Aspergillosis of the Lung - An Eighteen-Year Experience

doi:10.1378/chest.59.1.28

Chest

Volume 59, Issue 1, January 1971, Pages 28-32

https://doi.org/10.1378/chest.59.1.28 Get rights and content

We reviewed the records of 21 patients with aspergillosis seen at our institution during the past 18 years. Nine were treated by surgical resection, one by endocavitary infusion and 11 received no specific treatment. Those receiving no treatment either were not diagnosed before death or had associated severe systemic diseases. The association of aspergillosis with pulmonary infarction and ankylosing spondylitis is emphasized. The results of medical and surgical treatment are reviewed.

Section snippets

MATERIALS AND METHODS

This study represents 21 patients with aspergillosis of the lung admitted to the Veterans Administration Hospital between 1951 and 1969. Of the 21, nine were treated surgically, one medically, and 11 received no specific treatment.

Surgical treatment consisted of lobectomy in seven, pneumonectomy in one, and segmental resection in one. Specific medical treatment consisting of endocavitary infusions of amphotericin B and sodium iodide through a percutaneously placed endobronchial catheter was

RESULTS

In the present series of nine surgically resected patients, all have remained free of disease for periods from five months to 18 years. There was no operative death. Complications occurred in two, one with empyema following pneumonectomy, which was corrected by a modified Schede thoracoplasty, and the other a residual pleural space which responded to prolonged thoracotomy tube drainage.

The only medically treated patient is doing well one year following endocavitary infusions of amphotericin B

DISCUSSION

Several authorities have discussed the spectrum of Aspergillus infections and have suggested classifications.3, 4, 5, 6 We have tended to use the classification as suggested by Hinson et al³ in which the infections may be divided into saprophytic, allergic, and pyemic (disseminated) varieties. Our cases have belonged generally to the saprophytic group, with an occasional patient showing active lung invasion as a terminal event.

The clinical findings were varied and depended upon the associated

REFERENCES (13)

AslamPA et al.
Endocavitary infusion through percutaneous endobronchial catheter
Chest
(1970)
FinegoldSM et al.
Aspergillosis. A review and report of twelve cases
Amer J Med
(1959)
GolbergB
Radiological appearances in pulmonary aspergillosis
Clin Radiol
(1962)
KilmanJW et al.
Surgery for pulmonary aspergillosis
J Thorac and Cardiovas Surg
(1969)
HughesFA et al.
Primary pulmonary aspergillosis: Report of an unusual case successfully treated by lobectomy
Ann Surg
(1956)
HinsonKFW et al.
Bronchopulmonary aspergillosis
Thorax
(1952)

There are more references available in the full text version of this article.

Cited by (78)

