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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 2  |  Page : 359-360
Subcutaneous aspergillosis with coexisting atypical mycobacterial infection


1 Department of Microbiology, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Pondicherry - 605107, India
2 Department of Pathology, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Pondicherry - 605107, India
3 Department of Medicine, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Pondicherry - 605107, India

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Date of Web Publication12-Jun-2010
 

   Abstract 

A 60-year-old woman, a known diabetic and asthmatic, was admitted for acute exacerbation of chronic obstructive pulmonary disease. Physical examination revealed two soft nodules in the left infra axillary region. Fine needle aspiration cytology (FNAC) showed fungal granulomatous reaction suggestive of fungal infection. Periodic acid Schiff stain (PAS stain) revealed PAS positive, acutely branching, septate fungal hyphae. Wet mount of the aspirate revealed plenty of pus cells and branching septate hyphae. Ziehl-Neelsen (ZN) stain showed moderate numbers of acid fast bacilli. Culture yielded Aspergillus flavus and Mycobacterium fortuitum.

Keywords: Aspergillus flavus, mycobacterium fortuitum , subcutaneous infection

How to cite this article:
Duraipandian J, Rengasamy G, Madasamy B, Kulanthaivelu A, Subramanian G. Subcutaneous aspergillosis with coexisting atypical mycobacterial infection. Indian J Pathol Microbiol 2010;53:359-60

How to cite this URL:
Duraipandian J, Rengasamy G, Madasamy B, Kulanthaivelu A, Subramanian G. Subcutaneous aspergillosis with coexisting atypical mycobacterial infection. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Oct 20];53:359-60. Available from: https://www.ijpmonline.org/text.asp?2010/53/2/359/64349



   Introduction Top


Aspergillosis is primarily a pulmonary disease. Invasion of the lung tissue and dissemination to other organs may occur. [1] Subcutaneous aspergillosis may be primary, usually involving the sites of skin injury over the extremities or secondary following extension from contiguous sites or through the blood stream. [1],[2] Atypical mycobacteria can cause infection of the skin and soft tissues. Abscess formation at the site of the puncture wound is most often due to rapidly growing mycobacteria. The case is reported because of the rare presentation of a dual infection due to Aspergillus flavus and Mycobacterial fortuitum.


   Case Report Top


A 60-year-old woman was admitted with complaints of difficulty in breathing and cough with expectoration, of five days duration. Patient's medical records and history revealed that she has been a diabetic under poor control and also suffering from bronchial asthma for the past five years. She had been treated with oral steroids for the past two years. General examination showed two soft to firm, round, nodular lesions about two inches in size over the left side of the chest in the infra axillary region [Figure 1]. Auscultation of the chest revealed bilateral ronchi. Fine needle aspiration of the nodule yielded pus which was sent for both cytological and microbiological studies. Papanicolau stained [PAP] slides showed numerous foreign body type, multinucleated giant cells with intracytoplasmic fungal filaments. No other cells were found. Periodic acid-schiff stain [PAS] stained smear showed plenty of acutely branching, septate fungal hyphae [Figure 2]a. A wet mount of the pus showed plenty of pus cells and acute angled, branching, septate hyphae [Figure 2]b. Gram stained smear showed a few gram positive septate hyphae. Ziehl-Neelsen stain showed plenty of acid fast bacilli [Figure 2]c. Routine bacterial culture of the pus was sterile after 72 hours of incubation. Aspergillus flavus was isolated on Sabouraud's dextrose agar after 48 hours of incubation at room temperature (27˚C). [Figure 3]a and [Figure 2]d. Acid fast bacilli was isolated on Lowenstein- Jensen medium [LJ] at 37C and at 27C after five days of incubation [Figure 3]b. The organism was acid fast by 20% sulphuric acid and did not show any branching filamentous or beaded forms. Subculture on MacConkey agar yielded a growth of pink, moist elevated colonies after 48 hours of incubation at 37˚C which was acid fast by conventional Ziehl-Neelsen staining. The isolate was identified as Mycobacterium fortuitum based on the rapid growth on Lowenstein-Jensen medium, MacConkey agar, growth on LJ with 5% Nacl, positive Nitrate reduction and Aryl sulfatase tests. Bacterial and fungal culture of the sputum did not yield any pathogen including acid fast bacilli. Erythrocyte sedimentation rate and hemoglobin were 62mm/hour and 9.6gm% respectively. Total leucocyte count and differential counts were within normal limits. Fasting blood sugar and post-prandial sugar were 149mg/dl and 315mg/dl respectively.


