Pulmonary aspergillomas treated with corticosteroids

The development of an aspergilloma in a damaged lung is often a silent process, though such patients are more likely to have chronic cough and recurrent haemoptysis.

Two patients are described who had aspergillomas associated with chronic ill health, weight loss, and copious purulent and often bloodstained sputum. Treatment with antibiotics was ineffective but the response to corticosteroids was striking. Reasons are given for believing that the symptoms were due to an Arthus type of antigen-antibody reaction in the cavity wall.

Use of the immunodiffusion test in the serodiagnosis of aspergillosis

The diagnostic value of an immunodiffusion (ID) test with standardized precipitinogens derived from five Aspergillus species was determined with sera from 60 proven and 12 suspected cases of aspergillosis. The data demonstrated that the greatest number of aspergillosis cases were detected by the concurrent use of A. fumigatus and A. niger precipitinogens. With these precipitinogens, the ID test permitted the serodiagnosis of aspergillosis in 82% of the 60 proven cases and in 83% of the 12 suspected cases. The presence of one or more precipitins was indicative of aspergilloma, of allergic bronchopulmonary aspergillosis, or of invasive aspergillosis. Precipitins were detected in 93% of the sera from patients with aspergilloma, in 50% of the sera from patients with allergic bronchopulmonary aspergillosis, and in 88% of the sera from patients with invasive aspergillosis. Although the presence of one or two precipitin bands could indicate any form of aspergillosis, the presence of three or four was strong evidence of either aspergilloma or invasive aspergillosis. The ID test was found to be 100% specific in an evaluation of its effectiveness with 65 sera from individuals with other systemic mycotic infections, bacterial or neoplastic diseases, and from apparently normal humans. In diagnosed cases of aspergillosis, the examination of serial serum specimens provided information about the clinical course of the disease. A reduction in the number of precipitin bands and significant titer changes were noted as the patients responded to therapy.

The human alveolar macrophage: isolation, cultivation in vitro, and studies of morphologic and functional characteristics

Human alveolar macrophages were lavaged from surgically resected lungs and from lungs of normal subjects. Macrophages that had been purified by glass adherence were maintained in tissue culture for as long as 54 days. After 3-4 wk in vitro they underwent transformation into multinucleated giant cells. These aged cells had more than 30 times the phagocytic capacity that the same group of cells had had after 1 day in vitro. Phagocytosis of heat-killed Candida albicans was inhibited by iodoacetate, sodium fluoride, potassium cyanide, and low partial pressures of oxygen, suggesting that these cells require both oxidative and glycolytic energy sources for maximal particle ingestion. Alveolar macrophages and monocyte-derived macrophages killed Listeria monocytogenes with similar efficiency, but neutrophils were more efficient than either of the other cell types. Bacterial killing is probably not dependent upon myeloperoxidase in the monocyte-derived macrophage or in the alveolar macrophage since histochemical stains for peroxidase do not stain either cell type. C. albicans blastospores, which are killed by neutrophils and monocytes that contain myeloperoxidase, were not killed by human alveolar macrophages during the 4 hr of observation. Large cells with supernormal phagocytic capacity were recovered from patients with postobstructive pheumonia and from one patient with recurrent bacterial pneumonia, indicating that macrophage function can be altered in certain disease states. Human alveolar macrophages are unique human phagocytes in their dependence on an oxygen tension greater than 25 mm HG for maximal phagocytosis. Carbon dioxide tensions as high as 70 mm Hg did not alter phagocytosis when the pH of the medium was held constant. These data suggest that the increased susceptibility to pneumonia of patients with chronic bronchitis or atelectasis may be in part related to suboptimal phagocytosis by macrophages in areas of the lung with depressed oxygen tension.

