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PubMed2005

Fatal Scopulariopsis infection in a lung transplant recipient: a case report.

A case of a fatal Scopulariopsis infection is reported in a 63-year-old lung transplantation patient with a 7-week history of dyspnea that presented initially with pericardial and pleural fluid. Because of a respiratory arrest, the patient was intubated and received positive pressure ventilation. Later, obstructive shock developed due to a pericardial tamponade requiring pericardectomy and then urgent extracorporal membrane oxygenation. The working hypothesis was of disseminated cytomegalovirus infection because cultures from bronchoalveolar lavage and transbronchial biopsy specimens were positive. The pericardial biopsy specimen showed fungal hyphae. After the patient died from the infection, the fungus was identified as Scopulariopsis acremonium. This case report describes the first case, to our knowledge, of an insidious Scopulariopsis acremonium infection in an immunocompromised lung transplant patient, underscoring the importance of a direct, invasive approach and early treatment with anti-fungal therapy in immunocompromised patients.

Ascomycota↗
PubMed1997

Pulmonary infections mimicking cancer: a retrospective, three-year review.

Pulmonary infections can mimic or occasionally co-exist with pulmonary neoplasms. In order to determine the frequency and nature of these infections, we conducted a retrospective analysis, covering a 3-year period, of patients who were referred to our center with presumed lung cancer but turned out to have pulmonary infection instead. The overwhelming majority of patients (93.3%) referred to "rule out" lung cancer were documented as having a neoplastic process, and only 1.3% had an infection. Fungal infections (histoplasmosis, cryptococcosis, coccidiomycosis) accounted for 46%, mycobacteria for 27%, bacteria for 22%, and parasitic lesions (dirofilariasis) for 5% of these infections. The most common clinical manifestations were cough and chest pain, and the most common radiographic finding was a solitary pulmonary nodule. There were no specific clinical or radiographic features predictive of either infection or neoplastic disease. All patients responded to specific anti-infective therapy with or without surgical excision. Our data indicate that pulmonary infections mimic neoplasms very infrequently. However, establishing a specific diagnosis is critical, since the management and outcome of these two processes are entirely different.

Adolescent↗
PubMed1994

Invasive cavitary pulmonary aspergillosis in patients with cancer: a clinicopathologic study.

We studied the histopathology and clinicopathologic correlates of invasive cavitary pulmonary aspergillosis in 11 immunosuppressed patients with disseminated malignancy. In most patients cavities were produced by separation of necrotic from viable lung, resulting in an intracavitary sequestrum ("lung ball"). Central dissolution of large necrotic areas and suppurative granulomatous aspergillary pneumonia were additional causes of cavities in three patients. In four patients with chronic cavities sequestra had been replaced by intracavitary mycetomas ("fungus balls"). Neutrophils usually were numerous at the interface of the sequestrum and adjacent lung, but were minimally present in three patients with prolonged severe neutropenia. The lack of neutrophils in some patients suggests that factors other than neutrophil-derived proteases may be important in cavity formation. A prominent giant cell reaction was seen in three patients with chronic cavities. Hemoptysis occurred in five patients and massive hemoptysis due to a bronchoarterial fistula caused the death of one patient. The "air-crescent" sign was not observed radiographically in any patient and is therefore considered to be an insensitive marker for lung cavitation in invasive aspergillosis. Persistent intracavitary fungal growth may serve as a reservoir for recurrent fungal invasion in patients with prolonged or repeated episodes of severe neutropenia.

Adult↗
PubMed2002

Outcome of lung transplantation in patients with mycetomas.

