Secondary cutaneous aspergillosis due to Aspergillus flavus in an acute myeloid leukaemia patient following stem cell transplantation

ARTICLE

Skin infections due to moulds are very rare entities. Primary infections occur after a direct inoculation of the fungus into breaks of the skin and open wounds, e.g. burn wounds or diabetic gangraene [1]. Infecting or colonizing causing agents may be Fusarium, Scedosporium, and, particularly Aspergillus (A.) species. Increasingly, primary cutaneous aspergilloses (CA) are seen in AIDS patients, but also in patients suffering from septic, chronic granulomatosis. Besides, secondary CA caused by haematogeneous spread from invasive aspergillosis of the lungs or Aspergillus sepsis may develop. Causative agent is A. fumigatus, rarely A. flavus may be found. A. flavus infections show a poor response to common antifungals in vivo, in particular against intravenously administered amphotericin B. This may be due to a diminished in vitro susceptibility of A. flavus against this polyene antifungal.

Case report

Starting in February 1999, a 64-year-old patient suffered from a hypoblastic myelodysplastic syndrome (MDS) which was characterized by pancytopenia and cytogenetic aberrations. In June 1999, after the development of a secondary acute myeloblastic leukaemia, induction chemotherapy was performed, but only partial remission could be achieved. Thereafter, the patient received a second induction therapy followed by an allogenic (related, from his sister) peripheral blood stem cell transplantation (HLA haploid) conditioned with 2 Gy TBI (total body irradiation) and fludarabine in August 1999. Skin lesions of a limited graft versus host disease developed.

After haematopoietic reconstitution in September 1999, chest pain and dyspnoea occurred. A left-sided heart failure was found. Pneumonia had to be suggested. Chest computer tomography revealed multiple diffuse and central confluent infiltrations predominantly in the right but also in the left lung lobe, suggestive for aspergillosis lesions. Bronchoscopy was performed. In both the bronchoalveolar lavage fluid and bronchial secretion Aspergillus-Antigen (Pastorex^®, Sanofi Diagnostics Pasteur, Marnes-de-la-Coquette, France) was detected, additionally A. flavus grew on Sabouraud´s-4% dextrose agar (Fig. 1a). The respiratory symptoms worsened with the development of more extensive pulmonary infiltrates involving both lung fields (Fig. 1b). High frequency oscilating ventilation was necessary.

The patient's general condition deteriorated despite maximal support with resulting multi organ failure. The acute cardiac failure was treated with high dose catecholamines, renal failure was treated by haemofiltration. A striking neutropenia was remarkable. With the suspicion of an invasive pulmonary aspergillosis, antifungal treatment was started with amphotericin B (50 mg/d), than changed to Ambisome^® (liposomal encapsulated amphotericin B, 100 to 150 mg/d).

On the sides and back 4 or 5 erythematous to violaceous rounded nodular lesions appeared, which tended to haemorrhage (Figs. 2a and b). Biopsy from these lesions was performed. At 37° C a mould with yellowish-green thallus, oval and round or spherical vesicles with biserate phialides and rough-walled conidiophore stipes grew from skin tissue extremely fast (over night). Echinulate spherical and subspherical conidia were visible. Based on these characteristics species differentiation was A. flavus (Fig. 3).

Pathohistologically, a skin biopsy specimen showed multiple septated hyphae in a typical pattern with 45-degree dichotomous branching within the corium and subcutaneous tissue, using both PAS (Figs. 4a-c), and Grocott staining.

The in vitro susceptibility testing of the isolate using a microdilution method with HR (high resolution) medium (Oxoid/Unipath, Basingstoke, Hampshire, England) revealed the following values of minimum inhibitory concentration [mug ml^-1]: amphotericin B 2, Ancotil^® (5-fluorocytosine) medium susceptible, Sempera^® (itraconazole) 0.5, and Diflucan^® (fluconazole) 64. Despite high dosage antifungal therapy with liposomal amphotericin B, the patient died in October 1999 due to Aspergillus pneumonia associated with multiple aspergilloma of the lungs and generalized aspergillosis with disseminated haematogeneous spread to the heart, brain, and skin.

