[Surgical treatment for pulmonary aspergillosis]

Between 1985 and 1994, 141 patients with pulmonary aspergilloma underwent surgical treatment in 18 hospitals, which belong to Japanese Tuberculosis Research Committee. Applied surgical procedures are divided into two major categories. One is pulmonary resection variety, and the other is lung preserving or space reducing surgery. The former consists of 20 pneumonectomies, 62 lobectomies and 13 lesser operations. The latter is composed of combined mordalities of space reducing surgery (SRS) such as thoracoplasty, air-plombage, cavernoplasty and muscle plombage to reduce the cavity or the emphysematous bulla, which contains fungus balls within it. This kind of operation is applied for the patients, who have impaired lung function, strong pleural adhesion and severe complications. Triad of thoracoplasty, cavernoplasty and muscle plombage is the most frequent combination and was applied to 20 patients in this study. Operative mortality is one in pulmonary resection group and none in SRS group. Hospital deaths are two in the former and one in the latter. Success rate of operation is 95.8% in pulmonary resection, and 78.3% in SRS, especially 85.0% in the triad, mentioned above. However, SRS required a couple of additional operation on occasion to reach final success. Morbidity rate is 23.2% in pulmonary resection, and 17.4% in SRS. Thoracic empyema with or without bronchial fistula is the most common complication of the former. On the other hand, infection of the residual cavity and subcutaneus abcess are the main complications of the latter.

Early surgical management of invasive gingival aspergillosis in a neutropenic patient with leukemia: a case report

Primary invasive aspergillosis of the oral cavity is a rare but serious complication in immunocompromised patients. We report a case of gingival Aspergillus infection in a neutropenic patient with acute myelogenous leukemia, who was successfully treated by an early surgical approach in combination with antifungal medication and granulocyte colon stimulating factors.

Improved management of invasive pulmonary aspergillosis in neutropenic patients using early thoracic computed tomographic scan and surgery

PURPOSE

The prognosis of invasive pulmonary aspergillosis (IPA) occurring in neutropenic patients remains poor. We studied whether new strategies for early diagnosis could improve outcome in these patients.

PATIENTS AND METHODS

Twenty-three histologically proven and 14 highly probable IPAs in 37 hematologic patients (neutropenic in 36) were analyzed retrospectively.

RESULTS

The most frequent clinical signs associated with IPA were cough (92%), chest pain (76%), and hemoptysis (54%). Bronchoalveolar lavage (BAL) was positive in 22 of 32 cases. Aspergillus antigen test was positive in 83% of cases when tested on BAL fluid. Since October 1991, early thoracic computed tomographic (CT) scans were systematically performed in febrile neutropenic patients with pulmonary x-ray infiltrates. This approach allowed us to recognize suggestive CT halo signs in 92% of patients, compared with 13% before this date, and the mean time to IPA diagnosis was reduced dramatically from 7 to 1.9 days. Among 36 assessable patients, 10 failed to respond (amphotericin B [AmB] plus fluorocytosyne, n = 2; itraconazole + AmB, n = 8) and died of aspergillosis. Twenty-six patients were cured or improved by antifungal treatment (itraconazole with or without AmB, n = 22; voriconazole, n = 4). In 15 of 16 cases, surgical resection was combined successfully with medical treatment. Achievement of hematologic response, early diagnosis, unilateral pulmonary involvement, and highest level of fibrinogen value < 9 g/L were associated with better outcome.

CONCLUSION

In febrile neutropenic patients, systematic CT scan allows earlier diagnosis of IPA. Early antifungal treatment, combined with surgical resection if necessary, improves IPA prognosis dramatically in these patients.

[Drug treatment of invasive aspergillosis of the paranasal sinuses]

Aspergillosis belongs to the group of mycotic diseases of the paranasal sinuses. The invasive forms, and particularly the fulminant forms, are potentially fatal. Primary surgical intervention with complete removal of the mycotic mass should be performed. Additionally an antimycotic drug therapy with amphotericin B must be started. In a review of the literature, there is no case surviving an extended invasive aspergillosis after failure of the operative therapy and after failure of the postoperative amphotericin B treatment. We report an interesting case of a complete remission of an invasive, partially fulminant aspergillosis of the paranasal sinuses and frontal and basal regions. After incomplete removal of the mycotic mass by an endo- and extranasal approach, we started postoperative drug therapy with amphotericin B. Under this treatment the mycosis progressed. Additionally the patient developed severe renal side effects requiring suspension of the treatment. At this time, we started a combined antimycotic drug therapy with liposomal amphotericin B (AmBisome) and itraconazol. Within 10 weeks there was complete clinical and radiologic remission. The patient died 63 weeks after this treatment because of a fulminant bacterial pneumonia. Post mortem examination showed no aspergillosis in the skull base, the paranasal sinuses, or in the lung. The question arises as to whether this drug combination of liposomal amphotericin B (AmBisome) and itraconazol is a real alternative to high-risk surgical interventions in this region.

