Pulmonary aspergillosis: a spectrum of disease

Although many species of the fungus Aspergillus have been identified, the most common human pathogen is A. fumigatus, which has a worldwide distribution. Although any organ may become infected, pulmonary aspergillosis is the most common manifestation. The spectrum of pulmonary aspergillosis includes saprophytic aspergillomas, allergic bronchopulmonary aspergillosis, chronic necrotizing aspergillosis, and invasive aspergillosis. Immune status of the host, and the presence of underlying lung disease are important in determining the type of pulmonary involvement. Thus, the radiographic findings are variable. This article reviews the various manifestations of pulmonary aspergillosis, including the immune status of the patient, the presence of underlying lung disease, and the radiographic appearance of the different entities.

Binding assay of low density lipoprotein to Asp-hemolysin from Aspergillus fumigatus

Binding activity of Asp-hemolysin to low density lipoprotein (LDL) was measured. LDL binds to Asp-hemolysin with an affinity as high as the LDL receptor. The apparent Kd, determined by Scatchard plot analysis, was 8.9 x 10(-9) M [125I]LDL. Asp-hemolysin is thus identified as a novel LDL-binding protein.

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.

Central venous catheter infection by Aspergillus fumigatus in a patient with B-type non-Hodgkin lymphoma

Invasive Aspergillus infection is still a major problem in immunocompromised patients. A central venous catheter infection by Aspergillus fumigatus, however, has not yet been reported. We describe the case of a 10-year-old female patient with B-type non-Hodgkin lymphoma treated according to the German chemotherapy protocol NHL-BFM 90. Isolation of Aspergillus fumigatus from the blood was the first hint of invasive aspergillosis. A central venous catheter-associated infection was suggested, since Aspergillus was also isolated from the thrombotic tip of the removed catheter. Secondary pulmonary aspergillosis was documented radiologically. The patient was treated successfully by Ampho-thericin B and Itraconazol and explantation of the central venous catheter under conditions of complete hematopoietic regeneration of the bone marrow with omission of the final chemotherapeutic cycle.

Aspergillus laryngotracheobronchitis presenting as stridor in a patient with peripheral T cell lymphoma

Invasive aspergillosis is a serious opportunistic infection in immunocompromised patients. The case history is described of a 44 year old patient with peripheral T cell lymphoma who developed hoarseness and stridor after chemotherapy. Aspergillus fumigatus was isolated repeatedly from the sputum. Bronchoscopic examination showed symmetrical creamy-white exophytic lesions involving both vocal cords and the supraglottic area. There was diffuse tracheobronchitis with multiple raised cream-coloured plaques in the trachea which histologically consisted of numerous septate branching hyphae consistent with Aspergillus species. The lesions responded to systemic treatment with amphotericin B.

Amphotericin B-associated hypertension

OBJECTIVE

To report two cases of hypertension related to amphotericin B infusion.

CASE SUMMARY

A 63-year-old woman with Candida albicans bacteremia and an 84-year-old man with Aspergillus fumigatus pneumonia developed hypertension within minutes of amphotericin B administration. Both patients' blood pressure returned to baseline soon after the infusion of amphotericin B was stopped. Neither patient was rechallenged.

DISCUSSION

A causal relationship may exist between the administration of amphotericin B and these hypertensive episodes. Blood pressure in both patients normalized without treatment on discontinuation of the infusion. The mechanism of amphotericin B-associated hypertension is unclear but could include vasoconstricting properties of the drug or the administration of intravenous NaCl 0.9% prior to amphotericin B infusion. We recommend that intravenous NaCl 0.9% be administered following amphotericin B infusion and that the infusion be stopped if hypertensive episodes arise.

CONCLUSIONS

Both acute hypertension and hypotension can occur in patients receiving amphotericin B for systemic fungal infections.

Nosocomial outbreak of Aspergillus fumigatus infection among patients in a renal unit?

