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Fascitis Necrosante Por Apophysomyces Elegans, Moho De Biomédica 2004;24:239-51 FASCITIS NECROSANTE POR APOPHYSOMYCES ELEGANS INFORME DE CASO Fascitis necrosante por Apophysomyces elegans, moho de la familia mucoraceae, en paciente inmunocompetente Carmen Elena Ruiz 1, Myrtha Arango 2,3, Ana Lucía Correa 4, Luz Saider López 5, Angela Restrepo 2 1 Servicio de Cirugía, Hospital Pablo Tobón Uribe, Medellín, Colombia. 2 Grupo de Micología Médica y Experimental, Corporación para Investigaciones Biológicas, Medellín, Colombia. 3 Sección de Micología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia. 4 Servicio de Medicina Interna, Hospital Pablo Tobón Uribe, Medellín, Colombia. 5 Cirugía plástica, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia. Se presenta la historia de un niño de 7 años de edad, politraumatizado por accidente automovilístico, que falleció a consecuencia de infección por Apophysomyces elegans, un hongo de la familia Mucoracea. La invasión fue progresiva, inicialmente se observó una lesión puntiforme en la región lumbar izquierda que progresó a fascitis necrosante y, posteriormente, afectó la zona lumbar, los glúteos y el flanco derecho. El tratamiento antimicótico resultó inefectivo y el paciente falleció 8 semanas después de su accidente. Se presenta, además, una revisión de los casos atribuidos a este hongo. Palabras clave: Mucormicosis (zigomicosis), trauma, fascitis necrosante, Mucoracea, Apophysomyces elegans. Necrotizing fasciitis in an immunocompetent patient caused by Apophysomyces elegans A case study is presented of a 7-year-old boy, seriously injured in a car accident, who developed a fatal infection due to Aphophysomyces elegans - a mold of the Mucoracea family. Fungal invasion was initially manifested by a spotted wound in the left lumbar region which developed into a necrotizing fasciitis. Later this progressed to the right lumbar area, including the gluteus and the corresponding flank. Antimycotic treatment proved ineffective, and the child died 8 weeks after the accident. Other cases due to this fungus are reviewed. Key words: Mucormycosis (zygomycosis), trauma, necrotizing fasciitis, Mucoracea, Apophysomyces elegans. El término mucormicosis (zigomicosis) fácil entrar en contacto con sus esporas (1-4). A comprende un conjunto de entidades clínicas pesar de tan amplia distribución, la mucormicosis causadas por diversos mohos pertenecientes al es relativamente infrecuente y se presenta orden Mucorales. Estos microorganismos se especialmente en pacientes inmunosuprimidos caracterizan por poseer hifas anchas, con neutropenia o cáncer, en diabéticos y en desprovistas de septos, y por ser de crecimiento desnutridos (1,2). Suele diagnosticarse, rápido. Se les encuentra ampliamente distribuidos igualmente, en personas inmunocompetentes que en suelos, materia orgánica en descomposición han sufrido traumas (5-10). Las infecciones se y están presentes en el aire; por consiguiente, es adquieren por aerosol y, también, por ingestión o inoculación traumática (1,2,5-7,10). Correspondencia: Angela Restrepo, Corporación para Investigaciones Posiblemente, esta entidad es la afección micótica Biológicas (CIB), Carrera 72 A # 78B-141, Medellín, Colombia. más aguda, progresiva y grave que se conoce (1- Teléfono: (4) 441 0855; fax: (4) 441 5514 3,11-14). En gran parte, debido a que todos los [email protected] agentes etiológicos exhiben acentuado tropismo Recibido: 09/07/04; aceptado: 12/07/04 por los vasos sanguíneos que les permite alcanzar 239 RUIZ C.E., ARANGO M., CORREA A.L. et al. Biomédica 2004;24:239-51 diversos órganos para producir, posteriormente, distensión abdominal, taquicardia, escoriaciones émbolos y causar necrosis de los tejidos y heridas en ambas rodillas, antebrazo izquierdo circundantes (1-3,5,6). y cuero cabelludo; además, tenía fractura abierta de tibia izquierda. Se practicó laparotomía La mucormicosis reviste diferentes formas según exploratoria, la cual no reveló lesión interna, se su localización: rinocerebral, pulmonar, cutánea, redujo e inmovilizó la fractura, se suturaron todas gastrointestinal y diseminada; esta última puede las heridas en piel y se aplicó penicilina cristalina. comprometer hueso, riñón, corazón, mediastino y otros sitios del organismo. Más de la mitad de Por petición de la familia, se remitió a Medellín. los casos corresponde a la forma rinocerebral En urgencias del Hospital Pablo Tobón Uribe, (1-4,6,11), mientras que la cutánea representa ingresó un niño conciente, orientado en los tres apenas una décima parte de ellos (1,2,5,6,8,9,12). planos y con sobrepeso; con frecuencia cardiaca Debe anotarse que el diagnóstico clínico de la de 100 latidos por minuto, frecuencia respiratoria mucormicosis es difícil dado que sus síntomas de 24 por minuto, presión arterial