Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report

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Primary cutaneous involvement is a rare presentation and presents a challenge for early diagnosis. We report a case of primary cutaneous aspergillosis (PCA) in an immunocompromised patient with no evident prior skin trauma and with pulmonary dissemination. Case report We report the case of primary cutaneous aspergillosis involving the left ankle in a 5-year-old girl with no history of preceding trauma. The patient was undergoing chemotherapy for lymphoblastic leukemia. Aspergillus hyphae were identified on skin biopsy. Cultures grew Aspergillus flavus. The diagnosis of cutaneous aspergillosis enabled the diagnosis of probable pulmonary aspergillosis, although there was no mycopathological proof of lung infection. The patient was treated with initial Amphotericin B followed by Voriconazole with complete skin and respiratory response. Conclusion This case underscores the critical need to consider cutaneous aspergillosis in immunocompromised patients with necrotic skin lesions— even in the absence of obvious trauma—as prompt diagnosis and treatment are vital to prevent dissemination and and improve outcomes. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/15-454/v1", "name": "Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child..." } } ] } Home Browse Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article KALBOUSSI Y, CHENBAH W, CHOUAIEB H et al. Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.12688/f1000research.178649.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] Yasmine KALBOUSSI https://orcid.org/0009-0004-3616-2164 1,2 , Wafa CHENBAH 3,4 , Hamed CHOUAIEB 1,4 , [...] Nour GAALOUL 3,4 , Samar ISMAIL https://orcid.org/0000-0002-6152-0988 1,4 , Monia GUERMAZI 3,4 , Mariem BEN TICHA 4,5 , Imene KHAMMARI 1,4 , Yosra BEN YOUSSEF 3,4 , Akila FATHALLAH https://orcid.org/0000-0002-4613-6689 1,4 Yasmine KALBOUSSI https://orcid.org/0009-0004-3616-2164 1,2 , Wafa CHENBAH 3,4 , [...] Hamed CHOUAIEB 1,4 , Nour GAALOUL 3,4 , Samar ISMAIL https://orcid.org/0000-0002-6152-0988 1,4 , Monia GUERMAZI 3,4 , Mariem BEN TICHA 4,5 , Imene KHAMMARI 1,4 , Yosra BEN YOUSSEF 3,4 , Akila FATHALLAH https://orcid.org/0000-0002-4613-6689 1,4 PUBLISHED 30 Mar 2026 Author details Author details 1 Laboratory of Parasitology - Mycology, Farhat Hached University Hospital of Sousse, Sousse, Sousse, Tunisia 2 University of Monastir Faculty of Medicine of Monastir, Monastir, Monastir, Tunisia 3 Department of Hematology, Farhat Hached University Hospital of Sousse, Sousse, Sousse, Tunisia 4 University of Sousse Faculty of Medicine of Sousse, Sousse, Sousse, Tunisia 5 Department of Infectious diseases, Farhat Hached University Hospital of Sousse, Sousse, Sousse, Tunisia Yasmine KALBOUSSI Roles: Conceptualization, Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Wafa CHENBAH Roles: Conceptualization, Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Hamed CHOUAIEB Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Nour GAALOUL Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Samar ISMAIL Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Monia GUERMAZI Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Mariem BEN TICHA Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Imene KHAMMARI Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Yosra BEN YOUSSEF Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Akila FATHALLAH Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Pathogens gateway. Abstract Introduction Invasive aspergillosis is a severe infection that usually affects immunocompromised patients. Primary cutaneous involvement is a rare presentation and presents a challenge for early diagnosis. We report a case of primary cutaneous aspergillosis (PCA) in an immunocompromised patient with no evident prior skin trauma and with pulmonary dissemination. Case report We report the case of primary cutaneous aspergillosis involving the left ankle in a 5-year-old girl with no history of preceding trauma. The patient was undergoing chemotherapy for lymphoblastic leukemia. Aspergillus hyphae were identified on skin biopsy. Cultures grew Aspergillus flavus. The diagnosis of cutaneous aspergillosis enabled the diagnosis of probable pulmonary aspergillosis, although there was no mycopathological proof of lung infection. The patient was treated with initial Amphotericin B followed by Voriconazole with complete skin and respiratory response. Conclusion This case underscores the critical need to consider cutaneous aspergillosis in immunocompromised patients with necrotic skin lesions— even in the absence of obvious trauma—as prompt diagnosis and treatment are vital to prevent dissemination and and improve outcomes. READ ALL READ LESS Keywords Aspergillosis, cutaneous aspergillosis, neutropenia, invasive pulmonary aspergillosis, case report Corresponding Author(s) Yasmine KALBOUSSI ( [email protected] ) Close Corresponding author: Yasmine KALBOUSSI Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 KALBOUSSI Y et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: KALBOUSSI Y, CHENBAH W, CHOUAIEB H et al. Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.12688/f1000research.178649.1 ) First published: 30 Mar 2026, 15 :454 ( https://doi.org/10.12688/f1000research.178649.1 ) Latest published: 30 Mar 2026, 15 :454 ( https://doi.org/10.12688/f1000research.178649.1 ) Introduction Invasive aspergillosis is a severe and potentially fatal infection usually affecting immunocompromised patients. 1 , 2 Pulmonary involvement is the predominant presentation, whereas cutaneous localization is much less frequent. This can develop as a primary infection, usually arising from direct inoculation of the skin 3 or occur as part of a disseminated infection from the lung. 1 The true incidence of primary cutaneous aspergillosis (PCA) among immunocompromised patients is not well established but seems to be rising, possibly as a result of better recognition and the increasing number of immunocompromised individuals. 4 , 5 The major limitation in the management of these infections is the challenge of early diagnosis. We report a rare case of primary cutaneous aspergillosis (PCA) caused by Aspergillus flavus in a neutropenic and immunocompromised 5 year- old patient with no evident prior skin trauma. Case report A 5-year-old girl was admitted to the Haematology department of Farhat-Hached hospital (Sousse, Tunisia) in September 2024 for acute lymphoblastic leukemia. She received chemotherapy consisting of anthracyclines, L-asparaginase, cyclophosphamide, methotrexate and long-term corticosteroid therapy. In April 2025, she was admitted to receive consolidation chemotherapy. Seven days after the last dose, she developed high-grade fever (40 °C), concomitantly with the appearance of a small 5-mm black spot on her left ankle ( Figure 1 ). The patient was neutropenic, with an absolute neutrophil count <500/mm 3 for 5 days. The initial infectious workup was negative. She was started on broad-spectrum antibiotics made of Piperacillin-Tazobactam and Vancomycin. Three days later, the patient still febrile and the skin lesion grew larger about 1.5 cm, becoming swollen with a crusted center and red surrounding skin. Antibiotics were switched to Imipenem and Ciprofloxacin with no improvement. Figure 1. Primary cutaneous aspergillosis of the left ankle: A, Initial skin lesion; B, Day 4; C, Day 5; D, Two days after Amphotericin; E, Day 7 of Amphotericin B; F, Lesion aspect after Voriconazole switch; G and H, Complete skin remission under Voriconazole. When a mild cough appeared few days after, a full-body CT scan was done. It showed nodules and lung infiltrates with a halo sign highly suggestive of angio-invasive pulmonary aspergillosis. Intravenous amphotericin was started immediately. Within 12 hours, she became afebrile for the first time. The skin lesion on her ankle evolved: it became itchy, developed a necrotic center with a purplish halo, and later the center dried out, with a hemorrhagic edge and ulceration. Eventually, the necrotic center detached from the lesion. This necrotic tissue was sent to the mycology laboratory for analysis. Microscopic examination revealed large, septate, and irregular hyphae with acute-angle branching, suggestive of Aspergillus ( Figures 2 ). The specimen was cultured on Sabouraud dextrose agar supplemented with chloramphenicol (SC) and incubated at 30 °C. Fungal growth, 4 days after incubation, was consistent with Aspergillus. Identification using the Vitek MS PRIME (bioMérieux, France), yielded Aspergillus flavus. Antifungal susceptibility testing was carried out using the MIC Test Strip method (Liofilchem, Roseto degli Abruzzi, Italy). The minimum inhibitory concentrations (MICs) were as follows: 0.75 mg/L for Amphotericin B and 0,38 mg/L for Voriconazole. No respiratory specimens were submitted for mycological examination. Concurrently, the serum galactomannan index was measured using the Platelia Aspergillus enzyme immunoassay (Bio-Rad, France), yielding a positive result with an index value of 0.57. Figure 2. Mycological findings: A, large, septate, and irregular hyphae with acute-angle branching on Direct Examination suggestive of Aspergillus (X100); B, Aspergillus flavus growing on culture. Diagnosis of PCA with probable pulmonary dissemination was confirmed. Based on these findings, antifungal therapy was switched to Voriconazole, leading to complete resolution of the cutaneous lesions. The patient was subsequently discharged with a favorable outcome. With regular follow-up and local wound care, she achieved full recovery, and no relapse was observed at 6-month follow-up. Discussion We report a rare case of primary cutaneous aspergillosis (PCA) caused by Aspergillus flavus in a neutropenic patient with no evident prior skin trauma. The infection occurred following consolidation chemotherapy for acute lymphoblastic leukemia, during