Introduction
Background
Cutaneous aspergillosis is most commonly a cutaneous manifestation of disseminated infection with the fungus Aspergillus, although primary cutaneous disease can rarely occur, especially in the setting of burns or trauma. Aspergillosis typically begins as a pulmonary infection subsequent to inhalation of fungal spores. In the immunocompromised host, hematogenous dissemination and invasion of other organ systems, including the skin, can then follow the initial pulmonary infection.
Dermatologic manifestations of disseminated aspergillosis include single or multiple erythematous-to-violaceous plaques or papules, often characterized by a central necrotic ulcer or eschar. Skin lesions occur in 5-10% of patients with disseminated aspergillosis. Infrequently, they may be the presenting sign of systemic infection. Primary cutaneous aspergillosis occurs much less commonly in the absence of hematogenous disease. In these instances, the most typical presentation is implantation of the fungus following trauma, including infections at the site of intravenous cannulas, or venipuncture wounds, especially those that have been covered with occlusive dressings. Aspergillus is a frequent contaminant found in cultures of dystrophic nails, but it can occasionally cause a true onychomycosis.
Pathophysiology
Cutaneous aspergillosis is caused by infection with ubiquitous soil- and water-dwelling saprophytes of the Aspergillus genus. Typically, infection of the pulmonary system occurs via inhalation of fungal spores, which then leads to disseminated hematogenous infection with the organism. Aspergillus fumigatus is the most common pathogen associated with disseminated disease with cutaneous involvement, whereas Aspergillus flavus1 or Aspergillus terreus most often causes the less frequent primary infections of the skin. Aspergillus niger and Aspergillus ustus have also been cultured from cutaneous lesions. Infections of the sinuses, the lungs, or the skin can lead to disseminated disease, especially in patients who are immunocompromised.
Frequency
United States
Aspergillosis is the second most common opportunistic fungal infection in patients who are immunocompromised, accounting for as many as 20% of fungal infections in patients who have received bone marrow or solid organ transplants. Key risk factors include neutropenia from hematologic malignancy or chemotherapy, immunosuppressive therapy, AIDS, and cytomegalovirus infection.
Mortality/Morbidity
Disseminated aspergillosis is associated with a mortality rate of greater than 90%. In contrast, multiple case reports have documented resolution of primary cutaneous aspergillosis after surgical excision followed by, in some cases, systemic antifungal therapy.
Sex
No clear sexual predilection is reported.
Age
Neonates occasionally develop disseminated disease, presumably because of their immature immune mechanisms.
Clinical
History
Patients with disseminated aspergillosis often present with febrile illness, pneumonia, or sinusitis unresponsive to antibiotics. Other possible presentations include the following:
- Gradual onset of central nervous system symptoms
- Endocarditis
- Myocarditis
- Esophageal and intestinal ulcers
Physical
The pertinent physical findings below are limited to the skin examination.
- Cutaneous presentations of systemic aspergillosis most frequently begin as solitary or multiple erythematous or violaceous indurated papules or plaques. The lesions are often tender, but they can be asymptomatic. These manifestations evolve rapidly into centrally placed pustules, hemorrhagic vesicles, and, ultimately, black eschars. Involved areas can be large or small, can be localized or diffuse, and most often arise on the limbs and head. Truncal lesions are much less common.
- Primary cutaneous infections usually develop at the sites of an intravenous catheter or a venipuncture. Reports have also associated the use of occlusive dressings, armboards, nonsterile gauze, plaster casts, and adhesive tape with primary cutaneous aspergillosis.
- Skin lesions often initially appear as a localized cellulitis that develops into the typical necrotic ulcer or a black eschar.
- Aspergillus chevalieri has been reported to cause a distinct skin lesion that is more hyperkeratotic and vesiculopapular in nature.
Causes
Aspergillosis is an uncommon disease in patients who are not immunocompromised because normal neutrophilic and macrophagic functions prevent infection; however, any deficiency in these immunologic parameters increases the risk of aspergillosis. For example, systemic corticosteroid therapy is a known risk factor for cutaneous aspergillosis.
Some environmental risk factors have also been implicated; these factors include construction sites and contaminated ventilation systems, presumably caused by effects on spore distribution.
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| References |
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References
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Further Reading
Keywords
cutaneous aspergillosis, fungal infection, Aspergillus fumigatus, A fumigatus, Aspergillus flavus, A flavus, Aspergillus terreus, A terreus, Aspergillus chevalieri, A chevalieri, Aspergillus niger, A niger, Aspergillus ustus, A ustus
