COMMENTARY

Mucormycosis: When to Think Fungal Infection

Benjamin J. Park, MD

Disclosures

October 03, 2011

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On Sunday, May 22, 2011, one of the most devastating tornadoes in US history struck Joplin, Missouri, killing almost 160 people. This disaster has been overwhelming for the affected communities. More than a thousand people were injured, and many lost their homes and livelihoods. Afterward, some tornado survivors developed a rare fungal infection called mucormycosis. Combined with their traumatic injuries and losses, this infection has further slowed recovery of the town and its survivors.

Hello, I'm Dr. Benjamin Park, Medical Officer in the Mycotic Diseases Branch at the Centers for Disease Control and Prevention. I'm pleased to speak with you about mucormycosis today as part of the CDC Expert Video Commentary Series on Medscape.

What is known about mucormycosis? Mucormycosis is a family of diseases caused by Mucormycetes, a common class of fungi typically found in soil or decaying organic matter. This disease used to be called "zygomycosis." Mucormycosis cannot be directly transmitted between people or animals, so only those who have been exposed to Mucormycetes in their environment can be infected. Risk factors for these diseases include diabetes, immunosuppression, organ transplantation, iron overload states, or trauma.

After Mucormycetes mold spores enter or colonize the body, if host conditions are favorable, these spores can spread into the surrounding tissue and vascular system, rapidly causing necrosis and systemic infection. Mucormycetes can cause many types of infections, including rhinocerebral, pulmonary, and cutaneous and soft-tissue infections.

How does mucormycosis present? Like most fungal infections, mucormycosis resembles a bacterial infection in the initial presentation, but fungal lesions will often progress, because they will not respond to antibacterial or antiviral medications.

The most common type of mucormycosis is rhinocerebral, which presents initially as a persistent sinus infection. More severe progression will present with facial swelling and bloody nasal discharge. In the pulmonary form, patients will often initially have nonspecific symptoms such as fever, cough, chest pain, and dyspnea; the clinical presentation may be similar to other causes of pneumonia. Cutaneous mucormycosis can appear similar to bacterial causes of skin infection at first, with tenderness, erythema, and fluid drainage from the infection site. As the infection progresses, patients can develop blisters or ulcers as well as black necrotic lesions.

A fungal infection, including mucormycosis, should be considered if a patient has a persistent infection that is not responding to initial treatment. Methods for diagnosing fungal infections vary, but these infections are usually diagnosed in a laboratory through histopathology or fungal culture. It is important to order a fungal culture in these cases.

How and when should mucormycosis be treated? Fungal infections like mucormycosis can have mortality rates higher than 50% if they are not treated quickly and correctly. Mucormycosis should be treated with antifungal medications, and surgery is often necessary to resect and debride infected and necrotic tissue. Early diagnosis and initiation of treatment may lead to better outcomes; therefore, maintaining clinical suspicion for these infections is very important.

As a practicing clinician, when should you consider mucormycosis? Even though Mucormycetes exist naturally in the environment, a cluster of cutaneous mucormycosis as large as the one that occurred in Joplin is extremely rare. In this cluster, we suspect that the patients who developed these infections were exposed to Mucormycetes following the tornado through traumatic skin injuries, like puncture wounds, lacerations, burns, cuts, and abrasions. Most clinicians will see mucormycosis occurring as a sporadic case. Clinicians should consider mucormycosis when diagnosing a persistent or progressive skin, sinus, or respiratory infection if the patient has any of these clinical conditions:

  • Diabetes;

  • Immunosuppression;

  • Organ transplantation; or

  • Recent trauma.

In addition, there are other preventive measures that clinicians can take, including:

  • Thoroughly irrigate and debride wounds and necrotic tissue in patients who have had recent trauma, especially wounds that are highly contaminated with dirt and debris;

  • Encourage patients to avoid injury by wearing proper protective clothing such as long sleeves and pants, gloves, and boots when working with construction materials or debris;

  • Encourage patients to wash their skin injuries thoroughly with soap and water; and

  • Educate patients about the signs and symptoms of an infection and when to seek help.

Thank you!

Web Resources

CDC Mucormycosis

CDC. Notes from the field: fatal fungal soft-tissue infections after a tornado - United States, 2011. MMWR Morb Mortal Wkly Rep.2011;60:992.

CDC Mycotic Diseases Branch

CDC Mold After a Disaster

CDC Returning Home After a Disaster

CDC Emergency Preparedness and Response - Tornadoes

NIOSH Tornado Cleanup and Response

Benjamin J. Park, MD , is Chief Epidemiologist with the Mycotic Diseases Branch, US Centers for Disease Control and Prevention, in Atlanta, Georgia. Dr. Park is responsible for coordinating outbreak investigations and surveillance, as well as developing strategies to reduce the impact and occurrence of fungal diseases. Dr. Park received his bachelor's degree at Dartmouth College, Hanover, New Hampshire, and his MD at Mount Sinai School of Medicine, New York, New York. He completed his clinical rotations in internal medicine at the University of Michigan, Ann Arbor. He began his career at the CDC in 2002 when he joined as an Epidemic Intelligence Service Officer. His professional interests include prevention and control of fungal diseases domestically and internationally.

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