Apparent pulmonary mycetoma following invasive aspergillosis in neutropenic patients

Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment

Among all clinical manifestations of pulmonary aspergillosis, invasive pulmonary aspergillosis (IPA) is the most acute presentation. IPA is caused by Aspergillus hyphae invading the pulmonary tissue, causing either tracheobronchitis and/or bronchopneumonia. The degree of fungal invasion into the respiratory tissue can be seen as a spectrum, going from colonization to deep tissue penetration with angio-invasion, and largely depends on the host's immune status. Patients with prolonged, severe neutropenia and patients with graft-versus-host disease are at particularly high risk. However, IPA also occurs in other groups of immunocompromised and nonimmunocompromised patients, like solid organ transplant recipients or critically ill patients with severe viral disease. While a diagnosis of proven IPA is challenging and often warranted by safety and feasibility, physicians must rely on a combination of clinical, radiological, and mycological features to assess the likelihood for the presence of IPA. Triazoles are the first-choice regimen, and the choice of the drug should be made on an individual basis. Adjunctive therapy such as immunomodulatory treatment should also be taken into account. Despite an improving and evolving diagnostic and therapeutic armamentarium, the burden and mortality of IPA still remains high. This review aims to give a comprehensive and didactic overview of the current knowledge and best practices regarding the epidemiology, clinical presentation, diagnosis, and treatment of acute IPA.

Pulmonary Aspergilloma in a Young Immunocompetent Female: A Rare Clinical Dilemma

Depending on the host's immunological and respiratory systems, Aspergillus can induce infectious and allergic diseases. Most of the spread occurs in immunocompromised people, whereas aggressive disorder in immunocompetent patients is unusual. We report the case of a 19-year-old female who had shortness of breath, right-sided chest discomfort, and intermittent hemoptysis for six months before being diagnosed with pulmonary aspergilloma. The initial chest x-ray revealed a massive right pneumothorax and a 7.2 cm rounded opacity in the right lower lung. A subsequent computed tomography (CT) chest with contrast revealed a 6.7 cm cavitating mass occupying the right lower lobe. An open right thoracotomy and right lower lobectomy showed a cavitary fungus ball with septate branching hyphae and subsequent methenamine silver staining consistent with Aspergillus in conjunction with a positive Aspergillus antigen. We strongly suggest that pulmonary aspergillosis should be suspected regardless of age or immunocompetence in patients with prolonged cough, hemoptysis, unilateral chest discomfort, and pneumothorax.

Complications of chronic necrotizing pulmonary aspergillosis: review of published case reports

Chronic necrotizing pulmonary aspergillosis (CNPA), a form of chronic pulmonary aspergillosis (CPA), affects immunocompetent or mildly immunocompromised persons with underlying pulmonary disease. These conditions are associated with high morbidity and mortality and often require long-term antifungal treatment. The long-term prognosis for patients with CNPA and the potential complications of CNPA have not been well documented. The aim of this study was to review published papers that report cases of CNPA complications and to highlight risk factors for development of CNPA. The complications in conjunction associated with CNPA are as follows: pseudomembranous necrotizing tracheobronchial aspergillosis, ankylosing spondylarthritis, pulmonary silicosis, acute respiratory distress syndrome, pulmonary Mycobacterium avium complex (MAC) disease, superinfection with Mycobacterium tuberculosis, and and pneumothorax. The diagnosis of CNPA is still a challenge. Culture and histologic examinations of bronchoscopically identified tracheobronchial mucus plugs and necrotic material should be performed in all immunocompromised individuals, even when the radiographic findings are unchanged. Early detection of intraluminal growth of Aspergillus and prompt antifungal therapy may facilitate the management of these patients and prevent development of complications.

[Pathogenesis of chronic necrotizing pulmonary aspergillosis]

Chronic necrotizing pulmonary aspergillosis (CNPA) is a slowly progressive inflammatory destruction of lung tissue due to Aspergillus infection. The main radiographic features are chronic pulmonary infiltrates, progressive cavitation, and subsequent aspergilloma formation. Although pre-existing cavity is not seen, the presence of pre-existing airspaces such as emphysematous bullae, cannot be excluded. Chronic cavitary pulmonary aspergillosis (CCPA), which is synonymous with complex aspergilloma, shows one or more pre-existing and / or newly formed pulmonary cavities that may or may not contain an aspergilloma, and cavity expansion and / or increasing pericavitary infiltrates. CNPA can be distinguished from CCPA by careful observation of progression of the cavitary lesion if a series of adequate radiography films are available. In some cases, however, it is difficult to distinguish the two subtypes if prior radiographs are not available Aiso, intermediate or overlapping types may exist. We therefore clinically and therapeutically proposed the syndrome including both CNPA and CCPA as chronic progressive pulmonary aspergillosis (CPPA).

