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PubMed1998

[Chronic necrotizing pulmonary aspergillosis: infrequent form of aspergillosis].

BACKGROUND: Chronic necrotizing pulmonary aspergillosis (CNPA) is a chronic pulmonary infection caused by the genus Aspergillus, which usually involves moderately immunosuppressed patients. METHOD: We describe 3 patients with a toxic syndrome that had lasted several weeks or months, with lung infiltrates in the chest X-ray and the CT scan. Mycobacterium tuberculosis could not be isolated from different respiratory smears (sputum, bronchoaspiration, Barlett catheter and pulmonary punction in the third case). Moreover, there was no response to anaerobic treatment. RESULTS: All 3 patients were moderately immunosuppressed (2 men were COPD and the woman was an asthmatic patient). One of the men was being treated for a nocardiosis. In all three cases, A. fumigatus was isolated from de different respiratory smears. CONCLUSIONS: To diagnose a CPNA, a high degree of clinical suspicion is needed. The differential diagnose should be done with pulmonary tuberculosis and anaerobic infections. The presence of a member of the genus Aspergillus in the tracheobronchial secretions of a patient should not be systematically considered a saprofit, specially when other microorganisms can not be isolated.

Aged↗
PubMed1994

Pulmonary aspergillosis in patients with AIDS. Clinical and radiographic correlations.

OBJECTIVE: To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS. SUBJECTS AND METHODS: Six new cases of confirmed or probable pulmonary aspergillosis were discovered during a search of hospital records. These are reviewed with 30 previously reported cases with special attention to radiographic appearance of disease and how radiographic appearance influences clinical outcome. RESULTS: Symptoms of pulmonary aspergillosis in AIDS were nonspecific, most often including fever, cough, and dyspnea, and less commonly, chest pain or hemoptysis. Major risk factors for the development of pulmonary aspergillosis in patients with AIDS were steroid administration and neutropenia. Neutropenia was often a complication of therapies for AIDS, in particular, ganciclovir and zidovudine. Radiographic appearance of disease could be divided into three general categories. One third of the patients (13/36) presented with cavitary upper lobe disease resembling noninvasive or chronic necrotizing aspergillosis. Fatal hemoptysis occurred in 42 percent of patients with this form of disease. Twenty-two percent (8/36) of the cases presented as a nondescript focal alveolar opacity similar to invasive aspergillosis. In several patients, the focal infiltrate remained stable for several months, a feature that is unusual for aspergillosis in non-AIDS patients. The air crescent sign was present in none of the 36 reported cases. Patients with only focal disease had the best prognosis of patients with pulmonary aspergillosis. Bilateral alveolar or interstitial disease similar to invasive aspergillosis was present in 23 percent (9/36) of the patients. Bilateral disease appears to be a marker for disseminated infection and was associated with a high mortality due to aspergillosis. Two new forms of bronchial aspergillosis (5/36 cases) have been described previously. These patients presented with either obstructing fungal casts or bronchial pseudomembranes demonstrated bronchoscopically. In some patients with the bronchial forms of aspergillosis, transient alveolar opacities were seen on chest radiographs. These opacities may represent regions of atelectasis due to airway obstruction. One patient who had bilateral pneumothoraces without parenchymal opacities did not correspond to any of the three previously mentioned categories. Mortality due to aspergillosis was greater than 50 percent among AIDS patients. Death was subsequent to fatal hemoptysis or widespread pulmonary or systemic infection. CONCLUSION: Unlike other risk groups that tend to contract only one form of pulmonary aspergillosis, AIDS patients can develop the whole spectrum of aspergillosis-related pulmonary disorders, including chronic cavitary, invasive, and bronchial forms of aspergillosis. Clinical symptoms are nonspecific and major risk factors include neutropenia, which is often a side effect of various therapies for AIDS, and steroid administration. Patients with the chronic cavitary form of disease have an unusually high mortality due to fatal hemoptysis. Patients with bilateral pulmonary infiltrates and aspergillosis have a high mortality due to disseminated infection.

AIDS-Related Opportunistic Infections↗
PubMed2003

[Usefulness of galactomannan detection in the diagnosis and follow-up of hematological patients with invasive aspergillosis].

