Case Report Cutaneous infection caused by Aspergillus terreus Burcin Ozer, 1 Aydiner Kalaci, 2 Nizami Duran, 1 Yunus Dogramaci 2 and Ahmet Nedim Yanat 2 Correspondence Burcin Ozer burcinozer@yahoo.com 1 Department of Microbiology and Clinical Microbiology, School of Medicine, Mustafa Kemal University, Hatay, Turkey 2 Department of Orthopaedics and Traumatology, School of Medicine, Mustafa Kemal University, Hatay, Turkey Received 7 November 2008 Accepted 28 March 2009 Aspergillus species are widely distributed in nature, and more than 30 species have been reported to be involved in human and animal infection. Cutaneous infections due to Aspergillus terreus are particularly rare. In this report, we describe a case of cutaneous infection caused by A. terreus in a paediatric patient who underwent surgical treatment for an open tibial fracture secondary to an agricultural accident. Introduction Aspergillus species are widely distributed in nature; they have been predominantly isolated from soils, decaying vegetation and on a wide variety of organic matter (Sigler & Verweij, 2003). More than 30 species have been implicated in different human and animal infections (Sigler & Verweij, 2003). Patients who are immunocom- promised or who are receiving immunosuppressive drugs, notably bone marrow and organ transplant recipients, and those with haematological malignancies, are parti- cularly susceptible to these kinds of fungal infections (Richardson, 2005). The most important species of Aspergillus are Aspergillus fumigatus, Aspergillus flavus and Aspergillus niger; and infections due to Aspergillus terreus are increasingly being reported (Lass-Flo ¨rl et al., 2005; Cooke et al., 2003). Cutaneous infections are rare in aspergillosis. Primary cutaneous infection caused by Aspergillus may present as macules, papules, plaques or haemorrhagic bullae, which may progress into necrotic ulcers with an elevated border that is covered by a black eschar (Walmsley et al., 1993; Lucas et al., 1999). These infections have been described in immunocompromised children, in neonates and after traumatic injuries, with varying treatment options (Lucas et al., 1999; Richards & Mancini, 2000; Amod et al., 2000). Cutaneous infections due to A. terreus are particularly rare (Lass-Flo ¨rl et al., 2005; Steinbach et al., 2004). In this report, we describe a case of cutaneous infection caused by A. terreus in a paediatric patient who underwent surgical treatment for an open tibial fracture secondary to an agricultural accident. Case report A 7-year-old boy was admitted to Mustafa Kemal University Research Hospital, Hatay, Turkey, on 13 August 2007. Nine days before, he visited another hospital after an accident. His left lower extremity was crushed under a tractor in an arable field. He underwent an operation for a contaminated grade III open tibial fracture. He had been referred to Mustafa Kemal University Research Hospital for further follow-up. Additional surgical operations (debridement and wound closure) were planned and he was hospitalized. On admission, laboratory tests showed leukocytosis (white cell count 13 500 cells ml 21 ) with 51.7 % polymorphs, 35.6 % lymphocytes and 7.5 % eosinophils. His erythrocyte sedimentation rate was 67 mm at 1 h. A chest X-ray was normal. Other investigations like C-reactive protein, blood sugar, renal and liver function tests were normal. On examination, a large open wound with crusts covering the anteromedial aspect of the lower leg, extending from just below the knee to both malleoli, was observed (Fig. 1a). The appearance of the wound and the green colour of the exudate suggested that it was an infected wound. Cultures were taken after multiple and meticulous debridements of the wound, which were carried out in the surgical theatre and under general anaesthesia by orthopaedic surgeons. The culture of the exudate from the lesion was subcultured on 5 % sheep blood agar plate (bioMe ´rieux), in eosin methylene blue agar (bioMe ´rieux), in brain heart infusion broth and in thioglycolate broth (Merck), and incubated at 35 u C. Direct microscopic examination of the Gram stained exudate revealed polymorphonuclear leukocytes and occasional fungal hyphae (Supplementary Fig. S1 available with the online journal). No bacteria were isolated, but cultures yielded numerous identical fungal colonies. These colonies were taken and subcultured on Sabouraud dextrose agar (Merck) and incubated at 35 u C Images of the fungus are available as supplementary data with the online version of this paper. Journal of Medical Microbiology (2009), 58, 968–970 DOI 10.1099/jmm.0.007799-0 968 007799 G 2009 SGM Printed in Great Britain