Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor
doi: 10.4103/0378-6323.86498
PMID: 22016287

Cutaneous aspergillosis in a heart-transplant patient

Ana Brinca, David Serra, Maria M Brites, scar Tellechea, Amrico Figueiredo
 Department of Dermatology, Coimbra University Hospital, Coimbra, Portugal

Correspondence Address:
Ana Brinca
Praceta Dr. Mota Pinto, Av. Bissaya Barreto, Coimbra 3000-075
How to cite this article:
Brinca A, Serra D, Brites MM, Tellechea , Figueiredo A. Cutaneous aspergillosis in a heart-transplant patient. Indian J Dermatol Venereol Leprol 2011;77:719-721
Copyright: (C)2011 Indian Journal of Dermatology, Venereology, and Leprology


We describe the case of a 67-year-old female with three subcutaneous nodules that had been present for the previous 10 days. She suffered from type 2 diabetes mellitus for 10 years and had undergone heart transplantation for dilated cardiomyopathy 1 year earlier and was undergoing immunosuppression with prednisone 7.5 mg/day, tacrolimus 4 mg/day, and sirolimus 1 mg/day. She was febrile (38--39°C) and reported to have severe asthenia. She denied any respiratory, gastrointestinal, or urinary complaints. There was no palpable lymphadenopathy or hepatosplenomegaly. Chest examination revealed decreased breath sounds and dullness to percussion at the right base. Dermatological examination disclosed three firm and well-demarcated erythematous subcutaneous nodules, 2 cm in diameter, on the left thigh, abdomen, and right infraclavicular area [Figure - 1]. Nodules were only slightly painful.

Thoracic radiological evaluation documented a right pleural effusion and a large nodular opacity in the right inferior pulmonary lobe. Multiple cytological and histological examinations did not reveal neoplastic cells.

Figure 1: Skin lesion on the abdomen: erythematous subcutaneous nodule

Histopathological analysis of the skin lesions revealed a massive dermal and hypodermic neutrophilic infiltration [Figure - 2], and wide, septated, uniform hyphae were identified on periodic acid Schiff stain [Figure - 3]. Skin culture as well as bronchial aspirate culture isolated Aspergillus fumigatus. Blood cultures were persistently negative for bacteria and fungi. Antihuman immunodeficiency virus serology was negative.

Figure 2: Dermal and hypodermic neutrophilic infiltration (H and E, ×200)
Figure 3: Septated and branching hyphae (Periodic Acid Schiff, ×200; inset: ×40)

The patient was diagnosed with cutaneous aspergillosis secondary to pulmonary aspergillosis. Insulin therapy was provided to achieve optimal glycemic control. She was started on therapy with liposomic amphotericin B (L AmB) at 5 mg/kg body weight/day intravenously while maintaining the immunosuppressive drugs. About 2 weeks later, following aggravation of the condition with the emergence of new skin lesions, L AmB and sirolimus were suspended, tacrolimus was reduced to 1.5 mg/day, and voriconazole (VOR) was started at 5 mg/kg body weight twice daily orally. Although a clinical improvement was observed almost immediately after 2 days of therapy, followed 7 days later by the regression of skin lesions, the patient died of an extensive acute ischemic cerebrovascular disease after 3 weeks of using VOR, which was confirmed by brain computed tomography.

Fungal infections can cause significant morbidity and even mortality among transplant recipients. After Candida, Aspergillus is the most common genus causing opportunistic fungal infections in these patients. [1] It includes over 185 species, but the most common causative agents of opportunistic infections in humans are Aspergillus flavus, A. fumigatus, A. niger, A. terreus, and A. ustus.[2]

Cutaneous lesions are rare and are usually due to hematogenous dissemination from an underlying infected organ, more commonly the lungs - secondary cutaneous aspergillosis (SCA). More rarely, cutaneous lesions are due to direct inoculation - primary cutaneous aspergillosis - especially in the settings of burns or trauma. Risk factors for invasive aspergillosis include prolonged and severe neutropenia, glucocorticoid therapy, hematopoietic stem cell or solid-organ transplantation, advanced acquired immunodeficiency syndrome, and chronic granulomatous disease. [3] Cutaneous lesions occur in 5-10% of the patients with invasive aspergillosis and, on rare occasions, can be the presenting sign of systemic infection, as had occurred in our patient. In the presenting case, multiple subcutaneous nodules were the revealing lesions of SCA. When the histopathological examination of the cutaneous lesion revealed findings consistent with aspergillosis, a pulmonary primary focus of infection was searched for and found in our patient. Although the radiological findings pointed out to pulmonary neoplasia, this was not confirmed by various histopathological and cytological samples that, indeed, confirmed the infectious nature of the pulmonary mass.

Amphotericin B has been the classical antifungal drug of choice. As the initial therapy for invasive aspergillosis, VOR has shown better response rates, improved survival, and fewer severe adverse effects compared with amphotericin B. [4],[5] Itraconazole and caspofungin are other treatment options. In our patient, who was undergoing immunosuppression with prednisone, tacrolimus, and sirolimus, L AmB was the initial choice to maintain the immunosuppressive drugs because VOR may significantly increase the plasma concentrations of sirolimus, making it mandatory to suspend it.

Early diagnosis and prompt treatment are crucial in the setting of cutaneous aspergillosis, especially in SCA, as it represents an invasive infection with major morbidity and mortality potentials. Therefore, cutaneous nodular lesions arising in the setting of immunosuppression should always lead to search for a systemic infectious focus.

This case has the particularity to demonstrate the risk of fungal infections in transplant recipients even after 1 year of immunosuppression. Previous reports refer to this as a complication occurring in the early posttransplant course. Also, it reminds us that cerebrovascular disease is a leading cause of death in the elderly people, particularly those with diabetes mellitus.

Husain S, Alexander BD, Munoz P, Avery RK, Houston S, Pruett T, et al. Opportunistic mycelial fungal infections in organ transplant recipients: Emerging importance of non-Aspergillus mycelial fungi. Clin Infect Dis 2003;37:221-9.
[Google Scholar]
Mohapatra S, Xess I, Swetha JV, Tanveer N, Asati D, Ramam M, et al. Primary cutaneous aspergillosis due to Aspergillus niger in an immunocompetent patient. Indian J Med Microbiol 2009;27:367-70.
[Google Scholar]
Denning DW, Stevens DA. Antifungal and surgical treatment of invasive aspergillosis: Review of 2,121 published cases. Rev Infect Dis 1990;12:1147-201.
[Google Scholar]
Herbrecht R, Denning DW, Patterson TF, Bennett JE, Greene RE, Oestmann JW, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 2002;347:408-15.
[Google Scholar]
Muñoz P, Singh N, Bouza E. Treatment of solid organ transplant patients with invasive fungal infections: Should a combination of antifungal drugs be used? Curr Opin Infect Dis 2006;19:365-70.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections