ASPERGILLOSIS (ASPERGILLUS NIDULANS) INVOLVING BONE

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Aspergillus spp. osteoarticular infections: an updated systematic review on the diagnosis, treatment and outcomes of 186 confirmed cases

Aspergillus spp. osteoarticular infections are destructive opportunistic infections, while there is no clear consensus on their management. The purpose of this review is to investigate the current literature regarding Aspergillus spp. osteoarticular infections. An electronic search of the PubMed and Scopus databases was conducted considering studies that assessed osteoarticular infections from Aspergillus spp. We included only studies with biopsy proven documentation of positive cultures or histological findings for Aspergillus spp., and those with essential information for each case such as the anatomical location of the infection, the type of treatment (conservative, surgical, combination), the antifungal therapy, and the outcome. Overall, 148 studies from 1965 to 2021 including 186 patients were included in the review. One hundred and seven (57.5%) patients underwent surgical debridement in addition to antifungal therapy, while 79 (42.7%) patients were treated only conservatively. Complete infection resolution was reported in 107 (57.5%) patients, while partial resolution in 29 (15.5%) patients. Surgical debridement resulted in higher complete infection resolution rate compared to only antifungal therapy (70.0% vs. 40.5%, P < 0.001), while complete resolution rate was similar for antifungal monotherapy and combination/sequential therapy (58.3% vs. 54.5%; P = 0.76). Last, complete resolution rate was also similar for monotherapy with amphotericin B (58.1%) and voriconazole (58.6%; P = 0.95). The results of this study indicate that antifungal monotherapy has similar efficacy with combination/sequential therapy, while voriconazole has similar efficacy with amphotericin B. Moreover, surgical debridement of the infected focus results in better outcomes in terms of infection eradication compared to conservative treatment.

LAY SUMMARY

Antifungal monotherapy has similar efficacy with combination/sequential therapy, and voriconazole has similar efficacy with amphotericin B for the treatment of Aspergillus spp. osteoarticular infections, while surgical debridement of the infected focus improves the infection eradication rate.

Spondylodiscitis Caused by Aspergillus Species

Background: Spondylodiscitis caused by Aspergillus spp. is a rare but life-threatening clinical entity. However, a consensus on diagnostic criteria and most effective medical management is still missing. The present study is a review of all published cases of spondylodiscitis caused by Aspergillus spp., in an effort to elucidate epidemiology, patients’ characteristics, andand the medical and surgical treatment options and their effectiveness. Methods: A thorough review of all existing spondylodiscitis cases caused by Aspergillus was performed. Data regarding demographics, responsible fungus, time between symptoms’ onset and firm diagnosis, antifungal treatment (AFT), surgical intervention, andand the infection’s outcome were investigated. Results: A total of 118 Aspergillus spondylodiscitis cases, yielding 119 Aspergillus spp. isolates, were identified in the literature. The patients’ mean age was 40.6 years. Magnetic resonance imaging (MRI) (after its introduction) indicated the diagnosis in most cases (66.7%), while definite diagnosis was established through cultures in the majority of cases (73.7%). Aspergillus fumigatus was isolated in most cases (73; 61.3%), followed by Aspergillus flavus (15; 12.6%) andand Aspergillus nidulans and terreus (7; 5.9%, each). The mean time between symptoms’ onset and diagnosis was 5.7 months. Amphotericin B was the preferred antifungal regiment (84 cases; 71.2%), followed by voriconazole (31; 26.3%), and the mean AFT duration was 6.1 months. The final outcome was successful in 93 cases (78.8%). Furthermore, 77 patients (65.3%) underwent surgery. Conclusions: Spondylodiscitis caused by Aspergillus spp. represents a clinical challenge, requiring a multidisciplinary approach. The present review has shown that prolonged AFT has been the standard of care of the studied cases, while surgical treatment seems to play an important role in selected patents.

The first rare and fatal case of invasive aspergillosis of spinal cord due to Aspergillus nidulans in an Iranian child with chronic granulomatosis disease: review of literature

Background and Purpose:

Invasive aspergillosis (IA) of the central nervous system (CNS) is a devastating complication which is rarely reported in immunocompromised children.

In this case presentation, we reported a rare and fatal IA with spinal cord involvement in a 10-year-old child with X-linked chronic granulomatosis disease (CGD).

Case report:

The child had a previous history of pulmonary tuberculosis. A cervical spine X-ray revealed the involvement of cervical vertebrae (T4/T5) and ribs causing spinal cord compression and epidural abscess. The patient underwent a decompressive laminectomy and mass removal. The histopathology and culture results suggested IA. Despite the aggressive and prolonged therapy, he died within one year. Aspergillus nidulans was identified as the causative agent based on morphological and molecular studies.

Conclusion:

This synopsis represents the aggressive behavior of infection caused by A. nidulans in the CGD patient.

Genetic diversity and antifungal susceptibility patterns of Aspergillus nidulans complex obtained from clinical and environmental sources

The molecular epidemiology and antifungal susceptibility of Aspergillus nidulans species complex has not been well studied. To evaluate the genetic diversity and antifungal susceptibility patterns of clinical and environmental isolates of A. nidulans complex. Sixty clinical and environmental isolates of Aspergillus section Nidulantes were collected from five countries (Iran, The Netherlands, Spain, Portugal and Greece). The species were molecularly identified by sequencing of β-tubulin gene. The genetic diversity of A nidulans complex isolates (n = 54) was determined with a microsatellite genotyping assay. Antifungal susceptibility profile was determined using EUCAST method. The isolates were classified as A nidulans (46.7%), A spinulosporus (26.6%), A quadrilineatus (10%), A pachycristatus (3.3%), A rugulosus (3.3%), A unguis (5%), A creber, (1.7%), A olivicola (1.7%) and A sydowii (1.7%). Thirty-four sequence types (STs) were identified among the 54 A nidulans complex isolates. A high level of genetic diversity was found among A nidulans sensu stricto strains but low diversity was found among A spinulosporus strains. Amphotericin B showed high MICs to all species. The most active azole was posaconazole (GM = 0.64 mg/L), while itraconazole showed the highest MICs among azoles (GM = 2.95 mg/L). A spinulosporus showed higher MICs than A nidulans sensu stricto for all antifungals except for micafungin and anidulafungin. Interspecies variations may result in differences in antifungal susceptibility patterns and challenge antifungal therapy in infections caused by A nidulans. Differences in the distribution of STs or persistence of multiple STs might be related to the sources of isolation and niche specialisation.

Fungal spinal epidural abscess: a case series of nine patients

BACKGROUND CONTEXT

Fungal spinal epidural abscess (FSEA) is a rare entity with high morbidity and mortality. Reports describing the clinical features, diagnosis, treatment, and outcomes of FSEA are scarce in the literature.

PURPOSE

This study aimed to describe the clinical features, diagnosis, treatment, and outcomes of FSEA.

STUDY DESIGN

This study is designed as a retrospective clinical case series.

PATIENT SAMPLE

A continuous series of patients with the diagnosis of FSEA who presented at our institution from 1993 to 2016.

METHODS

We reviewed the electronic medical records of patients with SEA who were treated within our hospital system from 1993 to 2016. We only included SEA cases that were due to fungi. We also reviewed FSEA cases in the English language literature from 1952 to 2017 to analyze the features of FSEA.

RESULTS

From a database of 1,053 SEA patients, we identified 9 patients with FSEA. Aspergillus fumigatus was isolated from 2 (22%) patients, and Candida species were isolated from 7 (78%). Focal spine pain, neurologic deficit, and fever were demonstrated in 89%, 50%, and 44% of FSEA cases, respectively. Five of nine cases involved the thoracic spine, and eight were located anterior to the thecal sac. Three cases had fungemia, six had long symptom duration (>2 weeks) prior to presentation, seven had concurrent immunosuppression, and eight had vertebral osteomyelitis. Additionally, one case had residual motor deficit at last follow-up, one had S1 sensory radicular symptoms, two suffered recurrent FSEA, two died within hospitalization, and two died within 90 days after discharge.

