Date: 26 November 2013
The patient was a 610 g twin male born by spontaneous normal vaginal delivery at 23 weeks and 4 days gestation. He was started on benzyl penicillin and gentamicin for sepsis. On day 3, he developed metabolic acidosis, hyponatremia, anemia, thrombocytopenia and jaundice and his antibiotics were changed to vancomycin, cefotaxime and fluconazole.
On day 10, multiple circular skin papules with white eschars were noted on his back (Figure A). A full septic screen was repeated including skin scraping and biopsy for urgent microscopy and culture. Microscopy of skin scrapes revealed fungal elements including hyphae and fruiting heads suggestive of Aspergillus spp (Figure B). Lipid amphotericin B was commenced and fluconazole was stopped. Skin scrapings on culture grew Aspergillus fumigatus. A diagnosis of primary cutaneous aspergillosis was made. The patient responded to oral posaconazole 6mg/kg/8 hourly. All lesions disappeared after 44 days and he continued with posaconazole until day 60.
Published case at Langan et al Pediatr Dermatol 2010 Jul-Aug 27 (4) 403-4
Copyright: n/a
Notes:
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Yamik catheter for rinsing nasal and paranasal cavities. Image A
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Diagnosis: Aspergilloma with invasive aspergillosis evidence of invasion found in the lumbar spine and brain, in addition to heart.
Fungal endocarditis with NO evidence of bacterial endocarditismia.Additional image details:
A. Normal chest X ray:
This (normal) chest X-ray was taken about 6 weeks before endocarditis was diagnosed, and 3 months before death due to disseminated aspergillosis. No CT scan was done (a chest radiograph has a 10% false negative rate in leukaemic patients, compared with CT).B. Aspergillus niger Fungal ball:
Gross section of lung at autopsy showing a discrete, well-demarcated dark/black mass surrounded by a fibrotic capsule. There was no evidence of local invasion, or infarction. The patient had had acute myeloid leukaemia (M1) and responded poorly to chemotherapy. He developed A.niger endocarditis and disseminated disease to the kidneys, lumbar disc and heart, probably arisiong from this lesion. It is unclear whether this lung lesion was a partially cured ‘mycotic lung sequestrum’ following antifungal therapy, or originated as an aspergilloma. The confirmation of genus and species was obtained by PCR on blood and vegetations.C. Endocarditis:
Macroscopic view of the heart at autopsy, showing an infracted lesion on the papillary muscle of the mitral valve in the left ventricle. In addition the patient had large vegetations, which are not shown here. The confirmation of genus and species was obtained by PCR on blood and vegetations; the pericarditis was a manifestation of disseminated aspergillosis.D. Pericarditis due to Aspergillus niger:
Macroscopic view of the pericardium at autopsy, showing gross chronic haemorrhagic pericarditis. The confirmation of genus and species was obtained by PCR on blood and vegetations; the pericarditis was a manifestation of disseminated aspergillosis.E. Lumbar discitis:
Macroscopic lesion of a lumbar intervertebral vertebral at autopsy, showing haemorrhagic necrosis, caused by hyphal invasion and infarction. The confirmation of genus and species was obtained by PCR on blood and vegetations; the discitis was a manifestation of disseminated aspergillosis.
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