Cutaneous and Wound Aspergillosis

  • Arunaloke Chakrabarti
  • Shivsekhar Chatterjee
  • Bishan D. Radotra


Aspergillus infections of skin and wound have been increasingly reported in recent years. These diseases can range from non-invasive colonisation of wounds to invasive lesions that may serve as the aspergillosis portal of entry in immunosuppressed patients. Cutaneous aspergillosis can be broadly divided into: primary infections (starting from skin) and secondary infections (extending to skin from deeper tissues either contiguously or haematogenously). There has been marked increase in number of primary cutaneous aspergillosis cases in conjugation with prematurity, burn, HIV infection, organ transplantation, and malignancy. Wound aspergillosis affects mainly solid organ transplant recipients and those submitted to open-heart surgery. Small outbreaks of primary cutaneous aspergillosis have been reported in neonatal and surgical wards, and intensive care units in association with a contaminated environment. Simultaneous breach of skin and neutropenia predisposes a patient for cutaneous aspergillosis, though rare infection in healthy hosts has been reported. Demonstration of septate hyphae in tissue and isolation of Aspergilli help in diagnosis. Early diagnosis depends on increased awareness. These diseases can be of considerable morbidity and mortality if the patients are not managed aggressively. Combined surgery and antifungal therapy prevents the progression to disseminated aspergillosis, though surgery may be difficult in neonates and in HIV-infected patients.


Aspergillosis Burn Skin Diagnosis Management Wound 


  1. 1.
    Ozcan, D., Gulec, A. T. & Haberal, M. (2008) Multiple subcutaneous nodules leading to the diagnosis of pulmonary aspergillosis in a renal transplant recipient. Clin Transplant, 22, 120–3.PubMedGoogle Scholar
  2. 2.
    Galimberti, R., Kowalczuk, A., Hidalgo Parra, I., Gonzalez Ramos, M. & Flores, V. (1998) Cutaneous aspergillosis: a report of six cases. Br J Dermatol, 139, 522–6.Google Scholar
  3. 3.
    Langlois, R. P., Flegel, K. M., Meakins, J. L., Morehouse, D. D., Robson, H. G. & Guttmann, R. D. (1980) Cutaneous aspergillosis with fatal dissemination in a renal transplant recipient. Can Med Assoc J, 122, 673–6.PubMedGoogle Scholar
  4. 4.
    Choffray, A., Flageul, B., Dubertret, L. & Viguier, M. (2007) [Erysipelas-like dermatitis of the legs revealing aspergilloma of the maxillary sinus]. Ann Dermatol Venereol, 134, 851–4.CrossRefPubMedGoogle Scholar
  5. 5.
    Cahill, K. M., Mofty, A. M. & Kawaguchi, T. P. (1967) Primary cutaneous aspergillosis. Arch Dermatol, 96, 545–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Patterson, T. F. (2005) Aspergillus species. In Mandell, G., Bennet, J. & Dolin, R. (Eds.); Mandell, Douglas and Bennett’s Principles of Infectious Diseases. 6th edition, Elsevier Churchill Livingstone Publishers, Philadelphia, USA.Google Scholar
  7. 7.
    Walsh, T. J. (1998) Primary cutaneous aspergillosis – an emerging infection among immunocompromised patients. Clin Infect Dis, 27, 453–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Allo, M. D., Miller, J., Townsend, T. & Tan, C. (1987) Primary cutaneous aspergillosis associated with Hickman intravenous catheters. N Engl J Med, 317, 1105–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Myers, I. T. & Dunn, A. D. (1930) Aspergillus infection of the hand. JAMA, 95, 794–6.Google Scholar
  10. 10.
    Frank, L. & Alton, O. M. (1933) Aspergillosis: a case of post-operative skin infection. JAMA, 100, 2007–8.Google Scholar
  11. 11.
