[Successful treatment of invasive pulmonary aspergillosis with G-CSF and M-CSF during long-term bone marrow suppression in hypoplastic leukemia]

A 52-year-old man was admitted for treatment of hypoplastic leukemia (M 1). After induction chemotherapy with IDR and AraC, the patient developed prolonged febrile neutropenia, and a diagnosis of invasive pulmonary aspergillosis was made. We started administration of AMPH-B and G-CSF, but the patient showed no clinical improvement. M-CSF was added to the regimen, and this led to an increase in the white blood cell count with resolution of pneumonia. It is suggested that administration of M-CSF with antibiotics and G-CSF may be beneficial for treating acute leukemia patients with prolonged febrile neutropenia after intensive chemotherapy.

Innovative medical management with resection for successful treatment of pulmonary mucormycosis despite diagnostic delay

We present a case of primary pulmonary mucormycosis infection in a renal transplant recipient diagnosed serendipitously by computed tomography scan. Treatment included discontinuation of immunosuppressive regimen, initiation of antifungal therapy with amphotericin B lipid complex, administration of granulocyte-macrophage colony stimulating factor, surgical excision of the involved lobe, and outpatient treatment with amphotericin B with dialysis. The patient ultimately required transplant nephrectomy as a result of immunosuppression discontinuation.

Pulmonary infections in children with HIV infection

The epidemic of pediatric acquired immunodeficiency syndrome (AIDS) in the United States, which peaked during the mid-1980s and early 1990s, was characterized by a variety of opportunistic infections in children infected with human immunodeficiency virus (HIV), often as the presenting illness of their HIV infection. Pneumocystis carinii pneumonia (PCP) during infancy was responsible for significant morbidity and mortality, followed by many other opportunistic infections, including recurrent, serious bacterial infections; disseminated cytomegalovirus infection; and disseminated Mycobacterium avium complex (MAC) infection. Many of these infections involve the lower respiratory tract either as a primary site of infection or as one of the sites involved in disseminated disease. Since the mid- to late 1990s, the pediatric HIV epidemic in the United States has witnessed a dramatic decrease in the frequency of most opportunistic infections and other severe manifestations of HIV infection in children, primarily because of lower rates of mother-to-child HIV transmission, development and implementation of guidelines for PCP prophylaxis, and availability of highly active antiretroviral therapy. Far fewer children are at risk for clinical progression of HIV disease and for opportunistic infections. Despite these successful trends, pulmonary opportunistic infections and pulmonary disease remain common clinical manifestations of pediatric HIV disease.

Analysis of various treatments for pulmonary aspergillomas

The objective of this study was to analyze the results of various treatments for pulmonary aspergilloma and to determine the surgical indications. A total of 41 patients with pulmonary aspergilloma hospitalized at the National Minamifukuoka Chest Hospital between 1973 and 1999 were analyzed with regard to their response to treatment and long-term prognosis. Five asymptomatic patients who were untreated demonstrated no change in the clinical status of aspergilloma. Analysis of the short-term response revealed surgery to be the most effective treatment. Systemic and intracavitary injections of antifungal drugs were not definitely effective, although they had a positive effect in some patients. A survival analysis revealed that all eight patients who underwent surgery are still alive. Using the Cox proportional hazard model, it was found that the favorable prognostic factors were the absence of symptoms, the absence of a superimposed bacterial infection, and surgery. There were ten deaths: three from lung cancer and seven related to uncontrollable superimposed bacterial infections, often resulting in hemoptysis. We conclude that patients with asymptomatic pulmonary aspergillomas should be clinically observed for signs of the development of lung cancer, but do not require active treatment. On the other hand, patients who are symptomatic and have uncontrollable superimposed bacterial infection will benefit from surgery.