A method for the measurement of the antigen-binding activity of immunoglobulins precipitated in commercially available radial immunodiffusion plates

A method for determining the antigen-binding activities of specific immunoglobulins in serum is described. Samples of sera were applied to commercial immunodiffusion plates and unprecipitated proteins eluted. The precipitate circles were challenged with specific radio-labelled antigen and exposed to X-ray film. Blackened circles on the radioautograph were found to be good indices of the antigen-binding activity of each immunoglobulin and could be monitored using a Beckman Model R Analytrol. The height of each analytrol peak provided an objective estimate of the intensity of darkening. Variation in the amount of added radio-antigen had a direct effect upon the intensity of the darkened circle at low concentrations. At a given concentration of antigen, however, all antigen-binding sites became saturated and additional increases in antigen concentration did not further increase the density of blackening. The quantity of antigen required to just saturate the combining sites of a particular immunoglobulin is a measure of the antigen-binding activity of that immunoglobulin. The employment and some of the applications of this relatively simple radio-isotopic technique are discussed.

Inhalation experiments with extracts of Aspergillus fumigatus on patients with allergic aspergillosis and aspergilloma

A description is given of the reaction to inhalation of Aspergillus extract by seven patients with aspergillosis, including five with aspergillomas. The nature of, and possible causes for, such reactions are discussed on the basis of their resemblance to the symptomatology of the vegetable dust syndromes. The findings may contribute to a better understanding of the pathogenesis of fever in aspergillosis.

Precipitins with relevance to farmer's lung and aspergillosis in normal and other sera

Immunodiffusion, immunoosmophoresis, and precipitin inhibition tests were carried out on various categories of sera with extracts of Micropolyspora faeni (Thermopolyspora polyspora), Aspergillus fumigatus, and Thermoactinomyces vulgaris. The sera were from clinical cases of farmer's lung, from symptomless farm workers, from expectant mothers, from tuberculous and from asthmatic patients, and from patients with miscellaneous lung disorders. The clinical cases of farmer's lung became divisible into two groups by serological tests for antibody to a particular soluble antigenic component of M. faeni. The suggestion is made that one of these two groups of cases may be aetiologically unrelated to M. faeni. One of six sera tested in this group reacted strongly with an extract of T. vulgaris. Antibodies to certain components of some extracts of M. faeni and of A. fumigatus were found in a high proportion of normal sera. Possible reasons for this finding have been given.

Allergic aspergillosis: review of 32 cases

The clinical, radiographic, and laboratory findings have been reviewed in a series of 22 patients with definite and 10 with probable allergic aspergillosis. Episodes of segmental shadowing occurred most frequently in the upper lobes and tended to recur in the same segment. Radiologically visible mucoid impaction of a large bronchus was demonstrated in eight cases, and saccular bronchiectasis in six cases, in the affected segments. Two patients have recovered, eight continued to experience episodic symptoms and shadows for up to 13 years, and 11 are on steroid therapy with relief of airways obstruction and prevention of further lung shadows. Four, together with five others who probably represent a late stage of the disease, have upper lobe contraction. One patient developed aspergillomas and one died with invasive aspergillosis. Sputum has remained positive in all except one patient. Precipitins were present in all cases. They varied widely in strength and appeared to be more closely related to the amount of antigenic exposure than to the severity of the allergic manifestations. Allergy to Aspergillus fumigatus probably plays a dominant role in the symptomatology of those with asthma of late onset; evidence of underlying atopic diathesis and of increased spore exposure could usually be adduced in these patients. A quantitative interaction of atopic diathesis and contact with a growing source of fungal antigens will result in a locally florid bronchial reaction, with plugging and subsequent dilatation. The peripheral shadows are consistent with areas of collapse distal to bronchial occlusion. The frequency and distribution of mucoid impaction found in this series suggest that allergic aspergillosis may be a major cause of this uncommon syndrome, which could represent an exaggerated form of bronchial plugging.

Significance and interpretation of laboratory tests in pulmonary aspergillosis

The significance of the isolation of Aspergillus fumigatus from sputum may be difficult to interpret because of the frequent occurrence of this fungus in the atmosphere. Criteria are given for classifying positive sputa into two groups, ;fungus scanty' and ;fungus abundant', on the basis of cultural and microscopical findings. A relationship between sputum findings thus classified and the occurrence of Aspergillus antibodies in the patient's serum is demonstrated. The diagnostic importance of direct microscopical examination of sputum is noted. The precipitation patterns of sera to the unstandardized antigenic extracts of A. fumigatus at present available vary greatly. An arbitrary but practical classification of sera is suggested, based on the ;reactivity', or number of precipitation lines produced, and the ;range', or number of antigenic extracts with which the serum reacts.