The histological spectrum of chronic necrotizing forms of pulmonary aspergillosis

Imaging Spectrum in Chronic Pulmonary Aspergillosis

Chronic pulmonary aspergillosis (CPA) is a life-threatening respiratory fungal infection that is almost exclusively seen in patients with preexisting structural lung disease with no or mild immunosuppression. The clinical presentation and imaging findings are varied and often pose a diagnostic challenge; and the disease is often present for a long time before being correctly diagnosed. High-resolution chest computed tomography is the imaging modality of choice because it helps identify various forms of CPA, which can range from a simple aspergilloma and chronic cavitary form, to the subacute invasive and end-stage fibrotic form. The knowledge of the imaging features of this disease cannot be overemphasized because it can assist the clinician in reaching at an early diagnosis and timely initiation of appropriate antifungal therapy, thereby improving patient management and treatment outcome. Moreover, imaging also plays a pivotal role during follow-up in patients of CPA to assess the treatment response. In the current review, we present an illustrative review of radiologic patterns seen in various forms of CPA.

Granulomatous fungal and non-tuberculous mycobacterial infestation complicating chronic lung disease: Outcomes in patients undergoing lung transplantation

INTRODUCTION

Granulomatous infections are common in patients with chronic lung disease. We aim to study the incidence and clinicopathological features of granulomatous infections in a cohort of patients undergoing lung transplantation for end-stage chronic lung disease.

METHODS

Pathology reports of 50 explanted native lungs of patients who underwent lung transplantation since 2015 at our institution were reviewed. Four cases with granulomatous lesions were identified. Correlation was made with clinical findings in the 4 cases.

RESULTS

The granulomatous infections include non-necrotizing cryptococcal pneumonitis (case 1), necrotizing pneumonia due to Scedosporium sp. and Mycobacterium avium Complex (MAC) (Cases 2 and 3), and invasive Aspergillus pneumonia (Case 4). One patient received pre-transplant fungal prophylaxis (Case 4). Post-transplant infectious complications included invasive (Cases 2 and 4) and non-invasive (Case 1) fungal infections and bacterial pneumonia (Cases 1 and 2). Two patients (Cases 3 and 4) developed acute cellular rejection (ACR) in the first 30 days. The third patient (Case 1) was identified with ACR in the 9 months post-transplant and chronic lung allograft dysfunction at 29 months. In terms of mortality, 1 patient (Case 1) died at 30 months post-transplant from pseudomonal sepsis and chronic graft failure. Two patients with invasive fungal infections (Cases 2 and 4) are on secondary prophylaxis and doing well. One patient (Case 3) remains infection-free and on MAC prophylaxis.

CONCLUSIONS

In our case series, patients with chronic lung diseases with superimposed granulomatous infestations frequently experienced post-transplant complications. These include invasive infections and repeat ACRs that predispose patients to chronic graft dysfunction. Pre- and post-transplant antifungal prophylaxis reduces fungal load and complication risk post-transplant.

A Collaborative Tale of Diagnosing and Treating Chronic Pulmonary Aspergillosis, from the Perspectives of Clinical Microbiologists, Surgical Pathologists, and Infectious Disease Clinicians

Chronic pulmonary aspergillosis (CPA) refers to a spectrum of Aspergillus-mediated disease that is associated with high morbidity and mortality, with its true prevalence vastly underestimated. The diagnosis of CPA includes characteristic radiographical findings in conjunction with persistent and systemic symptoms present for at least three months, and evidence of Aspergillus infection. Traditionally, Aspergillus infection has been confirmed through histopathology and microbiological studies, including fungal culture and serology, but these methodologies have limitations that are discussed in this review. The treatment of CPA requires an individualized approach and consideration of both medical and surgical options. Most Aspergillus species are considered susceptible to mold-active triazoles, echinocandins, and amphotericin B; however, antifungal resistance is emerging and well documented, demonstrating the need for novel therapies and antifungal susceptibility testing that correlates with clinical response. Here, we describe the clinical presentation, diagnosis, and treatment of CPA, with an emphasis on the strengths and pitfalls of diagnostic and treatment approaches, as well as future directions, including whole genome sequencing and metagenomic sequencing. The advancement of molecular technology enables rapid and precise species level identification, and the determination of molecular mechanisms of resistance, bridging the clinical infectious disease, anatomical pathology, microbiology, and molecular biology disciplines.