CONCLUSIONS

In summary, the classic diagnostic triad (focal spine pain, neurologic deficit, and fever) is not of great clinical utility for FSEA. Biopsy, intraoperative tissue culture, and blood culture can be used to diagnose FSEA. The most common pathogens of FSEA are Aspergillus and Candida species. Therefore, empiric treatment for FSEA should cover these species while definitive identification is pending. FSEA is found in patients with poor baseline health status, which is the essential reason for its high mortality.

Aspergillus osteomyelitis: epidemiology, clinical manifestations, management, and outcome

BACKGROUND

The epidemiology, pathogenesis, diagnosis, and management of Aspergillus osteomyelitis are not well understood.

METHODS

Protocol-defined cases of Aspergillus osteomyelitis published in the English literature were reviewed for comorbidities, microbiology, mechanisms of infection, clinical manifestations, radiological findings, inflammatory biomarkers, antifungal therapy, and outcome.

RESULTS

Among 180 evaluable patients, 127 (71%) were males. Possible predisposing medical conditions in 103 (57%) included pharmacological immunosuppression, primary immunodeficiency, and neutropenia. Seventy-three others (41%) had prior open fracture, trauma or surgery. Eighty (44%) followed a hematogenous mechanism, 58 (32%) contiguous infections, and 42 (23%) direct inoculation. Aspergillus osteomyelitis was the first manifestation of aspergillosis in 77%. Pain and tenderness were present in 80%. The most frequently infected sites were vertebrae (46%), cranium (23%), ribs (16%), and long bones (13%). Patients with vertebral Aspergillus osteomyelitis had more previous orthopedic surgery (19% vs 0%; P = 0.02), while those with cranial osteomyelitis had more diabetes mellitus (32% vs 8%; P = 0.002) and prior head/neck surgery (12% vs 0%; P = 0.02). Radiologic findings included osteolysis, soft-tissue extension, and uptake on T2-weighted images. Vertebral body Aspergillus osteomyelitis was complicated by spinal-cord compression in 47% and neurological deficits in 41%. Forty-four patients (24%) received only antifungal therapy, while 121 (67%) were managed with surgery and antifungal therapy. Overall mortality was 25%. Median duration of therapy was 90 days (range, 10-772 days). There were fewer relapses in patients managed with surgery plus antifungal therapy in comparison to those managed with antifungal therapy alone (8% vs 30%; P = 0.006).

CONCLUSIONS

Aspergillus osteomyelitis is a debilitating infection affecting both immunocompromised and immunocompetent patients. The most common sites are vertebrae, ribs, and cranium. Based upon this comprehensive review, management of Aspergillus osteomyelitis optimally includes antifungal therapy and selective surgery to avoid relapse and to achieve a complete response.

Aspergillus vertebral osteomyelitis in immunocompetent subjects: case report and review of the literature

Aspergillus spondylodiscitis (AS) is rare in immunocompetent (IC) patients. A 65-year-old diabetic IC male subject presented with cervical AS 18 months after otomycosis. Two serological tests, mastoidectomy and biopsy of the sphenoid bone, were negative. A prevertebral biopsy identified A. flavus. The patient was successfully treated with voriconazole. Forty-three cases of AS in IC patients have been published. A predisposition was found in 84 % of cases. Fever was reported in 20 % of cases, whereas neurological defects were present in 41 %. Serology was inconsistently positive (5/7) and diagnosis was confirmed by biopsy or surgery. A. fumigatus was the most frequently isolated species (74 %). All episodes were medically treated, associated with surgery in 57 % of cases, and 73 % of patients fully recovered. AS must be discussed in IC patients presenting with risk factors, including diabetes mellitus. Biopsy is necessary to confirm diagnosis, since serology offers low sensitivity. Nevertheless, the prognosis is good.

