Pseudomembranous tracheobronchitis caused by Aspergillus in immunocompromised patients

Necrotizing Tracheitis Complicated by Tracheal Wall Perforation

Necrotizing tracheitis is a rare condition, mainly seen in immunocompromised patients, that may lead to pseudomembrane formation, airway obstruction and in severe cases, tracheal perforation. We present a case of a 32-year-old male with poorly controlled diabetes who presented with productive cough, dysphagia, and respiratory distress. Bronchoscopy revealed extensive tracheal necrosis along a 4-5 cm segment of cartilaginous trachea and was complicated by tracheal perforation with false passage into the anterior mediastinum. Once the airway was re-established, a multidisciplinary team discussed options for definitive airway management, including tracheal reconstruction, pulmonary stent, or tracheostomy. Ultimately, a distal XLT tracheostomy was placed. Microbiology specimens of the tracheal tissue were positive for Actinomyces. The patient was started on long-term antibiotics and diabetes management. At three-month follow-up, the trachea was patent with near complete mucosalization of the previously necrotic segment. An area of proximal tracheal stenosis was successfully managed with a customized tracheal T-tube. In conclusion, this is a case of necrotizing tracheitis complicated by tracheal perforation. Successful treatment required a multidisciplinary team for airway management as well as medical treatment of immunocompromising risk factors and antimicrobial therapy. This enabled timely healing of the trachea and a durable airway.

Pseudomembranous Aspergillus Tracheobronchitis: Case Report of a Rare Manifestation of Airway Invasive Aspergillosis

Aspergillus tracheobronchitis, an uncommon form of invasive pulmonary aspergillosis, is characterized by the development of a pseudomembrane, ulcers, or an obstruction that is predominantly confined to the tracheobronchial tree. Pseudomembranous Aspergillus tracheobronchitis is the most severe form of Aspergillus tracheobronchitis, and only a few cases have been reported in Korea. We report the characteristic chest CT findings in a patient diagnosed with pseudomembranous Aspergillus tracheobronchitis after bronchoscopy and successfully treated by proper antifungal treatment.

Is bronchoscopic view a reliable method in diagnosis of tracheobronchial aspergillosis in critically ill non-neutropenic patients?

INTRODUCTION

Pulmonary aspergillosis is the main respiratory fungal infection however; its diagnosis is missed or delayed in critically ill non-neutropenic patients. Despite the utility of fiberoptic bronchoscopy for the evaluation of tracheobronchial aspergillosis (TBA) in immunocompromised patients has been extensively studied, however its utility in critically ill non-neutropenic patients is underestimated.

OBJECTIVES

To assess the bronchoscopic changes suspected TBA relative to the microbiological and histopathological aspects in critically ill non-neutropenic patients admitted to respiratory intensive care unit (RICU).

METHODS

We prospectively studied 139 critically ill non-neutropenic patients admitted to RICU and had a clinical suspicion of broncho-pulmonary Aspergillus infection. Those patients were subjected to clinical and bronchoscopic assessment for the evaluation of suspected TBA. Microbiological culture of bronchoalveolar lavage (BAL) and histopathological examination of tracheobronchial biopsies were done.

RESULTS

Bronchoscopic changes suspected TBA were found in 48.2% of patients (67/139), where Aspergillus infection was confirmed microbiologically in 59.7% (40/67) and histopathologically in 56.7% (38/67). Of these changes, whitish plaques ± ulcers, pseudomembrane and/or sticky secretion with hyperemic mucosa were detected in 68.7%, 26.9% and 16.4% respectively. These changes were mostly seen in the main bronchi (54/67; 80.6%). The sensitivity, specificity, positive, negative predictive values and overall accuracy of these bronchoscopic changes as compared with BAL fluid results were 83.3%, 70.3%, 53.2%, 91.2% and 74.1% respectively.

CONCLUSIONS

Bronchoscopy could be a reliable procedure for TBA diagnosis in critically ill non-neutropenic patients. Whitish plaques ± ulcers were the prominent bronchoscopic changes with reasonable diagnostic accuracy for prediction of TBA.

Pseudomembranous Invasive Tracheobronchial Aspergillosis with Fulminant Hepatitis and Hemophagocytic Syndrome

Invasive tracheobronchial aspergillosis (ITBA), a rare form of invasive pulmonary Aspergillus infection (IPA), is predominantly confined to the tracheobronchial tree. We herein report a case of ITBA with severe necrotic pseudomembrane in a 57-year-old woman with fulminant hepatitis and hemophagocytic syndrome. Bronchoscopic findings revealed a widespread pseudomembranous formation of the trachea and bronchi. Aspergillus fumigatus was cultured from bronchial lavage fluid, and the histological findings of an endobronchial biopsy revealed necrosis and invasive hyphae. Although she responded to antifungal treatment, she ultimately died of a septic shock with Burkholderia cepacia 57 days after admission.