Aspergilloma and the surgeon

Aspergillus fungus is a ubiquitous saprophyte that is the causative organism for the development of an aspergilloma. The most common species causing an aspergilloma is the Apergillus fumigatus. An aspergilloma is a conglomeration of mucus, inflammatory cells and altered blood elements. Aspergillomas typically form in pre-existing lung pathology, most notably and commonly in old healed tuberculosis cavities. They are classified into simple and complex types that have clinical relevance. Symptoms are very variable and it is not uncommon to incidentally find a lung aspergilloma. In most case series, the most common presenting symptom is haemoptysis which varies from mild to catastrophic bleeds. Given the limited information about the natural history of the disease, there is unfortunately no recognised factor or variable which can predict how an aspergilloma will manifest itself, hence the manner of treatment is a still a topic of debate among treating physicians. The mainstay of treatment is surgical intervention and medical options although disappointing at the current stage, require further investigation in light of the newer available anti-fungal agents. The need for surgical intervention is however not as clear-cut as one would like, since many patients have multiple co-morbidities and other diffuse or focal lung pathology, making the decision process indeterminate in certain instances. In this review, we focus on the different surgical options available for the management of aspergilloma across variable clinical settings, and we propose an approach to its management.

A necrotic lung ball caused by co-infection with Candida and Streptococcus pneumoniae

Introduction

A necrotic lung ball is a rare radiological feature that is sometimes seen in cases of pulmonary aspergillosis. This paper reports a rare occurrence of a necrotic lung ball in a young male caused by Candida and Streptococcus pneumoniae.

Case report

A 28-year-old male with pulmonary candidiasis was found to have a lung ball on computed tomography (CT) of the chest. The patient was treated with β-lactams and itraconazole and then fluconazole, which improved his condition (as found on a following chest CT scan) and serum β-D-glucan level. The necrotic lung ball was suspected to have been caused by coinfection with Candida and S. pneumoniae.

Conclusion

A necrotic lung ball can result from infection by Candida and/or S. pneumoniae, indicating that physicians should be aware that patients may still have a fungal infection of the lungs that could result in a lung ball, even when they do not have either Aspergillus antibodies or antigens.

Aspergillosis: diagnosis and treatment

The incidence of invasive aspergillosis is increasing rapidly in the developed world with two Aspergillus spp., A. fumigatus and A. flavus, causing the majority of infections (85-90% and 5-10%, respectively). The major risk factors are profound neutropenia (< or =1000 x 10(6) cells/L), prolonged neutropenia, neutrophil function deficits, and corticosteroid therapy. Useful diagnostic techniques include sputum culture, CT scan, bronchoscopy with microscopy and culture, percutaneous lung biopsy, open lung biopsy and serology. Invasive aspergillosis has an almost 100% mortality rate if untreated. Amphotericin B is the usual first-line therapy although it is associated with a high failure rate. Itraconazole (> or =400 mg daily) is a useful alternative and surgical resection may be life saving in some cases. The efficacy of the initial therapy is critical for improving mortality rates.

Noninvasive pulmonary Aspergillus infections

Aspergillus can cause several forms of pulmonary disease ranging from colonization to invasive aspergillosis and largely depends on the underlying lung and immune function of the host. This article reviews the clinical presentation, diagnosis, pathogenesis, and treatment of noninvasive forms of Aspergillus infection, including allergic bronchopulmonary aspergillosis (ABPA), aspergilloma, and chronic pulmonary aspergillosis (CPA). ABPA is caused by a hypersensitivity reaction to Aspergillus species and is most commonly seen in patients who have asthma or cystic fibrosis. Aspergillomas, or fungus balls, can develop in previous areas of cavitary lung disease, most commonly from tuberculosis. CPA has also been termed semi-invasive aspergillosis and usually occurs in patients who have underlying lung disease or mild immunosuppression.