Infectious Lung Disease

Infectious diseases are one of the main causes of morbidity and mortality worldwide. With new pathogens continuously emerging, known infectious diseases reemerging, increasing microbial resistance to antimicrobial agents, global environmental change, ease of world travel, and an increasing immunosuppressed population, recognition of infectious diseases plays an ever-important role in surgical pathology. This becomes particularly significant in cases where infectious disease is not suspected clinically and the initial diagnostic workup fails to include samples for culture. As such, it is not uncommon that a lung biopsy becomes the only material available in the diagnostic process of an infectious disease. Once the infectious nature of the pathological process is established, careful search for the causative agent is advised. This can often be achieved by examination of the hematoxylin and eosin-stained sections alone as many organisms or their cytopathic effects are visible on routine staining. However, ancillary studies such as histochemical stains, immunohistochemistry, in situ hybridization, or molecular techniques may be needed to identify the organism in tissue sections or for further characterization, such as speciation.

Recent Advances in Diagnosing Chronic Pulmonary Aspergillosis

Purpose: The diagnosis of chronic pulmonary aspergillosis (CPA) is occasionally complicated due to poor sensitivity of mycological culture and colonization of Aspergillus species in the airway. Several diagnostic methods have been developed for the diagnosis of invasive pulmonary aspergillosis; however, their interpretation and significance are different in CPA. This study aimed to review the recent advances in diagnostic methods and their characteristics in the diagnosis of CPA.

Recent findings: Radiological findings of lung, histopathology, and culture are the gold standard of CPA diagnosis. Serodiagnosis methods involving the use of galactomannan and β-D-glucan have low sensitivity and specificity. An Aspergillus-specific IgG antibody assay showed good performance and had better sensitivity and reproducibility than conventional precipitant antibody assays. Currently, it is the most reliable method for diagnosing CPA caused by Aspergillus fumigatus, but evidence on its effectiveness in diagnosing CPA caused by non-fumigatus Aspergillus is lacking. Newly developed lateral flow device Aspergillus and detection of volatile organic compounds in breath have potential, but evidence on its effectiveness in diagnosing CPA is lacking. The increasing prevalence of azole-resistant A. fumigatus strains has become a threat to public health. Some of the azole-resistant-related genes can be detected directly from clinical samples using a commercially available kit. However, its clinical efficacy for routine use remains unclear, since resistance-related genes greatly differ among regions and countries.

Conclusion: Several issues surrounding the diagnosis of CPA remain unclear. Hence, further investigations and clinical studies are needed to improve the accuracy and efficiency of CPA diagnosis.

The scab-like sign: A CT finding indicative of haemoptysis in patients with chronic pulmonary aspergillosis?

OBJECTIVES

The aim of this study was to assess the CT findings that characterise haemoptysis in patients with chronic pulmonary aspergillosis (CPA).

METHODS

We retrospectively identified 120 consecutive patients with CPA (84 men and 36 women, 17-89 years of age, mean age 68.4 years) who had undergone a total of 829 CT examinations between January 2007 and February 2017. In the 11 patients who underwent surgical resection, CT images were compared with the pathological results.

RESULTS

The scab-like sign was seen on 142 of the 829 CT scans, specifically, in 87 of the 90 CT scans for haemoptysis and in 55 of the 739 CT scans obtained during therapy evaluation. In 48 of those 55 patients, haemoptysis occurred within 55 days (mean 12.0 days) after the CT scan. In the 687 CT scans with no scab-like sign, there were only three instances of subsequent haemoptysis in the respective patients over the following 6 months. Patients with and without scab-like sign differed significantly in the frequency of haemoptysis occurring after a CT scan (p<0.0001). Pathologically, the scab-like sign corresponded to a fibrinopurulent mass or blood crust.

CONCLUSIONS

The scab-like sign should be considered as a CT finding indicative of haemoptysis.

KEY POINTS

• Haemoptysis is commonly found in patients with CPA. • A CT finding indicative of haemoptysis in CPA patients is described. • Scab-like sign may identify CPA patients at higher risk of haemoptysis.

Lung Infections

A review of pulmonary infections of all types with diagnostic and morphological features.

Chronic Pulmonary Aspergillosis-Where Are We? and Where Are We Going?

Chronic pulmonary aspergillosis (CPA) is estimated to affect 3 million people worldwide making it an under recognised, but significant health problem across the globe, conferring significant morbidity and mortality. With variable disease forms, high levels of associated respiratory co-morbidity, limited therapeutic options and prolonged treatment strategies, CPA is a challenging disease for both patients and healthcare professionals. CPA can mimic smear-negative tuberculosis (TB), pulmonary histoplasmosis or coccidioidomycosis. Cultures for Aspergillus are usually negative, however, the detection of Aspergillus IgG is a simple and sensitive test widely used in diagnosis. When a fungal ball/aspergilloma is visible radiologically, the diagnosis has been made late. Sometimes weight loss and fatigue are predominant symptoms; pyrexia is rare. Despite the efforts of the mycology community, and significant strides being taken in optimising the care of these patients, much remains to be learnt about this patient population, the disease itself and the best use of available therapies, with the development of new therapies being a key priority. Here, current knowledge and practices are reviewed, and areas of research priority highlighted.

