Treatment and outcome of invasive Aspergillus infections in allogeneic BMT recipients

The outcome of invasive aspergillosis (IA) has been considered poor in allogeneic BMT recipients. We analyzed retrospectively the treatment and outcome of IA diagnosed during life in a recent cohort of 20 allogeneic BMT recipients. All patients were initially treated with amphotericin B (AmB) (conventional 16, liposomal 4). Due to toxicity, conventional AmB was changed to a liposomal preparation in 10 patients. Five patients also received itraconazole and three underwent surgery. Of 19 evaluable patients, two patients achieved a complete response and a partial response was observed in five patients (response rate 37%). The median survival was 37 days after the diagnosis. Only two patients (10%) were cured. The prognosis of allogeneic BMT recipients with IA has remained poor. Although treatment responses are common, immunosuppression aggravated by GVHD and its treatment, as well as the commonly disseminated presentation of IA, seem to be major obstacles to the success of therapy. Bone Marrow Transplantation (2000) 26, 759-762.

Management of invasive pulmonary aspergillosis in hematology patients: a review of 87 consecutive cases at a single institution

Eighty-seven patients with hematologic malignancies and invasive pulmonary aspergillosis (IPA) were identified between 1982 and 1995. Of these, 39 underwent lung resection on the basis of radiological detection of at least 1 lesion with imaging suggestive of aspergillosis (LISA). IPA was confirmed histologically in 35. The presence of LISA had 90% positive predictive value for IPA. The actuarial survival at 2 years was 36% for 37 patients treated surgically, 20% for 12 patients with unresected LISA but no cultures of Aspergillus species, and 5% for 21 patients diagnosed only by isolation of Aspergillus from respiratory secretions. Analysis by proportional hazard models showed a significant independent negative association between the radiological appearance of LISA and death from all causes. Relapsed hematologic disease was independently significantly associated with death. Age, sex, surgery, previous bone marrow transplantation, or Aspergillus isolation were not independent predictors of death. IPA presenting as LISA carries a relatively good prognosis, possibly explaining the better survival of patients undergoing surgery for such lesions.

Medical treatment of allergic fungal sinusitis

LEARNING OBJECTIVES

This review of allergic fungal sinusitis (AFS) will enable the reader to (1) differentiate AFS from the other forms of fungal sinusitis, (2) understand AFS pathophysiology, (3) recognize AFS clinical presentation, (4) prepare an effective treatment and follow-up strategy, and (5) avoid diagnostic and treatment pitfalls.

DATA SOURCES

All English language MEDLINE articles that cross-referenced allergy, fungal, and sinusitis from 1983-present. Other MESH words referenced included: antibodies, fungal; fungus diseases; IgE; spores, fungal; rhinosinusitis. Additional referenced articles, published abstracts, and conference proceedings were also utilized.

STUDY SELECTION

All case reports, studies, and review articles.

RESULTS

Allergic fungal sinusitis is a distinct form of non-invasive fungal sinusitis. It is under-diagnosed, and incidence varies by region. Dematiaceous fungi predominate. In the southwestern United States, Bipolaris spicifera is the most common cause. Patients present with nasal polyps, rhinosinusitis, and occasionally proptosis. CT scans show hypertrophic sinusitis and often hyperattenuating allergic mucin within the sinus cavities. Extra-sinus extension of disease is common. Surgical histopathology shows eosinophilic-lymphocytic mucosal inflammation and inspissated allergic mucin containing non-invasive fungal hyphae. All patients are atopic and have positive allergy skin tests to the AFS organism. Total serum IgE levels are usually elevated. AFS immunopathophysiology is analogous to allergic bronchopulmonary aspergillosis. Treatment requires surgery, postoperative oral corticosteroids (OCS), and aggressive allergy management including allergen immunotherapy. Oral corticosteroids reduce disease activity and forestall the need for recurrent sinus surgery. Postoperative changes in total serum IgE mirror the clinical status and may predict disease recurrence. Patients should be cooperatively followed by the medical specialist and surgeon because early sinus surgery for recurrence, together with aggressive medical management, gives the best outcome.

