Connie Price

Justin J Mitchell

Kyros Ipaktchi

Richard J Bowles

Patient Safety in Surgery

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Severe mycosis as a rare infection after a corn auger injury of the hand: a case report

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Bowles et al. Patient Safety in Surgery  (2015) 9:22 
DOI 10.1186/s13037-015-0061-xCASE REPORT Open AccessSevere mycosis as a rare infection after a corn
auger injury of the hand: a case report
Richard J Bowles1, Justin J Mitchell1, Connie Price2 and Kyros Ipaktchi3*Abstract
Mucormycosis is a rare but serious infection that can be seen in immunocompetent individuals who experience
traumatic injury. The authors report a case in a 28 year-old man who sustained a mangling hand injury in a corn
augur accident. After initial aggressive debridement ongoing tissue necrosis was seen, and in subsequent biopsies
invasive mucormycosis was diagnosed. The patient was successfully managed with immediate surgical debridement
and antifungal medication and showed no sign of infection at six-month follow-up.
Keywords: Agricultural injuries, Mangled hand, Mucormycosis, ZygomycosisBackground
Mucormycosis, formerly known as zygomycosis, is a rare
infection caused by fungal species that are commonly
found in soil and decaying organic matter. Though
mucormycosis is more likely in immunocompromised
individuals, traumatic injury may allow penetration of
the fungus through the mucocutaneous barrier and
aggressive infection may result. Typical for this infection
is the “angioinvasive” spreading of the disease process
which can result in a risk for loss of limb and life if not
rapidly controlled. Identification and treatment of this
serious infection is important as the mortality rate asso-
ciated with cutaneous mucormycosis has been shown to
be as high as 31% [1].
In this case report we describe an immunocompetent
patient involved in an agricultural accident who sus-
tained a mangled left hand that was complicated by a
subsequent mycotic infection.
Case presentation
A 28-year-old right-hand-dominant man was airlifted for
limb salvage to the level 1 trauma center where the
investigators practice after sustaining an agricultural ac-
cident in which his left hand was pulled into a corn
augur. The mangling injury of his hand included frac-
tures of his index through ring fingers with extensive* Correspondence: Kyros.ipaktchi@dhha.org
3Department of Orthopedic Surgery, Denver Health Medical Center, 777
Bannock St, Denver, CO 80204, USA
Full list of author information is available at the end of the article
© 2015 Bowles et al.; licensee BioMed Central
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reproduction in any medium, provided the or
Dedication waiver (http://creativecommons.or
unless otherwise stated.lacerations and exposed flexor tendons. There was a par-
tial degloving injury to his left palm (Figures 1 and 2).
The patient was otherwise stable and had no additional
injuries. Upon arrival he was taken emergently to the
operating room, where he underwent irrigation and de-
bridement, primary fusion with Kirschner wires of the
destroyed PIP joints in his left index, long, and ring fin-
gers, a split-thickness skin-graft to his left palm and long
finger from a left forearm donor site, and initiation of IV
antibiotics, administering vancomycin and ampicillin/
sulbactam. He recovered uneventfully and was dis-
charged home four days later without additional anti-
biotic therapy.
At his first follow-up appointment two weeks post-
operatively, he showed no sign of systemic infection but
was noted to have an extensive necrosis involving part
of his left long finger and the palmar skin graft (Figure 3).
Surgical debridement including amputation of the long
finger was scheduled and he underwent a filet flap clos-
ure of the second webspace after long finger ablation.
Tissue samples revealed both bacterial and mold growth,
and the Infectious Disease team was consulted. Due to
the suspicion for an invasive mucor mycosis he was
taken the next morning for additional irrigation and de-
bridement, and lipid-complex amphotericin B was added
to his antibacterial medications. Cultures were speciated
to coagulase-negative Staphylococcus, two different spe-
cies of Pseudomonas, and mycotic species including
Mucor and Aspergillus fumigates. He recovered well and
was later discharged home on hospital day five with a. This is an Open Access article distributed under the terms of the Creative
ommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
iginal work is properly credited. The Creative Commons Public Domain
g/publicdomain/zero/1.0/) applies to the data made available in this article,
Figure 1 Preoperative situation demonstrating extensive soft tissue laceration by corn grinding machinery (left). Postoperative view after
irrigation and debridement with partial soft tissue closure (right).
Bowles et al. Patient Safety in Surgery  (2015) 9:22 Page 2 of 5Hohn catheter and an outpatient antibiotic regimen
planned for four total weeks that included vancomycin 1
