A mould in the fold should never grow old: cutaneous aspergillosis in a preterm neonate.

A boy born at 25 weeks of gestation (birth weight, 560 g) because of feto-fetal transfusion syndrome (mono-chorionic, di-amniotic gemini) was noticed to have multiple skin lesions on the abdomen, buttocks, and thighs on his ninth day of life (Figs. 1(A) and (B)). His mother and twin brother had no apparent skin abnormalities. Microbiological cultures from skin swabs and scrapings yielded the growth of moulds, suggestive of Aspergillus species (Figs. 1(C)–(G)). Matrix-assisted laser desorption/ ionization time-of-flight mass spectrometry confirmed Aspergillus fumigatus. Species identification was confirmed using partial sequencing of the β-tubulin gene, and testing using the European Committee on Antimicrobial Susceptibility Testing (EUCAST) reference method revealed full susceptibility for amphotericin B, voriconazole, and echinocandins. The patient was started on liposomal amphotericin B (L-AmB at 5 mg/kg/d). An investigation of surfaces and ambient air in the delivery room and neonatal intensive care unit, inside and outside of the incubator, yielded no source of infection. Surgical debridement was deemed unfeasible because of the immaturity and extent of the lesions. With the use of L-AmB, the patient developed paralytic ileus. Micafungin (10 mg/kg/d) was added because of lack of a clinical response. The lesions increased and showed invasive growth towards subcutaneous tissues (Figs. 1(H) and (I)). Intravenous voriconazole was added at 8 mg/kg/d (loading of 12 mg/kg) in two daily doses, with a target range of 2–6 mg/L. Referring to the results of therapeutic drug monitoring, the dose had to be increased to 14 mg/kg/d. With triple therapy, the skin lesions began to decrease. After 37 days of therapy, L-AmB was stopped, after which the paralytic ileus resolved. Micafungin was discontinued after 38 days of therapy. In his ninth week of life, debridement of a necrotic lesion on the abdominal wall revealed a subjacent ileal fistula, necessitating surgical intervention. After a total duration of 62 days of anti-fungal treatment, voriconazole (total days of therapy, 46) was stopped. The patient was without skin sequelae at follow-up at the uncorrected age of 8 months.