Histological study of chronic pulmonary aspergillosis

Background

Chronic pulmonary aspergillosis (CPA) has been accepted the criteria for the diagnosis of pulmonary Aspergillus infection. Whereas, either pathophysiology or signs of CPA remains still controversial.

Methods

In this study, we histopathologically investigated 25 specimens of CPA, surgically resected.

Results

21 (84 %) of that comprised male. There were 21 cases with mild impairment of the immune system and/or a scar mostly due to old tuberculosis. There is a tendency for a negative correlation between peripheral blood white cell numbers and value level of beta-(1,3)-D-glucan. Four cases showed a granular fluorescent signal in granulation tissue surrounding the cavity without the fungal aspects itself.

Conclusions

In conclusion, acute inflammatory exudate along the terminal respiratory tract is most significant pathophysiolocial complication of the CPA, caused to organizing pneumonia, which derives fatal respiratory failure. In addition, the viability of fungus does not concern extension of exudative inflammation at the site of erosion along terminal airway.

[Pathogenesis of chronic necrotizing pulmonary aspergillosis]

Chronic necrotizing pulmonary aspergillosis (CNPA) is a slowly progressive inflammatory destruction of lung tissue due to Aspergillus infection. The main radiographic features are chronic pulmonary infiltrates, progressive cavitation, and subsequent aspergilloma formation. Although pre-existing cavity is not seen, the presence of pre-existing airspaces such as emphysematous bullae, cannot be excluded. Chronic cavitary pulmonary aspergillosis (CCPA), which is synonymous with complex aspergilloma, shows one or more pre-existing and / or newly formed pulmonary cavities that may or may not contain an aspergilloma, and cavity expansion and / or increasing pericavitary infiltrates. CNPA can be distinguished from CCPA by careful observation of progression of the cavitary lesion if a series of adequate radiography films are available. In some cases, however, it is difficult to distinguish the two subtypes if prior radiographs are not available Aiso, intermediate or overlapping types may exist. We therefore clinically and therapeutically proposed the syndrome including both CNPA and CCPA as chronic progressive pulmonary aspergillosis (CPPA).

Chronic Aspergillosis of the Lungs: Unravelling the Terminology and Radiology

The propensity for Aspergillus spp. to cause lung disease has long been recognised but the satisfactory classification of these disorders is challenging. The problems caused by invasive disease in severely neutropenic patients, saprophytic infection of pre-existing fibrotic cavities and allergic reactions to Aspergillus are well documented. In contrast, a more chronic form of Aspergillus-related lung disease that has the potential to cause significant morbidity and mortality is under-reported. The symptoms of this form of Aspergillus infection may be non-specific and the radiologist may be the first to suspect a diagnosis of chronic pulmonary aspergillosis. The current review considers the classification conundrums in diseases caused by Aspergillus spp. and discusses the typical clinical and radiological profile of patients with chronic pulmonary aspergillosis.

KEY POINTS

• The classification of Aspergillus -related lung disease is mired in confusion. • The chronic form of Aspergillus infection is associated with significant morbidity and mortality. • Progressive consolidation and cavitation with intracavitary material is the radiological hallmark.

Eosinophil deficiency compromises lung defense against Aspergillus fumigatus

Exposure to the mold Aspergillus fumigatus may result in allergic bronchopulmonary aspergillosis, chronic necrotizing pulmonary aspergillosis, or invasive aspergillosis (IA), depending on the host's immune status. Neutrophil deficiency is the predominant risk factor for the development of IA, the most life-threatening condition associated with A. fumigatus exposure. Here we demonstrate that in addition to neutrophils, eosinophils are an important contributor to the clearance of A. fumigatus from the lung. Acute A. fumigatus challenge in normal mice induced the recruitment of CD11b+ Siglec F+ Ly-6G(lo) Ly-6C(neg) CCR3+ eosinophils to the lungs, which was accompanied by an increase in lung Epx (eosinophil peroxidase) mRNA levels. Mice deficient in the transcription factor dblGATA1, which exhibit a selective deficiency in eosinophils, demonstrated impaired A. fumigatus clearance and evidence of germinating organisms in the lung. Higher burden correlated with lower mRNA expression of Epx (eosinophil peroxidase) and Prg2 (major basic protein) as well as lower interleukin 1β (IL-1β), IL-6, IL-17A, granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), and CXCL1 levels. However, examination of lung inflammatory cell populations failed to demonstrate defects in monocyte/macrophage, dendritic cell, or neutrophil recruitment in dblGATA1-deficient mice, suggesting that the absence of eosinophils in dlbGATA1-deficient mice was the sole cause of impaired lung clearance. We show that eosinophils generated from bone marrow have potent killing activity against A. fumigtaus in vitro, which does not require cell contact and can be recapitulated by eosinophil whole-cell lysates. Collectively, our data support a role for eosinophils in the lung response after A. fumigatus exposure.

