Targeted DPPC/DMPG surface-modified voriconazole lipid nanoparticles control invasive pulmonary aspergillosis in immunocompromised population: in-vitro and in-vivo assessment

Invasive pulmonary aspergillosis (IPA) is the most devastating Aspergillus-related lung disease. Voriconazole (VRZ) is the first-line treatment against IPA. Despite availability in oral and parenteral dosage forms, risks of systemic toxicity dictate alternative pulmonary administration. Inspired by natural lung surfactants, dipalmitoylphosphatidylcholine/dimyristoylphosphatidylglycerol (DPPC/DMPG) surface-modified lipid nanoparticles (LNPs) were scrutinized for pulmonary administration. DPPC/DMPG-VRZ-LNPs prepared using ultrasonication/thin film hydration were investigated for colloidal properties over 3-month shelf storage. They were stable with a slight change in entrapment efficiency. They provided a sustained VRZ release over 24 h, with a rapid initial release. In vitro aerosolization indicated higher percentages of VRZ deposited on stages corresponding to secondary bronchi and alveolar ducts. Moreover, intrapulmonary administration maintained high lung VRZ concentration (27 ± 1.14 µg/g) after 6 h. A preclinical study using a cyclophosphamide-induced neutropenic rat model demonstrated a 3-fold reduction in BALF-Galactomannan down to 0.515 ± 0.22 µg/L confirming DPPC/DMPG-VRZ-LNPs potential in hyphal growth inhibition. Histopathological examination of infected/nontreated lung sections exhibited dense fungal load inside alveoli and blood vessels indicating massive tissue and angio-invasiveness. Nevertheless, DPPC/DMPG-VRZ-LNPs-treated animals displayed minimal hyphae with no signs of invasiveness. The developed bioinspired nanoparticles serve as prospective bioactive nanocarrier candidates for pulmonary administration of VRZ in the management of IPA.

Aspergillus fumigatus cytochrome c impacts conidial survival during sterilizing immunity

IMPORTANCE

Aspergillus fumigatus can cause a life-threatening infection known as invasive pulmonary aspergillosis (IPA), which is marked by fungus-attributable mortality rates of 20%-30%. Individuals at risk for IPA harbor genetic mutations or incur pharmacologic defects that impair myeloid cell numbers and/or function, exemplified by bone marrow transplant recipients, patients that receive corticosteroid therapy, or patients with chronic granulomatous disease (CGD). However, treatments for Aspergillus infections remain limited, and resistance to the few existing drug classes is emerging. Recently, the World Health Organization classified A. fumigatus as a critical priority fungal pathogen. Our cell death research identifies an important aspect of fungal biology that impacts susceptibility to leukocyte killing. Furthering our understanding of mechanisms that mediate the outcome of fungal-leukocyte interactions will increase our understanding of both the underlying fungal biology governing cell death and innate immune evasion strategies utilized during mammalian infection pathogenesis. Consequently, our studies are a critical step toward leveraging these mechanisms for novel therapeutic advances.

A Pathology-based Case Series of Influenza- and COVID-19-associated Pulmonary Aspergillosis: The Proof Is in the Tissue

Rationale: Invasive pulmonary aspergillosis has emerged as a frequent coinfection in severe coronavirus disease (COVID-19), similarly to influenza, yet the clinical invasiveness is more debated. Objectives: We investigated the invasive nature of pulmonary aspergillosis in histology specimens of influenza and COVID-19 ICU fatalities in a tertiary care center. Methods: In this monocentric, descriptive, retrospective case series, we included adult ICU patients with PCR-proven influenza/COVID-19 respiratory failure who underwent postmortem examination and/or tracheobronchial biopsy during ICU admission from September 2009 until June 2021. Diagnosis of probable/proven viral-associated pulmonary aspergillosis (VAPA) was made based on the Intensive Care Medicine influenza-associated pulmonary aspergillosis and the European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology (ISHAM) COVID-19-associated pulmonary aspergillosis consensus criteria. All respiratory tissues were independently reviewed by two experienced pathologists. Measurements and Main Results: In the 44 patients of the autopsy-verified cohort, 6 proven influenza-associated and 6 proven COVID-19-associated pulmonary aspergillosis diagnoses were identified. Fungal disease was identified as a missed diagnosis upon autopsy in 8% of proven cases (n = 1/12), yet it was most frequently found as confirmation of a probable antemortem diagnosis (n = 11/21, 52%) despite receiving antifungal treatment. Bronchoalveolar lavage galactomannan testing showed the highest sensitivity for VAPA diagnosis. Among both viral entities, an impeded fungal growth was the predominant histologic pattern of pulmonary aspergillosis. Fungal tracheobronchitis was histologically indistinguishable in influenza (n = 3) and COVID-19 (n = 3) cases, yet macroscopically more extensive at bronchoscopy in influenza setting. Conclusions: A proven invasive pulmonary aspergillosis diagnosis was found regularly and with a similar histological pattern in influenza and in COVID-19 ICU case fatalities. Our findings highlight an important need for VAPA awareness, with an emphasis on mycological bronchoscopic work-up.