g intravenously twice daily, Zosyn 12 g continuous infu-
sion daily, and Posaconazole suspension 400 mg (10 mL)
orally twice daily.
He continued to show improvement at his follow-up
appointments with both Orthopaedic Surgery and Infec-
tious Disease. Approximately one week after discharge
his AFB cultures taken intraoperatively turned positive
by probe for Mycobacterium tuberculosis complex, which
stood in contrast to a negative PPD test that had been
documented within the previous two years. At this clinic
visit a new PPD was placed and later found to beFigure 2 Preoperative radiographs showing proximal interphalangial joint
phalanx fracture of the thumb.negative when read in his home town. A chest radio-
graph also showed no sign of TB infection. Ultimately
the positive AFB was attributed to an environmental
mycobacterial contaminant.
His weekly labs drawn by a home health agency were
otherwise unremarkable until approximately three weeks
after his discharge. At that time he was found to be neu-
tropenic with a white blood cell count of 3100 (absolute
neutrophil count 120), and he was admitted to the hos-
pital in his hometown where all of his antibiotics and
antifungals were held. He was discharged several days
later after recovery of his white blood cell count without
sign of infection or any further complication. Thoughfracture dislocations of left index, long, and ring fingers and proximal
Figure 3 Day 14 showing full thickness necrosis of the volar aspect of the long finger and a deep infection at the volar base of the ring finger
and distal palm (left). Postoperative aspect after long finger resection and filet flap coverage of volar defect with dorsal skin from long
finger (right).
Bowles et al. Patient Safety in Surgery  (2015) 9:22 Page 3 of 5his antibiotic regimen was not restarted (as he had
nearly completed his planned course), he remained free
of infection and healed well (Figure 4).
Conclusions
Mucormycosis is caused by organisms of the Mucorales
order, which are commonly found in nature growing as
mold on decaying plant matter and in the soil. The inci-
dence of mucormycosis is not well-established, but it is
estimated to be 1.7 cases per 1,000,000 people per year
[2]. Given its ubiquity, the fact that the incidence of
disease is so low is a testament to the effectiveness
with which the normal immune system handles these
organisms. Immunocompromised individuals more
likely to be infected; conditions associated with in-
creased risk of infection include poorly-controlled
diabetes, hematopoietic malignancy, and solid organ/
hematopoietic cell transplantation, among others [1].
There are infrequent case reports of mucormycosis
following trauma [3-7].Figure 4 Follow up after 6 months showing healed soft tissues free of signGenera from the order Mucorales are responsible
for most human infections caused by the fungal class
Zygomycetes. Though these infections were previously
termed either “mucormycosis” or “zygomycosis,” recent
studies suggest that “mucormycosis” should be the cor-
rect name [8]. Human infections are most commonly
attributed to Mucor, Rhizopus, Rhizomucor, though in-
fections caused by other genera – including Absidia,
Apophysomyces, Cunninghamella, and Saksenaea – have
also been documented [1].
Mucorales organisms may cause infection via inhal-
ation or ingestion of spores or by direct cutaneous
inoculation. All demonstrate infarction and necrosis
of infected tissue characterized by angioinvasion of
fungal hyphae [9]. Mucormycosis most commonly af-
fects the sinuses and lungs; skin is the third most
common manifestation [10]. Our patient’s injury was
the obvious source of his cutaneous inoculation, and
the severity of the trauma itself likely contributed to
his risk.s of infection.
Bowles et al. Patient Safety in Surgery  (2015) 9:22 Page 4 of 5Cutaneous mucormycosis may present initially with
varied appearances, including pustules/vesicles and
widely necrotic wounds. Bouza et al. describe “a cotton-
like growth that] may be observed over the surface of
the tissues, a clinical sign known as ‘hairy pus [10].’”
Our patient’s wounds did not demonstrate this sign, but
were necrotic and purulent. Their appearance did not
raise immediate suspicion for fungal infection specific-
ally, but given the mechanism and setting of his injury it
was important to consider fungal infection in his differ-
ential diagnosis, both on presentation and in the setting
of post-operative infection.
While both medical and surgical measures are in the
treatment of mucormycosis, prompt surgical debride-
ment remains the mainstay. Obtaining tissue samples for
histologic assessment is important in determining the
likely pathogen: In our case the early return to the OR
was indicated by the pathologic findings suspicious of
murcormycosis. The European Society for Clinical
Microbiology and Infectious Diseases (ESCMID) and the
European Confederation of Medical Mycology (ECMM)
recently published joint clinical guidelines for the diagnosis
and management of mucormycosis, writing “surgery when-
ever possible is strongly recommended to be combined