BACKGROUND: Lung transplantation has become an acceptable treatment option for many end-stage lung diseases. Pulmonary mycetomas are found in patients with end-stage lung diseases, especially sarcoidosis. The clinical course and long-term outcome of these patients after transplantation remains unknown. METHODS: We reviewed retrospectively the pathology reports of the explanted lungs from all lung and heart-lung transplantations performed at our institution between January 20, 1992, and June 26, 2000. Patients were included in our study if mycetomas were present on the specimens. Information on transplant date and type, diagnosis, information on antifungal therapy and fungal infections pretransplant and posttransplant, and clinical course after transplantation was recorded. RESULTS: Mycetomas were present in 3.0% of transplant recipients (9 of 303 patients). The underlying pulmonary diagnoses were sarcoidosis (six patients), and emphysema, idiopathic pulmonary fibrosis, and pneumoconiosis (one patient each). Seven patients received bilateral lung transplants, one patient received a heart/lung transplant, and one patient received a single lung transplant. Aspergillus was isolated from culture in five patients pretransplant and from five patients posttransplant. Six patients received treatment with itraconazole, or IV or inhaled amphotericin B prior to transplantation. All patients who survived transplantation received posttransplant antifungal therapy. Four patients died in the first month after transplantation. Two patients died at 17 months and 24 months posttransplant, respectively; one patient received a second transplant 30 months later; and two patients are alive and free from fungal infections 17 months and 18 months, respectively, after transplantation. All of the medium-term survivors received lengthy therapy with inhaled and systemic amphotericin B and itraconazole before and after transplantation. CONCLUSIONS: Lung transplant recipients with mycetomas have significantly reduced posttransplant survival. Careful selection of patients and aggressive antifungal therapies before and after transplantation have led to improved outcomes in patients with mycetomas. Additional research is needed to define the best therapeutic strategy for these patients during transplantation.

Adult↗
PubMed1997

Pulmonary complications in children with hematologic malignancies: accuracy of diagnosis with chest radiography and CT.

PURPOSE: To determine the diagnostic accuracy of chest radiography and computed tomography (CT) in patients with complications during treatment for hematologic malignancies. MATERIALS AND METHODS: CT scans were obtained 1 week or less before bronchoscopic sampling or biopsy in 48 pediatric patients (age range, 8 months to 18 years at diagnosis) undergoing treatment for leukemia, lymphoma, or myeloproliferative disease. Radiographs were obtained less than 1 week before CT. Pulmonary complications comprised fungal (n = 11), viral (n = 4), and bacterial (n = 5) pneumonias; cryptogenic organizing pneumonia ([COP] n = 4); and pulmonary tumor (n = 4). Chest radiographs and CT scans were rated independently by three radiologists who were unaware of these diagnoses. RESULTS: Satisfactory diagnostic accuracy, defined by the area under the receiver operating characteristic (ROC) curve, was noted for fungal pneumonia (radiography, ROC area = 0.82; CT, ROC area = 0.78), COP (radiography, ROC area = 0.75; CT, ROC area = 0.75), and pulmonary tumor (radiography, ROC area = 0.73; CT, ROC area = 0.83). Generalizability was good for fungal pneumonia (radiography, generalizability coefficient [GC] = 0.84; CT, GC = 0.84) and COP (radiography, GC = 0.75; CT, GC = 0.99). There was no statistically significant difference in diagnostic accuracy between radiography and CT for any of the diagnoses. CONCLUSION: Radiography and CT have satisfactory accuracies for fungal pneumonia and COP. For these conditions, CT identified more true-positive cases than did radiography.

Adolescent↗
PubMed1985

[Invasive aspergillar pneumopathy during the treatment of microcellular bronchial cancer. Efficacy of early antifungal treatment].

The invasive aspergillus pneumonias have been described particularly in chemotherapy for patients with haematological disorders. In respiratory disorders such cases are exceptional. The authors report a case of invasive aspergillus pneumonia, occurring during treatment of a small cell cancer; the rapid commencement of anti-fungal treatment by Amphotericin "B" and Flucytosine enabled an apparent cure of the tumour by radiotherapy and chemotherapy. The authors stress the difficulty of definitive diagnostic criteria at the beginning of the disorder and also the need to start anti-fungal treatment as soon as possible.