The biology of pulmonary aspergillus infections
2014, Journal of Infection
Citation Excerpt :
An aspergilloma may exist for years without causing symptoms and comes to clinical attention as an incidental finding. Although, most patients will experience mild hemoptysis resulting from local hyphal invasion of blood vessels lining the cavity or by mechanical friction of the aspergilloma with the cavity wall blood vessels.43,44 Allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus antigens and is a well-recognized complication of CF. Incidence rates vary between 2 and 15% and it usually affects adolescents and adults with CF.45,46 Inhaled conidia are trapped in the thick mucus layer covering the bronchial epithelial cell layer and their continued presence stimulates the release of inflammatory mediators.
Pulmonary aspergillus infections are mainly caused by Aspergillus fumigatus and can be classified based on clinical syndromes into saphrophytic infections, allergic disease and invasive disease. Invasive pulmonary aspergillosis, occurring in immunocompromised patients, reflects the most serious disease with a high case-fatality rate. Patients with cystic fibrosis and severe asthma might develop allergic bronchopulmonary aspergillosis, while saphrophytic infections are observed in patients with lung cavities mainly due to tuberculosis. Histopathologically, a differentiation can be made into angio-invasive and airway-invasive disease. If the host response is too weak or too strong, Aspergillus species are able to cause disease characterized either by damage from the fungus itself or through an exaggerated inflammatory response of the host, in both situations leading to overt disease associated with specific clinical signs and symptoms. The unraveling of the specific host – Aspergillus interaction has not been performed to a great extent and needs attention to improve the management of those clinical syndromes.
Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease
2014, Revista Iberoamericana de Micologia
La aspergilosis pulmonar invasiva (API) se observa en pacientes inmunodeprimidos por una enfermedad oncohematológica o en receptores de un trasplante alogénico de progenitores hematopoyéticos, y, con menor frecuencia, en pacientes con enfermedad pulmonar obstructiva crónica (EPOC).
El deterioro de la actividad mucociliar, la disminución de la función de los macrófagos y neutrófilos por la acción de los esteroides y el uso de antibióticos de amplio espectro intervienen en el desarrollo de la API en los pacientes con EPOC. Tanto los pacientes colonizados como los que ya tienen API son de edad avanzada, se hallan en estadios evolucionados de EPOC (GOLD ≥ III) y presentan un gran número de comorbilidades. La mortalidad en estos pacientes también es alta debido a la dificultad de obtener un diagnóstico definitivo de API en la EPOC. Los principales signos clínicos y radiológicos de API son inespecíficos en la EPOC y las muestras tisulares que confirman el diagnóstico son a menudo difíciles de obtener.
El mal pronóstico de la API en pacientes con EPOC mejoraría con un diagnóstico más precoz que permitiera la pronta instauración del tratamiento apropiado. Algunas herramientas, como escalas y algoritmos basados en factores de riesgo de API, podrían ayudar al reconocimiento temprano de esta complicación en la EPOC.
Invasive pulmonary aspergillosis (IPA) is a common infection in immunocompromised patients with hematological malignancies or allogenic stem cell transplantation, and is less frequent in the context of chronic obstructive pulmonary disease (COPD).
Mucociliary activity impairment, immunosuppression due to the inhibition of alveolar macrophages and neutrophils by steroids, and receiving broad-spectrum antibiotics, play a role in the development of IPA in COPD patients. Colonized patients or those with IPA are older, with severe CODP stage (GOLD ≥ III), and have a higher number of comorbidities. The mortality rate is high due to the fact that having a definitive diagnosis of IPA in COPD patients is often difficult. The main clinical and radiological signs of IPA in these types of patients are non-specific, and tissue samples for definitive diagnosis are often difficult to obtain.
The poor prognosis of IPA in COPD patients could perhaps be improved by faster diagnosis and prompt initiation of antifungal treatment. Some tools, such as scales and algorithms based on risk factors of IPA, may be useful for its early diagnosis in these patients.
Bronchoscopic removal of a large intracavitary pulmonary aspergilloma
2013, Chest
Pulmonary aspergilloma is a chronic fungal infection that has a high mortality when hemoptysis occurs. Surgery is the treatment of choice, but patients often have severe physiologic impairment putting them at risk for significant surgical morbidity and mortality. We present the case of a 63-year-old woman with a large aspergilloma, unfit for surgery due to medical reasons. The aspergilloma was enlarging, with progression of the patient's symptoms of anorexia, cough, chest discomfort, and hemoptysis. Bronchoscopy revealed an airway leading into a cavity with a large fungal ball. Biopsy confirmed Aspergillus fumigatus. Using flexible and rigid bronchoscopy, the aspergilloma was mechanically removed. Eighteen months later the patient reported no hemoptysis, reduced pain and cough, significant weight gain, and improved appetite, with no recurrence of the aspergilloma on repeat imaging. To our knowledge, this is the first reported case of bronchoscopic removal of a large cavitary aspergilloma. This important new treatment modality provides a viable alternative therapy for this potentially life-threatening problem.
