|Year : 2013 | Volume
| Issue : 2 | Page : 193-196
A case of dual infection in a paediatric trauma victim of primary cutaneous aspergillosis caused by Aspergillus flavus and Aspergillus terreus
V Tak1, P Mathur1, I Xess2, P Kale2, S Sagar3, MC Misra3
1 Department of Laboratory Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Microbiology, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
3 Department of Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||28-Dec-2012|
|Date of Acceptance||08-May-2013|
|Date of Web Publication||19-Jul-2013|
Department of Laboratory Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Aspergillus spp. are widely distributed throughout the environment. They are opportunistic pathogens causing infection at various sites in the body such as lungs, sinuses, eyes, skin, central nervous system etc., Primary cutaneous aspergillosis is an uncommon disease entity. Primary infections usually occur at sites having disruption of the skin and usually occur in burn patients, trauma and surgical patients. A 4-year-old girl who was run over by a truck and suffered extensive de-gloving injury to bilateral lower limbs developed greenish discharge and scaly lesions around the wound margins after 50 days of hospital stay. The skin biopsy demonstrated the presence of thin septate hyphae branching at acute angles and culture demonstrated growth of Aspergillus flavus and Aspergillus terreus. The child was started on voriconazole therapy for 3 weeks and the lesion healed satisfactorily. Subsequent skin biopsy culture was negative for fungi. Prompt diagnosis and management of such cases can salvage the limbs in severe trauma cases.
Keywords: Aspergillus terreus, Aspergillus flavus, primary cutaneous aspergillosis, trauma
|How to cite this article:|
Tak V, Mathur P, Xess I, Kale P, Sagar S, Misra M C. A case of dual infection in a paediatric trauma victim of primary cutaneous aspergillosis caused by Aspergillus flavus and Aspergillus terreus. Indian J Med Microbiol 2013;31:193-6
|How to cite this URL:|
Tak V, Mathur P, Xess I, Kale P, Sagar S, Misra M C. A case of dual infection in a paediatric trauma victim of primary cutaneous aspergillosis caused by Aspergillus flavus and Aspergillus terreus. Indian J Med Microbiol [serial online] 2013 [cited 2020 Dec 5];31:193-6. Available from: https://www.ijmm.org/text.asp?2013/31/2/193/115232
| ~ Introduction|| |
Aspergillus spp. is widely distributed throughout the environment. They are present in soil, water, air and a wide range of environmental surfaces and are opportunistic pathogens causing infection at various body sites. Primary cutaneous aspergillosis (PCA) is an uncommon disease entity. Primary infections usually occur at sites having disruption of the skin viz., sites of intravascular catheter insertion and macerated skin due to use of adhesive tapes and underneath the occlusive dressings. Therefore, PCA usually occurs in burn patients or trauma and surgical patients who lose large surface areas of skin epithelial barrier and are hence exposed to the vast number of spores present in the environment and at times underneath the dressings used to cover these wounds. Secondary cutaneous aspergillosis lesions arise from infected organs either by direct extension to the overlying skin or via infected emboli released in the bloodstream and seeding the skin at distant sites far away from the focus of primary infection. PCA may present as macules, papules, plaques or haemorrhagic bullae, which may progress into necrotic ulcers with an elevated border that is covered by a black eschar. ,,, It usually affects immunocompromised patients such as human immunodeficiency virus (HIV) seropositive individuals, patients on chronic steroid therapy, cancer, diabetic and neutropenic patients. ,,
Aspergillus fumigatus, Aspergillus flavus, Aspergillus niger and Aspergillus terreus are the usual species causing PCA.  The diagnosis of PCA is carried out on skin biopsy specimens by histopathology, culture and polymerase chain reaction examination for Aspergillus species. On histopathology, diagnosis of PCA is based on demonstration of septate hyphae invading the skin tissue. These septate hyphae are branching dichotomously at acute angles, but the identification of species is difficult on histopathological examination alone. Therefore, culture of the skin biopsy tissue helps us in speciating the etiological agent based on both macroscopic and microscopic features, which vary between different Aspergillus species. Macroscopic or gross examination of culture tubes on both obverse and reverse aspects shows differences in the colour, texture and other colony characteristics among various Aspergillus species for e.g., colony of A. fumigatus is dark green, A. flavus is yellowish-green, A. niger is black and A. terreus is cinnamon brown in colour. On microscopic examination, various Aspergillus species differ in type of conidiophore (long/short, rough/smooth), shape of vesicle (globose/spherical/hemi-spherical), arrangement of conidia on the vesicle (uni/biseriate, covering entire vesicle or only upper part of vesicle), presence or absence of fruiting bodies (Cleistothecia) etc.  Most clinical microbiology laboratories rely on morphological identification of Aspergillus species.
