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Cluster of rare fungal infections identified after tornado

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8382 (Published 12 December 2012) Cite this as: BMJ 2012;345:e8382

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In May 2011, a severe tornado killed 160 people in Missouri, USA, and injured 1000 others. Local doctors began reporting cases of severe injuries complicated by unusual fungal infections, and more active surveillance quickly identified 13 injured people with necrotising soft tissue infections caused by environmental fungi or mucormycoses. Five of them died within two weeks of diagnosis.

Penetrating trauma and a high number of injuries were the two factors most consistently associated with mucormycosis in a case-control study. The 13 cases had up to seven separate injuries, and a median of five each. They needed wide surgical excision of necrotic tissue, repeated an average of four times as infections progressed. DNA sequencing identified four different strains of Apophysomyces trapeziformis in infected wounds.

Nine people had been injured in houses in the path of the tornado, which touched down just west of the city of Joplin and moved east through the densely populated centre. Case patients and controls were caught off guard and unable to reach storm shelters or basements below ground.

Mucormycoses are rare but not unheard of after natural disasters, including the Indian Ocean tsunami in 2004, say the authors. Doctors treating injured people should consider the possibility when faced with infected necrotic wounds. Timely treatment with the right antifungal agent—in this case amphotericin B or posaconazole—might be life saving. Six of the patients in this series were treated initially with agents known to be inactive against mucormycoses. Three of them died.

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Cite this as: BMJ 2012;345:e8382