Urokinase-type plasminogen activator is required for the generation of a type 1 immune response to pulmonary Cryptococcus neoformans infection

Urokinase-type plasminogen activator (uPA)(-/-) mice cannot mount protective host defenses during infection with the opportunistic yeast Cryptococcus neoformans (52D). Because effective host defense against C. neoformans requires specific immune responses and the generation of type 1 (T1) cytokines, we determined how the absence of uPA impacts these processes. Wild-type (WT) and uPA(-/-) mice were inoculated with C. neoformans. Macrophage antifungal activity was assessed histologically, T lymphocyte responses in vivo and proliferation in vitro were quantified, and cytokine concentrations were determined by ELISA. uPA(-/-) macrophages have impaired antimicrobial activity. Regional lymph nodes of infected uPA(-/-) mice contained fewer cells than WT, suggesting impaired T cell proliferation in response to the pathogen in vivo. In vitro, uPA(-/-) T lymphocytes had impaired proliferative responses to C. neoformans rechallenge compared with WT. Infected WT mice generated T1 cytokines in the lung, characterized by high levels of IFN-gamma and IL-12. uPA(-/-) mice had decreased levels of IFN-gamma and IL-12, and increased IL-5, a type 2 cytokine. In the absence of uPA, the cytokine profile of regional lymph nodes shifted from a T1 pattern characterized by IFN-gamma and IL-2 to a weak, nonpolarized response. We conclude that in the absence of uPA, lymphocyte proliferative responses are diminished, and mice fail to generate protective T1 cytokines, resulting in impaired antimicrobial activity. This study provides novel evidence that uPA is a critical modulator of immune responses and of immune cell effector functions in vivo.

Combined medical surgical therapy for pulmonary mucormycosis in a diabetic renal allograft recipient

Mucormycosis is a rare opportunistic infection that complicates chronic debilitating diseases and immunosuppressed solid-organ transplant recipients. We present a case of life-threatening pulmonary mucormycosis in a diabetic renal allograft recipient who survived with reasonable renal function. Early recognition of this entity and prompt use of bronchoalveolar lavage (BAL) are critical to the outcome. Antifungal therapy combined with early surgical excision of infected, necrotic tissue appears to be the preferred course of action. Judicious withholding of immunosuppressants until fungemia cleared did not jeopardize allograft function.

Pulmonary aspergillosis

Aspergillus species are ubiquitous in the environment and are inevitably inhaled into the airways. Inhalation of Aspergillus conidia or mycelium fragments may result in colonisation of the airways. In susceptible hosts colonisation may subsequently cause disease. Patients with pre-existent cavities may develop aspergillomas which may be quiescent or cause symptoms especially recurrent haemoptysis. Acute invasive disease is potentially lethal in patients who are vulnerable to infection due to underlying lung diseases or immunosuppression. In addition to its ability to colonise the human respiratory tract, Aspergillus has a significant potential to act as a powerful allergen resulting in Aspergillus asthma and allergic bronchopulmonary aspergillosis. The various presentations of pulmonary disease caused by Aspergillus are reviewed here, focusing primarily on clinical aspects rather than basic science.

Pulmonary aspergillosis: clinical presentation, diagnosis and therapy

Pulmonary aspergillosis is a serious threat to those immunocompromised as a result of disease or therapy, and has been identified as a major cause of morbidity and mortality in asthmatic and cystic fibrosis patients. Pulmonary aspergillosis can occur in three principal forms: saprophytic, allergic and invasive. Saprophytic aspergillosis involves colonisation of the airways, without invasion or damage of viable tissue, and may present as an aspergilloma (fungus ball) consisting of a tangled mass of mycelium, fibrin, inflammatory cells and epithelial-cell debris. Necrotic tissue also may be invaded but usually only in those severely immunocompromised. Allergic aspergillosis is referred to frequently as allergic bronchopulmonary aspergillosis (ABPA), and may occur in approximately 25% of asthmatic and 10% of cystic fibrosis patients. ABPA presents as a non-infectious, potentially fatal inflammatory disease where antigens released by the fungal mycelium provoke an immune response. Invasive aspergillosis is probably the most serious form of the disease and involves the invasion of viable tissue. It occurs predominantly in patients with pre-existing lung damage, and can spread to other organs and distant sites in the body. Aspergillomas may be detected on chest X-ray as spherical-shaped objects, whilst allergic aspergillosis may be visualised by radiological techniques and computed tomography (CT) scan. Surgery may be employed in the case of aspergilloma, and chemotherapy relies upon the use of amphotericin B (liposomal and aerosolised) and itraconazole.

