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T cell vaccination in mice with invasive pulmonary aspergillosis.

Aspergillus fumigatus, an opportunistic fungal pathogen, is responsible for multiple airway diseases of an allergic and a nonallergic nature. In a murine model of invasive pulmonary aspergillosis, resistance is associated with a decreased lung inflammatory pathology and the occurrence of an IL-12-dependent Th1-type reactivity that are both impaired by IL-4. In the present study we assess the ability of Aspergillus crude culture filtrate Ags and the recombinant allergen Asp f 2 to induce protective antifungal responses in mice with invasive pulmonary aspergillosis. Similar to what occurred upon nasal exposure to viable A. fumigatus conidia, treatment of immunocompetent mice with Aspergillus crude culture filtrate Ags resulted in the development of local and peripheral protective Th1 memory responses, mediated by Ag-specific CD4+ T cells producing IFN-gamma and IL-2 capable of conferring protection upon adoptive transfer to naive recipients. Protective Th1 responses could not be observed in mice deficient of IFN-gamma or IL-12 and did not occur in response to Asp f 2, which, on the contrary, elicited high level production of inhibitory IL-4. The results show that Ags of Aspergillus exist with the ability to induce both Th1- and Th2-type reactivity during infection, a finding that suggests a possible mechanism through which potentially protective immune responses are inhibited in mice with the infection. However, the occurrence of Th1-mediated resistance upon vaccination with Aspergillus crude culture filtrate Ags, suggests the existence of fungal Ags useful as a candidate vaccine against invasive pulmonary aspergillosis.

Administration, Intranasal↗

Macrophage inflammatory protein-1 alpha is a critical mediator of host defense against invasive pulmonary aspergillosis in neutropenic hosts.

Invasive pulmonary aspergillosis is a devastating complication of immunosuppression that usually occurs in neutropenic patients. In this setting, augmentation of the antifungal activity of available immune cells may improve the outcome of the infection. Macrophage inflammatory protein-1 alpha (MIP-1 alpha) is a CC chemokine with potent chemotactic activity for various subsets of mononuclear leukocytes. We therefore tested the hypothesis that the influx of mononuclear cells into the lung in invasive pulmonary aspergillosis is in part mediated by MIP-1 alpha, and the manipulation of this ligand alters the outcome of the infection. We found that in both immunocompetent and neutropenic mice, MIP-1 alpha was induced in the lungs in response to intratracheal administration of Aspergillus fumigatus conidia. In neutrophil-depleted mice challenged with intratracheal conidia, there was evidence of invasive fungal pneumonia associated with a predominantly mononuclear leukocyte infiltrate. Ab-mediated depletion of MIP-1 alpha resulted in a 6-fold increase in mortality in neutropenic mice, which was associated with a 12-fold increase in lung fungal burden. Studies of single-cell suspensions of whole lungs revealed a 36% decrease in total lung leukocyte infiltration as a result of MIP-1 alpha neutralization. Flow cytometry on whole lung suspensions showed a 41% reduction in lung monocyte/macrophages as a result of MIP-1 alpha neutralization, but no difference in other lung leukocyte subsets. These studies indicate that MIP-1 alpha is a critical mediator of host defense against A. fumigatus in the setting of neutropenia and may be an important target in devising future therapeutic strategies against invasive aspergillosis.

Animals↗

Aspergillosis related to long-term nasal corticosteroid use.

Aspergillus is a ubiquitous mold that can cause several types of symptomatic infections: allergic aspergillosis, typically in young atopic patients; aspergillomas (often referred to as fungus balls); and invasive aspergillosis, typically seen in debilitated or immunocompromised patients. We describe an 85-year-old woman who was not immunocompromised but had invasive aspergillosis of the paranasal sinus that resulted in unilateral headache and retrobulbar optic neuropathy. After extensive differential diagnostic examination, we concluded that the condition was possibly related to the long-term use of nasal corticosteroids (fluticasone propionate aqueous nasal spray). Surgical removal of solid masses of Aspergillus organisms followed by extended treatment with antifungal agents resulted in a favorable outcome.