Invasive pulmonary aspergillosis associated with viral pneumonitis

The occurrence of invasive pulmonary aspergillosis (IPA) in critically ill patients with viral pneumonitis has increasingly been reported in recent years. Influenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA) are the two most common forms of this fungal infection. These diseases cause high mortality in patients, most of whom were previously immunocompetent. The pathogenesis of IAPA and CAPA is still not fully understood, but involves viral, fungal and host factors. In this article, we discuss several aspects regarding IAPA and CAPA, including their possible pathogenesis, the use of immunotherapy, and future challenges.

In vitro study on aspects of molecular mechanisms underlying invasive aspergillosis caused by gliotoxin and fumagillin, alone and in combination

Gliotoxin (GT) and fumagillin (FUM) are mycotoxins most abundantly produced by Aspergillus fumigatus during the early stages of infection to cause invasive aspergillosis (IA). Therefore, we hypothesized that GT and FUM could be the possible source of virulence factors, which we put to test adopting in vitro monoculture and the novel integrated multiple organ co-culture (IdMOC) of A549 and L132 cell. We found that (i) GT is more cytotoxic to lung epithelial cells than FUM, and (ii) GT and FUM act synergistically to inflict pathology to the lung epithelial cell. Reactive oxygen species (ROS) is the master regulator of the cytotoxicity of GT, FUM and GT + FUM. ROS may be produced as a sequel to mitochondrial damage and, thus, mitochondria are both the source of ROS and the target to ROS. GT-, FUM- and GT + FUM-induced DNA damage is mediated either by ROS-dependent mechanism or directly by the fungal toxins. In addition, GT, FUM and GT + FUM may induce protein accumulation. Further, it is speculated that GT and FUM inflict epithelial damage by neutrophil-mediated inflammation. With respect to multiple organ cytotoxicity, GT was found to be cytotoxic at IC50 concentration in the following order: renal epithelial cells < type II epithelial cells < hepatocytes < normal lung epithelial cells. Taken together, GT and FUM alone and in combination contribute to exacerbate the damage of lung epithelial cells and, thus, are involved in the progression of IA.

CT of invasive pulmonary aspergillosis (IPA) in cases with hematologic malignancy: Comparison of CT features in the group classified by the severity of neutropenia and underlying disease

PURPOSE

To identify differences in the radiological findings of invasive pulmonary aspergillosis (IPA) among patients classified by severity of neutropenia, and differences in underlying disease.

MATERIALS AND METHODS

We retrospectively reviewed computed tomography (CT) scans from the time of the diagnosis of IPA in 83 hematological malignancy patients with probable or proven IPA according to the EORTC-MSG criteria. We evaluated CT findings (radiological pattern, number of lesions, distribution, and presence of low attenuation area [LAA]), and compared the radiological findings of patients classified by degree of neutropenia with two different indicators (neutrophil count at the onset, and c-d-index) and underlying disease.

RESULTS

Neutropenia at the onset of IPA was associated with an increased frequency of LAA (p < 0.05), especially in FN (p < 0.01). Cases with a c-d-index of ≧5500 showed an increased incidence of the angio-invasive pattern. In contrast, cases with a c-d-index of 0 showed an increased incidence of the airway-invasive pattern (p < 0.05). The airway-invasive pattern was more frequent in cases with MM, while the angio-invasive pattern was more frequent in cases with AML (p < 0.01). Lower-predominant distribution was more frequent and random distribution was less frequent in cases with AML, random distribution was more frequent and lower-predominant distribution was less frequent in cases with ALL, and upper-predominant distribution was more frequent in cases with MDS (p < 0.05).

CONCLUSIONS

CT features of IPA vary according to the degree of neutropenia and underlying disease.