    Cawley, E. P. (1947) Aspergillosis and Aspergilli. Report of a unique case of the disease. Arch Int Med, 80, 423.Google Scholar
  12. 12.
    Grekin, R. H., Cawley, E. P. & Zheutlin, B. (1947) Generalized aspergillosis. Report of a case. Arch Pathol 43, 387–92.Google Scholar
  13. 13.
    Bruck, H. M., Nash, G., Foley, D. & Pruitt, B. A., Jr. (1971) Opportunistic fungal infection of the burn wound with phycomycetes and Aspergillus. A clinical-pathologic review. Arch Surg, 102, 476–82.PubMedGoogle Scholar
  14. 14.
    Granstein, R. D., First, L. R. & Sober, A. J. (1980) Primary cutaneous aspergillosis in a premature neonate. Br J Dermatol, 103, 681–4.CrossRefPubMedGoogle Scholar
  15. 15.
    Hui, A. N., Koss, M. N. & Meyer, P. R. (1984) Necropsy findings in acquired immunodeficiency syndrome: a comparison of premortem diagnoses with postmortem findings. Hum Pathol, 15, 670–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Murakawa, G. J., Harvell, J. D., Lubitz, P., Schnoll, S., Lee, S. & Berger, T. (2000) Cutaneous aspergillosis and acquired immunodeficiency syndrome. Arch Dermatol, 136, 365–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Emile-Weil, P. & Gaudin, L. (1919) Onychomychosis causes par Sterigmatocystis unguis. Arch de med exper et d’anat path, 28, 465.Google Scholar
  18. 18.
    Sartory, A. (1920) [Sur un champignon nouveau du genre Aspergillus isole dans un cas d’onychomycose]. Compt Rend Acad D Sc, 170, 523.Google Scholar
  19. 19.
    Van Burik, J. A., Colven, R. & Spach, D. H. (1998) Cutaneous aspergillosis. J Clin Microbiol, 36, 3115–21.PubMedGoogle Scholar
  20. 20.
    Pasqualotto, A. C. & Denning, D. W. (2006) Post-operative aspergillosis. Clin Microbiol Infect, 12, 1060–76.CrossRefPubMedGoogle Scholar
  21. 21.
    Munn, S., Keane, F., Child, F., Philpott-Howard, J. & Du Vivier, A. (1999) Primary cutaneous aspergillosis. Br J Dermatol, 141, 378–80.CrossRefPubMedGoogle Scholar
  22. 22.
    Frank, K. A., Merz, W. G. & Hutchins, G. M. (1988) Sclerotium formation in an Aspergillus flavus wound infection. Mycopathologia, 102, 185–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Florio, M., Marroni, M., Morosi, S. & Stagni, G. (2004) Nosocomial Aspergillus flavus wound infections following cardiac surgery. Infez Med, 12, 270–3.PubMedGoogle Scholar
  24. 24.
    Vandecasteele, S. J., Boelaert, J. R., Verrelst, P., Graulus, E. & Gordts, B. Z. (2002) Diagnosis and treatment of Aspergillus flavus sternal wound infections after cardiac surgery. Clin Infect Dis, 35, 887–90.CrossRefPubMedGoogle Scholar
  25. 25.
    Lenzi, J., Agrillo, A., Santoro, A., Marotta, N. & Cantore, G. P. (2004) Postoperative spondylodiscitis from Aspergillus fumigatus in immunocompetent subjects. J Neurosurg Sci, 48, 81–5.PubMedGoogle Scholar
  26. 26.
    Mallat, S. G., Aoun, M., Moussalli, A., Chelala, D. & Moukarzel, M. (2004) Cutaneous aspergillosis in a renal transplant recipient. J Med Liban, 52, 111–4.PubMedGoogle Scholar
  27. 27.
