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LETTER TO THE EDITOR
Year : 2018  |  Volume : 26  |  Issue : 4  |  Page : 185-186

Cutaneous mucormycosis in immunocompromised patients due to corticosteroid use


Manisa Celal Bayar University, Faculty of Medicine, Plastic, Aesthetic and Reconstructive Surgery Department, Manisa, Turkey

Date of Web Publication24-Sep-2018

Correspondence Address:
Dr. Merve Ozkaya Unsal
Manisa Celal Bayar University, Faculty of Medicine, Plastic, Aesthetic and Reconstructive Surgery Department, Manisa
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_38_18

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How to cite this article:
Evrenos MK, Unsal MO, Kececi Y. Cutaneous mucormycosis in immunocompromised patients due to corticosteroid use. Turk J Plast Surg 2018;26:185-6

How to cite this URL:
Evrenos MK, Unsal MO, Kececi Y. Cutaneous mucormycosis in immunocompromised patients due to corticosteroid use. Turk J Plast Surg [serial online] 2018 [cited 2018 Dec 17];26:185-6. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/4/185/242056



Sir,

Mucormycosis is a rare invasive fungi infection, belonging to the class of Zygomycetes.[1] It is mainly confined to patients with immunodeficiency and diabetic ketoacidosis. Mucormycosis commonly presents in five forms: pulmonary, rhinocerebral, gastrointestinal, cutaneous, or disseminated.[2] Usually, cutaneous forms have been reported in traumatic immunocompetent patients over the past years.[3]

We would like to present two immunocompetent cases with mucormycosis which had major trauma and were given corticosteroids in our clinic in 2016–2017.

A 24-year-old male patient was evaluated on emergency service after an onboard traffic accident on May 28, 2016. Debridement, open reduction internal fixation and soft-tissue repair for periorbital lacerations and the open tripod fracture were performed under emergency conditions. The patient was diagnosed with cerebral diffuse axonal injury by the neurosurgery department, and methylprednisolone treatment 20 mg/kg 4 × 1/day was given. On the 7th day of the procedure, right periorbital cellulitis, proptosis of the right orbit, black necrosis of the skin were observed; samples for microbiology and pathology were sent. The patient was diagnosed with the fungal infection. Histopathology confirmed mucormycosis [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Right periorbital cellulitis, proptosis of the orbit of patient 1

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Figure 2: View of the patient 1 after the last debridement

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Figure 3: Hematoxylin and eosin stain view of hyphae of Mucor in necrotic areas with × 100 (black arrows)

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Figure 4: View of hyphae with Gomori methenamine silver stain

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The other case was 37-year-old man transferred to our emergency service after fall from height. He had cervical fracture and an open left parasymphyseal fracture of the mandible with concomitant lacerations of mouth and lips which was contaminated with soil. Open reduction and internal fixation were performed. The patient was given 17 days' steroid treatment for spinal trauma, on the 15th day of hospitalization, a black necrotic wound was seen on the skin superior to upper lip which had abrasions due to trauma [Figure 5] and [Figure 6]. Samples were sent to microbiology and pathology for invasive fungal infections and diagnosis was confirmed with both.
Figure 5: Black necrotic wound superior to upper lip of patient 2

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Figure 6: View of the patient 2 after the last debridement

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Mucormycosis is a low-virulent opportunistic fungal infection that is frequently exposed in daily life.[2] The incidence is increasing in proportion to the increase in cancer, organ transplantation, and immunosuppressive agent used in recent years.[4] It has been reported that rarely, immunocompetent individuals develop mucormycosis after major disasters, burns, and major dirty traumas.[3] In our cases, it is considered that the corticosteroid treatment that was given may have induced the development of cutaneous mucormycosis after contamination with soil during trauma, because of the absence of known additional diseases before trauma. Mucormycosis surely be kept in mind in resistant wound infections in patients who have been treated with steroids after cranial or spinal trauma. The treatment can be achieved with both medical and surgical procedures. A multidisciplinary approach is important. Clear surgical margins are essential, and after debridement, defect closure may be possible with composite tissues. As this technical note's goal is to emphasize the diagnose of mucormycosis, we will share the treatment results of the patients after completion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Skiada A, Petrikkos G. Cutaneous zygomycosis. Clin Microbiol Infect 2009; 15 Suppl 5:41-5.  Back to cited text no. 1
    
2.
González Ballester D, González-García R, Moreno García C, Ruiz-Laza L, Monje Gil F. Mucormycosis of the head and neck: Report of five cases with different presentations. J Craniomaxillofac Surg 2012;40:584-91.  Back to cited text no. 2
    
3.
Kyriopoulos EJ, Kyriakopoulos A, Karonidis A, Gravvanis A, Gamatsi I, Tsironis C, et al. Burn injuries and soft tissue traumas complicated by mucormycosis infection: A report of six cases and review of the literature. Ann Burns Fire Disasters 2015;28:280-7.  Back to cited text no. 3
    
4.
Mignogna MD, Fortuna G, Leuci S, Adamo D, Ruoppo E, Siano M, et al. Mucormycosis in immunocompetent patients: A case-series of patients with maxillary sinus involvement and a critical review of the literature. Int J Infect Dis 2011;15:e533-40.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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