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N Engl J Med. Necrotizing Cutaneous Mucormycosis after a Tornado in Joplin, Missouri, in 2011
[Source: The New England Journal of Medicine, full text: (LINK). Abstract, edited.]
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Original Article
Necrotizing Cutaneous Mucormycosis after a Tornado in Joplin, Missouri, in 2011
Robyn Neblett Fanfair, M.D., M.P.H., Kaitlin Benedict, M.P.H., John Bos, M.P.H., Sarah D. Bennett, M.D., M.P.H., Yi-Chun Lo, M.D., Tolu Adebanjo, M.D., M.P.H., Kizee Etienne, M.P.H., Eszter Deak, Ph.D., M.P.H., Gordana Derado, Ph.D., Wun-Ju Shieh, M.D., Ph.D., M.P.H., Clifton Drew, D.V.M., Ph.D., Sherif Zaki, M.D., Ph.D., David Sugerman, M.D., M.P.H., Lalitha Gade, M.Pharm., Elizabeth H. Thompson, B.S., Deanna A. Sutton, Ph.D., David M. Engelthaler, M.S., James M. Schupp, M.B.A., Mary E. Brandt, Ph.D., Julie R. Harris, Ph.D., M.P.H., Shawn R. Lockhart, Ph.D., George Turabelidze, M.D., and Benjamin J. Park, M.D.
N Engl J Med 2012; 367:2214-2225 - December 6, 2012 - DOI: 10.1056/NEJMoa1204781
Background
Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri.
Methods
We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case?control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively.
Results
A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1?D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains.
Conclusions
We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.
The views expressed in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Mycotic Diseases Branch (R.N.F., K.B., S.D.B., T.A., K.E., E.D., L.G., M.E.B., J.R.H., S.R.L., B.J.P.) and Biostatistics Office (G.D.), Division of Foodborne, Waterborne, and Environmental Diseases; the Epidemic Intelligence Service, Office of Workforce and Career Development (R.N.F., S.D.B., Y.-C.L.); the Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology (W.-J.S., C.D., S.Z.); and the Division of Injury Response (D.S.), Centers for Disease Control and Prevention, Atlanta; the Missouri Department of Health and Senior Services, Jefferson City (J.B., Y.-C.L., G.T.); the University of Texas Health Science Center, San Antonio (E.H.T., D.A.S.); and the Translational Genomics Research Institute, Flagstaff, AZ (D.M.E., J.M.S.).
Address reprint requests to Dr. Park at 1600 Clifton Rd., MS C-09, Atlanta, GA 30333, or at bpark1@cdc.gov.
-Necrotizing Cutaneous Mucormycosis after a Tornado in Joplin, Missouri, in 2011
Robyn Neblett Fanfair, M.D., M.P.H., Kaitlin Benedict, M.P.H., John Bos, M.P.H., Sarah D. Bennett, M.D., M.P.H., Yi-Chun Lo, M.D., Tolu Adebanjo, M.D., M.P.H., Kizee Etienne, M.P.H., Eszter Deak, Ph.D., M.P.H., Gordana Derado, Ph.D., Wun-Ju Shieh, M.D., Ph.D., M.P.H., Clifton Drew, D.V.M., Ph.D., Sherif Zaki, M.D., Ph.D., David Sugerman, M.D., M.P.H., Lalitha Gade, M.Pharm., Elizabeth H. Thompson, B.S., Deanna A. Sutton, Ph.D., David M. Engelthaler, M.S., James M. Schupp, M.B.A., Mary E. Brandt, Ph.D., Julie R. Harris, Ph.D., M.P.H., Shawn R. Lockhart, Ph.D., George Turabelidze, M.D., and Benjamin J. Park, M.D.
N Engl J Med 2012; 367:2214-2225 - December 6, 2012 - DOI: 10.1056/NEJMoa1204781
Background
Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri.
Methods
We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case?control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively.
Results
A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1?D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains.
Conclusions
We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.
The views expressed in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Mycotic Diseases Branch (R.N.F., K.B., S.D.B., T.A., K.E., E.D., L.G., M.E.B., J.R.H., S.R.L., B.J.P.) and Biostatistics Office (G.D.), Division of Foodborne, Waterborne, and Environmental Diseases; the Epidemic Intelligence Service, Office of Workforce and Career Development (R.N.F., S.D.B., Y.-C.L.); the Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology (W.-J.S., C.D., S.Z.); and the Division of Injury Response (D.S.), Centers for Disease Control and Prevention, Atlanta; the Missouri Department of Health and Senior Services, Jefferson City (J.B., Y.-C.L., G.T.); the University of Texas Health Science Center, San Antonio (E.H.T., D.A.S.); and the Translational Genomics Research Institute, Flagstaff, AZ (D.M.E., J.M.S.).
Address reprint requests to Dr. Park at 1600 Clifton Rd., MS C-09, Atlanta, GA 30333, or at bpark1@cdc.gov.
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