species are commonly cultured from cutaneous infections in immunocompromised patients. In the upper extremity, primary cutaneous aspergillosis is often associated with skin injuries such as burns, surgical wounds, or sites of IV or catheter insertion and typically presents as erythema and induration progressing to necrosis [1
]. Treatment depends on the underlying condition of the patient but typically involves topical and/or systemic antifungal chemotherapy plus surgical debridement when clinical indicated [21
In contrast, disseminated invasive aspergillosis resulting in secondary cutaneous or soft tissue lesions is less common and more severe. Approximately 5–11% of disseminated Aspergillus
infections involve the skin [11
]. Invasive aspergillosis of the hand requiring amputation has been described in children being treated for hematologic malignancies [11
We present a case of a 61-year-old patient who developed a disseminated infection involving the hand, lung, and posterior thigh with a rare form of Aspergillus
known as A. ustus
. Since 1970, only 27 cases of disseminated A. ustus
infections have been reported [4
]. The fungus is found in food, soil, and indoor air environments and is believed to be an emerging nosocomial pathogen, particularly among transplant patients [16
]. It is characteristically resistant to multiple antifungal medications and may have an associated mortality rate as high as 50% [9
There are no standardized diagnostic or treatment protocols for A. ustus
. However, as with any infection in an immunocompromised patient, cultures for bacteria, fungi, viruses, and atypical pathogens should be performed. A serum galactomannan enzyme-linked immunosorbent assay or (1,3)-β-d
glucan assay may be helpful for diagnostic purposes as well as for monitoring postoperatively as levels have been shown to correlate with clinical course [5
]. Involvement of experts in infectious disease is paramount as empiric treatment for a variety of organisms is often needed.
In the treatment of A. ustus
, the antimicrobial regimen used in this case (caspofungin, intravenous amphotericin B, and topical terbinafine cream) has been successful in other reports [22
]. Dressing changes with sodium hypochlorite (also known as Dakin’s solution) may be a useful adjunct to antifungal therapy as the solution has been shown to have activity against Aspergillus
species in vitro [2
]. Reducing immunosuppression plays the vital role in managing these patients allowing for restoration of the patient’s ability to fight opportunistic pathogens. The issue should be promptly discussed with the team administering immunosuppressive agents.
While the role of surgery as it relates to A. ustus
infections remains to be determined, treatment success has been reported when antifungal agents have been used alongside lung resection [3
]. In addition, it is clear that surgical biopsy can facilitate early diagnosis, which is a key determinant of prognosis for patients with invasive aspergillosis in general [7
Hand surgeon must be aware of the atypical and aggressive nature of infections that occur in transplant patients and others who are immunocompromised. The need for early surgical intervention and multiple debridement procedures should be recognized. This case also illustrates the importance of collaboration between the hand surgery, infectious disease, and transplant teams in coordinating care for immunocompromised patients with unique hand infections. With early diagnosis, multiple debridements, aggressive antimicrobial chemotherapy, and careful modulation of immunosuppression, one may be able to achieve outcomes more functional than that of amputation.