Cutaneous Mucormycosis in the Setting of Disseminated Intravascular Coagulation Following Snakebite: A Rare Case Report

Rajendra Devanda; C Kanmani Indra

doi:10.4103/cdr.cdr_2_21

ONLINE ONLY ARTICLES - CASE REPORT

Year : 2022 | Volume : 6 | Issue : 2 | Page : 153

Cutaneous Mucormycosis in the Setting of Disseminated Intravascular Coagulation Following Snakebite: A Rare Case Report

Rajendra Devanda¹, C Kanmani Indra²
¹ Department of Dermatology, University College of Medical Sciences, Delhi, India
² Department of Dermatology, JIPMER, Puducherry, India

Date of Submission	05-Jan-2021
Date of Decision	05-Jun-2021
Date of Acceptance	12-Jul-2021
Date of Web Publication	26-Aug-2022

Correspondence Address:
C Kanmani Indra
Department of Dermatology, JIPMER, Gorimedu, Puducherry - 605 006
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cdr.cdr_2_21

Abstract

We report a case of cutaneous mucormycosis occurring in the setting of disseminated intravascular coagulation following snakebite in an adult. It occurred in the chest wall presenting as a necrotic patch with satellite spots. This case occurred in a different clinical scenario in which mucormycosis is not usually suspected. This highlights the importance of a wide range of clinical suspicion to diagnose such cases in an unusual scenario. Since mucormycosis spreads rapidly with a bad prognosis, it warrants early diagnosis and treatment. Hence, this case has been reported for its unusual presentation. There is also the need to suspect and diagnose these cases early for effective management.

Keywords: Cutaneous mucormycosis, disseminated intravascular coagulation, snake bite

How to cite this article:
Devanda R, Indra C K. Cutaneous Mucormycosis in the Setting of Disseminated Intravascular Coagulation Following Snakebite: A Rare Case Report. Clin Dermatol Rev 2022;6:153

How to cite this URL:
Devanda R, Indra C K. Cutaneous Mucormycosis in the Setting of Disseminated Intravascular Coagulation Following Snakebite: A Rare Case Report. Clin Dermatol Rev [serial online] 2022 [cited 2022 Sep 26];6:153. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/2/153/354747

Introduction

Rhizopus oryzae is the most common organism isolated in mucormycosis and is responsible for about 70% of all cases of mucormycosis.^[1] It has various presentations such as rhinocerebral, pulmonary, gastrointestinal, abdominopelvis, and cutaneous.^[2] Cutaneous mucormycosis usually presents as plaques, pustules, abscesses, necrotic or ulcerated lesions. Cutaneous infarction has been reported as a part of a disseminated mucormycosis.^[3] We present a case of cutaneous mucormycosis presenting as a necrotic patch in the chest wall in the setting of disseminated intravascular coagulation (DIC) following snakebite in an adult which is quite rare, hardly few cases reported in literature.

Case Report

A 22-year-old male nondiabetic with a history of hemotoxic snake bite 1 month back was admitted with 15-day history of cellulitis of the right lower limb with hypotension. The patient had multiorgan dysfunction, acute kidney injury, microangiopathic hemolytic anemia, DIC and Gram-negative sepsis due to Klebsiella pneumonia for which he was hospitalized for a month. The patient had low platelet count of 24,000/mm³, high prothrombin time of 60 s with international normalized ratio 5.5, and positive fibrin degradation product with elevated D-dimer. He was treated with antisnake venom and symptomatic treatment. Ten days after hospital stay, the patient developed dull erythematous patch over the right side of the chest wall which rapidly increased in size with multiple satellite spots. On examination, he had 3 cm × 3 cm well marginated indurated purple-colored patch with central necrosis over the right side of the chest wall with multiple satellite necrotic spots [Figure 1]. Differentials considered were purpura fulminans, ecthyma gangrenosum, and necrotizing fasciitis. Histopathological examination from the lesion showed necrosis of epidermal keratinocytes along with superficial and deep dermal infiltration with broad aseptate fungi branching at an obtuse angle with evidence of angioinvasion [Figure 2] and [Figure 3]. There was also evidence of deep dermal nerve invasion by the broad aseptate fungi. Gomori methenamine silver stain highlighted the fungal elements [Figure 4]. Tissue bit sent for fungal cultures grew Rhizopus species. Fungal blood culture was negative. Diagnosis of cutaneous mucormycosis in the setting of DIC following snake bite was made. He was started on liposomal amphotericin B at 5 mg/kg dose as intravenous infusion. The patient succumbed to his illness within 2 days. The portal of entry of cutaneous mucormycosis can be traumatic implantation, through the bloodstream to the skin or iatrogenic. The route of acquisition in this patient is still unknown; probably nontraumatic inoculation. The case is reported to highlight that cutaneous mucormycosis occurred in the setting of DIC following snake bite. The clinical morphology of the lesion was that of a necrotic patch in the chest wall which is a quite unusual site of occurrence of cutaneous mucormycosis.