PCA is usually reported to be caused by one species of Aspergillus. We report here, a rare case of cutaneous aspergillosis in a paediatric trauma case, caused by two different species of Aspergillus.
| ~ Case Report|| |
A 4-year-old girl child was admitted to our trauma centre after being run over by a truck in July 2012. The child suffered de-gloving injury to bilateral lower limbs. The injury extended in the right lower limb from proximal thigh to mid-leg region with open right knee joint capsule and the left lower limb. The skin was avulsed from distal part of left leg, foot and sole up to mid-foot region. Initially, the wound was cleaned and draped. Subsequently, dressing was carried out on alternate days under general anaesthesia in operation theatre; skin graft was carried out in mid-August. After about 50 days of hospital admission, the child developed a greenish scaly lesion and greenish exudate around the margins of the wound on the right leg [Figure 1]. The lesion was debrided and the skin tissue samples were sent to our laboratory for culture. The samples were processed for diagnosis of bacterial and fungal pathogens by standard methods. 
|Figure 1: Green yellow exudate and scaly lesion along the margins of the wound on the right lower limb of the patient|
Click here to view
The potassium hydroxide (KOH) mount of the specimen demonstrated the presence of thin hyaline septate hyphae invading the skin epithelium [Figure 2]a-c. A skin biopsy was repeated the next day from a different site along the wound margin, to rule out contamination, which also demonstrated invasion of skin by thin hyaline septate hyphae dividing at acute angles. The two tissue specimens were inoculated onto two tubes each of Saboraud's dextrose agar and Sabouraud's dextrose agar with chloramphenicol, one each of which were kept at 25°C and 37°C. Simultaneously, the biopsy material was also inoculated on blood and MaConkey agar for aerobic bacterial culture and on supplemented brain heart infusion blood agar, which was incubated anaerobically. The aerobic and anaerobic media did not grow any bacteria after 48 h of incubation and were reported as sterile. However, all the fungal culture tubes showed a growth of cottony white mycelia after about 48 h of incubation. On gross examination, two types of growth were seen as greenish yellow and cinnamon brown coloured moulds after 3 days [Figure 3]a and b. The lacto-phenol cotton blue mount of the yellowish green colonies demonstrated dichotomously branched septate hyphae with straight conidiophores with a rough surface ending in a vesicle having two layers of sterigmata (bi-seriate) bearing conidia all around the vesicle [Figure 4]. The cinnamon brown coloured colonies on lacto-phenol cotton blue mount demonstrated dichotomously branched septate hyphae with slightly smaller conidiophores with smooth surfaces and a bi-seriate vesicle bearing conidia only on the central two-thirds of the vesicle surface [Figure 5]a and b. The greenish yellow colony and cinnamon brown colonies based upon the morphology and colony characteristics were identified as A. flavus and A. terreus respectively. Initially, on the basis of the KOH mount report, the clinicians started Amphotericin B therapy. However, since the cultures also grew A. terreus, which is known to be resistant to polyene group of anti-fungals, the child's treatment was changed to voriconazole injection 7 mg/kg for first 1 week and later was put on oral voriconazole therapy 100 mg twice a day for 2 more weeks. The child responded well to therapy and the wound was healthy. A repeat skin biopsy after 2 weeks did not demonstrate any invasion of the skin tissue by fungal hyphae and the culture was sterile. The child was sero-negative for HIV infection and had a normal neutrophil count.
|Figure 2: (a-c) Potassium hydroxide mount of skin scraping showing growth of septate hyphae demonstrating dichotomous branching at acute angles interspersed between epithelial cells of skin|
Click here to view
|Figure 3: (a and b) Cinnamon brown coloured colonies of Aspergillus terreus and yellow green colonies of Aspergillus flavus|
Click here to view
|Figure 4: Rough condiophore ending in a vesicle covered by two layers of phialides (biseriate) bearing conidia all around the vesicle of Aspergillus flavus|
Click here to view
|Figure 5: (a and b) Smooth condiophore ending in a vesicle covered by two layers of phialides (biseriate) bearing conidia only on the upper two-third area of the vesicle of Aspergillus terreus|
Click here to view
| ~ Discussion|| |
The predisposition for burn and trauma victims to develop cutaneous aspergillosis likely involves physical cutaneous barrier disruption and depression of several host defence mechanisms, such as impaired or decreased phagocytosis, bacterial flora disturbances from the use of systemic antimicrobial agents and hyperglycemia from hyperalimentation. The development of PCA requires a disruption of both mechanical and immunologic barriers. As long as this mechanical barrier remains intact, PCA is infrequent, even if the patient is severely immunosuppressed. Mechanical integrity of the skin may be lost due to trauma (accidental, surgical or burn) or by maceration (sustained heat and moisture in a semi-occlusive environment). Therefore, it seems likely that integrity of skin epithelial barrier is the most important risk factor for PCA. Moreover, trauma leads to an initial strong Th 1 inflammatory reaction, which leads to an overproduction of acute phase reactants such as interleukin 1 (IL-1), IL-6 and tumour necrosis factor (TNF) α, which is followed by an anti-inflammatory Th 2 response as means of compensation. This manifests as reduced production of TNF α, impaired monocyte function and a state of partial or complete immune paralysis.  Broad spectrum antibiotic use in trauma patients may also predispose them for developing opportunistic fungal infections.