Fungal Infections

The incidence of invasive fungal infections has increased dramatically over the past two decades, mostly due to an increase in the number of immunocompromised patients.1–4 Patients who undergo chemotherapy for a variety of diseases, patients with organ transplants, and patients with the acquired immune deficiency syndrome have contributed most to the increase in fungal infections.5 The actual incidence of invasive fungal infections in transplant patients ranges from 15% to 25% in bone marrow transplant recipients to 5% to 42% in solid organ transplant recipients.6,7 The most frequently encountered are Aspergillus species, followed by Cryptococcus and Candida species. Fungal infections are also associated with a higher mortality than either bacterial or viral infections in these patient populations. This is because of the limited number of available therapies, dose-limiting toxicities of the antifungal drugs, fewer symptoms due to lack of inflammatory response, and the lack of sensitive tests to aid in the diagnosis of invasive fungal infections.1 A study of patients with fungal infections admitted to a university-affiliated hospital indicated that community-acquired infections are becoming a serious problem; 67% of the 140 patients had community-acquired fungal pneumonia.8

Surgical resection of persistent pulmonary fungus nodules and secondary prophylaxis are effective in preventing fungal relapse in patients receiving chemotherapy or bone marrow transplantation for leukemia

Antifungal therapy may be unable to eradicate invasive mycosis in leukemia patients. The presence of persisting pulmonary nodules owing to mycosis seems to increase the risk of fungal relapse after chemotherapy and transplant procedures. Between 1997 and 2004, 10 acute leukemia patients underwent pulmonary surgery for invasive mycosis. The median time from diagnosis of mycosis to surgery was 135 days (range 21-147). Three patients underwent emergency surgery, owing to hemoptysis. In the other seven patients with nodule/cavitation remaining after antifungal treatment, surgery (three wedge resections, four lobectomies) was scheduled before transplant. Pathologic examination confirmed two aspergillosis and three zygomycosis. The only side effect was pneumothorax in one case. Nine patients were considered cured. Six patients underwent bone marrow transplantation (three allogeneic, three autologous) with antifungal prophylaxis without relapse during the transplant procedure. In selected patients scheduled for bone marrow transplantation, surgical resection of localized pulmonary fungus nodules combined with antifungal prophylaxis seem to be an effective treatment for preventing mycotic relapse.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

Place de la chirurgie dans le traitement des aspergilloses thoraciques

INTRODUCTION

This article reviews the different forms of pulmonary disease caused by aspergillus and discusses the possible surgical treatments. The most well known is the classic aspergilloma which develops as a fungal ball in the centre of a pre-existing pulmonary cavity.

STATE OF KNOWLEDGE

One can distinguish simple (few symptoms, thin walled cavity without immediate complications) and complex forms (patient generally unwell, thick cavity, complications). In the complex form, surgical intervention must be considered as a last resort. In the simple form, surgery is relatively benign and prevents disease progression. Pleural aspergillosis can occur, usually following the surgical removal of a cavity either in the short or medium term. Given the loss of lung parenchyma thoracoplasty is often the only option.

OUTLINES

Two different scenarios occur in acute invasive aspergillosis where surgery may be indicated: firstly, surgery can be considered in the event of haemoptysis related to vascular erosion; secondly, resection of mycotic sequestrations before intensification or resumption of therapy may prevent a relapse. Semi-invasive aspergillosis usually occurs in territories of post-radiation fibrosis: after a phase of invasion equivalent to a lobar pneumonia, a secondary cavity appears containing a small fungal ball. Thoracoplasty is often the only surgical option. Ulcerating tracheobronchial aspergillosis has been observed following (cardio-) pulmonary transplant and this may progress to a characteristic invasive aspergillosis.

CONCLUSIONS

Finally, rare observations of parietal aspergillosis could be treated by surgical resection and associated with systemic antifungal therapy. Optimum management of these patients requires a multidisciplinary approach.

[Thoracic aspergillosis: indications for surgery for a multifaceted disease!]