Amphotericin B↗
PubMed1986

Deceptive patterns of uremic pulmonary edema.

Three uremic patients had chest x-ray changes due to pulmonary edema, but mimicking lobar pneumonia and fungal or metastatic disease. It is important to be aware of these deceptive radiographic patterns. Otherwise, a potentially disastrous delay in fluid removal, the mainstay of therapy, may result.

Adult↗
PubMedDate not supplied

Pulmonary aspergilloma simulating bronchogenic carcinoma.

When a pre-existing lung cavity is colonized by Aspergilius fumigatus, it forms a fungal ball (pulmonary aspergilloma) and the presenting symptom is usually haemoptysis that may be massive and often-times life threatening. The radiological finding is that of a ball-like structure within a lung cavitation and the typical air crescent around the ball both on plain radiography and CT scan of the chest. The present case is of a 50-year-old male who had a 25-year history of heavy smoking (40 cigarettes per day) and haemoptysis. Although the cavitating lesion, ball-like structure and the crescenteric rim of air were present on the radiographs, the possibility of bronchogenic carcinoma was held high in view. Flexible fibreoptic and transbronchial biopsies were negative for malignancy. Sputum and bronchoalveolar lavage examinations showed neither malignant cells nor fungal elements. Right thoracotomy, cavernostomy, removal of the fungal ball and obliteration of the cavity by suturing (capitonnage) were done with an uneventful postoperative period.

Aspergillosis↗
PubMed1999

[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↗
PubMed1982

Radiographic patterns of opportunistic lung infections and Kaposi sarcoma in homosexual men.

Thirty patients with lung involvement with Pneumocystis carinii and other opportunistic organisms, many of whom also had Kaposi sarcoma, were seen from December 1980 through March 1982. Clinical manifestations consisted of a prodrome of weeks to months with weight loss, fever, and malaise. When clinical pneumonia became apparent, four distinct radiographic patterns were identified. Pneumocystis carinii was uniformly present, and the most common pattern encountered was a relatively symmetric, homogeneous perihilar pneumonia that progressed to diffuse consolidation. Asymmetric and focal infiltrates were seen in patients who proved to have concomitant opportunistic infection, most commonly fungal in all but two cases. A third pattern of nodular and linear densities with or without adenopathy was seen in patients without pneumonia who had biopsy-positive Kaposi sarcoma involving the lung parenchyma. A fourth pattern represented a combination of any of the first three, and these patients had multiple infections as well as Kaposi sarcoma in the lung. Any significant change in the radiograph indicating progression of disease while on therapy prompted a rebiopsy, and in five of 10 patients other infections and/or Kaposi sarcoma were identified.

Adult↗
PubMed1996

Serodiagnosis and monitoring of Aspergillus infections after lung transplantation.

OBJECTIVE: To determine whether quantification of specific antifungal antibody responses in serum can provide supplemental information for the diagnosis of Aspergillus fumigatus infections and the monitoring of antifungal treatment in patients after lung transplantation. DESIGN: Retrospective study. SETTING: Center for lung transplantation, University Hospital Groningen, the Netherlands. PATIENTS: 4 patients with proven A. fumigatus infections after lung transplantation and fatal outcome. MEASUREMENTS: The IgG antibody response specific for A. fumigatus antigens was measured by enzyme-linked immunosorbent assay and was compared with radiographic features, cytologic findings, microbiological cultures, and clinical diagnosis. RESULTS: Increasing IgG antibody responses specific for A. fumigatus antigens closely paralleled cytologic or microbiological identification of A. fumigatus from bronchoalveolar lavage fluid and decrease of lung function. Increasing specific IgG antibody responses were found to precede radiographic identification of lung cavitation by 1 to 2 weeks, precede the diagnosis of aspergillosis by 2 to 20 weeks, and detect fungal reinfection. In most cases, successful antifungal treatment decreased specific IgG antibody response. A decrease in specific IgG antibody response correlated with the inability to culture or identify A. fumigatus in bronchoalveolar lavage fluid and with radiographic and clinical improvement. CONCLUSIONS: Specific IgG antibody responses in serum correlate with radiographic, cytologic, and microbiological findings and with the clinical diagnosis of A. fumigatus infections in patients who have had lung transplantation. Increased IgG antibody responses in serum may provide important information that is helpful in the diagnosis and early treatment of pulmonary fungal infections and in monitoring antifungal treatment.