the aplastic phase, and subsequently progressed to invasive pulmonary aspergillosis. This case demonstrates the rapid progression of an initially inconspicuous cutaneous lesion to a severe necrotizing infection. It underscores the importance of careful clinical evaluation, as seemingly minor skin findings may represent an entry point for invasive fungal disease. Clinicians should maintain a high index of suspicion for primary cutaneous aspergillosis in neutropenic patients. Therefore, even a localized skin lesion requires aggressive systemic antifungal therapy to prevent dissemination. Pediatric patients undergoing chemotherapy for hematological malignancies as illustrated by this 5-year-old girl, represent a high-risk cohort for invasive fungal infections. 1 , 2 The most associated disorders in children are leukemias and lymphomas. 3 However, some cases have been reported with immunocompetent patients. 4 Intensive regimens, including anthracyclines and cyclophosphamide, induce profound and prolonged neutropenia, which is the major risk factor for invasive aspergillosis. 5 Corticosteroids, a key component of leukemia protocols, further impair immune defenses by suppressing macrophage and neutrophil function, crippling the host’s ability to contain fungal invasion. Consequently, this immunocompromised state, defined by cytotoxic and steroid-induced deficits, creates a perfect environment for invasive fungal diseases. Cutaneous aspergillosis can occur either as a primary infection or as a secondary manifestation. 6 , 7 Primary cutaneous aspergillosis (PCA) typically results from the direct inoculation of spores into the skin via breaches in barrier integrity, such as at catheter insertion sites, trauma wounds, or beneath occlusive dressings. In contrast, secondary cutaneous involvement occurs almost exclusively through hematogenous dissemination 7 , 8 from a deep-seated focus, most commonly the lung. This form is associated with the angioinvasive behavior of Aspergillus species. Determining whether the infection is primary or secondary to a primary site, such as the lungs, is crucial for guiding treatment. 9 In our case, the initial isolated cutaneous lesion, which appeared concomitantly with the onset of fever , and the absence of radiological lung abnormalities at presentation, strongly supports the diagnosis of primary cutaneous aspergillosis with subsequent pulmonary dissemination. This occurred in the absence of any clinically apparent skin injury, which, to our knowledge, appears to be exceptional. However, a minor or unnoticed breach in the skin barrier cannot be excluded. This case highlights that primary cutaneous aspergillosis should be considered even in the absence of evident skin trauma. PCA can have different presentations: erythematous macules and papules with pain and itching, necrotizing skin lesions, hemorragic bullas, ulcerations with central necrosis or violaceous nodules. 10 The variety of presentations and the non-typical form of lesions lead to an underdiagnosis of PCA and emphasize on the importance of mycological examination in order to start antifungal treatment and avoid the dissemination. The definitive diagnosis of cutaneous aspergillosis relies on examination and culture of a deep tissue biopsy, as superficial samples are often inadequate. 11 Direct examination typically reveals septate hyphae with acute-angle branching, suggestive of Aspergillus , though not pathognomonic, as similar hyaline molds like Fusarium must be excluded. 8 While A. fumigatus predominates in invasive aspergillosis overall, accounting for approximately 53% of pediatric cases in the largest multicenter study, 1 A. flavus is notably prevalent in primary cutaneous infections (PCA), accounting for a significant proportion of cases. 6 , 12 Our case aligns with this epidemiological profile for PCA. Serological biomarkers, such as serum galactomannan (GM), provide valuable adjunctive evidence. In pediatric patients, GM assay offers good sensitivity and specificity, and a positive result in a high-risk clinical context strongly supports the diagnosis of invasive disease. 8 In this case, the positive GM antigenemia, concomitant with the cutaneous biopsy results and pulmonary imaging, was instrumental in confirming disseminated infection. According to the EORTC/MSGERC criteria, 13 our patient fulfilled the definition of proven invasive cutaneous aspergillosis, based on the demonstration of septate hyphae in direct examination from a deep skin biopsy and confirmatory culture yielding Aspergillus. However, imaging alone is insufficiently specific for diagnosing pulmonary aspergillosis, as current guidelines require microbiological evidence for a probable infection. The antifungal susceptibility testingc onfirmed a fully susceptible profile, with a notably low Voriconazole MIC of 0.38 mg/L, strongly justifying its use as primary therapy according to EUCAST guidelines. The patient’s sequential antifungal regimen—initial Amphotericin B followed by Voriconazole—is a common clinical strategy for managing suspected invasive fungal infections. 