60-Year-Old Patient with Invasive Mold Infection Consequent to an Encounter with a Barnyard Animal

Abstract

Abstract Introduction/Objective Lichtheimia and Scedosporium species are ubiquitous fungi associated with a range of clinical presentations. We report a complex soft tissue coinfection caused by Lichtheimia spp. and Scedosporium spp. following a puncture wound by a rooster spur. Methods/Case Report A 60-year-old immunosuppressed man with a history of heart transplant presented with a non-healing wound 2-months after sustaining a lower leg puncture secondary to a rooster spur. The patient was previously treated with Augmentin for presumed cellulitis without improvement. To characterize the ongoing disease process, the wound was sampled with tissue portions routed for both histopathologic review and culture. In short order, the biopsy demonstrated invasive hyaline pauciseptate fungal hyphae consistent with organisms of the Mucorales order. In congruence, culture rapidly revealed a mucoraceous mold, subsequently identified as a Lichtheimia spp. Thus, the patient was treated with liposomal amphotericin B. However, days later, a second fungus - a Scedosporium spp. - was isolated from the original specimen. Consequently, isavuconazonium sulfate therapy was added. Re-review of the initial biopsy enabled distinction of two populations of fungal hyphae plausibly representing both molds. Despite numerous debridements and optimal medical management, the patient was ultimately referred for amputation. Results (if a Case Study enter NA) NA. Conclusion When encountered in an immunocompromised host, providers understandably respond to an invasive mucoraceous mold with alarm followed by quick, decisive action. However, septate molds, such as the Scedosporium spp., can also be aggressive. Further, the presence of more than one invasive mold presents a treatment challenge as the mucormycetes may require surgery coupled with amphotericin B therapy; whereas, the a Scedosporium spp. may be wholly resistant to amphotericin B. This case illustrates the critical role that an alert pathologist plays in guiding management through integration of data from different diagnostic modalities. It also constitutes an emphatic reminder that an illness may be caused by more than one actionable, invasive fungus.