SLR - August 2015 - Prayash Patel

Infection with a Chlorophyllic Eukaryote after a Traumatic Freshwater Injury

References: Westblade LF, Ranganath S, Dunne WM Jr, Burnham CA, Fader R, Ford BA. Infection with a Chlorophyllic Eukaryote After Traumatic Freshwater Injury. N Engl J Med. 2015 Mar 5;372(10):982-4.

Scientific Literature Review
 
Reviewed By: Prayash Patel, DPM
Residency Program: Wyckoff Heights Medical Center
 
Podiatric Relevance: This article is an interesting article because freshwater soft tissue infections in the foot are rarely encountered, especially when dealing with fungal or chlorophyllic eukaryotic organisms. The authors believe chlorophyllic algae such as Desmodesmus armatus (D. armatus) is an infectious agent, which causes soft tissue infection and needs surgical debridement.

Methods: The authors explain two case studies they encountered with alga Desmodesmus armatus. In the first case, a 24-year-old male patient, with no past medical history, sustained a deep puncture wound to the right foot in a freshwater lake in Texas. In the second case, a 30-year-old male patient, with no past medical history, sustained a traumatic freshwater injury while jet-skiing, resulting in an open dislocation of the right knee and right femur. The authors also mentioned a previously reported case, a 30-year-old diabetic woman who had a surgical wound in the right foot, which was infected from river water and resulted in chlorophyllic algal infection from Chlorella saccharophlia.

Results: Both Patients underwent surgical debridement, however they did not receive any antifungal therapy. Fungal cultures showed D.armatus in both cases. The first patient had a full recovery without any sequelae. However, the second patient had recurrent methicillin-susceptible Staphylococcus aureus associated septic arthritis. The isolates obtained from both patients produced green colonies on Sabouraud’s dextrose agar and microscopic examination showed ovoid structures with infrequent spines and subcellular green-pigment spherules. According to the article, the morphologic characteristics are consistent with descriptions of D.armatus. The authors also discussed about 30-year-old female diabetic patient who underwent a surgical debridement and the diagnosis of chlorophyllic algal infection was made by means of histopathological and electron-microscopical examination of surgically excised tissue.    

Conclusions: The authors concluded from the three independent cases of soft tissue infection that D.armatus is an infectious agent. I personally believe soft tissue infections, whatever the cause, need to be treated appropriately with antibiotic therapy and surgical debridement when indicated. The authors in this article fail to mention whether the patients were treated with intravenous or oral antibiotics or antifungal agents. If  D.armatus is the infectious agent, appropriate antimicrobial therapy should be instituted.  

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