Cutaneous aspergillosis: a report of six cases

Skin invasion by Aspergillus is infrequent. We here describe six immunocompromised patients with skin manifestations caused by Aspergillus. A heart transplant recipient developed a primary cutaneous aspergillosis; two patients (one with chronic granulomatous disease and another treated with a high dose of corticosteroids) presented with nodular lesions secondary to haematogenous dissemination; and three patients with acute myelogenous leukaemia had skin dissemination by contiguity from orbit and sinus invasion. A. flavus was isolated in the three cases of leukaemia; the infection was due to A. fumigatus in the transplant recipient; A. fumigatus and A. versicolor were isolated in the patients with the secondary aspergillosis. In most cases, amphotericin B was useful, with clinical and mycological remission in four patients. A patient with leukaemia died without undergoing treatment, and a child carrier of chronic granulomatous disease died after only 12 days of treatment.

Changing role of invasive aspergillosis in AIDS--a case control study

OBJECTIVE

From December 1993 until January 1996 we observed 10 cases of invasive aspergillosis in a cohort of 140 patients with AIDS (7%). By contrast, no invasive aspergillosis was diagnosed in a cohort of 278 patients with AIDS between 1986 until 1993.

METHODS

Case controls were assigned randomly to each patient with invasive aspergillosis from the total pool of HIV-infected patients. Patients with invasive aspergillosis were studied retrospectively by matched-pairs analysis with respect to risk factors, radiological, microbiological and autopsy findings.

RESULTS

Patients with aspergillosis had more AIDS-defining events (3.5 [2-5] vs. 2 [2-3], median [range], P < 0.05) and a longer median survival time with full-blown AIDS (31.5 [14-45] months vs. 20.5 [5-32] months, P < 0.005) than their case controls. Patients with invasive aspergillosis tended to have lower white blood cell counts and exhibited significantly decreased median CD4 counts (7 [0-44]/mm3 vs. 27 [8-57]/mm3, P < 0.05).

CONCLUSIONS

Due to better management of opportunistic diseases and improved antiretroviral therapy, the lifespan of patients with full blown AIDS is prolonged. Patients who have survived four or more AIDS-defining events are at risk for invasive aspergillosis. This risk is associated with low white blood cell counts and CD4 cell counts.

Myelopathy resulting from invasive aspergillosis

Aspergillus, a ubiquitous mold, may cause invasive and fatal disease in immunosuppressed patients. Myelopathy is an uncommon presentation of invasive aspergillosis. This report describes three children admitted to the hospital between 1988 and 1995 who developed myelopathy as the first evidence of invasive aspergillosis. All had advanced leukemia and were profoundly immunosuppressed because of chemotherapy and broad-spectrum antibiotics. Weakness and pain presented first; then, sensation to pain and temperature was lost 2 to 6 days later, followed by complete myelopathy. Multiple brain lesions were seen on magnetic resonance imaging in one patient. Despite antifungal therapy, aspergillosis proved fatal within 1 month of onset of myelopathy in all patients. Physicians caring for immunocompromised children should be aware of myelopathy as a presentation of invasive aspergillosis.

Pulmonary aspergillosis and invasive disease in AIDS: review of 342 cases

Aspergillosis is an infrequent but commonly fatal infection among HIV-infected individuals. We review 342 cases of pulmonary Aspergillus infection that have been reported among HIV-infected patients, with a focus on invasive disease. Invasive pulmonary aspergillosis usually occurs among patients with <50 CD4 cells/mm3. Major predisposing conditions include neutropenia and steroid treatment. Fever, cough, and dyspnea are each present in >60% of the cases. BAL is often suggestive, but biopsy specimens are necessary for definite diagnosis. Amphotericin B is the mainstay of treatment and mortality is > 80%. Avoiding neutropenia and judicious use of steroids may be helpful in prevention. Aggressive diagnostic approach, early initiation of treatment, adequate dosing of antifungals, and close follow-up may improve the currently dismal prognosis.

