Aspergilosis diseminada con importante afectación cutánea / Disseminated aspergillosis with significant skin involvement

La Aspergilosis es una infección micótica oportunista que afecta principalmente a pacientes inmunodeprimidos con neutropenia, en quienes produce a menudo enfermedad invasiva de curso fulminante. Las manifestaciones cutáneas de la Aspergilosis son infrecuentes, apareciendo en el 5 a 10% de los casos diseminados. Comunicamos un caso de Aspergilosis en una mujer adulta con neutropenia severa por enfermedad hematológica, con afectación pulmonar y sinusal, que presenta múltiples lesiones ulceronecróticas en piel y mucosas, con evolución fatal. Las lesiones mucocutáneas de la Aspergilosis no son específicas, obligan a varios diagnósticos diferenciales y, como en este caso, la biopsia para estudio histopatológico y micológico es necesaria para el diagnóstico.

Aspergillosis is an opportunistic fungal infection that primarily affects immunocompromised patients with neutropenia, in whom invasive disease often results in fulminant course. Cutaneous manifestations of aspergillosis are rare, occurring in 5-10% of cases scattered. We report a case of aspergillosis in an adult woman with severe neutropenia for hematologic disease, lung and sinus disease, having multiple ulceronecróticas skin lesions and mucous membranes, with fatal outcome. The mucocutaneous lesions of aspergillosis are nonspecific, forcing several differential diagnoses, and as in this case, the biopsy for histopathological and mycological study is required for diagnosis.

Primary cutaneous aspergillosis and idiopathic bone marrow aplasia

Abstract: We describe the case of a 9-year-old boy with idiopathic bone marrow aplasia and severe neutropenia, who developed skin ulcers under cardiac monitoring electrodes. The diagnosis of primary cutaneous aspergillosis was made after the second biopsy and culture. Imaging investigation did not reveal internal fungal infection. The child was treated, but did not improve and died 3 months after admission. The report highlights and discusses the preventable risk of aspergillus skin infection in immunocompromised patients.

Aspergilosis traqueobronquial necrotizante en paciente crítico / Necrotizing tracheobronchial aspergillosis in an immunosuppressed patient. Report of one case

Necrotizing tracheobronchitis due to Aspergillus spp is a rare form of invasive aspergillosis. This infection is limited to or predominant in the bronchial tree. The clinical evolution is gradual: from mild non-specific manifestations of acute tracheobronchitis to severe acute respiratory insufficiency determined by a bronchial obstruction syndrome. We report a 38 years old female with systemic lupus erythematosus treated with methylprednisolone and cyclophosphamide. She developed an invasive aspergillosis, severe respiratory failure with predominant tracheobronchial damage and upper respiratory complications.

Success Rate and Risk Factors for Failure of Empirical Antifungal Therapy with Itraconazole in Patients with Hematological Malignancies: A Multicenter, Prospective, Open-Label, Observational Study in Korea

We assessed the success rate of empirical antifungal therapy with itraconazole and evaluated risk factors for predicting the failure of empirical antifungal therapy. A multicenter, prospective, observational study was performed in patients with hematological malignancies who had neutropenic fever and received empirical antifungal therapy with itraconazole at 22 centers. A total of 391 patients who had abnormal findings on chest imaging tests (31.0%) or a positive result of enzyme immunoassay for serum galactomannan (17.6%) showed a 56.5% overall success rate. Positive galactomannan tests before the initiation of the empirical antifungal therapy (P=0.026, hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.10-4.69) and abnormal findings on the chest imaging tests before initiation of the empirical antifungal therapy (P=0.022, HR, 2.03; 95% CI, 1.11-3.71) were significantly associated with poor outcomes for the empirical antifungal therapy. Eight patients (2.0%) had premature discontinuation of itraconazole therapy due to toxicity. It is suggested that positive galactomannan tests and abnormal findings on the chest imaging tests at the time of initiation of the empirical antifungal therapy are risk factors for predicting the failure of the empirical antifungal therapy with itraconazole. (Clinical Trial Registration on National Cancer Institute website, NCT01060462)

Hialohifomicosis cutánea en un paciente con leucemia linfoblástica / Cutaneous hyalohyphomycosis in a patient with acute lymphoblastic leukemia

Las infecciones fúngicas causadas por Aspergillus sp. y Candida sp. son causa importante de morbilidad y mortalidad en pacientes gravemente inmunodeficientes, especialmente en aquellos con neutropenia o receptores de trasplante de médula ósea o de órganos sólidos. Informamos sobre una hialohifomicosis cutánea en una mujer de 24 años de edad con leucemia linfoblástica.