CONCLUSIONS

Allergic fungal sinusitis is a new allergic disorder with recognizable clinical and histopathologic findings. Treatment requires aggressive allergy management, postoperative OCS, monitoring of total serum IgE, and medical/surgical co-management.

Indolent cutaneous mucormycosis with pulmonary dissemination in an asthmatic patient: survival after local debridement and amphotericin B therapy

We describe a 68-year-old asthmatic female patient with multiple pulmonary cavities. A preexisting ecthyma on the left lower leg became erythematous and swollen during exacerbation of her asthma which was under treatment with high-dose steroids. Nonseptate broad hyphae were found in her sputum, pus from the wound, and debrided skin tissue. Hematogenous spread of septic emboli from indolent cutaneous mucormycosis to both lungs was the suspected mechanism of dissemination. High-dose steroid therapy may have been the major contributory factor. The patient was successfully treated with local surgical debridement of the wound and intravenous amphotericin B.

Evaluation of Stachybotrys chartarum in the house of an infant with pulmonary hemorrhage: quantitative assessment before, during, and after remediation

Stachybotrys chartarum is an indoor mold that has been associated with pulmonary hemorrhage cases in the Cleveland, Ohio, area. This study applied two new quantitative measurements to air samples from a home in which an infant developed PH. Quantitative polymerase chain reaction and a protein synthesis inhibition assay were used to determine the level of S. chartarum spores and their toxicity in air samples taken before, during, and after a remediation program was implemented to remove the fungus. Initial spore concentrations were between 0.1 and 9.3 spores/m3 of air, and the toxicity of air particulates was correspondingly low. However, the dust in the house contained between 0.4 and 2.1 x 10(3) spores/mg (as determined by hemocytometer counts). The remediation program removed all contaminated wallboard, paneling, and carpeting in the water-damaged areas of the home. In addition, a sodium hypochlorite solution was used to spray all surfaces during remediation. Although spore counts and toxicity were high during remediation, air samples taken postremediation showed no detectable levels of S. chartarum or related toxicity. Nine isolates of S. chartarum obtained from the home were analyzed for spore toxicity, hemolytic activity, and random amplified polymorphic DNA banding patterns. None of the isolates produced highly toxic spores (>90 microg T2 toxin equivalents per gram wet weight spores) after growth for 10 and 30 days on wet wallboard, but three isolates were hemolytic consistently. DNA banding patterns suggested that at least one of these isolates was related to isolates from homes of infants with previously investigated cases.

Percutaneous management of intrapulmonary air and fluid collections

The radiologist's role in the management of intrapulmonary air and fluid collections is becoming more important. Improvements in percutaneous interventional techniques now allow the radiologist to offer patients an alternative treatment option with less morbidity and mortality than surgical resection. The use of CT allows optimal catheter placement and enables safe and effective percutaneous evacuation of intrapulmonary collections. In summary, image-guided percutaneous catheter drainage should (1) be the initial procedure performed to diagnose and treat lung abscesses not responding to conservative therapy; and (2) because of its effectiveness and safety, be considered as a treatment option in the management of symptomatic patients with intrapulmonary mycetomas.

Successful eradication of mucormycosis occurring in a pulmonary allograft

The zygomycetes are saprophytic fungi that rarely cause disease in the normal human host. In immunocompromised individuals, these organisms can cause invasive infections, collectively called mucormycosis. Mucormycosis is associated with a high mortality rate, especially in organ transplant recipients. In this report, we describe the first case of successfully treated mucormycosis involving a pulmonary allograft. Treatment consisted of surgical excision of the affected lobe and chest wall and lipid-complex amphotericin B. The lipid complex formulation permitted a prolonged course of therapy that was likely critical to eradication of the infection.