Aspergillus fumigatus is present in the environment worldwide and it is only able to infect debilitated or immunodepressed subjects. Nosocomial outbreaks of A. fumigatus infection have been associated with hospital reconstruction. Spores are released into the environment and are inhaled by immunodepressed patients housed in nearby Medical Units. Specific clinical syndromes are allergic bronchopulmonary aspergillosis and invasive pulmonary aspergillosis with characteristic radiological features. Invasive A. fumigatus infection is commonly fatal, even if promptly diagnosed and treated. Three consecutive cases of A. fumigatus infection occurred in debilitated patients housed in our Renal Unit while building renovation near the Unit was being performed. Two of these patients died and pulmonary and diffuse aspergillosis was found on postmortem examination. The third patient, highly suspected to be infected with Aspergillus, was aggressively and successfully treated with liposomal amphotericin B. Our experience suggests that fungal infections have gained increasing prominence in clinical medicine and they must be considered in chronic debilitated patients including dialysis patients, and that liposomal amphotericin B represents an important advance in the treatment of aspergillosis.

Novel mammalian cell cycle inhibitors, tryprostatins A, B and other diketopiperazines produced by Aspergillus fumigatus. II. Physico-chemical properties and structures

Two novel diketopiperazines named tryprostatins A and B and a new natural product belonging to the diketopiperazine series, designated as demethoxyfumitremorgin C, together with four known diketopiperazines, fumitremorgin C, 12,13-dihydroxyfumitremorgin C, fumitremorgin B and verruculogen, are new M phase inhibitors of the mammalian cell cycle, which were isolated from the secondary metabolites of Aspergillus fumigatus. The structures of tryprostatins A, B and demethoxyfumitremorgin C were determined mainly by the use of spectroscopic methods especially by detailed analyses of their 1H and 13C NMR spectra with the aid of 2D NMR techniques including pulse field gradient heteronuclear multiple-bond correlation (PFG-HMBC) spectroscopy. Their absolute configurations were determined on the basis of the optical rotational values and CD spectra.

Novel mammalian cell cycle inhibitors, tryprostatins A, B and other diketopiperazines produced by Aspergillus fumigatus. I. Taxonomy, fermentation, isolation and biological properties

Two novel diketopiperazines named tryprostatins A (1) and B (2) and a new natural product belonging to the diketopiperazine series, designated as demethoxyfumitremorgin C (3), together with four known diketopiperazines, fumitremorgin C (4), 12,13-dihydroxyfumitremorgin C (5), fumitremorgin B (6) and verruculogen (7), were isolated from the fermentation broth of Aspergillus fumigatus BM939 by the combined use of solvent extraction, silica gel column chromatography, preparative TLC and repeated-preparative HPLC. The diketopiperazines showed an inhibitory activity on the cell cycle progression of mouse tsFT210 cells in the M phase with the MIC values of 16.4 microM (1), 4.4 microM (2), 0.45 microM (3), 4.1 microM (4), 60.8 microM (5), 26.1 microM (6) and 12.2 microM (7), respectively.

Refractory pulmonary aspergillosis: compassionate trial with terbinafine

The frequency of bronchopulmonary aspergillosis is increasing due to the growing number of patients requiring steroids or other immunosuppressive therapies. Conventional treatments are ineffective in some patients and side-effects are an important issue. The aim of this work was to evaluate the effectiveness and safety of terbinafine, a new allylamine antimycotic drug, in three immunocompetent patients affected by lower respiratory tract aspergillosis [one chronic empyema due to Aspergillus fumigatus (AF) and two chronic necrotising aspergillosis] not responsive to the usual antimycotic therapies. In in vitro and animal model systems, terbinafine is as active as amphotericin B and itraconazole. Patients received terbinafine at doses ranging from 5 to 15 mg/kg per day, according to clinical status, for 3-5 months, depending on the clinical course of the disease and compliance. In patient 1 a negative anti-AF precipitin was obtained together with eradication of AF from the pleural cavity, which allowed a successful intrathoracic myo-omento-mammoplasty. In patients 2 and 3, AF was eradicated, anti-AF immunoprecipitins decreased, and clinical and radiological findings significantly improved. On the basis of the effectiveness of terbinafine demonstrated in this preliminary work, large studies to evaluate the use of terbinafine in bronchopulmonary aspergillosis are warranted. Moreover, the drug is not associated with resistance or significant side-effects.