Detection of immunoglobulins G and A to Aspergillus fumigatus by immunoblot analysis for monitoring Aspergillus-induced lung diseases

The aim of the study was to investigate whether patients with Aspergillus-induced lung disease can be monitored by immunoblot analysis to detect antibodies to Aspergillus fumigatus (Af). Immunoblotting was performed by incubating 57 longitudinally collected sera from 13 patients on nitrocellulose sheets, blotted with Af antigen, separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. Bound antibodies were demonstrated by peroxidase-labelled antihuman immunoglobulins (Ig)G and IgA antiserum and diaminobenzidine plus H2O2 as substrate. The immunoblot patterns were related to the patients' clinical status and time. Each patient had a characteristic immunoblot pattern that varied with time. There was a relationship between disease activity or clinical response and changes in immunoblot antibody patterns: a rise in anti-Af IgG and IgA antibodies was seen in sera collected during active disease, compared with before active disease, and a significant decline in anti-Af IgG and IgA was demonstrated in sera collected during recovery, compared with during active disease. Only in the acute stage of allergic bronchopulmonary aspergillosis were IgA antibodies against Af antigens of <20,000 Da demonstrated. Immunoblot analysis can be used to monitor the disease activity and the responses to treatment of patients with Aspergillus-induced lung diseases. Changes in specific immunoglobulin A may be more informative than specific immunoglobulin G.

[Successful therapy of pulmonary aspergillosis in a patient with non-Hodgkin lymphoma]

ANAMNESIS AND CLINICAL PICTURE: A 65-year old male with non-Hodgkin lymphoma developed severe invasive pulmonary aspergillosis during a state of leucopenia after chemotherapy.

INVESTIGATION

The initial manifestation was an infiltration in the right upper lobe of the lung, identified by lung scintigraphy as a peripheral wedge-shaped loss of perfusion. Both serum and bronchoalveolar lavage extreme high titre of Aspergillus antigen were seen as a laboratory indication of an invasive aspergillosis. The mould Aspergillus fumigatus was repeatedly isolated from bronchoalveolar lavage and bronchial secretion.

THERAPY AND CLINICAL COURSE

Treatment was started with amphotericin B plus 5-flucytosine together with repeatedly bronchoscopic instillation of miconazole followed by thoracosurgical intervention with resection of the right upper lobe of the lung. Despite prophylaxis by itraconazole, a relapse of invasive aspergillosis occurred three months later probably due to persistence of aspergillus fungal elements in the left lung. The aspergillosis relapse was treated at first with liposomal amphotericin B. After eighteen days of treatment this was changed to a combination of 5-flucytosine with oral application of itraconazole, and cure was achieved.

Invasive aspergillosis in the immunocompromised host: utility of computed tomography and bronchoalveolar lavage

OBJECTIVE

Bronchoalveolar lavage is performed almost routinely in immunocompromised patients with suspected pneumonia, but it has a low yield in the diagnosis of pulmonary aspergillosis. The aim of this study was to determine whether computed tomography (CT) is helpful in determining the likelihood of a positive bronchoalveolar lavage by allowing distinction of patients with angioinvasive aspergillosis from those with Aspergillus bronchopneumonia.

METHODS AND RESULTS

A retrospective study was performed including consecutive immunocompromised patients with suspected pneumonia who underwent CT scanning of the chest and bronchoalveolar lavage and who had definite diagnosis of pulmonary aspergillosis. The CT scans were reviewed by two chest radiologists and classified as showing features consistent with angioinvasive or airway invasive aspergillosis. Twenty-one patients met the inclusion criteria. Bronchoalveolar lavage was positive for fungi in two of 11 patients with CT findings consistent with angioinvasive aspergillosis and eight of 10 patients with CT scans consistent with Aspergillus bronchopneumonia (P < 0.01, chi-squared test). CT findings of angioinvasive aspergillosis included nodules measuring 1-3.5 cm in diameter in six, segmental consolidation in three, and both nodules and segmental consolidation in two patients. CT findings of Aspergillus bronchopneumonia including peribronchial consolidation in five, small centrilobular micronodules in one, and both in four patients.

CONCLUSIONS

Chest CT is helpful in determining the likelihood of successful diagnosis of pulmonary aspergillosis by bronchoalveolar lavage.

Serologic survey of free-living nestling prairie falcons (Falco mexicanus) for selected pathogens

Serum samples from 34 free-living nestling prairie falcons (Falco mexicanus) in southwestern Idaho were negative for antibodies to avian influenza virus, Newcastle disease virus, and three Aspergillus species. Serum from a single bird had hemagglutinating inhibition activity in response to Mycoplasma synoviae, and another bird's serum had slight activity in response to M. gallisepticum.