Pulmonary mucormycosis: the last 30 years

Pulmonary mucormycosis is relatively uncommon but an important opportunistic fungal infection in immunocompromised persons. The literature on the subject is sparse. We describe a recent case and review the literature to delineate the clinical characteristics of this infection. We searched the MEDLINE database for articles published in the English-language literature since 1970 and carefully analyzed 87 cases. The main risk factors were diabetes mellitus, hematologic cancers, renal insufficiency, and organ transplantation. Several patients had no apparent immune compromise. There was a predilection for involvement of the upper lobes. Air crescent signs on chest x-ray films were predictors of pulmonary hemorrhage and death from hemoptysis. Fiberoptic bronchoscopy was a useful diagnostic method, and histopathologic examination was more sensitive than fungal cultures. The overall survival rate was 44%. Patients treated with a combined medical-surgical approach had a better outcome than patients who did not undergo surgery. Thus, this relatively rare but often fatal disease should be suspected in immunocompromised patients who fail to respond to antibacterial therapy. Early recognition and aggressive management are warranted to maximize chances for cure. Optimal therapy requires systemic antifungal therapy, surgical resection, and, when possible, control of the patient's underlying disease.

Cryptococcosis in captive cheetah (Acinonyx jubatus): two cases

Cryptococcus neoformans is a yeast-like organism associated with pulmonary, meningoencephalitic, or systemic disease. This case report documents 2 cases of cryptococcosis with central nervous system involvement in captive cheetah (Acinonyx jubatus). In both cases the predominant post mortal lesions were pulmonary cryptococcomas and extensive meningoencephalomyelitis. Both cheetahs tested negative for feline immunodeficiency virus and feline leukaemia virus. The organism isolated in Case 2 was classified as Cryptococcus neoformans var. gattii, which is mainly associated with disease in immunocompetent hosts.

Aspergillus and other fungi

Opportunistic infections that arise in the immunocompromised host are a major cause of morbidity and mortality. Although bacterial infections are more frequent, invasive fungal infections occur commonly and carry higher risks in these immunocompromised patients. Newer antifungal agents, along with an occasional pulmonary resection, have improved the treatment options and the survival from invasive fungal infections in immunocompromised patients.

Thoracic blastomycosis and empyema

Blastomycosis is endemic in river valley areas of the southeastern and Midwestern United States. Pulmonary manifestations include chronic cough and pleuritic pain. Radiographic appearance of the infection can mimic bronchogenic lung carcinoma. Pleural effusion is rarely associated with this pulmonary infection, and empyema has not been previously reported. We report a case of pulmonary and pleural Blastomyces dermatitidis infection presenting as empyema thoracis. Diagnosis and treatment were attained with video-assisted thoracoscopic (VATS) pleural and lung biopsy and debridement.

[Exotic pulmonary mycoses]

The so-called exotic pulmonary mycoses are imported diseases in France. They are infrequent or exceptional and for this reason can be underdiagnosed or recognized with delay. Nevertheless, they are easily treatable infections with available antifungal agents. As a rule, the site of primary infection is the lung with ensuing clearance or chronic local infection and/or dissemination. Immunocompromised hosts are more prone to develop severe forms or reactivation of the disease.

[Management of hemoptysis in invasive pulmonary aspergillosis]

Invasive pulmonary aspergillosis is an opportunistic infection occurring in a background of severe immune depression. The majority of cases occur in patients who have malignant hematologic disease, particularly during chemotherapy induction or consolidations phases for acute non-lymphocytic leukemia. The principal risk factors are profound (PN < 500 per mm3) and prolonged (very high risk beyond 20 days) neutropenia, perturbed phagocyte function and cellular immune deficiency (AIDS, immunosuppressive treatment in organ and bone marrow recipients). Clinically, invasive pulmonary aspergillosis presents as acute non-specific pneumonia with cough, chest pain and fever. The severe infection rapidly becomes life-threatening. The development of massive hemoptysis is a major risk. We report four cases of invasive pulmonary aspergillosis in patients who had hemoptysis. All four patients developed non-specific pneumonia resistant to broad-spectrum antibiotics during post-chemotherapy aplasia. Computed tomography of the thorax and bronchoscopy with bronchoalveolar lavage was performed due to the occurrence of hemoptysis. In the first two cases, the patients were recovering from aplasia. The thoracic CT scan showed evidence of a cavitating mass with peripheral vessels. Bronchoscopy findings suggested mucosal lesions. The patients were managed surgically. Pathology confirmed the diagnosis of invasive pulmonary aspergillosis with the presence of ischemic necrosis of the pulmonary parenchyma harboring numerous aspergillus filaments. Outcome was favorable and chemotherapy was re-initiated in one case. These two patient died from their hematological disease a few months later. The other two patients remained in aplasia. A CT of the thorax showed multifocal infiltration with vascular contact. Bronchoscopy was again suggestive. One patient developed massive hemoptysis with respiratory distress. Embolization was performed but the patient died two days after onset of hemoptysis. In the last case, embolization was successful and outcome was favorable enabling a bone marrow allograft; the patient died a few months later from the hematological disease. The potential gravity of hemoptysis in the course of invasive pulmonary aspergillosis should lead to early treatment with emergency CT scan and, if possible, bronchoscopy with bronchoalveolar lavage to establish the therapeutic strategy based on surgical excision or embolization of the pulmonary or bronchial arteries.