Functional endoscopic sinus surgery and 109 mycetomas of paranasal sinuses

Mycetomas of paranasal sinuses are more frequently diagnosed with the widespread use of nasal endoscopy and computed tomography (CT). We present a series of 109 cases treated by functional endoscopic sinus surgery (FESS) with a mean follow-up of 29 months. All localizations were seen, and contrary to what was initially thought, seven cases presented in multiple sites. Several clinical presentations were found, from a pansinusal involvement to a simple mycetoma hanging in a superior meatus. A heterogeneous sinus opacity with microcalcifications on CT scan is very suggestive of the diagnosis, but a homogeneous opacity may be encountered even with bone lysis. FESS was performed in all cases to obtain a wide opening of the affected sinuses, permitting a careful extraction of all fungal material. In the postoperative period, no medical treatment is prescribed. With a mean follow-up of 29 months, only four recurrences were seen. This study reinforces the interest in FESS for cases of mycetoma of the paranasal sinuses.

Intracerebral Aspergillus abscess: case report and review of the literature

Intracranial aspergillosis is a rare pathologic condition, difficult to treat and often fatal, which generally affects immunodepressed patients. A case of brain abscess secondary to pulmonary localization in a patient with a non-Hodgkin lymphoma is described. The most significant clinico-pathological findings of intracranial aspergillosis are examined in the light of the relevant literature.

[A case of cerebral aspergillosis associated with induction chemotherapy for acute lymphoblastic leukemia]

A case of cerebral aspergillosis during induction chemotherapy for acute lymphoblastic leukemia was described. A 5-year-old boy complained of headache and left homonymous hemianopsia during induction chemotherapy for acute lymphoblastic leukemia. CT scan and MR imaging survey demonstrated cerebral fungal lesion as well as multifocal lung lesions. A cerebral lesion appeared as a low density mass in right occipital lobe with marginal enhancement on CT scan, and iso- and high-signal intensity appeared with marginal gadolinium enhancement on T1- and T2-weighted MR imaging. Although fungus balls in the lung responded well to daily intravenous administration of amphotericin-B for 2 months, the cerebral lesion showed a rather expansive character as invading into neighbouring falx, opposite occipital lobe, meninges, and occipital bone. Extensive removal of the brain lesion from the parenchyma, falx, invaded dura, and skull was surgically performed. The lesion was confirmed as aspergillosis by Grocott's methenamine histological stain. Surgical intervention and concomitant use of amphotericin-B for a month resulted in complete remission of the aspergillosis. After 6 years, a cranioplasty was successfully completed for the occipital bone defect.

Aspergilloma in the paracavernous region--two case reports

A 30-year-old male and a 40-year-old female presented with Aspergillus fungal granuloma in the cerebral locations involving the gasserian-ganglion and its divisions in one case and was densely adherent to the lateral dural wall of the cavernous sinus in the other. Both patients were otherwise healthy with no evidence of immuno-suppression. The lesions resembled benign tumor on preoperative imaging and intraoperative consistency and vascularity. The lesions were successfully and completely resected. Both patients developed major cerebral arterial territory infarcts in the postoperative phase, remote from the site of operation, leading to crippling neurological deficits in one patient and death in the other. The unusual location and the unusual and similar clinical course suggests that awareness of the possibility of ischemic complications after surgical resection of intracranial aspergillomas is necessary.

Aspergillomas of the sphenoid sinus: a series of 10 cases treated by endoscopic sinus surgery

We report our experience with 10 cases of sphenoidal aspergillomas treated by endoscopic sinus surgery (ESS). Chronic symptoms such as cough, post-nasal discharge, dysphonia and even facial pain can be encountered in the history. Computerised tomography and, occasionally, magnetic resonance imaging are of great help in the assessment of this disease, especially when extensive skull base involvement is present. The radiological presentation can vary from an heterogeneous to homogeneous opacity with or without bone lysis to a frank pseudotumoural appearance. Four diagnostic tools have been evaluated to confirm the diagnosis: histology, direct smear, fungal cultures, and serology for Aspergillus. ESS has been successfully carried out without morbidity in all cases. No recurrence of the disease is seen after a mean follow-up of 27 months.

