Background
Cutaneous aspergillosis is usually a cutaneous manifestation of disseminated infection with the fungus Aspergillus. Primary cutaneous disease is rare and is most commonly caused by Aspergillus fumigatus and Aspergillus flavus. Rare cutaneous infections have been reported with Aspergillus terreus.
Colonization of burn eschars by Aspergillus is common, and reports have described primary cutaneous infection in immunocompetent patients in association with agricultural trauma.[1] Usually, however, aspergillosis 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, often follows 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. In primary cutaneous aspergillosis, 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. Note the image below. Aspergillus is a frequent contaminant found in cultures of dystrophic nails, but it can occasionally cause a true onychomycosis.
Primary cutaneous aspergillosis at a site of an intravenous catheter in a boy with leukemia. 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. A fumigatus is the most common pathogen associated with disseminated disease with cutaneous involvement, whereas A flavus[2] or A terreus most often causes the less frequent primary infections of the skin. Aspergillus niger and Aspergillus ustus have also been cultured from cutaneous lesions.[3] Infections of the sinuses, the lungs, or the skin can lead to disseminated disease, especially in patients who are immunocompromised.
Epidemiology
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 for cutaneous aspergillosis 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 for cutaneous aspergillosis.
Age
Neonates occasionally develop disseminated aspergillosis, presumably because of their immature immune mechanisms.
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