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A rare case of angioinvasive aspergillosis aortic graft infection causing peripheral thromboembolism. J Vasc Surg Cases Innov Tech 2022; 9:101069. [PMID: 36852322 PMCID: PMC9958056 DOI: 10.1016/j.jvscit.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022] Open
Abstract
Angioinvasive aspergillosis is a fungal infection that rarely involves vascular grafts. This case illustrates a patient with a history of aortic arch Dacron graft reconstruction presenting with acute bilateral lower extremity ischemia. The patient underwent emergent open thromboembolectomy. The intraluminal contents had an atypical appearance for thromboembolism, and histologic examination was consistent with aspergillosis. Cardiac computed tomography and transesophageal echocardiography showed an aortic arch graft vegetation. Aortic graft excision and reconstruction were performed for control of the fungal source. Investigation into the etiology of thromboembolism should include consideration for septic emboli in patients with indwelling vascular grafts. When suspected, graft excision should be considered for definitive management.
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Giammarino AT, Sarmiento IC, Scheinerman SJ, Winalski J, Lazzaro RS, Brinster DR, Hemli JM. Robotic-assisted closed-chest management of a fungal-infected prosthetic aortic graft: a case report. J Med Case Rep 2022; 16:186. [PMID: 35534872 PMCID: PMC9087969 DOI: 10.1186/s13256-022-03380-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background Fungal prosthetic graft infections are associated with high mortality, typically requiring aggressive surgical debridement. We present an alternative, minimally invasive approach to address these challenging clinical cases. Case presentation A 76-year-old Caucasian male with prior aortic root and arch replacement presented with localized chest wall tenderness after being hit by a car door. Computed tomography angiogram incidentally identified fluid in the anterior mediastinum, surrounding his ascending aortic graft. Rather than undertaking a high-risk reoperative sternotomy and redo complex aortic reconstruction, we elected to proceed with a robotic-assisted, minimally invasive debridement of the aortic graft, coupled with an omental wrap, entirely within the closed chest. Microbiology was positive for Aspergillus species. The patient made an uncomplicated recovery and was discharged home on antifungal therapy, likely to continue indefinitely. Conclusions Infected prosthetic aortic grafts can be successfully managed with debridement and pedicled omental flap coverage via a minimally invasive approach within the closed chest, obviating the morbidity of a complex reoperative open procedure.
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Affiliation(s)
| | - Iam Claire Sarmiento
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - SJacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - John Winalski
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - Richard S Lazzaro
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA
| | - Jonathan M Hemli
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, 130 East 77th Street, 4th floor, New York, NY, 10075, USA.
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Tano A, Kato K, Seike Y, Matsuda H, Suzue T, Kaneko Y, Kodama M, Sawayama Y, Miyamoto A, Yagi N, Nakagawa Y. Case report: Vascular graft infection due to Aspergillus species presenting with recurrent vascular occlusion. BMC Cardiovasc Disord 2022; 22:138. [PMID: 35365071 PMCID: PMC8974158 DOI: 10.1186/s12872-022-02571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background An aortic graft implantation is an effective therapeutic method for various aortic diseases. However, it is known that sometimes these implanted grafts can be the foci of infections. Here we report a rare case of graft infection that presented multiple embolisms of aortic branches and peripheral organs. Case presentation A 63-year-old Japanese woman with a history of aortic graft implantation presented with occlusions of large arteries in different loci and time points, with elevation of non-specific inflammatory markers. Thoracic contrast-computed tomography (CT) captured vegetation in the descending aortic graft and the [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) showed accumulation of FDG in the same site, suggesting a graft infection. Despite all these suspicious findings, repeated blood culture examinations never detected any microorganisms. A diagnosis of Aspergillus graft infection was made based on an elevated serum β-D glucan (βDG) and a positive Aspergillus galactomannan (GM) antigen test. The patient subsequently had surgery with replacement of the descending aortic graft and anti-fungal drugs were instituted with significant improvement noted. Conclusion In the present case, the patient’s specific feature in the anatomical vascular construction, past operation, and basal fundamental diseases collaboratively contributed to the pathogenesis of the present infection. It is important to recognize the risk of graft infection and conduct imaging studies when indicative symptoms emerge. The negativity in blood culture studies often makes detection of pathogenic microbes extremely difficult. This case suggests that non-cultural tests such as bDG and GM can be useful for diagnosis and starting appropriate anti-fungal drugs in the early stages.