with medical treatment [11].”
Defining the extent of debridement necessary remains
challenging, the capacity of mucormycosis to spread via
angioinvasion may entail debridement so aggressive as
to include amputation [12]. In our patient, amputation
of the long finger and debridement to healthy-appearing
bleeding tissue were sufficient to control the spread of
infection; in more proximal lesions, this may be more
challenging, as other authors have reported [13].
Standard antifungals may not be effective against
mucormycosis. The ESCMID/ECCM paper recommends
liposomal (or lipid-complex) amphotericin B as first-line
antifungal therapy and recommends against the use of
amphotericin B deoxycholate due to its side-effect pro-
file. Posaconazole, a newer triazole agent, is recom-
mended as salvage therapy for patients who fail primary
antifungals due to refractory disease, intolerance, or
both.
The basis for these recommendations is born out
in previous case reports describing mucormycosis.
Lineberry et al. recently reported success treating an
upper extremity Rhizopus infection with surgical de-
bridement in a 54-year-old woman without predis-
posing risk factors [4]. Seguin et al. recounted the
case of a 39-year-old immunocompetent patient who
required repeated debridements and ultimately above-
knee amputation to control a lower leg wound infection
with Absidia corymbifera [7]. Additionally, Moran et al.
catalogued seven cases of upper extremity mucormycosis,
four of which ultimately resulted in amputation; theyconcluded that early recognition and surgical debride-
ment remains the central therapy in the treatment of
these infections [3].
Even with surgery, these infections are so serious and
difficult to manage that death may ultimately occur.
Kontogiori et al. describe a fatal case of necrotizing fas-
ciitis in a 25-year-old, previously healthy farmer who
died 19 days after sustaining open lower extremity frac-
tures infected by multiple organisms including Rhizopus
despite once or twice daily debridement and aggressive
antifungal therapy.6 Similarly Horre et al. reported the
case of a 38-year-old otherwise healthy man who died
18 days after sustaining abdominal trauma in a bike acci-
dent that resulted in intraabdominal infection with
Candida albicans and Absidia corymbifera; daily debride-
ment and amphotericin B plus flucytosine failed to stop
his infection.5.
In our patient, surgical debridement and lipid-complex
amphotericin B were used while he was in-house, and
posaconazole was substituted for amphotericin for his
outpatient regimen given its oral route of administration
(versus intravenous for amphotericin). No specific rec-
ommendations for duration of treatment were made in
the ECSMID/ECMM report; our patient’s therapy was
discontinued at four weeks after he became neutropenic.
He remained free of any sign of infection at his follow-
up six months later.
We attribute our success in managing this patient to
prompt surgical management and appropriate antifungal
therapy, and cannot overstate the importance of collab-
oration between our orthopaedic surgery and infectious
disease teams in facilitating early recognition and treat-
ment of this potentially devastating infection.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the editor-in-chief of this journal. IRB ap-
proval was not required for this manuscript.
Abbreviations
PIP joint: Proximal interphalangeal joint; IV: Intravenous; G: Gram; mL: milliliter;
AFB cultures: Acid fast bacilli cultures; PPD test: Purified protein derivative test
(Tuberculin test); TB infection: Tuberculosis infection; ESCMID: European Society
for Clinical Microbiology and Infectious Diseases; ECMM: European Confederation
of Medical Mycology.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
RJB carried out the literature review and initial formatting/outline/writing of
the manuscript. JJM performed the majority of writing/editing of the
manuscript and provided intellectual content. CSP provided all background
related to infectious disease treatment, interpretation of references, and
information on medical management. JC was instrumental in treatment of
the patient, editing of the manuscript and providing critically important
Bowles et al. Patient Safety in Surgery  (2015) 9:22 Page 5 of 5imaging and intellectual content. KI is the senior author, provided the case
and idea and oversaw all writing, editing, and compilation of the manuscript.
All authors read and approved the final manuscript.
Author details
1Department of Orthopaedic Surgery, University of Colorado School of
Medicine, 12631 E. 17th Avenue, Aurora, CO 80045, USA. 2Department of
Medicine, Infectious Diseases, Denver Health Medical Center, 777 Bannock
Street, Denver, CO 80204, USA. 3Department of Orthopedic Surgery, Denver
Health Medical Center, 777 Bannock St, Denver, CO 80204, USA.
Received: 10 November 2014 Accepted: 15 April 2015
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Severe mycosis as a rare infection after a corn auger injury of the hand: a case report

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