The usefulness of galactomannan detection using the Platelia Aspergillus test for the diagnosis of invasive aspergillosis was studied in 849 sera from 54 hematological patients with prolonged neutropenia, which were classified according to the risk for invasive aspergillosis. Three patients developed a proven invasive aspergillosis, one a probable invasive aspergillosis and 17 patients a possible invasive aspergillosis. Thirty-three patients showed no evidence of invasive aspergillosis. All patients with proven invasive aspergillosis had a high risk for invasive aspergillosis, while the one having probable invasive aspergillosis had intermediate risk. Detection of galactomannan in this study showed a sensitivity of 66.7% for patients with proven invasive aspergillosis and 50% for patients with proven and probable invasive aspergillosis. The specificity was 98% or higher in all groups studied. The predictive positive and negative values for patients with proven invasive aspergillosis were 66.7% and 98%, respectively. A rise in the concentration of galactomannan was observed in patients who failed to respond to the antifungal treatment. Galactomannan antigenemia preceded post-mortem histological diagnosis of invasive aspergillosis in two patients by 17 and 81 days, respectively. In conclusion, detection of galactomannan by the Platelia Aspergillus test allows for a specific and relatively sensitive diagnosis of invasive aspergillosis in hematological patients with a high and intermediate risk for invasive aspergillosis.

Antifungal Agents↗
PubMed2004

[Cerebral aspergillosis].

INTRODUCTION: The brain is almost always a localization of invasive aspergillosis, after hematogenous spread from pulmonary aspergillosis. Brain aspergilosis is not rare and is one of the worst prognosis factors of invasive aspergillosis. STATE OF ART: The incidence of this severe mycosis is currently on the rise due to the development of major immunosuppressive treatments. Brain aspergillosis is noteworthy for its vascular tropism, leading to infectious cerebral vasculitis, mainly involving thalamoperforating and lenticulostriate arteries, with a high frequency of thalamic or basal nuclei lesions. Extra-neurologic features that suggest this diagnosis are: i) risk factors for invasive aspergillosis (major or prolonged neutropenia, hematologic malignancies, prolonged corticosteroid treatment, bone marrow or solid organ transplant, AIDS); ii) persistent fever not responding to presumptive antibacterial treatment; iii) respiratory signs (brain aspergillosis is associated with pulmonary aspergillosis in 80 to 95 p. 100 of cases). Perspectives. Two recent major improvements in brain aspergillosis management must be outlined: i) for diagnostic purposes, the development of testing for Aspergillus antigenemia (a non-invasive procedure with good diagnostic value for invasive aspergillosis); ii) for therapeutic purposes, the demonstration that voriconazole is better than amphotericin B in terms of clinical response, tolerance and survival, for all types of invasive aspergillosis, the benefit being probably even greater in case of brain aspergillosis because of the good diffusion of voriconazole into the central nervous system. CONCLUSIONS: Brain aspergillosis is a severe emerging opportunistic infection for which diagnostic and therapeutic tools have recently improved. Thus, this diagnostic must be suspected early, especially in the immunocompromised patient, in the event of respiratory symptoms and when the brain lesions are localized in the central nuclei and the thalamus.

Antifungal Agents↗
PubMed2001

Invasive pulmonary aspergillosis in neutropenic patients during hospital construction: before and after chemoprophylaxis and institution of HEPA filters.

Between September 1993 and December 1993, during extensive hospital construction and indoor renovation, a nosocomial outbreak of invasive pulmonary aspergillosis occurred in acute leukemia patients treated in a regular ward that has only natural ventilation. The observed infection rate was 50%. Chemoprophylaxis with intravenous continuous low-dose amphotericin B was then instituted as a preventive measure. During the next 18 months invasive pulmonary aspergillosis developed in 43% of acute leukemia patients. After that period a new hematology ward was opened with an air filtration system through high-efficiency particulate air filtration (HEPA) filters, and a bone marrow transplantation program was started on the hematology service. During the following three years, none of the acute leukemia or bone marrow transplantation patients who were hospitalized exclusively in the hematology ward developed invasive pulmonary aspergillosis, although 29% of acute leukemia patients who were housed in a regular ward, because of shortage of space in the new facility, still contracted invasive pulmonary aspergillosis. Overall, 31 patients were diagnosed with invasive pulmonary aspergillosis during almost five years: 74% of patients recovered from invasive pulmonary aspergillosis, and 42% are long-term survivors; 26% of patients died of resistant leukemia with aspergillosis, but no one died of invasive pulmonary aspergillosis alone. In conclusion, during an on-going construction period, an extremely high incidence rate of invasive pulmonary aspergillosis in acute leukemia patients undergoing intensive chemotherapy was observed. Institution of low-dose intravenous amphotericin B prophylaxis marginally reduced the incidence rate of invasive pulmonary aspergillosis. Keeping patients in a special ward with air filtration through a HEPA system eliminated invasive pulmonary aspergillosis completely. Among patients who developed invasive pulmonary aspergillosis, early diagnosis and treatment are probably the explanation for the favorable outcome.

Adult↗
PubMed1994

Computed tomographic scanning of the lung in patients with allergic bronchopulmonary aspergillosis and in asthmatic patients with a positive skin test to Aspergillus fumigatus.

