title: Invasive mold infections following combat-related injuries.
abstract: BACKGROUND
  Major advances in combat casualty care have led to increased survival of patients with complex extremity trauma. Invasive fungal wound infections (IFIs) are an uncommon, but increasingly recognized, complication following trauma that require greater understanding of risk factors and clinical findings to reduce morbidity.
  
  
  METHODS
  The patient population includes US military personnel injured during combat from June 2009 through December 2010. Case definition required wound necrosis on successive debridements with IFI evidence by histopathology and/or microbiology (Candida spp excluded). Case finding and data collected through the Trauma Infectious Disease Outcomes Study utilized trauma registry, hospital records or operative reports, and pathologist review of histopathology specimens.
  
  
  RESULTS
  A total of 37 cases were identified: proven (angioinvasion, n=20), probable (nonvascular tissue invasion, n=4), and possible (positive fungal culture without histopathological evidence, n=13). In the last quarter surveyed, rates reached 3.5% of trauma admissions. Common findings include blast injury (100%) during foot patrol (92%) occurring in southern Afghanistan (94%) with lower extremity amputation (80%) and large volume blood transfusion (97.2%). Mold isolates were recovered in 83% of cases (order Mucorales, n=16; Aspergillus spp, n=16; Fusarium spp, n=9), commonly with multiple mold species among infected wounds (28%). Clinical outcomes included 3 related deaths (8.1%), frequent debridements (median, 11 cases), and amputation revisions (58%).
  
  
  CONCLUSIONS
  IFIs are an emerging trauma-related infection leading to significant morbidity. Early identification, using common characteristics of patient injury profile and tissue-based diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal amphotericin B and a broad-spectrum triazole pending mycology results) among patients with suspicious wounds.
authors.affiliation: Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Tyler
authors.initials: T
authors.lastname: Warkentien
authors.forename: Carlos
authors.initials: C
authors.lastname: Rodriguez
authors.forename: Bradley
authors.initials: B
authors.lastname: Lloyd
authors.forename: Justin
authors.initials: J
authors.lastname: Wells
authors.forename: Amy
authors.initials: A
authors.lastname: Weintrob
authors.forename: James R
authors.initials: JR
authors.lastname: Dunne
authors.forename: Anuradha
authors.initials: A
authors.lastname: Ganesan
authors.forename: Ping
authors.initials: P
authors.lastname: Li
authors.forename: William
authors.initials: W
authors.lastname: Bradley
authors.forename: Lakisha J
authors.initials: LJ
authors.lastname: Gaskins
authors.forename: Françoise
authors.initials: F
authors.lastname: Seillier-Moiseiwitsch
authors.forename: Clinton K
authors.initials: CK
authors.lastname: Murray
authors.forename: Eugene V
authors.initials: EV
authors.lastname: Millar
authors.forename: Bryan
authors.initials: B
authors.lastname: Keenan
authors.forename: Kristopher
authors.initials: K
authors.lastname: Paolino
authors.forename: Mark
authors.initials: M
authors.lastname: Fleming
authors.forename: Duane R
authors.initials: DR
authors.lastname: Hospenthal
authors.forename: Glenn W
authors.initials: GW
authors.lastname: Wortmann
authors.forename: Michael L
authors.initials: ML
authors.lastname: Landrum
authors.forename: Mark G
authors.initials: MG
authors.lastname: Kortepeter
authors.forename: David R
authors.initials: DR
authors.lastname: Tribble
mesh_terms: D000328:Adult; D000346:Afghanistan / Q000453:epidemiology; D000935:Antifungal Agents / Q000627:therapeutic use; D001753:Blast Injuries / Q000382:microbiology*; D005658:Fungi / Q000145:classification; D006801:Humans; D008297:Male; D008889:Military Personnel; D009181:Mycoses / Q000453:epidemiology / Q000382:microbiology*; D013997:Time Factors; D014481:United States; D014946:Wound Infection / Q000188:drug therapy / Q000382:microbiology* / Q000601:surgery; D055815:Young Adult
chemical_list: D000935:Antifungal Agents