The recombinant antigen ASPND1r from Aspergillus nidulans is specifically recognized by sera from patients with aspergilloma

A 996 bp Aspergillus nidulans cDNA encoding the ASPND1 immunodominant antigen was cloned and expressed in Escherichia coli as a fusion protein with the enzyme glutathione S-transferase (GST) from Schistosoma japonicum. The GST-ASPND1 fusion protein was purified from isolated bacterial inclusion bodies by preparative SDS-PAGE. After cleavage with thrombin, the ASPND1 recombinant antigen (ASPND1r) and the GST protein were separated by SDS-PAGE and immunoblotted with a number of different human sera. The sera from 22 (88%) of 25 patients with an aspergilloma recognized the ASPND1r recombinant antigen on immunoblots. Forty-nine normal human sera and 14 sera from patients with other infections were unreactive. The ASPND1r expressed in E. coli could therefore be used, in combination with previously reported recombinant antigens, as a standardized antigen for serological and clinical diagnosis of Aspergillus-associated diseases.

Two strategies for managing invasive aspergillosis: a decision analysis

We devised a diagnostic approach based on screening plasma for an Aspergillus antigen with use of a sandwich enzyme-linked immunosorbent assay (ELISA), thoracic computed tomographic scanning, and radionuclide imaging for managing patients at risk for invasive aspergillosis. We used a decision analytic model to compare this alternative strategy with the conventional strategy, which relies only on the presence of clinical symptoms, persistent fever, and chest roentgenographic findings. Use of the alternative strategy reduced the number of patients who would receive antifungal treatment empirically, but this strategy was more expensive. The specificity of the sandwich ELISA had a significant impact on cost, but the sensitivity did not. A 13% prevalence of infection resulted in equal costs for both strategies. As much as 43.3% of the patients treated empirically could be given liposomal amphotericin B (L-AmB) before the conventional strategy became the most expensive. The costs of the alternative strategy were less than those of the conventional strategy when >5.3% of all patients, irrespective of strategy, were treated with L-AmB.

Impaired host defense, hematopoiesis, granulomatous inflammation and type 1-type 2 cytokine balance in mice lacking CC chemokine receptor 1

CC chemokine receptor 1 (CCR1) is expressed in neutrophils, monocytes, lymphocytes, and eosinophils, and binds the leukocyte chemoattractant and hematopoiesis regulator macrophage inflammatory protein (MIP)-1alpha, as well as several related CC chemokines. Four other CCR subtypes are known; their leukocyte and chemokine specificities overlap with, but are not identical to, CCR1, suggesting that CCR1 has both redundant and specific biologic roles. To test this, we have developed CCR1-deficient mice (-/-) by targeted gene disruption. Although the distribution of mature leukocytes was normal, steady state and induced trafficking and proliferation of myeloid progenitor cells were disordered in -/- mice. Moreover, mature neutrophils from -/- mice failed to chemotax in vitro and failed to mobilize into peripheral blood in vivo in response to MIP-1alpha. Consistent with this, -/- mice had accelerated mortality when challenged with Aspergillus fumigatus, a fungus controlled principally by neutrophils. To test the role of CCR1 in granuloma formation, we injected Schistosoma mansoni eggs intravenously, and observed a 40% reduction in the size of lung granulomas in -/- mice compared to +/+ littermates. This was associated with increased interferon-gamma and decreased interleukin-4 production in -/- versus +/+ lung lymph node cells stimulated with egg-specific antigen, suggesting that CCR1 influences the inflammatory response not only through direct effects on leukocyte chemotaxis, but also through effects on the type 1-type 2 cytokine balance. Thus CCR1 has nonredundant functions in hematopoiesis, host defense, and inflammation.

Chronic invasive aspergillosis in apparently immunocompetent hosts

Seventeen cases of invasive aspergillosis occurring since 1987 in apparently immunologically normal hosts have been reviewed: 9 of invasive sinus aspergillosis, 2 of isolated brain abscesses, 3 of pneumonia (1 in a patient who developed mediastinitis), 2 of lymph node aspergillosis, and 1 of osteomyelitis of the foot. Two of the 9 patients with sinus aspergillosis died; the rest were stable up to March 1993. They responded initially to combined surgical and medical therapy. Both patients with brain abscesses survived following surgery, but one had neurological sequelae. Both patients with pneumonia were well following therapy with amphotericin B; one also received itraconazole. The patient with mediastinitis died, but this disease was diagnosed late. The patients with lymph node involvement were lost to follow-up, as was the patient with osteomyelitis. Invasive aspergillosis may be common in Pakistan. Greater awareness would allow earlier diagnosis and therapy, thereby improving the outcome.

