Aspergillus ustus is an uncommon clinical species which is poorly susceptible to antifungals. We report two cases of A. ustus infections that occurred in allogeneic stem cell transplant recipients while they were receiving either voriconazole or caspofungin. Prolonged use of these new antifungal agents may increase the risk of the emergence of resistant organisms. CASE REPORTPatient 1 was a 29-year-old male, weighing 80 kg, who was diagnosed with acute lymphoblastic leukemia in October 2002. During initial chemotherapy-induced neutropenia, he developed fever, cough, and nodular pulmonary infiltrates visible by computed tomography (CT) scan, suggestive of possible lunginvasive aspergillosis (2). Cultures of sputum were negative for Aspergillus, and Aspergillus antigenemia (Platelia Aspergillus assay; Bio-Rad, Marnes-la-Coquette, France) remained negative (index Ͻ 0.5). Treatment with oral voriconazole (200 mg twice a day after the loading dose) was initiated on 22 December 2002. Granulocyte recovery occurred 4 days later and was associated with the complete resolution of pulmonary lesions. A myeloablative genoidentical hematopoietic stem cell transplant (HSCT) was performed during the first complete remission, on 13 March 2003. A pre-HSCT lung CT scan revealed no abnormality. Voriconazole was continued as a secondary prophylaxis. Between April 2003 and January 2004, the patient experienced three episodes of severe graft-versus-host disease (GVHD), which were treated with cyclosporine, an increased dosage of steroids, and mycophenolate mofetil. In September 2003, the patient, who was afebrile, developed several necrotic cutaneous lesions for which he was admitted to the hospital. The chest CT scan revealed a nonspecific infiltrate in the right inferior pulmonary lobe. Mycological examination of a cutaneous biopsy specimen revealed septate and branched hyphae consistent with Aspergillus spp. A culture yielded Aspergillus ustus, which was identified by morphological methods, with confirmation by sequencing of the ITS1-5.8S-ITS2 region (Fig. 1). Cultures of sputum were also positive for A. ustus. Several Aspergillus antigenemia tests were positive, with galactomannan index values of up to 3. Voriconazole was discontinued, and amphotericin B deoxycholate (1 mg/kg of body weight/day) was started. Six days later, the patient developed right-leg paresis. Brain magnetic resonance imaging (MRI) revealed a single frontal lesion compatible with aspergillosis. Treatment was switched to liposomal amphotericin B (3 mg/kg/day) and caspofungin (70 mg/day). The patient clinically improved, with complete regression of both cutaneous lesions and neurological abnormalities. Subsequent brain MRIs showed progressive regression of the lesion with scar formation. Subsequent lung CT scans showed a size decrease and excavitation of the pulmonary lesion. Aspergillus antigenemia decreased and remained negative after 18 December 2003. The patient later experienced several episodes of hemoptysis. Fungal hyphae compatible with a zygomycete wer...

We report the first case of cutaneous mucormycosis after a scorpion sting in Tunisia. Histopathology showed broad aseptate hyphae suggestive of a Zygomycete. Saksenaea vasiformis was identified by PCR amplification and sequencing of the fungal DNA on a cutaneous biopsy. Successful treatment was obtained by surgery and liposomal amphotericin B. CASE REPORTA previously healthy 14-year-old patient was admitted to Robert Debré hospital (Paris) with a left calf lesion following a scorpion sting in Tunisia 10 days before. At that time, he had been hospitalized for 4 days in an intensive care unit for acute renal failure and pulmonary edema induced by the scorpion venom. When he came back to France, the lesion due to the scorpion sting failed to heal.On the day of admission, the patient had a limping gait. Physical examination of the left calf revealed a painful, indurated, erythematous, 5-cm lesion. Ultrasonic tomography revealed a diffuse, soft tissue swelling. The white blood cell count was 14.1 ϫ 10 9 /liter with 71% neutrophils, the platelet count was 395 ϫ 10 9 /liter, and the C-reactive protein level was less than 10 mg/liter. The patient was started on antibacterial therapy with cefotaxime and fosfomycin according to our local guidelines for antibiotic treatment (9).On day 5, the lesion grew to a 10-cm area of swelling and induration, with a central area of black blisters. No sample was taken at this stage. The patient had a fever (38.7°C) and experienced severe pain. The white blood cell count was 18.9 ϫ 10 9 /liter with 80% neutrophils, and the C-reactive protein level was 52 mg/liter. Three blood cultures performed between day 1 and day 5 were sterile. A second ultrasonic tomography showed an extension within subcutaneous tissues, with collection of fluids. Because of the increasing area of the wound, vancomycin and metronidazole were added to the treatment regimen.On day 7, the patient required local debridement to remove devitalized tissues, including muscles and fascia. A 7-cm incision was made to evacuate the necrotizing tissue. A piece of debrided tissue was submitted for microbiological and histopathological examination. On day 12, histological analysis showed many areas of necrosis and nonspecific inflammation. Within the necrotic areas, branched, broad, nonseptate fungal hyphae suggestive of Zygomycetes were found. The material was inoculated onto routine bacteriological media and Sabouraud dextrose agar. On the Sabouraud dextrose agar, there were few colonies of filamentous fungi, with no evidence of sporulation, and the loss of viability of the isolate, possibly due to growth conditions, precluded subcultures on specific media (11), impaired any further mycological identification. All other cultures on solid media were negative for bacteria. The cutaneous biopsy, kept frozen at Ϫ80°C, was then sent to the National Reference Center for Mycoses and Antifungals, Pasteur Institute, for molecular studies. Tissues were ground, and DNA extraction was performed as previously described (16). Direct examinat...

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