We reviewed the different clinical forms of thoracic aspergillosis and detailed surgical options. Classical aspergiloma where a tuft of Aspergillus grows in a parenchymal cavity is the most well-known entity. Simple forms (little clinical expression, thin-walled cavity without impact on neighboring tIssue) can be distinguished from complex forms (poor general status, thickened cavity, sequellae). Surgery is the last resort for complex forms, but the procedure is benign for simple forms allowing interruption of the spontaneous evolution. Pleural aspergillosis is a common complication of the excision procedure, whether performed early or at mid-term. Thoracoplasty is often required due to the Volume of parenchyma removed. Surgery can be proposed for acute invasive aspergillosis in two situations: to prevent cataclysmic hemoptysis due to a paravascular lesion, or for resection of sequestered mycotic deposits which could lead to generalized reinfection. Semi-invasive aspergillosis is usually observed in areas of post-radiation fibrosis where the typical aspergillar excavation appears after the initial phase of invasion leading to lobular pneumonia. Thoracoplasty is often the only surgical option. Ulcerated aspergillar tracheobronchitis is observed after (heart)-lung transplantation and raises the risk of characteristic invasive aspergillosis. Finally rare observations of parietal aspergillosis have been treated by surgical resection in combination with systemic antifungal agents. Multidisciplinary consultation is required to establish the most appropriate approach.

Clinical manifestations and treatment outcomes of pulmonary aspergilloma

BACKGROUND

Pulmonary aspergilloma usually results from the ingrowth of colonized Aspergillus from a damaged bronchial tree, a pulmonary cyst, or from the cavities of patients with underlying lung diseases. In the present study, we analyzed the clinical features, diagnostic methods, and managements of 36 patients with pulmonary aspergilloma.

METHODS

Thirty-six patients were diagnosed as having pulmonary aspergilloma at Chung-Ang University Hospital between February 1988 and February 2000. Their medical records were reviewed retrospectively.

RESULTS

The age of patients (median +/- SD) was 53.3 +/- 11.8 years, the male to female ratio was 2.36:1, and the most frequent symptom was hemoptysis, which occurred in 24 patients (65%). The most common underlying disease was pulmonary tuberculosis (81%), and the upper lobes of both lungs were the most frequently involved sites. Nine patients received a chest CT in the prone position and seven of these showed a movable fungus ball. Eleven patients were positive for the precipitin antibody to A. fumigatus. Twenty patients underwent surgical resection, and post-operative complications were reported in seven cases. The post-operative mortality was 5.6% (2/36).

CONCLUSION

Pulmonary aspergilloma usually develops in the patients with underlying lung diseases. Resectional lung surgery is considered the mainstay of therapy for pulmonary aspergilloma. However, this operation is associated with significant complications and death in some cases. Therefore, it is necessary to develop reasonable criteria for selection of candidates for such surgery.

Effect of direct infusion of antifungal agent on invasive pulmonary aspergillosis in a patient with acute leukemia

Invasive pulmonary aspergillosis is a serious problem in the treatment of patients with acute leukemia. A 52-year-old woman with acute myeloid leukemia developed invasive pulmonary aspergillosis during remission induction chemotherapy. Initially, we treated her with a continuous intravenous drip infusion of amphotericin B, together with itraconazole, given orally. A peripheral crescentic cavity formed in the fungal lesion after the number of neutrophils recovered, and we therefore performed a direct infusion of miconazole into the cavity transbronchially. The lung lesion resolved dramatically shortly after this treatment. In this patient, the transbronchial infusion of an antifungal agent seemed to have been very useful for bringing about prompt resolution of the fungal lesion.

Surgical outcome of pulmonary resection in chronic necrotizing pulmonary aspergillosis

BACKGROUND

Surgical treatment of chronic necrotizing pulmonary aspergillosis is hazardous and controversial.

METHODS

Ten patients (8 men, 2 women; mean age, 50 years) with chronic necrotizing pulmonary aspergillosis underwent pulmonary resection between 1989 and 2000. Single segmentectomy or lobectomy, pneumonectomy, or bilobectomy and multisegmentectomy were performed. Clinicopathologic features of these patients were reviewed to clarify the role of surgical intervention for chronic necrotizing pulmonary aspergillosis.

RESULTS

The mean time from the onset of clinical symptoms to operation was 5.3 years. Surgical intervention was undertaken because of prolonged illness in 4 patients and hemoptysis in 6 patients. All patients survived. Three major complications (1 late empyema, 2 bronchopleural fistulas) occurred in the large dead space in the right pleural cavity. All survivors were free of aspergillosis at a mean follow-up time of 4.8 years, and only 1 patient required antifungal drugs for relapse during the follow-up period.

CONCLUSIONS

Aggressive pulmonary resection in chronic necrotizing pulmonary aspergillosis should be considered when patients have prolonged illness or frequent hemoptysis. Empyema and bronchopleural fistula are the main complications. Concomitant thoracoplasty or intrathoracic transposition of the chest wall musculature is recommended in cases involving a large residual pleural cavity on the right side.