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Affiliation(s)
- Ayami Tano
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Koichi Kato
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan.
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Suzue
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yoshihiro Kaneko
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Misato Kodama
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yuichi Sawayama
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Akashi Miyamoto
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Noriaki Yagi
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
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Moya-Sánchez E, Ruiz-Carazo E. Aspergillus flavus infection in an aortic graft: Imaging findings. RADIOLOGIA 2017; 60:175-176. [PMID: 29029758 DOI: 10.1016/j.rx.2017.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/19/2017] [Accepted: 09/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- E Moya-Sánchez
- Complejo Hospitalario Universitario Granada, Granada, España.
| | - E Ruiz-Carazo
- Complejo Hospitalario Universitario Granada, Granada, España
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Zosimas D, Abukar A, Srilekha A. A rare case of peripheral vascular graft infection by Aspergillus fumigatus and review of the literature. Ann R Coll Surg Engl 2016; 99:e34-e35. [PMID: 27659379 DOI: 10.1308/rcsann.2016.0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We present an unusual case of a 74-year-old woman who presented with a pseudoaneurysm at the site of a previous prosthetic femoro-popliteal bypass graft and underwent an urgent repair with pseudoaneurysm excision and extra-anatomic placement of an autologous venous graft. Microbiology examination revealed Aspergillus fumigatus infection of the graft, which is a very rare condition. Long-term antifungal medication has been administrated with positive outcome. Only a few cases have been reported in literature, mainly involving aortic grafts. Most patients are immunocompetent and with late presentation. Successful outcome can only be achieved with long-term antifungal treatment and extra-anatomic replacement of the graft.
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Affiliation(s)
- D Zosimas
- General Surgical Department, Queen's Hospital, Romford , Essex , UK
| | - A Abukar
- General Surgical Department, Queen's Hospital, Romford , Essex , UK
| | - A Srilekha
- General Surgical Department, Queen's Hospital, Romford , Essex , UK
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Liu HC, Lu MC, Lin YC, Lai YC, Jan MS, Lin WL, Chen CM. Aortic graft infection caused by invasive pulmonary aspergillosis. Surg Infect (Larchmt) 2015; 16:112-3. [PMID: 25761085 DOI: 10.1089/sur.2014.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hsu-Chung Liu
- 1 Division of Chest Medicine, Department of Internal Medicine, Cheng Ching Hospital , Taichung City, Taiwan, Republic of China
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Perdomo J, Yuh DD, Bonde P. Aspergillus Pseudoaneurysm Post Aortic Valve Replacement. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2014; 2:196-9. [PMID: 26798740 DOI: 10.12945/j.aorta.2014.14-025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 08/04/2014] [Indexed: 11/18/2022]
Abstract
Thoracic aortic mycotic aneurysms caused by Aspergillus fumigatus postoperatively are rare and devastating complications. These cases are usually attributed to intraoperative contamination of surgical equipment. We present a patient who had an ascending aortic mycotic aneurysm 20 weeks post aortic valve replacement. A high index of suspicion allowed for diagnosis and prompt treatment, although the patient presented in an unusual manner. Treatment included both medical and surgical therapy to minimize morbidity and mortality. Despite treatment our patient suffered long-lasting consequences due to the aggressive nature of the disease. Cases presented in the literature and this experience show that a high index of suspicion must be maintained in such patients regardless of immune status and postoperative interval, in order to avoid long-lasting sequelae.