Vertebral osteomyelitis and epidural abscess due to Aspergillus nidulans resulting in spinal cord compression: case report and literature review

Vertebral osteomyelitis caused by Aspergillus nidulans is rare and usually affects immunocompromised patients. This report presents a case of thoracic vertebral osteomyelitis with epidural abscesses due to A. nidulans in a 40-year-old immunocompetent female who presented with back pain, numbness and weakness of both lower limbs. Magnetic resonance imaging demonstrated osteomyelitis involving the thoracic (T)1-T3 vertebral bodies with epidural abscesses, resulting in spinal compression. The patient underwent a decompression laminectomy of T1-T3 and debridement of the thoracic epidural inflammatory granuloma. Histopathology revealed fungal granulomatous inflammation. The patient received 6 mg/kg voriconazole every 12 h (loading dose on day 1) followed by 4 mg/kg voriconazole twice daily for 1 month, administered intravenously. The patient returned with recurrent back pain 16 months after initial presentation. A. nidulans was identified by fungal culture and polymerase chain reaction. The patient showed no evidence of recurrence 1 year after a 6-month course of oral voriconazole. The key to the effective treatment of Aspergillus osteomyelitis is not to excise the abscess, but to administer systemic antifungal drug therapy.

Invasive aspergillosis osteomyelitis in children--a case report and review of the literature

Immunocompromised patients are at high risk of secondary infection associated with high morbidity. In children these complications include fungal osteomyelitis due to continuous infiltration or hematogenous spread. The case of a 4-year-old boy is presented who developed lumbalgia and thigh pain during ongoing chemotherapy for acute lymphatic leukemia. MRI revealed infarct-like lesions in the femur and L5 vertebra, which were biopsied. The histologic diagnosis was consistent with angioinvasive aspergillosis. A multifocal osseous presentation has rarely been described in children and an overview of the literature is presented. Invasive aspergillosis is a rare complication to be considered in children with MRI-detected bony lesions of infarct-like appearance.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

Osteomyelitis due to Aspergillus spp. in patients with chronic granulomatous disease: comparison of Aspergillus nidulans and Aspergillus fumigatus

OBJECTIVE

Chronic granulomatous disease (CGD) is a rare inherited disorder of NADPH oxidase in which phagocytes fail to generate reactive antimicrobial oxidants. Invasive fungal infections are an important cause of morbidity and mortality in CGD patients, with Aspergillus spp. being the most frequent fungal pathogens. We reviewed the reported cases of osteomyelitis in CGD patients due to Aspergillus nidulans and compared them with those due to Aspergillus fumigatus.

METHODS

Twenty-four cases of osteomyelitis due to Aspergillus spp. in 22 male CGD patients were found in MEDLINE.

RESULTS

Fourteen cases (58%) were due to Aspergillus nidulans and ten cases to Aspergillus fumigatus. No other aspergilli were reported as causes of osteomyelitis. Osteomyelitis due to Aspergillus nidulans was associated with pulmonary infection and involved 'small bones' more frequently than Aspergillus fumigatus osteomyelitis (p=0.032). Half of the CGD patients with Aspergillus nidulans osteomyelitis died compared with none of those with Aspergillus fumigatus osteomyelitis (p=0.019). In both Aspergillus nidulans and Aspergillus fumigatus cases, cure was achieved by prompt antifungal treatment combined with surgery and immunotherapy.

CONCLUSION

Aspergillus nidulans causes osteomyelitis in CGD patients relatively frequently compared with Aspergillus fumigatus and may be accompanied by higher mortality. This contrasts with the low frequency with which Aspergillus nidulans causes osteomyelitis in patients with other types of immunodeficiency.

