Primary Cutaneous Aspergillosis Associated with Hickman Intravenous Catheters

We describe nine patients with underlying hematologic cancer in whom primary cutaneous aspergillosis developed at the sites of Hickman intravenous catheters. Our patients, 17 to 74 years of age, were all immunocompromised either from their primary disease or from chemotherapy, and the Hickman catheters had been placed to provide venous access for chemotherapy or hyperalimentation or both. Clinical signs of infection included erythema, induration, and cutaneous or subcutaneous necrosis at the point of entry into the subclavian vein, in the subcutaneous tunnel, or at the exit site from the skin. Diagnosis was confirmed by positive wound culture for Aspergillus flavus in all but one patient. Treatment consisted of intravenous amphotericin B, oral flucytosine, and local wound care. Three patients recovered completely without operative débridement; three others recovered after operative débridement and delayed grafting. Two patients died of disseminated aspergillosis, and one died of unrelated causes while recovering from primary cutaneous aspergillosis. Successful treatment required resolution of aplasia or leukopenia, catheter removal, systemic treatment with amphotericin B, and local wound care. We conclude that primary cutaneous aspergillosis, a rare infection, may occur at the sites of Hickman catheters in immunocompromised patients, and that it is a serious complication requiring prompt diagnosis and treatment. (N Engl J Med 1987; 317:1105–8.), ASPERGILLUS organisms are ubiquitous saprophytes that usually live on decaying vegetation and rarely behave as pathogens in a normal host.¹ When their spores are aerosolized, infection, usually airborne, may arise. In an otherwise healthy host, aspergillus is rarely invasive, but it can colonize mucosal surfaces, including the paranasal sinuses,² upper and lower respiratory tracts,³ external auditory canal,⁴ and gastrointestinal tract.⁵ Cooper et al.⁶ cite only 14 cases of invasive aspergillosis occurring in apparently immunocompetent hosts between 1943 and 1981. In the presence of immunosuppression, however, aspergillus may be invasive. Patients most commonly affected are those with hematologic and lymphoreticular cancer,….