Notes from the Field: Fatal Fungal Soft-Tissue Infections After a Tornado --- Joplin, Missouri, 2011

On May 22, 2011, at 5:34 p.m. a tornado with winds >200 mph struck Joplin, Missouri, injuring approximately 1,000 persons and causing 159 deaths. On June 3, a local physician notified the Springfield-Greene County Health Department and the Missouri Department of Health and Senior Services (MODHSS) of two patients hospitalized with tornado injuries who had suspected necrotizing fungal soft-tissue infections. MODHSS initiated active surveillance for such infections at hospitals and laboratories serving patients injured in the tornado, and CDC began assisting MODHSS with identification of fungal isolates. By June 10, eight patients with necrotizing fungal soft-tissue wound infections caused by Mucormycetes (formerly Zygomycetes) were identified. On June 14, a CDC field team arrived in Missouri to assist with the onsite investigation.

As of July 19, a total of 18 suspected cases of cutaneous mucormycosis had been identified, of which 13 were confirmed. A confirmed case was defined as 1) necrotizing soft-tissue infection requiring antifungal treatment or surgical debridement in a person injured in the tornado, 2) with illness onset on or after May 22, and 3) positive fungal culture or histopathology and genetic sequencing consistent with a Mucormycete. No additional cases have been reported since June 17.

The field team reviewed medical charts to describe the 13 confirmed cases. The median age of the patients was 48 years (range: 13--76 years); seven were female, and all were white. Injuries sustained during the tornado included lacerations (12 patients), fractures (11), and blunt trauma (nine). The 13 patients had an average of four wounds documented in the medical chart when they were examined at the emergency department. Post-trauma wound management included surgical debridement for all 13 patients and removal of a foreign body from six. Wooden splinters were the most common foreign body, found in the wounds of four patients. Two patients had diabetes, and none were immunocompromised. Ten patients required admission to an intensive-care unit, and five died.

CDC received 48 clinical specimens, including 32 fungal isolates and 16 tissue blocks collected from wounds for microscopic evaluation, immunohistochemical staining, and DNA sequencing; specimens from all 13 patients yielded the Mucormycete Apophysomyces trapeziformis. Further laboratory and epidemiologic studies are ongoing, including case-control studies to evaluate risk factors for infection.

Cutaneous mucormycosis is a rare infection caused by fungi of the order Mucorales, which typically are found in soil and decaying wood and other organic matter. Although cutaneous mucormycosis often is opportunistic, affecting patients with diabetes, hematologic malignancy or solid organ transplant (1), A. trapeziformis often is associated with immunocompetent hosts after traumatic implantation of fungal spores (2). The case-fatality rate for cutaneous mucormycosis has ranged from 29% to 83%, depending on severity of disease and underlying medical condition of the patient (1). Early diagnosis, aggressive surgical debridement, and administration of systemic antifungals have been associated with improved outcomes (1).

Cutaneous mucormycosis has been reported after previous natural disasters (3,4); however, this is the first known cluster occurring after a tornado. None of the infections were found in persons cleaning up debris. Health-care providers should consider environmental fungi as potential causes of necrotizing soft-tissue infections in patients injured during tornados and initiate early treatment for suspected infections. Additional information is available at http://www.cdc.gov/mucormycosis.

Reported by

Infectious Disease Pathology Br; Kaitlin Benedict, Tolu Adebanjo, Julie Harris, Shawn Lockhart, Joyce Peterson, Shirley McClinton, Lalitha Gade, Kizee Etienne, Steven Hurst, Lynette Benjamin, Anne Whitney, Shanna Bolcen, Mary Brandt, Benjamin Park, Office of Infectious Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC. George Turabelidze, John Bos, Eddie Hedrick, David Byrd, Missouri Dept of Health and Senior Svcs. Robyn Neblett Fanfair, Sarah Bennett, Yi-Chun Lo, EIS officers, CDC. Corresponding contributor: Robyn Neblett Fanfair, rcneblett@cdc.gov, 404-639-2359.

References

1. Skiada A, Petrikkos G. Cutaneous zygomycosis. Clin Microbiol Infect 2009;15 Suppl 5:41--5.
2. Alvarez E, Stchigel A, Cano J, et al. Molecular phylogenetic diversity of the emerging mucoralean fungus Apophysomyces: proposal of three new species. Rev Iberoam Micol 2010;27:80--9.
3. Andresen D, Donaldson A, Choo L, et al. Multifocal cutaneous mucormycosis complicating polymicrobial wound infections in a tsunami survivor from Sri Lanka. Lancet 2005;365:876--8.
4. Patino JF, Castro D, Valencia A, et al. Necrotizing soft tissue lesions after a volcanic cataclysm. World J Surg 1991;15:240--7.