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PubMed2003

Free latissimus dorsi flap used in treatment of cerebral aspergillosis: a case report and review of the literature.

Cerebral aspergillosis infection is a rare disease in children that carries extremely high morbidity and mortality. Although occurring most commonly in the immunosuppressed patient, cerebral aspergillosis infection has been reported after trauma or neurosurgical procedures. Amphotericin B is the main medical therapy for cerebral aspergillosis. However, surgical treatment is often required for cases of abscess or granuloma formation. Despite aggressive antifungal treatment and surgical intervention, aspergillosis of the central nervous system is often fatal. We present a case report in which a free latissimus dorsi muscle flap was used in conjunction with antifungal medication and surgical debridement to treat intracranial and epidural aspergillosis in a young male following complex craniofacial trauma.

Amphotericin B↗
PubMed1987

CT findings of aspergillosis in the paranasal sinuses.

The diagnosis of aspergillosis in the paranasal sinuses is preoperatively difficult to make in spite of the increasing number of reports showing its prevalence. However, because symptoms are usually non-diagnostic and infection is usually confined to a single sinus, X-ray findings are often suspect for possible neoplasm. We have studied six patients with aspergillosis, all of whom were suspected of having sinus tumors, but were otherwise healthy persons. Affected sinuses were examined by CT and the diagnosis of non-invasive aspergillosis was confirmed by operation. In this report, we have compared the CT and X-ray findings in our cases of aspergillosis. These findings indicate that CT is useful in the preoperative diagnosis of sinus aspergillosis.

Aged↗
PubMed1997

Postmortem analysis of invasive aspergillosis in a tertiary care hospital.

To estimate the incidence of fatal invasive aspergillosis in a 1500-bed tertiary-care hospital and to investigate the utility of laboratory diagnostic approaches, necropsy protocols and microbiological data from 1994 and 1995 were reviewed. Among 694 necropsies from 1693 patients who died in these two years, 27 (4%) cases of invasive aspergillosis were identified. Twelve cases of invasive aspergillosis were found after transplantation of solid organs, three after bone marrow transplantation, four in patients with haematological malignancies, and five in patients with solid tumours. In 15 cases (56%) invasive aspergillosis was not suspected before death. In patients in whom serum sampling was performed seven days antemortem, the Aspergillus latex agglutination test had a sensitivity of 53% (9/17). Culture of tracheal secretions or bronchoalveolar lavage fluid from patients with pulmonary aspergillosis yielded Aspergillus fumigatus in 88% (14/16).

Adult↗
PubMed2001

Accuracy of percutaneous lung biopsy for invasive pulmonary aspergillosis.

BACKGROUND: Invasive pulmonary aspergillosis is fulminant and often fatal in immunosuppressed patients. Percutaneous biopsy may select patients who could benefit from surgical resection. OBJECTIVE: We sought to determine the accuracy of percutaneous biopsy for pediatric invasive pulmonary aspergillosis. MATERIALS AND METHODS: We retrospectively reviewed 28 imaging-guided percutaneous biopsies of the lungs of 24 children with suspected pulmonary aspergillosis. Twenty-two were being treated for malignancy and two for congenital immunodeficiency; 15 had received bone-marrow transplants. The accuracy of the percutaneous lung biopsy was determined by subsequent surgical resection, autopsy, or clinical course. RESULTS: Histopathological studies showed ten biopsy specimens with septate hyphae, indicating a mold, and seven with Aspergillus flavus colonies in culture. The remaining 18 biopsies revealed no fungi. No patient had progressive aspergillosis after negative biopsy. Invasive pulmonary mold was detected by percutaneous biopsy with 100% (10/10) sensitivity and 100% (18/18) specificity. Percutaneous biopsy results influenced the surgical decision in 86% (24 of 28) of the cases. Bleeding complicated the biopsy in 46% (13/28) and hastened one death. CONCLUSION: Percutaneous biopsy of the lung is an accurate technique for the diagnosis of invasive pulmonary aspergillosis and correctly determines which immunosuppressed pediatric patients would benefit from therapeutic pulmonary resection.

Aspergillosis↗
PubMed2003

Voriconazole for invasive aspergillosis in oncohematological patients: a single-center pediatric experience.