[A case of invasive pulmonary aspergillosis accompanied with Aspergillus meningitis]

A 53-year-old female was admitted to our hospital complaining of chest pain and gait disturbance. Examinations on admission showed that she was immunocompetent except the negative tuberculin test. The chest X-ray showed infiltrative shadows with old tuberculous lesions in the bilateral upper lung fields. In CT, a mass lesion was revealed in the lesion, which destructed the fifth thoracic vertebra and invaded into the epidural space. She died of meningitis on the 18th day after admission. On autopsy, it was made clear that the mass lesion was caused by Aspergillus fumigatus, and that the meningitis was the result of the invasion of the fungus into the epidural space.

[Allergic bronchopulmonary aspergillosis (ABPA) in patients with cystic fibrosis (CF): clinical significance, diagnosis and therapy]

Intermittent or long term treatment with antibiotics, progredient destruction of the lungs as well as dystrophy of individuals are predisposing factors for the colonization of the respiratory tract with Aspergillus fumigatus in CF patients. Allergic bronchopulmonary aspergillosis (ABPA) is a significant problem in CF patients. It has been reported with an incidence of 10%. The diagnosis of ABPA in patients with CF is difficult since it is common for both diseases to have several of the same clinical and laboratory features. Prednisolone with an initial dose of between 0,5-1,0 mg/kg/day remains the treatment of choice for ABPA. The doses reduction and the duration of the treatment depend on clinical findings and on serum IgE levels.

[Invasive aspergillosis: nosocomial origin of epidemics. Review of the literature]

The growing incidence of nosocomial invasive aspergillosis is related with the development of new therapies and the presence of Aspergillus spores in the patients'vicinity. Earth moving, demolition or renovation works adjacent to or inside the hospital are undoubtfully implied in this process. Potted plants and individual sachets of ground pepper distributed to patients are another significant source of Aspergillus spores. The extrinsic and multiple causes of hospital contamination may explain the numerous problems in our studies of strain typing, whatever the methods used (phenotype and genotype).

[Extralobar sequestration presenting increased serum CA19-9 and associated with lung aspergillosis--an unusual case]

In a thirty-four-year old man, an asymptomatic abnormal mass shadow was detected in S10 of the left lower lobe on chest X-ray film. The serum CA19-9 was abnormally elevated 395 U/ml). The definitive histological diagnosis was not obtained by both transbronchial and percutaneous lung biopsy preoperatively. Surgery demonstrated that an abnormal mass was separated from S10 of the left lower lobe by a fibrous tissue, and it contained severe inflammatory changes and abscess. Extralobar pulmonary sequestration was diagnosed, but aberrant arteries were not conformed. Sequestered lung and a part of the lower lobe were resected en bloc. The serum CA19-9 level returned to normal postoperatively. Aspergillus was only detected in the sequestered lung by postoperative cultre. Moreover, CA19-9 level in the fluid of this sequestered lung was markedly high, 50,000 U/ml. Production of CA19-9 was demonstrated in bronchial epithelium of the sequestered lung immunohistochemically. Extralobar pulmonary sequestration associated with aspergillosis and high serum CA19-9 is very rare. To our knowledge, this is the first reported case in the literatures.

Aspergillosis in immunocompromised paediatric patients: associations with building hygiene, design, and indoor air

BACKGROUND

Nosocomial aspergillosis is a well known complication of immunosuppression in cancer patients and those undergoing transplantation and has usually been associated with major building construction or demolition. An observational study is reported of the hospital environment associated with an outbreak of aspergillosis in a paediatric oncology ward.

METHODS

All cases of aspergillosis were identified from the hospital records and categorised as definite or probable according to the extent of supportive clinical and laboratory findings. All relevant aspects of building ventilation, air filtration, and aerosol generation considered relevant were examined and air samples for fungi were taken in triplicate at 25 sites using a slit sampler with appropriate culture media.