Histopathological implications of Aspergillus infection in lung

This paper opens with a discussion on the significance of invasive fungal infections in advanced contemporary medicine, with an emphasis on the intractability of disease management and the difficulties of diagnosis. This is followed by a discussion concerning classification, histopathological features, and pathophysiology. While it has been largely accepted that Aspergillus species is recognized by cellular receptors and attacked by neutrophils, the radiological and macroscopic findings linking infection with neutropenia remain unconfirmed. In an effort to gain a better understanding of the pathophysiology and pathogenesis of invasive aspergillosis, we wish to emphasize the utility of radiological and histopathological examinations since these can provide detailed information on the extremely complex interaction between the causative microbes and tissue responses. A review of noninvasive or semi-invasive aspergillosis is also provided, with particular emphasis on chronic necrotizing pulmonary aspergillosis, which is recognized as a transition form of simple pulmonary aspergilloma and invasive pulmonary aspergillosis, although few findings have been reported in this area.

Management of chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a relatively rare, slowly progressive pulmonary syndrome caused by Aspergillus spp. The scarcity of clinical evidence for its management is an important issue. Oral azoles are recommended as the primary treatment of CPA; however, the evidence for their effectiveness is insufficient. Azole-resistant A. fumigatus is rapidly increasing and becoming a serious concern. Because long-term administration of azoles is the mainstay of CPA, azole resistance may pose a serious threat. Furthermore, prolonged oral administration of azoles may lead to increased azole resistance in CPA patients. Therefore, alternative management strategies for CPA must be considered, and one option may involve the use of intravenous antifungals such as echinocandins and polyens. The utility of these antifungals, however, has not been well evaluated and remains controversial because the drugs are expensive and require patients to be admitted to the hospital for their use. New antifungal drugs with novel mechanisms of action are also needed.

Pulmonary aspergillosis in immunocompetent patients without air-meniscus sign and underlying lung disease: CT findings and histopathologic features

BACKGROUND

Pulmonary aspergillosis in immunocompetent patients has been described as a saprophytic infection with pre-existing lung lesions showing an air-meniscus sign on chest radiograph or CT scans. There have been rare articles dealing with pulmonary aspergillosis in immunocompetent patients without pre-existing lung lesions.

PURPOSE

To evaluate the CT findings of pulmonary aspergillosis in immunocompetent patients without air-meniscus and underlying lung disease and to correlate the CT findings and pathologic features of pulmonary aspergillosis in these patients.

MATERIAL AND METHODS

A total of seven surgically proven pulmonary aspergillosis found in immunocompetent patients without an air-meniscus and underlying lung disease (M:F = 1:6; mean age 63.4 years) were included. On CT, the lesion shape, margin, type, location, diameter, presence of satellite nodules, presence of CT halo sign or hypodense sign, and interval growth were evaluated. Histopathologic features of each lesion were classified as one of the following; primary aspergilloma, chronic necrotizing pulmonary aspergillosis, or invasive pulmonary aspergillosis. Correlation between CT findings and pathological features was performed.

RESULTS

All lesions presented as a nodule or mass unable to differentiate from malignancy. Most lesions had well-defined margins (n = 4), appeared as solid lesions (n = 7), and were located in the upper lobe (n = 5). Mean diameter of lesions was 2.3 cm. Satellite nodules (n = 2), CT halo sign (n = 1), and hypodense sign (n = 4) were found. Only one lesion increased in size during follow-up. Lesions were pathologically classified as primary aspergilloma (n = 3) and chronic necrotizing pulmonary aspergillosis (n = 4). The hypodense sign on CT was pathologically proved as dense fungal hyphae filled in bronchus and CT halo sign as parenchymal hemorrhage.

CONCLUSION

Pulmonary aspergillosis predominantly presented as a nodule or mass mimicking malignancy in the upper lobes on CT scan in elderly without underlying lung disease and immunosuppressive conditions except for age, and was histopathologically revealed to be either primary aspergilloma or chronic necrotizing pulmonary aspergillosis.