Invasive fungal infections most frequently caused by Aspergillus sp. and Candida sp. are significant causes of morbidity and mortality in severely immunocompromised patients, especially those who are neutropenic or who have undergone bone marrow or solid-organ transplant. We report a case of cutaneous hyalohyphomycosis in a 24-year-old female with acute lymphoblastic leukemia.

Manifestaciín bucal de paracoccidioidomicosis asociada a aspergilosis: presentación de caso / Manifestaciín oral paracoccidioidomycosis associated with aspergillosis: a case report

Paracoccidioidomicosis y Aspergilosis son micosis causadas respectivamente por los hongos Paracoccidioides brasiliensis y Aspergillus fumigatus, que afectan con mayor frecuencia los pulmones y posteriormente se propagan para otras regiones del cuerpo. La asociación de estas dos micosis en pacientes que no presentaban inmunosupresión es poco común. Descripción de caso clínico resaltadas: Paciente de sexo masculino de 49 años, presentó lesión en el paladar, orofaringe y región retromolar. Los exámenes histológicos, citopatológicos y microbiológicos confirmaron el diagnóstico de paracoccidioidomicosis asociada a aspergilosis. Históricamente los hongos se han considerado como la causa de infecciones de relativa significancia; sin embargo, en los últimos años se ha visto un aumento importante de las enfermedades que causan. El reconocimiento del agente etiológico en cultivos es importante para poder implementar el tratamiento adecuado, ya que éstos pueden producir daños irreversibles o llevar a la muerte del paciente. El objetivo de este trabajo fue mostrar por medio del caso clínico de un paciente que presentaba las dos mucosis asociadas em mucosa bucal y orofaringe la necesidad de exámenes complementares para el diagnóstico de las enfermedades bucales cuando los exámenes de laboratorio de rutina indican la presencia de enfermedades asociadas

Paracoccidioidomycosis and aspergillosis are, respectively, mycosis caused by Paracoccidioides brasiliensis and Aspergillus fumigatus fungi, which, most frequently, attack the lungs and later spread to other body regions. The association between both mycosis is rare in patients that do not present immunosuppression. A 49-year-old man presented with oral lesion, besides lesions on palatum, retromolar and oropharyngeal regions. Histopathological and microbiological exams confirmed the diagnosis of paracoccidioidomycosis associated to aspergillosis. Historically, fungi have been considered as the cause of relatively important infections, but, in the last years, a significant increase of diseases caused by fungi is evidenced. The recognition of the etiological agent in culture is important for the suitable treatment, once these fungi can cause irreversible damages or even death. The purpose of this study was to demonstrate, through the case of a patient who presented both mycosis associated, the need of complementary exams for the diagnosis of oral diseases, when routine laboratorial exams indicate the presence of another disease associated

A Congruous Superior Quadrantanopsia Following a Junctional Scotoma Induced by Asperogillosis

A 69-year old man presented to us with decreased vision in his right eye and a relative afferent pupillary defect. Under the presumption that he was suffering from retrobulbar optic neuritis or ischemic optic neuropathy, visual field tests were performed, revealing the presence of a junctional scotoma. Imaging studies revealed tumorous lesions extending from the sphenoid sinus at the right superior orbital fissure, with erosion of the right medial orbital wall and optic canal. Right optic nerve decompression was performed via an endoscopic sphenoidectomy, and histopathologic examination confirmed the presence of aspergillosis. The patient did not receive any postoperative antifungal treatment; however, his vision improved to 20 / 40, and his visual field developed a left congruous superior quadrantanopsia 18 months postoperatively. A junctional scotoma can be caused by aspergillosis, demonstrating the importance of examining the asymptomatic eye when a patient is experiencing a loss of vision in one eye. Furthermore, damage to the distal optic nerve adjacent to the proximal optic chiasm can induce unusual congruous superior quadrantanopsia.

Estudio de costo del tratamiento de la aspergilosis invasora en pacientes oncológicos pediátricos: Santiago. Chile / Economical evaluation of the treatment of invasive aspergillosis in pediatric oncology patients: Santiago. Chile

Introducción: La aspergilosis invasora (AI) es una infección oportunista grave en pacientes inmunocompro- metidos. Pacientes receptores de transplantes y oncológicos representan el grupo de mayor riesgo. El tratamiento antifúngico involucra hospitalización prolongada y altos recursos económicos. Objetivo: Estimar los costos involucrados en el tratamiento de la AI como complicación intercurrente en pacientes con cáncer. Pacientes y Método: Estudio caso-control, retrospectivo. Estima el costo del tratamiento de AI en pacientes pediátricos oncológicos del Hospital Luis Calvo Mackenna durante los años 2007 y 2008. Resultados: Se incluyeron 13 pacientes con AI y sus respectivos 13 controles. El costo atribuible de la hospitalización en aquellos pacientes que cursaron con AI fue de US $23.600. El costo atribuible para cada indicador fue: US $16.500 para días de hospitalización; US $7.000 para medicamentos antifúngicos y US $100 para galactomanano sérico. Discusión: En este estudio, el costo del tratamiento de AI se debe principalmente a la estadía hospitalaria y fármacos antifúngicos. Encontramos tres pacientes que desarrollaron AI estando en ambiente protegido.

Introduction: Invasive aspergillosis (IA) is a serious opportunistic infection in immunocompromised patients. Transplant recipients and patients with cancer represent the highest risk group. The antifungal treatment involves prolonged hospitalization and high economic resources. Objective: to estimate costs represented by IA as an intercurrent complication of oncologic treatment. Patients and Method: Retrospective case-control study. Estimation of the cost of treatment in pediatric oncologic patients with IA in the Hospital Luis Calvo Mackenna during the years 2007-2008 was done. A control for each case of IA paired by sex, age, number of diagnosis and clinical department was selected. Results: There were 13 patients during the observation period. The attributable cost of treatment of aspergillosis was US $ 23,600 and the cost for each indicator was: hospital days US $ 16,500; antifungal therapy US $ 7,000; and serum galactomannan US $ 100. Discussion: In this study, the cost of treating IA is mainly due to hospitalization and antifungal medications. Three patients acquired IA in spite of staying in a protected environment.

Surgical Treatment of Native Valve Aspergillus Endocarditis and Fungemic Vascular Complications

Systemic infection with Aspergillus is an opportunistic disease that affects mainly immunocompromised hosts, and is associated with a high mortality rate. It typically occurs in patients with several predisposing factors, but Aspergillus endocarditis of native valves is rare and experience in diagnosis and treatment is limited. We report a case of native valve endocarditis caused by Aspergillus. A 35-yr-old male patient who underwent pericardiocentesis four months previously for pericardial effusion of unknown etiology presented with right leg pain and absence of the right femoral artery pulse. Cardiac echocardiography revealed severe mitral insufficiency with large mobile vegetations, and computed tomographic angiography showed embolic occlusion of both common iliac arteries. We performed mitral valve replacement and thromoembolectomy, and Aspergillus was identified as the vegetation. We started intravenous amphotericin B and oral itraconazole, but systemic complications developed including superior mesenteric artery aneurysm and gastrointestinal bleeding. After aggressive management, the patient was discharged 78 days post surgery on oral itraconazole. He was well at 12 months post discharge but died in a traffic accident 13 months after discharge.

Aspergilosis sinusal no invasiva por Aspergillus parasiticus en niño inmunocomprometido / Non invasive sinusal aspergillosis by Aspergillus parasiticus in an immunecompromised child

El presente trabajo tiene la finalidad de exponer un caso clínico de un niño inmunosuprimido con antecedentes de hospitalización previa, a los 6 años de edad con múltiples síntomas y signos (poliadenopatías, desnutrición, sepsis en cavidad bucal y foco pulmonar, además de pancitopenia). Permaneció en terapia intermedia durante 38 días, cumpliendo varios esquemas antibióticos sin buena respuesta a los mismos. Fue derivado al Hospital Ricardo Gutiérrez (Buenos Aires) desconociéndose la terapéutica seguida en esa oportunidad. Cinco años después (2007) es ingresado nuevamente a nuestro hospital por cuadro de epistaxis cefaléa, compromiso del estado general y neutropenia febril, por lo que se inicia tratamiento antibiótico, además de estudio con mielograma confirmándose el diagnóstico de leucemia linfocítica aguda. Cinco días después de su ingreso expulsa espontáneamente, desde las fosas nasales material granulomatoso el cual fue enviado a estudio micológico (examen directo y cultivo), detectándose alta presencia de Aspergillus parasiticus en ambos exámenes, lo cual fue ratificado por histopatología como una aspergilosis sinusal no invasiva. El paciente fue remitido a la Sala de Inmunodeprimidos donde recibió tratamiento intravenoso con 350 mg/día de anfotericina B-complejo lipídico y terapia específica para LLA. Presentó una evolución tórpida y al 12º día el paciente falleció por su mal estado general y progresión terminal de su enfermedad de base.

This present paper is meant to reveal the clinical case of an immunesuppressed boy having been previously in a hospital, when he was 6, showing multiple symptoms and signs (polyadenopaties, malnutrition, buccal sepsis and pulmonary focus, in addition to pancitopia). He stayed under intermediate therapy for 38 day being submitted to varied antibiotic schemes, though yielding no satisfactory responses to them. Later on he was derived to the Hospital Ricardo Gutiérrez (Buenos Aires), yet therapeutics used at that place being unknown. Five years later (2007), he is admitted again in our hospital because of cephalea epistaxis, a compromised health condition and fevered neutropenia, so he is given an antibiotic treatment in addition to a mielographic studyyet it is confirmed the diagnosis of an acute lymphocytic leukemia. Five days after his admittance, he discharges granulomatous matter from his nasal cavities which was sent for a mycological study. Direct exam and culture, detecting high presence of Aspergillus parasiticus on both exams which was ratified by histopathology as a non invasive sinusal aspergillosis. The patient was sent to the Immunedepressed Ward where he received intravenous treatment with 350mg/day anfotericina Blipidic complex and a specific therapy for LLA. He had a torpid evolution and on the 12nd day the patient died as a result of his very bad health condition as well as the terminal progression of his base disease.

Aspergilosis esfenoidal, una sospecha poco habitual / Sphenoid aspergillosis, an unusual suspect

La enfermedad aislada del seno esfenoidal constituye sólo el 2%-3% de toda la patología sinusal y en la mayoría de los pacientes es de tipo inflamatorio. Asimismo, es poco frecuente la Invasión fúngica de dicho seno esfenoidal en un individuo sano e inmunocompetente, siendo extremadamente rara en niños. Nos planteamos recordar esta patología haciendo presentación de nuestra última experiencia y obtener conclusiones para mantener siempre un espectro amplio en cuanto a los diagnósticos diferenciales a tener en cuenta. El presente caso clínico expone la experiencia vivida en nuestro centro con una patología poco frecuente como es la aspergilosis esfenoidal aislada, con los antecedentes personales, características clínicas, métodos diagnósticos, pronóstico y tratamientos óptimos. Presentamos el caso de un varón de 73 años con historia de cefaleas intensas de larga evolución inicialmente sensibles a tratamiento analgésico, de localización retroocular bilateral, y que en los últimos 2 meses se hacen resistentes al tratamiento y comienzan a irradiarse a región naso-frontal derecha con mayor intensidad y con isonofobia, fotofobia, cortejo neurovegetativo, pérdida de peso, dolor cervical frecuente, intenso prurito ocular y ocasionalmente visión borrosa. Sin rinorrea, fiebre, ni ningún otro síntoma propio de un cuadro infeccioso. Los síntomas iniciales de la enfermedad del seno esfenoidal son poco precisos, de instauración insidiosa y crónica, y difíciles de caracterizar. Hasta el 70%, se manifiestan por alteraciones visuales que generalmente, Indican complicaciones inmediatas. Está asociada a peor pronóstico que en otras localizaciones por la posible extensión intracraneal precoz. Así, podemos considerar que la aspergilosis fulminante de senos paranasales en general, y del seno esfenoidal particularmente, representa una importante causa de morbi/mortalidad en pacientes cuyo estado inmunitario es deficiente, pero actualmente el patrón...

Isolated sphenoid sinus disease represents only 2-3% of the total sinus pathology and when it is present, it usually has an inflammatory origin. It seldom affects an immunocompetent person, and it is very rare in children. Our goal is to draw attention to this pathology introducing our recent experience, and to draw conclusions in order to always bear in mind a wide spectrum of possible differential diagnoses. We present the clinical experience at our hospital with a rare pathology such as isolated sphenoidal aspergillosis, reviewing the patient's personal background, clinical features, diagnosis techniques, prognosis and optimal therapy. Our patient is a 73-year-old male with long-term intense headache located in the frontal and periocular regions. Initially, common analgesics were strong enough to relieve the pain, but eventually it became more and more intense, with no response to medication. In addition, he presented cervical pain, photophobia, sonophobia, weight loss, ocular tingling and blurred vision. There was no rhinorrea, fever, or any other infectious symptom. Initial sphenoid sinus pathology symptoms are not very precise, with a latent and chronic set up, and theyare also hard to characterize. Up to 70% of patients show visual disturbances, which generally derive in immediate complications. Prognosis is worse than in other location because of early intracranial dissemination. Thus, sphenoid aspergillosis can be considered as being a potentially lethal disease in immunodeficient patients, but nowadays, fungal behavior is changing. This was the case here, as the patient remained immunocompetent.

