Aspergillus Infection of Abdominal Wall Biologic Mesh

The use of acellular dermal matrix for contaminated abdominal wall reconstruction, after emergency surgery, and fungal infections of the abdominal wall have been described [1–4]. A 42-year-old woman was transferred to our tertiary care center with signs of peritonitis. On physical examination, she was found to have a fungating rectal mass. She was taken emergently to the operating room where she was found to have a perforated colon with gross peritoneal contamination due to complete distal obstruction by rectal cancer. We performed a partial sigmoid colectomy of the perforated segment. The patient was hemodynamically unstable, preventing definitive management of the rectal cancer. Because of volume resuscitation and bowel edema, we were unable to close the abdominal fascia primarily. Temporary abdominal closure was achieved using a vacuum pack fashioned in the operating room. We then returned to the operating room several times over the following week for repeated washouts, but as we did not believe she would be able to tolerate an abdominoperineal resection, a diverting end–colostomy and muocus fistula was created with plans for an oncologic procedure in the future.

After bowel edema resolved, the fascia was still unable to be closed because of retraction. We elected to use human acellular dermal matrix (AlloDerm; LifeCell, Branchburg, NJ) as a bioprosthetic mesh for abdominal closure, with the skin left open. We managed the exposed biologic mesh with a vacuum-assisted closure device (V.A.C.; KCI, San Antonio, TX). She remained critically ill in the intensive care unit, and on hospital day 20, a greenish growth was seen on the surface of her abdominal mesh (Fig. 1). Culture revealed fungal conidia and hyphal elements (Fig. 2), later speciating as Aspergillus fumigatus. At this point, in concert with the advice of our infectious disease colleagues, the wound care regimen was modified to a wet-to-dry dressing changed three times daily, using gauze soaked in amphotericin B. Despite the fact that neither drain fluid nor blood cultures grew bacteria or fungus, she decompensated clinically because of presumed fungal sepsis. She deteriorated further over the next several days and required increasing hemodynamic support. Subsequently, she was placed on comfort care at the request of her family and expired.

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FIG. 1.

Aspergillus infection of bioprosthetic mesh.

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FIG. 2.

Fungal elements isolated from bioprosthetic mesh.