de 129/44 mm son similares a los de otras enfermedades y, Hg y presión arterial media de 72 mm Hg. también, porque inicialmente puede parecer Presentaba cicatriz de laparotomía superior y benigno. Por consiguiente, el diagnóstico suele ser múltiples heridas superficiales en tórax posterior, tardío por lo que la enfermedad progresa hasta miembros superiores e inferiores, escoriaciones volverse incontrolable (1,2,13-15). Las series de y flictenas en región lumbar izquierda que llegaban casos informados en Estados Unidos señalan que hasta la parte lateral y anterior del hemiabdomen la fascitis necrosante se presenta con una ipsilateral. Entre los exámenes de laboratorio frecuencia de 500 a 1.500 casos por año y que su ordenados se anotaron los siguientes: mortalidad global está cercana al 20% (16). hemoglobina, 11,2 mg/dl; hematocrito, 34, y el El tratamiento de la mucormicosis presenta citoquímico de orina fue normal. Se inició especiales dificultades no sólo por su diagnóstico tratamiento con cefalotina, dipirona y líquidos tardío sino también porque sólo se dispone de un endovenosos. fármaco - no siempre efectivo -, la anfotericina B, Tres días más tarde se halló un paciente álgido, disponible en formulaciones a base de deoxicolato pálido pero afebril; con frecuencia cardiaca de 108 o liposomales (1,2,14,15,17). Recientemente, un latidos por minuto; frecuencia respiratoria de 22 nuevo triazol, el posaconazol, ha mostrado ser por minuto; presión arterial de 124/81 mm Hg; efectivo con actividad in vitro y, actualmente, en creatinina de 0,55 mg/dl; nitrógeno ureico en etapa de ensayo clínico (18,19). En casos sangre de 15. Al ser llevado a cirugía se anotaron abordables quirúrgicamente, es necesario, pequeñas áreas con quemaduras de tercer grado además, recurrir al desbridamiento de los tejidos en glúteo izquierdo y de segundo grado en otras necróticos (1,2,9,10,12,13). áreas, con flictenas y laceración en ambos Se describe a continuación el caso de un niño flancos. En el área lumbar izquierda había una politraumatizado quien, como consecuencia de un herida de 4 cm x 0,3 cm, aproximadamente, que accidente de tránsito, desarrolló múltiples lesiones comprometía piel y tejido subcutáneo y otra área de los tejidos blandos. La inoculación traumática de 0,3 cm x 0,3 cm, aproximadamente, que de un hongo de la familia Mucoraceae, mostraba a su alrededor pigmentación negruzca. Apophysomyeces elegans, resultó en infección Además, existían varias heridas no suturadas en diseminada, progresiva y fatal. antebrazo izquierdo, quemadura de 1 cm x 1 cm en maléolo derecho y varias laceraciones en el Presentación del caso frontal izquierdo, incluso, una herida suturada En el hospital de Corozal (Sucre) se atendió un frontoparietal de 4 cm. En este momento se realizó niño de 7 años de edad, estudiante, natural y lavado y desbridamiento exhaustivo, escarotomía, residente en Medellín, previamente sano, quien dermabrasión de la cara y afrontamiento de doce horas antes había sufrido politraumatismo heridas. Se aplicó sulfaplata más xilocaína al 1%, en accidente de tránsito. El paciente presentaba sin epinefrina. 240 Biomédica 2004;24:239-51 FASCITIS NECROSANTE POR APOPHYSOMYCES ELEGANS Se practicaron cultivos de las lesiones que, antibióticos, continuó con ciprofloxacina y se inició posteriormente, demostraron Pseudomonas ampicilina-sulbactam y gentamicina. El niño aeruginosa (más de 100.000 UFC), Enterococcus presentó febrícula y los reactantes de fase aguda faecalis y Staphylococcus aureus. En consecuencia, iban en aumento. se añadió gentamicina, 160 mg por día, intra- A las dos semanas, al reducir en forma cerrada la venosos, al esquema antibiótico; posteriormente, fractura de tibia y colocar yeso muslopédico, se los datos del antibiograma hicieron suspender la apreció que las heridas de la rodilla izquierda cefalotina y la gentamicina, y se reemplazaron estaban sanas. En el tronco continuaba la por ciprofloxacina y ampicilina. Al día siguiente, necrosis fascio-grasa pero sin secreción purulenta. el paciente tenía dolor en glúteo izquierdo, A las cuatro semanas, tal necrosis había afectado genitales y presentaba, además, hidrocele la región lumbar, el glúteo y el flanco izquierdo postraumático doloroso. El niño se encontraba con compromiso del tejido subcutáneo y la fascia, estable hemodinámicamente. respetando los músculos (figura 1). En este Una nueva curación en miembro inferior izquierdo momento, el paciente entró en estado crítico y hecha al séptimo día de hospitalización mostró fue llevado a la unidad de cuidados especiales, una herida limpia en la rodilla. No se halló deterioro donde le suspendieron la ciprofloxacina y la de otras heridas, como tampoco del estado ampicilina sulbactam, iniciaron imipenen y general del paciente. Sin embargo
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