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1</a>A&#41;&#46; One of the lesions on the lateral surface of his left elbow was a tense 1&#46;5-cm blister containing blood-stained pus with a fluid level &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The patient reported no other symptoms&#46; The onset of these lesions coincided with a progressive increase in serum galactomannan levels&#44; which rose from previously undetectable levels to a level of 0&#46;9&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the patient&#39;s condition and the general clinical picture&#44; skin biopsy samples were taken for histology and microbial culture&#46; Histologic examination of the elbow lesion showed a purulent subepidermal blister and an underlying infiltrate composed of abundant polymorphonuclear leukocytes that caused notable tissue destruction&#44; with weakened structures&#44; collagen bundles with an unstructured appearance&#44; and effacement of adnexal structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Higher magnification and periodic acid-Schiff &#40;PAS&#41; staining showed septate linear structures with dichotomous acute-angle &#40;45&#176;&#41; branching throughout the dermis and extending into the more superficial areas of the subcutaneous tissue&#46; These structures had an approximate diameter of 3<span class="elsevierStyleHsp" style=""></span>&#956;m and a length of up to 80<span class="elsevierStyleHsp" style=""></span>&#956;m in some sections and were consistent with hyalohyphomycosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Culture in Sabouraud agar produced <span class="elsevierStyleItalic">Aspergillus flavus</span>&#44; which was sensitive to voriconazole and echinocandins in the ETEST &#40;Biom&#233;rieux&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Intensive antifungal treatment was initiated with voriconazole &#40;loading dose of 400<span class="elsevierStyleHsp" style=""></span>mg followed by a maintenance dose of 200<span class="elsevierStyleHsp" style=""></span>m&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and intravenous anidulafungin &#40;loading dose of 200<span class="elsevierStyleHsp" style=""></span>mg followed by 100<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Three days later&#44; the patient developed right hemiparesis&#46; In the staging study&#44; the chest computed tomography &#40;CT&#41; scan showed previously undetected cavitated lesions in the right upper lobe of the lung &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; The brain CT scan showed 2 nonvascular frontal lesions consistent with a stroke secondary to infection &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; We decided to escalate the treatment to intravenous amphotericin B &#40;400<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h adjusted to the patient&#39;s weight&#41;&#46; After 7 days&#44; however&#44; the patent developed severe dyspnea requiring oxygen support&#44; aphasia&#44; and general deterioration of health&#46; A second brain scan showed multiple lesions similar to the lesions on the first scan but involving the entire brain parenchyma&#46; The patient died as a result 2 days later&#46; The family did not agree to an autopsy and we were therefore unable to collect brain tissue for microbiologic analysis&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Aspergillus</span> species are members of the eumycetes and are widely distributed in the environment&#46; They are opportunistic pathogens that pose a particular threat to immunosuppressed individuals&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> particularly those with neutropenia&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The most common species are <span class="elsevierStyleItalic">Aspergillus fumigatus</span> and <span class="elsevierStyleItalic">A&#160;flavus&#46;</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Aspergillus</span> species are ubiquitous in soil and vegetation&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Although aspergillosis mainly affects the lungs&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> it can also affect the liver&#44; brain&#44; and skin&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Between 5&#37; and 27&#37; of invasive aspergillosis cases involve the skin&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;6</span></a> Cutaneous aspergillosis can be primary or secondary&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7</span></a> and these forms can be distinguished by the location and extension of lesions&#44; which are widespread in secondary infections&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3&#44;7</span></a> Secondary cutaneous aspergillosis generally originates from the lungs&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> but it can also originate from the paranasal sinuses or the upper respiratory tract&#44; although these forms are much less common&#46; Primary aspergillosis is generally caused by direct skin inoculation through wounds from contaminated objects&#44; intravenous lines<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> at venipuncture sites on the arms&#44; or even through dressings covering areas