Pleural aspergillosis in a patient with recurrent spontaneous pneumothorax: The challenge of an optimal therapeutic approach

Unusual Aspergillus Pleural Effusion in a Patient With Immunodeficiency

Pleural aspergillosis is a rare form of invasive bronchopulmonary aspergillosis that is most often seen in immunocompromised hosts. It appears because of the coagulative necrosis of lung tissue induced by the Aspergillus species, which promotes the formation of a fungal pleural effusion. We present the case of a 51-year-old liver transplant patient on chronic immunosuppression therapy who presented with respiratory failure and was found to have a large left-sided pleural effusion from invasive aspergillosis. After thoracentesis, he started antifungal therapy with isavuconazole. This newer, second-generation broad-spectrum triazole is non-inferior to voriconazole but with less hepatotoxicity and was noted to have an improvement in his symptoms. In the differential diagnosis of pulmonary effusions in immunocompromised patients, it is crucial to consider invasive aspergillosis, as demonstrated by our case. This case study highlights the importance of quick diagnosis and treatment to enhance outcomes in this vulnerable population.

Spontaneous pleural aspergillosis in an immunocompetent young adult treated with minimally invasive surgery

Spontaneous cases of pleural aspergillosis in healthy adults are rare, and the optimal therapeutic approach has not been established. Here we report a rare case of spontaneous pleural aspergillosis in an otherwise healthy young adult. Two-stage surgery with decortication and cavernostomy, followed by systemic antifungal therapy, finally resulted in a successful resolution of his empyema without any serious complications. In young patients with good pulmonary compliance, less invasive procedures, such as thoracoscopic decortication and/or carvernotomy, is a potential treatment option.

Aspergillus pleural empyema in a chronic smoker - A case report and review of literature

Aspergillus species are ubiquitous saprophytic fungi that are present in the air, water, soil, and decaying vegetables. Clinical features of Aspergillus infection largely depend on the interplay between the fungi and the host immune status. We present a case of a chronic smoker with shortness of breath who was found to have diffuse bronchiectatic changes and empyema of the right lung. Emphysema was also noticed in the left lung. Rare Aspergillus fumigatus was identified in the pleural fluid, while the acid-fast stain and bacterial cultures were negative. The patient's serum Aspergillus fumigatus IgG antibody and galactomannan antigen were negative; however, the pleural galactomannan antigen was elevated. He was treated with video-assisted thoracoscopic surgery (VATS) and partial decortication of the right lung, along with intravenous voriconazole. Despite aggressive therapeutic measures, he died after a prolonged hospital stay. Aspergillus pleural empyema is rare but can be fatal; however, it is not included in the classification for pulmonary aspergillosis. Clinicians should be vigilant to evaluate for fungal empyema in patients with chronic obstructive pulmonary diseases, even without profound immunosuppression.

Antifungal Drugs TDM: Trends and Update

PURPOSE

The increasing burden of invasive fungal infections results in growing challenges to antifungal (AF) therapeutic drug monitoring (TDM). This review aims to provide an overview of recent advances in AF TDM.

METHODS

We conducted a PubMed search for articles during 2016-2020 using "TDM" or "pharmacokinetics" or "drug-drug-interaction" with "antifungal," consolidated for each AF. Selection was limited to English language articles with human data on drug exposure.

RESULTS

More than 1000 articles matched the search terms. We selected 566 publications. The latest findings tend to confirm previous observations in real-life clinical settings. The pharmacokinetic variability related to special populations is not specific but must be considered. AF benefit-to-risk ratio, drug-drug interaction (DDI) profiles, and minimal inhibitory concentrations for pathogens must be known to manage at-risk situations and patients. Itraconazole has replaced ketoconazole in healthy volunteers DDI studies. Physiologically based pharmacokinetic modeling is widely used to assess metabolic azole DDI. AF prophylactic use was studied more for Aspergillus spp. and Mucorales in oncohematology and solid organ transplantation than for Candida (already studied). Emergence of central nervous system infection and severe infections in immunocompetent individuals both merit special attention. TDM is more challenging for azoles than amphotericin B and echinocandins. Fewer TDM requirements exist for fluconazole and isavuconazole (ISZ); however, ISZ is frequently used in clinical situations in which TDM is recommended. Voriconazole remains the most challenging of the AF, with toxicity limiting high-dose treatments. Moreover, alternative treatments (posaconazole tablets, ISZ) are now available.

CONCLUSIONS

TDM seems to be crucial for curative and/or long-term maintenance treatment in highly variable patients. TDM poses fewer cost issues than the drugs themselves or subsequent treatment issues. The integration of clinical pharmacology into multidisciplinary management is now increasingly seen as a part of patient care.

Successful management of Aspergillus infection of an open window thoracostomy with topical liposomal amphotericin B

We present the case of a previously healthy 54-year-old man who was hospitalized for an Aspergillus fumigatus infection of an open window thoracotomy. Patient was successfully treated for 8 consecutives weeks with daily topical pleural liposomal amphotericine B administered by soaked gauzes combined with systemic therapy.

Isavuconazole-Animal Data and Clinical Data

The treatment of invasive fungal infections has deeply evolved in the last years with the inclusion of new antifungals, mainly new azoles (i.e., posaconazole, isavuconazole), to the therapeutic armamentarium. This review focuses on the role of isavuconazole for treating the most important invasive fungal infections both in animals and humans (hematological and non-hematological patients).

Spontaneous pneumothorax secondary to chronic cavitary pulmonary histoplasmosis

Histoplasma capsulatum

is a dimorphic fungus that causes histoplasmosis. Chronic cavitary pulmonary histoplasmosis is rare, and typically manifests as apical cavitary lesions in patients with pre-existing chronic obstructive pulmonary disease. We report a case involving a 60-year-old female who presented to our facility with acute onset of dyspnea and dry cough. Chest x-ray revealed a large left-sided pneumothorax with nearly complete collapse of the left lung. A chest computed tomography scan revealed a left upper lobe cavitary lesion with a bronchopleural fistula. After thoracic surgical bleb resection, a surgical specimen sent for biopsy was positive for Histoplasma capsulatum. The patient’s pneumothorax was subsequently diagnosed as chronic cavitary pulmonary histoplasmosis, and itraconazole treatment was initiated. After admission, the patient underwent a thoracotomy with decortication to improve lung expansion; however, the patient’s pneumothorax persisted. After a prolonged hospital stay and serial chest x-rays that showed stable residual pneumothorax, the patient was discharged to a long-term acute care facility and itraconazole treatment was continued. Two months after discharge, a repeat chest x-ray showed resolution of her left-sided pneumothorax. This case report highlights the importance of considering pulmonary histoplasmosis (or other endemic pulmonary fungal infections) when a patient presents with apical cavitary lesions.