Aortobronchial Fistula in a Pediatric Patient With Massive Hemoptysis: Treatment by Means of an Aortic Endograft

We present an 11-year-old girl with acute myelogenous leukemia and hemoptysis from abscess erosion into the descending thoracic aorta. We report a pediatric case of an aortobronchial fistula treated with an aortic endograft and discuss the technical limitations and potential complications of this procedure.

[Pulmonary cryptococcosis: analysis of nine cases]

OBJECTIVE

To investigate the diagnosis and treatment of pulmonary cryptococcosis.

METHODS

A total of 9 cases of pulmonary cryptococcosis, diagnosed at Sir Run Run Shaw Hospital of Zhejiang University from January 2002 to August 2004, identified by pathological examinations, were retrospectively studied.

RESULTS

The patients consisted of 7 males and 2 females aged from 28 to 69 years. Pulmonary nodules, either solitary or multiple, present in 8 of the 9 cases, were the most common CT finding. The diagnosis was confirmed in all cases by pathological study. The lung specimens of 5 cases were obtained by CT guided transthoracic needle aspiration lung biopsy, and these 5 cases were treated with fluconazole, after 0.5 - 1 year of follow-up, the pulmonary lesion essentially vanished. The other 4 cases were confirmed after surgery.

CONCLUSIONS

Most pulmonary cryptococcosis presented as pulmonary nodules or masses on CT, either solitary or multiple. Pathology was essential to the diagnosis. Fluconazole is active against cryptococcus neoformans, and appears to be effective in the treatment.

Pulmonary coccidioidomycosis that formed a fungus ball with 8-years duration

Coccidioidomycosis, caused by inhaling Coccidioides immitis, is a mycosis imported from endemic regions including the southwestern United States. C. immitis is so virulent that even a short-term stay in the endemic area can provide a chance for infection. Here, we report a 33-year-old Japanese man with formation of a fungus ball inside the pulmonary cavity secondary to coccidioidomycosis with a duration of 8 years, which is considered rare. He was infected with C. immitis in the United States in 1996. A nodule remained in the lung, which later cavitated with fungus ball formation. We identified Coccidioides immitis in the cultured specimen from the cavity and serum antibodies against it. We performed a lobectomy in 2003 since anti-fungal treatment was only temporarily effective. He is still free of disease 6 months later.

[Invasive pulmonary aspergillesis]

AIM

To evaluate the results of therapy of invasive pulmonary aspergillesis (IPA) in one medical center from 2000 to 2005.

MATERIAL AND METHODS

Diagnosis of IPA was made according to the International criteria. Incidence of verified IPA was 2%, probable--84%, possible--14%.

RESULTS

IPA was diagnosed in 50 cases in 49 patients aged 16- 78 years, median 35. Most of the patients consisted of acute leukemia cases (54%). Intensive cytostatic therapy was given in 41% cases. In 54% IPA developed in critical neutropenia, median of duration of which being 29 days (3 to 144 days). 29 patients received glucocorticoid drugs. In diagnosis of IPA Aspergillus spp was isolated in 46% cases (A. fumigatus-59%, A. flavus-29%, A. niger-4%, A-versicolor-4%, in 1 (4%) case identification was not made. Positive antigen Aspergillus was detected in 27 cases. All the patients had pulmonary involvement detected at x-ray or computed tomography. Coincidence of pulmonary lesions seen at x-rays and computer tomograms was only in 30% patients. Cure was achieved in 44%, lethality was 56%. Overall survival in IPA for 90 days was 47%. Amphotericine was effective in 29%. Voriconasol--in 3 of 5 patients, kaspofungin--in 3 of 7. Surgical treatment was given to 4 patients.

CONCLUSION

Lethality in IPA for 5 years when basic therapy was amfotericin B reached 56%. Reduction of lethality can be achieved due to early diagnosis of the infection and administration of voriconasol at the initial stage of IPA. It is necessary to conduct multicenter studies to ascertain indications for combined antifungal therapy.

Successful treatment of pulmonary mucormycosis in an allogenic bone-marrow transplant recipient with combined medical and surgical therapy

Mucormycosis is a rare, but severe, complication in allogenic bone-marrow recipients with a mortality rate of about 80%. Moreover, its incidence appears to have increased within the last decade. We report a case of pulmonary and nasal mucormycosis in a 55-y-old patient, which occurred 1 y after BMT. Treatment combining 4 months of amphotericin B, early surgical resection of infected tissue and discontinuation of immunosuppressive treatment allowed the cure of this mould infection.

Aspergilloses respiratoires complexes : difficultés diagnostiques et thérapeutiques

INTRODUCTION

Respiratory aspergillosis with different physiopathologic mechanisms can be associated in one patient in rare occasions.

CASE REPORT

We review three cases associating an allergic bronchopulmonary aspergillosis (ABPA) and an other form of aspergillosis: aspergilloma, chronic necrotizing pulmonary aspergillosis and we present a review of literature.

CONCLUSION

Such associations result in diagnostic and therapeutic difficulties. Corticosteroid treatment used for ABPA can increase the risk of severe infections. Such cases are a good indication of systemic antifungal therapy.

[Moulds asthma]

Mould allergy revealed by skin prick tests or by measuring specific IgE (RAST), is frequently diagnosed throughout the world. It is associated to clinical asthma, sometimes severe. Thanks to the know how of teams of specialists, surveys are carried out in home-, work- and school environments, and calendars of moulds found in our country are regularly updated. This allows practitioners to determine specific sensitisation tests (selection of skin prick tests, and RAS tests), and helps them play a role in the diagnosis strategy and the recommendations for necessary eviction and building sanitation measures. These measures are all the more important as until now standardised extracts for specific hyposensitisation to moulds are not yet available.

[Acute myeloblastic leukemia (M5) and aspergilloma in a 75-year-old man]

We report here a case of pulmonary aspergilloma in a patient with acute myeloblastic leukemia. We present the clinical and radiological characteristics of this case. Aspergillus flavus was isolated. The antifungal treatment was unsuccessful. Pulmonary aspergillomas are associated with a high mortality in the immunocompromised host. It is important to know the diagnostic approach and the surgical and medical treatment of this disease.

Clinical manifestations and treatment outcomes of pulmonary aspergilloma

BACKGROUND

Pulmonary aspergilloma usually results from the ingrowth of colonized Aspergillus from a damaged bronchial tree, a pulmonary cyst, or from the cavities of patients with underlying lung diseases. In the present study, we analyzed the clinical features, diagnostic methods, and managements of 36 patients with pulmonary aspergilloma.

METHODS

Thirty-six patients were diagnosed as having pulmonary aspergilloma at Chung-Ang University Hospital between February 1988 and February 2000. Their medical records were reviewed retrospectively.

RESULTS

The age of patients (median +/- SD) was 53.3 +/- 11.8 years, the male to female ratio was 2.36:1, and the most frequent symptom was hemoptysis, which occurred in 24 patients (65%). The most common underlying disease was pulmonary tuberculosis (81%), and the upper lobes of both lungs were the most frequently involved sites. Nine patients received a chest CT in the prone position and seven of these showed a movable fungus ball. Eleven patients were positive for the precipitin antibody to A. fumigatus. Twenty patients underwent surgical resection, and post-operative complications were reported in seven cases. The post-operative mortality was 5.6% (2/36).

CONCLUSION

Pulmonary aspergilloma usually develops in the patients with underlying lung diseases. Resectional lung surgery is considered the mainstay of therapy for pulmonary aspergilloma. However, this operation is associated with significant complications and death in some cases. Therefore, it is necessary to develop reasonable criteria for selection of candidates for such surgery.

[Pulmonary aspergilloma, diagnosis and treatment]

Pulmonary aspergilloma is a saprophytic form of aspergillosis, and the diagnosis is usually based on radiological findings such as thickened cavitary wall and fungus ball, and on positive serum antibody. Up to 58% of the patients with aspergilloma in Japan have medical history of tuberculosis. Serum anti-Aspergillus antigen is almost always positive in aspergilloma patients but aspergillus antigen is usually negative. Massive hemoptysis can be a fatal complication of aspergilloma, and the most common complication was respiratory failure according to our study. Surgical resection is the only promising intervention to cure the aspergilloma, however, low pulmonary function does not allow operation. Antifungal treatment is chosen for those who are out of operation indication, but the efficacy of antifungal treatment against aspergilloma is controversial. Some patients with aspergilloma show progressive form, and we define such aspergillosis as CNPA, chronic necrotizing aspergillosis, although the original entity of CNPA by Binder et al. is different. We make a diagnosis of CNPA only if all the following entity meets, 1; progressive shadows in radiological findings regardless of the presence of aspergilloma, 2; have some symptoms such as cough, sputum, hemosputum, hemoptysis or fever, 3; proof of Aspergillus attribution by mycological or pathological examination, 4; positive systemic inflammatory reaction, 5; neglect of other etiology of pulmonary diseases. Since CNPA is usually progressive, patients with CNPA should be treated with antifungals.

