Page 126 - Journal of Special Operations Medicine - Winter 2015

Culture studies of the skin-flap revealed the presence of
a coagulase-negative Staphylococcus, which is a com-
monly observed skin commensal, the gram-negative Figure 3 Photograph
8,9
taken 10 days post-
rod Enterobacter cloacae, and a yeast. Antibiotic sus- ciprofloxacin treatment,
ceptibility studies of the E. cloacae demonstrated suscep- wound measurements:
tibility to gentamicin, trimethoprim sulfamethoxazole, 7.9cm × 4cm × 0.1cm.
ciprofloxacin, and cefepime. Clindamycin therapy was Note purulence and
discontinued and ciprofloxacin therapy was initiated at edema.
18 days postinjury.

The yeast was cultured on cornmeal agar (a common at this visit were 7.9cm × 4cm × 0.1cm. The 29-day
laboratory growth medium) and calcofluor-white and postinjury evaluation showed further reduction of the
lactophenol cotton blue staining was used to visualize wound volume to 6.8cm × 4cm × 0.1cm, and 68 days
fungal elements. 10,11 This analysis revealed the presence postinjury evaluation showered further reduction of the
of budding yeasts and hyphae with arthroconidia (Fig- wound volume to 3.8cm × 1.8cm × 0cm (Figures 4 and
ures 1 and 2). A germ-tube test was used to rule out 5). This represents a 36% decrease in overall wound
Candida albicans (a ubiquitous fungal pathogen) and volume with respect to the initial postdebridement mea-
the isolate was finally identified as Trichosporon asahii surement. In addition, reductions in edema, pain, and
by using the Vitek 2 automated identification system (bio- surrounding erythema were noted. Follow-up visits re-
Mérieux SA; http://www.biomerieux-diagnostics.com/ vealed that the wound continued to resolve with con-
vitek-2). An infec tious disease specialist was consulted, ventional treatment and without antifungal therapy.
12
and a 10-day course of ciprofloxacin was recommended.
It was also recommended that fluconazole therapy be
initiated if the wound did not improve during the 10-
day ciprofloxacin treatment. Figure 4 Photograph
taken 16 days post-
ciprofloxacin treatment.
Note reduction in wound
area, purulence, and
edema.
Figure 1
Lactophenol cotton
blue stain of
T. asahii isolated
from patient wound Figure 5 Photograph
site. Note the taken 23 days
presence of budding post-ciprofloxacin
yeast and hyphae treatment. Note
with arthroconidia. further reduction
in wound area and
purulence.

Distinguishing Features of E. cloacae
Figure 2 Calcofluor- E. cloacae is a well-described opportunistic pathogen that
white staining of 13,14
T. asahii derived gains entrance via the skin or gastrointestinal tract.
from patient wound It has worldwide distribution and can be easily isolated
15
site. Note the from environmental surfaces. Identification is typically
presence of hyphae based on morphological features and basic biochemis-
and budding yeast. try. E. cloacae forms creamy-tan colonies when plated
on blood agar media (the most common bacterial isola-
tion medium), it appears rod-shaped upon microscopic
examination, it lacks the enzyme cytochrome oxidase a,
A 22-day postinjury follow-up revealed an overall re- and is positive for the enzyme catalase (Figure 6). 16,17
duction in redness and pain and the presentation of a Each of these characteristics can be rapidly determined
cleaner wound bed (Figure 3). Wound measurements in a field laboratory for a presumptive identification.

114 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015