    Kronman, M. P., Baden, H. P., Jeffries, H. E., Heath, J., Cohen, G. A. & Zerr, D. M. (2007) An investigation of Aspergillus cardiac surgical site infections in 3 pediatric patients. Am J Infect Control, 35, 332–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Forestier, E., Remy, V., Lesens, O., Martinot, M., Hansman, Y., Eisenmann, B. & Christmann, D. (2005) A case of Aspergillus mediastinitis after heart transplantation successfully treated with liposomal amphotericin B, caspofungin and voriconazole. Eur J Clin Microbiol Infect Dis, 24, 347–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Findlay, G. H., Roux, H. F. & Simson, I. W. (1971) Skin manifestations in disseminated aspergillosis. Br J Dermatol, 85, 94–7.CrossRefGoogle Scholar
  30. 30.
    Hashmi, K. U., Ahmed, P., Satti, T. M., Raza, S., Chaudhry, Q. U., Ikram, A., Kamal, M. K. & Akhtar, F. M. (2007) Cutaneous aspergillosis as a first manifestation of systemic infection in allogeneic haematopoietic stem cell transplantation. J Pak Med Assoc, 57, 324–6.PubMedGoogle Scholar
  31. 31.
    Stiller, M. J., Teperman, L., Rosenthal, S. A., Riordan, A., Potter, J., Shupack, J. L. & Gordon, M. A. (1994) Primary cutaneous infection by Aspergillus ustus in a 62-year-old liver transplant recipient. J Am Acad Dermatol, 31, 344–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Woodruff, C. A. & Hebert, A. A. (2002) Neonatal primary cutaneous aspergillosis: case report and review of the literature. Pediatr Dermatol, 19, 439–44.Google Scholar
  33. 33.
    Singh, S. A., Dutta, S., Narang, A. & Vaiphei, K. (2004) Cutaneous Aspergillus flavus infection in a neonate. Indian J Pediatr, 71, 351–2.CrossRefPubMedGoogle Scholar
  34. 34.
    Groll, A. H., Jaeger, G., Allendorf, A., Herrmann, G., Schloesser, R. & Von Loewenich, V. (1998) Invasive pulmonary aspergillosis in a critically ill neonate: case report and review of invasive aspergillosis during the first 3 months of life. Clin Infect Dis, 27, 437–52.Google Scholar
  35. 35.
    Prasad, P. V., Babu, A., Kaviarasan, P. K., Anandhi, C. & Viswanathan, P. (2005) Primary cutaneous aspergillosis. Indian J Dermatol Venereol Leprol, 71, 133–4.CrossRefPubMedGoogle Scholar
  36. 36.
    D’antonio, D., Pagano, L., Girmenia, C., Parruti, G., Mele, L., Candoni, A., Ricci, P. & Martino, P. (2000) Cutaneous aspergillosis in patients with haematological malignancies. Eur J Clin Microbiol Infect Dis, 19, 362–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Grossman, M. E., Fithian, E. C., Behrens, C., Bissinger, J., Fracaro, M. & Neu, H. C. (1985) Primary cutaneous aspergillosis in six leukemic children. J Am Acad Dermatol, 12, 313–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Mays, S. R., Bogle, M. A. & Bodey, G. P. (2006) Cutaneous fungal infections in the oncology patient: recognition and management. Am J Clin Dermatol, 7, 31–43.CrossRefPubMedGoogle Scholar
  39. 39.
    Torrelo, A., Hernandez-Martin, A., Scaglione, C., Madero, L., Colmenero, I. & Zambrano, A. (2007) [Primary cutaneous aspergillosis in a leukemic child]. Actas Dermosifiliogr, 98, 276–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Klein, K. C. & Blackwood, R. A. (2006) Topical voriconazole solution for cutaneous aspergillosis in a pediatric patient after bone marrow transplant. Pediatrics, 118, e506–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Park, S. B., Kang, M. J., Whang, E. A., Han, S. Y., Kim, H. C. & Park, K. K. (2004) A case of primary cutaneous aspergillosis in a renal transplant recipient. Transplant Proc, 36, 2156–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Pla, M. P., Berenguer, J., Arzuaga, J. A., Banares, R., Polo, J. R. & Bouza, E. (1992) Surgical wound infection by Aspergillus fumigatus in liver transplant recipients. Diagn Microbiol Infect Dis, 15, 703–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Arikan, S., Uzun, O., Cetinkaya, Y., Kocagoz, S., Akova, M. & Unal, S. (1998) Primary cutaneous aspergillosis in human immunodeficiency virus-infected patients: two cases and review. Clin Infect Dis, 27, 641–3.CrossRefPubMedGoogle Scholar
  44. 44.
