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LETTER TO THE EDITOR
Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 610-612  

Cutaneous aspergillosis presenting as surgical site infection


1 Department of Dermatology, Command Hospital, Pune, Maharashtra, India
2 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Pathology, Command Hospital, Pune, Maharashtra, India
4 Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission14-Aug-2020
Date of Decision08-Nov-2021
Date of Acceptance25-Nov-2021
Date of Web Publication18-Mar-2022

Correspondence Address:
Vikas Pathania
Department of Dermatology, Command Hospital (SC), Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_451_20

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How to cite this article:
Pathania V, Shankar P, Kaur K, Vashisht D, Kashif A W, Kothari R. Cutaneous aspergillosis presenting as surgical site infection. Med J DY Patil Vidyapeeth 2022;15:610-2

How to cite this URL:
Pathania V, Shankar P, Kaur K, Vashisht D, Kashif A W, Kothari R. Cutaneous aspergillosis presenting as surgical site infection. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Jul 4];15:610-2. Available from: https://www.mjdrdypv.org/text.asp?2022/15/4/610/339946



Dear Sir,

Aspergillosis is an uncommon opportunistic fungal infection caused by an ubiquitously occurring fungus in immunocompromised patients.[1] Aspergillus spp. presenting as a nosocomial infection is even rarer, contributing only 1.3% of hospital-wide fungal infections of which the most common presentation being that of necrotizing bronchopneumonia.[2] Cutaneous lesions are, however, rare in aspergillosis.[3]

A 45-year-old housewife was referred to the dermatology outpatient department with two nodulo-pustular lesions over the right chin and right cheek overlying diffuse erythematous and indurated tender ill-defined 3 cm × 3 cm swelling which spontaneously ruptured with continuous seropurulent, odorless, and nongrainy discharging sinuses [Figure 1]. She gave a history of a nonhealing wound following a rotation advancement flap on modified radical neck dissection for oral carcinoma 6 months back and 3 months of chemotherapy and radiotherapy thereafter when she reported with present lesions. She was evaluated for the possibility of postoperative pyogenic surgical site infection, atypical mycobacterial infection, and actinomycosis while being managed empirically with broad-spectrum antibiotics with transient partial relief. Serial pus swabs were sent for Gram stain, acid-fast bacilli,  Mycobacterium tuberculosis Scientific Name Search lymerase chain reaction (PCR), and culture which were negative. The patient was evaluated and excluded for other causes of immunosuppression, namely HIV infection, diabetes mellitus, hematological and solid-organ malignancies, and tuberculosis infection. Sonography of the swelling suggested soft-tissue swelling, whereas a fine-needle aspiration cytology revealed an acute inflammatory aspirate. Noncontrast computerized tomographic scan of the mandible showed a small collection in the superficial tissues but no evidence of osteomyelitis. A skin biopsy was taken from the indurated mass adjacent to the sinuses which revealed dense mixed inflammatory infiltrate without granuloma formation within the papillary dermis [Figure 2]a comprising lymphocytes, plasma cells, eosinophils, and histiocytes with the destruction of capillaries causing necrosis [Figure 2]b suggestive of a nonspecific infective pathology but negative for Gram and Ziehl–Neelsen stain. A direct smear preparation (10% KOH) from the swab taken from the sinus showed acute-angled branched hyaline septate hyphae with scattered vesicles. Swab stick from the ulcer edge was put on Sabouraud dextrose agar (SDA) with antibiotics and without cycloheximide at 25°C. After 5 days of incubation, green-colored colonies were seen on SDA [Figure 3]. A lactophenol cotton blue (LCB) preparation was prepared from the growth which showed hyaline septate hyphae with acute-angle branching [Figure 4]. A repeat culture and isolation revealed similar findings. A tissue PCR could not be done due to the unavailability of fungal primers. A diagnosis of Aspergillus fumigatus was made. The isolate was subjected to antifungal susceptibility testing by micro broth dilution method and was found to be sensitive to itraconazole, amphotericin B, and caspofungin. She was treated with oral itraconazole 200 mg twice daily for a period of 6 months with complete resolution of the swelling and the sinuses [Figure 5].
Figure 1: Nodulo-pustules overlying erythema and induration over right cheek and chin