Voriconazole is a new triazole active orally and parenterally that recently proved effective in the treatment of invasive aspergillosis and in empirical antifungal therapy for persistently febrile neutropenic patients. Limited data are available for pediatric patients. We report our experience with voriconazole in seven children with invasive aspergillosis, i.e., four girls and three boys with a median age of 5 (range 2-13) years affected by acute lymphoblastic leukemia (3), acute myeloid leukemia (2), refractory anemia with excess of blasts (1), and severe aplastic anemia (1). First-line therapy in all patients was liposomal amphotericin B (AmBisome) administered at a dosage of 3-5 mg/kg day. Voriconazole was administered for a median 8 (range 2-15) weeks. Response was complete and partial in two patients, respectively, stable in one, and there was no response (failure) in two. The voriconazole treatment was well tolerated. Four patients died-two of progressive aspergillosis. Three patients are alive and well 6, 5, and 4 months after the diagnosis of aspergillosis. Voriconazole appears to be an effective salvage treatment for invasive aspergillosis in pediatric patients, with good responses in patients who recover from neutropenia or are not relapsing.

Adolescent↗
PubMed2003

Successful treatment of pulmonary invasive aspergillosis with voriconazole in patients who failed conventional therapy.

BACKGROUND: The incidence of fungal infections, including those due to Aspergillosis species has continued to increase in recent years. Invasive aspergillosis remains an important cause of morbidity and mortality, despite therapeutics interventions. PATIENTS AND METHODS: We reported five cases of invasive pulmonary aspergillosis treated with voriconazole failing to respond to conventional treatments. RESULTS: The clinical and radiological resolution of pulmonary aspergillosis reported in these cases following therapy with voriconazole is remarkable, considering the infections had proved refractory to standard antifungal therapies. Long-term therapy (in two cases > or = 1 year, in one case 6 months) was very well tolerated by patients who were unable to tolerate other antifungal agents. CONCLUSION: Therapy with voriconazole offers a new therapeutic option for otherwise difficult-to-treat infections and the potential to significantly improve the management of Aspergillosis infections.

Adult↗
PubMed1978

The assessment of immunologic and clinical changes occurring during corticosteroid therapy for allergic bronchopulmonary aspergillosis.

Twenty-two patients with allergic bronchopulmonary aspergillosis have been treated and evaluated for a period ranging from two months to nine years. Twelve are available for periodic blood sampling. Data are presented suggesting the following: (1) Patients with allergic bronchopulmonary aspergillosis have high initial levels of total serum immunoglobulin E (IgE). These levels are significantly higher in those patients who had not been previously treated with prednisone for the control of asthma. (2) Treatment with alternate day prednisone (0.5 mg/kg given on alternate days) caused clinical and roentgenologic improvement as well as marked decreases in total serum IgE but does not necessarily prevent recurrence of the disease. (3) Total and specific IgE against Aspergillus antigen may increase prior to and during exacerbations of disease. (4) Specific IgG and IgE against Aspergillus antigen are increased in most patients with allergic bronchopulmonary aspergillosis and reflect disease activity as evidenced by x-ray and clinical exacerbations in some cases. (5) Lymphocyte transformation using Aspergillis antigen, as measured by the whole blood technic, is present in patients with allergic bronchopulmonary aspergillosis, but serial changes in lymphocyte transformation do not correlate with disease activity. (6) Precipitin reactions are present in patients with allergic bronchopulmonary aspergillosis, but presence or absence does not reflect disease activity in most cases.

Antigens, Fungal↗
PubMed1986

Significance of isolation of Aspergillus from the respiratory tract in diagnosis of invasive pulmonary aspergillosis. Results from a three-year prospective study.

The isolation of Aspergillus species from respiratory secretions has been regarded as being of limited usefulness in the antemortem diagnosis of invasive pulmonary aspergillosis. One hundred and eight consecutive patients were evaluated in whom Aspergillus species were isolated from respiratory secretions. Invasive aspergillosis was not demonstrated in non-immunosuppressed patients or in patients with solid tumors in the absence of neutropenia. Lung tissue was examined in 17 patients with leukemia and/or neutropenia; all had invasive aspergillosis. Tissue examination was not performed in 20 neutropenic patients; of 17 not receiving antifungal therapy, 16 died. Multivariate statistical analysis showed that neutropenia and absence of cigarette smoking were significant predictors of invasive aspergillosis in patients with respiratory tract cultures yielding Aspergillus. All cases of invasive aspergillosis were associated with A. fumigatus or A. flavus. The isolation of A. fumigatus or A. flavus from the respiratory tract of a patient with leukemia and/or neutropenia is highly predictive of invasive infection. Empiric amphotericin B therapy, without the necessity for tissue diagnosis, should be considered in this patient subgroup.