Histopathologic diagnosis of fungal infections in the 21st century

Fungal infections are becoming more frequent because of expansion of at-risk populations and the use of treatment modalities that permit longer survival of these patients. Because histopathologic examination of tissues detects fungal invasion of tissues and vessels as well as the host reaction to the fungus, it is and will remain an important tool to define the diagnostic significance of positive culture isolates or results from PCR testing. However, there are very few instances where the morphological characteristics of fungi are specific. Therefore, histopathologic diagnosis should be primarily descriptive of the fungus and should include the presence or absence of tissue invasion and the host reaction to the infection. The pathology report should also include a comment stating the most frequent fungi associated with that morphology as well as other possible fungi and parasites that should be considered in the differential diagnosis. Alternate techniques have been used to determine the specific agent present in the histopathologic specimen, including immunohistochemistry, in situ hybridization, and PCR. In addition, techniques such as laser microdissection will be useful to detect the now more frequently recognized dual fungal infections and the local environment in which this phenomenon occurs.

Chronic aspergillus infections of the respiratory tract: diagnosis, management and antifungal resistance

PURPOSE OF REVIEW

Chronic pulmonary aspergillosis (CPA) is a relatively rare, slowly progressive pulmonary syndrome due to Aspergillus spp. that requires specific knowledge in terms of disease entity, diagnosis, management and azole resistance. This review focuses on the recent understanding of CPA entity and the emergence of azole resistance in CPA.

RECENT FINDINGS

Due to complexities related to patients' background and limited pathological evidence, the disease entity of CPA was incomprehensive and numerous names were previously used. The disease entities and nomenclature of subtypes of CPA have recently been proposed, though previous literature had grouped several different forms of CPA together. Recent advances in the methodology of susceptibility testing have indicated increasing azole resistance in Aspergillus spp. CPA is potentially involved in producing azole resistance and associated with poor response to azoles.

SUMMARY

As there are few publications regarding CPA, there are still many unanswered questions. However, updating of disease entity will promote the clinical and basic research in this field. Moreover, the emergence of antifungal drug resistance of Aspergillus is becoming a major concern. Thus, more evidence and research regarding drug resistance are required to improve the outcome of CPA.

Diagnostic significance of Aspergillus species isolated from respiratory samples in an adult pneumology ward

Although the diagnostic significance of isolating Aspergillus spp. from respiratory cultures has been studied in immunocompromised hosts with invasive pulmonary aspergillosis (IPA), little is known of such infections in immunocompetent patients with other forms of aspergillosis. In this study of adult pneumology ward patients, we examined the association between Aspergillus spp. and disease prevalence. Laboratory records from April 1998 to March 2009 were reviewed to identify patients with Aspergillus spp. in respiratory samples. Correlations between the isolated species and clinical characteristics of patients were evaluated. During the study period, 165 Aspergillus spp. isolates were detected in the respiratory cultures of 139 patients. Of these patients, 62 (45%) were colonized with Aspergillus spp. and displayed no clinical symptoms of aspergillosis, while 77 (55%) had a form of pulmonary aspergillosis, characterized as either chronic necrotizing pulmonary aspergillosis (CNPA) (48%), aspergilloma (29%), IPA (13%), or allergic bronchopulmonary aspergillosis (ABPA) (10%). The dominant species were Aspergillus fumigatus (41%), A. niger (32%), and A. versicolor (12%). A. fumigatus was most commonly isolated in patients with IPA, aspergilloma, and CNPA, whereas A. niger was the dominant species in colonized patients and those with ABPA. Isolation of an Aspergillus spp. from respiratory samples does not confirm it as the etiologic pathogen because airway colonization by Aspergillus spp. is a common feature in several chronic lung diseases. Repeated isolation of the identical Aspergillus species and detection of anti-Aspergillus antibodies and/or Aspergillus antigens in sera are needed to determine the isolate represents the etiologic agent of disease.

Granulomatous lung disease: an approach to the differential diagnosis

CONTEXT

Granulomas are among the most commonly encountered abnormalities in pulmonary pathology and often pose a diagnostic challenge. Although most pathologists are aware of the need to exclude an infection in this setting, there is less familiarity with the specific histologic features that aid in the differential diagnosis.

OBJECTIVE

To review the differential diagnosis, suggest a practical diagnostic approach, and emphasize major diagnostically useful histologic features. This review is aimed at surgical pathologists who encounter granulomas in lung specimens.

DATA SOURCES

Pertinent recent and classic peer-reviewed literature retrieved from PubMed (US National Library of Medicine) and primary material from the institutions of both authors.

CONCLUSIONS

Most granulomas in the lung are caused by mycobacterial or fungal infection. The diagnosis requires familiarity with the tissue reaction as well as with the morphologic features of the organisms, including appropriate interpretation of special stains. The major noninfectious causes of granulomatous lung disease are sarcoidosis, Wegener granulomatosis, hypersensitivity pneumonitis, hot tub lung, aspiration pneumonia, and talc granulomatosis.

