title: Fungal necrotizing fasciitis, an emerging infectious disease caused by Apophysomyces (Mucorales).
abstract: BACKGROUND
  The mucoralean fungi are emerging causative agents of primary cutaneous infections presenting in the form of necrotizing fasciitis.
  
  
  OBJECTIVE
  The aim of this study was to investigate a series of suspected necrotizing fasciitis cases by Apophysomyces species over one-year period in a northern Indian hospital.
  
  
  METHODS
  The clinical details of those patients suspected to suffer from fungal necrotizing fasciitis were recorded. Skin biopsies from local wounds were microscopically examined and fungal culturing was carried out on standard media. The histopathology was evaluated using conventional methods and special stains. Apophysomyces isolates were identified by their morphology and by molecular sequencing of the internal transcribed spacer (ITS) region of the ribosomal genes. Antifungal susceptibility testing was carried out following EUCAST guidelines and treatment progress was monitored.
  
  
  RESULTS
  Seven patients were found to be suffering from necrotizing fasciitis caused by Apophysomyces spp. Six isolates were identified as Apophysomyces variabilis and one as Apophysomyces elegans. Five patients had previously received intramuscular injections in the affected area. Three patients recovered, two died and the other two left treatment against medical advice and are presumed to have died due to their terminal illnesses. Posaconazole and terbinafine were found to be the most active compounds against A. variabilis, while the isolate of A. elegans was resistant to all antifungals tested.
  
  
  CONCLUSIONS
  Apophysomyces is confirmed as an aggressive fungus able to cause fatal infections. All clinicians, microbiologists and pathologists need to be aware of these emerging mycoses as well as of the risks involved in medical practices, which may provoke serious fungal infections such as those produced by Apophysomyces.
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Jagdish
authors.initials: J
authors.lastname: Chander
authors.affiliation: Mycology Unit, Medical School and IISPV, Universitat Rovira i Virgili, Reus, Spain. Electronic address: albertomiguel.stchigel@urv.cat.
authors.forename: Alberto Miguel
authors.initials: AM
authors.lastname: Stchigel
authors.affiliation: Mycology Reference Laboratory, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain.
authors.forename: Ana
authors.initials: A
authors.lastname: Alastruey-Izquierdo
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Mayank
authors.initials: M
authors.lastname: Jayant
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Kiran
authors.initials: K
authors.lastname: Bala
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Hena
authors.initials: H
authors.lastname: Rani
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Uma
authors.initials: U
authors.lastname: Handa
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Rajpal Singh
authors.initials: RS
authors.lastname: Punia
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Usha
authors.initials: U
authors.lastname: Dalal
authors.affiliation: Government Medical College Hospital (GMCH), Chandigarh, India.
authors.forename: Ashok Kumar
authors.initials: AK
authors.lastname: Attri
authors.affiliation: Mycology Reference Laboratory, Spanish National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain.
authors.forename: Araceli
authors.initials: A
authors.lastname: Monzon
authors.affiliation: Mycology Unit, Medical School and IISPV, Universitat Rovira i Virgili, Reus, Spain.
authors.forename: José Francisco
authors.initials: JF
authors.lastname: Cano-Lira
authors.affiliation: Mycology Unit, Medical School and IISPV, Universitat Rovira i Virgili, Reus, Spain.
authors.forename: Josep
authors.initials: J
authors.lastname: Guarro
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000494:pharmacology / Q000627:therapeutic use; D021821:Communicable Diseases, Emerging / Q000453:epidemiology / Q000382:microbiology*; D003428:Cross Infection / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology / Q000601:surgery; D004271:DNA, Fungal / Q000235:genetics; D021903:DNA, Ribosomal Spacer / Q000235:genetics; D003646:Debridement; D003881:Dermatomycoses / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology* / Q000601:surgery; D048909:Diabetes Complications / Q000382:microbiology; D019115:Fasciitis, Necrotizing / Q000453:epidemiology / Q000382:microbiology*; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D007273:Injections, Intramuscular / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009090:Mucorales / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification* / Q000472:pathogenicity; D009091:Mucormycosis / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology* / Q000601:surgery; D016533:Mycological Typing Techniques; D009894:Opportunistic Infections / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology* / Q000601:surgery; D011446:Prospective Studies; D021521:Ribotyping; D016019:Survival Analysis; D014946:Wound Infection / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology / Q000601:surgery
chemical_list: D000935:Antifungal Agents; D004271:DNA, Fungal; D021903:DNA, Ribosomal Spacer
keywords: Apophysomyces; Emerging fungi; Fascitis necrotizante; Hongos emergentes; Mucorales; Mucormicosis; Mucormycosis; Necrotizing fasciitis