Isolated pulmonary cryptococcosis in pregnancy

BACKGROUND

Isolated pulmonary cryptococcosis in an immunocompetent parturient host is a rare event. Little is known about this condition, its prognosis, and its treatment in the immunocompetent pregnant woman.

CASE

A 28-year-old woman, para 3, was diagnosed with isolated pulmonary cryptococcosis postpartum. She had delivered a healthy neonate at term who revealed no clinical features compatible with maternal-fetal transmission. The woman was monitored closely throughout the course of her disease and radiogic, clinical, and serologic resolution was achieved after treatment with fluconazole.

CONCLUSION

Patients with pulmonary cryptococcosis present with clinical pictures similar to other well-known diseases such as septic pulmonary emboli or choriocarcinoma. Treatment with triazole antifungal therapy yielded favorable results in our patient with this rare condition.

Many faces of pulmonary aspergillosis

Aspergillus is a ubiquitous fungus. It is commonly isolated as an upper respiratory tract saprophyte and is the most frequent contaminant in laboratory specimens. Because species of aspergillus are omnipresent, one must be cautious in ascribing a causal role to the fungus obtained from patients. Aspergillus has low pathogenicity for humans and animals and rarely invades the immunologically competent host. Although the fungus can affect any organ system, the respiratory tract is involved in >90% of afflicted patients. Pulmonary aspergillosis, depending whether the host is atopic or immunosuppressed, may be classified under four categories: allergic or hypersensitivity syndromes, saprophytic colonization, invasive (infective) dissemination, and chemical or toxic pneumonitis. These entities differ clinically, radiologically, immunologically, and in their response to various therapeutic agents. An increased awareness, an aggressive approach to securing the diagnosis, and instituting early and appropriate therapy are needed to reduce the high morbidity and mortality caused by many of the aspergillus-related syndromes.

[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.

[Chronic necrotizing pulmonary aspergillosis: infrequent form of aspergillosis]

BACKGROUND

Chronic necrotizing pulmonary aspergillosis (CNPA) is a chronic pulmonary infection caused by the genus Aspergillus, which usually involves moderately immunosuppressed patients.

METHOD

We describe 3 patients with a toxic syndrome that had lasted several weeks or months, with lung infiltrates in the chest X-ray and the CT scan. Mycobacterium tuberculosis could not be isolated from different respiratory smears (sputum, bronchoaspiration, Barlett catheter and pulmonary punction in the third case). Moreover, there was no response to anaerobic treatment.

RESULTS

All 3 patients were moderately immunosuppressed (2 men were COPD and the woman was an asthmatic patient). One of the men was being treated for a nocardiosis. In all three cases, A. fumigatus was isolated from de different respiratory smears.

CONCLUSIONS

To diagnose a CPNA, a high degree of clinical suspicion is needed. The differential diagnose should be done with pulmonary tuberculosis and anaerobic infections. The presence of a member of the genus Aspergillus in the tracheobronchial secretions of a patient should not be systematically considered a saprofit, specially when other microorganisms can not be isolated.