zygomycetes in human disease. Clin Microbiol Rev

Verweij PE: Activity of posaconazole in treatment of experimental disseminated zygomycosis. Antimicrobial agents and Chemother

Violin L: Invasive cutaneous mucormycosis caused by Absidia Corymbifera after allogeneic bone marrow transplantation. Bone Marrow Transplant

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Absidia Corymbifera in an immune competent accident victim with multiple abdominal injuries: case report

Absidia Corymbifera in an immune competent accident victim with multiple abdominal injuries: case report

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