Apophysomyces trapeziformis Infection Associated with a Tornado Related Injury

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.