Military doctors fight to defeat fungal infections

• Victims are mostly soldiers or Marines
• Fungus is nearly undetectable at first
• Military doctors use a diluted bleach to kill the fungus

Military doctors are fighting to defeat a fungal infection that has killed a handful of direly wounded troops in Afghanistan and infected scores of others, often requiring that more of their limbs be cut away to get above diseased areas.

Out of about 100 troops diagnosed with the organism in the past three years, six have died either from the fungus or other causes, says Navy Cmdr. Carlos Rodriguez, who has led investigations into the infection. The victims are mostly soldiers or Marines who suffer the worst wounds of the war, multiple amputations from roadside bombs.

The fungi exist in the soil, and appear to be prevalent in two hard-fought southern Afghanistan provinces of Helmand and Kandahar. For the typical patient, the organism is blown deep into blast wounds from buried explosives — known as improvised explosive devices or IEDs — during foot patrols in those regions, Rodriguez says.

"All the stuff that lives in the dirt is getting jammed in there," says Army Lt. Col. John Oh, director of trauma at the Army's Landstuhl Regional Medical Center in Germany.

New guidelines were published Nov. 1 urging combat doctors to soak wounds with a diluted bleach called Dakins consisting of sodium hypochlorite — a product once used on World War I combat casualties — as a precaution to kill the fungus before it takes hold.

The fungus is nearly undetectable at first because infected tissue initially appears healthy. Surgeons cutting away dead bone and flesh from blast wounds will stop short of areas that appear healthy to preserve as much of a limb as possible.

"Even for somebody that's very experienced, it's hard to tell exactly what's dead and what's alive," Oh says.

Within days or even hours after the operation, infected tissue begins to die and more of a limb must be cut away, doctors say. Making matters worse, the two of the most common fungal organisms infecting troops — Mucor and Aspergillus terreus — can take days or weeks to positively identify.

One medical theory is that troops who suffer massive blast damage are particularly vulnerable because their immune systems are weakened from receiving large amounts of donated blood to stay alive.

Rodriguez said doctors have gotten better at identifying the fungus, but the answer lies in killing or cutting out spores before they infect.

As a result, the new guidelines urge military doctors in Afghanistan to begin using the diluted bleach and anti-fungal medications on those wounded troops who are most at risk for the infection: those suffering multiple amputations and lower torso damage from blasts, and who have received massive transfusions of blood.