Pathology of small airways disease

CONTEXT

The term small airways disease encompasses a generally poorly understood group of lung diseases that may arise primarily within the small airways or secondarily from diseases primarily affecting the bronchi or lung parenchyma. Their histology may be confusing; however, because treatments and prognoses vary, correct pathologic diagnosis is important.

OBJECTIVE

To present a nonexhaustive review of the pathology of primary and secondary small airways diseases, including small airways disease related to tobacco; to various other exposures, including mineral dusts; to diseases involving other areas of the lung with secondary bronchiolar involvement; and to recently described bronchiolitic disorders.

DATA SOURCES

Current literature is reviewed.

CONCLUSIONS

Small airways diseases include a wide variety of diseases of which the pathologist must consider. Uncommon conditions such as diffuse idiopathic neuroendocrine cell hyperplasia and diffuse panbronchiolitis may show relatively specific diagnostic features histologically; however, most small airways diseases exhibit nonspecific histologic features. Conditions not considered primary pulmonary diseases, such as collagen vascular diseases, bone marrow transplantation, and inflammatory bowel disease, must also be considered in patients with small airways changes histologically. Clinical and radiologic correlation is important for obtaining the best possible diagnosis.

Impact of mold infections in explanted lungs on outcomes of lung transplantation

INTRODUCTION

Little is known about the incidence or significance of mold infections in the explanted lungs of lung transplant recipients.

METHOD

We reviewed the histopathology of the explanted lungs from 304 patients who underwent lung transplantation at our institution from 2005 to 2007 and received alemtuzumab induction therapy and posttransplant voriconazole prophylaxis.

RESULTS

Invasive mold infections were present in the explanted lungs of 5% (14 of 304) of patients, including chronic necrotizing pneumonias (n=7), mycetomas (n=4), and invasive fungal pneumonias (n=3). Only 21% (3 of 14) received immunosuppressive therapy within 1 year before lung transplantation, suggesting that lung damage itself predisposed patients to mold infections. The risk of mold infection was higher in patients with cystic fibrosis (11%, 4 of 35) than other underlying lung diseases (4%, 10 of 269). Pulmonary mold infections were not diagnosed or suspected in 57% (8 of 14) of patients. Despite secondary voriconazole prophylaxis, fungal infections developed in 43% (6 of 14) of patients with mold infections of the explanted lungs compared with 14% (42 of 290) of patients without mold infections (P=0.01). Three patients developed invasive fungal infections while on voriconazole prophylaxis and three developed fungal infections more than 8 months after the discontinuation of voriconazole. The mortality attributable to invasive fungal infections among patients with mold infections of the explanted lungs was 29% (4 of 14).

CONCLUSION

Invasive mold infections in the explanted lungs are often not recognized before lung transplantation and are associated with poor outcomes.

Chronic pulmonary aspergillosis - longterm follow-up over 20 years, a case report

We describe a case of chronic pulmonary aspergillosis complicated with a slowly growing aspergilloma followed for two decades without specific intervention. It developed with no background of local or systemic immune dysfunction in a middle aged female. The case illustrates many features of this disease as well as uniquely documenting the natural radiological evolution from a small non-specific cystic lesion to a massive aspergilloma. The aspergilloma subsequently autolysed and the patient's condition changed to an allergic phenotype with development of widespread bronchiectasis and pulmonary fibrosis. We briefly discuss the range of disease aspergillus can cause in humans, its differential diagnosis and treatments.

Noninvasive pulmonary Aspergillus infections

Aspergillus can cause several forms of pulmonary disease ranging from colonization to invasive aspergillosis and largely depends on the underlying lung and immune function of the host. This article reviews the clinical presentation, diagnosis, pathogenesis, and treatment of noninvasive forms of Aspergillus infection, including allergic bronchopulmonary aspergillosis (ABPA), aspergilloma, and chronic pulmonary aspergillosis (CPA). ABPA is caused by a hypersensitivity reaction to Aspergillus species and is most commonly seen in patients who have asthma or cystic fibrosis. Aspergillomas, or fungus balls, can develop in previous areas of cavitary lung disease, most commonly from tuberculosis. CPA has also been termed semi-invasive aspergillosis and usually occurs in patients who have underlying lung disease or mild immunosuppression.