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Figure 2: (a) H and E, ×100: Showing papillary dermis with dense mixed inflammatory infiltrate without granulomas. (b) H and E, ×400: Showing infiltrate comprising of lymphocytes, plasma cells, eosinophils, and histiocytes with the destruction of capillaries causing necrosis

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Figure 3: Green colonies of Aspergillus fumigatus on Sabouraud dextrose agar

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Figure 4: Lactophenol cotton blue preparation, ×400: Showing conidiophores with uniseriate phialides

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Figure 5: Resolution of discharging sinuses and swelling 6 months after treatment

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Inhalation of spores is believed to be the usual route of transmission in invasive aspergillosis in severely immunocompromised hosts, especially in the setting of HIV infection, hematological malignancies, and solid-organ transplant patients.[4] Primary cutaneous Aspergillosis is extremely rare and involves sites of skin injury such as a mycetoma in a diabetic patient with nephrotic syndrome.[5] In a nosocomial setting, these would include sites of indwelling intravenous catheters, occlusive dressings, burns, or postsurgical. Infections arising from sites of puncture may present with erythema and induration which progresses to necrosis that extends radially from the initial focus and is usually accompanied with fever and a mortality rate of 30%–75%.[6] In cases of occlusive dressings, the infection may simulate pyoderma gangrenosum where an area of raised erythema with accompanying pain and discomfort may rapidly increase in size and the center of the lesion may evolve to purple, black, and finally ulcerate.[7] The most common species implicated in cutaneous aspergillosis includes Aspergillus flavus (44%) and Aspergillus fumigatus (26%); other uncommon ones being Aspergillus terreus, Aspergillus niger, Aspergillus glaucus, Aspergillus chevalieri, and Aspergillus ustus. A presumptive diagnosis of primary cutaneous aspergillosis can be made immediately by potassium hydroxide preparation from the roof of a bulla, sinus, or smear of the biopsy specimen. However, one has to be mindful of airborne contamination as the organism is ubiquitously found. A skin biopsy from the center of the lesion and a tissue PCR can confirm the diagnosis. In this case, characteristic colony morphology on SDA and LCB preparation from the growth showing acute-angled branched septate hyphae and conidiophores with uniseriate phialides covering the upper half of the vesicles helped identify Aspergillus fumigatus over other Aspergillus species. A repeat culture and isolation were also done to rule out the possibility of contamination. Antifungal agents demonstrated to be effective in Aspergillus spp. infections include voriconazole, itraconazole, and amphotericin B along with surgical debridement where indicated.[3] Finally, it is pertinent to mention that preventive measures, such as creating barriers between high-risk patients and construction areas in a hospital, wet cleaning of wards, regular sampling for airborne spores, use of HEPA filtration, and laminar airflow models in clinical areas, can prevent nosocomial spread of aspergillosis.[4],[7] The case highlights cutaneous aspergillosis as a rare cause of surgical site infection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma VK, Krishna SG, Gupta C, Kumawat M. Cutaneous aspergilloma in an immunocompetent patient treated with itraconazole. Indian J Dermatol Venereol Leprol 2011;77:626.  Back to cited text no. 1
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2.
Fridkin SK, Jarvis WR. Epidemiology of nosocomial fungal infections. Clin Microbiol Rev 1996;9:499-511.  Back to cited text no. 2
    
3.
Prasad PV, Babu A, Kaviarasan PK, Anandhi C, Viswanathan P. Primary cutaneous aspergillosis. Indian J Dermatol Venereol Leprol 2005;71:133-4.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Vonberg RP, Gastmeier P. Nosocomial aspergillosis in outbreak settings. J Hosp Infect 2006;63:246-54.  Back to cited text no. 4
    
5.
Padhi S, Uppin SG, Uppin MS, Umabala P, Challa S, Laxmi V, et al. Mycetoma in South India: Retrospective analysis of 13 cases and description of two cases caused by unusual pathogens: Neoscytalidium dimidiatum and Aspergillus flavus. Int J Dermatol 2010;49:1289-96.  Back to cited text no. 5
    
6.
van Burik JA, Colven R, Spach DH. Cutaneous aspergillosis. J Clin Microbiol 1998;36:3115-21.  Back to cited text no. 6
    
7.
Denning DW. Invasive aspergillosis. Clin Infect Dis 1998;26:781-803.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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