of macerated skin or catheters in patients requiring invasive procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinically&#44; aspergillosis manifests as erythematous papules and macules that progress to nodules<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and eventually to ulcers with areas of central necrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;7</span></a> Blisters are uncommon and may&#44; as in our case&#44; contain pus&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Standard diagnostic procedures are the potassium hydroxide technique &#40;or similar&#41; and an incisional skin biopsy with sufficient depth&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7</span></a> Histology shows septate hyphae measuring 3 to 5<span class="elsevierStyleHsp" style=""></span>&#956;m in diameter and 50 to 100<span class="elsevierStyleHsp" style=""></span>&#956;m in length&#44; 45&#176; branching&#44; absence of blistering with PAS or Gomori methenamine silver stains&#44; and abundant polymorphonuclear cells involving the entire wall&#44; with angiocentric necrosis in many cases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Serum galactomannan levels should always be tested when aspergillosis is suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> A progressive increase to a level over 0&#46;5 in serial measurements points to a diagnosis of invasive bronchopulmonary or systemic aspergillosis&#44; particularly in immunosuppressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleItalic">Aspergillus</span> infection is confirmed by polymerase chain reaction&#46; Treatment consists of amphotericin B &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47; 24<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; combined with echinocandins &#40;50-100<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; or voriconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Debridement of necrotic lesions and rapid restoration of immunity are important&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We have presented a case of pustular cutaneous aspergillosis in an immunosuppressed patient&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fonda-Pascual P&#44; Fern&#225;ndez-Gonz&#225;lez P&#44; Moreno-Arrones OM&#44; Miguel-G&#243;mez L&#46; Aspergilosis cut&#225;nea secundaria pustulosa en paciente inmunosuprimido&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;287&#8211;290&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation&#46; A&#44; Painless erythematous nonfluctuant nodule on the left abdominal flank&#46; B&#44; Pustule containing blood-stained pus with a fluid level on an indurated erythematous base&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histologic features of the pustule following incisional biopsy&#46; A&#44; Large subepidermal blister with major underlying tissue destruction affecting the entire dermis and subcutaneous tissue &#40;hematoxylin-eosin staining&#44; original magnification &#215;<span class="elsevierStyleHsp" style=""></span>20&#41;&#46; B&#44; Dense neutrophilic infiltration with destruction of dermal collagen and associated vasculitis &#40;hematoxylin-eosin original magnification &#215;100&#41;&#46; C&#44; Detail showing dense neutrophil infiltration in the dermis and around barely perceivable filamentous structures &#40;hematoxylin-eosin&#44; original magnification &#215;200&#41;&#46; D&#44; Higher magnification and periodic acid-Schiff &#40;PAS&#41; staining showing septate linear structures with acute-angle branching consistent with the clinical and microbiologic diagnosis of cutaneous aspergillosis &#40;PAS &#215;40&#44; original magnification &#215;400&#41;&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiologic study after 3 days&#46; A&#44; Cranial computed tomography &#40;CT&#41; scan showing a nonvascular lesion in the right parasagittal-parietal region with internal spots of bleeding and a considerable intracranial mass consistent with cerebritis &#40;&#42;&#41;&#46; B&#44; CT scan of the chest area showing a cavitated nodule in the anterior segment of the right upper lobe&#44; consistent with aspergilloma &#40;&#43;&#41;&#46;</p>"
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                      "titulo" => "Aspergilosis cut&#225;nea secundaria en paciente inmunodeprimido"
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                        0 => array:2 [
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                            0 => "S&#46; Blanco Barrios"
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                            0 => "M&#46;A&#46; Mennink-Kersten"
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        "identificador" => "xack341081"
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">We thank Dr Carmen Moreno from the Pathology Laboratory and the Radiodiagnostic Unit at Hospital Ram&#243;n y Cajal&#46;</p>"
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Case and Research Letters
Pustular Secondary Cutaneous Aspergillosis in an Immunosuppressed Patient
Aspergilosis cutánea secundaria pustulosa en paciente inmunosuprimido
P. Fonda-Pascuala,b,
Autor para correspondencia
pfondap@gmail.com

Corresponding author.