Molecular Basis of Pulmonary Disease

Pulmonary pathology includes a large spectrum of both neoplastic and non-neoplastic diseases that affect the lung. Many of these are a result of the unusual relationship of the lung with the outside world. Every breath that a human takes brings the outside world into the body in the form of infectious agents, organic and inorganic particles, and noxious agents of all types. Although the lung has many defense mechanisms to protect itself from these insults, these are not infallible; therefore, lung pathology arises. Damage to the lung is particularly important given the role of the lung in the survival of the organism. Any impairment of lung function has widespread effects throughout the body, since all organs depend on the lungs for the oxygen they need. Pulmonary pathology catalogs the changes in the lung tissues and the mechanisms through which these occur. This chapter presents a review of lung pathology and the current state of knowledge about the pathogenesis of each disease. It suggests that a clear understanding of both morphology and mechanism is required for the development of new therapies and preventive measures.

Correlation of lung abnormalities on high-resolution CT with clinical graft-versus-host disease after allogeneic versus autologous bone marrow transplantation in children

BACKGROUND

Late-onset noninfectious pulmonary complications (LONIPCs) are life-threatening complications of bone marrow transplantation (BMT). Several pathological patterns are described in the literature with different prognoses, and with different relationships to graft-versus-host disease (GVHD). The role of high-resolution CT (HRCT) is not yet well established.

OBJECTIVE

To illustrate different patterns of LONIPCs on HRCT in allogeneic versus autologous BMT in order to investigate the correlation with chronic GVHD (cGVHD).

MATERIALS AND METHODS

A total of 67 HRCT scans were performed in 24 patients with noninfectious pulmonary disease at least 3 months after BMT (16 allogeneic, 8 autologous). Abnormality patterns and extension on HRCT images were correlated with the clinical outcome and with the severity of cGVHD.

RESULTS

Of 24 patients, 9 showed LONIPCs (1 autologous, 8 allogeneic). There was a significant association between abnormalities on HRCT and severe cGVHD (P = 0.038), with no specific pattern. Prognosis seemed to be related to the severity of cGVHD and not to the extent of abnormalities on HRCT.

CONCLUSION

The significant association between abnormalities on HRCT and severe GVHD suggests that LONIPCs can be a pulmonary manifestation of the disease. HRCT is a useful tool when combined with clinical data.

Fungal Infections

The incidence of invasive fungal infections has increased dramatically over the past two decades, mostly due to an increase in the number of immunocompromised patients.1–4 Patients who undergo chemotherapy for a variety of diseases, patients with organ transplants, and patients with the acquired immune deficiency syndrome have contributed most to the increase in fungal infections.5 The actual incidence of invasive fungal infections in transplant patients ranges from 15% to 25% in bone marrow transplant recipients to 5% to 42% in solid organ transplant recipients.6,7 The most frequently encountered are Aspergillus species, followed by Cryptococcus and Candida species. Fungal infections are also associated with a higher mortality than either bacterial or viral infections in these patient populations. This is because of the limited number of available therapies, dose-limiting toxicities of the antifungal drugs, fewer symptoms due to lack of inflammatory response, and the lack of sensitive tests to aid in the diagnosis of invasive fungal infections.1 A study of patients with fungal infections admitted to a university-affiliated hospital indicated that community-acquired infections are becoming a serious problem; 67% of the 140 patients had community-acquired fungal pneumonia.8

[Bronchopulmonary aspergillosis infections in the non-immunocompromised patient]

The definition of broncho-pulmonary aspergillosis infections in non-immunocompromised patients remains vague and a wide range of clinical, radiological and pathological entities have been described with a variety of names, i.e. simple aspergilloma, complex aspergilloma, semi-invasive aspergillosis, chronic necrotizing pulmonary aspergillosis, chronic cavitary and fibrosing pulmonary and pleural aspergillosis, pseudomembranous tracheobronchitis caused by Aspergillus, and invasive aspergillosis. However, these disease entities share common characteristics suggesting that they belong to the same group of pulmonary aspergillosis infectious disorders: 1- a specific diathesis responsible for the deterioration in local or systemic defenses against infection (alcohol, tobacco abuse, or diabetes); 2- an underlying bronchopulmonary disease responsible or not for the presence of a residual pleural or bronchopulmonary cavity (active tuberculosis or tuberculosis sequelae, bronchial dilatation, sarcoidosis, COPD); 3- generally, the prolonged use of low-dose oral or inhaled corticosteroids and 4- little or no vascular invasion, a granulomatous reaction and a low tendency for metastasis. There are no established treatment guidelines for broncho-pulmonary aspergillosis infection in non-immunocompromised patients, except for invasive aspergillosis. Bronchial artery embolization may stop hemoptysis in certain cases. Surgery is generally impossible because of impaired respiratory function or the severity of the comorbidity and when it is possible morbidity and mortality are very high. Numerous clinical cases and short retrospective series have reported the effect over time of the various antifungal agents available. Oral triazoles, i.e. itraconazole, and in particular voriconazole, appear to provide suitable treatment for broncho-pulmonary aspergillosis infections in non-immunocompromised patients.

