A 28-year-old right-hand-dominant man was airlifted for limb salvage to the level 1 trauma center where the investigators practice after sustaining an agricultural accident in which his left hand was pulled into a corn augur. The mangling injury of his hand included fractures of his index through ring fingers with extensive lacerations and exposed flexor tendons. There was a partial degloving injury to his left palm (Figures 1 and 2). The patient was otherwise stable and had no additional injuries. Upon arrival he was taken emergently to the operating room, where he underwent irrigation and debridement, primary fusion with Kirschner wires of the destroyed PIP joints in his left index, long, and ring fingers, a split-thickness skin-graft to his left palm and long finger from a left forearm donor site, and initiation of IV antibiotics, administering vancomycin and ampicillin/sulbactam. He recovered uneventfully and was discharged home four days later without additional antibiotic therapy.  
At his first follow-up appointment two weeks post-operatively, he showed no sign of systemic infection but was noted to have an extensive necrosis involving part of his left long finger and the palmar skin graft (Figure 3). Surgical debridement including amputation of the long finger was scheduled and he underwent a filet flap closure of the second webspace after long finger ablation. Tissue samples revealed both bacterial and mold growth, and the Infectious Disease team was consulted. Due to the suspicion for an invasive mucor mycosis he was taken the next morning for additional irrigation and debridement, and lipid-complex amphotericin B was added to his antibacterial medications. Cultures were speciated to coagulase-negative Staphylococcus, two different species of Pseudomonas, and mycotic species including Mucor and Aspergillus fumigates. He recovered well and was later discharged home on hospital day five with a Hohn catheter and an outpatient antibiotic regimen planned for four total weeks that included vancomycin 1 g intravenously twice daily, Zosyn 12 g continuous infusion daily, and Posaconazole suspension 400 mg (10 mL) orally twice daily. 
He continued to show improvement at his follow-up appointments with both Orthopaedic Surgery and Infectious Disease. Approximately one week after discharge his AFB cultures taken intraoperatively turned positive by probe for Mycobacterium tuberculosis complex, which stood in contrast to a negative PPD test that had been documented within the previous two years. At this clinic visit a new PPD was placed and later found to be negative when read in his home town. A chest radiograph also showed no sign of TB infection. Ultimately the positive AFB was attributed to an environmental mycobacterial contaminant.
His weekly labs drawn by a home health agency were otherwise unremarkable until approximately three weeks after his discharge. At that time he was found to be neutropenic with a white blood cell count of 3100 (absolute neutrophil count 120), and he was admitted to the hospital in his hometown where all of his antibiotics and antifungals were held. He was discharged several days later after recovery of his white blood cell count without sign of infection or any further complication. Though his antibiotic regimen was not restarted (as he had nearly completed his planned course), he remained free of infection and healed well (Figure 4).