Primary Cutaneous Aspergillosis as a Healthcare-Associated Infection: A Case Report

Primary cutaneous aspergillosis (PCA) is an infection of the skin and soft tissues caused by fungi of the genus Aspergillus, with rare secondary systemic involvement. It occurs predominantly in immunosuppressed patients, but in immunocompetent individuals it may arise after exposure to a large fungal inoculum, with or without disruption of the skin barrier. We report a case of PCA in a nosocomial context. A 46-year-old man with no relevant medical history was admitted to a tertiary trauma hospital after a workplace accident in a truck parking lot, where he was crushed between two trailers. On admission (day 0), he presented with fractures and dislocations, bilateral pneumothorax with right-sided hemothorax, and liver injuries. Because of suspected acute obstruction of the right popliteal artery, he underwent surgical revascularization and medial fasciotomy of the limb on day 1. After surgery, he was admitted to the intensive care unit (ICU), dependent on mechanical ventilation and hemodynamically unstable. After 7 days, debridement of ischemic muscle within the fasciotomy was performed at the bedside in the ICU. Over the following days, still dependent on invasive ventilatory and hemodynamic support, he required dialysis for refractory hyperkalemia. On day 14, vasoactive drugs were successfully weaned. On day 19, the team noted whitish-greenish plaques on the muscle surface of the right leg (photo 1). Direct microscopic examination of scrapings from the lesion revealed abundant fungal elements of the genus Aspergillus. Investigation for systemic fungal involvement was negative, and voriconazole was initiated. The patient required two additional surgical procedures on the limb for debridement of devitalized tissues. On day 31, he developed worsening ventilatory parameters and needed to restart vasoactive drugs, progressing to death hours later. Investigation into the source of infection identified two probable contributors: recent installation of an air-conditioning unit in the ICU cubicle where the patient was staying and construction work taking place outside the ICU. In this case, environmental exposure, together with major cutaneous barrier disruption and relative immunosuppression secondary to severe trauma and critical illness, triggered the event. Although PCA was not directly responsible for the fatal outcome, it was an easily preventable infection. This is one of the few reports of PCA as a healthcare-associated infection.