Adolescent↗
PubMed1992

Operation for cavitating invasive pulmonary aspergillosis in immunocompromised patients.

Invasive pulmonary aspergillosis is a specific form of pulmonary Aspergillus infection that occurs almost exclusively in immunocompromised patients. It differs both histologically and in its clinical course from classic aspergillomas. During a 5-year period (1986-1990), 8 patients underwent resection for cavitating invasive pulmonary aspergillosis that developed as a consequence of neutropenia during chemotherapy for malignancy. There were no perioperative deaths and no complications. This contrasts with reports of operation for classic aspergillomas. Histologic examination of the resected specimens showed that cavitating invasive pulmonary aspergillosis differed from classic aspergillomas. They consisted of necrotic lung tissue invaded by fungus with separation from the surrounding lung so that the sequestrum had the appearance of a fungus ball. Pulmonary aspergillosis is a common complication of profound neutropenia. The first hemoptysis in this group of patients is often life-threatening. The excellent results of operation in our series of patients may be attributed to their young age, good pulmonary function, and limited operation. This has lead us to recommend early surgical intervention in invasive aspergillosis once cavitation develops.

Adolescent↗
PubMed2006

[Aspergillosis in systemic diseases treated with steroids and/or immunosuppressive drugs: report of 9 cases and review of the literature].

This is a multicentric retrospective study of aspergillosis in patients treated by corticosteroids and/or immunosuppressive drugs for systemic diseases and a review of the literature. Nine patients, 5 men and 4 women, mean age of 62.8 years old were included among which Horton's diseases (3 cases), systemic lupus erythematosus (2), polymyositis (1), microscopic polyangiitis (1), idiopathic thrombocytopenic purpura (1), rheumatoid polyarthritis (1). Aspergillosis occurred in average 28.4 month after the diagnosis of systemic disease, and 28 months after the beginning of its treatment: corticosteroids in all cases, at a dose of 50.8 mg/day (equivalent prednisone) in average, cyclophosphamide (2 cases), methotrexate (1), intravenous immunoglobulins (1), leflunomide (1). All cases were invasive or chronic pulmonary aspergillosis located in the lungs (6 cases), or in the brain (3). Revealing symptoms were mild and non specific. Lymphopenia was severe in most cases, in average 472 lymphocytes/mm3 and 283 CD4+/mm3. The diagnosis was confirmed 20.75 days after the first symptoms in invasive aspergillosis, and 18.5 months in the chronic pulmonary cases, by cultures in 7 cases (broncho-alveolar lavage: 4; cerebral biopsy: 3), and direct microscopy examination of broncho-alveolar lavage in 2 cases. Specific serology was positive in 4 cases. Patients were treated by voriconazole (4 cases), itraconazole (2), amphotericin B (1), association of caspofungin and voriconazole (1), successive voriconazole and itraconazole (1). Six patients recovered from aspergillosis with 10.8 months of following time, 3 patients died a few days after confirmation of the diagnosis. Fifty-four cases of the literature are analysed.

Adrenal Cortex Hormones↗
PubMed2001

Surgical outcome of pulmonary resection in chronic necrotizing pulmonary aspergillosis.