    Roilides, E., Holmes, A., Blake, C., Pizzo, P. A. & Walsh, T. J. (1993) Impairment of neutrophil antifungal activity against hyphae of Aspergillus fumigatus in children infected with human immunodeficiency virus. J Infect Dis, 167, 905–11.PubMedGoogle Scholar
  45. 45.
    Nash, G., Foley, F. D., Goodwin, M. N., Jr., Bruck, H. M., Greenwald, K. A. & Pruitt, B. A., Jr. (1971) Fungal burn wound infection. JAMA, 215, 1664–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Panke, T. W., Mcmanus, A. T. & Spebar, M. J. (1979) Infection of a burn wound by Aspergillus niger. Gross appearance simulating ecthyma gangrenosa. Am J Clin Pathol, 72, 230–2.PubMedGoogle Scholar
  47. 47.
    Panke, T. W., Mcmanus, A. T., Jr. & Mcleod, C. G., Jr. (1978) "Fruiting bodies" of Aspergillus on the skin of a burned patient. Am J Clin Pathol, 69, 188–9.PubMedGoogle Scholar
  48. 48.
    Chakrabarti, A., Gupta, V., Biswas, G., Kumar, B. & Sakhuja, V. K. (1998) Primary cutaneous aspergillosis: our experience in 10 years. J Infect, 37, 24–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Romero, L. S. & Hunt, S. J. (1995) Hickman catheter-associated primary cutaneous aspergillosis in a patient with the acquired immunodeficiency syndrome. Int J Dermatol, 34, 551–3.CrossRefPubMedGoogle Scholar
  50. 50.
    Mccarty, J. M., Flam, M. S., Pullen, G., Jones, R. & Kassel, S. H. (1986) Outbreak of primary cutaneous aspergillosis related to intravenous arm boards. J Pediatr, 108, 721–4.CrossRefPubMedGoogle Scholar
  51. 51.
    Amod, F. C., Coovadia, Y. M., Pillay, T. & Ducasse, G. (2000) Primary cutaneous aspergillosis in ventilated neonates. Pediatr Infect Dis J, 19, 482–3.CrossRefPubMedGoogle Scholar
  52. 52.
    Mousa, H. A. (1999) Fungal infection of burn wounds in patients with open and occlusive treatment methods. East Mediterr Health J, 5, 333–6.PubMedGoogle Scholar
  53. 53.
    Dohil, M., Prendiville, J. S., Crawford, R. I. & Speert, D. P. (1997) Cutaneous manifestations of chronic granulomatous disease. A report of four cases and review of the literature. J Am Acad Dermatol, 36, 899–907.Google Scholar
  54. 54.
    Pasqualotto, A. C. (2009) Differences in pathogenicity and clinical syndromes due to Aspergillus fumigatus and Aspergillus flavus. Med Mycol, 47 (Suppl 1) S261–70.CrossRefGoogle Scholar
  55. 55.
    Ajith, C., Dogra, S., Radotra, B. D., Chakrabarti, A. & Kumar, B. (2006) Primary cutaneous aspergillosis in an immunocompetent individual. J Eur Acad Dermatol Venereol, 20, 738–9.CrossRefPubMedGoogle Scholar
  56. 56.