At autopsy, in all lung lobes multiple aspergillomata with diameters from 0.5 to 4 cm were seen together with confluent mycotic bronchopulmonic lesions. Within the left ventricular wall of the heart an aspergilloma with 0.5 cm diameter was found. The left ventricular septum and dorsal wall of the heart contained six aspergillomata, showing diameters from 1 to 1.5 cm (Fig. 5). The periphery of these aspergillomata showed necrotic zones. Septicopyemic abscesses with Aspergillus infiltrations were found in the skin.

In the brain multifocal intracerebral pyogenic focal encephalitis caused by Aspergillus infection was seen. Due to septicopyemic vascular occlusions consecutive haemorrhagic infarctions in adjacent brain tissue had developed. This may be interpreted as an alternative cause of death.

Discussion

Cutaneous aspergillosis: frequency

A high percentage of cases with CA have been reported in neutropenic cancer patients. It has also emerged as a significant infection among a variety of immunocompromised patients, including neonates, after organ or bone marrow transplantation, chronic granulomatous disease, autoimmune diseases receiving corticosteroids, and patients with burn wounds [2].

Despite an increasing occurrence of invasive aspergillosis, predominantely of the lungs, there are relatively less frequent reports on CA in the recent literature. Aspergillosis is the second most frequent life-threatening mycotic infection in patients suffering from haematological malignancies. D'Antonio et al. [3] evaluated skin infections caused by Aspergillus in patients with haematological disorders. Twelve cases of CA occurred among 4,448 consecutive patients with acute leukaemia. Three additional cases were seen in chronic myeloid leukaemia and myelodysplastic syndrome. Cutaneous involvement occurred in 4% of patients with documented Aspergillus infection. Up to 1998 more than 50 cases of CA in cancer patients have been reported in the literature [1]. In addition, CA has been estimated to occur in up to 10% of non-HIV patients with disseminated Aspergillus infection and in 4% of haemotological patients with invasive pulmonal aspergillosis and secondary haematogenous spread [3]. It should be mentioned that from our point of view this percentage of 10% seems to be too high.

Recently, Kaiser et al. [4] carefully described the clinical feature of 35 proven cases of invasive aspergilloses. Thirty-three patients (94%) had pulmonary apsergillosis, other involved organs and tissues were: heart 4 (11%), liver 3 (8.5%), kidney 3 (8.5%), spleen 2 (5.7%), and both skin, mediastinum, and central nervous system one each (corresponding to 2.9%).

Primary cutaneous aspergillosis

Primary CA usually involves sites of skin injury and occurs as traumatic inoculation. In particular, burns of second and third degree may be colonized or infected by moulds, in the first line by Aspergillus species [5-9]. Primary skin infection by Aspergillus has been reported at intravenous catheter sites. In particular, adhesive and occlusive dressings and tapes for venous access devises, e.g. Tegaderm^®, may be contaminated by Aspergillus spores [10]. Cases of primary aspergillosis of the skin in patients with acquired immunodeficiency syndrome have been reported, all of them with a history of maceration of the skin from the use of adhesive tape or intravenous catheters [11]. Other reports demonstrated primary CA in surgical wounds, damaged skin, sites of venesection and pyoderma gangraenosum [12, 13].

A recent paper by Munn et al. [14] described two previously fit young people who were admitted to the neurosurgical unit following spinal trauma with resulting tetraplegia. They were immunocompromised because of high-dose corticosteroids and lymphocytopenia. Primary CA as erythematous plaques studded with pustules mimicking cutaneous Candida infection developed on the back. The cause was that the skin remained occluded by the bed sheets despite a special spinal rotating bed.

Thakur et al. [15] were the first who described a patient with recalcitrant pemphigus vulgaris that required aggressive immunosuppression and in whom invasive, necrotizing CA developed at multiple sites, which was followed by septic shock and death.

Primary CA is usually seen in immunocompromised hosts. However, even in immunocompetent patients a primary CA has been reported [16]. Lakhanpal et al. [17] recently reported a further immunocompetent patient with CA. They were able to find only five further reports on CA in immunocompetent hosts to date.

