Aspergilloma in a patient with an occult congenital pulmonary airway malformation

Thoracoscopic surgery for congenital lung malformations: Does previous infection really matter?

BACKGROUND/ PURPOSE

Elective resection of congenital lung malformations (CLMs) is still debatable. The two main risks are malignant transformation and recurrent pulmonary infections. Our study aimed to assess the effect of previous pulmonary infection on the intraoperative and postoperative courses of thoracoscopic surgery for CLMs.

METHODS

This is a retrospective study including all thoracoscopic lung resections for CLMs between 2010 and 2019. Ninety patients were included. There was a history of previous pulmonary infection in 28 patients (group A) and no such history in 62 patients (group B).

RESULTS

The median age at operation for group A was 20.4 months (IQR:14.9-41.4) versus 15.1 months (IQR:9.7-20.8) in group B (p = 0.006). There were 10 conversions (35.7%) in group A and 8 (12.9%) in group B (p = 0.02). The operative time was significantly shorter in group B (p<0.002). In group A, 32.1% of patients experienced postoperative fever versus 11.3% of group B (p = 0.03), with higher antibiotics requirement (28.6% versus 6.5% respectively, p = 0.007). However, no significant differences were found in terms of postoperative complications (p = 0.99).

CONCLUSION

Earlier intervention for CLMs before the development of pulmonary infection carries higher chances for the success of the thoracoscopic approach with shorter operative time and more uneventful postoperative courses.

Rare Infant Case of Pulmonary Aspergilloma Highlighting Common Challenges With Voriconazole Dosing

We describe a 6-week-old male-term infant with a pulmonary aspergilloma diagnosed following lobectomy for suspected pleuropulmonary blastoma, with characteristic histopathologic findings and Aspergillus detected by polymerase chain reaction. Intensive testing did not reveal primary or secondary immunodeficiency. During 5 weeks treatment with voriconazole including regular therapeutic drug monitoring and dose adjustment, a level in the target range was never achieved. When the patient developed photosensitivity, treatment was stopped without relapse over 12 months follow-up. Voriconazole dosing is notoriously challenging in children. We review the cumulative published experience with voriconazole use in infants to highlight even greater difficulty in infants. Pulmonary aspergillosis is typically a disease affecting immunocompromised or critically ill patients. In children, it is well described in those with chronic granulomatous disease (CGD) as a complication of immunosuppressive antineoplastic chemotherapy and rarely in extremely- or very-low birthweight premature neonatal intensive care patients. The diagnosis is extremely rare in children without underlying risk factors. To our knowledge, this is the first report of a pulmonary aspergilloma in an immunocompetent infant.

Surgical management of pulmonary aspergillosis in pediatric population

INTRODUCTION

Aspergillosis is an invasive infection that affects mainly immunocompromised patients, and the lung is the most common site of infection. We reviewed our experience with the surgical management of pulmonary aspergillosis (PA) in pediatric population at a tertiary care institution.

METHODS

A retrospective chart review was conducted for pediatric patients (<16 years) who were managed for PA over the period from January 2001 to December 2016. Demographic, clinical, and outcome data were retrieved, and descriptive data were generated.

RESULTS

Eighty patients had microbiologically-proven PA over the period of the study, and 38 of them (48%) had a surgical intervention during their management. Among the surgical group, there were 19 males and 19 females with a mean age of 9.4 years (0.5-16). Thirty-five patients (92%) were in an immunocompromised state (10 of them have had bone marrow transplant), 2 patients had cystic lung disease, and 1 had scleroderma. All had fever and respiratory symptoms at presentation and received systemic antifungal medications. All had Computerized tomography (CT) scan examinations which showed features suggestive of the disease. Surgical procedures included lung biopsy in 13 patients (34%), segmentectomy in 12 patients (32%), lobectomy in 8 patients (21%), debridement/cavernostomy in 3 patients (8%), and 2 patients had pneumonectomy (5%). Histopathological examination revealed invasive fungal infection in 20 patients (53%) and aspergilloma in 18 (47%). Eleven patients (29%) died owing to a combination of fungal infection and the underlying disease. Three other patients, not included in the surgical series, died secondary to severe pulmonary hemorrhage while waiting for surgery. All had cavitation on CT scan near the hilum of the lung.

CONCLUSIONS

Pulmonary aspergillosis is a severe invasive infection with a significant mortality. Early surgical intervention is recommended in patients who do not improve on antifungal medication, especially in those with cavitating lesions, in order to improve outcome.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

IV.

A fatal case of congenital pulmonary airway malformation with aspergillosis in an adult

Congenital cystic adenomatoid malformation, currently referred as congenital pulmonary airway malformation (CPAM), is one of the rare lung malformations seen in adults. We report a case of a 59-year-old male with a chronic cough and hemoptysis that was not amenable to bronchial embolization. Further work up revealed cystic changes with fungal ball and type 1 CPAM. Patients with this condition who survive to adulthood usually suffer from recurrent respiratory bacterial infections. Only three cases of fungal involvement have ever been described. We present a fatal case, as well as the oldest patient.

Congenital cystic adenomatoid malformation of lung in adults: 2 rare cases report and review of the literature

Congenital cystic adenomatoid malformation (CCAM), also named congenital pulmonary airway malformation (CPAM), is a congenital abnormality of lung which is uncommon in adults. Here we present 2 adult cases of CCAM with unusual clinical and pathologic findings. One case was complicated with aspergillosis which was seldom reported. The other case was suffered bilateral lesions and the patient's mother had been previously radiographically discovered bilateral cystic lesions that CCAM could not be ruled out. A review of currently published related literatures has also been provided.