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We report the first case of mixed pulmonary infection with Strongyloides stercoralis and Blastomyces dermatitidis. Histopathology from the lung biopsy showed structures consistent with B. dermatitidis and S. stercoralis. A parasitology exam from a bronchi alveolar lavage yielded an immature rhabditiform larva and female worm. Fungal cultures grew B. dermatitidis.
Infection of the lower respiratory tract, acquired by way of the airways and confined to the lung parenchyma and airways, typically presents radiologically as one of three patterns: (1) focal nonsegmental or lobar pneumonia, (2) multifocal bronchopneumonia or lobular pneumonia, and (3) focal or diffuse "interstitial" pneumonia. These patterns can be useful in identifying the etiological organism in the appropriate clinical setting. To serve the purpose of this article, these patterns are used as the primary method of classification of pulmonary infections caused by different organisms. Mycobacterial and fungal pulmonary infections are reviewed separately because of their wide range of radiographic appearance that depend on the stage of the disease at presentation. This article discusses the clinical and radiographic features of the most common causes of pneumonia, primarily in the adult population of the United States.
A 10-year-old Thoroughbred gelding was admitted to the Veterinary Medical Teaching Hospital of the University of California-Davis with a 2-week history of intermittent fever and acute onset of lethargy, anorexia, and ataxia. Although the clinical signs were nonspecific, the results of initial hematologic and biochemical analysis were consistent with a chronic inflammatory process. Thoracic radiographs revealed an increased fine reticulonodular interstitial opacity throughout the dorsal caudal lung fields. Cytologic examination of bronchoalveolar lavage (BAL) fluid showed mixed inflammation with many mononuclear phagocytes containing single, spherical, intracytoplasmic fungal organisms. Four mold species were cultured in low numbers from the BAL fluid. One of the fungal elements observed on the culture plates was identified as Acremonium strictum by real-time polymerase chain reaction (PCR). A diagnosis of fungal pneumonia due to A strictum was made based on the results of thoracic imaging, cytologic evaluation, culture, and PCR testing. The horse made an uneventful recovery with supportive treatment and was disease-free based on normal physical, radiographic, and cytologic findings at 21 days after presentation. To our knowledge, this is the first report of isolation of A strictum from the BAL fluid of a horse with interstitial pneumonia.
INTRODUCTION: We sought to determine whether chest radiography can be reliably used to distinguish persistent or relapsing pulmonary lymphoma from a variety of infectious and noninfectious pulmonary conditions that can occur in children receiving treatment for lymphoma. METHODS: We studied chest radiographs of 37 patients (30 with non-Hodgkin's lymphoma, and seven with Hodgkin's disease) who died of paediatric lymphoma or of treatment complications. Pulmonary findings at autopsy comprised lung tumour (n = 14), pleural tumour (n = 12), pneumonia (n = 22), adult respiratory distress syndrome (ARDS; n = 16), haemorrhage (n = 27), and infarction (n = 13). Using a 4-point scale and without knowledge of autopsy findings, three radiologists independently rated antemortem radiographs for the presence of pulmonary tumour, pleural tumour, pneumonia in general, pneumonia caused by viral, bacterial, fungal, and protozoan pathogens, ARDS, pulmonary haemorrhage, and pulmonary infarction. Diagnostic accuracy was defined by the area under the receiver-operating-characteristic curve (AZ). RESULTS: Diagnostic accuracy was good for pulmonary tumour (AZ, 0.71 +/- 0.6), protozoan pneumonia (AZ, 0.77 +/- 0.06), and ARDS (AZ, 0.86 +/- 0.07) but poor for all other conditions. The absence of both pleural effusions and mediastinal/right hilar lymphadenopathy was significantly associated (P < or = 0.04) with the absence of lung tumour. DISCUSSION: The pulmonary processes in these patients can all demonstrate diffuse airspace opacification, and many patients had multiple lung abnormalities at autopsy. The radiologist-readers were unable to identify which pulmonary conditions were responsible for radiographic findings in most patients. The readers were able to identify patients who did not have pulmonary lymphoma. If pulmonary involvement with lymphoma is unlikely, bronchoscopy with bronchoalveolar lavage may be sufficient to establish a diagnosis. When pulmonary lymphoma is a clinical consideration, open lung biopsy is usually required for diagnosis.
