UNASSIGNED: Fungal infections in neonates, particularly primary cutaneous aspergillosis (PCA), pose significant risks to premature infants with very low birth weight. This report chronicles the case of a 22-week gestational age female, with a birth weight of 430 g, who developed extensive cutaneous aspergillosis leading to extremity compartment syndrome- a first in the medical and surgical literature.
METHODS: A female micro preemie born at 22 weeks and 2 days was critically ill during her first week of life. On first day of life, attempts were made to establish intravenous access in all extremities. Eventually, the neonatal team established a peripherally inserted central catheter (PICC) in the left upper extremity. She had surfactant therapy due to lung immaturity and was on high frequency oscillatory ventilation. A large patent ductus arteriosus was treated soon after birth with intravenous acetaminophen. On day seven of life, she developed skin blisters rapidly progressing to necrotic eschars, particularly on the right lower extremity, leading to compromised limb circulation. Consultations with pediatric surgery and orthopedics one week later resulted in bedside medial and lateral escharotomies to salvage the limb. Tissue biopsy confirmed Aspergillus species, prompting a dual antifungal treatment with liposomal Amphotericin B and Voriconazole. The lesions gradually resolved with diligent wound care and aggressive physical therapy, yet a residual contracture of the right foot\'s dorsal area persisted, necessitating splinting.
UNASSIGNED: Over the course of treatment, her cutaneous lesions resolved, and no further debridement was required. Aggressive physical therapy was initiated for residual contractures that the infant developed due to full thickness necrosis of the cutaneous infection. Due to concurrent pulmonary complications and tracheomalacia, surgical intervention for the contracture has been postponed.
CONCLUSIONS: This case highlights the critical importance of early detection and treatment of PCA in preterm infants, the challenges in managing complex cases in the NICU and the need for a multidisciplinary approach to care.

Select Aspergillus species can produce oxalate as a fermentation byproduct, which may react with calcium ions to produce insoluble calcium oxalate crystals in tissues. These crystals are frequently associated with pulmonary Aspergillus infections, yet are rarely described in primary cutaneous aspergillosis. Herein, we report the presence of calcium oxalate crystals detected on cutaneous specimens from primary cutaneous Aspergillus niger and Aspergillus fumigatus infections in an immunocompromised, premature infant. No metabolic sources of oxalosis were found.

UNASSIGNED: Aspergillosis is an uncommon fungal infection in which primary cutaneous sites are very rare, and most cases occur in patients with immunocompromised status. Although primary cutaneous aspergillosis is usually encountered in immunocompromised patients, it also occurs in immunocompetent individuals.
UNASSIGNED: We report a case of primary cutaneous aspergillosis in a 46-year-old immunocompetent woman with diabetes mellitus after tattooing. She presented with erythematous papules, papulopustules and a plaque on the right lower limb of more than two years duration which had failed to respond to antihistamine treatment. Histological examination of a skin biopsy sample showed oval spores in the corneous layer, a slightly thickened epidermis, and infiltrating lymphocytes and neutrophils around the blood vessels in the superficial dermis. Aspergillus fumigatus was isolated and identified in cultures. Clinical and biological examinations did not reveal any systemic localization of aspergillosis, ruling out a hypothesis of blood dissemination. Lesions resolved completely after systemic antifungal treatment with itraconazole.
UNASSIGNED: Clinical lesions of primary cutaneous aspergillosis are nonspecific and usually present as a variety of lesions, including macules, papules, nodules, plaques, purpura, blood blisters, and pustules. The nonspecific features and variety of lesions can lead to misdiagnosis and delayed treatment. Direct microscopy, microbiological culture, and histopathological examination are helpful for diagnosing primary cutaneous aspergillosis. Moreover, the physicians should be aware of the possibility of Aspergillus infection in tattooed cases.

Aspergillosis is a systemic fungal infection that commonly affects immunocompromised individuals and, less frequently, immunocompetent individuals. It is the most common opportunistic fungal disease after candidiasis. This is primarily a pulmonary infection and can also involve other body sites like paranasal sinuses and cutaneous tissues. Aspergillus fumigatus , Aspergillus niger , and Aspergillus flavus are the common species infecting humans. Primary cutaneous aspergillosis (PCA) is usually caused by A. flavus and A. fumigatus . It is commonly seen in immunocompromised patients such as those suffering from diabetes, malignancies, tuberculosis, human immunodeficiency virus, or patients on long-term steroids and antibiotics. In this article, we report a case of PCA, in the immediate postoperative period, following a road traffic accident, in an immunocompetent patient. This posed a diagnostic challenge to the treating physicians. A. flavus was confirmed with 10% potassium hydroxide mount, lactophenol cotton blue, and growth on Sabouraud dextrose agar from tissue culture sample. Antifungal treatment was initiated with oral itraconazole 200 mg after performing antifungal susceptibility testing based on Clinical and Laboratory Standards Institute guidelines. The patient\'s condition improved and was discharged. Thus, early detection of PCA combined with medical and surgical intervention can successfully eradicate infection and help in preventing disseminated aspergillosis.

We describe a case of primary cutaneous aspergillosis caused by Aspergillus fumigatus, and elucidate the underlying genetic and immunological mechanisms.
Routine clinical and laboratory investigations were performed. Whole-exome sequencing of the patient\'s DNA suggested the presence of a CARD9 mutation, which was confirmed by Sanger sequencing. Innate and adaptive immunological responses of patient-derived CARD9-deficient cells were evaluated with ELISA and flow cytometry. Cutaneous and pulmonary aspergillosis models were established in Card9 knockout (KO) mice, which were compared with wild-type and immunosuppressed mice, to explore the pathogenesis and Aspergillus susceptibility.
A 45-year-old man presented with a 37-year history of skin lesions on his face. A diagnosis of primary cutaneous aspergillosis was made through histopathology, immunohistochemistry, and tissue culture. Sanger sequencing of CARD9 showed a homozygous frame-shift mutation (c.819_820insG, p.D274fsX60), which led to the lack of CARD9 expression. Peripheral blood mononuclear cells from the patient showed selective impairment of proinflammatory cytokines, and Th1-, Th17-, and Th22-associated responses upon fungus-specific stimulation. The cutaneous aspergillosis model established in Card9 KO mice presented with persistent infection, with fungal germs and short hyphae in tissue, consistent with the patient\'s lesions. Skin lesions in immunosuppressed mice were more severe, and led to death. Unlike our patient, Card9 KO mice were relatively susceptible to pulmonary aspergillosis, with reasons to be investigated.
This is, to our knowledge, the first report that links cutaneous aspergillosis to CARD9 mutation. This work enriches both the phenotypic spectrum of CARD9 deficiencies and the genetic background of cutaneous aspergillosis.

Primary cutaneous aspergillosis is a rare, life-threatening fungal infection in premature infants. We report a case of primary cutaneous aspergillosis caused by Aspergillus tamarii in an extremely low birthweight infant. The infant was delivered by cesarean section with complications from an intrauterine infection, brain intraventricular hemorrhage, tension pneumothorax and cardiac tamponade. On the 12th day of life, he developed erythematous maceration with erosion on his back. Septate hyphae were detected on two occasions from specimens of the skin lesion. The manifestations of the colony and slide culture showed the characteristics of A. tamarii. The nucleotide sequences of internal transcribed spacer regions of the ribosomal RNA gene, partial sequences of β-tubulin and calmodulin gene were compatible with those of A. tamarii. Of the known Aspergillus species, Aspergillus fumigatus and Aspergillus flavus have been reported in previous studies as the major causative agents in primary cutaneous aspergillosis, whereas human infection by A. tamarii is rare. We consider that A. tamarii is important as an unusual opportunistic human pathogen among premature infants.