Cutaneous Aspergillosis in an Acute Lymphoblastic Leukemia Patient After Allogeneic Hematopoietic Stem Cell Transplantation

G. Ozlem tunçcan, A. Sahika Zeynep Aki, A. Nalan Akyürek, S. Gülsan Sucak, S. Esin

Author address: 

Gazi University Faculty of Medicine, ANKARA, Turkey

Abstract: 

Infections are one of the major causes of mobidity and mortality after haematopoietic stem cell transplantation (HSCT). Opportunistic infections including Aspergillus species are the major pathogens in HSCT recipients during severe immunosuppression. Despite efffective antifungal treatment more than half of the transplant patients with invasive aspergillosis die because of infection. Although lung and sinuses are accepted as the primary portal of aspergillus hyphae, primary cutaneous aspergillosis (PCA) might be a rare form of locally invasive disease in transplant patients under severe immunosuppression. Here we report a case with acute lymphoblastic leukemia (ALL) who underwent allogeneic HSCT and developed PCA during acute graft versus host disease (aGvHD) associated severe immunosuppression. Case: A 26 year- old man with the diagnosis of T cell ALL underwent allogeneic HSCT in second complete remission. He received cyclosporin A and long- term methotrexate as GvHD prophylaxis. He developed acute overall grade II skin GvHD on day +28 after HSCT. Because of corticosteriod refractory skin GvHD he received mesenchymal stem cells on day +94 after HSCT. On day +143, during steroid dose tappering after the resolution of skin GvHD findings, he developed fever unresponsive to antibacterial treatment and skin lesions including 1 x 2 cm ecchymotic nonulcerated nodular lesion on the upper third of the left leg and 3x2 cm ecchymosis nonulcerated nodular lesion on the distal third of the right tibia. Histological examination of the biopsy specimen from the nodular lesion on the upper leg showed LPG positive branched aspergillus hyphae in deep dermis and subcutaneous adipose tissue consisting with cutaneous aspergillosis. Infections of sinuses and pulmonary cavities were excluded by paranasal computerised tomography (CT) and high resolution CT of lungs. Molecular analysis for galactomannan, aspergillus PCR and panfungal PCR were negative. Multiple blood cultures were negative for fungal etiology. The nodule on upper leg was removed surgically. However because of the anatomical localization the second nodule on distal tibia could not be removed by surgery. He is still on oral voriconasole treatment with partial response for noduler lesion on distal tibia. Conclusion: Every skin lesion in immunocompromised patients should be carefully examined for the possibility of infections. A rapidly growing lesion with an area of central necrosis is the typical clinical manifestation of cutaneous Aspergillosis involvement. These skin lesions might occur as the first clinical manifestation of disseminated disease. Early diagnosis and rapid initiation of systemic effective anti- fungal treatment for cutaneous aspergillosis is important for successful outcome in immunocompromised patients.
2009

abstract No: 

P162

Full conference title: 

4th Trends in Medical Mycology
    • TIMM 4th (2012)