, P. Fernández-Gonzáleza,b, O.M. Moreno-Arronesa,b, L. Miguel-Gómeza
a Servicio de Dermatología, Hospital Universitario Ramón y Cajal , Madrid, España
b Grupo de Dermatología Experimental y Biología Cutánea, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, España
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<span class="elsevierStyleItalic">Aspergillus</span> species can cause serious primary or secondary skin infections&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> We present a case of pustular cutaneous aspergillosis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 56-year-old man with type IgA multiple myeloma was evaluated for painless skin nodules measuring over 1<span class="elsevierStyleHsp" style=""></span>cm and a large blister of recent onset on his left elbow&#46; The patient had stage IIIA disease and had been under follow-up for 4 years&#46; He had received several treatments&#44; including 4 cycles of chemotherapy with bortezomib 1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> every 4 days&#44; 4 cycles separated by a week of cyclophosphamide 500<span class="elsevierStyleHsp" style=""></span>mg once a day for 3 days&#44; and dexamethasone 40<span class="elsevierStyleHsp" style=""></span>mg every 2 days for 12 days&#46; He had also received radiation therapy and undergone hematopoietic stem cell transplantation&#46; Following a relapse in 2015&#44; it was decided to attempt mini-allogenic transplantation with reduced-intensity FluMel-ATG conditioning &#40;70<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> melphalan&#44; fludarabine 30<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#47;d&#44; bortezomib 1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#44; and anti-thymocyte globulin 2<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#41; and an increase in melphalan infusion dose to 150<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Forty days after the transplantation&#44; the patient was evaluated by a dermatologist as he suddenly developed painless erythematous subcutaneous nodules measuring approximately 3<span class="elsevierStyleHsp" style=""></span>cm on the anterior surface of both thighs and on the left abdominal flank &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; One of the lesions on the lateral surface of his left elbow was a tense 1&#46;5-cm blister containing blood-stained pus with a fluid level &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The patient reported no other symptoms&#46; The onset of these lesions coincided with a progressive increase in serum galactomannan levels&#44; which rose from previously undetectable levels to a level of 0&#46;9&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the patient&#39;s condition and the general clinical picture&#44; skin biopsy samples were taken for histology and microbial culture&#46; Histologic examination of the elbow lesion showed a purulent subepidermal blister and an underlying infiltrate composed of abundant polymorphonuclear leukocytes that caused notable tissue destruction&#44; with weakened structures&#44; collagen bundles with an unstructured appearance&#44; and effacement of adnexal structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Higher magnification and periodic acid-Schiff &#40;PAS&#41; staining showed septate linear structures with dichotomous acute-angle &#40;45&#176;&#41; branching throughout the dermis and extending into the more superficial areas of the subcutaneous tissue&#46; These structures had an approximate diameter of 3<span class="elsevierStyleHsp" style=""></span>&#956;m and a length of up to 80<span class="elsevierStyleHsp" style=""></span>&#956;m in some sections and were consistent with hyalohyphomycosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; Culture in Sabouraud agar produced <span class="elsevierStyleItalic">Aspergillus flavus</span>&#44; which was sensitive to voriconazole and echinocandins in the ETEST &#40;Biom&#233;rieux&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Intensive antifungal treatment was initiated with voriconazole &#40;loading dose of 400<span class="elsevierStyleHsp" style=""></span>mg followed by a maintenance dose of 200<span class="elsevierStyleHsp" style=""></span>m&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and intravenous anidulafungin &#40;loading dose of 200<span class="elsevierStyleHsp" style=""></span>mg followed by 100<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Three days later&#44; the patient developed right hemiparesis&#46; In the staging study&#44; the chest computed tomography &#40;CT&#41; scan showed previously undetected cavitated lesions in the right upper lobe of the lung &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; The brain CT scan showed 2 nonvascular frontal lesions consistent with a stroke secondary to infection &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; We decided to escalate the treatment to intravenous amphotericin B &#40;400<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h adjusted to the patient&#39;s weight&#41;&#46; After 7 days&#44; however&#44; the patent developed severe dyspnea requiring oxygen support&#44; aphasia&#44; and general deterioration of health&#46; A second brain scan showed multiple lesions similar to the lesions on the first scan but involving the entire brain parenchyma&#46; The patient died as a result 2 days later&#46; The family did not agree to an autopsy and we were therefore unable to collect brain tissue for microbiologic analysis&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Aspergillus</span> species are members of the eumycetes and are widely distributed in the environment&#46; They are opportunistic pathogens that pose a particular threat to immunosuppressed individuals&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> particularly those with neutropenia&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The most common species are <span class="elsevierStyleItalic">Aspergillus fumigatus</span> and <span class="elsevierStyleItalic">A&#160;flavus&#46;</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Aspergillus</span> species