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LETTER TO EDITOR
Year : 2003  |  Volume : 49  |  Issue : 2  |  Page : 187-8

Post operative abdominal wall mucormycosis mimicking as bacterial necrotising fasciitis.




Correspondence Address:
R M Prasad


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Source of Support: None, Conflict of Interest: None


PMID: 12867706

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How to cite this article:
Prasad R M, Bose S M, Vaiphei K, Verma G R. Post operative abdominal wall mucormycosis mimicking as bacterial necrotising fasciitis. J Postgrad Med 2003;49:187

How to cite this URL:
Prasad R M, Bose S M, Vaiphei K, Verma G R. Post operative abdominal wall mucormycosis mimicking as bacterial necrotising fasciitis. J Postgrad Med [serial online] 2003 [cited 2019 Nov 11];49:187. Available from: http://www.jpgmonline.com/text.asp?2003/49/2/187/886


Sir,

A thirty-five years old non-diabetic female, who underwent epigastric herniorrhaphy in a peripheral hospital, was refered with spreading cellulitis and blackish discoloration of the wound after three days. At admission she was dehydrated, febrile and oliguric. There was a 21x12 cm. wound with necrotic floor and spreading cellulitis in the anterior abdominal wall. The rectus sheath was intact. With a clinical diagnosis of postoperative bacterial necrotising fasciitis, debridement was carried out and the excised tissue was submitted for microbiological and histopathological examination. She was put on cefotaxime, and metronidazole. Repeated debridements later resulted in removal of most of the anterior abdominal wall. The histopathology of the excised tissue showed extensive necrotizing inflammation and broad, aseptate fungal profiles of mucormycosis within the necrotic tissue. Grams stain showed gram negative bacilli and culture grew E. coli.

She was started on amphotericin-B, 50 mg/day, and increased to 75mg/day after 10 days. The disease was brought under control after 30 days of systemic amphotericin therapy. Healthy granulation tissue grew later which was covered with a split skin graft. The patient was discharged after seventy days of hospitalization.

Mucor is a zygomycetic fungus. It causes acute and rapidly progressive fungal infection usually in immunocompromised hosts but has also been reported in healthy patients[1] like in the present case.

Abdominal wall mucormycosis develops following contamination of traumatic or surgical wounds by this opportunistic fungus either from outside[2] or the wound may get secondarily invaded endogenously in those patients who have undergone surgery for gastrointestinal mucormycosis. In the present case fungus appears to have entered into the wound either through contaminated surgical instruments/ sutures or dressing material.

Disease is usually misdiagnosed as postoperative bacterial necrotizing fasciitis owing to its similar clinical presentation. So far only two cases of post surgical abdominal wall mucormycosis have been described.[3],[4]

Early diagnosis, repeated extensive surgical debridements, administration of Amphotericin-B and broad spectrum antibiotics leads to survival in up to 73% cases.[5] Amphotericin-B should be administered in high doses (1-1.2mg/kg/day) and continued for 2-4 weeks till the progression of disease is arrested.

It may be concluded that postoperative abdominal wall mucormycosis, though a rare disease, can be easily misdiagnosed as bacterial necrotising fasciitis. A high index of suspicion, prompt histopathological confirmation, repeated surgical debridements and amphotericin-B, are the cornerstones in the management of this disease.

 
 :: References Top

1.Verma GR, Lobo DN, Minz R, Bose SM, Gupta KL. Disseminated mucormycosis in healthy adults. J Postgrad Med 1995;41:40-2.  Back to cited text no. 1    
2.Gartenberg G, Bottone EJ, Keush GT, Weitzman I. Hospital acquired mucormycosis (Rhizopus rhizopodiformis) of skin and subcutaneous tissue. Epidemiology, mycology and treatment. N Engl J Med 1978;299:1115-7.  Back to cited text no. 2    
3.Lakshmi V, Rani TS, Sharma S, Mohan VS, Sundaram C, Rao RR, et al. Zygomycotic necrotizing fascitis caused by apophycomyces elegans. J Clin Microbiol 1993;31:1368-9.  Back to cited text no. 3    
4.Mathews MS, Raman A, Nair A. Nosocomial Zygomycetic post surgical necrotizing fascitis in a healthy adult caused by apophycomyces elegens in South India. J Med Vet Mycol 1997;35:61-3.  Back to cited text no. 4    
5.Parfrey NA. Improved diagnosis and prognosis of mucormycosis. A clinicopathologic study of 33 cases. Medicine 1986;65:113-23.  Back to cited text no. 5    



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Indian Journal of Medical Research. 2010; 131(6): 765-770
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2 Novel perspectives on mucormycosis: Pathophysiology, presentation, and management
Spellberg B, Edwards J, Ibrahim A
CLINICAL MICROBIOLOGY REVIEWS. 2005; 18 (3): 556-559
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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow