Successful Treatment of Primary Cutaneous Aspergillus Ustus Infection in Post-Allogeneic Stem Cell Transplant Patient

Cutaneous Aspergillus ustus is a rare infection described in immunocompromised hosts with sparse literature on effective treatment options. We present a case of successfully treated cutaneous A. ustus infection in an allogeneic hematopoietic cell transplant (HCT) recipient with severe acute graft-vs-host disease (GVHD). This case highlights the need for careful dermatologic surveillance and vigilance in the care of allogeneic HCT recipients with impaired skin function, occlusive dressings, or sites of trauma, and describes a potentially useful treatment regimen in this setting. A 36 year-old woman underwent allogeneic HCT from an HLA-mismatched unrelated donor after myeloablative conditioning to treat Philadelphia-chromosome-positive acute lymphoblastic leukemia. She developed Stage IV acute GVHD of the skin and gut on Day +19, with 6 liters of diarrhea daily and 100% skin involvement with bullae and diffusely denuded skin. Skin care was provided according to a burn protocol, with full-body topical steroid ointment and occlusive dressings changed every 3 days. Skin GVHD resolved within 30 days of treatment initiation. On Day +43, at a prior urinary catheter securement site, ulcerated lesions were noted which progressed to eschar. Skin biopsy and culture isolated angioinvasive Aspergillus ustus. Treatment was initiated with amphotericin B and oral and topical terbinafine, and repeated local debridement. Immunosuppressive therapies were weaned as tolerated. Aspergillusgalactomannan levels were tested serially and mirrored the clinical course. After 3 months of therapy, the ulcerated skin lesions resolved completely and there have been no new areas of cutaneous fungal disease. The patient was discharged from the hospital on IV amphotericin B and oral terbinafine. Aspergillus ustus is a rare cause of angioinvasive fungal skin infections in immunocompromised patients. There is no standard treatment approach, and outcomes reported in the literature are poor. This case illustrates the potential for successful treatment of this infection following prompt recognition, even in a patient with severe GVHD on multiple immune suppressive medications.