[Pulmonary aspergillosis: clinical findings and surgical treatment]

Between 1980 and 1995, 10 patients underwent thoracotomy for pulmonary aspergillosis. In six patients, hemoptysis and bloody sputum were the chief complaints. The other complaints were nonspecific. Six patients had a history of pulmonary tuberculosis, and two of those patients underwent upper lobectomy. Aspergillosis had developed in the residual space. A fungus ball was observed on the preoperative chest X-ray and CT scan films in seven patients. Lobectomy was done in three patients, segmentectomy in two, and partial pulmonary resection in four. The patients with lesions that had grown in the residual space underwent curettage with muscle plombage. Three patients underwent thoracoplasty. An additional operation was done in two patients because of poor residual lung expansion. No patient had recurrence. We conclude that surgical treatment should be based on symptoms and on pathological findings.

[Aspergillosis of maxillary sinus: a case report]

A case of semi-invasive maxillary aspergillosis that presented with epiphora and responded well to surgical treatment is reported. Sixteen percent of cases of chronic sinusitis are produced by mycosis (particularly aspergillosis). The infection may be limited to the affected sinus (non-invasive forms) or may destroy the sinus wall, without tissue invasion (semi-invasive forms) or with tissue invasion (invasive forms). The diagnosis is mainly histological. Cultures present a high percentage of false positives and negatives. Treatment consists of surgical debridement of the sinus. Systemic amphotericin B is reserved for invasive aspergillosis (particularly fulminant cases).

Aspergillus sinusitis: clinical aspects and treatment outcomes

Seventy-two cases of Aspergillus sinusitis were analyzed during a period of 14 years from January 1980 through October 1993. There were 60 cases of primary type and 12 cases of secondary type. The maxillary and ethmoid sinuses were most commonly affected in both primary and secondary types. The sphenoid sinus was commonly involved in secondary type. Fourteen (23%) cases of primary type and 4 (33%) cases of secondary type demonstrated sinus wall destruction on computed tomography or magnetic resonance images. Seventy percent of primary type and all cases of secondary type showed focal or diffuse areas of increased attenuation in the soft tissue mass on computed tomography scans. Sixteen cases assessed by magnetic resonance imaging showed decreased signal intensities on T1-weighted images and markedly reduced signal intensities on T2-weighted images. Fifty-nine (98%) of 60 cases of primary type were noninvasive, and 1 was invasive. In secondary type, 10 (83%) of 12 patients had noninvasive disease. The most common coexisting disease in secondary aspergillosis was diabetes mellitus. Thickened mucosa with necrotic brownish green material, which was the most common finding in both types, was found in 33 patients with primary type and in 5 with secondary type. Surgery was performed in most cases, among which 4 patients received chemotherapy after surgery with amphotericin B with or without flucytosine. All patients were cured without recurrence during a mean follow-up period of 13 months.

Aspergillus endocarditis in chronic granulomatous disease

We report the first case, to our knowledge, of Aspergillus endocarditis in chronic granulomatous disease in a patient who also had an atrial septal defect. A diagnosis was made on culture of the organism from the mass despite extensive prior investigation. The presence of distinctive skin lesions as a diagnostic clue of fungaemia is highlighted. Possible advances in diagnosis by detection of fungal cell wall components and in prophylaxis by use of itraconazole are referred to. We conclude that fungal endocarditis should be considered in this condition, especially in the presence of a structural heart defect.

Soft-tissue fungal infections: surgical management of 12 immunocompromised patients