Aspergillus nidulans infection in chronic granulomatous disease

Chronic granulomatous disease (CGD) is a rare inherited disorder of the NADPH oxidase complex in which phagocytes are defective in generating reactive oxidants. As a result, patients with CGD suffer from recurrent bacterial and fungal infections. The most common fungal infections are caused by Aspergillus species. Aspergillus nidulans is a rare pathogen in most patient populations with quantitative or qualitative neutrophil defects. We have reviewed all cases in which A. nidulans was isolated from patients at the National Institutes of Health (Bethesda, MD) between 1976 and 1997. A. nidulans infection occurred in 6 patients with CGD, but was not a pathogen in any other patient group. Aspergillus fumigatus was a more common pathogen in CGD compared with A. nidulans, but A. nidulans was more virulent. A. nidulans was significantly more likely to result in death compared with A. fumigatus, to involve adjacent bone, and to cause disseminated disease. Patients with A. nidulans received longer courses of amphotericin B therapy than patients with A. fumigatus, and were treated with surgery more often. In contrast to A. fumigatus, A. nidulans was generally refractory to intensive antifungal therapy, suggesting that early surgery may be important. These data show that A. nidulans is a distinct pathogen in CGD and its isolation carries more severe implications than that of A. fumigatus.

Virulence studies of Aspergillus nidulans mutants requiring lysine or p-aminobenzoic acid in invasive pulmonary aspergillosis

To identify steps in fungal intermediary metabolism required by Aspergillus spp. during invasive pulmonary aspergillosis, we have developed murine models involving Aspergillus nidulans as the inoculum. The advantages of using A. nidulans over Aspergillus fumigatus or Aspergillus flavus, which are the most common agents of clinical disease, are the well-understood genetics of A. nidulans and a large range of mutants of this species which are affected in a variety of metabolic pathways. Comparison of the virulence of A. nidulans strains carrying mutations which block the biosynthesis of lysine (lysA2) and p-aminobenzoic acid (pabaA1) shows that lysA2 strains have reduced virulence while pabaA1 strains are entirely nonpathogenic. The pathogenicity of pabaA1 strains can be restored by supplementing the drinking water of animals with p-aminobenzoic acid. The results indicate that the availability of lysine in the lung is limited, and p-aminobenzoic acid is probably not available at all. Thus, models of invasive pulmonary aspergillosis involving A. nidulans can be used to identify metabolic pathways that may be essential for the pathogenicity of A. fumigatus, the predominant pathogenic species, suggesting potential new targets for antifungal therapy.

Surgical management of pulmonary infections in chronic granulomatous disease of childhood

Chronic granulomatous disease of childhood is an inheritable disorder of phagocytic cell respiratory burst resulting in recurrent, life-threatening, catalase-positive infections. The lung is the most common site of infection, and pulmonary disease is the primary cause of death in greater than 50% of children with chronic granulomatous disease. Still, the role of surgery in management of this disease remains undefined. Between 1974 and 1990, 19 patients with chronic granulomatous disease required 31 thoracic interventions at our institution. Patients ranged in age from 2.5 to 27 years (mean age, 15 years). Seventeen of 19 patients (89%) had had previous pulmonary infections. Patients presented as toxic (temperature > 38.5 degrees C, chest pain, and cough) in 22 instances before the 31 procedures. Aggressive surgical intervention for diagnosis and extirpation of localized infections was undertaken with lobectomy/pneumonectomy with or without other procedures (5), bisegmentectomy (2), segmentectomy with or without other procedures (5), or wedge with or without other procedures (13). In five instances, an empyema was drained; a chest tube for a sterile collection was placed in one instance. There was one intraoperative death, and 3 patients died 22 to 600 days postoperatively with overwhelming sepsis. The mean hospitalization was 101 days (range, 24 to 600 days). Wound complications occurred in 5 patients, requiring 17 separate anesthetic debridements. A change in therapy was dictated by the results of the procedure in 23 of 31 instances (74%). Thoracic surgeons must be aware of this rare cause of immunosuppression in these children and, due to the unusual nature of the pulmonary infections, should follow an aggressive approach in their diagnosis and management.