Administration, Topical↗

Treatment of invasive aspergillosis: relation of early diagnosis and treatment to response.

Aspergillus infections in patients with cancer are difficult to diagnose, and such diagnoses are frequently made at necropsy. Earlier therapy has been proposed to provide better response. We reviewed 17 consecutive patients with documented aspergillosis to determine the impact of earlier diagnosis and prompt treatment with amphotericin B. Sixteen had hematologic malignancies, and all had marked granulocytopenia. Six were diagnosed and treated within 96 h of the appearance of infiltrates. Three of these six had complete resolution of all signs and symptoms of aspergillus infection. The other three had a partial response to therapy despite continued granulocytopenia. All 11 patients in whom antifungal therapy was either delayed (six) or not given (five) for at least 2 weeks after the infiltrate was present diet with progressive aspergillosis aggressive diagnostic methods to establish the diagnosis of aspergillosis are warranted so that antifungal therapy can be started early, which may then be successful in resolving these potentially fatal infections.

Agranulocytosis↗

Antigenemia detected by radioimmunoassay in systemic aspergillosis.

Because of difficulties in antemortem diagnosis of systemic aspergillosis, a radioimmunoassay to an Aspergillus fumigatus carbohydrate was developed and evaluated in patients with mycotic or bacterial infections. Antigenemia was detected in sera obtained antemortem from four of seven patients with systemic aspergillosis and in pleural fluid from an Aspergillus empyema but not in control sera or pleural fluid from 43 patients or 27 normal donors. When characterized with reference to onset of disease, antigenemia was an early sign of infection. This study shows the usefulness of the Aspergillus antigen radioimmunoassay for early, specific immunodiagnosis of systemic aspergillosis.

Antigens, Fungal↗

Allergic bronchopulmonary aspergillosis: staging as an aid to management.

Five stages of allergic bronchopulmonary aspergillosis were identified in 40 patients studied for several years. The stages are acute, remission, exacerbation, corticosteroid-dependent asthma, and fibrotic. The acute stage has all criteria of the disease and responds to prednisone. The remission stage is free from significant asthma or exacerbations. The exacerbation stage has recurrent flares of acute allergic bronchopulmonary aspergillosis. The corticosteroid-dependent asthma stage may have recurrent exacerbations of allergic bronchopulmonary aspergillosis and severe asthma. The fibrotic stage is an advanced stage of radiographic abnormalities with asthma, irreversible and partially reversible obstructive pulmonary function changes, and poor prognosis. Measurement of IgE and IgG antibodies against Aspergillus fumigatus is of diagnostic value in all stages.

Acute Disease↗

[Undiagnosed lung cancer complicated by intracavitary aspergillosis].

A 54-year-old man was treated with an antifungal agent (itraconazole) for post-tuberculous intracavitary aspergillosis. Though clinical and radiological findings indicated that the patient's symptoms had gone into remission, aspergillosis recurred 4 months after the cessation of antifungal chemotherapy, requiring that the patient undergo an operation. Intraoperative and pathological findings revealed a squamous cell carcinoma contiguous to the cavity containing the aspergilloma. Though a few cases of aspergilloma within cavitating pulmonary carcinomas have been reported in the literature, the case of lung cancer we report was thought to arise from preformed lung scars surrounding a post-tuberculous cavity that contained an aspergilloma. Although conclusive distinctions between neoplasms and fungal infections are difficult to make, careful observation of the radiographic features is necessary when treating patients with fungus ball-type aspergillosis.

Aspergillosis↗

[Peritoneal fistulization in pleural aspergillosis associated with skin lesions].

This report describes the development of a pleuroperitoneal fistula complicating pleural aspergillosis in a 63-year old non-immunocompromised man treated with itraconazole. The patient presented a confluent granuloma of the abdomen while an abscess of the abdominal wall was disclosed. Skin involvement, usually described in disseminated aspergillosis, has not been reported in pleuropulmonary aspergillosis.

Abdominal Muscles↗

Computed tomographic scan of the chest, latex agglutination test and plasma (1AE3)-beta-D-glucan assay in early diagnosis of invasive pulmonary aspergillosis: a prospective study of 215 patients.

BACKGROUND AND OBJECTIVES: Blood and radiologic tests are frequently used for diagnosis of invasive pulmonary aspergillosis, but it remains unknown which is more useful for its early diagnosis. Aim of the study was to compare usefulness of computed tomographic (CT) scan of chest, latex agglutination (LA) test and determination of plasma (1-->3)-beta-D-glucan (BDG) levels for early diagnosis of invasive pulmonary aspergillosis (IPA). DESIGN AND METHODS: We treated 215 consecutive patients who underwent cytotoxic chemotherapy. From initiation of chemotherapy until death or discharge, blood samples were taken weekly and subjected to LA and BDG tests. We performed chest CT scans when patients had any signs of pulmonary infection or an antibiotic-resistant fever. RESULTS: Of the 215 patients, 30 (14. 0%) were diagnosed as having IPA. In sixteen cases the diagnosis was definite and in 14 it was suspected. In patient-based analysis, sensitivities of LA and BDG were 44% and 63%, respectively. Sensitivity tended to be lower in patients with IPA localized to the lung than those with disseminated invasive aspergillosis. Specificities were 93% and 74%, respectively. Either a halo or an air-crescent was observed in 7 of the 16 patients with IPA, and all of the IPA patients showed some abnormal signs on chest CT scans. On average, CT scan signs preceded a positive LA test by 7.1 days and a positive BDG assay by 11.5 days. In 6 of the 11 patients who became positive for either LA or BDG assay, CT scan signs preceded the positive results by more than seven days. INTERPRETATION AND CONCLUSIONS: Chest CT scan is more beneficial than the blood tests and X-ray for early diagnosis of IPA.

Adjuvants, Immunologic↗

[Aspergillosis in pulmonary transplantation].

BACKGROUND: Fungal infections are a frequent cause of morbidity an mortality in transplant recipients. Aspergillus spp. is an ubiquitous fungus capable of producing diverse clinical entities with varying severity. OBJECTIVE: To study the incidence and severity of Aspergillus spp. infections in lung transplantation, analysing the different clinical presentations and response to antifungal drugs. METHODS: A review was made of the clinical histories of all patients undergoing lung transplantation who developed positive Aspergillus spp. cultures in our centre between June 1991 and December 1996. RESULTS: Eleven of 49 transplanted patients (22%) developed Aspergillus spp. infections. Four patients presented invasive aspergillosis forms and 7 tracheobronchitis. In spite of antifungal treatment 3 patients (30%) died of invasive aspergillosis as a direct consequence of the infection. Of the 7 patients with tracheobronchitis, 2 were ulcerative and 1 pseudomembranous, all responded to antifungal treatment. Three patients (10.3%) developed Aspergillus spp. infections despite prophylaxis with itraconazole. CONCLUSION: Invasive aspergillosis in the immediate posttransplant period was mortal despite treatment. As opposed, aspergillar tracheobronchitis have been overcome using combined treatments of liposomal or lipidic amphotericin, itraconazole and nebulised amphotericin.

Adolescent↗

[Role of computed tomography in pulmonary aspergillosis. 20 cases].

