Date: 26 November 2013
This patient with ABPA and chronic cavitary pulmonary aspergillosis has been stabilized on voriconazole treatment for >5 years. She had a degree of photosensitivity most of that time, noticed early in the course of voriconazole treatment. She is oxygen and wheelchair dependent and doesn’t go outside very much, so most of her light exposure has been indoor light. She developed rough scaly patches over her face, neck and lower arms. Dermatological review indicated multiple solar keratoses”. Skin biopsy from the right forearm confirmed this clinical diagnosis – “skin showing hyperkeratosis with a little parakeratosis and acanthosis. The keratinocytes have a glassy appearance but show nuclear atypia with dyskeratotic cells, and occasional suprabasal mitoses. The intraepidermal sweat ducts are spared. Appearances suggest an actinic keratosis with moderate to severe dysplasia.” These features are characteristic of a low grade premalignant change.
She was treated with local 5-fluorouracil cream (Efudix) (3 cycles) to the affected lesions. These photos were taken at the apogee of inflammation. The inflammation resolved after discontinuing the cream. This reaction is expected with application of this mild chemotherapy agent. Alternative or supplementary treatments include cryotherapy, curettage and cautery, if necessary. Following treatment her skin was much softer and considerably improved. Voriconazole has been stopped, and posaconazole substituted.
Copyright:
DW Denning and JE Ferguson, University Hospital of South Manchester. 22/07/08
Notes: n/a
Images library
-
Title
Legend
-
Bilateral A. fumigatus endophthalmitis in association with pulmonary and cerebral aspergillosis, complicating severe autoimmune disease treated with intense immunosuppression. Right eye.
-
Bilateral A. fumigatus endophthalmitis in association with pulmonary and cerebral aspergillosis, complicating severe autoimmune disease treated with intense immunosuppression. Left eye.
-
Aspergillus keratitis – a case of fungal keratitis following amnoiotic membrane transplantation (AMT) for bullous keratopathy. Slit-lamp photograph of left eye showing ring shaped stromal infiltrate.
-
A 14 year old boy with a T cell lymphoma received induction chemotherapy with high dose dexamethasone. At no time during this therapy was he neutropenic. Three weeks into treatment his dexamethasone was reduced and stopped due to gastro-intestinal side effects. On recovery of his abdominal symptoms, he developed sudden onset of severe right sided pleuritic chest pain. Initially, he was thought to have a pulmonary embolism as a chest X-ray showed a solid wedge shaped area of consolidation. He then developed a cough and temperature and sputum grew Aspergillus fumigatus. The wedge shaped lesion developed cavitation. Despite AmBisome at 5mg/Kg, commenced within 4 days of onset of symptoms, the chest X-ray appearance got gradually worse over the following week. This led to substitution of Ambisome by caspofungin and voriconazole. He developed a thyroid cyst with haemorrhage that on aspiration grew A. fumigatus. His chest X-ray continued to worsen. He underwent a right lower lobe lobectomy, which confirmed the diagnosis of invasive pulmonary aspergillosis. Unfortunately the thyroid cyst continued to increase in size resulting in removal of the right lobe of the thyroid.
Chest CT scan carried out 3 weeks after lobectomy revealed new lesions within the right upper lobe of the lung. At this time the voriconazole therapy was stopped and posaconazole started. The area of the thyroid remains free of Aspergillus and the lung lesions appear to be improving 6 weeks after the start of posaconazole.
, 
, 
-
Aspergillus keratitis. Severe peripheral lesion due to aspergillus unlikely to respond well to treatment.
-
Aspergillus keratitis. Corneal scar at end of treatment of case in previous slide.Vision recovered to 6/9.
-
Aspergillus keratitis. Severe central aspergillus infection with a “cheesey†looking area of the lesion and hypopyon (fluid level of inflammatory cells in the anterior chamber)
 treatment.){kind=link}