Cluster of Deadly Fungal Infection Investigated in Post-Tornado Joplin, Missouri

On May 22, 2011, the town of Joplin, Missouri was ravaged by a tornado that left nearly 160 dead and over 1000 injured. Of the injured, was a subset of 13 individuals suffering from a rare fungal infection, mucormycosis. A case-control study of survivors reported in the Dec. 6 issue of the New England Journal of Medicine, found disaster-stricken individuals with penetrating wounds may be at increased risk of necrotizing fungal infections.

Caused by an environmentally acquired mold, the infection typically affects soft-tissue in individuals with weakened immune systems. The fungus itself is ubiquitous in the environment. Most often found in soil, decomposing and other organic matter, mucormycosis does not usually pose any risk to the general population. The study, upon mapping the location of the infected cluster, found each individual was injured in the heaviest hit area from the tornado. Researchers postulate that a single environmental source of the mold was swept across a large area by the category-5 tornado and was basically forced into victims wounds (Fanfair, et al 2012).

Although mucormycosis is more commonly known to affect people with immunosuppressive conditions such as AIDS, poorly controlled diabetes, or long-term steroid use, findings from the Joplin cluster suggest that disaster affected populations that have experienced skin-breaking trauma may also be at risk for necrotizing soft-tissue infections despite being immune-competent (Fanfair, et al 2012). "It's important to remember that in these [Joplin] cases, we're talking about people who had extensive injuries," said Dr. Thomas Patterson, chief of the division of infectious diseases at the University of Texas Health Science Center at San Antonio.

Prognosis is poor. Even with typical treatment (aggressive surgery to remove infected areas and intravenous amphotericin B) the death rate ranges from 25 to 85 percent. Of the 13 individuals in NEJM case-study, five died. Those who survive may have to live with disfiguration due to extensive surgical debridement. Complications vary depending on the area affected. Mucormycosis may involve sinus, lung, and brain infection. As a result, thrombosis, nerve damage, and blindness may occur. In the Joplin cluster, most individuals were treated with anti-fungal medicine, though some received antibiotics, and others initially received antifungal medicine that could not treat mucormycosis specifically.

"In real time, it's hard to know what you're treating," said senior researcher Dr. Benjamin Park, a medical officer at the CDC’s mycotic diseases branch. Doctors might preemptively start patients on antibiotics (drugs that fight bacteria) or antifungals (drugs that fight fungi) without having laboratory confirmation of the infection-causing agent.

The CDC suggests while aid workers have not been infected in the past, protective clothing, such as gloves, longs sleeves and pants, should be worn while handling debris. In order to protect vulnerable populations from infection during natural disasters, researchers suggest implementing early warning systems, emergency shelters, and educate people about reducing household dangers by securing furniture and hazardous materials (Fanfair, et al 2012). 



Neblett Fanfair, R., Benedict, K., Bos, J., Bennett, S. D., Lo, Y. C., Adebanjo, T., … & Park, B. J. (2012). Necrotizing Cutaneous Mucormycosis after a Tornado in Joplin, Missouri, in 2011. New England Journal of Medicine, 367(23), 2214-2225.

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