Recurrent respiratory papillomatosis complicated by aspergillosis: a case report with review of literature.

Pulmonary extension of recurrent invasive papillomatosis often poses a diagnostic challenge to the examining bronchoscopist, pathologist, radiologist and surgeon, in distinguishing it as a benign lesion that is confined to the mucosa and extending along the branches of the tracheobronchial tree from true invasion of a malignant tumor. We document here a case of recurrent invasive respiratory papillomatosis which initially presented as a laryngeal papilloma. After multiple recurrences, the patient presented with bronchopulmonary involvement, complicated by invasive aspergillosis in a non-immunocompromised setting.

case of invasive aspergillosis in a patient with no identifiable immunodeficiencies

Invasive fungal infections usually affect patients with immunodeficiencies and very rarely patients with no known or identifiable risk factors. Diagnosis could be delayed in patients without previously known immunodeficiencies due to a low index of suspicion, leading to a delay in treatment and a potential poor outcome. We report a case of a postpartum woman with no history of immuno-compromised disease who developed left hemiparesis with evidence of invasive aspergollosis affecting the nervous system, and leading to fatal outcome. The patient had a mass-like lesion in the neuroimaging with soft tissue shadowing in the chest x-ray leading to initial diagnosis of tuberculosis. The brain biopsy showed changes consistent with a diagnosis of aspergillosis. The source of the aspergillus infection was not clear. Aspergillus infection should be considered in patients with no identifiable immunodeficiencies who have abnormal brain imaging and chest x-ray, as early treatment may alter the outcome

Association of Cholesterol Granuloma and Aspergillosis in the Sphenoid Sinus

Cholesterol granuloma (CG) is usually associated with chronic middle ear disease, and is not common in the paranasal sinuses. Additionally, it is very rare for cases of CG to be associated with a fungal infection. However, in this paper, we report a case of sphenoid sinus CG that is associated with aspergilloma in a 78-year-old male patient who presented with right hemifacial pain, headache and toothache. CT revealed the presence of an expansile cystic mass lesion in the sphenoid sinus that showed a high signal intensity on both the T1 and T2 weighted images. This mass was later determined to be CG. The suspected etiologic mechanisms of both CG and aspergilloma of the paranasal sinuses are similar, and impaired drainage and obstruction of the ventilation of the paranasal sinuses are considered to be the causative mechanism of both diseases. Overall, the results of this study indicate that the use of MRI findings could be helpful for differentiating CG from other paranasal sinus mass lesions.

Aspergillus iris granuloma in a young male: a case report with review of literature.

Endogenous aspergillosis is a rare occurrence. Endogenous Aspergillus endophthalmitis is a rare but devastating infection usually associated with disseminated aspergillosis or with intravenous drug abuse. We report a case of an isolated Aspergillus iris granuloma in a young immunocompetent male patient with review of the literature.

Galactomannan antigenemia for the diagnosis of invasive aspergillosis in neutropenic patients with hematological disorders.

OBJECTIVES: Invasive aspergillosis (IA) is among the most common invasive fungal infections in neutropenic patients with hematological disorders in the authors' institution, King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand Previous studies have reported the Aspergillus galactomannan enzyme immunosorbent assay (GMEIA) may be a useful diagnostic tool for IA. The authors evaluated the performance of the GM EIA for the diagnosis and monitoring of the course of IA in KCMH. MATERIAL AND METHOD: The authors prospectively performed the study from June 2002 to January 2004 in a consecutive series of adult neutropenic patients with hematological disorders who were at risk for developing IA. During hospitalization, serum galactomannan levels were measured once or twice weekly using the Platellia Aspergillus EIA test kit. The sensitivity and specificity of the GM EIA were calculated according to the proportion of patients with true and false positive and negative tests. RESULTS: There were 50 treatment episodes in 44 patients with 5 proven, 12 probable, and 33 possible or no IA. The cutoff GM index of > 0.75 was determined with a sensitivity of 94.1% and a specificity of 78.8%. There was a close relationship between clinical outcome and the kinetics of GM indices. CONCLUSION: The GM EIA is a useful diagnostic toolfor the diagnosis and monitoring of the course oflA in the presented institute.