Pseudomembranous tracheitis caused by Aspergillus fumigatus in the setting of high grade T-cell lymphoma

Pseudomembranous tracheitis (PMT) is a rare condition most commonly caused by fungal or bacterial infection that is characterized by a pseudomembrane that partially or completely covers the tracheobronchial tree. PMT is most commonly found in immunocompromised patient populations, such as post-chemotherapy, AIDS, post-transplant and hematological malignancies. Due to its rarity, PMT is often not included in the differential diagnosis. This case describes a 65 year old male with persistent fever and refractory cough despite high dose empiric antibiotics. Subsequent bronchoscopy with biopsy revealed pseudomembranous tracheitis due to Aspergillus fumigatus in the setting of T-cell lymphoma. PMT should be considered in the differential diagnosis of refractory cough in the immunocompromised population. However, it has been described in patients with nonspecific respiratory symptoms such as dyspnea, cough, and other airway issues.

Case Report of a Child after Hematopoietic Cell Transplantation with Acute Aspergillus Tracheobronchitis as a Cause for Respiratory Failure

Rapid respiratory failure due to invasive mycosis of the airways is an uncommon presentation of Aspergillus infection, even in immunocompromised patients, and very few pediatric cases have been reported. Patients with Aspergillus tracheobronchitis present with nonspecific symptoms, and radiologic studies are often noninformative, leading to a delay in diagnosis. Prompt initiation of adequate antifungal therapies is of utmost importance to improve outcome. We report the case of a 9-year-old girl with chronic myelogenous leukemia who developed respiratory distress 41 days after hematopoietic cell transplantation and rapidly deteriorated despite multiple interventions and treatment modalities.

Aspergillus pseudomembranous tracheobronchitis in an immunocompetent individual: A diagnostic conundrum with therapeutic challenge

Aspergillus tracheobronchitis is an extremely uncommon manifestation of Aspergillus infection. Most of the cases described in the literature are in the immunosuppressed individuals and is almost uniformly fatal. Immunocompetent individuals do manifest the disease, but the disease if diagnosed early can be appropriately treated and thus can be life-saving. Here, we describe a similar case which was diagnosed only at autopsy.

Aspergillus tracheobronchitis in a mild immunocompromised host

Aspergillus tracheobronchitis is a form of invasive pulmonary aspergillosis in which the Aspergillus infection is limited predominantly to the tracheobronchial tree. It occurs primarily in severely immunocompromised patients such as lung transplant recipients. Here, we report a case of Aspergillus tracheobronchitis in a 42-year-old man with diabetes mellitus, who presented with intractable cough, lack of expectoration of sputum, and chest discomfort. The patient did not respond to conventional treatment with antibiotics and antitussive agents, and he underwent bronchoscopy that showed multiple, discrete, gelatinous whitish plaques mainly involving the trachea and the left bronchus. On the basis of the bronchoscopic and microbiologic findings, we made the diagnosis of Aspergillus tracheobronchitis and initiated antifungal therapy. He showed gradual improvement in his symptoms and continued taking oral itraconazole for 6 months. Physicians should consider Aspergillus tracheobronchitis as a probable diagnosis in immunocompromised patients presenting with atypical respiratory symptoms and should try to establish a prompt diagnosis.

Aspergillus tracheobronchitis, bronchopleural fistula and empyema after lobectomy for aspergilloma

Aspergillus tracheobronchitis and Aspergillus empyema are two rare manifestations of Aspergillus infection. This case report presents a patient with chronic obstructive pulmonary disease who developed a pseudomembranous Aspergillus tracheobronchitis, bronchopleural fistula and empyema 16 months after lobectomy for an aspergilloma. Bronchoscopy proved to be important for assessment of severity. Combined systemic anti-fungal treatment (voriconazole) and open window thoracostomy were used to successfully treat the patient.

Pseudomembranous Aspergillus tracheobronchitis: a potential for high mortality in low-risk patients

Pseudomembranous Aspergillus tracheobronchitis (PMATB) is a relatively uncommon form of invasive pulmonary aspergillosis. PMATB is characterized by necrosis and sloughing of the respiratory epithelium resulting from the invasion of the tracheobronchial mucosa by Aspergillus species. The prognosis for patients with PMATB and underlying immune compromise is poor, but existing data suggest that the outcome of PMATB occurring in patients without overt immune compromise is favorable. To investigate the clinical features and prognosis for immunocompetent patients with PMATB in the study center, 10 patients with histologically and microbiologically confirmed PMATB lacking overt immune compromise over a 9-year period were retrospectively identified. Although all patients ultimately received systemic antifungal therapy, 4 patients required mechanical ventilation and 3 patients died. This report indicates that PMATB occurring in immunocompetent patients may exhibit an aggressive course, with rapid progression of lung parenchymal involvement and a fatal outcome.