BACKGROUND: Surgical treatment of chronic necrotizing pulmonary aspergillosis is hazardous and controversial. METHODS: Ten patients (8 men, 2 women; mean age, 50 years) with chronic necrotizing pulmonary aspergillosis underwent pulmonary resection between 1989 and 2000. Single segmentectomy or lobectomy, pneumonectomy, or bilobectomy and multisegmentectomy were performed. Clinicopathologic features of these patients were reviewed to clarify the role of surgical intervention for chronic necrotizing pulmonary aspergillosis. RESULTS: The mean time from the onset of clinical symptoms to operation was 5.3 years. Surgical intervention was undertaken because of prolonged illness in 4 patients and hemoptysis in 6 patients. All patients survived. Three major complications (1 late empyema, 2 bronchopleural fistulas) occurred in the large dead space in the right pleural cavity. All survivors were free of aspergillosis at a mean follow-up time of 4.8 years, and only 1 patient required antifungal drugs for relapse during the follow-up period. CONCLUSIONS: Aggressive pulmonary resection in chronic necrotizing pulmonary aspergillosis should be considered when patients have prolonged illness or frequent hemoptysis. Empyema and bronchopleural fistula are the main complications. Concomitant thoracoplasty or intrathoracic transposition of the chest wall musculature is recommended in cases involving a large residual pleural cavity on the right side.

Adult↗
PubMedDate not supplied

The spectrum of orbital aspergillosis: a clinicopathological review.

Orbital aspergillosis is an uncommon but serious infection that may first present to the ophthalmologist. Usually arising from the paranasal sinuses, it may present in manifold ways within the orbit. Some presentations, such as optic nerve involvement, can respond to systemic corticosteroids, leading to delays in diagnosis and possibly iatrogenic potentiation of the infectious process. In this review, pertinent clinical and radiographic findings are discussed, and the literature is summarized. Classic approaches to therapy include local treatment, debridement, and systemic amphotericin B. We review novel approaches to treating orbital aspergillosis and detail a flow-chart for its management. Four patients from the spectrum of orbital aspergillosis are also described: initially presenting as an infection of an exenteration socket, a complex dacryocystitis, and optic nerve tumor, and post-operative periorbital swelling. Physicians should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of invasive aspergillosis. In the neutropenic or otherwise immunocompromised patient, a high index of suspicion must be maintained as delays in diagnosis of fulminant aspergillosis may lead to overwhelming and rapidly progressive infection. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly itraconazole and liposomal amphotericin B, may be beneficial in selected patients.

Adult↗
PubMed1996

Aspergillosis in systemic lupus erythematosus.

Infection is the major cause of morbidity and mortality in systemic lupus erythematosus (SLE). Although various fungi account for a substantial number of these lethal infections, aspergillosis, an important opportunistic infection in immunosuppressed patients, is described rarely. Only 23 cases have been reported in the English-language medical literature. Risk factors for acquiring aspergillosis in these patients were high grade disease activity, granulocytopenia, use of steroids and other immunosuppressive treatment and presence of bacterial infection. The diagnosis in most patients was delayed and they died. Here, we describe three SLE patients with invasive aspergillosis. Features of our patients' diseases were similar to those reported previously. Aspergillosis appeared while they had active SLE treated with high dose corticosteroids. In 2 patients the fungal infection was systemic and diagnosed post mortem. Both were leukopenic and had concurrent bacterial infection and one received amphotericin B prior to death. In the third, the infection was localized to a transplanted kidney and was cured by nephrectomy. Aspergillosis should be suspected in patients with active SLE, who are immunocompromised and sustain concomitant bacterial infections. The currently poor prognosis may be improved with more aggressive diagnostic investigation and treatment.

Adolescent↗
PubMed1986

Detection of fungal antigen in body fluids for diagnosis of invasive aspergillosis.

In clinical trials, the diagnostic utility of a radioimmunoassay (RIA) to detect Aspergillus antigen was demonstrated in sera obtained from patients with invasive pulmonary, endothelial, and disseminated aspergillosis, in cerebrospinal fluids from patients with Aspergillus meningoencephalitis, and in bronchoalveolar lavage fluids from patients with invasive pulmonary aspergillosis. The RIA was further evaluated in three blinded, controlled clinical trials. In one, sera were collected prospectively from patients with acute leukemia. Antigenemia was detected in four patients with invasive pulmonary aspergillosis (IPA) due to A. flavus, appeared early in the course of infection of three patients concurrent with the onset and evolution of lung infiltrates, and remitted with antifungal chemotherapy. Antigenemia was not detected in three patients before the onset of IPA, in eight leukemic controls, or in the 24 normals. In contrast, seven bronchoscopies were performed in five patients with IPA; fungi were not isolated in three. In a second study, antigenemia was found in coded sera from two patients with invasive aspergillosis but not in eight controls. In the third controlled study, 616 sera from 79 hematology patients admitted on 152 occasions were analyzed for circulating fungal antigen. The diagnostic utility of the RIA was confirmed and levels of antigenemia correlated with the patients' clinical course. These studies demonstrate the utility of the Aspergillus antigen RIA for diagnosis of invasive aspergillosis in hospitalized high risk patients.