    Hedayati, M. T., Pasqualotto, A. C., Warn, P. A., Bowyer, P. & Denning, D. W. (2007) Aspergillus flavus: human pathogen, allergen and mycotoxin producer. Microbiology, 153, 1677–92.CrossRefPubMedGoogle Scholar
  57. 57.
    Gene, J., Azon-Masoliver, A., Guarro, J., De Febrer, G., Martinez, A., Grau, C., Ortoneda, M. & Ballester, F. (2001) Cutaneous infection caused by Aspergillus ustus, an emerging opportunistic fungus in immunosuppressed patients. J Clin Microbiol, 39, 1134–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Ricci, R. M., Evans, J. S., Meffert, J. J., Kaufman, L. & Sadkowski, L. C. (1998) Primary cutaneous Aspergillus ustus infection: second reported case. J Am Acad Dermatol, 38, 797–8.CrossRefPubMedGoogle Scholar
  59. 59.
    Ugurlu, S., Maden, A., Sefi, N., Sener, G. & Yulug, N. (2001) Aspergillus niger infection of exenterated orbit. Ophthal Plast Reconstr Surg, 17, 452–3.CrossRefPubMedGoogle Scholar
  60. 60.
    Vagefi, P. A., Cosimi, A. B., Ginns, L. C. & Kotton, C. N. (2008) Cutaneous Aspergillus ustus in a lung transplant recipient: emergence of a new opportunistic fungal pathogen. J Heart Lung Transplant, 27, 131–4.CrossRefPubMedGoogle Scholar
  61. 61.
    Verweij, P. E., Van Den Bergh, M. F., Rath, P. M., De Pauw, B. E., Voss, A. & Meis, J. F. (1999) Invasive aspergillosis caused by Aspergillus ustus: case report and review. J Clin Microbiol, 37, 1606–9.Google Scholar
  62. 62.
    Mcginnis, M. R. (1980) Infection of a burn wound by Aspergillus niger. Am J Clin Pathol, 74, 118.PubMedGoogle Scholar
  63. 63.
    Mowad, C. M., Nguyen, T. V., Jaworsky, C. & Honig, P. J. (1995) Primary cutaneous aspergillosis in an immunocompetent child. J Am Acad Dermatol, 33, 136–7.CrossRefPubMedGoogle Scholar
  64. 64.
    Walmsley, S., Devi, S., King, S., Schneider, R., Richardson, S. & Ford-Jones, L. (1993) Invasive Aspergillus infections in a pediatric hospital: a ten-year review. Pediatr Infect Dis J, 12, 673–82.CrossRefPubMedGoogle Scholar
  65. 65.
    Richards, K. A. & Mancini, A. J. (2000) A painful erythematous forearm nodule in a girl with Hodgkin disease. Diagnosis: primary cutaneous aspergillosis. Arch Dermatol, 136, 1165–70.CrossRefPubMedGoogle Scholar
  66. 66.
    Roth, J. G., Troy, J. L. & Esterly, N. B. (1991) Multiple cutaneous ulcers in a premature neonate. Pediatr Dermatol, 8, 253–5.CrossRefPubMedGoogle Scholar
  67. 67.
    Cornely, O. A., Pels, H., Bethe, U., Seibold, M., Toepelt, K., Soehngen, D. & Ritzkowsky, A. (2001) A novel type of metastatically spreading subcutaneous aspergillosis without epidermal lesions following allogeneic stem cell transplantation. Bone Marrow Transplant, 28, 899–901.CrossRefPubMedGoogle Scholar
  68. 68.
    Goel, R. & Wallace, M. L. (2001) Pseudoepitheliomatous hyperplasia secondary to cutaneous aspergillosis. Am J Dermatopathol, 23, 224–6.CrossRefPubMedGoogle Scholar
  69. 69.
    Soto-Hurtado, E. J., Marin-Gamez, E., Segura-Dominguez, N. & Jimenez-Onate, F. (2005) Pleural aspergillosis with bronchopleurocutaneous fistula and costal bone destruction: a case report. Lung, 183, 417–23.Google Scholar
  70. 70.