Invasive tracheobronchial aspergillosis in a patient with systemic lupus erythematosus-dermatomyositis overlap syndrome

A 45-year-old man was referred to our hospital with a 3-month history of dyspnea, polyarthralgia, myalgia and weight loss. He was diagnosed with systemic lupus erythematosus/dermatomyositis overlap syndrome with lung involvement, which presented as organizing pneumonia. However, a bronchoscopic examination revealed the presence of multiple plaque-like white lesions with ulcers on the bronchial membrane, located mainly in the central airway. The pathological specimens obtained from bronchoscopy showed numerous filamentous fungal hyphae that were aggressively invading the bronchial walls, suggesting a diagnosis of invasive tracheobronchial aspergillosis. The present case, along with a review of the literature, demonstrates that invasive tracheobronchial aspergillosis can occur in patients who do not appear to be immunosuppressed. This case of aspergillosis should thus be recognized as an extremely rare presentation of an Aspergillus infection.

Aspergillus tracheobronchitis: report of 8 cases and review of the literature

Aspergillus tracheobronchitis (AT) is an infrequent but severe form of invasive pulmonary aspergillosis in which the fungal infection is entirely or predominantly confined to the tracheobronchial tree. We reviewed 8 cases of AT diagnosed in our tertiary care center during an 18-year period, as well as 148 cases previously reported in the English literature from 1985 to July 2011. The demographic, clinical, imaging, bronchoscopic, and outcome characteristics of every eligible patient were excerpted, and predictors of inhospital mortality were identified by logistic regression. Solid organ transplantation (SOT) (44.2%), hematologic malignancy (21.2%), neutropenia (18.7%), and chronic obstructive pulmonary disease (15.4%) were the most common underlying conditions reported. Most cases occurred in patients receiving long-term corticosteroid treatment (71.8%) or chemotherapy (25.0%). Fever and respiratory complaints (cough, dyspnea, stridor, or wheezing) were the most frequent symptoms; one-third of patients developed acute respiratory distress at presentation, and 15.1% were asymptomatic at the time of diagnosis. Initial imaging studies were not informative in 47.4% of the cases. Aspergillus fumigatus was the predominant species (74.4%). The pseudomembranous form was the most commonly observed (31.9% of cases) and was more frequent in neutropenic patients (p = 0.007), whereas ulcerative AT (31.2%) was associated with SOT (p = 0.001). The most frequent antifungal monotherapy regimens were amphotericin B deoxycholate (23.1%) and itraconazole (18.6%), whereas combined therapy was administered in 35.9% of the cases. Overall inhospital mortality was 39.1%, with neutropenia (odds ratio [OR], 20.47; p < 0.001) and acute respiratory distress at presentation (OR, 9.54; p = 0.002) as independent prognostic factors. Our pooled analysis of the literature shows that AT remains a rare opportunistic infection with a nonspecific presentation and a variable course depending on the nature of the predisposing factor.

Tracheobronchial manifestations of Aspergillus infections

Human lungs are constantly exposed to a large number of Aspergillus spores which are present in ambient air. These spores are usually harmless to immunocompetent subjects but can produce a symptomatic disease in patients with impaired antifungal defense. In a small percentage of patients, the trachea and bronchi may be the main or even the sole site of Aspergillus infection. The clinical entities that may develop in tracheobronchial location include saprophytic, allergic and invasive diseases. Although this review is focused on invasive Aspergillus tracheobronchial infections, some aspects of allergic and saprophytic tracheobronchial diseases are also discussed in order to present the whole spectrum of tracheobronchial aspergillosis. To be consistent with clinical practice, an approach basing on specific conditions predisposing to invasive Aspergillus tracheobronchial infections is used to present the differences in the clinical course and prognosis of these infections. Thus, invasive or potentially invasive Aspergillus airway diseases are discussed separately in three groups of patients: (1) lung transplant recipients, (2) highly immunocompromised patients with hematologic malignancies and/or patients undergoing hematopoietic stem cell transplantation, and (3) the remaining, less severely immunocompromised patients or even immunocompetent subjects.

Tracheobronchitis in the Intensive Care Unit

Tracheobronchitis can be broadly defined as inflammation of the airways between the larynx and the bronchioles. Clinically, this syndrome is recognized by an increase in the volume and purulence of the lower respiratory tract secretions and is frequently associated with signs of variable airflow obstruction. In the intensive care unit (ICU), tracheobronchitis is a relatively common problem with an incidence as high as 10.6% [1]. Although tracheobronchitis is associated with a significantly longer length of ICU stay and a prolonged need for mechanical ventilation, it has not been shown to increase mortality. These outcomes can be improved through the use of antimicrobial agents [1].