Surgical Management and Outcomes of Cutaneous Mold Infections in Immunocompromised Children
Jaclyn T. Mauch, BA, Shelby L. Nathan, MS, Valeriy Shubinets, MD, Ines C. Lin, MD.
University of Pennsylvania, Philadelphia, PA, USA.
Background: Cutaneous mold infections occur infrequently but can be life-threatening in immunocompromised children. The literature regarding its surgical management is limited. This study aims to describe the surgical management and outcomes of cutaneous mold infections in immunocompromised children.
Methods: Patients receiving an inpatient skin biopsy at a single pediatric hospital in 2003-2017 were identified using CPT and ICD-9/10 billing codes. Inclusion criteria were immunocompromised status, less than 21 years of age, and surgical excision of a confirmed cutaneous mold infection. Demographic information, details of immunosuppression, operative details, and 6-month post-operative outcomes were collected.
Results: 17 patients were identified (average age; 6.8 years; range: 0.2-19.5 years) with 21 excised lesions. Etiology of immunocompromised state were treatment for malignancy (13; 76%), aplastic anemia (2; 12%), primary immune deficiency (1; 6%), and treatment for sideroblastic anemia (1; 6%). Fungal organisms included Rhizopus, Rhizomucor, Aspergillus, Alternaria, Curvularia, and Bipolaris Australiensis. 7 patients had confirmed systemic infection. Affected anatomic regions included limb (15; 71%), chest (2; 10%), axilla, back, abdomen, and head (1 or 5% each). All patients received systemic antifungal treatment. Excisions occurred, on average, within 1.7 days of initial biopsy (range: 0-7 days). When specified, margins were between 0.5 and 2.0 cm, and surgeons employed intraoperative fungal detection techniques in 8 cases (47%). 2 patients (11%) received further excision or amputation, either due to identification of fungus at margins or infection recurrence. Excision size ranged between 1.2 and 80.0 cm2 (average: 13.5 cm2). Definitive closure was achieved by secondary intention/dressings changes (9; 43%), skin graft (6; 29%), a skin substitute (2; 10%), delayed primary closure (2; 10%), and immediate primary closure (2; 10%). Surgical closure dates ranged from 0-34 days after initial resection (average: 16.2 days). Secondary intention took from 49 to 230 days to wound closure (average: 117 days). 3 patients (18%) developed infection recurrences, and 2 of these passed away by 6 months post-op. Overall, 14 patients were alive 6-months post-resection (82%).
Conclusions: This study demonstrates the overall success of surgical excision of focal cutaneous fungal infections in immunocompromised pediatric patients. We find a strong consideration for at minimum 0.5cm margins and intra-operative pathologic study when considering surgical treatment for this rare but serious infection.
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