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.

Aspergillosis in bone marrow transplant recipients

Invasive aspergillosis in bone marrow transplant recipient is associated with a high mortality. Diagnosis is often delayed because the inflammatory response is blunted by immunosuppression. The gold standard of tissue biopsy is often considered too in invasive as the procedure is often complicated by bleeding and secondary infection. Recent finding on non-invasive tests such as serial measurement of peripheral blood galactomannan antigen or DNA appears to be promising. However, the limited availability of such tests and requirement for expertise are still hampering their use in routine clinical management. More often than not, initiation of antifungal therapy is empirical and based on suggestive radiological changes. Amphotericin B remains the gold standard of therapy but liposconal preparation may prove to be less nephrotoxic and equally effective. Treatment outcome depends more on the acceleration of the recovery of the immune system and the reduction of anti-GVHD therapy than the antifungal agent followed by surgical resection. The efficacy of many reported anti-aspergillosis prophylactic regimen has not been proved in randomized control trials. Despite the absence of data, such policy should still be considered in transplant units with high incidence of aspergillus or undergoing renovation.

An EORTC multicentre prospective survey of invasive aspergillosis in haematological patients: diagnosis and therapeutic outcome. EORTC Invasive Fungal Infections Cooperative Group

OBJECTIVES

The EORTC Invasive Fungal Infections Cooperative Group (IFICG) conducted a prospective survey by questionnaire of all cases of invasive aspergillosis (IA) in cancer patients to ascertain current diagnostic and therapeutic approaches.

METHODS

All members of the IFICG were asked prospectively to complete a detailed questionnaire for each IA case identified in their institution over a 12-month period.

RESULTS

One hundred and thirty questionnaires were returned. All cases were independently evaluated (DWD & JC) and 123 were eligible. Cases came from 20 hospitals in eight countries and the number of cases per institution varied from 1-21. Acute myeloid leukaemia (AML) (60, 49%), acute lymphoblastic leukaemia (ALL) (21, 17%) and lymphoma (11, 9%) were the most frequent underlying diseases, and 16 (12%) patients had received an allogeneic bone marrow transplant. Pulmonary involvement was present in 87%, infection of sinuses/nose in 16% and brain in 8%. The chest radiograph was initially normal in 9% of those with primary pulmonary disease. The diagnosis was confirmed in 50%, probable in 31% and possible in 19%. The evidence for IA was on the basis of clinical and radiological features alone in 28%, with culture or histology in another 31% and 9%, respectively, and with both culture and histology in 29%. In three (2%) patients with diagnosis was based on culture or histology alone. Treatment was given to 120 patients (98%)-amphotericin B 75%, lipid-associated amphotericin B 36%, itraconazole 40%, flucytosine 12%, growth factors 33%, lobectomy 5%. At 3 months after diagnosis or first suspicion of IA, 44 (36%) patients were alive and 79 (64%) dead. Outcome was best in those with AML (30% death and 46% with a complete antifungal response or cure). Growth factors (mostly granulocyte colony stimulating factor) appeared not to influence outcome (P = 0.99).

CONCLUSION

IA remains a considerable diagnostic and therapeutic challenge. No single diagnostic procedure was universally successful and a multifaceted approach including surgery is necessary. There was no discernable difference in outcome between initial therapy with amphotericin B, itraconazole or lipid-associated amphotericin B, although numbers are limited and the study was retrospective.

Surgical therapy for pulmonary aspergillosis in immunocompromised patients

BACKGROUND

Medical management for invasive pulmonary aspergillosis (IPA) is often unsatisfactory. Antifungal therapy may be unable to eradicate IPA in the immunocompromised or neutropenic patient.

METHODS

We retrospectively reviewed the surgical management of IPA in 13 immunocompromised patients at our institution. Twelve patients underwent perioperative bone marrow transplantation (4 autologous, 8 allogenic). All 13 patients received antifungal therapy. Eleven patients were neutropenic at the time of operation.