Isolated fungal soft-tissue infections are uncommon but may cause severe morbidity or mortality among transplant recipients and other immunosuppressed patients. Twelve immunocompromised patients illustrating three patterns of infection were treated recently at the Duke University Medical Center. These groups comprised (I) locally aggressive infections, (II) indolent infections, and (III) cutaneous manifestations of systemic infection. Patient diagnoses included organ transplant, leukemia, prematurity, chronic obstructive pulmonary disease, and rheumatoid arthritis. Time from immunosuppression to biopsy ranged from 5.5 to 31 weeks. Organisms included Aspergillus, Rhizopus, Fusarium, Paecilomyces, Exophiala, and Curvularia. Patients presented with necrotic ulcerations or nodules. Surgical treatment ranged from radical debridement to excisional biopsy to none. Antifungal chemotherapy also was employed in some cases. The mortality rate was 33 percent, two patients dying without evidence of fungal infection. Six of the eight survivors cleared their infections. Necrotic skin lesions with surrounding erythema in this population call for prompt examination, biopsy, and culture. Group I lesions mandate radical excision with rapid intraoperative microscopic control and systemic antifungal medication. Group II requires surgical control with or without antifungal therapy. Group III requires systemic antifungal therapy for metastatic infection. In our opinion, treatment of fungal soft-tissue infection should be tailored to infection type and requires a team approach of surgeon and expert infectious disease consultation.

Aspergillosis of the sphenoid sinus: presentation as a pituitary mass and postoperative gallium-67 imaging

Invasive aspergillosis of the paranasal sinuses is an uncommon, but well-recognized, form of fungal infection. We describe an elderly female patient with invasive aspergillosis of the sphenoid sinus and associated osteomyelitis of the skull base, with clinical presentation as a pituitary mass. Postoperative gallium scan showed intense uptake in the sphenoid sinus, which resolved after treatment with amphotericin-B. This case demonstrates some of the pathologic and clinical features of invasive aspergillosis and suggests a potential role for gallium-67 imagining in monitoring clinical response to therapy.

One-stage surgical treatment of pulmonary aspergilloma with cavernostomy and muscle transposition flap: a case report

A 47-year-old female with cough and recurrent haemoptysis was admitted to Ratchaburi Hospital. Chest X-ray revealed a fungal ball in RUL. Aspergillus fumigatus was diagnosed by fungus culture from the material of the fungus ball. A one-stage cavernostomy was done and the fungus ball was then removed, obliteration of the cavity with intrathoracic transposition of extrathoracic skeletal muscle (latissimus dorsi) was performed. She recovered well, and haemoptysis disappeared. The body weight increased to 48 kgs in 4 postoperative months. (Fig. 6)

Aspergillus infection of the neck with an extradural component: an unusual presentation

A 66-year-old Chinese male, diabetic and hypertensive for more than 10 years, had excision of right cerebellar abscess in 1985. Histology then was suggestive of Aspergillus colonies. He presented to the ENT Department 7 years later, in September 1992, with complaints of a left-sided neck lump and fullness for 3 months which was shown on histology and culture to be Aspergillosis. CT scan findings revealed extradural involvement with erosions of parts of the cervical vertebrae. The patient, however, did not show any signs of spinal cord involvement. This case illustrates the long indolent period which Aspergillus infection can take. It also highlights the fact that it can mimic the radiological features of a highly malignant lesion. Follow-up CT scans of the patient revealed resolution of the lesion with itraconazole therapy.

Treatment of invasive pulmonary aspergillosis in severely neutropenic children with malignant disorders using liposomal amphotericin B (AmBisome), granulocyte colony-stimulating factor, and surgery: report of five cases

Five children with malignancies developed invasive pulmonary aspergillosis during chemotherapy-induced neutropenia. All patients were treated with liposomal amphotericin B and human recombinant granulocyte colony-stimulating factor. Two patients did not recover from bone marrow aplasia and died from organ-infiltrating fungal invasion. Two patients who recovered from bone marrow aplasia survived after surgery of the pulmonary lesions. The fifth patient had a complete resolution of invasive pulmonary aspergillosis after neutrophil recovery without surgical intervention. We conclude that not only the antifungal treatment but also the recovery of granulocytes are important in localizing invasive forms of Aspergillus infections in patients with profound immunosuppression.

Invasive Aspergillus sinusitis in pediatric bone marrow transplant patients. Evaluation and management

OBJECTIVES

To evaluate the following: the incidence of invasive Aspergillus sinusitis (AS); the value of surveillance nasal cultures and screening radiologic studies in predicting AS; the clinical criteria used to decide on surgical biopsy in patients suspected of having AS; the surgical and medical management of AS; and the outcome of AS in the peritransplantation period of children who underwent bone marrow transplantation.

DESIGN

Retrospective medical chart review.

SETTING

Tertiary care children's hospital.

PATIENTS

Eighty pediatric patients who underwent bone marrow transplantation for a variety of refractory malignant neoplasms or lymphohematopoietic disorders at the Children's National Medical Center, Washington, DC, from April 1, 1988, to September 30, 1993.