    Gupta, M., Sharma, N. L., Kanga, A. K., Mahajan, V. K. & Tegta, G. R. (2007) Onychomycosis: clinico-mycologic study of 130 patients from Himachal Pradesh, India. Indian J Dermatol Venereol Leprol, 73, 389–92.CrossRefPubMedGoogle Scholar
  71. 71.
    Veer, P., Patwardhan, N. S. & Damle, A. S. (2007) Study of onychomycosis: prevailing fungi and pattern of infection. Indian J Med Microbiol, 25, 53–6.CrossRefPubMedGoogle Scholar
  72. 72.
    Bereston, E. S. (1945) Onychomycosis and dermatomycosis caused by Trychophyton rubrum and Aspergillus nidulans. Arch Dermatol Venerol, 52, 162–5.Google Scholar
  73. 73.
    Perman, M. J. & Kauls, L. S. (2007) Transilluminator burns in the neonatal intensive care unit: a mimicker of more serious disease. Pediatr Dermatol, 24, 168–71.CrossRefPubMedGoogle Scholar
  74. 74.
    Herbrecht, R., Denning, D. W., Patterson, T. F., Bennett, J. E., Greene, R. E., Oestmann, J. W., Kern, W. V., Marr, K. A., Ribaud, P., Lortholary, O., Sylvester, R., Rubin, R. H., Wingard, J. R., Stark, P., Durand, C., Caillot, D., Thiel, E., Chandrasekar, P. H., Hodges, M. R., Schlamm, H. T., Troke, P. F. & De Pauw, B. (2002) Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med, 347, 408–15.CrossRefPubMedGoogle Scholar
  75. 75.
    Frankenbusch, K., Eifinger, F., Kribs, A., Rengelshauseu, J. & Roth, B. (2006) Severe primary cutaneous aspergillosis refractory to amphotericin B and the successful treatment with systemic voriconazole in two premature infants with extremely low birth weight. J Perinatol, 26, 511–4.CrossRefPubMedGoogle Scholar
  76. 76.
    La Nasa, G., Littera, R., Maccioni, A., Ledda, A., Vacca, A. & Contu, L. (2004) Voriconazole for the treatment of disseminated nodular cutaneous aspergillosis in a patient affected by acute myeloid leukemia. Hematol J, 5, 178–80.CrossRefPubMedGoogle Scholar
  77. 77.
    Auffret, N., Janssen, F., Chevalier, P., Guillemain, R., Amrein, C. & Le Beller, C. (2006) [Voriconazole photosensitivity: 7 cases]. Ann Dermatol Venereol, 133, 330–2.PubMedGoogle Scholar
  78. 78.
    Van Burik, J. A., Colven, R. & Spach, D. H. (1998) Itraconazole therapy for primary cutaneous aspergillosis in patients with AIDS. Clin Infect Dis, 27, 643–4.CrossRefPubMedGoogle Scholar
  79. 79.
    Santos, R. P., Sanchez, P. J., Mejias, A., Benjamin, D. K., Jr., Walsh, T. J., Patel, S. & Jafri, H. S. (2007) Successful medical treatment of cutaneous aspergillosis in a premature infant using liposomal amphotericin B, voriconazole and micafungin. Pediatr Infect Dis J, 26, 364–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2009

Authors and Affiliations

  • Arunaloke Chakrabarti
    • 1
  • Shivsekhar Chatterjee
    • 2
  • Bishan D. Radotra
    • 3
  1. 1.Department of Medical MicrobiologyPostgraduate Institute of Medical Education & ResearchChandigarhIndia
  2. 2.Division of Infectious DiseasesHarper University HospitalDetroitUSA
  3. 3.Department of HistopathologyPostgraduate Institute of Medical Education & ResearchChandigarhIndia

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