Necrotising pulmonary aspergillosis complicating the management of patients with obstructive airways disease

Aspergillus tracheobronchitis in critically ill patients with chronic obstructive pulmonary diseases

Aspergillus tracheobronchitis (ATB) is considered as an unusual form of invasive aspergillosis and has a fatal outcome. There is little current information on several aspects of chronic obstructive pulmonary diseases (COPD) complicated by ATB, the frequency of which is expected to increase in the coming years. In a prospective study of invasive bronchial-pulmonary aspergillosis (IBPA) in a critically ill COPD population, three proven cases of ATB were identified. The three new cases, combined with eight previously reported cases of COPD with ATB over a 30-year period (1983-2013), were analysed. Among 153 critically ill COPD patients admitted to the ICU, eight cases were complicated by ATB [23.5% of IBPA (8 of 34); and 5.2% of COPD (8 of 153)], and three cases were finally diagnosed as proven ATB by histopathological findings. Among the three new cases reported and the eight published cases, the overall mortality rate was 72.7% (8 of 11 cases), with a median of 11.5 days (range, 7-27 days) between admission to death. The mortality rate was significantly higher in patients with invasive pulmonary aspergillosis (IPA) [100% (8 of 8 patients)] than in patients without parenchyma invasion [0% (0 of 3 patient), P = 0.006]. Seven patients (77.8%) received systemic corticosteroid therapy and three patients (33.3%) inhaled corticosteroids before diagnosis with ATB. Dyspnoea resistant to corticosteroids (77.8%) was the most frequent symptom. The radiological manifestations progressed rapidly in three patients (75%) who had normal chest X-rays (CXRs) at admission. Pseudomembranous lesions were the most frequent form (54.5%) observed by bronchoscopy. Aspergillus fumigatus was the most frequently isolated pathogen (40%). ATB is an uncommon cause of exacerbation in approximately 5% of critically ill COPD patients admitted to the ICU, and may progress rapidly to IPA with a high mortality rate. Dyspnoea resistant to corticosteroids and appropriate antibiotics with a negative CXR should raise the suspicion of ATB. Early diagnosis of ATB is based on bronchoscopic examination and proven diagnosis maybe safely established with a bronchial mucous biopsy.

Semi-invasive pulmonary aspergillosis in an immunosuppressed patient: a case report

Background

The authors present the high-resolution computed tomography findings of an immunosuppressed patient with semi-invasive pulmonary aspergillosis.

Case presentation

The main finding consisted of irregular, thick-walled cavity in the right upper lobe and a mass with soft-tissue attenuation within it and thickening of adjacent pleura. Additional findings were bronchial wall thickening associated with a 'tree-in-bud' pattern. Following the clinical, laboratorial and imaging criteria, the diagnosis of semi-invasive pulmonary aspergillosis was defined and antifungical treatment was introduced.

Conclusion

The patient responded well to the treatment with improvement in his systemic symptoms and regression of the pulmonary lesions.

Necrotizing Aspergillosis of large airways: CT findings in eight patients

PURPOSE

The aim of this study was to evaluate the CT findings of pathologically proven necrotizing aspergillosis of the large airways (necrotizing Aspergillus bronchitis).

METHOD

Medical records and imaging studies from two tertiary medical centers were reviewed for pathologically proven cases of necrotizing aspergillosis of the large airways. Fiberoptic bronchoscopic examination and CT scans of the chest were available in all cases. Two thoracic radiologists who were blinded to the clinical and pathologic data reviewed the thoracic CT scans retrospectively and reached a final decision. The CT images were evaluated for the presence, distribution, and extent of CT findings.

RESULTS

The study included eight patients, seven men and one woman, ranging in age from 28 to 67 years (mean age 46 years). All patients had histopathologically proved necrotizing Aspergillus of the large airways and no other superimposed infections. Six patients had leukemia, one had chronic liver disease, and one had chronic obstructive lung disease. All patients had bronchial wall thickening and focal bronchial narrowing involving a lobar or segmental bronchus. The bronchial narrowing was irregular or nodular in seven patients and smooth in one. Atelectasis distal to a narrowed bronchus was present in five patients.

