Lower-Extremity Zygomycosis in a Patient with Traumatic Injuries

Abstract

Zygomycosis, also called mucormycosis, is an aggressive fungal infection found rarely in patients who have sustained traumatic injuries. Traumatic contact with an extremity may introduce the fungi through the mucocutaneous barrier, and progression of the infection can be fatal if vascular invasion, tissue infarction, and necrosis occur. Zygomycosis is usually found in immunocompromised individuals, but trauma may introduce and potentiate infection in patients without preexisting risk factors1-3. Although it is a rare complication of trauma, identification of the infection is important because the overall mortality rate from documented cutaneous zygomycosis inoculation has been reported to be as high as 31%4. Successful treatment depends primarily on early diagnosis and surgical debridement and secondarily on administration of appropriate antifungal medications. This case report describes an immunocompetent polytraumatized patient who died twenty-four days after an open femoral fracture that was complicated by a necrotizing lower-extremity zygomycosis infection. A fifteen-year-old, otherwise healthy girl was transferred from a community hospital after ejection from a motor vehicle traveling at a high speed in a rural setting. Major injuries included a ruptured spleen, liver laceration, bladder rupture, pneumothorax, pulmonary contusions, pelvic fractures, and bilateral femoral fractures (Fig. 1-A). A laparotomy and splenectomy were performed at the initial treatment facility prior to transfer to the regional trauma center, where the patient arrived in hypovolemic shock. After resuscitation, she underwent a repeat laparotomy and external fixation of both femora. Pelvic external fixation and preperitoneal pelvic packing were done as a part of our institutional protocol for the treatment of hemodynamically unstable pelvic fractures5. The patient was then transferred to the interventional radiology suite for distal hepatic artery embolization and investigation of absent distal lower-extremity pulses, which had been initially palpable in the emergency department. The left internal iliac artery was found …