Rapidly Deteriorating Digits 

WFJSM Challenge Case: Rapidly Deteriorating Digits

Paul Persad, MD; Elizabeth Palavecino, MD 

A 51-year-old man with a past medical history of end stage renal disease (ESRD) secondary to Goodpasture's disease, diabetes mellitus, hyperlipidemia and hypertension was transferred to our facility from an outside hospital for fever and gangrenous changes to his middle and ring fingers.  His medical regimen included cyclophosphamide and prednisone. 

The patient stated that he injured his right hand while cutting his lawn.  Over the next 3 days he noted worsening pain, paresthesia, discoloration then numbness that spread from the tips to the base of the middle and ring fingers. He reported fevers over 101 F.   Despite broad spectrum antibiotics, including vancomycin and piperacillin/tazobactam, amputation of the involved fingers was necessary. 

Pathologic evaluation of the surgical specimens revealed gangrenous necrosis of the digits with  angioinvasive fungal elements seen with H&E stain (Figure 1 and 2). A Gomori methenamine silver (GMS) stain revealed numerous branching hyphae (Figure 3).  The morphology of the organism recovered in culture allowed the identification of the fungal organism causing the infection (Figure 4).

RDD_Figure1.jpg RDD_Figure2.jpg
RDD_Figure3.jpg RDD_Figure4.jpg

What organism is most likely pathogenic in this situation?  




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