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Invasive burn wound infection due to Curvularia species
Bums (1993) 19, (I), 77-79
Printed in Great Britain
77
Invasive burn wound infection due to Curdaria species J. M. Still Jr, E. J. Law, G. I. Pereira and E. Singletary Humana Hospital, Bum Center, Georgia, USA
A 3-year-old white-skinned female sustained a 44 per cent deep partial and full skin thickness burn due fo petrol. She developed an invasive wound infection due to a fungus later idenfified as Curvularia species, an organism, usually a saprophyte, not previously reporfed as a cause of invasive bum wound infection. Treatment with surgical excision and Amphofericin B resulted in cure.
Introduction This report describes, apparently for the first time, a bum wound infection with a species of Cutvularia.
Case history A 3.year-old white-skinned female was burned when her father was pouring petrol into the carburettor and the fuel ignited. The child’s burning clothing was put out by rolling her on the ground. Resuscitation was carried out. The patient was admitted to another hospital and then transferred to Humana Hospital Bum Center by helicopter. She had been intubated prior to transfer. Ringer’s lactate was given en route. The past history revealed seizures in infancy but was otherwise essentially unremarkable. Physical examination revealed bums of the face, arms and legs, and patchy areas on the trunk covering approximately 44 per cent of the body surface. The bums were felt initially to be mostly of partial skin thickness. Her admitting laboratory measurements were within normal limits, except for a white count of 19 000/mm3. The patient was initially treated with Travase and Silvadene to the arms and Silvadene to other areas. Resuscitation was uneventful. On postbum day 1 she was taken to surgery for debridement and application of cadaver skin. By postbum day 3 she was developing small round black cutaneous lesions, which were very extensive, on the arms and legs (Figure I). She was taken to surgery where tangential excision and application of cadaver skin was carried out. Full thickness biopsies at this time revealed fungi with invasion of the dermis believed initially to be grossly consistent with Aspergillus (Figure2). Most of the fungi were believed to have been removed. She ran a febrile course during her early bum stay and was found to have Psetld. aeruginosa in the blood stream on postbum day 4. Pseudomonas was also cultured from her left arm at about this time. On postbum day 5 she was taken to surgery again where further tangential excision and further application of cadaver skin were performed. Invasive fungi were again found to be present. $3 1993 Butterworth-Heinemann 0305-4179/93/010077-03
Ltd
This procedure removed the dark lesions in toto. After postbum day 5 she was treated with Amphotericin B for approximately 10 days, 1 mg/kg/day being the prescribed dose. On postbum day 8, she was taken back to surgery where split thickness grafting to her right arm, hand and areas to the thighs was carried out. Multiple biopsies at this time revealed no evidence of fungi. Further grafting was carried out on postbum day 13. Slow healing of the donor sites was a problem and further split thickness grafting was delayed until postbum day 21. Debridement and removal of staples was carried out on postbum day 29. Final application of pigskin to donor sites of the back and some small areas of split thickness grafting was carried out on postbum day 36. These grafts healed well. Throughout her course the patient’s chest X-rays remained clear. Wound colonization with other organisms occurred prior to healing. At various times Flavobacttium mmingosepficum, Acinetobatter species and group D enterococcus were recovered from the wounds. Still later Staph. aureus was recovered from the wound. This appeared to be a colonization without invasive infection. The patient was treated with various systemic antibiotics including tobramycin and Timentin, and later Fortaz. The fungal organism invading the wounds was eventually identified as Cur&aria species. The organisms were cultured on Sabouraud’s dextrose agar, Emmons modified at room temperature. They were identified by appearance of the colonies and microscopic morphology. The conidia were typical of Cuwularia species, being brown curved multi-celled with a swollen central portion. This was later found to be sensitive to Amphotericin B and other antifungal agents, but sensitivity reports were not available in time to influence therapy. The patient’s grafts healed well. The wounds of the back eventually healed and she was discharged, doing well, on postbum day 48. Approximately 3 months after her original admission, she was readmitted for reconstructive release of the wrist. At that time she was in good health, her only problem being her residual bum scars.
