To the Editors: A spergillosis is the most common mold infection in immune compromised patients,1 and can be nosocomially acquired. We report 2 cases of primary cutaneous aspergillosis (PCA) in previously healthy pediatric patients with multiple traumatic injuries after motor vehicle accidents. CASE 1 A previously healthy 6-year-old boy with a history of prematurity and mild intermittent asthma was admitted to the pediatric intensive care unit after he suffered pulmonary contusions and a mediastinal hematoma in a motor vehicle accident. He developed acute respiratory distress syndrome requiring venoarterial extracorporeal membranous oxygenation. He received systemic corticosteroids for his lung injury and vancomycin for Staphylococcus aureus bacteremia. He developed erythematous bullous lesions on his left proximal forearm, which underwent necrosis with central ulceration (see Fig. 1). Tissue culture grew Aspergillus fumigatus and he was treated with intravenous voriconazole for 21 days, followed by 10 days of oral therapy.FIGURE 1: Bullous lesion of the left forearm after undergoing necrosis and ulceration.CASE 2 A previously healthy 2-year-old girl suffered pulmonary contusions and thoracic spondylolisthesis in a motor vehicle accident. She developed acute respiratory distress syndrome requiring high-frequency oscillatory ventilation and completed a 2-week course of methylprednisolone. Sputum cultures grew Acinetobacter baumanii and Moraxella catarrhalis for which she was treated with vancomycin and cefotaxime. She developed multiple indurated erythematous papules with central eschar on her extremities. Wound culture grew A. fumigatus. She completed a 6-week course of voriconazole, with resolution of the lesions. DISCUSSION PCA is typically associated with alterations in skin integrity and immune compromise. The morphology of lesions varies. It may first manifest as erythema and induration, but can progress to papules, nodules, macules, plaques, pustules, vesicles, bullae or ulcers.1 Diagnosis is typically made by skin biopsy for histopathology and culture. Amphotericin B has historically been first-line therapy; however, voriconazole has been shown to be superior in adults, has a good safety profile in children and offers oral administration.2 Our patients were previously healthy, without underlying immune suppression, but other factors likely caused transient alteration in their defenses. They suffered multiple traumatic injuries, and may have had unrecognized alterations in skin integrity. Trauma is known to alter cellular and humoral immunity, with an initial proinflammatory response to the injury characterized by activation of nuclear factor-κB with resultant increases in acute phase reactants such as cytokines, specifically interleukin (IL)-1b, IL-6, IL-8 and tumor necrosis factor-α. After this proinflammatory state, a compensatory antiinflammatory response syndrome or immune paralysis can occur. Patients develop impaired monocyte function with decreased expression of human leukocyte antigen DR and decreased production of tumor necrosis factor-α, resulting in predominance of the Th2 lymphocyte pattern.3 Posttraumatic impairment of monocyte activity has been shown to correlate with severity of injury, and is predictive of the development of systemic inflammatory response syndrome.4 Corticosteroids have been associated with PCA, with impairment of glycemic control, phagocytic function and strength of the skin barrier.5 Broad spectrum antibiotics can also increase susceptibility to fungal infections in immune compromised patients. Emily B. Martin, MD Department of Pediatrics Division of Critical Care Ochsner Medical Center Jefferson, LA Paul A. Gastañaduy, MD, MPH Department of Pediatrics Division of Pediatric Infectious Diseases Emory University School of Medicine Andres F. Camacho-Gonzalez, MD Allison C. Ross, MD Department of Pediatrics Division of Pediatric Infectious Diseases Emory University School of Medicine Children’s Healthcare of Atlanta at Egleston Kiran Hebbar, MD Department of Pediatrics Division of Pediatric Care Emory University School of Medicine Children’s Healthcare of Atlanta at Egleston Atlanta, GA