SOFT-TISSUE FUNGAL-INFECTIONS - SURGICAL-MANAGEMENT OF 12 IMMUNOCOMPROMISED PATIENTS

Isolated fungal soft-tissue infections are uncommon but may cause seve re morbidity or mortality among transplant recipients and other immuno suppressed patients. Twelve immunocompromised patients illustrating th ree patterns of infection were treated recently at the Duke University Medical Center. These groups comprised (I) locally aggressive infecti ons, (II) indolent infections, and (In) cutaneous manifestations of sy stemic infection. Patient diagnoses included organ transplant, leukemi a, prematurity, chronic obstructive pulmonary disease, and rheumatoid arthritis. Time from immunosuppression to biopsy ranged from 5.5 to 31 weeks. Organisms included Aspergillus, Rhizopus, Fusarium, Paecilomyc es, Exophiala, and Curvularia. Patients presented with necrotic ulcera tions or nodules. Surgical treatment ranged from radical debridement t o excisional biopsy to none. Antifungal chemotherapy also was employed in some cases. The mortality rate was 33 percent, two patients dying without evidence of fungal infection. Six of the eight survivors clear ed their infections. Necrotic skin lesions with surrounding erythema i n this population call for prompt examination, biopsy, and culture. Gr oup I lesions mandate radical excision with rapid intraoperative micro scopic control and systemic antifungal medication. Group II requires s urgical control with or without antifungal therapy. Group III requires systemic antifungal therapy for metastatic infection. In our opinion, treatment of fungal soft-tissue infection should be tailored to infec tion type and requires a team approach of surgeon and expert infectiou s disease consultation.