INTERVENTION

Diagnostic surgical biopsies, surgical débridement, and treatment with amphotericin B.

MAIN OUTCOME MEASURE

Resolution of AS and discharge from the hospital.

RESULTS

Seventy-two patients had screening sinus radiographs, 27 of which showed abnormalities. Aspergillus sinusitis developed in three of the patients with abnormal screening radiographs. Fifty-eight patients had screening nasal cultures. One culture was positive for Aspergillus, and histopathologically proved AS developed in this patient. Twelve diagnostic biopsies were done in nine patients. Three biopsy specimens showed histopathologic evidence of AS. The three patients with AS were successfully treated with aggressive surgical and medical therapy and were discharged from the hospital.

CONCLUSION

The incidence of AS was 4% (3/80) in the patients who underwent bone marrow transplantation. Screening radiographs, while not a good predictor of AS, have a role in evaluation of patients undergoing bone marrow transplantation to define preexisting sinus disease. Screening nasal cultures do not reliably predict AS. When AS is suspected and diagnostic biopsy is considered, the seven clinical criteria outlined in this article should be used. Survival of immunocompromised patients with AS requires early diagnosis and aggressive surgical and medical therapy.

Trans-superior meatal approach to the sphenoid sinus

We have recently operated on patients with isolated lesions of the sphenoid sinus using the trans-superior meatal approach that we developed. This may be one of the least traumatic methods for treating the isolated lesions of the sphenoid sinus. Though it has a few limitations, this approach provides a direct and safe short-cut to the sphenoid sinus and is well tolerated by the patient under local anesthesia. We present our experience with transnasal trans-superior meatal approach to the sphenoid sinus and introduce the technique with case reports.

Aspergillus sinusitis in patients with AIDS: report of three cases and review

Invasive aspergillosis is an uncommon but increasingly reported complication of AIDS. Sinusitis, usually bacterial in etiology, is frequently seen among human immunodeficiency virus (HIV)-infected patients. We discuss the cases of three patients with AIDS and invasive aspergillus sinusitis seen at our institutions and those of 15 patients who are described in the literature. Seven of the 18 had brain involvement, 3 had orbital involvement, and 7 had mastoid or other bony disease. Three had evidence of concomitant invasive pulmonary aspergillosis. Of 15 patients with evaluable histories, 11 had recognized risks for invasive aspergillosis; 6 had previous sinusitis, otitis, or polyposis; and 11 had prior conditions indicative of advanced HIV-related disease. Despite aggressive surgical intervention and systemic antifungal therapy, nearly all patients died as a result of aspergillosis.

Pulmonary resection for invasive Aspergillus infections in immunocompromised patients

Standard antifungal medical therapy of invasive pulmonary aspergillosis that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less than a 5% survival. In view of these dismal mortality rates, we adopted an aggressive approach with resection of the involved area of lung along with systemic antifungal therapy when localized invasive pulmonary aspergillosis developed in these patients. Between January 1987 and December 1993, 14 patients with hematologic diseases and 2 liver transplant recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (range 1 to 45 days) after the diagnosis was clinically suggested and confirmed by chest computed tomographic scans. Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracoplasty, nine lobectomies, and five wedge resections (one patient with hematologic disease had two procedures). All patients were treated before and after the operation with antifungal agents. Nine (64%) of 14 patients with hematologic disease and 2 (100%) of 2 liver transplant recipients survived the hospitalization with no evidence of recurrent Aspergillus infection after a median 8 months of follow-up (range 3 to 82 months). The five hospital deaths (all patients with hematologic diseases) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple organ system failure with presumed disseminated Aspergillus infection in one. Four of the five deaths were in patients with allogeneic bone marrow transplants. Two of the three patients requiring resection of multiple foci of infection died, as did the only patient who was preoperatively ventilator dependent. In immunocompromised patients with hematologic diseases or liver transplantation with invasive pulmonary aspergillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.

Subclavian artery branch ligation reduces hemorrhage during resection of pulmonary aspergilloma

Treatment of a 71-year-old woman with recurrent massive hemoptysis secondary to an aspergilloma and pleural aspergillosis is reported. Branches of the subclavian artery were ligated using an anterior approach before performing the thoracotomy, and pleuropneumonectomy was accomplished after ligation of the costal arteries. This technique provided a relatively bloodless field and minimized blood loss.