LB-7. Apophysomyces trapeziformis Infection Associated with a Tornado Related Injury
Session: Poster Abstract Session: Late Breaker Posters
Saturday, October 22, 2011
Room: Poster Hall B1
Background: 

On May 22, 2011, an F5 tornado struck Joplin, Missouri injuring 2 immunocompetent teens. This is the first report which defines the role of AF as an aggressive fungal pathogen. 

Method:  

Clinical & laboratory manifestations of infections following environmentally contaminated wounds suffered during a tornado are outlined, emphasizing mechanism of injury, co-morbidities, and diagnostic and treatment challenges.

Result:

Apophysomyces infection was noted following injuries in a 16 yr old boy and 13 yr old girl. Pathology of debrided tissue showed multiple fungal hyphae, angioinvasion and the presence of environmental debris. Aggressive serial debridement in patient 1 involved resection of ribs, pericardium, liver, and lung. AF was resistant to caspofungin, micafungin and voriconazole and susceptible to amphotericin 0.25 ug/ml, itraconazole 1 ug/ml, posaconazole and terbinafine 0.125 ug/ml. Ampho B was utilized with addition of posa when oral therapy was feasible.

 

Patient 1

Patient 2

Mechanism of Injury

Back seat passenger ejected from airborne MVA

Front seat passenger ejected from MVA

Major Injuries

Soft tissue/rib fractures resulting in flail chest, pulmonary contusion, open humeral fracture, liver laceration & perinephric hematoma

Facial fractures, complex lacerations of her scalp and right thigh 

Day of Infection

10 days following injury

10 days following injury

Tissue debridement (# debridement procedures)

Skin/soft tissue, ribs, pericardial cavity, liver, lung (12)

Skin and soft tissue (10)

Fungal Pathogens

Apophysomyces trapeziformis, C tropicalis, Aspergillus fumigatus

Apophysomyces trapeziformis, C famata, C tropicalis, C ciferrii, C albicans

Bacterial Pathogens (*MDR)

P aerugionsa*, B cepacia*, Pandorae sp.*

 

Ecoli*, E cloacae, VRE*

Conclusion:  

This is the first report of an unusually aggressive necrotizing infection, which was heralded by fever, pain and rapidly advancing necrotic appearance to wounds, caused by A trapeziformis. Co-infection with atypical environmental organisms demonstrating high grade multi-drug antibiotic resistance produced additional treatment challenges. Systemic antifungal, antibacterial therapy and particularly aggressive serial tissue debridement was critical to achieve cure.


Subject Category: J. Clinical practice issues

Gina Weddle, RN, MSN, Infectious Disease, The Children's Mercy Hospital, Kc, MO, Kimberly Gandy, MD, Cardiac Surgery, Children's Mercy Hospital, Kansas City , MO, Denise Bratcher, DO, Children's Mercy Hosp & Univ MO Kansas City Sch of Med, Kansas City, MO, Barbara Pahud, MD MPH, Infectious Disease, Children's Mercy Hospital, KC, MO and Mary Anne Jackson, MD, FIDSA, Children's Mercy Hospitals and Clinics, Kansas City, MO

Disclosures:

G. Weddle, None

K. Gandy, None

D. Bratcher, None

B. Pahud, None

M. A. Jackson, None

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