Discussion Cumularia is a genus of rapidly growing soil saprophytes of the class Deuteromycetes. The organism is usually known as a saprophyte that is extremely rare as an invasive organism in man. In our patient, invasive bum wound infection due to this organism was identified and confirmed by multiple biopsies. To our knowledge this is the first such reported case of wound invasion in a bum patient. Saprophytic fungi are usually invasive only in patients who are immunocompromised, but curvularia infections have been reported in
Bums (1993) Vol. 19/No.
78
Figure I. Postbum day 3. Scattered cutaneous lesions are n zadily visible.
I
caused by Curuularia pallescense. de la Monte and Hutchins (1985) reported a case with pulmonary and cerebral infection with Curvularia lunata treated by surgery and Amphotericin. Another case of disseminated C. lunata was reported by Rohwedder et al. (1979). His patient developed a recurrence of infection after refusing to continue therapy with Amphotericin B. Curvularia endocarditis due to Curvulariagmiculati was reported by Coffrnan (1971) in a patient who failed to survive. In the cases reported by Monte and Hutchins, Lampert et al. and Rohwedder et al. (1979) surgical excision and Arnphotericin B were advised. The two patients, respectively reported by Monte and Hutchins and Lampert et al., were treated with a combination of surgery and Arnphoteritin B with cure. In our patient, excision of the wound together with a short course (10 days) of Amphotericin yielded a successful result. No specialized imrnunocompetence tests were carried out in our patient. The patient had a white count between 3000 and 5000/mm3 for 4 days prior to the onset of the fungal infection. Sensitivity data reported after the conclusion of antifungal therapy revealed that the organism was susceptible to Amphotericin B, fluconazole, Schering 39304 and itraconazole. Concurrent with the fungal infection, our patient developed Pseud. aeruginosa septicaemia, which was treated with timentin and tobramycin, and responded well. Fungal infections are a long encountered problem in the management of bum patients. In 1971, Nash et al. reported a marked increase over previous levels of mycotic infections, with Phycomycetes and Aspwgilli accounting for many of these cases. Speabar et al. (1982) reported that, of 1513 patients admitted to Brooke Army Medical Center, 8.2 per cent or 118 cases developed an invasive fungal infection. Candida of some type was responsible for 38.5 per cent of these infections. The remaining 61.5 per cent were due to non-candidal fungal organisms, primarily fusarium, aspergillus and phycomycetes. Non-candidal fungal mortality between 1973 and 1977 was 87.4 per cent, falling to 25 per cent in 1978. Their conclusion was that such infections are ‘insidious’, more lethal and more difficult to treat than bacterial infections and that they are frequently diagnosed only on post-mortem examination. Aggressive early excision was the recommended therapy. Systemic antifungal agents were employed only when the infection was disseminated. Excision and grafting and a brief course of Amphotericin B was the treatment regimen followed in our patient, and this approach resulted in successful recovery. Two procedures were required to obtain removal of all of the involved tissue. The graft take was essentially uneventful. The patient was asymptomatic when admitted for reconstructive surgery 3 months later.
Figure 2. Postbum day 3. Invasion of the bum wound demonstrated by fungal Gomor methenamine silver stain. Arrow shows subepidermal fungal invasion. ( x 22.)
References patients without obvious immunocompromise. Contamination of the wound probably occurred when the patient was
rolled in the dirt to extinguish the fire. Lampert et al. (1977) reported a case with pulmonary and cerebral mycetomas
Coffman S. M. (i9n) Curvularia endocarditis following cardiac surgery. Am. J C/in. Pafhol. 56, 466. de la Monte S. M. and Hutchins G. M. (1985) Disseminated Cur&aria infection. Arch. Pafhol. Lab. Med. 109, 62.