BACKGROUND: Allergic bronchopulmonary aspergillosis is a disease of asthmatic patients which may follow a protracted course and result in chronic lung damage such as central bronchiectasis. In asthma uncomplicated by allergic bronchopulmonary aspergillosis, in particular in asthmatic patients with immediate hypersensitivity type skin reactions to Aspergillus fumigatus, the incidence of bronchiectasis is uncertain. METHODS: Computed tomographic (CT) scans were performed in 17 asthmatic patients of mean (SE) age 60.1 (2.5) years, FEV1 49.4 (5.8)% predicted with allergic bronchopulmonary aspergillosis (all with current or previous positive precipitins to A fumigatus) and in 11 asthmatic patients of mean (SE) age 49.5 (5.8) years, FEV1 75.5 (6.5)% predicted, skin test positive for A fumigatus, but without the clinical or serological features of allergic bronchopulmonary aspergillosis (non-allergic bronchopulmonary aspergillosis group). RESULTS: Bronchial dilatation was more common in the group with allergic bronchopulmonary aspergillosis, affecting 14 patients compared with two in the non-allergic bronchopulmonary aspergillosis group. Evidence of bronchiectasis was found in 43 of a possible 102 lobes of patients with allergic bronchopulmonary aspergillosis, compared with three of a possible 66 in the non-allergic bronchopulmonary aspergillosis group. Bronchial wall thickening was common to both, affecting 16 and nine patients respectively. Pleural thickening on CT scanning was common in the group with allergic bronchopulmonary aspergillosis, being noted in 14 patients compared with only three in the non-allergic bronchopulmonary aspergillosis group. CONCLUSIONS: Bronchiectasis is common in allergic bronchopulmonary aspergillosis but occurs only occasionally in asthmatic patients with a positive skin test to A fumigatus but without other features of the disease.

Aspergillosis, Allergic Bronchopulmonary↗
PubMed1994

Aspergillosis of the brain and paranasal sinuses in immunocompromised patients: CT and MR imaging findings.

OBJECTIVE: With the increased survival of patients with severe immunosuppression, it has become more important to recognize the various forms of cerebral and craniofacial aspergillosis. Currently, only small series of patients with this infection have been described; the radiographic diagnosis of cerebral and craniofacial aspergillosis has varied and has been relatively nonspecific. The purpose of our study was to identify neuroimaging patterns in patients with cerebral and craniofacial aspergillosis. Recognition of radiographic patterns of aspergillosis may facilitate earlier radiologic diagnosis and prompt therapy. MATERIALS AND METHODS: The imaging and clinical data of eight immunosuppressed patients with cerebral aspergillosis and one patient each with aspergillosis of the orbit, paranasal sinus, and calvaria were evaluated retrospectively. All patients were at risk of developing infection by virtue of poorly controlled diabetes or other types of congenital or acquired immunosuppression (e.g., steroids, chemotherapy). Patients were selected for study if the diagnosis of aspergillosis was established by means of biopsy or autopsy and CT scanning or MR imaging was available for review. CT scans and MR images were compared by two experienced neuroradiologists, who were aware of the diagnosis of aspergillosis, to see if common radiographic patterns could be identified that could be used as predictors of this type of infection. RESULTS: Five patients with cerebral aspergillosis had multiple ring-enhancing lesions consistent with abscesses. Characteristic findings were multiple lesions, an irregular ring of contrast enhancement, and hypointensity of the ring on T2-weighted MR images. Three patients had cortical and subcortical hypodensities on CT scanning or hyperintensities on MR imaging consistent with cerebral cortical and subcortical infarction. Two of these three had superimposed hematoma formation. Three patients had craniofacial aspergillosis. One patient each had enhancing mucosal thickening of the paranasal sinus with secondary intracranial dural enhancement, abnormal enhancement of the optic nerve and sheath with infiltrating enhancing soft tissue within the intraorbital fat, and an enhancing diploetic lesion of the calvaria with underlying dural enhancement. CONCLUSION: Three different neuroimaging patterns of cerebral aspergillosis were identified in immunosuppressed patients. The first pattern was multiple areas of hypodensity on CT scans or hyperintensity on T2-weighted MR images involving the cortex and/or subcortical white matter consistent with multiple areas of embolic infarction. This pattern could be seen with or without superimposed hemorrhage, identified as hyperdensity on CT scans or as hyperintensity on T1-weighted MR images. The second pattern was multiple intracerebral ring-enhancing lesions consistent with abscesses. The ring was irregular and of low signal on T2-weighted MR images. The third pattern was dural enhancement associated with enhancing lesions in the adjacent paranasal sinus structure or calvaria or dural enhancement of the optic sheath with associated optic nerve and intraorbital fat enhancement. Recognition of these three patterns of aspergillosis in immunosuppressed patients may lead to more effective diagnosis and treatment planning.

Adolescent↗