OBJECTIVE: Aspergilloma is the most common form of pulmonary aspergillosis. The purpose of this work was to compare computed tomographic findings with features observed on standard radiographs. PATIENTS AND METHODS: We retrospectively reviewed 20 cases of pulmonary aspergilloma. These patients (mean age 36 years) were followed after cure of pulmonary tuberculosis and consulted for hemoptysis. All underwent computed tomography (CT) and standard radiographic explorations. Serology was positive for Aspergillus in 16 cases and clinical and radiographic findings led to the diagnosis in the 4 others. Both supine and prone positions were used for thoracic CT. Slice thickness was 5 mm without contrast injection. RESULTS: In many cases, standard films evidenced the typical mycetoma seen as a rounded mass of soft tissue density filling a portion of a preexisting cavity or as an air crescent sign, but atypical alveolar opacities, aeric images without aspergillosis colonization and parenchymal destruction predominated in certain cases. The CT-scan demonstrated these features even better revealing the typical cavity in 80% of the cases or an air crescent in 20%. Mobility of the fungus ball was demonstrated by comparison of the prone and supine images. The characteristic CT features allowed certain diagnosis of aspergilloma in 6 patients with atypical radiographic or serologic results. DISCUSSION: Computed tomography is highly contributive to the diagnosis of pulmonary aspergillosis, particularly in case of small cavities that may be missed on the standard films. Recognition of the mobility of the fungal ball enables differentiation from a tumor or infectious lesion. CT is also helpful for guiding transparietal treatment. CONCLUSION: A computed tomography series should be obtained in former tuberculosis patients consulting for hemoptisis.

Adult↗

Clinics in diagnostic imaging (64). Invasive pulmonary aspergillosis.

A 30-year-old woman undergoing chemotherapy for acute myeloid leukemia developed fever. Chest radiograph showed ill-defined nodules in the mid and lower zones. CT showed multiple nodules that cavitated with commencement of anti-fungal therapy. Follow-up CT showed complete resolution of the pulmonary nodules, confirming the diagnosis of invasive pulmonary aspergillosis. Aspergillus fumigatus presents clinically as aspergilloma, invasive pulmonary aspergillosis or allergic bronchopulmonary aspergillosis depending on the immune status of the host. The different manifestations are discussed and imaging features of representative clinical case studies are illustrated.

Adult↗

Aerosol hamycin is effective for prophylaxis and therapy in a rat model of pulmonary aspergillosis.

Invasive pulmonary aspergillosis is a major life threatening complication among transplant recipient and patients receiving cancer chemotherapy. In a rat model of progressive pulmonary aspergillosis that is characterized by hyphal bronchopneumonia, aerosol hamycin (aero-H; 0.68 mg/kg given 2 days before infection) significantly delayed mortality in rats compared with animals in control group. The first death in the aero-H-treated group occurred on day 12, by which time six of the eight control animals had died. The same dose of aero-H given as treatment (0.68 mg/kg given 24 h after infection and than daily for 6 days) was also effective. In this trial, eight of the ten animals treated with aero-H survived for 7 day, whereas only one of ten control animals survived. Colony counts in lungs homogenates obtained 24 h after infection showed an 80-fold reduction in the number of viable spores in animals that had received 2.8 mg/kg doses of aero-H 2 days prior to infection. At 48 h after administrating a single 0.68 or 1.36 mg/kg dose of aero-H, mean lung concentrations were 1.25 and 2.60 mg/g tissue, respectively. From the results of the present study it was concluded that aero-H killed inhaled spores and delays the progression of pulmonary aspergillosis by inhibiting mycelial proliferation.

Aerosols↗

[A case of ankylosing spondylitis associated with pulmonary aspergillosis and amyloidosis].

A 56-year-old man was admitted because of diarrhea, cough, weight loss, and disturbance of consciousness. He had been diagnosed as having ankylosing spondylitis at 18-years old. The spondylitis progressed until there was complete rigidity of the spine including the neck, hip and knee joints. Human leukocyte antigen (HLA) B27, which has been characteristic of ankylosing spondylitis, was also present in this case. A chest radiograph showed pleural thickness and a cavity in the right upper lobe; and a soft tissue mass and fluid level was found in the cavity. Aspergillus fumigatus was detected in the sputum and pulmonary aspergillosis was diagnosed. Biopsy of the colon revealed that a large interstitial amyloidosis. Despite the treatment of the patient's malnutrition and lung aspergillosis using amphotericin B, the clinical course was rapidly progressive and the patient died of respiratory failure due to lung aspergillosis. It is important to be aware of these rare complications, which are correlated with the prognosis in cases of ankylosing spondylitis.