Uneventful outcome of unrelated hematopoietic stem cell transplantation in a patient with leukemic transformation of Kostmann syndrome and long-lasting invasive pulmonary mycosis

Kostmann syndrome (KS) is an inherited hematological disorder characterized by an absolute neutrophil count (ANC) <0.2 x 109/L and life-threatening bacterial infections. Granulocyte-colony stimulating factor (G-CSF) makes it possible to reach an ANC of 1.0 x 109/L and consequently to reduce significantly the occurrence of severe infections. Absence of response to G-CSF, G-CSF receptor mutation, and leukemic transformation are absolute indications to perform hematopoietic stem cell transplantation (HSCT). Pulmonary mycosis does not represent an absolute contraindication to bone marrow transplantation (BMT), although a relapse rate of 30-50% has been reported, despite adequate medical and surgical treatment. Mycotic pneumonia recurrence shows a mortality rate above 80%, especially in the presence of persisting immunosuppression. We report on a KS patient with long-lasting fungal pneumonia who developed myelodysplasia and subsequent acute myeliod leukemia (AML) conversion resistant to antiblastic therapy. Despite surgical excision and secondary prophylaxis, recurrence of the pulmonary lesion occurred prior to the unrelated HSCT. In spite of these poor prognostic characteristics, outcome was uneventful and the patient is alive and well in continuous complete remission with no signs of fungal infection.

Blastomycosis

Blastomycosis is an endemic mycoses in the central United States caused by a dimorphic fungus, Blastomyces dermatitidis, that exists in nature in mycelial phase and converts to yeast phase at body temperature. The organism may produce epidemics of infection following a point source of infection or sporadic endemic infection. Blastomycosis can be a subclinical illness with subsequent protection against progressive infection afforded by cellular immune mechanisms, but it may present with progressive disease with either pulmonary or extrapulmonary disease or both. Itraconazole has been shown to be the drug of choice for both infections, except in cases of life-threatening infection when amphotericin B should be used.

Histoplasmosis

The diagnosis of histoplasmosis depends on recognition of the different clinical manifestations of infection, accompanied by knowledge of the accuracy and limitations of tests used for diagnosis of fungal infections. Although most infections are asymptomatic, histoplasmosis can be severe, or even fatal, in patients who have experienced a heavy exposure, have underlying immune defects, or develop progressive disease that is not recognized and treated. This article provides an up-to-date clinical review of histoplasmosis, focusing on recognition, diagnosis, and management.

Aspergillosis. Pathogenesis, clinical manifestations, and therapy

Diseases caused by Aspergillus species are increasing in importance, especially among immunocompromised hosts. Clinical manifestations are variable, ranging from allergic to invasive disease, largely depending on the status of the host's immune system. This article focuses on the pathogenesis and clinical manifestations of diseases caused by Aspergillus species, with more detailed discussion on therapy of the most morbid manifestation, invasive aspergillosis.

[Retrospective analysis of seven cases of pulmonary cryptococcosis]

OBJECTIVE

To understand the diagnosis and treatment of pulmonary cryptococcosis.

METHODS

Patients diagnosed as having pulmonary cryptococcosis in the past 15 years were retrospectively studied. Their demographic data, respiratory symptoms, diagnostic methods, chest radiograph, immune state, antifungal therapy and follow-up results were analyzed.

RESULTS

Thirty cases of cryptococcosis were diagnosed, of which 7 were diagnosed as having pulmonary cryptococcosis, one of them presented with concomitant meningitis. Of the 7 patients, 4 were male and 3 were female, with a median age of 41.8. All were HIV negative; one case was immunocompromised with a history of colon cancer and glucocorticoid therapy for 8 months, while others were immunocompetent. Three patients complained of low fever or cough and sputum, while 4 others presented no symptoms. The X-ray and chest CT showed unilateral or bilateral patches, nodules or cavities. The diagnosis was made by pathology and bacterial culture of sputum or bronchoalveolar lavage fluid. Amphotericin B plus flucytosine were initially given to 4 patients, all of them developed liver and renal abnormalities to some degree after therapy. Three patients were given fluconazole or itraconazole initially. All the 7 patients with pulmonary cryptococcosis responded favorably to antifungal therapy and the prognosis was good.

CONCLUSIONS

Clinically pulmonary cryptococcosis was less common than cryptococcal meningitis. Pathology and cryptococcal culture were essential to the diagnosis. For immunocompetent patients with pulmonary cryptococcosis, the prognosis was good.

