Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011

N Engl J Med. 2012 Dec 6;367(23):2214-25. doi: 10.1056/NEJMoa1204781.


Background: Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri.

Methods: We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case-control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively.

Results: A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1-D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains.

Conclusions: We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Case-Control Studies
  • DNA, Fungal / analysis
  • DNA, Ribosomal
  • Dermatomycoses / epidemiology
  • Dermatomycoses / etiology*
  • Dermatomycoses / mortality
  • Disasters
  • Fasciitis, Necrotizing / epidemiology
  • Fasciitis, Necrotizing / etiology*
  • Fasciitis, Necrotizing / mortality
  • Female
  • Humans
  • Male
  • Middle Aged
  • Missouri / epidemiology
  • Mucorales / classification
  • Mucorales / genetics
  • Mucorales / isolation & purification*
  • Mucormycosis / epidemiology
  • Mucormycosis / etiology*
  • Mucormycosis / mortality
  • Risk Factors
  • Skin / injuries
  • Soft Tissue Infections / epidemiology
  • Soft Tissue Infections / etiology*
  • Soft Tissue Infections / mortality
  • Tornadoes*
  • Wounds and Injuries / complications*
  • Young Adult


  • DNA, Fungal
  • DNA, Ribosomal