Still et al.: Bum wound infection due to Curvufariaspecies
Lampert R. I’., Hutto J. H., Donnelley W. H. et al. (1977) Pulmonary and cerebral mycetoma caused by Ctrwclluti~ p&scense. 1. Pediatr. 91, 603. Nash G., Foley F. D., Goodwin M. N. et al. (1971) Fungal bum wound infection. JAMA 215, 1664. Rohwedder J. J., Simmons, J. L., Colfer H. et al. (1979) Disseminated Cuuvulntia ltrnnta infection in a football player. Arch. Intern. Med. 139, 940.
Burns
79
Speabar M. J., Walters M. J. and Pruitt B. A. (1982) Improved survival with aggressive surgical management of non-candidal fungal infections of the bum wound. 1, Trauma 22, 867. Paper accepted
24 June 1992.
Correspondence should be addressed to: Dr E. J. Law, 1220 George C. Wilson Drive, PO Box 3726, Augusta, GA 30914-3726, USA.
As the official bi-monthly journal of the International Society for Burn Injuries, Burns regularly publishes supplementary issues on selected topics in burn research and treatment. Two supplements accompanied the 1992 volume of the journal, and are now available from Butterworth-Heinemann:
Supplement 1 Volume 18
The Growth and Clinical Use of Cultured Keratinocytes Guest Editor: Professor L. Donati Department of Plastic Surgery, University of Milan, Niguarda Ca’Granda Hospital, Milan, Italy
Supplement 2 Volume 18
50 Years of Burn Wound Care A supplement dedicated to Professor Rudi P. Hermans, MD, on the occasion of his retirement Guest Editor: M.H.E. Hermans ConvaTec, Princeton, New Jersey, USA Butterworth-Heinemann and the International Society for Burn Injuries are keen to promote burn care and research, and would welcome suggestions for future supplements to the journal. If you would like to discuss an idea for a supplementary issue, require more information about the journal, or would like to place an order, please contact: The Medical Journals Group, Butterworth-Heinemann, Linacre House, Jordan Hill, Oxford, OX2 8DP. UK. Tel: 0865 310366 Fax: 0865 310898 Telex 83111 BHPOXF G
Printed in Great Britain
77
Invasive burn wound infection due to Curdaria species J. M. Still Jr, E. J. Law, G. I. Pereira and E. Singletary Humana Hospital, Bum Center, Georgia, USA
A 3-year-old white-skinned female sustained a 44 per cent deep partial and full skin thickness burn due fo petrol. She developed an invasive wound infection due to a fungus later idenfified as Curvularia species, an organism, usually a saprophyte, not previously reporfed as a cause of invasive bum wound infection. Treatment with surgical excision and Amphofericin B resulted in cure.
Introduction This report describes, apparently for the first time, a bum wound infection with a species of Cutvularia.
Case history A 3.year-old white-skinned female was burned when her father was pouring petrol into the carburettor and the fuel ignited. The child’s burning clothing was put out by rolling her on the ground. Resuscitation was carried out. The patient was admitted to another hospital and then transferred to Humana Hospital Bum Center by helicopter. She had been intubated prior to transfer. Ringer’s lactate was given en route. The past history revealed seizures in infancy but was otherwise essentially unremarkable. Physical examination revealed bums of the face, arms and legs, and patchy areas on the trunk covering approximately 44 per cent of the body surface. The bums were felt initially to be mostly of partial skin thickness. Her admitting laboratory measurements were within normal limits, except for a white count of 19 000/mm3. The patient was initially treated with Travase and Silvadene to the arms and Silvadene to other areas. Resuscitation was uneventful. On postbum day 1 she was taken to surgery for debridement and application of cadaver skin. By postbum day 3 she was developing small round black cutaneous lesions, which were very extensive, on the arms and legs (Figure I). She was taken to surgery where tangential excision and application of cadaver skin was carried out. Full thickness biopsies at this time revealed fungi with invasion of the dermis believed initially to be grossly consistent with Aspergillus (Figure2). Most of the fungi were believed to have been removed. She ran a febrile course during her early bum stay and was found to have Psetld. aeruginosa in the blood stream on postbum day 4. Pseudomonas was also cultured from her left arm at about this time. On postbum day 5 she was taken to surgery again where further tangential excision and further application of cadaver skin were performed. Invasive fungi were again found to be present. $3 1993 Butterworth-Heinemann 0305-4179/93/010077-03
Ltd