Adult↗
PubMed2002

Saprophytic fungal infections and complications involving the bronchial anastomosis following human lung transplantation.

STUDY OBJECTIVE: To demonstrate an association between saprophytic fungal infections occurring at the bronchial anastomosis (BA) and the development of additional complications arising at this site. DESIGN: Retrospective review. SETTING: University lung transplant center. MATERIALS AND METHODS: Review of all single-lung and double-lung transplant (LTX) recipients who underwent transplantation between June 1993 and December 2000. All recipients were subjected to surveillance bronchoscopy with biopsy at predetermined intervals and when clinically indicated. Bronchial wash fluid and biopsy material were examined using appropriate fungal stains and culture techniques. An infection was defined when fungal organisms were identified in tissue specimens. RESULTS: Fifteen saprophytic fungal infections involving the BA were identified in 61 LTX recipients (24.6%) who survived a minimum of 75 days post-transplantation. Infections were attributed to Aspergillus sp (n = 9), Candida sp (n = 2), Torulopsis sp (n = 1), and mixed flora (ie, Penicillium + Candida, two patients; and Aspergillus + Candida, one patient). Saprophytic fungal infections occurred by a median of postoperative day 35 (range, 13 to 159 days). Airway complications involving the BA ultimately developed in 11 of 61 recipients (18%). These complications included symptomatic bronchial stenosis (nine patients), bronchomalacia (one patient), and fatal hemorrhage (one patient). Bronchial complications arose in 7 of 15 recipients (46.7%) with saprophytic fungal infections of the BA in contrast to 4 of 46 (8.7%) without infections (p = 0.003, Fisher exact test). Also demonstrated was a positive correlation between anastomotic infections and bronchial complications (Phi coefficient = 0.43; p = 0.001), while logistic regression analysis revealed that the absence of anastomotic infections predicted the absence of such complications (p = 0.002). The risk of developing an additional complication following an anastomotic infection in patients with infections was five times that of those recipients without an infection (relative risk, 5.36; 95% confidence interval [CI], 1.82 to 15.79). The odds in favor of a bronchial complication following an infection were eight times greater than in those recipients without infection (odds ratio, 8.31; 95% CI, 1.96 to 35.16). CONCLUSIONS: Following LTX, saprophytic fungal infections of the BA are associated with serious airway complications.

Adult↗
PubMed2004

Successful treatment of Fusarium proliferatum pneumonia with posaconazole in a lung transplant recipient.

A 62-year-old lung transplant recipient had Fusarium proliferatum pneumonia during itraconazole prophylaxis. Severe dyspnea and emphysema ensued, requiring supplemental oxygen therapy. Therapeutic options for this patient were limited; renal insufficiency and cyclosporine use precluded amphotericin B therapy, and susceptibility testing indicated that itraconazole and fluconazole had poor activity against F proliferatum. Treatment with posaconazole, a new triazole in clinical development for the prophylaxis and treatment of fungal infection, resulted in rapid clinical improvement and successful eradication of F proliferatum. Posaconazole may provide effective treatment for difficult-to-treat Fusarium infections.

Antifungal Agents↗
PubMed2004

[Clinical analysis of nosocomial pulmonary fungal infection in patients with cancer].