Amyloidosis↗

[Intraoperative massive pulmonary hemorrhage due to pulmonary aspergillosis].

A 16-year-old girl had suffered from chronic graft versus host disease (GVHD) caused by peripheral blood stem cell transplantation (PBSCT) after chemotherapy for neuroblastoma and pulmonary aspergillosis of the right upper lobe. She presented with hematemesis and underwent upper gastrointestinal endoscopy under general anesthesia. At the end of the examination, massive pulmonary hemorrhage occurred suddenly. A double lumen endobronchial tube was inserted for unilateral ventilation in order to control hemorrhage, and right pulmonary hemorrhage was found. Pulmonary scintigram and angiography could not demonstrate the bleeding site, and we suspected that pulmonary hemorrhage had been caused by pulmonary aspergillosis because aspergillus is known to have pathologically invasive character to the adjacent tissue and blood vessels. Despite right pneumonectomy was performed to control pulmonary hemorrhage, she died five days later from multiple organ failure. This case suggests that immediate unilateral ventilation is useful for the isolation of the bleeding lung when pulmonary hemorrhage is massive and we should know the risk of pulmonary hemorrhage in patients with pulmonary aspergillosis.

Adolescent↗

Invasive maxillary aspergillosis: report of a case and review of the literature.

A case of invasive aspergillosis of the maxillary sinus in an immunocompromised patient is presented. Aspergillosis of the paranasal sinuses is uncommon, however, its incidence has shown a marked increase in number in the recent years. It has been classified into four types: allergic, noninvasive, invasive and fulminant. Immunocompromised patients are particularly at the risk of fulminant invasive aspergillosis. Early diagnosis is essential in order to avoid the high morbidity and mortality associated with the destructive disease and to instigate treatment before irreversible conditions arise.

Aged↗

[Bronchopulmonary aspergillosis: study of 17 cases].

Aspergillosis is a fungic infection depending on the local or general physiologic and immunologic state of the host. We report the result of retrospective five year study (1995-1999) about 17 cases in the laboratory of Parasitology-Mycology of Rabta hospital in Tunis. Six aspergillomas were observed, they occurred after a pulmonary tuberculosis, two cases of allergic broncho-pulmonary aspergillosis described in two asthmatic patients, nine cases of invasive pulmonary aspergillosis complicating two cancers, one leukaemia, six chronic granulomatous disease. Aspergillus fumigatus is the most frequent species (67%). The clinical and biological characteristic of those will be studied, and compared with those of the literature.

Adult↗

Isolated sphenoid sinus aspergillosis: report of two cases.

Aspergillus fungus can be found worldwide and is the most common fungal infection of the paranasal sinuses. Despite this ubiquity, aspergillosis of the sphenoid sinus as an isolated disease in an otherwise healthy person is quite rare. We report two cases in this article: one was a 53-year-old woman who suffered from bloody postnasal drip for 2 weeks and the other a 61-year-old woman suffered from facial swelling for 2 months. Central dense areas, which are characteristic for Aspergillus sinus infection, were found on their computer tomographs. Both patients were managed by functional endoscopic sinus surgery without recurrence within the 6-month follow-up period. A survey of the reports in the literature indicated that the occurrence of isolated sphenoid sinus aspergillosis was predominantly in elderly females. Hormone changes which occur during this age might play a role in the pathogenesis of fungal infection. Treatment with an anti-fungal agent was not suggested for non-invasive aspergillosis. Instead, surgery played a major role in the treatment.

Aspergillosis↗