Aspergillus fumigatus conidial metalloprotease Mep1p cleaves host complement proteins

Innate immunity in animals including humans encompasses the complement system, which is considered an important host defense mechanism against Aspergillus fumigatus, one of the most ubiquitous opportunistic human fungal pathogens. Previously, it has been shown that the alkaline protease Alp1p secreted from A. fumigatus mycelia degrades the complement components C3, C4, and C5. However, it remains unclear how the fungal spores (i.e. conidia) defend themselves against the activities of the complement system immediately after inhalation into the lung. Here, we show that A. fumigatus conidia contain a metalloprotease Mep1p, which is released upon conidial contact with collagen and inactivates all three complement pathways. In particular, Mep1p efficiently inactivated the major complement components C3, C4, and C5 and their activation products (C3a, C4a, and C5a) as well as the pattern-recognition molecules MBL and ficolin-1, either by directly cleaving them or by cleaving them to a form that is further broken down by other proteases of the complement system. Moreover, incubation of Mep1p with human serum significantly inhibited the complement hemolytic activity and conidial opsonization by C3b and their subsequent phagocytosis by macrophages. Together, these results indicate that Mep1p associated with and released from A. fumigatus conidia likely facilitates early immune evasion by disarming the complement defense in the human host.

Fatal Invasive Pulmonary Aspergillosis Associated with Nonspecific Interstitial Pneumonia: An Autopsy Case Report

Invasive pulmonary aspergillosis (IPA) usually occurs in patients with severe immunodeficiencies involving neutropenia. Underlying lung disease is a well-known risk factor of IPA; however, interstitial lung disease has not been recognized as a risk factor of IPA. We herein report a patient with fibrotic nonspecific interstitial pneumonia who experienced IPA without neutropenia. His IPA was fatal and showed unusually slow disease progression over one month. The computed tomography findings showed only nonspecific consolidation and no typical lesions suggestive of IPA. Finally, the autoptic findings revealed numerous Aspergillus fungi, neutrophilic pulmonary necrosis, and vessels invaded by Aspergillus fungi.

A possible role for fumagillin in cellular damage during host infection by Aspergillus fumigatus

Virulence mechanisms of the pathogenic fungus Aspergillus fumigatus are multifactorial and depend on the immune state of the host, but little is known about the fungal mechanism that develops during the process of lung invasion. In this study, microarray technology was combined with a histopathology evaluation of infected lungs so that the invasion strategy followed by the fungus could be described. To achieve this, an intranasal mice infection was performed to extract daily fungal samples from the infected lungs over four days post-infection. The pathological study revealed a heavy fungal progression throughout the lung, reaching the blood vessels on the third day after exposure and causing tissue necrosis. One percent of the fungal genome followed a differential expression pattern during this process. Strikingly, most of the genes of the intertwined fumagillin/pseurotin biosynthetic gene cluster were upregulated as were genes encoding lytic enzymes such as lipases, proteases (DppIV, DppV, Asp f 1 or Asp f 5) and chitinase (chiB1) as well as three genes related with pyomelanin biosynthesis process. Furthermore, we demonstrate that fumagillin is produced in an in vitro pneumocyte cell line infection model and that loss of fumagillin synthesis reduces epithelial cell damage. These results suggest that fumagillin contributes to tissue damage during invasive aspergillosis. Therefore, it is probable that A. fumigatus progresses through the lungs via the production of the mycotoxin fumagillin combined with the secretion of lytic enzymes that allow fungal growth, angioinvasion and the disruption of the lung parenchymal structure.

Pulmonary Nontuberculous Mycobacteriosis and Chronic Lower Respiratory Tract Infections in Patients with Allergic Bronchopulmonary Mycosis without Cystic Fibrosis

Objective The frequency of pulmonary nontuberculous mycobacteriosis (pNTM), chronic lower respiratory tract infections (cLRTIs), and pneumonia in patients with allergic bronchopulmonary mycosis (ABPM) without cystic fibrosis has not yet been fully investigated. Methods We retrospectively analyzed 42 patients with ABPM focusing on the frequency of pNTM and cLRTIs, acute exacerbation of cLRTIs, and pneumonia. Results During a median follow-up period of 2,299 days (range, 118-6,138 days), 7 patients developed pNTM (mainly Mycobacterium avium complex), and 21 patients developed cLRTI (mostly from Staphylococcus aureus followed by Pseudomonas aeruginosa). Twelve patients developed 21 episodes of acute exacerbation of cLRTIs, and 4 patients developed pneumonia. Conclusion Patients with ABPM can have concomitant NTM infection and, not uncommonly, cLRTI, and they can also sometimes develop pneumonia or an acute exacerbation of cLRTI.