14 , 15 Most patients treated with one or the other had full recovery. 16 However, this approach requires careful consideration due to on going debates about potential antagonistic interactions between the two drug classes. 17 Surgical debridementand oral Itraconazole are also therapeutic options with extended lesions. 18 Conclusion This clinical case highlights the importance of considering cutaneous aspergillosis in immunocompromised patients presenting with skin lesions that progress to necrosis, even in the absence of trauma history. Particular attention must be paid to such lesions, as prompt diagnosis and treatment are crucial to prevent dissemination and reduce infection-related mortality. Consent to publish A written consent was provided and signed by the patient’s parent, including the authorization for publishing clinical details and/or clinical images. Data availability statement The CARE chechlist is publicly available at Zenodo. 19 Title: Completed CARE checklist associated with the manuscript entitled “Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report”. DOI: https://doi.org/10.5281/zenodo.18860965 . 19 License: CC0 1.0 . Acknowledgements The authors would like to thank the laboratory technicians and nursing staff for their valuable contribution to the patient’s care. References 1. Burgos A, Zaoutis TE, Dvorak CC, et al. : Pediatric Invasive Aspergillosis: A Multicenter Retrospective Analysis of 139 Contemporary Cases. Pediatrics. 2008; 121 (5): e1286–e1294. PubMed Abstract | Publisher Full Text 2. Bernardeschi C, Foulet F, Ingen-Housz-Oro S, et al. : Cutaneous Invasive Aspergillosis: Retrospective Multicenter Study of the French Invasive-Aspergillosis Registry and Literature Review. Medicine (Baltimore). 2015; 94 (26): e1018. PubMed Abstract | Publisher Full Text | Free Full Text 3. Torrelo A, Hernández-Martín A, Scaglione C, et al. : Primary Cutaneous Aspergillosis in a Leukemic Child. Actas Dermosifiliogr. (Engl. Ed.). 2007; 98 (4): 276–278. PubMed Abstract | Publisher Full Text 4. Camus M, Anyfantakis V, Dammak A, et al. : Aspergillose cutanée primitive chez un agriculteur immunocompétent. Ann. Dermatol. Venereol. 2010; 137 (5): 373–376. PubMed Abstract | Publisher Full Text 5. Groll AH, Castagnola E, Cesaro S, et al. : Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or allogeneic haemopoietic stem-cell transplantation. Lancet Oncol. 2014; 15 (8): e327–e340. Publisher Full Text 6. Saghrouni F, Gheith S, Yaacoub A, et al. : Primary cutaneous aspergillosis due to Aspergillus flavus in a neutropenic patient. J. Mycol. Médicale. 2011; 21 (4): 285–288. Publisher Full Text 7. Mays SR, Bogle MA, Bodey GP: Cutaneous Fungal Infections in the Oncology Patient: Recognition and Management. Am. J. Clin. Dermatol. 2006; 7 (1): 31–43. Publisher Full Text 8. Dagenais TRT, Keller NP: Pathogenesis of Aspergillus fumigatus in Invasive Aspergillosis. Clin. Microbiol. Rev. 2009; 22 (3): 447–465. PubMed Abstract | Publisher Full Text | Free Full Text 9. Park KD: Diagnosis and Treatment of Cutaneous Aspergillosis. J. Mycol. Infect. 2021; 83–86. Publisher Full Text 10. Nakashima K, Yamada N, Yoshida Y, et al. : Primary Cutaneous Aspergillosis. Acta Derm. Venereol. 2010; 90 (5): 519–520. Publisher Full Text 11. Van Burik JAH, Colven R, Spach DH: Cutaneous Aspergillosis. J. Clin. Microbiol. 1998; 36 (11): 3115–3121. Publisher Full Text 12. Pasqualotto AC, Denning DW: Post-operative aspergillosis. Clin. Microbiol. Infect. 2006; 12 (11): 1060–1076. Publisher Full Text 13. Donnelly JP, Chen SC, Kauffman CA, et al. : Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium. Clin. Infect. Dis. 2020; 71 (6): 1367–1376. PubMed Abstract | Publisher Full Text | Free Full Text 14. Patterson TF, Thompson GR, Denning DW, et al. : Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin. Infect. Dis. 2016; 63 (4): e1–e60. Publisher Full Text 15. Herbrecht R, Denning DW, Patterson TF, et al. : Voriconazole versus Amphotericin B for Primary Therapy of Invasive Aspergillosis. N. Engl. J. Med. 2002; 347 (6): 408–415. PubMed Abstract | Publisher Full Text 16. Tatara AM, Mikos AG, Kontoyiannis DP: Factors affecting patient outcome in primary cutaneous aspergillosis. Medicine (Baltimore). 2016; 95 (26): e3747. PubMed Abstract | Publisher Full Text | Free Full Text 17. Vazquez JA, Arganoza MT, Vaishampayan JK, et al. : In vitro interaction between amphotericin B and azoles in Candida albicans. Antimicrob. Agents Chemother. 1996; 40 (11): 2511–2516. Publisher Full Text 18. Avkan-Oğuz V, Çelik M, Satoglu IS, et al. : Primary Cutaneous Aspergillosis in Immunocompetent Adults: Three Cases and a Review of the Literature. Cureus. 2020; 12 (1): e6600. Publisher Full Text 19. Kalboussi Y, Chenbah W, Chouaieb H, et al. : Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report. [Data set]. Zenodo. 2026. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 Mar 2026 ADD YOUR COMMENT Comment Author details Author details 1 Laboratory of Parasitology - Mycology, Farhat Hached University Hospital of Sousse, Sousse, Sousse, Tunisia 2 University of Monastir Faculty of Medicine of Monastir, Monastir, Monastir, Tunisia 3 Department of Hematology, Farhat Hached University Hospital of Sousse, Sousse, Sousse, Tunisia 4 University of Sousse Faculty of Medicine of Sousse, Sousse, Sousse, Tunisia 5 Department of Infectious diseases, Farhat Hached University Hospital of Sousse, Sousse, Sousse, Tunisia Yasmine KALBOUSSI Roles: Conceptualization, Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Wafa CHENBAH Roles: Conceptualization, Data Curation, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Hamed CHOUAIEB Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Nour GAALOUL Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Samar ISMAIL Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Monia GUERMAZI Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Mariem BEN TICHA Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Imene KHAMMARI Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Yosra BEN YOUSSEF Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Akila FATHALLAH Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 30 Mar 2026, 15:454 https://doi.org/10.12688/f1000research.178649.1 Copyright © 2026 KALBOUSSI Y et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article KALBOUSSI Y, CHENBAH W, CHOUAIEB H et al. Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.12688/f1000research.178649.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 30 Mar 2026 Views 0 Cite How to cite this report: Rakkez R. Reviewer Report For: Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.5256/f1000research.197060.r481919 ) The direct URL for this report is: https://f1000research.com/articles/15-454/v1#referee-response-481919 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 18 May 2026 Rim Rakkez , Hematology, University Hospital of Martinique (Ringgold ID: 55525), Fort-de-France Bay, Fort-de-France, Martinique Approved VIEWS 0 https://doi.org/10.5256/f1000research.197060.r481919 I would like to thank the authors for this article, which is very interesting scientifically and written in clear, fluid English. However, I have a few comments that require minor revisions. First, in the case report, you mentioned that ... Continue reading READ ALL I would like to thank the authors for this article, which is very interesting scientifically and written in clear, fluid English. However, I have a few comments that require minor revisions. First, in the case report, you mentioned that the patient was admitted for consolidation chemotherapy. Could you specify the protocol used for ALL treatment? What was his hematological status? Second, Could you indicate after how many days of neutropenia did the cough appear? were the antifungal biomarkers performed ? you did mention the cutaneous lesion and its link to fever, but you did not specify the initial imaging done at the start, which showed no pulmonary lesions. This should be clearly stated in the case report. Finally, in the discussion, I think it is better to go straight to the core of the topic and avoid a review of the case. In addition, the epidemiology section on this cutaneous aspergillus infection should be slightly expanded to include whether many cases have been described in leukemic children. In conclusion, this case report demonstartes that one should not hesitate to biopsy any skin lesion mainly in the absence of infectious or microbiological documentation in a febrile neutropenic patient Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: acute leukemias, myeloid malignancies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Rakkez R. Reviewer Report For: Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.5256/f1000research.197060.r481919 ) The direct URL for this report is: https://f1000research.com/articles/15-454/v1#referee-response-481919 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Ben Abdallah R. Reviewer Report For: Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.5256/f1000research.197060.r472149 ) The direct URL for this report is: https://f1000research.com/articles/15-454/v1#referee-response-472149 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Apr 2026 Rim Ben Abdallah , Institut Pasteur de Tunis, Place Pasteur, Tunisia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.197060.r472149 General comments : This manuscript describes a rare of primary cutaneous aspergillosis in a neutropenic child. Invasive aspergillosis represents a major cause of morbidity and mortality in immunocompromised patients, particularly in pediatric populations with prolonged neutropenia. The ... Continue reading READ ALL General comments : This manuscript describes a rare of primary cutaneous aspergillosis in a neutropenic child. Invasive aspergillosis represents a major cause of morbidity and mortality in immunocompromised patients, particularly in pediatric populations with prolonged neutropenia. The topic is therefore of clear clinical interest. The case highlights the diagnostic challenges posed by atypical presentations of invasive fungal infections and emphasizes the importance of early recognition of cutaneous lesions. 