Pulmonary aspergilloma with good antifungal response
2009, Revista de Patologia Respiratoria
Aspergillus sp es una familia de hongos ubicuos que se adquieren mediante la inhalación de esporas y, en pacientes predispuestos, produce afectación pulmonar, siendo el aspergiloma la forma más común y mejor conocida. Se caracteriza por una bola fúngica constituida por hifas del hongo, células inflamatorias, fibrina, moco y restos titulares. Habitualmente, el aspergiloma se forma en una cavidad pre-existente del pulmón causada por diferentes patologías como tuberculosis, sarcoidosis, bronquiectasias, fibrosis quística, bullas, espondilitis anquilosante, neoplasias o infecciones pulmonares.
Clínicamente los pacientes suelen estar asintomáticos o paucisintomáticos siendo la hemoptisis el síntoma más frecuente. El diagnóstico de la enfermedad se basa en la clínica y en los hallazgos de la radiografía, combinado con la serología y los cultivos microbiológicos.
El tratamiento del aspergiloma es controvertido, dependiendo de varios factores. Presentamos dos casos de aspergiloma que han sido tratados con itraconazol con buena evolución.
Aspergillus sp is a ubiquitous family of fungi that are acquired through the inhalation of spores. Aspergilloma is the most common and best known of pulmonary involvement by Aspergillus. It is characterized by a ball made up of fungal hyphae, inflammatory cells, fibrin, mucus and debris holders. Typically, the Aspergilloma is forming in a pre-existing cavity in the lung, caused by various diseases such as tuberculosis, sarcoidosis, bronchiectasis, cystic fibrosis, bullae, ankylosing spondylitis, tumors or lung infections.
Clinically, patients are often asymptomatic being the hemoptisis the most common symptom.
The diagnosis of the disease is based on clinical findings and in the radiography, combined with serology and microbiologic cultures.
The treatment is controversial depending on several factors. We present two cases of Aspergilloma who have been treated with Itraconazole with good results.
Aspergillus-related lung disease
2008, Respiratory Medicine CME
Citation Excerpt :
Sometimes these patients are asymptomatic; however, up to 75% of patients present with hemoptysis98 or productive cough, chest pain, dyspnea, fever, weight loss, or clubbing. Life threatening bleeding may occur from bronchial blood vessels, and may be due to local invasion of blood vessels lining the cavity, endotoxins released from the fungus, or mechanical irritation of the exposed vasculature inside the cavity.99–101 Although aspergillomas are usually single, they may also be present bilaterally.
Aspergilli are ubiquitous fungi with branched septate hyphae. Aspergillus produces a wide variety of diseases determined by the inoculating dosage, the ability of the host to resist infection at local and systemic levels and the virulence of the organism. These entities differ clinically, radiologically, immunologically, and in their response to various therapeutic agents. Although the fungus can affect any organ system, the respiratory tract is involved in >90% of affected patients. A broad knowledge is required to timely diagnose and aggressively treat the potentially lethal manifestations of Aspergillus-related pulmonary diseases.
The clinical spectrum of pulmonary aspergillosis
2002, Chest
Citation Excerpt :
Bleeding usually occurs from bronchial blood vessels. Theories on the cause of the hemoptysis include local invasion of blood vessels lining the cavity, endotoxins released by the fungus with hemolytic properties, and mechanical friction of the aspergilloma with the cavity wall blood vessels.2,14,15 The mortality rate from hemoptysis ranges between 2% and 14%.16,17,18,19,20
Aspergillus is a ubiquitous fungus that causes a variety of clinical syndromes in the lung, ranging from aspergilloma in patients with lung cavities, to chronic necrotizing aspergillosis in those who are mildly immunocompromised or have chronic lung disease. Invasive pulmonary aspergillosis (IPA) is a severe and commonly fatal disease that is seen in immunocompromised patients, while allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus antigens that mainly affects patients with asthma. In light of the increasing risk factors leading to IPA, such as organ transplantation and immunosuppressive therapy, and recent advances in the diagnosis and treatment of Aspergillus-related lung diseases, it is essential for clinicians to be familiar with the clinical presentation, diagnostic methods, and approach to management of the spectrum of pulmonary aspergillosis.

View all citing articles on Scopus

: The purpose of this report is to review our experience with 21 patients with aspergillosis and to show certain unusual features associated with this disease.

View full text

Chest

Aspergillosis of the Lung - An Eighteen-Year Experience

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Chest

Amer J Med

Clin Radiol

J Thorac and Cardiovas Surg

Primary pulmonary aspergillosis: Report of an unusual case successfully treated by lobectomy

Ann Surg

Bronchopulmonary aspergillosis

Thorax