title: Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011.
abstract: 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.
authors.affiliation: Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, USA.
authors.forename: Robyn
authors.initials: R
authors.lastname: Neblett Fanfair
authors.forename: Kaitlin
authors.initials: K
authors.lastname: Benedict
authors.forename: John
authors.initials: J
authors.lastname: Bos
authors.forename: Sarah D
authors.initials: SD
authors.lastname: Bennett
authors.forename: Yi-Chun
authors.initials: YC
authors.lastname: Lo
authors.forename: Tolu
authors.initials: T
authors.lastname: Adebanjo
authors.forename: Kizee
authors.initials: K
authors.lastname: Etienne
authors.forename: Eszter
authors.initials: E
authors.lastname: Deak
authors.forename: Gordana
authors.initials: G
authors.lastname: Derado
authors.forename: Wun-Ju
authors.initials: WJ
authors.lastname: Shieh
authors.forename: Clifton
authors.initials: C
authors.lastname: Drew
authors.forename: Sherif
authors.initials: S
authors.lastname: Zaki
authors.forename: David
authors.initials: D
authors.lastname: Sugerman
authors.forename: Lalitha
authors.initials: L
authors.lastname: Gade
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Thompson
authors.forename: Deanna A
authors.initials: DA
authors.lastname: Sutton
authors.forename: David M
authors.initials: DM
authors.lastname: Engelthaler
authors.forename: James M
authors.initials: JM
authors.lastname: Schupp
authors.forename: Mary E
authors.initials: ME
authors.lastname: Brandt
authors.forename: Julie R
authors.initials: JR
authors.lastname: Harris
authors.forename: Shawn R
authors.initials: SR
authors.lastname: Lockhart
authors.forename: George
authors.initials: G
authors.lastname: Turabelidze
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Park
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D004271:DNA, Fungal / Q000032:analysis; D004275:DNA, Ribosomal; D003881:Dermatomycoses / Q000453:epidemiology / Q000209:etiology* / Q000401:mortality; D004190:Disasters; D019115:Fasciitis, Necrotizing / Q000453:epidemiology / Q000209:etiology* / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008923:Missouri / Q000453:epidemiology; D009090:Mucorales / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D009091:Mucormycosis / Q000453:epidemiology / Q000209:etiology* / Q000401:mortality; D012307:Risk Factors; D012867:Skin / Q000293:injuries; D018461:Soft Tissue Infections / Q000453:epidemiology / Q000209:etiology* / Q000401:mortality; D055869:Tornadoes; D014947:Wounds and Injuries / Q000150:complications*; D055815:Young Adult
chemical_list: D004271:DNA, Fungal; D004275:DNA, Ribosomal