Aspergillus quadrilineatus, a new causative agent of fungal sinusitis

Aspergillus quadrilineatus was found to be the etiologic agent of pansinusitis in a patient suffering from acute nonlymphoblastic leukemia and who had undergone allogeneic bone marrow transplantation. A. quadrilineatus was cultured from biopsy specimens of the maxillary sinus, and tissue sections with fungal stains showed a necrotic area containing dichotomously branching septate hyphae, which is morphologically consistent with Aspergillus species. The patient was successfully treated with a combination of surgical debridement, granulocyte transfusions, and intravenous administration of amphotericin B-cholesterol sulfate colloidal dispersion. This is the first report of an infection caused by A. quadrilineatus.

Aspergillus epidural abscess and cord compression in a patient with aspergilloma and empyema. Survival and response to high dose systemic amphotericin therapy

A 57-yr-old man with a chronic lung cavity presumed to be related to ankylosing spondylitis and/or old cavitary tuberculosis presented with hemoptysis and rapidly developed lower extremity paresis and hypoesthesia. On chest radiograph he had a left upper lobe lesion suggestive of aspergilloma combined with a large left empyema with bronchopleural fistula. Serologic analysis demonstrated precipitins and very high titer IgG antibodies to Aspergillus fumigatus antigens. Decompressive laminectomy from T1 to T5 was performed, with drainage of A. fumigatus culture-positive material from an epidural abscess compressing the spinal cord. Chest drainage was required for control of the empyema. With a total course of 3 g of intravenously administered amphotericin B, rehabilitative therapy, and chronic empyema drainage, he is now at home and ambulatory with assistance. He is also being followed by regular serum assays of IgG antibodies to Aspergillus proteins. We report the case of an apparent long-term survivor of a formerly lethal and/or nonreversible paraplegic condition. The critical factors compared with previous cases with a poor outcome would appear to be prompt neurosurgical intervention, restoration of a normal number of T-cells, effective long-term chest drainage, and high dose amphotericin treatment.

Chronic granulomatous disease with cranial fungal osteomyelitis and epidural abscess. Case report

A patient is described with osteomyelitis of the cranium and epidural abscess due to Aspergillus fumigatus as the presenting manifestations of chronic granulomatous disease. The diagnosis was suggested by the unusual nature of the organism isolated and confirmed by appropriate laboratory studies. The details of diagnostic assessment and therapeutic management are discussed, and the central nervous system manifestations of chronic granulomatous disease are reviewed.

Aspergillus osteomyelitis. Report of a case and review of the literature

Aspergillus is a ubiquitous saprophytic fungus seldom pathogenic for normal hosts. Aspergillus osteomyelitis occurs infrequently and is typically limited to patients with predisposing factors, including leukocyte dysfunction, malignancy with neutropenia, steroid or antibiotic therapy, pulmonary aspergillosis, and surgical manipulation. The spine is most frequently affected, and the clinical presentation is nonspecific (50% afebrile). Diagnosis requires demonstration of characteristic, acutely branching, broad, septate hyphae in biopsy material, and culture of Aspergillus. Therapy includes debridement of necrotic bone and loculated purulence combined with amphotericin B and possibly 5-fluorocytosine or rifampin.

Epidural abscess, vertebral destruction, and paraplegia caused by extending infection from an aspergilloma

An aspergilloma developed in a lung cyst in a 53-year-old man. Aspergillus infection then contiguously spread to the epidural space, causing an abscess, vertebral destruction, and paraplegia at the level of T4. Chronic alcoholism, liver cirrhosis, and corticosteroid treatment may have been predisposing factors in this patient. Although Aspergillus epidural abscess has been described infrequently, this complication has not been described in association with an aspergilloma. Symptoms, signs, or roentgenographic or laboratory findings suggestive of vertebral or meningeal pathologic lesions in patients with aspergilloma should alert the physician to the possibility of contiguous spread of infection.