Cerebral embolism through hematogenous dissemination of pulmonary mucormycosis complicating relapsed leukemia

Invasive mucormycosis in patients with hematological diseases mostly occurs in the lungs. Invasive mucormycosis of other anatomical sites is relatively infrequent and its pathogenesis has not so far been well elucidated. Here, we describe an autopsy case of pulmonary invasive mucormycosis complicated by cerebral embolism with infarct. A 77-year-old Japanese woman with relapsed acute myeloid leukemia complained of left visual disturbance and weakness of the lower limbs. The diagnosis of leukemic infiltration to the central nervous system was made. Repeated intrathecal injection of methotrexate plus cytarabine resulted in partial amelioration of the neurologic symptoms. However, the patient then developed fever, dyspnea, and subsequent right hemiparesis. A computed tomography (CT) scan showed a consolidative shadow with halo sign in the left lung field, which was compatible with either invasive pulmonary aspergillosis or mucormycosis. These findings accounted for fever and dyspnea, but not hemiparesis. Despite antifungal therapy, the patient succumbed to death after two weeks. Autopsy revealed pulmonary invasive mucormycosis with a fungal ball in the lumina of the adjacent ascending aorta. Intriguingly, autopsy and postmortem CT scan identified left cerebral infarct due to mucormycosis, which accounted for the right hemiparesis. It is likely that the fungal ball caused the cerebral embolism through hematogenous dissemination. We should suspect hematogenous dissemination when we see a patient with pulmonary invasive mucormycosis developing neurologic symptoms.

The Aspergillus fumigatus pkcA G579R Mutant Is Defective in the Activation of the Cell Wall Integrity Pathway but Is Dispensable for Virulence in a Neutropenic Mouse Infection Model

Aspergillus fumigatus is an opportunistic human pathogen, which causes the life-threatening disease, invasive pulmonary aspergillosis. In fungi, cell wall homeostasis is controlled by the conserved Cell Wall Integrity (CWI) pathway. In A. fumigatus this signaling cascade is partially characterized, but the mechanisms by which it is activated are not fully elucidated. In this study we investigated the role of protein kinase C (PkcA) in this signaling cascade. Our results suggest that pkcA is an essential gene and is activated in response to cell wall stress. Subsequently, we constructed and analyzed a non-essential A. fumigatus pkcA^G579R mutant, carrying a Gly579Arg substitution in the PkcA C1B regulatory domain. The pkcA^G579R mutation has a reduced activation of the downstream Mitogen-Activated Protein Kinase, MpkA, resulting in the altered expression of genes encoding cell wall-related proteins, markers of endoplasmic reticulum stress and the unfolded protein response. Furthermore, PkcA^G579R is involved in the formation of proper conidial architecture and protection to oxidative damage. The pkcA^G579R mutant elicits increased production of TNF-α and phagocytosis but it has no impact on virulence in a murine model of invasive pulmonary aspergillosis. These results highlight the importance of PkcA to the CWI pathway but also indicated that additional regulatory circuits may be involved in the biosynthesis and/or reinforcement of the A. fumigatus cell wall during infection.

[Mixed types of pulmonary aspergillosis]

OBJECTIVE

To describe the clinical features of mixed types of pulmonary aspergillosis (MTPA), and therefore to improve the diagnosis and treatment of MTPA.

METHODS

This study retrospectively analyzed 3 patients with MTPA in Peking University First Hospital from November 2010 to 2012. "Invasive pulmonary aspergillosis (IPA), pulmonary aspergilloma, allergic bronchopulmonary aspergillosis (ABPA)" were used as the Chinese and English keywords, to search the literatures from Wanfang database and Pubmed database until to May 2014.

RESULTS

There were 3 patients with MTPA, respectively with aspergilloma and IPA (patient 1), ABPA and IPA (patient 2), aspergilloma and IPA (patient 3). The cultures of respiratory secretions of the patients all yielded A.fumigatus. Patient 1 was treated by amphotericin B; Patient 2 was treated by intravenous itraconazole and glucocorticoid; Patient 3 was treated by oral voriconazole and inhaled corticosteroid, and the aspergilloma was surgically removed at the same time. Eventually, patients 1 and 2 died, while the symptoms of patient 3 were significantly improved. Drug sensitivity test of A. fumigatus showed resistance to amphotericin B or itraconazole. By far there was no concept of MTPA in the literatures and there were only 3 relevant case reports.

