Anna-Maria Mitropoulou

Background: Primary post-traumatic aspergillosis is an uncommon fungal infection resulting from direct inoculation of Aspergillus species into disrupted skin and soft tissue. Although it is more frequently encountered in immunocompromised patients, severe localized infection may also occur after traumatic inoculation, particularly in the presence of previously unrecognized predisposing conditions. Involvement of the hand is rare. Case Presentation: A 68-year-old man was referred to our department with a progressive necrotizing infection of the right hand following an occupational agricultural injury. The initial injury had been surgically treated at another institution. On presentation, extensive necrosis involved the palmar aspect of the hand; the index, middle, and ring fingers; and the hypothenar region. The patient had no known systemic condition predisposing him to fungal infection at presentation. During hospitalization, however, persistent hyperglycemia led to the diagnosis of previously unrecognized and uncontrolled diabetes mellitus. Surgical exploration revealed extensive soft-tissue necrosis, thrombosed vessels, poorly perfused and friable tendinous structures, and exposed bony structures of the middle and ring fingers. Aspergillus fumigatus was repeatedly isolated from wound and deep-tissue specimens. Antifungal therapy was initially started with amphotericin B but was discontinued because of a severe allergic reaction and replaced with voriconazole. Three sequential surgical debridements were performed. Magnetic resonance imaging demonstrated extensive soft-tissue involvement without evidence of osteomyelitis. A fourth operation combined further debridement with amputation of the irreversibly damaged middle and ring fingers and immediate reconstruction of the resulting defect with local flap coverage. Subsequent cultures were negative, and the postoperative course was uncomplicated. Conclusions: Post-traumatic A. fumigatus infection of the hand is rare but may lead to extensive soft-tissue destruction. An invasive fungal infection should be considered in progressive necrotizing wounds following contaminated trauma, particularly when the clinical course is atypical or refractory to conventional antibacterial treatment. Early microbiological diagnosis, systemic antifungal therapy, repeated surgical debridement, and recognition of underlying predisposing conditions are essential for successful management.

Background and Clinical Significance: Ganglioneuromas are rare benign tumors of neural crest origin, with gastrointestinal involvement being uncommon and ampullary localization exceptionally rare. Pancreatic neuroendocrine tumors (NETs) are also uncommon neoplasms with variable biological behavior. The coexistence of these two entities is unusual, particularly in the absence of an identifiable hereditary syndrome. Case Presentation: A 38-year-old man presented with hematemesis and multiple episodes of melena over 18 h and was found to have significant anemia with borderline hemodynamic stability. Upper gastrointestinal endoscopy revealed an enlarged, actively bleeding papilla of Vater, and initial hemostasis was achieved with adrenaline injection and endoscopic clipping. However, recurrent massive bleeding developed within 36 h, accompanied by hemodynamic instability. Repeat endoscopy confirmed ongoing hemorrhage, and the patient subsequently underwent emergency pancreaticoduodenectomy. Histopathological examination demonstrated an ampullary ganglioneuroma and an incidental well-differentiated pancreatic neuroendocrine tumor (WHO Grade 2). Surgical margins were negative, and no lymph node metastases were identified. Further evaluation for hereditary endocrine syndromes was unremarkable. The patient remains asymptomatic, with no evidence of recurrence during a 10-year follow-up period. This case highlights the diagnostic and therapeutic challenges associated with rare periampullary tumors. Although ganglioneuromas are typically benign, their anatomical location may result in severe clinical manifestations such as life-threatening bleeding. The coexistence with a pancreatic NET raises questions regarding potential shared pathogenesis, although no genetic syndrome was identified. Limitations of endoscopic management in uncontrolled bleeding and the importance of definitive surgical intervention are emphasized. Conclusions: This case highlights an exceptionally rare coexistence of ampullary ganglioneuroma and pancreatic neuroendocrine tumor presenting with life-threatening gastrointestinal bleeding. Although ganglioneuromas are benign, their anatomical location may result in severe clinical manifestations. Early recognition and decisive surgical management are crucial when endoscopic control fails. Favorable long-term outcomes can be achieved following complete resection.