BACKGROUND & OBJECTIVE: Nosocomial fungal infection is an important complication of cancer patients. Among them, pulmonary fungal infection is over 20%. This study was designed to analyze and evaluate risk factors, and clinical features of nosocomial pulmonary fungal infection in patients with cancer. METHODS: In 1 229 patients with malignant tumor, clinical records of 78 patients with nosocomial pulmonary fungal infection were retrospectively analyzed. RESULTS: Pulmonary fungal infection rate was 6.35% (78/1 229). The major fungus was Candida albicans (68.18%). The main risk factors were age of > or =50 years (P< 0.005), primary site (lung cancer, P< 0.001), cancer stage (stage IV, P< 0.005), pulmonary radiotherapy (P< 0.001), chemotherapy (P< 0.001), and long-term hospitalization ( >2 weeks, P< 0.005). CONCLUSION: The effective methods to reduce nosocomial pulmonary fungal infection in patients with cancer are reducing risk factors, early diagnosis, and timely treatment.

Adult↗
PubMed2003

Fungal pneumonias in transplant recipients.

Fungi are ubiquitous in the environment. Opportunistic fungal pneumonias in the immunocompromised host continue to increase most commonly due to Aspergillus sp. Affected patients are usually hematopoietic stem cell and lung transplant recipients. Clinical presentation is protean, and the diagnosis is challenging. Culture of respiratory specimens has limited utility. The detection of circulating fungal antigens and DNA seems promising, but more studies are needed. Value of prophylactic strategies or preemptive therapy remains contentious. New antifungal drugs for managing invasive pulmonary aspergillosis continue to emerge, with better safety, efficacy, and pharmacologic profiles.

Antifungal Agents↗
PubMed1995

The pulmonary nodule after lung transplantation. Cause and outcome.

In the immunocompromised patient, the pulmonary nodule remains a diagnostic and therapeutic challenge. We studied the incidence, cause, diagnosis, and therapy of pulmonary nodules after lung transplantation (LTx). Eight out of 64 patients (12.5%) developed pulmonary nodules after a median follow-up of 5.8 months (range, 1 to 10 months). The median age was 30.5 years (range, 21 to 62 years). Solitary pulmonary nodules (n = 2) disappeared spontaneously within 3 weeks and were suspected to be of infectious origin. The cause of multiple nodules (n = 6) was posttransplant lymphoproliferative disorder (PTLD [n = 3]), aspergillosis (n = 2), and abscesses caused by Pseudomonas aeruginosa and Staphylococcus aureus (n = 1). After an initial chest radiograph, CT with fine-needle biopsy was the most valuable diagnostic tool. In six patients, nodules resolved within 10 weeks (median, 8 weeks). Two patients, however, died of sepsis (P aeruginosa and S aureus and Aspergillus, respectively). The differential diagnosis of pulmonary nodules after LTx primarily comprises PTLD and infection (bacterial or fungal). To improve the outcome, early, aggressive treatment is mandatory; therefore, serial CT scans are strongly recommended to be part of the diagnostic armamentarium in LTx recipients.

Adult↗
PubMed2005

Non-small cell lung cancer coexisting with pulmonary aspergilloma.

A 77-year-old male with a long-standing history of smoking and working in mines was referred to our department for the evaluation of an enlarging subpleural mass in the right upper lobe. Both transbronchial and computed tomography-guided biopsies of the mass were non-diagnostic. A partial resection of the right S2 mass under video-assisted thoracic surgery (VATS) confirmed the diagnosis of primary non-small cell lung cancer. VATS right upper lobectomy (ND2a) was then performed for complete resection. Histological examination revealed that the mass composed of adenocarcinoma and the dilated bronchioles contained Aspergillus, the fungal component. Here we report a rare case of non-small cell lung cancer coexisting with pulmonary aspergillosis. The morphologic coexistence pattern of the two pathologies was believed to be the colonization of saprophytic Aspergillus in the bullous air spaces, obstructed by or contained within the tumor, according to the progression of the lung cancer.

Adenocarcinoma↗