Serial monitoring of Aspergillus antigen in the early diagnosis of invasive aspergillosis. Preliminary investigations with two examples

A recently developed sandwich ELISA, which detects Aspergillus galactomannan, was tested retrospectively in serial serum samples from an allogeneic bone marrow transplant recipient with proven invasive aspergillosis (patient 1) and another with suspected disease (patient 2). Galactomannan was detected in the serum 4 and 28 days, respectively, before pulmonary infiltrates suggestive of fungal infection first became apparent on the chest X-ray. Aspergillus was detected by ELISA and PCR in BAL fluid samples from both patients, and in CSF from patient 1. The diagnosis was confirmed at autopsy for patient 1 by histopathology and the recovery of Aspergillus fumigatus from the lung and brain. Furthermore, in both patients the course of the antigen titer in the serum during antifungal treatment corresponded with the clinical outcome. These results confirm that the sandwich ELISA appears to be useful for the early diagnosis of invasive aspergillosis. The value of the test for monitoring the response to antifungal treatment remains to be established in prospective trials.

Pulmonary aspergilloma and AIDS. A comparison of HIV-infected and HIV-negative individuals

OBJECTIVE AND METHODS

While pulmonary aspergilloma has been well described in immunocompetent hosts, to date and to our knowledge, there has not been a description of pulmonary aspergilloma in the HIV-infected individual. A retrospective review of cases seen by the Bellevue Hospital Chest Service from January 1992 through June 1995 identified 25 patients with aspergilloma. To investigate the impact of HIV status on pulmonary aspergilloma, we compared clinical presentation, progression of disease, treatment, and outcome in the HIV-infected patient vs the HIV-negative patient with aspergilloma.

RESULTS

Of the 25 patients identified, 10 were HIV-infected and 15 were HIV-negative. Predisposing diseases included tuberculosis (18/25, 72%), sarcoidosis (4/25, 16%), and Pneumocystis carinii pneumonia (3/25, 12%). All 25 patients had evidence of aspergilloma on chest CT. In addition, 17 of 25 patients had evidence of Aspergillus species in fungal culture, pathologic specimens, or immunoprecipitins. Hemoptysis was present in 15 of 25 (60%) (11/15 [73%] of the HIV-negative group vs 4/10 [40%] of the HIV-infected group). Severe hemoptysis (> 150 mL/d) occurred in 5 of 15 (33%) of the HIV-negative group vs 1 of 10 (10%) of the HIV-infected group. Disease progression occurred more frequently among the HIV-infected group (4/8, 50% vs 1/13, 8% in HIV-negative individuals). All patients with disease progression had lymphocyte subset CD4+ < 100 cells per microliter. Four of eight (50%) of the HIV-infected group vs 1 of 13 (8%) of the HIV-negative group died.

SUMMARY AND CONCLUSIONS

We conclude the following: (1) although tuberculosis and sarcoidosis are the most prevalent predisposing diseases, P carinii pneumonia in the HIV-infected individual is a risk factor for pulmonary aspergilloma; (2) HIV-infected individuals with CD4+ < 100 cells per microliter are more likely to have disease progression despite treatment; and (3) HIV-negative patients are more likely to have hemoptysis requiring intervention.

Th1 and Th2 cytokines in mice with invasive aspergillosis

With a murine model of invasive aspergillosis we investigated cytokine production by CD4+ T helper cells and the effects of cytokine administration or neutralization on the course and outcome of infection. Patterns of susceptibility and resistance to infection were obtained with different strains of mice injected with different inocula of Aspergillus fumigatus conidia. Mice surviving the primary infection also resisted a subsequent lethal infection that was associated with production of gamma interferon by CD4+ T splenocytes. Impaired neutrophil antifungal activity, observed in susceptible mice, was concomitant with a predominant production of interleukin-4 (IL-4) by CD4+ splenocytes. In these mice, exogenous administration of IL-12 failed to induce resistance to infection; in contrast, treatment with soluble IL-4 receptor cured more than 70% of the mice from primary infection and resulted in the onset of acquired resistance to a subsequent lethal infection. These findings indicate that in murine invasive aspergillosis, production of IL-4 by CD4+ T cells may be one major factor discriminating susceptibility and resistance to infection.

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.

Pneumatocele complicated by fungal lung abscess in Job's syndrome. Successful lobectomy with the aid of videothoracoscopy

Hyperimmunoglobulin E (Job's) syndrome, is a complex immune disorder characterized by complications involving, pulmonary and cutaneous infections. An 11-year-old girl presented with a pneumatocele superinfected by aspergillosis and occupying almost the entire right lower lobe. Lobectomy was performed with the aid of videothoracoscopic instruments, and 9 months later the patient is doing well.

A painful knee in an immunocompromised patient

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