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Affiliation(s)
- Joel Perdomo
- Bonde Artificial Heart Laboratory, Center for Advanced Heart Failure and Transplantation, Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA; and
| | - David D Yuh
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Pramod Bonde
- Bonde Artificial Heart Laboratory, Center for Advanced Heart Failure and Transplantation, Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA; and
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Ferrero E, Ferri M, Viazzo A, Trevisan A, Psacharopulo D, Ripepi M, Gibello L, Nessi F. Fungal infection of aortic Endograft because of Aspergillus fumigatus. Ann Vasc Surg 2014; 28:1795.e11-4. [PMID: 24858585 DOI: 10.1016/j.avsg.2014.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 04/01/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
Abstract
A 59-year-old male, referred to our center with a ruptured aortic aneurysm, underwent urgent endovascular repair and femoro-femoral crossover bypass. An endograft infection because of Aspergillus fumigatus occurred about 20 days after surgery. We removed the endograft and femoral prosthesis and we then performed an aorto-bi-iliac bypass with autogenous reversed superficial femoral veins. Five days after surgery, the patient died. Microbiological examination and postmortem examination showed the presence of A. fumigatus in femoral prosthesis, aortic wall, and periaortic exudate.
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Affiliation(s)
- Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy.
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Andrea Viazzo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Alessandra Trevisan
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Daniele Psacharopulo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Matteo Ripepi
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Lorenzo Gibello
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Franco Nessi
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
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Mixed infection of an atypical Mycobacterium and Aspergillus following a cryopreserved fat graft to a face. J Craniofac Surg 2013; 24:1676-8. [PMID: 24036751 DOI: 10.1097/scs.0b013e31828f27ee] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report a chronic infection of a patient who received a cryopreserved fat graft on her face. A 22-year-old female patient presented with multiple abscesses of her face. Four months previously, she received a second fat graft with the fat harvested at a previous surgery which was cryopreserved for 2 months. On examination, she had tender erythematous nodules on both cheeks. A computed tomography of her neck showed multiple peripheral enhancing nodular lesions. In an open pus fungus culture, Aspergillus fumigatus growth was observed. On the Mycobacterium Other Than Tuberculosis identification PCR, Mycobacterium fortuitum was found. She was treated with levofloxacin, clarithromycin, and minocycline for 11 months, and finally the symptoms subsided. To avoid infection after the fat graft, cryopreserved fat should not be used as a possible grafting material. In cases of persistent infection, or in cases of waxes and gains after drainage of pus and short-term antibiotics therapy, atypical Mycobacterium or Aspergillus should be suspected and a PCR for them should be carried out.
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Early fungal infection in an aortic prosthesis with probable cerebral metastasis: the success of a conservative strategy. Clin Drug Investig 2013; 33 Suppl 1:S41-5. [PMID: 23381984 DOI: 10.1007/s40261-012-0020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Infection of an aortic prosthesis presents a diagnostic and therapeutic challenge. Fungal infections are rarely described and among these Candida spp. are the most prevalent agents. Although the therapeutic approach to prosthetic bacterial infection may be conservative, in the case of fungal etiology, surgery, such as the removal and substitution of the device, debridement and repair of the infected prosthesis is usually warranted. The authors describe the case of a 48-year-old man, with a thoraco-abdominal aneurysm of the aorta, submitted to surgery for insertion of a prosthetic aortic duct. The procedure was made difficult by Candida albicans empyema associated with an aortic prosthesis infection that was complicated by probable cerebral metastasis. Antifungal therapy was the initial option, as the steady clinical, laboratory and radiological improvement deferred a surgical intervention. This case demonstrates the success of a conservative approach in a very serious fungal infection of a thoraco-abdominal aorta prosthesis.
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Oyama J, Zhou L, Mehta SA, Laury AR, Tsakonas JS, Laks H, Honda HM, Yang EH. Aspergillus fumigatus vegetation of a prosthetic aortic root graft with mycotic aneurysm and subarachnoid hemorrhage. Int J Infect Dis 2013; 17:e773-6. [PMID: 23312824 DOI: 10.1016/j.ijid.2012.11.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 11/23/2012] [Accepted: 11/29/2012] [Indexed: 10/27/2022] Open
Abstract
A 58-year-old woman with a history of Bentall aortic graft and bioprosthetic aortic valve replacement 3 months prior to admission, presented with headache and fever. Imaging yielded a large obstructive filling defect in the ascending aorta, a subarachnoid hemorrhage, and a mycotic aneurysm. Intraoperative specimens grew Aspergillus fumigatus, and despite aggressive measures the patient died. Aspergillus infections of prosthetic vascular grafts are rare surgical complications and are difficult to diagnose given the low incidence of positive microbiology cultures and the long median time between surgery and diagnosis. Treatment has consisted of antifungal and surgical treatment, although mortality remains high.