RESULTS

The mean interval from diagnosis of aspergillosis to operation was 42 days (range, 3 to 135 days). Eighteen operations were performed on the 13 patients. Seven patients had resections from multiple pulmonary sites, whereas 6 had a single lesion resected. The average lesion resected was 3.7 cm in greatest diameter (range, 1 to 9 cm). After a mean follow-up of 21 months (range, 0 to 9 years), 3 patients (23%) are alive with no evidence of aspergillosis, 6 patients (46%) died without evidence of aspergillosis, and 4 patients (31%) died secondary to aspergillus infection. All 4 patients who died of aspergillus infection received an allogenic bone marrow transplantation. Two patients with direct extrapulmonic extension of IPA at time of operation died of recurrent aspergillus infections. Three of 4 patients who died of aspergillus infection had an absolute neutrophil count less than 1,300 cells/microL at time of operation. The mean absolute neutrophil count of the patients who cleared the aspergillus infection was 5,538 cells/microL. The mean survival of allogenic bone marrow transplant recipients was 5.2 months, and for recipients of autografts was 51.4 months.

CONCLUSIONS

In this series, surgical resection of IPA cleared the aspergillus infection in 69% of the patients. Neutropenia, extrapulmonic extension of IPA, and allogenic bone marrow transplantation may predict a worse prognosis. Surgical resection of IPA in immunocompromised patients is an effective form of therapy in a properly selected patient population.

Bronchopulmonary aspergilloma: a reappraisal

BACKGROUND

Classically, most complications observed after operations for aspergilloma occurred in patients with sequelae of tuberculosis. Because the incidence of tuberculosis has declined over the past two decades, aspergilloma is expected to develop with increasing frequency in patients without previous tuberculosis. Therefore, our hypothesis was that operative outcome should have improved during the most recent years in comparison with our previous experience.

METHODS

Operative outcome of 12 recently accrued patients was evaluated and compared with a historic control group of 55 patients, previously reported by the same center.

RESULTS

As expected, only 17% of patients of the present series had a history of tuberculosis, compared with 57% in the former series. Postoperatively, there was no mortality. Major morbidity has decreased, although this difference is not statistically significant: bleeding decreased from 44% to 9% of patients; space problems decreased from 47% to 18%; and prolonged hospital stay (>30 days) decreased from 32% to 9%.

CONCLUSIONS

Our results support a trend toward improved postoperative outcome of operations for aspergilloma owing to a decreased incidence of aspergilloma growing in tuberculous cavitations.

Aggressive surgical management in localized pulmonary mycotic and nonmycotic infections for neutropenic patients with acute leukemia: report of eighteen cases

OBJECTIVE

To prevent hemoptysis and relapse during subsequent chemotherapy-induced neutropenia in patients with localized forms of invasive pulmonary aspergillosis, we adopted an aggressive surgical approach.

METHODS

From 1988 to 1996, 18 patients with hematologic diseases were referred with the diagnosis of localized invasive pulmonary aspergillosis. The diagnosis was based on clinical features, failure to respond to antibiotic therapy, an air crescent sign suggestive of aspergillosis on the computed tomographic scan (39%), and retrieval of fungi by bronchoalveolar lavage (44%).

RESULTS

The following procedures were done: one pneumonectomy, four bilobectomies, seven lobectomies, six wedge resections, and one lobectomy with wedge resection (one patient had two procedures). No perioperative deaths or complications occurred. The histologic examination confirmed the diagnosis of invasive pulmonary aspergillosis in 12 patients. The six other diagnoses were as follows: one case of classic aspergilloma, one case of pneumonia, and four cases of pulmonary abscess. According to univariate analysis, thoracic pain was less common in the group with noninvasive pulmonary aspergillosis (1/6) than in the group with invasive pulmonary aspergillosis (8/12) (p < 0.05). Sixteen patients required subsequent hematologic treatments. Sixty-six percent of the patients are alive with a mean follow-up of 29.1 +/- 27.8 months (range 2 to 103 months), with no statistically significant difference between the invasive and the noninvasive pulmonary aspergillosis groups. Five patients died of a recurrence of their malignant disease at a mean of 17.2 +/- 12.5 months (range 2 to 30 months), and one had a cerebral recurrence of Aspergillus infection during a bone marrow transplantation 3 months later.

CONCLUSION

Aggressive surgical management radically improves the prognosis of invasive pulmonary aspergillosis, even if the surgical indications include some nonmycotic infections because of the difficulty in establishing the clinical diagnosis.

