Chest
Volume 112, Issue 2, August 1997, Pages 541-548
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selected reports
Chronic Necrotizing Pulmonary Aspergillosis*: Approach to Management

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Objective

To describe our experience with 6 patients and to review the current literature to update the approach to the diagnosis and treatment of chronic necrotizing pulmonary aspergillosis.

Design

Patient reports and MEDLINE® review of English-language literature published after 1980.

Results

Chronic necrotizing pulmonary aspergillosis (CNPA) is a subacute infection most commonly seen in patients with altered local defense from preexisting pulmonary disease or in patients with risk factors that alter systemic immune status. Delays in diagnosis are common. Although initial reports advocated intravenous amphotericin B, itraconazole has emerged as a better initial therapy because of its documented efficacy and minimal toxicity. The dose and duration of therapy should be based on clinical response. In patients who do not respond to medical therapy, pulmonary resection can be considered, but postoperative morbidity is high. Recurrent or relapsing infections occur; chronic maintenance therapy with itraconazole can be considered in patients with residual parenchymal scarring. A wide range of mortality rates has been reported for CNPA. Outcome is most likely influenced by severity of comorbid conditions, extent of underlying pulmonary disease, delays in diagnosis, and initiation of effective therapy.

Section snippets

Methods

We used MEDLINE® to review the English-language literature published after 1980. Our search terms included Aspergillus, chronic, or necrotizing, or all of these. Summary data are presented in Table 1. A pathologic diagnosis required demonstration of septate hyphae typical of Aspergillus species invading lung parenchyma on biopsy specimens, accompanied by Aspergillus culture growth. When fungal invasion was not demonstrated, criteria for a clinical diagnosis included growth of Aspergillus

Patient 1

A 53-year-old man with COPD experienced increased sputum production, fevers, night sweats, and weight loss for 1 month. The admission chest radiograph revealed a left upper lobe cavitary infiltrate with a pleural-based density. Despite broad-spectrum antibiotic therapy for 2 weeks, his symptoms persisted. Bronchoscopy was performed for a more definitive diagnosis. Bronchial washings grew A niger and cytology revealed no malignancy. In the absence of a diagnosis, continued deterioration and a

Discussion

The cases described here are illustrative of many of the major features of CNPA. CNPA is associated with considerable morbidity and mortality.7, 8 Often, the diagnosis is not made early in the course of illness.8 Even when promptly diagnosed, the pulmonary and systemic abnormalities and potentially toxic therapy combine to make medical treatment only variably effective. Most patients are poor candidates for pulmonary resection, and postoperative complications are common.8 We have reviewed the

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