Pulmonary infections are a significant cause of morbidity after liver transplantation; Gram-negative bacilli, cytomegalovirus, and Pneumocystis carinii were the usual pulmonary pathogens in the earlier studies in liver transplant recipients receiving cyclosporine. We prospectively assessed the impact of pulmonary infection in 101 consecutive liver transplant recipients receiving the new immunosuppressive agent tacrolimus (FK506). Fifteen percent (15/101) of the patients had 19 episodes of pneumonia; 58% (11/19) of the pneumonias were bacterial, 37% (7/19) were fungal, and 5% (1/19) were protozoal (Toxoplasma gondii). Twenty-seven percent of the bacterial pneumonias were due to Legionella. None of the patients had cytomegalovirus or P carinii pneumonia. Seven percent (7/10) of the study patients had fungal pneumonitis; 4% had invasive aspergillosis and 3% had cryptococcosis. Mortality was significantly higher (53%, 8/15) for patients with pneumonia than for patients without pneumonia (10%, 9/86, P = 0.0004). Only fungal pneumonias were the direct cause of death; 63% (5/8) of the deaths were in patients with fungal pneumonitis. Our data suggest a changing pattern of microbial etiologies of pneumonitis in the era of modern immunosuppressive agents. We show that P carinii pneumonia and cytomegalovirus can be effectively curtailed with appropriate prophylaxis. Fungal infections, on the contrary, not only constituted a major proportion of the pneumonia, but also carried the highest pneumonia-associated mortality. Legionella infections can be overlooked unless specialized laboratory methodology (cultured on selective media, urinary antigen) are applied routinely on all cases of pneumonia. We recommend routine culture on the water supply for Legionella in all transplant centers.
A 56-year-old man with idiopathic pulmonary fibrosis developed acute symptoms, including fever and cough. Chest X-ray and CT scan films revealed consolidations and ground glass opacities in the bilateral lungs suggestive of massive pneumonia and acute respiratory distress syndrome (ARDS). Microscopic examination by a transbronchial lung biopsy from the right middle lobe demonstrated numerous hyphae of aspergillus. Despite treatment with anti-fungal agents, respiratory failure rapidly progressed, and the patient died on the 21st hospital day. Postmortem examination of the lung showed multiple abscesses with hyphae of aspergillus invading into small pulmonary artery and alveoli, which were the characteristic findings of invasive pulmonary aspergillosis (IPA). In addition, diffuse alveolar damage was also present, associated with the typical features of UIP such as honeycombing in the bilateral lungs. The serum anti-influenza B virus antibody was high at 512-fold. Therefore, it was speculated that influenza B virus infection triggered superimposed aspergillus infection leading to fatal IPA associated with ARDS.
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OBJECTIVES: Invasive pulmonary aspergillosis (IPA) is increasingly recognized as a cause of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD) treated with corticosteroids. For these patients admission in intensive care unit (ICU) is often required for life-support and mechanical ventilation. Whether this approach improves outcome is unknown. DESIGN AND SETTING: Retrospective study in a university hospital intensive care unit. PATIENTS: Between November 1993 and December 1997, 23 COPD patients were admitted in our ICU and received antifungal agents for possible IPA. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The clinical features and the outcome were reviewed. Diagnosis of IPA was classified as confirmed (positive lung tissue biopsy and/or autopsy) or probable (repeated isolation of Aspergillus from the airways with consistent clinical and radiological findings). Among the 23 patients treated for Aspergillus, 16 fulfilling these criteria for IPA were studied. Steroids had been administered at home to all patients but one and were increased during hospitalization in all. Twelve patients suffered a worsening of their bronchospasm precipitating acute respiratory failure. During ICU stay all patients required mechanical ventilation for acute respiratory failure. Although amphotericin B deoxycholate was started when IPA was suspected (0.5-1.5 mg/kg per day), all patients died in septic shock (n = 5) or in multiple-organ failure. CONCLUSIONS: The poor prognosis of intubated COPD patients with IPA, in spite of antifungal treatment suggests that further studies are required to define the limits and indications for ICU management of these patients.
