Aspergillus is a fungus with spores present in the air but usually does not cause disease unless it reaches an individual with a compromised immune system.

In 1729, the Italian priest and biologist Pier Antonio Micheli classified the genus Aspergillus. He observed the fungus under a microscope and compared the shape of it to a holy water sprinkler called aspergillum (from the Latin spargere that means to sprinkle). It was only in 1809 that Johann Heinrich Friedrich Link a German mycologist described the fungus [1]. Much later in 1856 the famous Rudolf Virchow reported the first case of human pulmonary aspergillosis [2].

Aspergillus is a genus composed of hundreds of mold species that can be found in different environments worldwide. They are a pervasive group of fungi, which from time to time, may produce significant and occasionally deadly infections in humans. Aspergilli are known to produce diverse toxins, including a very powerful carcinogen known as aflatoxin. These fungi may be found ubiquitous anywhere there is waste, decomposing, or standing matter.

It has been historically speculated that the curse of Egyptian pharaohs associated with tomb diggings may in fact, be attributed to thousand-year-old Aspergillus niger survived in the decomposing flesh and wraps of the mummies. Moreover when those caskets were pried open, the fungi was most probably aerosolized by way of dust and inhaled by the excavator. Several weeks or months later, the digger was afflicted by a mysterious pneumonia, from which he subsequently died.

Typically only patients with compromised immune systems or who suffer from other lung conditions [cystic fibrosis, chronic obstructive pulmonary disease (COPD), severe asthma] are susceptible to Aspergillus. Additionally patients with cancer, on chemotherapy or chronic steroid therapy, transplant recipient patients, patients with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), chronic granulomatous disease (CGD) among others are also susceptible hosts [3,4].

The major forms of disease are predominantly paranasal sinus, allergic bronco-pulmonary or pulmonary infections but cardiac, orthopedic, and ophthalmic infections have also being reported [5-14]. Immunosuppression is a significant contributing factor to those infections [15,16]. Aspergillus can spread to patients through air, food, or direct contact. There are several reported cases in the literature, including the lower extremities with multiple debridements for extensive gangrene; others regarding burn patient with lesions mimicking methicillin resistant staphylococcus aureus (MRSA) and a cluster of cutaneous Aspergillus niger infections that transpired on a transplant unit adjacent to a kitchen [15-17]. Aspergillus has been isolated in 367 molds in hospital air and from 23 patients [18].

Dirty air conditioning units, compost piles and moist or flood-damaged houses can produce a high number of Aspergillus spores. Although compromised immune system remains a crucial factor.

Fungal infections of the vaginal tract account for a substantial number of patient telephone and e-mail consultations, office visits, and over the counter and prescription drug over utilization.

Identifying pseudo-hyphae on a potassium hydroxide (KOH) wet mount preparation and obtaining a fungal culture are two necessary steps before starting therapy. Identifying the specific fungus is required to achieve targeted therapeutic success.

Aspergillus is not a common fungus complicating chronic or recurrent vaginal infections and there is only one publication found in the recent literature that reports the prevalence of Aspergillus genital infections in women [19].

In the same publication, Baggish and Ventolini described 16 Aspergillus infections in patients with chronic unresponsive infections of the vulva, vestibule, and/or vagina. It is important to notice that neither of those patients had a compromised immunity system. The authors reported to have prescribed Itraconazole for 30 days and to have effectively resolved the lower genital tract colonization in that cohort of patients [19].

Itraconazole is a potent inhibitor of most human fungal pathogens including Aspergillus sp. Baggish and Ventolini therefore concluded that given the appropriate opportunistic settings (recurrent infections and perhaps and altered local immune response), Aspergillus fungus can and will cause serious infections. Additionally they recommended keeping a high index of suspicion for Aspergillus species colonization in patients which chronic vaginal fungal infections and to include Aspergillus in the differential diagnosis [19].

Fruiting bodies and hyphae of Aspergillus are also rarely observed in routine Papanicolau smears. When discovered, differentiating between an infection and a contamination should be made; due to the toxicity of the antifungal involved to treat a true infection, the psychological impact that causes to the patient and the necessary assessment of the immune status and follow-up requirements [20].

Regarding research on Aspergillus as a cause of opportunistic vaginal infections, most of this research has focused on finding their growth patterns, the virulence factors produced by them as well as developing new methods for their diagnosis and to assessing the effect of environmental factors on their gene expression.

Fungi that grow over a widespread range of extracellular pH, including the vaginal cavity, must have evolved to sense and respond correctly to their environment. For instance Aspergillus, a human opportunistic pathogen colonizes and infects anatomical sites of diverse pH. This ability is governed by signal transduction pathways like the one that activates the transcription factor Rim101p [21].

Additionally, in a house-to-house survey by means of cluster sampling 1,344 married women from urban and rural areas of Upper Egypt were interviewed and examined in 2002 by Sullam et al. [22], to study the extent and causes of reproductive tract infections. Overall prevalence was found to be 52.8% with Aspergillus species at 7.4%. The authors identified women at high risk of developing reproductive tract infections as those with an intrauterine device and those practicing vaginal douching.

Aspergillus fungus can and will cause serious infections with the right opportunistic vaginal settings: recurrent infections altered local or systemic immune response. Therefore keeping a high index of suspicion for Aspergillus species colonization in patients with recurrent vaginal fungal infections and patients who are immuno compromised is recommended.