Liposomal amphotericin B and surgery in the successful treatment of invasive pulmonary mucormycosis in a patient with acute T-lymphoblastic leukemia

Pulmonary mucormycosis is a usually fatal opportunistic infection in immunocompromised patients. We describe the first case of an adult patient with hematological malignancy and profound neutropenia to survive a disseminated pulmonary Rhizomucor pusillus infection. Early diagnostic procedures combined with high doses of liposomal amphotericin B and surgical resection may have contributed to the successful outcome.

Therapeutic approach in pulmonary mycetoma. Analysis of 27 patients

BACKGROUND

Pulmonary mycetoma is a characteristic clinical-radiological lesion due to colonization of aspergillus or candida species in pre-existing pulmonary cavities following a number of diseases.

METHODS

We revisited 27 records of such admitted patients (19 M, 8 F; range age 16-27 yrs) analysing diagnostic approach and therapy. Predisposing conditions were sequelae of tuberculosis or lung abscess, bronchiectasis, bullous emphysema, leukaemia/ lymphoma, diabetes mellitus, corticosteroids and/or immunosuppressant administration and antiblastic chemotherapy. All patients had a characteristic chest X-ray and the most common symptoms were cough and haemoptysis. Diagnosis of pulmonary mycetoma was based on positive sputum culture for aspergillus or candida species and/or positive result for aspergillus precipitin test. Eleven patients received only medical treatment, eight pts only a surgical one and eight patients both medical and surgical ones. Antifungal drugs administered were itraconazole or amphotericin B or fluconazole.

RESULTS

In the follow-up, six out of eleven patients who had received only medical treatment, cannot be found; five patients or their relatives were interviewed by phone: two of them enjoyed good health and three had died. Sixteen patients underwent thoracic surgery and one of them died because of postsurgical complications. In the follow-up, only nine patients out of this last group were interviewed by phone 2 to 8 years after surgery: seven of them enjoyed good health while two patients had died because of disease not related to pulmonary mycetoma.

CONCLUSIONS

Aspergilloma treatment is related to the extension of disease and clinical conditions of patients but surgical resection associated with drug administration, when possible, is the treatment of choice.

Pneumonia in pregnancy

Although the advent of broad-spectrum antibiotics has markedly improved the maternal outcomes of pneumonia complicating pregnancy, pneumonia remains a significant condition that may complicate pregnancy. This article has reviewed the inherent physiologic respiratory changes that accompany pregnancy and the common causes of pneumonia in the pregnant woman. The clinical course of bacterial pneumonia seems to be minimally altered by pregnancy, whereas viral pneumonia carries a significantly worse prognosis when encountered during gestation. Prompt diagnosis, the initiation of respiratory support, and appropriate antimicrobial/antiviral therapy are key components of therapy for women in whom pregnancy is complicated by pneumonia. Because preterm labor frequently accompanies pneumonia, women should be monitored closely for the occult onset of preterm labor and appropriate interventions initiated if indicated. Perhaps even more important than interventions to treat acute pneumonia are efforts directed at active immunization or prophylactic therapy to prevent the development of pneumonia in select patient populations. The combination of these efforts is essential to optimize medical care for pregnant women.

[A case of non-invasive pulmonary aspergillosis that rapidly deteriorated]