This procedure removed the dark lesions in toto. After postbum day 5 she was treated with Amphotericin B for approximately 10 days, 1 mg/kg/day being the prescribed dose. On postbum day 8, she was taken back to surgery where split thickness grafting to her right arm, hand and areas to the thighs was carried out. Multiple biopsies at this time revealed no evidence of fungi. Further grafting was carried out on postbum day 13. Slow healing of the donor sites was a problem and further split thickness grafting was delayed until postbum day 21. Debridement and removal of staples was carried out on postbum day 29. Final application of pigskin to donor sites of the back and some small areas of split thickness grafting was carried out on postbum day 36. These grafts healed well. Throughout her course the patient’s chest X-rays remained clear. Wound colonization with other organisms occurred prior to healing. At various times Flavobacttium mmingosepficum, Acinetobatter species and group D enterococcus were recovered from the wounds. Still later Staph. aureus was recovered from the wound. This appeared to be a colonization without invasive infection. The patient was treated with various systemic antibiotics including tobramycin and Timentin, and later Fortaz. The fungal organism invading the wounds was eventually identified as Cur&aria species. The organisms were cultured on Sabouraud’s dextrose agar, Emmons modified at room temperature. They were identified by appearance of the colonies and microscopic morphology. The conidia were typical of Cuwularia species, being brown curved multi-celled with a swollen central portion. This was later found to be sensitive to Amphotericin B and other antifungal agents, but sensitivity reports were not available in time to influence therapy. The patient’s grafts healed well. The wounds of the back eventually healed and she was discharged, doing well, on postbum day 48. Approximately 3 months after her original admission, she was readmitted for reconstructive release of the wrist. At that time she was in good health, her only problem being her residual bum scars.
Discussion Cumularia is a genus of rapidly growing soil saprophytes of the class Deuteromycetes. The organism is usually known as a saprophyte that is extremely rare as an invasive organism in man. In our patient, invasive bum wound infection due to this organism was identified and confirmed by multiple biopsies. To our knowledge this is the first such reported case of wound invasion in a bum patient. Saprophytic fungi are usually invasive only in patients who are immunocompromised, but curvularia infections have been reported in
Bums (1993) Vol. 19/No.
78
Figure I. Postbum day 3. Scattered cutaneous lesions are n zadily visible.
I
caused by Curuularia pallescense. de la Monte and Hutchins (1985) reported a case with pulmonary and cerebral infection with Curvularia lunata treated by surgery and Amphotericin. Another case of disseminated C. lunata was reported by Rohwedder et al. (1979). His patient developed a recurrence of infection after refusing to continue therapy with Amphotericin B. Curvularia endocarditis due to Curvulariagmiculati was reported by Coffrnan (1971) in a patient who failed to survive. In the cases reported by Monte and Hutchins, Lampert et al. and Rohwedder et al. (1979) surgical excision and Arnphotericin B were advised. The two patients, respectively reported by Monte and Hutchins and Lampert et al., were treated with a combination of surgery and Arnphoteritin B with cure. In our patient, excision of the wound together with a short course (10 days) of Amphotericin yielded a successful result. No specialized imrnunocompetence tests were carried out in our patient. The patient had a white count between 3000 and 5000/mm3 for 4 days prior to the onset of the fungal infection. Sensitivity data reported after the conclusion of antifungal therapy revealed that the organism was susceptible to Amphotericin B, fluconazole, Schering 39304 and itraconazole. Concurrent with the fungal infection, our patient developed Pseud. aeruginosa septicaemia, which was treated with timentin and tobramycin, and responded well. Fungal infections are a long encountered problem in the management of bum patients. In 1971, Nash et al. reported a marked increase over previous levels of mycotic infections, with Phycomycetes and Aspwgilli accounting for many of these cases. Speabar et al. (1982) reported that, of 1513 patients admitted to Brooke Army Medical Center, 8.2 per cent or 118 cases developed an invasive fungal infection. Candida of some type was responsible for 38.5 per cent of these infections. The remaining 61.5 per cent were due to non-candidal fungal organisms, primarily fusarium, aspergillus and phycomycetes. Non-candidal fungal mortality between 1973 and 1977 was 87.4 per cent, falling to 25 per cent in 1978. Their conclusion was that such infections are ‘insidious’, more lethal and more difficult to treat than bacterial infections and that they are frequently diagnosed only on post-mortem examination. Aggressive early excision was the recommended therapy. Systemic antifungal agents were employed only when the infection was disseminated. Excision and grafting and a brief course of Amphotericin B was the treatment regimen followed in our patient, and this approach resulted in successful recovery. Two procedures were required to obtain removal of all of the involved tissue. The graft take was essentially uneventful. The patient was asymptomatic when admitted for reconstructive surgery 3 months later.
