Fungal Cellulitis

HBOT is effective for nearly all infections, including fungal. As this report illustrates, many of these infections are difficult or impossible to treat without the use of HBOT. Given the almost total lack of side effects with HBOT, it seems like the best way to treat these types of conditions.

Periorbital Cellulitis Secondary to Conidiobolus Incongruus

Mary E. Temple, Pharm.D., Michael T. Brady, M.D., Katalin I. Koranyi, M.D., and Milap C. Nahata, Pharm.D., Colleges of Pharmacy and Medicine, The Ohio State University, and Children's Hospital, Columbus, Ohio

Abstract

A previously healthy, 18-month-old girl developed edema and erythema around her left eye 1 week after getting sand in that eye. The patient did not respond to oral or intravenous antibiotics. A mass developed around the eye, and biopsy revealed Conidiobolus incongruus. The patient failed to respond to amphotericin B 1 mg/kg, and susceptibility tests indicated multiantifungal resistance. A combination of antifungal therapy, hyperbaric oxygen, and surgery was required for successful treatment. Three months after treatment the child was disease free. There is no definitive therapy for Conidiobolus incongruus infections, although various drugs have been administered with some success. When susceptibility tests determine multidrug resistance, radical resection with antifungal chemotherapy and hyperbaric oxygen may be necessary as well as lifesaving.

Surgical resection appeared to complement the benefits of HBO treatment, amphotericin B, and itraconazole in our patient. Hyperbaric oxygen treatment was effective in five reported patients, one involving C. coronatus infection in the maxillofacial region and four involving rhinocerebral mucormycosis.[14,15] Hyperbaric oxygen's fungistatic effects make it valuable in treating fungal infections.[16] It increases oxygen tension in unaffected surrounding tissue, which reduces tissue acidosis and inhibits fungal growth. It also may provide an additive effect with amphotericin B because the latter is most effective in an aerobic environment.[17] Since amphotericin B causes oxidative damage to fungal membranes, higher oxygen concentrations may potentiate its effects.

In our patient, amphotericin B 1 mg/kg/day was used initially with natamycin ophthalmic drops once a preliminary fungal etiology was identified. Liposomal amphotericin B was not used, as it has not been shown to work better than conventional amphotericin B (personal communication, J. Bennett, M.D., August 30, 1995).[13] When susceptibility tests indicated multiresistance to available antifungal agents, radical resection of the fungal mass followed by long-term itraconazole and HBO treatment was undertaken.

Medical management, when effective, is preferred. However, for lesions that are unresponsive to antifungal chemotherapy, HBOT and surgical resection may be necessary as well as lifesaving.