CONCLUSION

MTPA is a new subtype of pulmonary aspergillosis, which is more complicated and severe, and perhaps with drug resistance. MTPA should be treated by comprehensive therapies on the basis of sensitive and effective antifungal drugs.

Altered CD8(+) T-cell counts as an early predictor of prognosis in critically ill immunocompromised patients with invasive pulmonary aspergillosis

BACKGROUND

The number of critically ill immunocompromised (CIIC) patients has increased dramatically in recent years, and they represent a high risk population for invasive pulmonary aspergillosis (IPA) infection. Host immunity should play a major role in determining the outcome and recovery of these patients. The purpose of this study was to evaluate the dynamic changes in host immune status and its potential influence on prognosis in CIIC patients with IPA.

METHODS

We monitored the evolution of a number of key cellular and humoral parameters on days 1, 3, and 10 (D1, D3 and D10) following ICU admission in sixty-two CIIC patients with microbiological evidence of IPA. We included immunoglobulins IgG, IgA and IgM, complement factors C3 and C4, and lymphocyte subgroups CD3(+), CD4(+), CD8(+), CD28(+)CD4(+), and CD28(+)CD8(+) T cells, CD19(+) B cells, and CD3(-)CD16(+)CD56(+) natural killer cells (NK).

RESULTS

The primary outcome was 28-day mortality. Thirty-eight (61.3%) patients died within the 28 days following ICU admission. Compared to patients who died, CD3(+), CD8(+), CD28(+)CD8(+) T-cell counts on D1, D3, and D10, CD28(+)CD4(+) T-cell counts on D3 and D10, and NK counts on D3 and D10 were significantly higher in survivors. Receiver operating characteristic (ROC) analysis of immune parameters predicting 28-day mortality revealed area under the curve (AUC) values of 0.82 (95% CI 0.71-0.92), 0.94 (95% CI 0.87-0.99), and 0.94 (95% CI 0.85-0.99) for CD8(+) T-cell counts for D1, D3, and D10 respectively, and 0.84 (95% CI 0.75-0.94), 0.92 (95% CI 0.85-0.99), and 0.90 (95% CI 0.79-0.99) for CD28(+)CD8(+) T-cell counts for D1, D3, and D10 respectively. Kaplan-Meier survival analysis showed that CD8(+) T-cell counts <149.5×10(6) cells/L and CD28(+)CD8(+) T-cell counts <75×106 cells/L at ICU admission were associated with lower survival probabilities in CIIC patients with IPA (both Log rank: P < 0.001).

CONCLUSIONS

Low CD8(+) and CD28(+)CD8(+) T-cell counts were associated with high mortality in CIIC patients with IPA. Early counts of CD8(+) and CD28(+)CD8(+) T cells in CIIC patients with IPA may be valuable for predicting outcome.

Prognostic value of serum galactomannan index in critically ill patients with chronic obstructive pulmonary disease at risk of invasive pulmonary aspergillosis

BACKGROUND

Critically ill chronic obstructive pulmonary disease (COPD) patients admitted to an intensive care unit (ICU) due to respiratory failure are at particularly high risk of Aspergillus infection. The serum galactomannan index (GMI) has proven to be one of the prognostic criteria for invasive pulmonary aspergillosis (IPA) in classical immunocompromised patients. However, the prognostic value of serum GMI in critically ill COPD patients needs evaluation. The purpose of this study is to investigate the prognostic value of serum GMI in patients with severe COPD.

METHODS

In this single-center prospective cohort study, serum samples for GMI assay were collected twice a week from the first day of ICU admission to the day of the patients' discharge or death. Patients were divided into two groups according to their clinical outcome on the 28th day of their ICU admission. Univariate analysis and survival analysis were tested in these two groups.

RESULTS

One hundred and fifty-three critically ill COPD patients were included and were divided into survival group (106 cases) and non-survival group (47 cases) according to their outcome. Univariate analysis showed that the highest GMI level during the first week after admission (GMI-high 1st week) was statistically different between the two groups. Independent prognostic factors for poor outcome in severe COPD patients were: GMI-high 1st week >0.5 (RR: 4.04, 95% CI: 2.17-7.51) combined with accumulative dosage of corticosteroids >216 mg before the RICU admission (RR: 2.25, 95% CI: 1.11-4.56) and clearance of creatinine (Ccr) ≤ 64.31 ml/min (RR: 2.48, 95% CI: 1.22 ± 5.07).