Figure 2. Postbum day 3. Invasion of the bum wound demonstrated by fungal Gomor methenamine silver stain. Arrow shows subepidermal fungal invasion. ( x 22.)
References patients without obvious immunocompromise. Contamination of the wound probably occurred when the patient was
rolled in the dirt to extinguish the fire. Lampert et al. (1977) reported a case with pulmonary and cerebral mycetomas
Coffman S. M. (i9n) Curvularia endocarditis following cardiac surgery. Am. J C/in. Pafhol. 56, 466. de la Monte S. M. and Hutchins G. M. (1985) Disseminated Cur&aria infection. Arch. Pafhol. Lab. Med. 109, 62.
Still et al.: Bum wound infection due to Curvufariaspecies
Lampert R. I’., Hutto J. H., Donnelley W. H. et al. (1977) Pulmonary and cerebral mycetoma caused by Ctrwclluti~ p&scense. 1. Pediatr. 91, 603. Nash G., Foley F. D., Goodwin M. N. et al. (1971) Fungal bum wound infection. JAMA 215, 1664. Rohwedder J. J., Simmons, J. L., Colfer H. et al. (1979) Disseminated Cuuvulntia ltrnnta infection in a football player. Arch. Intern. Med. 139, 940.
Burns
79
Speabar M. J., Walters M. J. and Pruitt B. A. (1982) Improved survival with aggressive surgical management of non-candidal fungal infections of the bum wound. 1, Trauma 22, 867. Paper accepted
24 June 1992.
Correspondence should be addressed to: Dr E. J. Law, 1220 George C. Wilson Drive, PO Box 3726, Augusta, GA 30914-3726, USA.
As the official bi-monthly journal of the International Society for Burn Injuries, Burns regularly publishes supplementary issues on selected topics in burn research and treatment. Two supplements accompanied the 1992 volume of the journal, and are now available from Butterworth-Heinemann:
Supplement 1 Volume 18
The Growth and Clinical Use of Cultured Keratinocytes Guest Editor: Professor L. Donati Department of Plastic Surgery, University of Milan, Niguarda Ca’Granda Hospital, Milan, Italy
Supplement 2 Volume 18
50 Years of Burn Wound Care A supplement dedicated to Professor Rudi P. Hermans, MD, on the occasion of his retirement Guest Editor: M.H.E. Hermans ConvaTec, Princeton, New Jersey, USA Butterworth-Heinemann and the International Society for Burn Injuries are keen to promote burn care and research, and would welcome suggestions for future supplements to the journal. If you would like to discuss an idea for a supplementary issue, require more information about the journal, or would like to place an order, please contact: The Medical Journals Group, Butterworth-Heinemann, Linacre House, Jordan Hill, Oxford, OX2 8DP. UK. Tel: 0865 310366 Fax: 0865 310898 Telex 83111 BHPOXF G