[Aspergillosis for the pulmonologist]

[The tree that hides the forest: aspergillosis associated with bronchial carcinoma (about two cases)]

Endobronchial aspergilloma and intracavitary pulmonary aspergilloma may clinically and radiologically mimic a bronchial neoplasia, hence the importance of systematically searching for an association. A confirmed association completely changes the prognosis as well as the therapeutic approach. We here report two cases with two different forms of pulmonary aspergilloma associated with bronchial carcinoma.

[Could pleural aspergillosis happen to be a complication of pleural drainage?]

Four cases of nosocomial aspergillosis are described where the responsibility of pleural drainage is advocated. Infection was pulmonary once, pleural three times. Pleural suction had been long lasting with incomplete re-expansion of the lung and major air leaks. The hypothesis of the responsibility of pleural drainage in the advent of aspergillosis is reinforced by the revision of medical papers, which leads to the conviction that similar cases have been described yet, even though the mechanism of the contamination had not been understood. Prevention needs to limitate the lasting of the suction, especially if there are major air leaks. Cure needs total re-expansion of the lung and suppression of any pleural cavity, even if a thoracoplasty is needed. An anti-fungal therapy is not always needed.

[Chronic necrotizing pulmonary aspergillosis following an infection by Mycobacterium malmoense]

Pneumonia due to Mycobacterium malmoense is rare and usually occurs in damaged lung as is the case with Aspergillus infections. We report the case of a patient who developed chronic necrotizing pulmonary aspergillosis following an infection by atypical mycobacteria. A 53-year-old woman was hospitalized because of weight loss and fever. Direct examination of sputum smear was positive for acid fast bacilli and PCR and culture led to the diagnosis of infection with M. malmoense. Treatment was begun with clarithromycin, rifampicin and ethambutol. Despite initial improvement and excellent adherence to treatment, fever and weight loss recurred 6 months later. Relapse of the mycobacterial infection was excluded and the final diagnosis was necrotizing pulmonary aspergillosis. Infection with A. fumigatus complicating the treatment of M. malmoense is unusual. The management is challenging because of strong interactions between voriconazole and rifampicin, and thus requires a multidisciplinary and specialized approach.

[Huge aspergilloma developed within a zone of scleroderma-related pulmonary fibrosis]

In pulmonary aspergilloma, Aspergillus colonizes and proliferates as a saprophyte in deterged cavities deprived of local defense. Although pulmonary tuberculosis constitutes the one well-know predisposing factor, other causes can create favorable conditions. We describe a first published case of a huge aspergilloma which developed within a zone of pulmonary fibrosis secondary to systemic scleroderma. The patient was a 58-year-old woman in poor general health who experienced repeated episodes of hemoptysis and dyspnea. Physical examination disclosed sclerodactyly, generalized cutaneous sclerosis and Raynaud's phenomenon. There was no clinical history of pulmonary tuberculosis or bronchectasis. Aspergillosis serology was positive. Broncho-alveolar liquid was positive for Aspergillus fumigatus at direct examination and after culture. Immunological assessment confirmed scleroderma. The chest computed tomography scan showed a huge oblong-shaped opacity in the upper left lobe which had developed within a zone of pulmonary fibrosis. Medical management was instituted. The clinical course was marked by repeating hemoptysis and the stability of pulmonary lesions after two years. Management of scleroderma-related pulmonary aspergiloma remains difficult and complicated. Prognosis depends on the course of both conditions, scleroderma and aspergillosis.