Cutaneous and paranasal aspergillosis in an immunocompetent patient

Abstract

A 26-year-old Libyan woman presented with asymptomatic nodulo-ulcerative skin lesions present for 1 year. Three years prior to presentation, she had experienced a nasal discharge followed by the development of a nodule in the nasal cavity and a plaque on the hard palate. These lesions had gradually increased in size and ulcerated, resulting in perforation of the nasal septum and palate. Two years later, the patient noticed the appearance of skin lesions: a nodule on the right thumb and numerous nodulo-ulcerative lesions on the extremities. General physical examination was normal with no significant lymphadenopathy. Examination of the oral cavity revealed perforation of the distal nasal septum, with a perforated nodular plaque involving the entire palate, associated with subluxation of the upper incisors (Fig. 1a). On skin examination, multiple firm nodules and nodulo-ulcerative lesions with a central eschar and raised margins were observed. The lesions ranged in size from 0.5 to 5 cm and were distributed on the right hand and fingers, left upper arm (Fig. 1b), left calf, and right thigh. Routine laboratory investigations (liver function tests, serum calcium, electrolytes, lipid profile, urine and stool culture studies) were normal. Immunoelectrophoresis disclosed normal levels of immunoglobulins IgG, IgA, and IgM. Serologic studies for human immunodeficiency virus (HIV) and syphilis, and a tuberculin test, were all negative. A Giemsa-stained tissue smear was negative for Leishmania tropica organisms. Radiological studies disclosed a slight haziness of the maxillary sinuses with perforation of the nasal septum. A chest X-ray was normal. Histopathologic examination of biopsies taken from both the palate and from ulcerated and nonulcerated skin lesions was performed, and all showed similar findings. The biopsy of a nonulcerated skin lesion showed pseudoepitheliomatous epidermal hyperplasia with neutrophilic microabscesses (Fig. 2a). A dermal diffuse and nodular granulomatous mixed infiltrate of lymphocytes, histiocytes, giant cells, numerous eosinophils, and neutrophilic microabscesses was seen in all tissues examined. Septate hyphae were present both within giant cells and free in the dermis (Fig. 2b). The hyphae were branching at a 45 degrees angle and were positive on periodic acid-Schiff and Grocott methenamine silver stains (Fig. 2c). Fungal culture studies of material taken from an ulcerated skin lesion grew Aspergillus flavus. Blood cultures were negative for Aspergillus sp. or other microorganisms. The patient was treated with intravenous amphotericin B, but the medication was discontinued due to her intolerance to the drug. She was subsequently lost to follow-up.

Combined mucormycosis and aspergillosis of the oro-sinonasal region in a patient affected by Castleman disease

“…Invasive aspergillosis is rare and mainly affects immune-compromised hosts, causing destruction of the antral wall, antral pain, swelling, with or without sequelae from orbital invasion or intracranial extension. Following an initial sino-nasal localisation, oral lesions may develop, especially to the palate or the alveolar process, which appear as yellow to black necrotic ulcers of the palate or the posterior tongue [14,23]. Delayed diagnosis or inappropriate treatment may result in massive tissue destruction and possible extension into the cranial base and/or vault and orbit, via the blood flow, and determine blindness, lethargy, seizure and eventually death [2].…”

Primary cutaneous aspergillosis due to Aspergillus tamarii in an immunocompetent host

“…The usual site of infections are lung, central nervous system and sinuses 3 4. Cutaneous aspergillosis is an uncommon opportunistic fungal infection that may occur either as a primary or a secondary infection 5.…”

Invasive aspergillosis in a user of inhaled cocaine: rhinosinusitis with bone and cartilage destruction

“…Few studies have reported the effect of IA on the central portion of the face in immunocompetent individuals 1,2,4,5,11 . Thus far, no study has reported its occurrence in relation to cocaine abuse.…”

“…Aspergillosis is an infection caused by saprophytic fungi of the genus Aspergillus, which typically occurs in immunosuppressed patients 1,2 . The main routes of entry are the respiratory tract, skin, cornea, and ear, and the infection may be localized or disseminated by contiguity or vascular invasion 2,3 .…”

“…It rarely affects immunocompetent patients 1,5 . It was described in young individuals with predisposing factors to fungal colonization and proliferation, such as atopia; nasal polyps; and a history of allergic rhinitis, asthma, and recurrent sinusitis 2 .…”