In patients with human immunodeficiency virus infection CA occur with emerging frequency [18]. In 2000, Murakawa et al. [19] described 11 patients with CA in HIV-infected patients and reviewed 13 additional cases that they found published in the literature. All reported patients had very low CD4 counts with a median of 0.006 x 10⁹/l, indicating that they were in an advanced stage of infection. Interestingly, not all HIV patients were neutropenic as is characteristic for the development of an aspergillosis. Thus, the major risk factor of aspergillosis in HIV-infected patients seems to be neutropenia caused by myelotoxic drugs, e.g. zidovudine and ganciclovir. A cytomegaly virus infection may be associated [18, 20].

Secondary cutaneous aspergillosis

Secondary cutaneous infections due to Aspergillus species are commonly a result of haematogenous seeding from a primary focus of infection, most often the lung, occurring in highly immunocompromised hosts [1]. More rarely these secondary lesions may develop from contiguous extension to the skin from underlying structures, e.g. the lungs. The lesions may be single or multiple, may not be tender, and occur most commonly on the extremities [10]. On the contrary, the patient described here was affected exclusively on his trunk.

Non-HIV-related secondary CA lesions initially appear as erythematous macules or papules that evolve to haemorrhagic bullae or ulcerative nodules [21]. Histological examination reveals invasion of local blood vessels and infarction of the skin, corresponding to the visual appearances [22]. Skaria et al. [23] described a metastatic Aspergillus panniculitis in the case of blastic transformation of a myelodysplastic syndrome and agranulocytosis. The skin lesion showed a single subcutaneous inflammatory nodule, which was clearly demonstrated by histology to be of embolic origin.

Interestingly, A. flavus is more often present in primary CA, whereas most disseminated infections are caused by A. fumigatus [24]. Also, Lakhanpal et al. [17] found that primary CA is usually caused by A. flavus and A. niger. In accordance with that, in this case of a secondary CA, we were able to isolate A. flavus both from bronchial secretion and bronchoalveolar lavage fluid and later on from a skin tissue sample. In addition, occasionally further Aspergillus species have been reported in CA. Tritz and Woods [25] described a disseminated infection with A. terreus in an immunocompromised host suffering from acute myeloid leukaemia, with haematogenous spread of the mould to the skin. More recently, A. chevalieri has been reported to cause morphologically distinct skin lesions, which appear erythematous, hyperkeratotic, and vesiculopapular in nature [26].

James et al. [27] used a repetitive DNA probe to type clinical and environmental isolates of A. flavus from a cluster of cutaneous infections in a neonatal intensive care unit. The probe was used to investigate two cases of cutaneous A. flavus infection in low-birth-weight infants. Both infants were transported by the same ambulance and crew to the hospital on the same day. A. flavus strains of the same genotype were isolated from both infants, from a canvas bag used to store the tape in the ambulance, and from the tape tray in the ambulance isolette.

Treatment of cutaneous aspergillosis

It appears reasonable to use itraconazole for the treatment of patients for whom primary CA has been localized at least several centimetres from a vascular catheter exit site and for whom there is no evidence of extracutaneous aspergillosis [28]. Patients receiving itraconazole should be monitored carefully. Thus, if there is any sign of a diminished response to this triazole, the management regimen should be changed to intravenous amphotericin B.

In their excellent minireview concerning CA, Burik et al. [1] do not recommend the use of itraconazole as a first line therapy for cutaneous Aspergillus infections involving vascular catheter exit sites or tunnel infections, secondary CA, or extensive primary cutaneous disease. These severe infections require the intravenous application of amphotericin B. Consequent surgical debridement improves the clinical outcome of CA.

Recently, Lass-Flörl et al. [29] demonstrated that in vitro testing of susceptibility to amphotercin B is a reliable predictor of clinical outcome in invasive aspergillosis. Irrespective of species - A. fumigatus, A. flavus and A. terreus - all six out of 29 patients with isolates against which the minimum inhibitory concentration was < 2 mug/ml survived, whereas most (22/23) of those with isolates resistant to amphotericin B with MIC values >= 2 mug/ml - as it was the case in our patient - died.

Article accepted on 16/8/01

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