1. Abstract - and and improve outcomes” → remove duplicate “and”. 2. Introduction 'No evident prior skin trauma' is an important point, but it could be better contextualised by briefly mentioning that PCA is usually associated with skin breaches caused by catheters, dressings or trauma, which makes this case unusual. - 5 year- old patient” → correct spacing: 5-year-old patient - The abbreviation 'PCA' should be used throughout the remainder of the manuscript after the first definition of primary cutaneous aspergillosis. 3. Case report : -clearer justification of PCA diagnosis : The authors should clarify: whether the ankle lesion was located near an intravenous catheter site, dressing, or skin injury, whether any local predisposing factors were present (skin maceration, adhesive tape, occlusion, trauma) - Lack of mycological confirmation from respiratory samples: The authors should explain why respiratory sampling was not performed (e.g. clinical instability). - The authors should clarify the exact interval between chemotherapy and the onset of symptoms; the timing of neutropenia and its duration and the interval between the appearance of skin lesions and pulmonary symptoms.. - If possible, it would be helpful to include other biological elements, such as CRP, and other microbiological analyses to rule out bacterial or viral infection. - The reported serum galactomannan index is positive at 0.57. The authors should clarify the positivity cut-off point used. - The six-month follow-up is valuable, but the report could be strengthened by including additional details, such as the presence or absence of residual scarring, imaging follow-up of pulmonary lesions and continuation of antifungal prophylaxis. 4. Discussion 1. The main limitation of the discussion is the interpretation of the infection as primary cutaneous aspergillosis that has disseminated to the lungs. A diagnosis of PCA requires compelling evidence that the skin lesion occurred prior to systemic involvement. In this case, however, pulmonary lesions were detected shortly after the cutaneous lesion, and no mycological confirmation was obtained from respiratory samples. The authors should clearly state this limitation in their interpretation of the primary cutaneous origin, and discuss the possibility of secondary cutaneous involvement. 2. « In this case, the positive GM antigenemia, concomitant with the cutaneous biopsy results and pulmonary imaging, was instrumental in confirming disseminated infection ». The role of galactomannan antigenemia in confirming disseminated infection may be overstated, particularly given the borderline index value (0.57) and the absence of microbiological confirmation from respiratory samples. The authors may consider presenting this result as supportive evidence rather than definitive proof of dissemination. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: parasitology-mycology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Ben Abdallah R. Reviewer Report For: Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.5256/f1000research.197060.r472149 ) The direct URL for this report is: https://f1000research.com/articles/15-454/v1#referee-response-472149 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 Mar 2026 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 30 Mar 26 read read Rim Ben Abdallah , Institut Pasteur de Tunis, Place Pasteur, Tunisia Rim Rakkez , University Hospital of Martinique (Ringgold ID: 55525), Fort-de-France Bay, Martinique Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Rakkez R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 18 May 2026 | for Version 1 Rim Rakkez , Hematology, University Hospital of Martinique (Ringgold ID: 55525), Fort-de-France Bay, Fort-de-France, Martinique 0 Views copyright © 2026 Rakkez R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I would like to thank the authors for this article, which is very interesting scientifically and written in clear, fluid English. However, I have a few comments that require minor revisions. First, in the case report, you mentioned that the patient was admitted for consolidation chemotherapy. Could you specify the protocol used for ALL treatment? What was his hematological status? Second, Could you indicate after how many days of neutropenia did the cough appear? were the antifungal biomarkers performed ? you did mention the cutaneous lesion and its link to fever, but you did not specify the initial imaging done at the start, which showed no pulmonary lesions. This should be clearly stated in the case report. Finally, in the discussion, I think it is better to go straight to the core of the topic and avoid a review of