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Affiliation(s)
- Jared Oyama
- Division of Cardiology, Department of Medicine, UCLA Cardiovascular Center, University of California at Los Angeles Medical Center, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095, USA
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12
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Calcaterra D, Bashir M, Gailey MP. Ascending aortic graft thrombosis and diffuse embolization from early endoluminal Aspergillus infection. Ann Thorac Surg 2012; 94:1337-9. [PMID: 23006693 DOI: 10.1016/j.athoracsur.2012.02.099] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 01/25/2012] [Accepted: 02/20/2012] [Indexed: 10/27/2022]
Abstract
We present a 43-year-old man who underwent emergent replacement of the ascending aorta for type A dissection and hemiarch reconstruction with a 28-mm prosthetic graft. Dramatic neurologic symptoms, renal failure, and bowel ischemia developed on postoperative day 5. A computed tomography scan showed a large floating thrombus in the ascending aortic graft and massive peripheral embolization throughout the body.
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Affiliation(s)
- Domenico Calcaterra
- Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242-1062, USA.
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Barros M, Lozano F, Gomez–Zancajo R, Torres J. True mycotic false aneurysm due to aspergillus: Three lesions in two cases and literature review. Int J Angiol 2011. [DOI: 10.1007/s00547-005-1093-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Abstract
While invasive aspergillosis occurs typically in severely immunocompromised patients, cases of surgical site infection have been reported in immunocompetent individuals. The Medline, LILACS and EMBASE databases were searched for descriptions of cases of post-operative aspergillosis, and references from relevant articles and conference abstracts were reviewed. More than 500 cases of post-operative aspergillosis were found. Cardiac surgery (n = 188), ophthalmological surgery (n > 90) and dental surgery (n > 100) were associated with the majority of cases. Other cases involved wound infections (n = 22), bronchial infections (n = 30), mediastinitis (n = 11), pleural aspergillosis (n = 1), infections following orthopaedic surgery (n = 42), vascular prosthetic surgery (n = 22), breast surgery (n = 5), abdominal surgery (n = 10) and neurosurgery (n = 25). In most patients, the source was presumed to be airborne infection during the surgical procedure. Prevention of these infections requires special care of the ventilation system in the operating room. Successful treatment requires rapid diagnosis, surgical debridement and antifungal therapy, often with voriconazole. In order to improve the outcome, better diagnostic methods are needed, particularly for cases of endocarditis and aortitis.
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Affiliation(s)
- A C Pasqualotto
- School of Medicine, The University of Manchester and Wythenshawe Hospital, Manchester, UK
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Paterson DL. New clinical presentations of invasive aspergillosis in non-conventional hosts. Clin Microbiol Infect 2004; 10 Suppl 1:24-30. [PMID: 14748800 DOI: 10.1111/j.1470-9465.2004.00840.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Infections by Aspergillus spp. are most typically associated with invasive pulmonary aspergillosis. However, an increasing number of reports deal with unusual manifestations of invasive aspergillosis. In the lung this may take the form of chronic invasive pulmonary aspergillosis, bronchocentric granulomatosis or tracehobronchitis. A number of extrapulmonary infections have been noted, sometimes in immunocompetent individuals. Examples include vertebral osteomyelitis, primary cutaneous aspergillosis (such as in premature neonates), prosthetic vascular graft infection and infective endocarditis. Early recognition of these entities, prompt initiation of new, highly active antifungal therapies and adjunctive surgical management may improve the prognosis of these conditions.
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Affiliation(s)
- D L Paterson
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Suite 3A, Falk Medical Building, Pittsburgh, PA 15213, USA.
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