Animals↗
PubMed1997

Fatal primary cutaneous aspergillosis in a bone marrow transplant recipient: nosocomial acquisition in a laminar-air flow room.

A case of primary cutaneous aspergillosis occurring in an allogeneic bone marrow transplant recipient in a laminar airflow room is reported. The patient developed grade III graft-versus-host-disease and epidermolysis. Although the patient had remained in his laminar airflow room from the graft onward, he subsequently developed primary cutaneous aspergillosis. The aspergillosis became invasive and the patient died. The patient was probably contaminated by air containing conidia when he left the sterile room for endoscopy, and the fluidized bed used may have contributed to the local development of the disease. This nosocomial aspergillosis stresses the necessity of performing invasive procedures under laminar airflow protection to prevent Aspergillus contamination in immunocompromised hosts at risk for aspergillosis.

Adult↗
PubMed1998

Invasive aspergillosis in severely neutropenic patients over 18 years: impact of intranasal amphotericin B and HEPA filtration.

The impact of intranasal amphotericin B and high-efficiency particulate air (HEPA) filtration on the incidence of invasive aspergillosis was reviewed in patients from 1977 to 1994 undergoing intensive chemotherapy. Overall, the incidence of proven invasive aspergillosis was reduced from 24.4% (1977-1984) to 7.1% (1985-1991) (P < 0.001) following the introduction of intranasal prophylaxis, but when probable cases of aspergillosis were included and lymphoma cases excluded, there was no change in incidence. Following the introduction of HEPA filtration, patient exposure to aspergillus spores as measured by air sampling was markedly reduced and there were no new cases of invasive aspergillosis. HEPA filtration proved effective in reducing invasive aspergillosis and has allowed increasingly aggressive treatment regimens to be introduced.

Administration, Intranasal↗
PubMed1997

[A nidulans bronchial aspergillosis after treatment of low-grade lymphoma with fludarabine].

Pulmonary aspergillosis is a common complication in neutropenic patients. The most important fungus is Aspergillus fumigatus. We report a case of invasive pulmonary aspergillosis due to Aspergillus nidulans secondary to fludarabine therapy. There are few cases of pulmonary aspergillosis due to Aspergillus nidulans (one chronic necrotizing pulmonary aspergillosis, one aspergilloma). Fludarabine induces a marked decreased of CD4 lymphocyte count responsible for opportunistic infections. It is the first case of aspergillosis after fludarabine therapy and the occurrence of such infection must be considered after purine analog therapy.

Antineoplastic Agents↗
PubMed1999

Amphotericin B with and without itraconazole for invasive aspergillosis: A three-year retrospective study.

BACKGROUND: Treatment of invasive aspergillosis is frequently unsuccessful, so innovations in therapy are needed. Clinical studies demonstrate that itraconazole may be an effective alternative to amphotericin B. Itraconazole also has been combined with amphotericin B in animal models of aspergillosis, but this regimen produced antagonistic effects. OBJECTIVES: To determine the role of itraconazole in the adjunctive treatment of invasive aspergillosis. METHODS: A review was conducted of all patients with definite or probable aspergillosis from January 1995 to December 1997 who were treated with conventional amphotericin B alone or in combination with itraconazole. RESULTS: Of 21 patients, 10 received amphotericin B and 11 received the combination. The two groups of patients were comparable clinically at baseline (including similar mean APACHE III scores). Both groups received similar doses and days of amphotericin B treatment. Of the patients who received combination therapy, nine (82%) were cured or improved, and of those who received only amphotericin B, five (50%) were cured or improved. CONCLUSIONS: This study demonstrates that itraconazole and amphotericin B given together are not clinically antagonistic and that the promise of combination therapy for aspergillosis should be evaluated further in a randomized clinical trial.

APACHE↗