CONCLUSIONS

The positive GMI-high 1st week (>0.5) combined with an accumulative dosage of corticosteroids >216 mg before the ICU admission and a low Ccr may predicate a poor outcome of critically ill COPD patients.

Establishment and application of real-time quantitative PCR for diagnosing invasive aspergillosis via the blood in hematological patients: targeting a specific sequence of Aspergillus 28S-ITS2

BACKGROUND

Invasive aspergillosis (IA) is an important cause of morbidity and mortality in immunocompromised individuals. This study was conducted to identify a desirable target DNA sequence for the diagnosis of aspergillosis using real-time quantitative polymerase chain reaction (qPCR).

METHODS

Genomic DNA was extracted from Aspergillus, Candida, and bacteria species, and qPCR was applied to validate a partial ribosomal DNA 28S-ITS2 sequence. Ethylenediaminetetraacetic acid-anticoagulated blood samples were collected from 72 febrile hematological patients, while total DNA was isolated from plasma and whole blood for the Aspergillus qPCR. The results were analyzed using a receiver operating characteristic curve. All cases were evaluated using the revised European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) diagnostic criteria.

RESULTS

Use of qPCR yielded positive results for 15 Aspergillus species but negative results for Candida species, bacterial strains, and human DNA. The limit of detection was one copy per microliter of DNA. Analytical sensitivity and specificity were six copies of DNA and 100%, respectively. The standard curve showed that qPCR was reliable for Aspergillus detection and that significantly more DNA copies were obtained from whole blood than from plasma (P < 0.001). At a cut-off value ≥ 25 copies/μL, the diagnostic sensitivity and specificity for IA using 28S-ITS2 qPCR were 90.9% and 73.4%, respectively.

CONCLUSIONS

The use of qPCR with whole blood to detect and verify the 28S-ITS2 sequence is a specific and useful way to diagnose IA.

Initial computed tomography findings of invasive pulmonary aspergillosis in non-hematological patients

BACKGROUND

The computed tomography (CT) findings of invasive pulmonary aspergillosis (IPA) are unclear in non-hematological patients. The present study was a retrospective evaluation of CT images in non-hematological patients with IPA.

METHODS

All adult patients who met the 2008 European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria for proven or probable IPA were included during a 5-year study at our institutions. Initial CT findings in our cohort were retrospectively reviewed by two independent thoracic radiologists blinded to patient demographics and clinical outcomes. The presence, pattern, and distribution of abnormalities were recorded.

RESULTS

Twenty-three non-hematological patients with pathologically confirmed IPA were included in our study. Areas of ground-glass opacities were present in 14 patients (61%), which were bilateral in 10 patients and unilateral in four. This pattern mainly involved the middle and upper lung zones. Air-space consolidation was identified in 12 patients (52%), and the areas were distributed along the bronchus or subpleura in most cases. Other findings, including five small nodules (22%), three macronodules (13%), and one halo sign (4%), were less common.

CONCLUSIONS

CT findings of IPA in non-hematological patients frequently manifested as acute bronchopneumonia, and ground-glass opacities and air-space consolidations were the most common CT findings of IPA in these patients.

Detection of galactomannan in bronchoalveolar lavage fluid samples of patients at risk for invasive pulmonary aspergillosis: analytical and clinical validity

Invasive pulmonary aspergillosis (IPA) is frequent and often fatal in immunosuppressed patients. Timely diagnosis of IPA improves survival but is difficult to make. We examined the analytical and clinical validity of galactomannan (GM) testing of bronchoalveolar lavage (BAL) fluid in diagnosing IPA in a mixed population by retrospectively reviewing records of 251 consecutive at-risk patients for whom BAL fluid GM testing was ordered. The performance of the enzyme immunoassay was evaluated by using a range of index cutoffs to define positivity. Three samples were associated with proven IPA, 56 were associated with probable IPA, 63 were associated with possible invasive fungal disease (IFD), and 129 were associated with no IFD. Using a BAL fluid GM index of ≥0.8 (optimal optical density [OD] index cutoff identified by a receiver operating characteristic curve), the sensitivity in diagnosing proven and probable IPA was 86.4%, and the specificity was 90.7%. At this cutoff, positive and negative predictive values were 81% and 93.6%, respectively. However, an OD index value of ≥3.0 corresponded to a 100% specificity, thus ruling the disease in, irrespective of the pretest probability. Conversely, an OD index cutoff of <0.5 corresponded to a high sensitivity, virtually always ruling the disease out. For all values in between, the posttest probability of IPA depends largely on the prevalence of disease in the at-risk population and the likelihood ratio of the OD index value. Detection of GM in BAL fluid samples of patients at risk of IPA has an excellent diagnostic accuracy provided results are interpreted in parallel with clinico-radiological findings and pretest probabilities.

