A 38-year-old woman with a past medical history of morbid obesity, presented with burns totaling 45 % of her total body surface area (TBSA) following an explosion while cooking cannabis wax. She suffered full thickness burns to the bilateral lower extremities, feet, breasts, buttocks, and abdomen with additional concern for inhalational injury.
Aggressive fluid resuscitation using a modified Brooke formula based on the patient's adjusted ideal body weight was given. She was taken emergently to the operating room for escharotomies to release circumferential third-degree burns extending from her bilateral thighs down to her feet. Postoperatively, she remained intubated and was severely hypotensive. Fluid resuscitation was uptitrated to match urine output and she was started on norepinephrine. Her clinical status continued to decline rapidly as she began to have increasing oxygenation demands, renal failure, and metabolic acidosis requiring continuous renal replacement therapy. Unfortunately, she developed ventilator-associated pneumonia with rapid progression to acute respiratory distress syndrome. Low tidal volume ventilation strategies and scheduled proning were used. Early surgical debridement was delayed due to rapidly declining clinical status including hemodynamic instability to reduce the risk for intraoperative complications.
On hospital day seven, the patient had sufficiently stabilized and was taken to the operating room for her first debridement. Tangential excision and wound bed preparation of her bilateral lower extremities and feet with cadaver allograft placement was performed. Her surgical wounds were placed in Vashe-soaked gauze and dressed with standard burn dressings. Over the next two weeks she underwent an additional five tangential debridements, including her abdomen and torso. On hospital day 20, the patient demonstrated significant medial foot necrosis down to bone and underwent a left below-the-knee guillotine amputation. On hospital day 24, she underwent placement of a percutaneous tracheostomy, due to chronic ventilator dependence, and placement of split thickness skin graft to her torso. Dressing takedown revealed healthy uptake of the autograft. Despite the patient's encouraging torso grafts, her bilateral lower extremity grafts repeatedly failed. Deep tissue cultures of her bilateral lower extremities grew vancomycin-resistant Enterococcus faecium and a yeast. Bone biopsy of the exposed left tibia was obtained intraoperatively and also grew a fungus.
The patient's hospitalization was complicated by numerous nosocomial infections. Three weeks into her stay, she developed fever and worsening leukocytosis. Blood and respiratory cultures were obtained. Blood cultures grew Enterococcus casseliflavus from the arterial line and Lactobacillus species from peripheral blood cultures. Simultaneously, respiratory cultures grew methicillin-sensitive Staphylococcus aureus (MSSA), Group B streptococcus, and Stenotrophomonas. Due to clinical deterioration, the isolates were considered pathogenic and were treated with targeted antimicrobials.
The patient's tissue devitalized rapidly after every thorough debridement of her lower extremities, and her cadaver grafts never succeeded. Due to the recurrent allograft failure on day 34, she was taken for fascial excision and wound bed preparation of the bilateral lower extremities, with a right guillotine below-the-knee amputation. Her surgical wounds appeared clean and healthy the following day. Two days later, a visible growth of mold was found across the entire wound bed. Thus, she was taken back to the operating room for a repeat debridement. Operative tissue cultures were obtained. Local wound care was switched to full-strength Dakin's solution. Infectious Disease was updated and the patient was started on liposomal amphotericin B and isavuconazonium. Twenty-four hours later, her wounds demonstrated visible mold again. She continued to deteriorate:developing renal failure and requiring multiple vasopressors. The following day, her wounds developed a thin coating of black tissue, the cause of which was unclear if it was fungal involvement or it was secondary to necrosis. Again, an aggressive debridement was repeated with bilateral guillotine above-the-knee amputations. Within 72 h her wounds became malodorous and showed recurrent fungal growth. At hospital day 43, she was taken back emergently for an aggressive debridement of her bilateral lower extremities. Local wound care was transitioned to acetic acid to enhance inhibition of fungal growth.
On hospital day 45, the patient's bilateral lower extremities again showed fungal growth. The option of bilateral hip disarticulation was discussed with her family. Based on what the family believed to be her wishes and in the setting of relentlessly invasive fungal growth, despite aggressive debridements and antifungal therapy, the decision was made to cease further operative intervention. She showed no promise of improvement. The fungal infection appeared to spread past the level of the hip and up to the lower portion of the back within a few days. Palliative care was consulted and her family was allowed to visit. She was placed on comfort care measures and expired within a few hours.
The post-mortem report of the fungal culture from the left tibia bone biopsy showed Geotrichum candidum. Fungal culture and mold identification from intraoperative tissue taken after the first identification of clinical mold grew Rhizopus species and Fusarium species. All subsequent cultures obtained during her debridement grew fungi.