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Necrotizing fasciitis is a soft tissue infection involving the skin and subcutaneous tissue down to the fascia overlying muscle. The infection is usually polymicrobial, with beta-hemolytic streptococci being the most commonly isolated microbe.1 Fungus as a cause of necrotizing fasciitis is extremely rare and is usually associated with immunosuppression, poorly controlled diabetes, and chronic alcohol use.1 Trauma has been identified as a risk factor for developing fungal infection, likely because of a prolonged hospital course and the resultant suppressed immunologic state in critically ill patients.1 Zygomycosis is the third most common cause of invasive fungal infection and reports of necrotizing soft tissue infections due to zygomycosis demonstrate a mortality rate of 26 to 29 per cent.2 Cutaneous zygomycosis infection can be classified into three types: localized to the skin, deep tissue extension, and disseminated. In the presence of deep tissue extension, symptoms of necrotizing fasciitis include induration, blistering, pustules or necrotic ulceration, and sepsis. Zygomycosis infection should be included on the differential diagnosis in trauma patients, especially if there is concern for mold growing within the wound.2 When working up necrotizing fasciitis, it is important to collect tissue cultures during surgical debridement. However, Zygomycosis is unique in that a large proportion of cultures do not yield a fungus.2
Treatment of fungal wound infections revolves around prompt diagnosis, initiation of systemic antifungal therapy, and urgent surgical debridement of all necrotic tissue.1 In one case series, patients with zygomycosis on average underwent 10 surgical debridements.2 Hyperbaric oxygen (HBO) therapy has also shown to be an effective adjunctive therapy to fungal necrotizing fasciitis. In vitro studies have shown that HBO inhibits fungal growth, corrects lactic acidosis, elevates tissue oxygen levels leading to increasing rates of tissue healing, enhances leukocytemediated phagocytosis, elevates levels of growth factors, and promotes angiogenesis.3
Interestingly, there is a paucity of research and case reports of fungal wound infections, especially in the trauma population. In this case report, we present a previously healthy 39-year-old male admitted to the trauma service for multiple gunshot wounds to the abdomen, who developed fungal necrotizing fasciitis originating from a bullet wound, whose treatment included multiple surgical debridements, systemic antifungal therapy, adjunctive topical wound therapies, negativepressure vacuum dressing, and ultimately HBO therapy.
A 39-year-old black man presented to the emergency...