Cutaneous aspergillosis infects the wounds usually 50 days to 60 days after injury.  It is caused mainly by A. flavus and A. fumigatus in both immunocompromised and non-immunocompromised patients.  In a 10 year study of cutaneous aspergillosis at Postgraduate Institute of Medical Education and Research, Chandigarh, A. flavus was the most common species.  Cutaneous infections due to A. terreus are particularly rare. ,
Paediatric trauma leading to PCA is a relatively uncommonly reported disease entity, although cutaneous aspergillosis cases are known in neonates and have been also reported as outbreaks in certain neonatal wards. Martin et al. reported growth of A. fumigatus in a 6-year-old boy and 2-year-old girl child, both suffering from major pulmonary trauma along with multiple injuries.  Ozer et al. from Turkey reported A. terreus infection in a 7-year-old boy with an open tibial fracture following an accident during agricultural activity.  Children who are trauma victims are otherwise healthy whose immune system is not as well developed as adults and due to the additional stress of multiple injuries leading to relative immune-paralysis, develop PCA. Therefore, the girl child in our case was also healthy before the traumatic injury, but subsequently during the course of treatment of de-gloving injury involving large surface area of body developed PCA after about 50 days of injury. The infection probably either came from the spores present in the soil at the time of accident or subsequently during the child's stay in the hospital probably from the environmental air.
An extensive search of literature revealed that this is probably the first case of PCA caused by two different species of Aspergillus viz. A. flavus and A. terreus in a paediatric trauma victim. It is therefore essential to maintain a high index of suspicion. The different antifungal susceptibility of both species could result in treatment failure if proper identification of both moulds was not carried out in time. Given the extensive area of involvement, and the excellent response to treatment, we feel that prompt diagnosis and management of such cases can salvage the limbs in severe trauma cases.
| ~ References|| |
|1.||van Burik JA, Colven R, Spach DH. Cutaneous aspergillosis. J Clin Microbiol 1998;36:3115-21. |
|2.||Walmsley S, Devi S, King S, Schneider R, Richardson S, Ford-Jones L. Invasive Aspergillus infections in a pediatric hospital: A ten-year review. Pediatr Infect Dis J 1993;12:673-82. |
|3.||Chakrabarti A, Gupta V, Biswas G, Kumar B, Sakhuja VK. Primary cutaneous aspergillosis: Our experience in 10 years. J Infect 1998;37:24-7. |
|4.||Stone HH, Cuzzell JZ, Kolb LD, Moskowitz MS, McGowan JE Jr. Aspergillus infection of the burn wound. J Trauma 1979;19:765-7. |
|5.||Ozer B, Kalaci A, Duran N, Dogramaci Y, Yanat AN. Cutaneous infection caused by Aspergillus terreus. J Med Microbiol 2009;58:968-70. |
|6.||Collee JG, Diguid JP, Fraser AG. Mackie and McCartney Practical Medical Microbiology. 14 th ed. Edinburgh: Churchill Livingstone; 1996. |
|7.||Tschoeke SK, Ertel W. Immunoparalysis after multiple trauma. Injury 2007;38:1346-57. |
|8.||Lass-Flörl C, Griff K, Mayr A, Petzer A, Gastl G, Bonatti H, et al. Epidemiology and outcome of infections due to Aspergillus terreus: 10-year single centre experience. Br J Haematol 2005;131:201-7. |
|9.||Steinbach WJ, Benjamin DK Jr, Kontoyiannis DP, Perfect JR, Lutsar I, Marr KA, et al. Infections due to Aspergillus terreus: A multicenter retrospective analysis of 83 cases. Clin Infect Dis 2004;39:192-8. |
|10.||Martin EB, Gastañaduy PA, Camacho-Gonzalez AF, Ross AC, Hebbar K. Primary cutaneous aspergillosis in two pediatric trauma patients. Pediatr Infect Dis J 2012;31:427-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]