Extensive Exserohilum infection in a burn patient

CASE REPORT A 71-year-old woman originally hospitalized with 40% total body surface area fourth-degree burns (ie, into subcutaneous tissue) and respiratory failure subsequently had skin discoloration in her groin and overlying her exposed quadriceps. Her hospital course was complicated by fever and episodes of hypotension in spite of broad antimicrobial coverage with levofloxacin, vancomycin, andmeropenem and fluconazole. She underwent 2 surgical debridements separated by 6 days to her right lower extremity, right side of the chest, and right arm down to fascia. Pathology specimens from her right lower extremity debrided tissue showed necrosis with no organisms seen on routine or special stains. Tissue cultures were pending from the right arm and right side of the chest from her first and second operations, respectively. Physical examination found an exposed right quadriceps muscle with areas of greenish-grey discoloration (Fig 1). Extending from the left proximal medial thigh was a velvety greenish-yellow confluent plaque with flecks of brown pigmentation and scattered pink macules on the leading edge of the plaque (Fig 2). Pseudomonas infection was in the differential diagnosis because of the greenish color and necrosis in the clinical setting of a burn patient. Also in the differential diagnosis was a fungal infection because of the velvety appearance and brownish-black discoloration.