The pulmonary diseases caused by the Aspergillus species include invasive forms, for example, invasive pulmonary aspergillosis, chronic necrotizing pulmonary aspergillosis, and non-invasive pulmonary aspergillosis. Though these forms are defined pathologically by the presence of the Aspergillus species that invades the lung tissue, they are used as clinical entities. We report a case of non-invasive pulmonary aspergillosis which, from the clinical data, appeared likely to be misdiagnosed as the chronic invasive form. A 45 year-old man received chemoradiotherapy for lung cancer as well as undergoing an left upper lobectomy. Two weeks after the surgery the patient developed a cough, high fever and chest pain. Chest radiography and chest computed tomography showed a rapidly enlarging cavity with an internal mass and infiltration in the left lower lung field. A transbronchial biopsy specimen of the cavity wall showed fungal hyphae. Bronchial washing culture grew Aspergillus fumigatus. Itraconazole and amphotericin B were administered, but the patient's condition did not improve. A left lower lobectomy was performed. The histologic findings showed that the fungal hyphae were only on the surface of the cavity wall, and were surrounded by necrosis and widespread inflammatory cell infiltration. No fungal invasion of the viable lung tissue was seen. The area of infiltration revealed an organizing pneumonia without Aspergillus or other organisms. Our final diagnosis was non-invasive pulmonary aspergillosis. There has been no recurrence of the lung cancer or of the pulmonary aspergillosis in the three years since surgery. It is reported that non-invasive pulmonary aspergillosis passes through a period so active that it seems to be the invasive form for its entire clinical course. To avoid confusion in diagnosis, establishment of a comprehensive clinical classification of pulmonary aspergillosis will be needed.

Pulmonary fungal infection: emphasis on microbiological spectra, patient outcome, and prognostic factors

STUDY OBJECTIVES

To investigate the microbiological spectra, patient outcome, and prognostic factors of pulmonary fungal infection.

DESIGN

The medical and microbiological records of patients with pulmonary fungal infection were retrospectively analyzed.

SETTING

A university-affiliated tertiary medical center.

PATIENTS AND METHODS

From January 1988 to December 1997, all cases of pulmonary fungal infection were reviewed. The criteria for inclusion were obvious lung lesion shown on chest radiographs and one of the following: (1) the presence of fungi in or isolation of fungi from the biopsy specimen of open thoracotomy, thoracoscopy, transbronchial lung biopsy, or ultrasound-guided percutaneous needle aspiration/biopsy; or (2) isolation of fungi from pleural effusion or blood, with no evidence of extrapulmonary infection.

RESULTS

A total of 140 patients were included. Ninety-four cases of pulmonary fungal infection (67%) were community acquired. The most frequently encountered fungi were Aspergillus species (57%), followed by Cryptococcus species (21%) and Candida species (14%). There were 72 patients with acute invasive fungal infection, with a mortality rate of 67%. Multivariate logistic regression analysis showed that nosocomial infection (p = 0.014) and respiratory failure (p = 0.001) were significantly and independently associated with death of acute invasive fungal infection.

CONCLUSIONS

Pulmonary fungal infection of community-acquired origins is becoming a serious problem. It should be taken into consideration for differential diagnosis of community-acquired pneumonia. Furthermore, acute invasive fungal infection is associated with a much higher mortality rate for patients with nosocomial infection or complicating respiratory failure. Early diagnosis with prompt antifungal therapy, or even with surgical intervention, might be warranted to save patients' lives.

[Invasive nosocomial pulmonary aspergillosis]

Immunodepressed patients, particularly those with neutropenia or bone marrow or organ grafts, are at risk of developing nosocomial invasive pulmonary aspergilosis. The favoring factors, early diagnostic criteria and curative treatment protocols are well known. Prognosis remains however quite severe with a death rate above 50%. Preventive measures are required for the treatment of these high-risk patients and epidemiology surveillance is needed in case of aspergillosis acquired in the hospital.

Coccidioidomycosis in non-endemic areas: a case series

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis, which is endemic to the south-western United States. Manifestations range from flu-like illness to pneumonia and septic shock. Diagnosis may be delayed or missed in non-endemic areas because of the low index of suspicion. We describe a series of 23 patients with coccidioidomycosis at one institution in a non-endemic area. Diagnosis was often delayed. In two patients, the route of exposure could not be determined, but 20 patients had a history of residence or travel to endemic areas, and the remaining patient had an occupational history of exposure to fomites from an endemic region. Five patients were immunosuppressed. Most patients responded well to medical therapy, surgery, or both. Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled to endemic areas or who are immunosuppressed.