Pulmonary resection for invasive Aspergillus infections in immunocompromised patients

Standard antifungal medical therapy of invasive pulmonary aspergillosis that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less than a 5% survival. In view of these dismal mortality rates, we adopted an aggressive approach with resection of the involved area of lung along with systemic antifungal therapy when localized invasive pulmonary aspergillosis developed in these patients. Between January 1987 and December 1993, 14 patients with hematologic diseases and 2 liver transplant recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (range 1 to 45 days) after the diagnosis was clinically suggested and confirmed by chest computed tomographic scans. Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracoplasty, nine lobectomies, and five wedge resections (one patient with hematologic disease had two procedures). All patients were treated before and after the operation with antifungal agents. Nine (64%) of 14 patients with hematologic disease and 2 (100%) of 2 liver transplant recipients survived the hospitalization with no evidence of recurrent Aspergillus infection after a median 8 months of follow-up (range 3 to 82 months). The five hospital deaths (all patients with hematologic diseases) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple organ system failure with presumed disseminated Aspergillus infection in one. Four of the five deaths were in patients with allogeneic bone marrow transplants. Two of the three patients requiring resection of multiple foci of infection died, as did the only patient who was preoperatively ventilator dependent. In immunocompromised patients with hematologic diseases or liver transplantation with invasive pulmonary aspergillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.

Fatal haemoptysis in pulmonary filamentous mycosis: an underevaluated cause of death in patients with acute leukaemia in haematological complete remission. A retrospective study and review of the literature. Gimema Infection Program (Gruppo Italiano Malattie Ematologiche dell'Adulto)

A retrospective study on a consecutive series of 116 patients affected by acute leukaemia with documented pulmonary filamentous mycosis (FM) admitted between 1987 and 1992 to 14 tertiary-care hospitals in Italy was made in order to evaluate the characteristics of those patients who developed fatal massive haemoptysis. In 59/116 cases of pulmonary FM the infection was the principal cause of death and in 12 of these patients a massive haemoptysis was responsible for death. The diagnosis of FM infection was made ante-mortem in only four out of these 12 patients. The autopsy was performed in 11/12 patients and documented a FM infection. The mycetes isolated were: Hyphomycetes spp. (three patients), Mucorales spp. (two patients), Aspergillus spp. (seven patients). At the time of the massive haemoptysis the mean neutrophil count was 7.2 x 10(9)/l, and no patient had relevant thrombocytopenia (mean 184 x 10(9)/l, range 28-350) or coagulative abnormalities. The mean time which elapsed between resolution of chemotherapy-induced neutropenia (WBC < 10(9)/l) and occurrence of haemoptysis was 7 d. No signs or symptoms predictive of this fatal complication were identified. Massive haemoptysis can be the cause of death in patients with acute leukaemia and pulmonary FM which in the majority of patients was not diagnosed in vivo. This complication occurs most frequently shortly after the recovery from chemotherapy-induced aplasia. The mechanism of lesion is unknown, but it may involve the vascular tropism of FM and the release of leucocyte enzymes. Better preventive and therapeutic antifungal treatments are needed to avoid this serious, albeit rare, complication.

Treatment of invasive aspergillosis

Invasive aspergillosis is generally a life-threatening invasive opportunistic mycosis affecting principally the upper and lower respiratory tract. Therapeutic response rates vary considerably from one host group to another with particularly high mortality rates in bone marrow transplant, liver transplant and patients with aplastic anaemia or AIDS. Only two drugs are useful for therapy, amphotericin and itraconazole. Recent advances in the formulation of amphoterin B (AmBisome and Amphocil) have resulted in intravenous preparations with lower toxicity, particularly nephrotoxicity, but it has yet to be shown that they have an increased therapeutic index for the treatment of invasive aspergillosis. Itraconazole can only be used orally and in some particularly high-risk or critically ill patients adequate serum concentrations cannot be achieved. The addition of flucytosine or rifampicin to amphotericin B therapy has, at best, only a marginal benefit. Surgery is essential for some manifestations of invasive aspergillosis. This article reviews therapeutic strategies including criteria for initiation of therapy, combination and sequential therapy, duration of therapy and secondary prophylaxis and indications for surgery in invasive aspergillosis.