Aspergillus osteomyelitis. Report of four cases and review of the literature

Four cases of Aspergillus osteomyelitis are presented and the world literature is reviewed, for a total of 19 cases. Aspergillus osteomyelitis is largely a disease of immunosuppressed hosts, although wound and other infections in "normal" hosts are seen. In children, contiguous spread from an adjacent pulmonary infection is most common, whereas in adults hematogenous spread is the rule. The survival rate in immunocompromised patients is poor, whereas the cure rate is uniform in "normal" hosts. A combined medical-surgical therapeutic approach has been used most often and seems appropriate.

Invasive aspergillosis of the hand

Aspergillosis is a fungal infection which may disseminate from the lung to bone, meninges, heart, or other organs. It is commonly found in patients with debilitating disease and those undergoing chemotherapy. A 6-year-old boy, seen at Fitzsimons Army Medical Center while being treated for acute monomyelocytic leukemia, developed invasive aspergillosis of the hand, requiring resection of the central three rays. This rare presentation of the disease required radical surgery to control its local manifestations and to prevent widespread dissemination.

Virulence genetics of Aspergillus nidulans Eidam: a review

Studies of the influence of genotypic alterations on the murine virulence of Aspergillus nidulans Eidam are reviewed to emphasize the potential of this fungus for genetic studies of virulence.

Recognition and successful management in pulmonary aspergillosis in leukemia

Invasive pulmonary aspergillosis is a common fungal infection in the compromised host. The outcome has been generally poor and, until recently, most reports are derived from autopsy series. We report nine patients with leukemia and the characteristic clinical presentation of pulmonary infarction. There is histological evidence that infarction is due to fungal invasion of the pulmonary arterial system with distal hemorrhagic infarction, cavitation, and mycetoma formation. This complete evolution was detected in six patients, none of whom had previous cavitary pulmonary disease. Therapy included amphotericin B (9 patients), aerosolized nystatin (6 patients), and 5-fluorocytosine (5 patients). Complete resolution of the pulmonary lesions occurred in six patients with a subsequent median survival of 13.5 months (range: 5-32+ months). Three patients died with continuing pulmonary infiltrate. Despite the antifungal chemotherapy, resolution seemed to correlate best with recovery of circulating neutrophils.

Aspergillosis presenting as spinal cord compression. Case report

✓ A case of pulmonary aspergillosis resembling bronchogenic carcinoma with extension to the thoracic vertebrae is presented. Therapy is discussed and the need for awareness of this potentially fatal infection stressed.

Pulmonary aspergillosis. A survey of its occurrence in patients with chronic lung disease and a discussion of the significance of diagnostic tests

The occurrence of pulmonary aspergillosis and of precipitins, positive skin tests, and sputum containing abundant Aspergillus fumigatus has been assessed and correlated in a survey of 107 consecutive patients attending hospital in Bristol with various chronic chest diseases. The series included three with aspergilloma, five with allergic aspergillosis, and one with chronic invasive aspergillosis. Of 46 asthmatic patients, 11% had definite and 22% had probable or definite allergic aspergillosis.

Seven patients (15%) in the asthmatic group were found to have chronic upper lobe contraction, probably attributable to long-standing allergic aspergillosis. One of these patients developed aspergilloma, and another, invasive aspergillosis.

The significance of precipitins is discussed, based on the survey patients together with 21 additional patients who had aspergillosis but were from outside the survey. In the survey patients without definite aspergillosis, precipitins and positive sputum were significantly associated and were found most commonly in patients with asthma, bronchiectasis, or cavitated lungs. Two patients with invasive aspergillosis who had weak precipitins are reported. We think that precipitins reflect recent or continuing fungal growth in body tissues or within damaged bronchi, and that their presence can be a useful indication of occult fungal colonization, which might rarely become invasive if host resistance were lowered as by steroids.

Allergic aspergillosis is a more common condition and a more frequent cause of upper lobe damage than has been appreciated.