Chronic obstructive pulmonary disease patients with invasive pulmonary aspergillosis: benefits of intensive care?

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.

Increasing volume and changing characteristics of invasive pulmonary aspergillosis on sequential thoracic computed tomography scans in patients with neutropenia

PURPOSE

In patients with neutropenia, thoracic computed tomography (CT) halo and air-crescent signs are recognized as major indicators of invasive pulmonary aspergillosis (IPA). Nevertheless, the exact timing of CT images is not well known.

PATIENTS AND METHODS

Seventy-one thoracic CT scans were analyzed in 25 patients with neutropenia with surgically proven IPA.

RESULTS

On the first day of IPA diagnosis with early CT scan (d0), a typical CT halo sign was observed in 24 of 25 patients. At that time, the median number of thoracic lesions was two (range, one to six), and pulmonary involvement was bilateral in 12 cases. The halo sign was present in 68%, 22%, and 19% of cases on d3, d7, and d14, respectively. Similarly, the air-crescent sign was seen in 8%, 28%, and 63% of cases on the same days. Otherwise, a nonspecific air-space consolidation aspect was seen in 31%, 50%, and 18% of cases on the same days. The analysis of calculated aspergillary volumes on CT showed that, despite antifungal treatment, the median volume of lesions increased four-fold from d0 to d7, whereas it remained stable from d7 to d14. Overall, 21 patients (84%) were cured by the medical-surgical approach.

CONCLUSION

In patients with neutropenia, CT halo sign is a highly effective modality for IPA diagnosis. The duration of the halo sign is short, and it demonstrates the value of early CT. The increase of the aspergillosis size on CT in the first days after IPA diagnosis is not correlated with a pejorative immediate outcome when using a combined medical-surgical approach.

Fungal infections in transplant recipients

Fungi are ubiquitous and the respiratory tract is exposed to aerosolized spores of both fungi that are "pathogenic" even in the normal host, such as Cryptococus neoformans, and those that are "opportunistic", such as Candida and Aspergillus species, among others. Although these latter species may occasionally form fungal balls or induce allergic phenomena in the normal host, they produce more invasive diseases in immunosuppressed patients. Among these diseases, pseudomembranous aspergillosis has recently been described. The diagnostic approach to these entities, and, in particular, the thin dividing line between colonization and infection are addressed, along with the diagnostic value of the various procedures. New prophylactic regimens are reviewed such as the possibility of using amphotericin aerosols in combination with systemic azole administration. The authors would emphasize the importance of restoring lung defences by not only decreasing immunosuppressive regimens but also considering the use of newly available recombinant cytokines such as growth factors, to reduce neutropenia, for instance, in addition to antifungal drugs when infection is diagnosed. However, immunomodulation procedures are far from being well established.

Successful treatment of invasive aspergillosis in chronic granulomatous disease by granulocyte transfusions followed by peripheral blood stem cell transplantation

Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder characterized by impaired microbial killing and susceptibility to bacterial and fungal infections. Cure of the disease can be achieved by stem cell transplantation when performed early in its course, and before severe infections have developed. Invasive aspergillosis constitutes a very high risk for transplantation. We report a 4-year-old boy with X-linked CGD who underwent successful HLA-identical peripheral blood stem cell (PBSC) transplantation during invasive pulmonary aspergillosis and osteomyelitis of the left fourth rib, which was unresponsive to antifungal treatment. During the 2 months prior to the transplant he received G-CSF-mobilized granulocyte transfusions (GTX) from unrelated donors three times a week in addition to the antifungal treatment. This resulted in clinical improvement in his respiratory status. He also received GTX during the aplastic period after the conditioning regimen, until he had engrafted. Post-transplant superoxide generation test revealed that neutrophil function was within normal range. One year post transplant the CT scan showed almost complete clearance of the pulmonary infiltrates and a marked improvement in the osteomyelitic process. Based on other reports and our own experience, GTX can serve as important treatment in patients with CGD who have failed conventional anti-fungal treatment and for whom stem cell transplantation is the only chance for cure.