are ubiquitous in soil and vegetation&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Although aspergillosis mainly affects the lungs&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> it can also affect the liver&#44; brain&#44; and skin&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Between 5&#37; and 27&#37; of invasive aspergillosis cases involve the skin&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;6</span></a> Cutaneous aspergillosis can be primary or secondary&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7</span></a> and these forms can be distinguished by the location and extension of lesions&#44; which are widespread in secondary infections&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3&#44;7</span></a> Secondary cutaneous aspergillosis generally originates from the lungs&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> but it can also originate from the paranasal sinuses or the upper respiratory tract&#44; although these forms are much less common&#46; Primary aspergillosis is generally caused by direct skin inoculation through wounds from contaminated objects&#44; intravenous lines<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> at venipuncture sites on the arms&#44; or even through dressings covering areas of macerated skin or catheters in patients requiring invasive procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinically&#44; aspergillosis manifests as erythematous papules and macules that progress to nodules<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and eventually to ulcers with areas of central necrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;7</span></a> Blisters are uncommon and may&#44; as in our case&#44; contain pus&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Standard diagnostic procedures are the potassium hydroxide technique &#40;or similar&#41; and an incisional skin biopsy with sufficient depth&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7</span></a> Histology shows septate hyphae measuring 3 to 5<span class="elsevierStyleHsp" style=""></span>&#956;m in diameter and 50 to 100<span class="elsevierStyleHsp" style=""></span>&#956;m in length&#44; 45&#176; branching&#44; absence of blistering with PAS or Gomori methenamine silver stains&#44; and abundant polymorphonuclear cells involving the entire wall&#44; with angiocentric necrosis in many cases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Serum galactomannan levels should always be tested when aspergillosis is suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> A progressive increase to a level over 0&#46;5 in serial measurements points to a diagnosis of invasive bronchopulmonary or systemic aspergillosis&#44; particularly in immunosuppressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleItalic">Aspergillus</span> infection is confirmed by polymerase chain reaction&#46; Treatment consists of amphotericin B &#40;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47; 24<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; combined with echinocandins &#40;50-100<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; or voriconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Debridement of necrotic lesions and rapid restoration of immunity are important&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We have presented a case of pustular cutaneous aspergillosis in an immunosuppressed patient&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fonda-Pascual P&#44; Fern&#225;ndez-Gonz&#225;lez P&#44; Moreno-Arrones OM&#44; Miguel-G&#243;mez L&#46; Aspergilosis cut&#225;nea secundaria pustulosa en paciente inmunosuprimido&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;287&#8211;290&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation&#46; A&#44; Painless erythematous nonfluctuant nodule on the left abdominal flank&#46; B&#44; Pustule containing blood-stained pus with a fluid level on an indurated erythematous base&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histologic features of the pustule following incisional biopsy&#46; A&#44; Large subepidermal blister with major underlying tissue destruction affecting the entire dermis and subcutaneous tissue &#40;hematoxylin-eosin staining&#44; original magnification &#215;<span class="elsevierStyleHsp" style=""></span>20&#41;&#46; B&#44; Dense neutrophilic infiltration with destruction of dermal collagen and associated vasculitis &#40;hematoxylin-eosin original magnification &#215;100&#41;&#46; C&#44; Detail showing dense neutrophil infiltration in the dermis and around barely perceivable filamentous structures &#40;hematoxylin-eosin&#44; original magnification &#215;200&#41;&#46; D&#44; Higher magnification and periodic acid-Schiff &#40;PAS&#41; staining showing septate linear structures with acute-angle branching consistent with the clinical and microbiologic diagnosis of cutaneous aspergillosis &#40;PAS &#215;40&#44; original magnification &#215;400&#41;&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiologic study after 3 days&#46; A&#44; Cranial computed tomography &#40;CT&#41; scan showing a nonvascular lesion in the right parasagittal-parietal region with internal spots of bleeding and a considerable intracranial mass consistent with cerebritis &#40;&#42;&#41;&#46; B&#44; CT scan of the chest area showing a cavitated nodule in the anterior segment of the right upper lobe&#44; consistent with aspergilloma &#40;&#43;&#41;&#46;</p>"
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                      "titulo" => "Review of the safety&#44; tolerability&#44; and drug interactions of the new antifungal agents caspofungin and voriconazole"
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        "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">We thank Dr Carmen Moreno from the Pathology Laboratory and the Radiodiagnostic Unit at Hospital Ram&#243;n y Cajal&#46;</p>"
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Información del artículo
ISSN: 15782190
Idioma original: Inglés
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