Invasive cavitary pulmonary aspergillosis in patients with cancer: a clinicopathologic study

We studied the histopathology and clinicopathologic correlates of invasive cavitary pulmonary aspergillosis in 11 immunosuppressed patients with disseminated malignancy. In most patients cavities were produced by separation of necrotic from viable lung, resulting in an intracavitary sequestrum ("lung ball"). Central dissolution of large necrotic areas and suppurative granulomatous aspergillary pneumonia were additional causes of cavities in three patients. In four patients with chronic cavities sequestra had been replaced by intracavitary mycetomas ("fungus balls"). Neutrophils usually were numerous at the interface of the sequestrum and adjacent lung, but were minimally present in three patients with prolonged severe neutropenia. The lack of neutrophils in some patients suggests that factors other than neutrophil-derived proteases may be important in cavity formation. A prominent giant cell reaction was seen in three patients with chronic cavities. Hemoptysis occurred in five patients and massive hemoptysis due to a bronchoarterial fistula caused the death of one patient. The "air-crescent" sign was not observed radiographically in any patient and is therefore considered to be an insensitive marker for lung cavitation in invasive aspergillosis. Persistent intracavitary fungal growth may serve as a reservoir for recurrent fungal invasion in patients with prolonged or repeated episodes of severe neutropenia.

Localized invasive pulmonary aspergillosis in patients with neutropenia. Effectiveness of surgical resection

BACKGROUND

Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in patients with neutropenia. Two severe complications with poor outcome can be observed after apparently successful IPA medical treatment: severe hemoptysis and IPA relapse during subsequent cytotoxic treatments. Early surgical therapy has not been considered routinely in the management of localized IPA.

METHODS

Six consecutive patients (four women, two men; median age, 52 years) with localized cavitating IPA diagnosed during chemotherapy-induced aplasia were treated with early surgical resection after hematologic recovery.

RESULTS

All patients received a lobectomy. Surgery was uneventful. This procedures allows patients to proceed with further intensive chemotherapy and/or bone marrow transplantation without IPA reactivation.

CONCLUSIONS

For selected patients, surgical resection of localized IPA with unique cavitating lesion, which prevents hemoptysis and IPA recurrence and allows for subsequent cytotoxic treatment, may be recommended.

Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment

From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.

Operation for cavitating invasive pulmonary aspergillosis in immunocompromised patients

Invasive pulmonary aspergillosis is a specific form of pulmonary Aspergillus infection that occurs almost exclusively in immunocompromised patients. It differs both histologically and in its clinical course from classic aspergillomas. During a 5-year period (1986-1990), 8 patients underwent resection for cavitating invasive pulmonary aspergillosis that developed as a consequence of neutropenia during chemotherapy for malignancy. There were no perioperative deaths and no complications. This contrasts with reports of operation for classic aspergillomas. Histologic examination of the resected specimens showed that cavitating invasive pulmonary aspergillosis differed from classic aspergillomas. They consisted of necrotic lung tissue invaded by fungus with separation from the surrounding lung so that the sequestrum had the appearance of a fungus ball. Pulmonary aspergillosis is a common complication of profound neutropenia. The first hemoptysis in this group of patients is often life-threatening. The excellent results of operation in our series of patients may be attributed to their young age, good pulmonary function, and limited operation. This has lead us to recommend early surgical intervention in invasive aspergillosis once cavitation develops.

Fatal haemoptysis associated with invasive pulmonary aspergillosis treated with high-dose amphotericin B and granulocyte-macrophage colony-stimulating factor (GM-CSF)

Opportunistic pulmonary infections are a leading cause of morbidity and mortality in patients with chemotherapeutically treated neoplasias. With increasingly aggressive cytotoxic regimens causing prolonged neutropenia, the risk of systemic mycoses and in particular of invasive pulmonary aspergillosis has increased. We review the case of a 10-year-old child suffering from relapsed lymphoblastic leukaemia and from high-dose amphotericin B-treated invasive pulmonary aspergillosis acquired during long-standing neutropenia in the initial phase of remission induction chemotherapy. The patient died in remission after GM-CSF-induced bone marrow recovery and clinical and radiological improvement with stable plasmatic coagulation and normal thrombocyte count. Peracute massive pulmonary bleeding caused by the simultaneous arrosion of a greater pulmonary artery and a lobar bronchus by a liquefactive fungal focus was responsible. In patients with chemotherapeutically induced neutropenia and invasive aspergillosis, bone marrow recovery may lead to the liquefaction of pulmonary foci, and, in view of the well-known vasotropic nature of the infection, to a potentially lethal arrosion bleeding. With the emerging use of colony-stimulating factors for shortening and overcoming neutropenia, this so far rare complication may become of increasing importance.

Bronchoscopy findings in invasive pulmonary aspergillosis

Two patients with invasive aspergillosis had unusual endobronchial appearances at fibreoptic bronchoscopy. Diagnosis was achieved by endobronchial biopsy.

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.