Skin involvement as the first manifestation of systemic aspergillosis in patients after allogeneic hematopoietic cell transplantation

Abstract

Summary:Skin involvement due to a systemic infection with Aspergillus species in the course of allogeneic hematopoietic cell transplantation is extremely rare. We report the clinical course of two patients with hematologic malignancies who underwent allogeneic hematopoietic cell transplantation (HCT) and developed disseminated skin involvement as the first clinical symptom of a proven systemic Aspergillus infection. Bone Marrow Transplantation (2001) 27, 753-755. Keywords: cutaneous Aspergillus infection; HCT; BMT; STX; skin infection Aspergillus species are increasingly recognized as major fungal pathogens in severely immunosuppressed or neutropenic patients, particularly after allogeneic hematopoietic cell transplantation (HCT). 1 The risk of developing systemic Aspergillus infection increases with the duration of immunosuppression. The most common manifestation of an Aspergillus infection in these patients is invasive pulmonary aspergillosis characterized by hyphal invasion and destruction of pulmonary tissue. 2,3 Hematogenous dissemination as a secondary event occurs in 20-50% of these patients and most commonly involves the central nervous system and the gastrointestinal tract. 4 The overall mortality is up to 82% and reflects the clinical importance of Aspergillus infection in immunosuppressed or neutropenic patients. 5 Solitary extrapulmonary Aspergillus infection occurs most frequently in the maxillary sinuses 6,7 and colonization of the nasal sinuses can lead to endogenous spread to the lungs causing invasive pulmonary aspergillosis. The skin is a rare site of infection, 8 and cutaneous infections are most often found at the entry site of Hickman catheters. 4,7,9,10 Cutaneous aspergillosis is a poorly described entity Case report No. 1A 50-year-old male with Philadelphia-positive chronic myeloid leukemia in accelerated phase received a non-T cell-depleted bone marrow graft (1.2 × 10 8 MNC/kg BW) from his HLA-identical, MLC-negative brother. He was conditioned with busulfan (10 mg/kg), thiotepa (750 mg/kg) and cyclophosphamide (120 mg/kg) and received methotrexate and cyclosporine as GVHD prophylaxis. On day −1 twice daily prophylactic aerosol inhalation of 10 mg amphotericin B was started. On day +2 he developed fever of unknown origin and was empirically treated with a combination of cefotaxim, piperacillin and vancomycin. Because there was no resolution of the fever, intravenous (i.v.) amphotericin B was started at a dose of 0.8 mg/kg/day on day +4. On day +9 a round warm red swelling resembling a small furuncle appeared on the right thigh. This lesion grew rapidly and was extremely painful. On day +13 this lesion measured approximately 5 cm in diameter and in the centre a circular area of necrosis, 2 cm in diameter, had developed (Figure 1). Until that time microbiological examination of multiple blood cultures had yielded no positive result. Necrotic tissue from the lesion on the right thigh was sent for microbiological culture and histological examination. Both microbiological and histological exa...

Primary cutaneous aspergillosis caused by Aspergillus.fumigatus in an immunocompetent patient

“…Besides, the immune status of the infected patient should be evaluated as the host underlying immunity plays a critical role in the treatment of aspergillosis. [ 6 ] Schimmelpfennig et al [ 7 ] reported a case in which aspergillosis developed and progressed in a patient with chronic myeloid leukemia despite prompt therapy with amphotericin B. Resistance testing of Aspergillus fumigatus isolated from the lesion against amphotericin B showed that this species is fully sensitive to amphotericin B in vitro.…”

A near fatal case of invasive aspergillosis

“…Later in the course of the disease, these lesions evolve into black eschars. The skin lesions present in our patient resolved within days of initiation of antifungal regimen [12,13]. …”

Update on invasive aspergillosis: clinical and diagnostic aspects

“…Cytotoxic chemotherapy within a month of death is a risk factor associated with dissemination [97]. As mentioned, skin lesions may be the first clinical manifestation and may lead to the diagnosis [98]. Uncommon manifestations of disseminated aspergillosis include endophthalmitis [99], empyema, arthritis [100], intestinal infarction [101] and thyrotoxicosis [102].…”