A 15 year old boy comes in five days after his leg was injured by debris during a tornado
What is in the differential?
hemorrhagic bulla
Our patient had documented mucormycosis which is not a common pathogen however is reported after tornadoes and other natural disasters.
Thirteen cases were identified after a tornado in Joplin Missouri in 2011. Five individuals died from the infection traced to Apophysomyces trapeziformis ;a parasitic soil fungus of the order Mucorales. The mechanism was felt to be implantation of contaminated soil or water into open wounds from injuries sustained in the tornado. The majority of cases were necrotizing skin infections although pneumonia was also reported with immune suppressed individuals at highest risk.
In addition to the Joplin tornado, mucormycosis has been reported after a volcanic eruption in Columbia in 1985 and after the Indonesian tsunami in 2004.
Many of the affected had open wounds which turned black and then developed a white fuzzy mold about five days later. The greatest success came from treating with a combination of surgery, antifungals and antibiotics.
DIFFERENTIAL FOR HEMORRHAGIC BULLAE
non immune hemorrhagic bullae from fondaparinux
and Mucor
Diabetic pt with necrotizing fasciitis
The differential for hemorrhagic bullae spans diseases from a simple friction blood blister to necrotizing fasciitis. History and clinical clues will be important. Necrotizing fasciitis classically presents as pain out of proportion to the area of inflammation and can present with pain even before lesions are apparent.
Lovatt C, Ye W, Yousuf H. Probable fondaparinux-associated bullous hemorrhagic dermatosis. CMAJ 2921 May 31;193:E801-4. Jessica Harmon, MD; Raffi Kapitanyan, MD | May 6, 2025 | Contributor Information
Weinhold B Rare fungal illness follows tornado. Environ Health Perspct 2013 Apr 1;121(4):a116.
Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011. Neblett Fanfair R, Benedict K et al. New England Journal of Medicine 2012;367(23):2214-2225
uloMucormycosis due to Apophysomyces species complex - 25 years' experience at a tertiary care hospital in southern India. Pamidimukkala U, Sudhaharan S et al. Medical Mycology 2020;58(4):425-433
Fungal diseases as neglected pathogens: A wake-up call to public health officials. Rodrigues ML & Nosanchuk JD. PLoS Neglected Tropical Diseases 2020;14(2):e0007964