Chronic necrotizing pulmonary aspergillosis in a renal transplant recipient

Chronic necrotizing pulmonary aspergillosis is a chronic semi invasive pulmonary disease. It is an uncommon disease and has never been reported in transplant recipients. We report a case of chronic necrotizing pulmonary aspergillosis in a renal transplant recipient.

Chronic necrotizing pulmonary aspergillosis

INTRODUCTION

Chronic necrotizing pulmonary aspergillosis (CNPA) is a cavitary, infectious process of lung parenchyma with slow progressive course. Vascular invasion and dissemination to other organs are unusual.

CASE REPORT

We presented a 25-year old man with bilineal acute leukaemia who developed pulmonary and systemic symptoms. Chest CT showed nodular consolidations and cavitary lesions in both lungs. Bronchial biopsy revealed necrotic hyphae but it was negative for Aspergillus by culture. Serum was positive for antibodies to Aspergillus, but it was negative for antigens. A thoracoscopic lung biopsy of the upper left lobe revealed necrosis of lung tissue, with acute and chronic inflammation of the cavity wall and the presence of hyphae consistent with Aspergillus species.

CONCLUSION

Although confirmation of the diagnosis is difficult, a combination of characteristic clinical, radiological and histological findings and either serological results positive for Aspergillus or the isolation of Aspergillus from respiratory samples are highly indicative of CNPA.

Rare form of semi-invasive aspergillosis in immunocompetent patient: case report

Chronic necrotizing or semi-invasive aspergillosis represents a disease commonly occurred in patients with mild immunodeficiency. We report a case of chronic necrotizing pulmonary aspergillosis in immunocompetent patient without underlying disease. The discovery of the disease was made accidentally, by finding a nodular opacity on a routine chest X-ray. The diagnostic was confirmed by pathological and bacteriological examination. With specific antifungal treatment, no complete eradication was obtained and the patient has a slow evolution with many relapses.

[Invasive pulmonary aspergillosis with hemoptysis; a resected case whose bleeding point is detected pathologically]

A 55-year-old man, who presented with recurrent episodes of hemoptysis, was referred to our hospital under the diagnosis of invasive aspergillosis with a cavity in the right lung. Computed tomography showed a large thick-walled cavity in the right upper lung. He underwent right upper lobectomy. Pathological findings showed a large cavity in right upper lobe. Aspergillus was found in the cavity. A pseudoaneurysm, which was thought to be a cause of hemoptysis, originated from a ruptured pulmonary artery and protruded into the cavity. Hemoptysis is well-known symptom in aspergillosis patients, and surgery for aspergillosis with hemoptysis is sometimes performed. But it is very rare that bleeding point is detected microscopically.

[Autopsy case of corticosteroid-induced invasive pulmonary aspergillosis with cavity-formation]

Invasive pulmonary aspergillosis (IPA) is an important and fatal complication in the patients with neutropenic or immunosuppressed condition. In spite of intensive treatment with anti-fungal drugs, the prognosis of the patients who have been suffered from IPA is extremely poor. This case was an 85-year-old Japanese man who was diagnosed as idiopathic thrombocytopenic purpura (ITP). He underwent high-dose corticosteroids and gamma-globulin therapy. During the hospitalization, he complained respiratory symptoms, and the abnormal shadow suggesting pulmonary infiltration and cavitation was pointed out on chest imaging. He was diagnosed as IPA because of high level of serum beta-D-glucan and positive for aspergillus antigen. Although he underwent intensive care with anti-fungal drug administration and artificial respiration, he died of respiratory distress on the 68th hospitalization. Postmortem examination disclosed severe bronchopneumonia, cavitation and pulmonary arterial thrombi in both lungs. Histological examination showed widely distributed epitheloid cell granulomata with central necrosis containing aspergillus hyphae, and vasodestructive growth of fungus with occasional organized thrombi.