   Discussion Top


Subcutaneous aspergillosis is a relatively less frequent condition than pulmonary aspergillosis. Healthy hosts can develop subcutaneous aspergillosis by traumatic inoculation of fungal spores. [3],[4] The swelling in the present case was non-tender and gradually progressing in size over the past nine months; the overlying skin was normal. Aspergillus species and atypical mycobacteria are widely prevalent in the environment. The patient reported here is a farmer with a poor control of diabetes and on intermittent oral steroid therapy. The mode of infection could be a trivial trauma leading to inoculation of the spores. There was no history of surgery or local trauma at the site. Atypical mycobacteria are also known to produce subcutaneous lesion following minor trauma. [5],[6],[7]

The case highlights the need for a thorough and careful 'microscopic examination' of aspirated material to detect the fungal elements in such unusual infections. Cytological diagnosis is a well established method for differentiation of infective from neoplastic lesions and it is a rapid, sensitive and an important tool for the diagnosis of mycotic infections. [8],[9] Culture studies, however, are obligatory for identification of the causative fungi.

Acknowledgement

0We wish to thank our Director Dr.D.Rajagovindan for granting permission to send this case report for publication.

 
   References Top

1.Kwong Chung KJ, Bennett JE. Aspergillosis. In: Kwong-Chung KJ, Benett JE, editors. Medical Mycology. 2 nd ed. Philadelphia: Lea and Febiger; 1992. p. 201-47.   Back to cited text no. 1      
2.Jo-Anne H.Van Burik, Colven R, Spach DH. Cutaneous Aspergillosis. J Clin Microbiol 1998;36:3115-21.   Back to cited text no. 2      
3.Madhavan M, Aurora AL, Gupta KR, Sibal RN. Subcutaneous facial aspergillosis. J Postgrad Med 1977;23:140-2.  Back to cited text no. 3  [PUBMED]  Medknow Journal  
4.Rabbani MZ, Amir M, Khan MY, Khan AS, Ali Z. Primary Aspergillosis of the Cheek. A diagnostic Dilemma. J Pak Med Assoc 2007;57:613-15.  Back to cited text no. 4  [PUBMED]    
5.Okano A, Shimazaki C, Ochiai N, Hatsuse M, Takahashi R, Ashihara E, et al. Subcutaneous infection with Mycobacterium fortuitum after allogeneic bone marrow transplantation. Bone Marrow Transplant 2001;28:709-11.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Yen-Shu Kuo, Hong-Jen Chiouyl, Yi Hong Chou, See-Ying Chiou, Cheng-Yen Chang. Solitary Subcutaneous Non-tuberculous Mycobacterial Infection: A Case Report and Its Ultrasound Appearance. Chin J Radiol 2004;29:47-51.   Back to cited text no. 6      
7.Subbarao EK, Tarpay MM, Marks MI. Soft-tissue infections caused by Mycobacterium fortuitum complex following penetrating injury. Am J Dis Child 1987;141:1018-20.  Back to cited text no. 7  [PUBMED]    
8.Geramizadeh B, Kheirandish P, Fatheezadeh P, Jannesar R. Fine needle aspiration of subcutaneous masses caused by Aspergillus: A report of 2 cases. Acta Cytol 2005;49:666-8.  Back to cited text no. 8  [PUBMED]    
9.Vairani G, Rebeschini R, Barbazza R. Hepatic and subcutaneous abscesses due to aspergillosis. Initial diagnosis of a case by intraoperative fine needle aspiration cytology. Acta cytol 1990;34:891-4.  Back to cited text no. 9  [PUBMED]    

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Correspondence Address:
Jeyakumari Duraipandian
Department of Microbiology, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Pondicherry- 605 107
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.64349

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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