S5055 When Fungi Invade the Unexpected: A Rare Case of Hand Mucormycosis Following Liver Transplant

Introduction: Mucormycosis is a rare, angioinvasive fungal infection that carries a high mortality rate, predominantly occurring in immunocompromised hosts. Among transplant populations, the incidence of mucormycosis is between 0.4% and 16%, with liver transplant recipients accounting for a small proportion (0%-2%). Although pulmonary and rhino-orbital-cerebral forms are more common, cutaneous forms remain an under recognized manifestation. Delayed diagnosis is associated with poor outcomes, emphasizing the importance of early clinical suspicion. We present a rare case of cutaneous mucormycosis occurring after liver transplant, highlighting the diagnostic challenges and importance of early intervention. Case Description/Methods: A 51-year-old man with decompensated cirrhosis due to alcohol use disorder status post liver transplant 1 month ago presented with incisional pain and redness despite recent treatment for suspected cellulitis. On exam, the patient was tachycardic with an erythematous, swollen, and tender surgical incision. Several red to purple indurated papules with superficial erosion were noted on the right hand, progressively enlarging since their onset 2 weeks prior. Labs showed a leukocytosis of 17.2 × 109/L. Computed tomography (CT) abdomen showed a hepatic subcapsular fluid collection concerning for a superinfected hematoma. CT of the hand showed nodular skin thickening and ulceration over the dorsum of the second metacarpal, without osseous involvement. The patient was started on broad spectrum antibiotics. Biopsy of the lesion revealed diffuse suppurative and necrotizing granulomas and numerous fungal organisms, consistent with mucormycosis. Ziehl-Neelsen stain was negative for acid-fast bacilli. The patient was treated with amphotericin B, wide local excision of the lesions, and reduction of his immunosuppressive medications. Discussion: Mucormycosis is a severe complication following organ transplant with mortality rates exceeding 50%. Cutaneous forms occur via direct inoculation of spores into the skin and can mimic benign postoperative complications, delaying diagnosis. Diagnosis relies on tissue biopsy and culture. Prompt recognition is crucial and treatment should not be delayed, as the infection can progress rapidly. Treatment includes systemic antifungal therapy, surgical debridement, and careful reduction in immunosuppression. This case emphasizes the need for early intervention and raises consideration for reassessing antifungal prophylaxis in high-risk liver transplant recipients.