the case. In addition, the epidemiology section on this cutaneous aspergillus infection should be slightly expanded to include whether many cases have been described in leukemic children. In conclusion, this case report demonstartes that one should not hesitate to biopsy any skin lesion mainly in the absence of infectious or microbiological documentation in a febrile neutropenic patient Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise acute leukemias, myeloid malignancies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Rakkez R. Peer Review Report For: Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.5256/f1000research.197060.r481919) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/15-454/v1#referee-response-481919 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Ben Abdallah R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Apr 2026 | for Version 1 Rim Ben Abdallah , Institut Pasteur de Tunis, Place Pasteur, Tunisia 0 Views copyright © 2026 Ben Abdallah R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions General comments : This manuscript describes a rare of primary cutaneous aspergillosis in a neutropenic child. Invasive aspergillosis represents a major cause of morbidity and mortality in immunocompromised patients, particularly in pediatric populations with prolonged neutropenia. The topic is therefore of clear clinical interest. The case highlights the diagnostic challenges posed by atypical presentations of invasive fungal infections and emphasizes the importance of early recognition of cutaneous lesions. 1. Abstract - and and improve outcomes” → remove duplicate “and”. 2. Introduction 'No evident prior skin trauma' is an important point, but it could be better contextualised by briefly mentioning that PCA is usually associated with skin breaches caused by catheters, dressings or trauma, which makes this case unusual. - 5 year- old patient” → correct spacing: 5-year-old patient - The abbreviation 'PCA' should be used throughout the remainder of the manuscript after the first definition of primary cutaneous aspergillosis. 3. Case report : -clearer justification of PCA diagnosis : The authors should clarify: whether the ankle lesion was located near an intravenous catheter site, dressing, or skin injury, whether any local predisposing factors were present (skin maceration, adhesive tape, occlusion, trauma) - Lack of mycological confirmation from respiratory samples: The authors should explain why respiratory sampling was not performed (e.g. clinical instability). - The authors should clarify the exact interval between chemotherapy and the onset of symptoms; the timing of neutropenia and its duration and the interval between the appearance of skin lesions and pulmonary symptoms.. - If possible, it would be helpful to include other biological elements, such as CRP, and other microbiological analyses to rule out bacterial or viral infection. - The reported serum galactomannan index is positive at 0.57. The authors should clarify the positivity cut-off point used. - The six-month follow-up is valuable, but the report could be strengthened by including additional details, such as the presence or absence of residual scarring, imaging follow-up of pulmonary lesions and continuation of antifungal prophylaxis. 4. Discussion 1. The main limitation of the discussion is the interpretation of the infection as primary cutaneous aspergillosis that has disseminated to the lungs. A diagnosis of PCA requires compelling evidence that the skin lesion occurred prior to systemic involvement. In this case, however, pulmonary lesions were detected shortly after the cutaneous lesion, and no mycological confirmation was obtained from respiratory samples. The authors should clearly state this limitation in their interpretation of the primary cutaneous origin, and discuss the possibility of secondary cutaneous involvement. 2. « In this case, the positive GM antigenemia, concomitant with the cutaneous biopsy results and pulmonary imaging, was instrumental in confirming disseminated infection ». The role of galactomannan antigenemia in confirming disseminated infection may be overstated, particularly given the borderline index value (0.57) and the absence of microbiological confirmation from respiratory samples. The authors may consider presenting this result as supportive evidence rather than definitive proof of dissemination. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise parasitology-mycology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Ben Abdallah R. Peer Review Report For: Case Report: Primary Cutaneous Aspergillosis in a Neutropenic Child with Pulmonary Dissemination: A case report [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2026, 15 :454 ( https://doi.org/10.5256/f1000research.197060.r472149) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/15-454/v1#referee-response-472149 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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