Aspergillosis in liver transplant recipients: successful treatment and improved survival using a multistep approach

BACKGROUND

Invasive aspergillosis is a life-threatening complication in liver transplant recipients, with a reported mortality rate of more than 90%. Treatment is difficult, and no single agent is uniformly effective in treating this patient population.

METHODS

We retrospectively reviewed all fungal cultures from 200 liver transplant patients between 1996 and 1999 at a single tertiary referral center.

RESULTS

A diagnosis of aspergillosis was made in 6 patients. Five patients had pulmonary involvement; 1 presented with an inguinal mass. Time from transplant to infection ranged from 1 week to 34 months. Treatment included surgical intervention and medical treatment. All patients infected with Aspergillus fumigatus were treated with a sequential protocol of lipid complex amphotericin followed by itraconazole. The major side effect of treatment was worsening renal function. One patient died of intracranial hemorrhage during treatment.

CONCLUSION

Successful treatment of aspergillosis in liver transplant recipients should include early diagnosis, sequential medical treatment with lipid amphotericin B and itraconazole, and surgical intervention for invasive disease.

Severe aplastic anemia associated with hepatitis and complicated by pulmonary aspergillosis: response to immune suppression and antifungal therapy

The true etiology of severe aplastic anemia is unknown; however, autoimmune activation of T-lymphocytes is one of the potential causes. Stem cell transplantation is regarded as a first line therapy if a fully matched sibling is available. Immunosuppressive therapy is reserved for those who have no matched sibling available for transplant, or for those individuals who fall outside the age range eligible for stem cell transplantation. This case describes a child with a hepatitis-associated severe aplastic anemia for whom a fully matched sibling was available but a transplant was postponed due to active hepatitis. While awaiting bone marrow transplantation, the child acquired a life-threatening aspergillosis infection treated with amphotericin B, granulocyte infusions, and surgical resection of the involved lung. A decision was made to proceed with immunosuppressive therapy while waiting for successful treatment of the fungal infection. Following administration of equine anti-thymocyte globulin (ATG), high dose granulocyte colony stimulating factor (G-CSF), cyclosporine, and steroids, the child had partial hematopoietic reconstitution and is now followed in our clinic. This case demonstrates the extraordinary multidisciplinary care required during the early phases of treating severe aplastic anemia. With such care, recovery is a possibility.

The clinical spectrum of pulmonary aspergillosis

Aspergillus is a ubiquitous fungus that causes a variety of clinical syndromes in the lung, ranging from aspergilloma in patients with lung cavities, to chronic necrotizing aspergillosis in those who are mildly immunocompromised or have chronic lung disease. Invasive pulmonary aspergillosis (IPA) is a severe and commonly fatal disease that is seen in immunocompromised patients, while allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus antigens that mainly affects patients with asthma. In light of the increasing risk factors leading to IPA, such as organ transplantation and immunosuppressive therapy, and recent advances in the diagnosis and treatment of Aspergillus-related lung diseases, it is essential for clinicians to be familiar with the clinical presentation, diagnostic methods, and approach to management of the spectrum of pulmonary aspergillosis.

Invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis is the most common fungal pulmonary infection in certain immunocompromised patients. The most commonly affected patients are hematopoietic stem cell transplant recipients and patients with hematological malignancies undergoing intensive chemotherapy. The survival of patients with invasive pulmonary aspergillosis is very poor because of difficulties in early diagnosis and lack of effective treatment options. Research efforts are being made constantly to improve different diagnostic techniques. Early, repeated, high resolution computed tomography of the chest, and sequential nonculture-based monitoring of Aspergillus antigen and DNA can improve earlier diagnosis. New antifungal drugs for treatment and prevention of invasive pulmonary aspergillosis continue to emerge, with better safety, efficacy, and pharmacologic profiles.

Prior invasive pulmonary and cerebellar mucormycosis is not a primary contraindication to perform an autologous stem cell transplatation in leukemia

Mucormycosis infections, caused by fungi of the families Rhizopus, Mucor or Absidia, are typically rapidly progressive and often fatal. We report a 27-year-old male with acute myeloid leukemia (AML) developing an invasive pulmonary-CNS mucormycosis during the neutropenic period after salvage induction chemotherapy; the infection was successfully controlled with surgery and antifungal therapy. The patient received two courses of consolidation chemotherapy and underwent autologous stem cells transplantation (ASCT) while receiving secondary antifungal systemic prophylaxis with liposomal Amphotericin B (L-AMB, Ambisome). There was no clinical, radiological or microbiological evidence of mycotic reactivation during the bone marrow transplantation (BMT) procedure.