Figure 1: Cutaneous mucormycosis showing well-defined indurated violaceous patch of size 3 cm × 3 cm with central necrosis seen over the right side of the chest wall extending onto the upper abdomen with multiple satellite necrotic spots present

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Figure 2: Biopsy of cutaneous mucormycosis shows broad aseptate fungi branching at an obtuse angle (skin hematoxylin and eosin stain with ×100 magnification)

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Figure 3: Biopsy of cutaneous mucormycosis shows fungal elements showing angioinvasion (skin hematoxylin and eosin stain with ×100 magnification)

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Figure 4: Biopsy of cutaneous mucormycosis shows fungal elements in the dermis (Grocott methenamine silver stain with ×100 magnification)

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Discussion

Mucormycosis is a fungal infection with a high mortality rate in unrecognized or untreated cases that occurs in immunocompromised patients because of uncontrolled diabetes mellitus, organ transplantation, neutropenia, cancer, immunosuppressant uses, and increased serum level of iron.^[1] Cutaneous mucormycosis in our patient occurred in an adult patient with DIC and snake bite which is quite unusual. So, the diagnosis becomes difficult in such a different clinical scenario of presentation of cutaneous mucormycosis. With other differentials such as purpura fulminans and ecthyma gangrenosum presenting similarly, correct diagnosis requires a great deal of suspicion. Despite aggressive therapy, mucormycosis mortality is very high so it is considered as a medical emergency and early diagnosis is essential. Mucormycosis infection is characterized by extensive angioinvasion that results in vessel thrombosis and subsequent tissue necrosis which result in decreased antifungal penetration to the focus of infection. Histopathological examination in our case showed angioinvasion and neural invasion. Cutaneous mucormycosis can be a primary form by direct inoculation to the skin or it can be secondary form, by dissemination from other location, more commonly from a rhinocerebral infection.^[4] In our case, the route of entry is unknown. Fungal culture positivity in Sabouraud's dextrose agar media can be seen in about 72%–89% patients.^[5] Demonstration of the organism in tissue biopsy specimen and confirmation of the species by culture remains the gold standard for the diagnosis.^[5] There are no serologic blood tests that are currently available to confirm the infection. Mucorales are saprophytic fungi characterized by irregular broad, aseptate, thick-walled hyphae found ubiquitously in the environment, particularly in the soil and decaying vegetable matter.^[6] Mucormycosis treatment is multidisciplinary. Underlying immunosuppression correction and a combination of radical surgical treatment and antifungal therapy are required for correct fungal infection control and to improve survival rates.^[7] Conventional amphotericin B, dosed at 1.0–1.5 mg/kg/day, is the preferred treatment or liposomal amphotericin B can be used, especially in patients who develop renal toxicity from conventional amphotericin B. Our case showed cutaneous mucormycosis presenting as a necrotic patch, which had an unusual location. The patient developed the lesion after hospitalization in the setting of DIC following snakebite which is quite a rare presentation. Thus, such a different clinical scenario of presentation of cutaneous mucormycosis warrants a great deal of suspicion for proper diagnosis and management of such cases. The case is reported to highlight this fact and early diagnosis of such cases.

Conclusion

We report a case of cutaneous mucormycosis occurring in the setting of DIC following snakebite in an adult. It occurred in the chest wall presenting as a necrotic patch with satellite spots. This case occurred in a different clinical scenario in which mucormycosis is not usually suspected. Hence the case is reported to highlight the need to consider such diagnosis of cutaneous mucormycosis in a different scenario as in snake bite and DIC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank the patient for giving consent to report this case in the journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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