Cutaneous mucormycosis in an extremely premature infant

This case concerns a female infant born at 23+4/40 weighing 460 g. She was referred to us on day 6 with focal intestinal perforation, requiring small bowel resection and ileostomy. On day 7, skin necrosis was seen extending bilaterally from under the endotracheal tube (ETT) fixation (figure 1). Removing the device revealed extensive soft tissue damage. Honey dressings were applied and a nonadhesive method (bonnet & ties) used to resecure ETT. Antifungal prophylaxis was continued and antibiotics (tazocin, clindamycin, vancomycin) commenced as swabs from area grew Escherichia coli. Necrosis progressed to full thickness injury by day 11 (figure 2). Debridement of wounds was not felt to be a viable option due to anatomical position. Providing ongoing intensive care was impossible with progression of necrosis and no ways to secure respiratory support long term due to her size (ie, tracheostomy). Intensive care was stopped on day 12. Postmortem examination showed presence of mucormycosis throughout the necrotic tissue. Mucormycosis is a rare, invasive fungal infection caused by Zygomycota phylum often seen cutaneously (commonly under areas of adhesive dressings) and gastrointestinally in neonates, with reported mortality of up to 85%. Hyperglycaemia, corticosteroids, extremely low birth weight and broadspectrum antibiotics are recognised factors predisposing to mucormycosis. Debridement of affected tissue and intravenous amphotericin B are treatments of choice, but its rarity and propensity to occur under adhesive dressings make late recognition more likely. Preterm babies will commonly have both predisposing factors and adhesive dressings in place (eg, ETT fixation). We present this case to raise awareness of this rare, but often fatal, infection.