RESULTS

Six cases of aspergillosis were identified over one year out of the 148 patients who attended the unit - the only part of the hospital where cases were found. Examination of the building services and function suggested that the cause or source was isolated to this paediatric oncology/haematology ward and may have been attributed to a defective disposal conduit door as well as the dispersal of a contaminated aerosol from the ward vacuum cleaner which had the highest measured concentrations of Aspergillus fumigatus in or around the building (65 colony forming units (cfu)/m3 compared with 0-6 cfu/m3 elsewhere). No further cases were identified in the two years after these hygiene arrangements were changed.

CONCLUSIONS

The investigation of this outbreak of nosocomial aspergillosis identified several possible sources of fungally contaminated aerosol which could have been implicated as the cause. Their modification was followed by a reduction in the incidence of further cases. Each should be incorporated as an issue of importance in hospital building design and hygiene.

Bronchopulmonary and disseminated granulomatous disease associated with Aspergillus fumigatus and Candida species infection in a golden retriever

A seven-year-old, female golden retriever was referred for a paroxysmal, chronic cough and dyspnea, dysphagia, facial pruritus, anterior uveitis, and deteriorating general condition. A severe, mixed interstitial and alveolar pattern, with poorly defined amorphous lesions, was seen on thoracic radiographs. Multiple, whitish nodules disseminated on the hyperemic respiratory mucosa were noted on bronchoscopy. Escherichia coli and Aspergillus fumigatus were cultured from the bronchoalveolar lavage. Granulomatous lesions in numerous organs were identified during necropsy, and Aspergillus fumigatus and Candida spp. were cultured from lung and kidney tissues. Microscopic granulomatous lesions were compatible with mycotic infection; however fungal organisms were not observed.

Allergic bronchopulmonary aspergillosis in lung allograft recipients

Following lung transplantation for end-stage cystic fibrosis, two male patients presented with shortness of breath, peripheral blood eosinophilia and segmental lung collapse. At bronchoscopy, each had bronchial mucous plugging containing Aspergillus fumigatus. This finding was associated with a systemic eosinophilia and skin test positivity to Aspergillus. Augmented steroid therapy resulted in the successful resolution of the symptoms. We believe that these are the first reported cases of allergic bronchopulmonary aspergillosis in lung allograft recipients.

Ex vivo effects of macrophage colony-stimulating factor on human monocyte activity against fungal and bacterial pathogens

The ex vivo effects of macrophage colony-stimulating factor (M-CSF) on antifungal and antibacterial activities of human elutriated monocytes were studied. Cells were isolated prior to the initiation of therapy, on day 3 and at week 7, in six patients with an advanced malignancy receiving M-CSF in a phase I study. Superoxide anion production by monocytes in response to N-formyl methionyl leucyl phenylalanine was enhanced at day 3 of therapy (P = 0.011). In addition, at day 3, fungicidal activity against blastoconidia of Candida albicans was enhanced by M-CSF treatment (P = 0.026), whereas antifungal activity against hyphae of Aspergillus fumigatus was not significantly changed. Bactericidal activity against Staphylococcus aureus was increased at day 3 (P = 0.004). By Northern blot analysis, M-CSF does not upregulate the expression of components of the NADPH-oxidase, the multicomponent enzyme system responsible for generation of superoxide radicals by monocytes. Instead, the predominant effect of M-CSF on circulating monocytes is probably a post-transcriptional effect. In conclusion, these findings suggest that administration of M-CSF to patients may enhance microbicidal activities and thus may provide a useful adjunct to conventional antimicrobial therapy.

Exogenous lipoid pneumonia complicated by Mycobacterium fortuitum and Aspergillus fumigatus infections

We report the case of a nonimmunocompromised female patient, who developed exogenous lipoid pneumonia with Mycobacterium fortuitum infection at diagnosis, later followed by Aspergillus fumigatus infection. The association of exogenous lipoid pneumonia with atypical mycobacterial infection is uncommon but well-recognized, but, to our knowledge, association with A. fumigatus infection has not previously been reported.