287 Invasive Fungal Infections in Burns: Case Series and Review of the Literature

Despite advances in burn care, infection remains the most frequent complication and cause of death. Topical and systemic antimicrobials have been the cornerstone in burn treatment, but have also led to a tenfold increase in the incidence of fungal infections. The mainstay of treatment is aggressive surgical debridement as well as topical and systemic antifungals. Despite prompt aggressive treatment, delayed diagnosis and high fungal burden lend to a disturbingly high mortality. As experience with invasive fungal infections is still rare for any one unit, we reviewed our experience with invasive fungal infections. Review of known cases of invasive fungal infections was performed. Demographics, burn data, culture data and hospital course were abstracted for analysis. Case 1:55-year-old man with 43% total body surface area (TBSA) burns to bilateral upper extremities (BUE), anterior torso and head after a flash fire while burning brush. He rolled in mud prior to presentation. Despite doing well initially, he developed multisystem organ failure. Invasive fungal infection was suspected, and amphotericin B was started on hospital day (HD) 6. He was taken to surgery on HD 7 where the infection was found to invade the skull and facial musculature. He continued to decline and died on HD 8. Cultures became positive for scedosporium A. and fusarium species 14 days after injury. Case 2: 63-year-old man with 51% TBSA burns to head, BUE, bilateral lower extremities (BLE), and posterior trunk after a plane crash. He had a prolonged course, complicated by stroke and multisystem organ failure. On HD 29, fungal infection was suspected and fluconazole was added. Wound cultures from HD 29 became positive for Rhizopus species on HD 34 for which posaconazole was initiated. He continued to decline and died on HD 50. Case 3: 43-year-old woman with 51.5% TBSA burns to head, neck, BUE, anterior trunk, and BLE after a flash fire while burning leaves. She rolled in mud prior to presentation. On HD 7 she had a cardiac arrest. Broad spectrum antimicrobials were started, including caspofungin. A wound culture from HD 10 became positive for mold on HD 11, which was updated to Mucor species on HD 17. Amphotericin B was started on HD17. The patient was taken back to the OR for multiple excisions on HD’s 14, 19, 21, and 24. She died on HD 25. Invasive fungal infections in burns have high morbidity and the limited case series at our institution had 100% mortality. All cases had a delay in diagnosis and the empiric antifungals chosen were not broad enough. In large burn injuries a high index of suspicion is necessary to treat and potentially salvage these high risk patients. Early diagnosis and treatment of invasive fungal infections will improve patient outcomes and potentially prevent mortality.