CONCLUSION

The CT findings of necrotizing bronchial aspergillosis include bronchial wall thickening, which is often nodular, and narrowing of the bronchial lumen, which is often associated with distal atelectasis.

Semiinvasive pulmonary aspergillosis in chronic obstructive pulmonary disease: radiologic and pathologic findings in nine patients

OBJECTIVE

The purpose of this study is to assess the radiographic, thin-section CT, and histologic findings of semiinvasive aspergillosis in patients with chronic obstructive pulmonary disease (COPD).

MATERIALS AND METHODS

The study included nine patients with COPD seen at the Hospital de Sant Pau during a 3-year period who had histopathologically proven aspergillosis with tissue invasion. Chest radiography and thin-section (2-mm collimation) CT of the chest were available in all cases.

RESULTS

Nine patients had semiinvasive aspergillosis proven at autopsy (n = 7) or by thoracoscopically guided lung biopsy (n = 2). The radiologic findings consisted of parenchymal consolidation (n = 6) and nodules larger than 1 cm in diameter (n = 3). Parenchymal consolidation involved the upper lobes in five patients and was bilateral in four. Cavitation was present in two of the patients with consolidation and in two of the patients with nodular opacities. Adjacent pleural thickening was revealed by CT in four patients. Histologically, the areas of consolidation represented active inflammation and intraalveolar hemorrhage containing Aspergillus organisms. In the three patients with multiple cavitated nodules, a variable degree of central necrosis was observed. The inflammatory infiltrate extended into the surrounding lung parenchyma, and adjacent areas of hemorrhage were also seen. Aspergillus colonies were identified within the lung tissue.

CONCLUSION

Upper lobe consolidation or multiple nodules in patients with COPD should raise the possibility of semiinvasive aspergillosis.

Murine model of invasive pulmonary aspergillosis following an earlier stage, noninvasive Aspergillus infection

Aspergillus spp. occasionally cause invasive pulmonary aspergillosis following noninvasive infection in patients with underlying bronchopulmonary disorders regardless of their systemic immunological conditions. We developed a murine model of invasive pulmonary aspergillosis following an earlier stage, noninvasive Aspergillus infection. BALB/c mice were inoculated intratracheally with agarose beads containing Aspergillus fumigatus conidia. Two weeks after inoculation, half of the mice were immunosuppressed with cortisone acetate. During a 4-week observation period, the survival rate of infected immunosuppressed mice was significantly lower (P < 0.01) than that of infected nonimmunosuppressed mice. The number of CFU in the lungs gradually decreased in the nonimmunosuppressed mice, whereas a time-related significant increase (P < 0.05) of CFU was demonstrated in the immunosuppressed mice. In the lungs of the nonimmunosuppressed mice, there was marked accumulation of neutrophils, lymphocytes, and macrophages (in this order) around the agarose beads in the bronchi. Aspergillus hyphae were surrounded by the inflammatory cells and did not invade the lung parenchyma. In contrast, in the immunosuppressed mice, Aspergillus hyphae proliferated markedly and invaded the lung parenchyma after immunosuppression. In this model, the two-dimensional extents of the lesions were also evaluated with an image-processing system. Time-related increase of the area of peribronchial necrotic lesions was significant (P < 0.05) after immunosuppression. This model should therefore be useful for investigating the pathophysiology of noninvasive Aspergillus infection and invasive pulmonary aspergillosis and also for clarifying the mechanism of conversion to the invasive disease from the noninvasive stage.

Chronic necrotising pneumonia caused by Aspergillus niger

A woman with asthma developed chronic necrotising semi-invasive pneumonia due to mixed Aspergillus niger and Candida albicans infection; though not severely immunosuppressed, she may have been predisposed by long term oral corticosteroid and recurrent oral antibiotic treatment. The diagnosis should be considered in patients with chronic airflow limitation who develop cavitating pneumonia.