Pathological diagnosis of granulomatous lung disease: a review

Granulomas in the lung are common diagnostic problems encountered by pathologists. They occur in a wide range of pulmonary conditions, ranging from common entities to uncommon ones and including both infections and non-infectious diseases. This review summarizes the main histological features that help distinguish various granulomatous lung diseases. It concentrates on the most important and common entities that may be encountered and emphasizes helpful features in the differential diagnosis.

Rapid formation of Aspergillus mycetoma in a patient receiving corticosteroid treatment. Serial radiographic observation over two months

This study presents the case of rapidly progressing pulmonary aspergillosis in a 47-year-old woman who had healed cavitations of pulmonary tuberculosis in the right upper lobe. She had been treated for pulmonary tuberculosis seven years prior to admission. The initial manifestations of the disease on admission included cough, dyspnea, hemoptysis, pulmonary infiltrate, and renal failure. As anti-myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA) were positive, she was diagnosed with ANCA-associated vasculitis and treated with corticosteroids. This treatment resulted in remission of the vasculitis. However, she developed new pulmonary symptoms and an enlarged cavitary lesion associated with the rapid formation of a fungal, ball-shaped shadow that was serially observed by radiological analysis. Pulmonary resection was finally performed because of acute progressive respiratory failure due to massive recurrent hemoptysis. A subsequent pathological analysis revealed a mass of hyphae with acute-angle branching, features consistent with Aspergillus, within the cavitary lesion, and she was diagnosed with pulmonary aspergillosis. The rapid development of pulmonary aspergillosis associated with the formation of an Aspergillus mycetoma should be attributed to the loss of normal immune mechanisms due to immunosuppressive treatment.

AS, Gasparetto EL, Escuissato DL. Tomografia computadorizada na avaliação da aspergilose pulmonar angioinvasiva em pacientes com leucemia aguda

OBJETIVO: O objetivo deste trabalho foi avaliar os principais achados na tomografia computadorizada de pacientes portadores de leucemia aguda complicada com aspergilose pulmonar angioinvasiva. MATERIAIS E MÉTODOS: Foram estudadas, retrospectivamente, as tomografias computadorizadas de 19 pacientes, avaliando-se a presença de consolidações, nódulos e massas, com ou sem sinal do halo, escavação e sinal do crescente aéreo. RESULTADOS: Áreas de consolidação foram o achado mais comum, ocorrendo em 12 dos 19 casos. A maioria delas apresentou o sinal do halo, enquanto escavação foi encontrada em 5 dos 12 casos com consolidações, sendo um deles com sinal do crescente aéreo. Nódulos e massas ocorreram em, respectivamente, seis e quatro casos, a maioria com sinal do halo. Escavação foi encontrada em apenas um caso de massa. Outros achados observados foram pavimentação em mosaico (dois casos), áreas de vidro fosco esparsas (três casos) e envolvimento pleural (sete casos), sob a forma de derrame ou espessamento. CONCLUSÃO: Áreas de consolidação, massas ou nódulo, mesmo solitário, com sinal do halo, quando vistos na tomografia computadorizada em um contexto clínico apropriado, são altamente sugestivos de aspergilose angioinvasiva.

Eosinophilia: secondary, clonal and idiopathic

Blood eosinophilia signifies either a cytokine-mediated reactive phenomenon (secondary) or an integral phenotype of an underlying haematological neoplasm (primary). Secondary eosinophilia is usually associated with parasitosis in Third World countries and allergic conditions in the West. Primary eosinophilia is operationally classified as being clonal or idiopathic, depending on the respective presence or absence of a molecular, cytogenetic or histological evidence for a myeloid malignancy. The current communication features a comprehensive clinical summary of both secondary and primary eosinophilic disorders with emphasis on recent developments in molecular pathogenesis and treatment.

The radiological spectrum of pulmonary aspergillosis

Imaging findings in the pulmonary aspergilloses can answer important clinical questions. Steroid-responsive chronic asthma due to allergic bronchopulmonary aspergillosis can be differentiated from simple asthma by computed tomography (CT) evidence of extensive and severe central bronchiectasis, mucoid impaction, or small airways lesions. The simple aspergilloma can be differentiated from the complex aspergilloma by the absence of: constitutional symptoms, para-cystic lung opacities, cyst expansion, or progressive pleural thickening. The CT halo sign is a transient finding that can provide a probable diagnosis of early invasive pulmonary aspergillosis in patients who are at extraordinarily high risk of the infection. Patients with a halo sign at baseline are more likely to have a satisfactory treatment response than those without this indicator.