Amputation, AML, and the Interdisciplinary Approach: A Case Report

Case Diagnosis: Patient with AML undergoing treatment complicated by mucormycosis of the left hand resulting in transradial amputation

Case Description or Program Description: 63 year old female actively undergoing treatment for acute myeloid leukemia had been recently hospitalized for enterococcus bacteremia and neutropenic fever. She experienced significant functional decline, requiring much assistance with ADLs. Acute care stay was complicated by IV infiltration of left hand and subsequent soft-tissue infection and necrosis. Pathology confirmed hyphae and wound culture grew Rhizopus concerning for mucormycosis of the left hand. She was transitioned to posaconazole and underwent left transradial amputation before transfer to acute inpatient rehab.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: Our patient had a complicated rehab course. With recent chemotherapy, myelosuppresive medications, as well as amputation, the patient had significant anemia and thrombocytopenia. She required multiple transfusions of PRBCs and platelets. Residual limb wound required wound vac therapy, and pregabalin was started for phantom limb pain. Interdisciplinary care was critical, with conference involving the hematology/oncology, physiatry, infectious disease, neuropsychology, and plastic surgery teams.

Discussion (relevance): While rhizopus is commonly found in the environment, healthcare-associated mucormycosis is rare. When it does occur the skin is the most common site of infection. Patients at highest risk of infection and complications are the immunocompromised. Hematologic malignancies, solid organ transplantation, and treatment with immunosuppressants all predispose patients to opportunistic infections which can further complicate the inpatient rehabilitation course.

Conclusions: Patients with cancer may have significant complications due to the nature of their illness. Because of this, organized interdisciplinary care is paramount in the rehabilitation of cancer patients. Our patient was actively undergoing cancer treatment, and her rehabilitation course was exacerbated by amputation of her hand due to rare infection with mucormycosis. Despite her complicated course, she made excellent progress in therapy and was able to return home with plans for possible stem-cell transplant and prosthesis creation in the future.