With AIDS related tuberculosis in the pediatric population on the rise, we review our experience with 14 such children. A brief review of the pertinent literature is also presented.
Immunocompromised patients are susceptible to infections by a wide range of organisms. In the past several decades, AIDS epidemic, advances in the treatment of cancer, organ transplantation, and immunosuppressive therapy have resulted in large numbers of patients who develop abnormalities in their immune system. Moreover, mildly impaired host immunity as it occurs in chronic debilitating illness, diabetes mellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid administration, and chronic obstructive lung disease have also been regarded as predisposing factors of pulmonary infections. Imaging plays a crucial role in the detection and management of patients with pulmonary infectious diseases. When pulmonary infection is suspected, knowledge of the varied radiographic manifestations will narrow the differential diagnosis, helping to direct additional diagnostic measures, and serving as an ideal tool for follow-up examinations. Combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infection occurring in the immunocompromised patients.
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In an immunocompromised patient with fever and pulmonary infiltrates, it frequently is difficult to decide which invasive procedure, if any, to use to obtain a definitive diagnosis. Because most lung infiltrates in immunosuppressed patients are caused by bacteria and sputum usually is readily available for examination, empiric therapy with potent, safe, broad spectrum, antibacterial drugs often is successful. Invasive procedures that prove a diagnosis may result in substantive changes in therapy in perhaps as few as 10 to 20 per cent of patients, and the procedure itself may harm the patient. In a unique study in which patients with acute pneumonitis without neutropenia were randomized to either empiric antibiotic treatment or treatment based on results of open lung biopsy, patients with open lung biopsy had a worse outcome, possibly related to morbidity of open lung biopsy. Furthermore, no diagnoses were provided by open lung biopsy that were not treated by the empiric regimen. A missed treatable disease may be tragic, however. A thoughtful clinician must evaluate each patient with careful consideration of the history in light of the underlying disease and its treatment, rapidity of clinical course, physical examination, and laboratory data, particularly the chest radiograph, sputum examination, and bleeding parameters. Fiberoptic bronchoscopy with washings and brushings is very safe; the addition of transbronchial biopsy adds diagnostic power at the price of some complications. Bronchoalveolar lavage is a very promising technique that probably will find widespread use. However, none of the foregoing techniques is completely sensitive. When no diagnosis is established and bronchoscopy studies are negative, open lung biopsy must be considered, especially when the chest radiograph or computed tomography scan suggests focal disease or lymphadenopathy. Needle aspiration can be used, particularly if local experience is favorable and lung disease is peripheral. When evaluating a procedure, local experience must be considered rather than reliance on published diagnostic yields and complication rates. New diagnostic and therapeutic developments may change decision analysis in the near future. At present, cultures for viruses and fungi and serologic techniques have little application at most medical centers, and decisions on data from invasive procedures pivot on interpretation of histology and smears. Development of assays for antigen (for example, Aspergillus) and rapid culture techniques (for example, cytomegalovirus and the shell vial method), coupled with new, effective antimicrobials, may demand maximum effort for a definitive diagnosis in every patient.
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Inhalant exposure to Aspergillus fumigatus (Asp. f.) antigens induces marked inflammatory and immunological alterations in the lungs of horses affected with chronic obstructive pulmonary disease (COPD). In this study we investigated the role of specific allergen(s) present in Asp. f. on systemic and pulmonary IgE and IgG responses in control and COPD-affected horses, using an enzyme-linked immunosorbent assay (ELISA) and immunoblotting techniques. Compared with controls, horses affected with COPD had significantly higher levels of BALF IgE and IgG to somatic Asp. f. antigens as well as to the allergen 1/a (Asp. f. 1/a). Serum levels of IgE and IgG against these antigens did not differ between control and COPD-affected horses. Antigen specific IgE and IgG levels did not correlate between BALF and serum. Scanning of Asp. f. and IgE and IgG blots revealed bands that are recognised by both IgE- and IgG-specific antibodies. Additionally, all horses responded with BALF IgE- and IgG-specific for 93, 35, 31 and 23 kDa allergens, suggesting that these antigens are involved in the induction of airway IgE and IgG responses. These allergens may have the potential to be used as biomarkers for the diagnosis of Asp. f. related exacerbations of equine COPD.
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