Page 125 - Journal of Special Operations Medicine - Winter 2015

An Ongoing Series

Recovery of Bacteria and Fungi From a Leg Wound

Michael A. Washington, PhD; Jason C. Barnhill, PhD;
Megan A. Duff, EMT-B; Jaclyn Griffin, NP

ABSTRACT

Acute and chronic wound infections can both be en- While the patient in this case may not be representative
countered in the deployed setting. These wounds are of the military population, this case serves to illustrate
often contaminated by bacteria and fungi derived from how an unusual coinfection can be acquired, identified,
the external environment. In this article, we present the and treated, and it may serve as a model for the evalua-
case of a wound infection simultaneously colonized by tion of similar cases in the deployed environment.
Enterobacter cloacae (a bacterial pathogen) and Tricho-
sporon asahii (an unusual fungal pathogen). We describe Case Presentation
the examination and treatment of the patient and review
the distinguishing characteristics of each organism. An 89-year-old hypertensive white male presented to
the emergency room at Tripler Army Medical Center,
Keywords: infection, bacteria, fungi, Enterobacter cloacae, Honolulu, Hawaii, with an infected wound on the left
Trichosporon asahii shin (2 days postinjury). His medical history was sig-
nificant only for past rheumatic fever (contracted during
the Second World War) and valvular heart disease. The
patient indicated that the wound was obtained as the re-
Introduction
sult of a fall suffered while jogging in a local park on the
Fungal infections are a constant cause of morbidity and island of Oahu in Hawaii. He was initially given baci-
mortality in tropical climates. In fact, a recent study has tracin and instructed to follow-up with his primary care
1
shown that the prevalence of soil fungal contamination in manager (PCM). He attempted self-care for a period of
a given location is directly related to the distance of that 8 days and then saw his PCM, who referred him to the
location from the equator, with those locations closest Vascular Limb Salvage Clinic.
to the equator having the greatest levels of contamina-
tion. The complex traumatic and routine wounds sus- Upon examination (11 days postinjury), it was noted
2
tained by military personnel are often contaminated and that the wound was red, painful, and covered with a
have been found to harbor numerous bacterial and fun- black eschar over the entire wound bed. Limb circulation
gal species. Given that US military personnel routinely was normal and popliteal and anterior tibial pulses were
3
operate in tropical locations throughout the African and palpable. Pitting edema (2+) was noted at the wound
the Asia-Pacific regions, knowledge of the pathogenic site. The patient’s hematology profile indicated a slight
fungi endemic to these regions is essential for the proper lymphopenia (11.3%; range, 19% to 48%) and his ba-
diagnosis and treatment of coinfected wounds. This is sic metabolic profile was unremarkable. The wound was
4,5
particularly true in resource-limited countries in which debrided and a portion of the desiccated skin flap was
the true prevalence and distribution of fungal pathogens sent to the laboratory for culture and sensitivity studies.
may be unknown. While laboratory support to de- Wound measurements postdebridement were 8.7cm ×
6
ployed forces may be limited, microbiology capability is 4.9cm × 0.2cm. Empiric clindamycin therapy was ini-
often available in combat support hospitals and can be tiated and topical Iodosorb (Smith & Nephew; http://
augmented to support the presumptive identification of smith-nephew.com) application begun. The patient was
fungal pathogens. Here, we describe the bacterial and advised to limit physical activity to allow the wound to
7
fungal coinfection of a wound site on an elderly man. heal and to return for a follow-up examination.

113