How invasive aspergillosis may have a beneficial effect after single lung transplantation

We report the case of a 52-year-old female, who received a left single lung transplantation for end-stage smoking-induced emphysema in 1997. During the last 4 years, she experienced a progressive decline in FEV1, which we attributed to the development of bronchiolitis obliterans syndrome, stage 2. In 2007 she experienced an invasive aspergillosis of the native lung upper lobe, which resolved after 3 months of adequate treatment with voriconazole. After resolution of the infection, both FVC (forced vital capacity) and FEV1 became surprisingly better, due to fibrosis of the affected lobe, compatible with infection-induced volume reduction of the native lung.

NAC is associated with additional alleviation of lung injury induced by invasive pulmonary aspergillosis in a neutropenic model

AIM

Neutropenic individuals are at high risk for invasive pulmonary aspergillosis (IPA), a life-threatening infection. To evaluate the therapeutic potential of antioxidants, IPA was induced in neutropenic mice and the effect of N-acetyl-l-cysteine (NAC) on oxidative stress levels and lung injury was analyzed.

METHODS

Mice were pretreated with three daily intraperitoneal injections of 150 mg/kg cyclophosphamide, followed by intratracheal inoculation with 4.5x10(6) conidia of Aspergillus fumigatus. The infected mice were then randomly assigned to an amphotericin B (AMB) group, an AMB plus NAC group, or an untreated control (C) group. In each group, the duration of treatment was 24, 48, or 72 h, and activities such as appearance, feeding, and dermal temperature were observed throughout the experiment. Sera and lung tissues were collected and analyzed by quantitative enzyme-linked immunosorbent assay (ELISA) for total protein, superoxide dismutase (SOD), malondialdehyde (MDA), tumor necrosis factor-alpha (TNF-alpha), and interleukin-10 (IL-10) levels. The wet/dry weight ratio of the lung was also calculated and lung sections were stained with hematoxylin-eosin for pathological examination and with methenamine silver stain for fungus detection.

RESULTS

Compared with the mice untreated with NAC, mice in the AMB plus NAC group had increased SOD and reduced MDA levels both systemically and locally at 24, 48, and 72 h after inoculation with conidia. NAC treatment also decreased the pulmonary protein content at 48 and 72 h and the lung wet/dry weight ratio at 24 and 48 h. Additionally, NAC enhanced pulmonary production of TNF-alpha and IL-10 at 24 h and 48 h.

CONCLUSION

In combination with antifungal therapy, NAC treatment can alleviate oxidative stress and lung injury associated with IPA in neutropenic mice.Acta Pharmacologica Sinica (2009) 30: 980-986; doi: 10.1038/aps.2009.83.

[Pathophysiology of invasive fungal infection in diabetic patients]

It has been known that diabetes mellitus impairs functioning of neutrophil, macrophage, cellular immunity, humoral immunity, and iron metabolism. In addition to them, diabetes-related angiopathy leads a patient to being at high-risk individual for several kinds of infectious diseases. Therefore, diabetes has been accepted as one of the important risk factors for invasive fungal infection. From the viewpoint of pathology, the present review describes both pathophysiology of immunosuppression induced by diabetes and histopathological characteristics of typical forms in invasive fungal infection when it occurred as an opportunistic infection; those are candidiasis, aspergillosis, and cryptococcosis. We wish to draw that pathophysiological explanation still remains obscuring of relationship between diabetes and invasive fungal infection.

A case of pulmonary semi-invasive aspergillosis developing fatal acute exacerbation

A 80-year-old male was referred for detailed examination of left apical fibrotic changes in the chest radiograph. Six years later, several cavitary lesions with thickening of the pleura developed. Anti tuberculosis therapy had no effects. Despite intravenous administration of antibiotics, the cavities became larger and the infiltrates progressed to the left lower lobe. The air crescent was observed in one of the cavities. Repeated sputum examinations revealed Aspergillus niger only. With administration of anti fungal drug, infiltrates were faded. Four months after the cessation of antifungal drug high fever associated with new infiltrates developed. Sputum culture showed Aspergillus flavus. Infiltrates over the entire left lung field and in the right upper lobe were observed. On CT film necrotic lung tissue was strongly suggested in the cavity. The patients died of respiratory failure. Although initial course of the presented case was compatible with semi-invasive pulmonary aspergillosis (SIPA), fluminant and fatal exacerbations which may be very unusual in SIPA, developed in later. The mycetoma-like ball may be occasionally made of necrotic lung parenchyma instead of fungal mycelia in SIPA.