LAUSR

To the Editor: Cutaneous aspergillosis is rare, and mostly seen in patients with chronic disease and immunosuppression, commonly associated with catheters, open wounds, or burns. It usually presents as small cellulitic areas and progresses quickly to necrotic ulcers with black eschars. Eumycetoma due to Aspergillus is exceptionally rare (van de Sande, 2013). Medical therapy most often is not curative, requiring surgical intervention for the treatment of eumycetoma. Herein, we report a case of eumycetoma due to Aspergillus species vividly responding to itraconazole in a healthy young boy. A 9-year-old boy from Rajasthan (India), presented with a large, painless swelling over right foot. The child was otherwise normal without any history of illness, except for a fall with minor trauma five years back. Subsequently swelling appeared over right foot, which gradually enlarged with multiple sinuses discharging seropurulent material containing black grains (Figure 1A). Multiple courses of antibiotics and indigenous medicines prescribed by local practitioners were of no benefit. X-ray of the right foot revealed multiple lytic lesions over calcaneum and cuboid. Black grains from the discharge showed septate hyphae under microscope on three consecutive occasions. A deep punch biopsy from the swelling revealed mild to moderate lymphomononuclear infiltrate mixed with polymorphs, eosinophils, and hemosiderin laden macrophages in the dermis. Few lymphoid aggregates, giant cells containing fungal hyphae, and histiocytic collection along with vascular proliferation were also noted (Figure 2A). Though KOH preparation showed septate branching hyphae, microbial and mycological culture of the discharge and skin biopsy did not yield any growth. Molecular diagnosis after extraction of DNA from the tissue and PCR sequencing led to the identification as Aspergillus species with a close possibility between: A. ustus, A. calidoustus, A. pseudodeflectus (Figure 2B). Itraconazole 100 mg twice daily was started with a regular monitoring of liver function test. All sinuses healed and swelling decreased substantially within 6 months of starting therapy (Figure 1B) and besides clinical improvement, significant radiological improvement was also observed. The child was able to walk and