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   A Case Of Mucormycosis Of Thigh Introduction: Mucormycosis, previously known as Zygomycosis refers to infections caused by diverse fungal organisms in the order Mucorales. Multiple organisms are implicated to cause Mucormycosis such as, but not limited to, Rhizopus spp., Mucor spp. and Apophysomyces spp. Their presentations are atypical, require longer duration to arrive at a clinching diagnosis, require prolonged intensive care and have worse manifestations of sepsis with high mortality. Though a rare entity seen in surgical practice. Most of these infections are rapidly progressive and exhibit high mortality (~50%) even after active management; the mortality rates approach nearly 100% among patients with disseminated disease.3-6 The principal risk factors implicated in mucormycosis include uncontrolled diabetes and diabetic ketoacidosis, prolonged steroid therapy, persistent neutropaenia, desferoxamine therapy, haematological malignancies, illicit use of intravenous drugs, autoimmune disorders, prophylaxis with voriconazole or echinocandins, and the breach of cutaneous or mucous membrane barrier due to trauma, burns and surgical wounds.1, 2 However, it has also been described in patients with no underlying disease.1, 2 Mucormycosis is fast emerging fungal infection in India. In a meta‐analysis of all the zygomycosis cases reported from India, Diwakar et al. describe an overall prevalence of ROC (58%), cutaneous (14%), pulmonary (6%), disseminated (7%), gastrointestinal (7%) and isolated renal (7%).21 Here we describe an atypical case of soft tissue infection of thigh in a Type 2 diabetes mellitus patient, who had a trivial prick injury. Fungal aetiology was found and patient required serial extensive debridements. Here we describe the case in detail regarding the presentation, progression of the disease with the difficulties faced in early diagnosis and management of the case. Case presentation: A 45 years old man, Farmer by occupation, from Thiruvallur District, Tamil Nadu. Came to the General Surgery outpatient department of Saveetha Medical College and Hospital, Thandalam. He presented to us with chief complaints of Swelling and skin discoloration over Left thigh region for a period of 10 days. He gave a preceding history of trauma (a thorn prick injury acquired at work fields) over the Left thigh region 10 days back. The injury progressed over the days from a small prick injury to the present lesion. (Figure 1). He also gave history of fever for 4-5 days accompanied with pain over the region and pus discharge from the site of lesion. He was a known case of Diabetes mellitus for past 5 years and was on irregular medications. On Clinical examination he was conscious, oriented, well-built and moderately-nourished. He was febrile and haemodynamically stable. There was no peculiar finding on systemic examination. On local examination of the left thigh an induration of size 15 x 15 cm is seen over the mid-thigh region. There was blackish discoloration of the skin around the region. A discharging sinus can be seen over the centre of the lesion, with active pus discharge. On palpation it was firm, non-fluctuant and local warmth and tenderness was present.  He was admitted in the ward with the initial working diagnosis of Cellulitis of Left Thigh. Ultrasound of Left thigh showed subcutaneous edema. Routine investigation were sent. Wound debridement was done and patient was started on IV antibiotic therapy with Inj. Piptaz and Inj. Metro, (cultures sent showed) and later due to rapid progression of disease and increasing counts, and fever spikes IV antibiotics was stepped up to Inj. Imipenem. Inj. Human insultard was started to manage the blood sugar levels. In view of the rapid progression of the disease with deteriorating condition of patient serial extensive wound debridements were done both Intra operatively and in ward. Extensive wound debridement was done until bleeding was noted, intra operatively on day 1 and day ? of admission, Intra op fungal moulds were noticed around the edges and were removed. Tissue samples were taken and sent for fungal culture and biopsy. Post operatively patient developed fever which was managed conservatively. {total counts} . Fungal cultures and biopsy showed Multiple branching hyphae. Empirical IV antifungals  –  Amphotericin B and flucanozle alongside of proper local care and dressings. However, patient general condition rapidly deteriorated requiring ICU care and he died on ?? Discussion: Cellulitis is often caused by gram positive cocci. Anaerobes are another cause for more severe and aggressive forms of cellulitis. Approximately 50% of such infections are polymicrobial; the remainder is caused by single organisms. Fungal aetilogy in cellulitis is as such very rarely seen. Mucormycosis (previously called zygomycosis) is a serious but rare fungal infection caused by a group of moulds called Mucormycetes. Fungi that most commonly cause mucormycosis are: Rhizopus species, Mucor species, cunninghamella bertholletiae, Apophysomyces species, and Lichtheimia (formerly Absidia) species [1]. Mucormycosis can affect nearly any part of the body, but it most commonly affects the sinuses or the lungs in people who have weakened immune systems. Based on anatomic localisation Mucormycosis can be classified into 6 common forms namely 1)Rhino cerebral, 2)Pulmonary, 3)Cutaneous, 4)Gastrointestinal 5)Disseminated and 6) uncommon presentation [1]. Though a rare entity seen in surgical practice. Most of these infections are rapidly progressive and exhibit high mortality (~50%) even after active management; the mortality rates approach nearly 100% among patients with disseminated disease.3-6 In a meta‐analysis of all the zygomycosis cases reported from India, Diwakar et al. describe an overall prevalence of ROC (58%), cutaneous (14%), pulmonary (6%), disseminated (7%), gastrointestinal (7%) and isolated renal (7%).21 Mucorales are ubiquitous fungi commonly found in soil and decaying matter. It mainly affects individuals with immunocompromised states like uncontrolled diabetes and diabetic ketoacidosis, prolonged steroid therapy, persistent neutropaenia, desferoxamine therapy, haematological malignancies, illicit use of intravenous drugs, autoimmune disorders, prophylaxis with voriconazole or echinocandins, and the breach of cutaneous or mucous membrane barrier due to trauma, burns and surgical wounds. Major route of infection is via inhalation of conida, other routes include ingestion and traumatic inoculation. Cutaneous infections are usually associated with trauma, burns and surgical wounds. Mucorales forms hyphae in and around blood vessels, they can invade the blood vessels producing tissues infarction, necrosis and thrombosis. Neutrophils are key host defence against these fungi, the individuals with neutropenia or neutrophil dysfunction (eg: Diabetic) are at higher risk of infection.    Conclusion: References:
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