Pulmonary aspergilloma: analysis of prognosis in relation to haemoptysis and survey of treatment

Observational study of the recent efficacy and economy of itraconazole vs. voriconazole in perioperative pulmonary aspergillosis

Background

Antifungal therapy is a common treatment option for pulmonary aspergillosis, but its use to prevent recurrence and relieve symptoms in patients with pulmonary aspergillosis remains controversial. This study aimed to explore the short-term efficacy and cost of itraconazole vs. voriconazole in the treatment of pulmonary aspergillosis during the perioperative period.

Methods

We retrospectively collected the clinical data of 55 patients with pulmonary aspergillosis who underwent surgery and received itraconazole or voriconazole as antifungal therapy between January 1, 2016, and October 31, 2022, at the Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical University. We analyzed the effects of different antifungal therapies on the incidence of adverse events, short-term efficacy, and cost-effectiveness of pulmonary aspergillosis treatment.

Results

Except for the younger average age of patients in the itraconazole group, there were no significant differences in baseline characteristics such as sex, BMI, underlying lung disease, accompanying symptoms, and lesion location between the voriconazole and itraconazole groups. There was no significant difference in the incidence of adverse events or short-term efficacy, including recovery, symptom improvement, and recurrence rates, during the administration of the antifungal regimens between the two groups. Regarding economic cost efficiency, there was no significant difference in the median hospitalization costs between the two groups. However, despite the longer antifungal treatment duration in the itraconazole group, the cost of itraconazole was significantly lower than that of voriconazole.

Conclusion

Both itraconazole and voriconazole effectively prevented the recurrence of pulmonary aspergillosis. They are similar in terms of the incidence of adverse events and short-term efficacy; however, itraconazole is more economical.

Mortality in chronic pulmonary aspergillosis: a systematic review and individual patient data meta-analysis

BACKGROUND

Despite antifungal treatment, chronic pulmonary aspergillosis (CPA) is associated with substantial morbidity and mortality. We conducted a systematic review and meta-analysis to evaluate rates of mortality and its predictors in CPA.

METHODS

A systematic literature search was conducted across MEDLINE (PubMed), Scopus, Embase, and Web of Science to identify studies in English, reporting mortality in CPA, from database inception to Aug 15, 2023. We included clinical studies, observational studies, controlled trials, and abstracts. Case reports, animal studies, letters, news, and literature reviews were excluded. Authors of studies published since 2016 were also contacted to obtain anonymised individual patient data (IPD); for other studies, summary estimates were extracted. Subgroup analysis was done for differences in overall 1-year and 5-year mortality, data source, study design, risk of bias, country, Human Development Index, age groups, and the underlying lung disease. We used random-effects meta-analyses to estimate pooled mortality rates. Subgroup analyses and meta-regression were done to explore sources of heterogeneity. One-stage meta-analysis with a stratified Cox proportional hazards model was used to estimate the univariable and hazards for mortality, adjusting for age, sex, type of CPA, treatment, and underlying pulmonary comorbidities. This study was registered with PROSPERO (CRD42023453447).

FINDINGS

We included 79 studies involving 8778 patients in the overall pooled analysis and 15 studies involving 1859 patients in the IPD meta-analysis. Pooled mortality (from 70 studies) was estimated at 27% overall (95% CI 22-32; I2 =95·4%), 15% at 1 year (11-19; I2 =91·6%), and 32% at 5 years (25-39; I2 =94·3%). Overall mortality in patients with CPA with pulmonary tuberculosis as the predominant predisposing condition was 25% (16-35; I2 =87·5%; 20 studies) and with chronic obstructive pulmonary disease was 35% (22-49; I2 =89·7%; 14 studies). Mortality in cohorts of patients who underwent surgical resection was low at 3% (2-4). In the multivariable analysis, among predisposing respiratory conditions, pulmonary tuberculosis history had the lowest mortality hazard (relative to an absence of the disease at baseline), whereas worse outcomes were seen with underlying malignancy; subacute invasive pulmonary aspergillosis and chronic cavitary pulmonary aspergillosis subtypes of CPA were also significantly associated with increased mortality relative to simple aspergilloma on multivariable analysis. Mortality hazard increased by 25% with each decade of age (adjusted hazard ratio 1·25 [95% CI 1·14-1·36], p<0·0001).

INTERPRETATION

CPA is associated with substantial mortality. Advancing age, CPA subtype, and underlying comorbidities are important predictors of mortality. Future studies should focus on identifying appropriate treatment strategies tailored to different risk groups.

FUNDING

None.

Clinical Significance of Aspergillus Sensitisation in Chronic Pulmonary Aspergillosis

OBJECTIVE

Aspergillus sensitisation (AS) is seen in many patients with chronic pulmonary aspergillosis (CPA). However, the clinical relevance of AS in CPA remains unclear. In this study, we assess the clinical significance of AS in CPA.

METHODS

We retrospectively analysed the data of CPA subjects, defining AS as Aspergillus fumigatus-IgE ≥ 0.35 kUA/L. We excluded subjects with asthma, allergic bronchopulmonary aspergillosis, chronic obstructive pulmonary disease (COPD) and diffuse parenchymal lung diseases (DPLD). The primary objective was to compare the demographic and clinical characteristics, lung functions (via spirometry) and treatment outcomes in CPA subjects with or without AS. The secondary objective was to explore the association between AS and airflow obstruction on spirometry using multivariable logistic regression analysis.

RESULTS

We included 232 CPA subjects (119 females, 113 males) with a mean ± SD age of 42.1 ± 13.7 years. AS was present in 92 (39.7%) CPA patients (CPA-AS group). CPA-AS patients had higher SGRQ total scores, a higher prevalence of fungal ball, more frequent airflow obstruction and experienced more CPA relapses during follow-up compared to those without AS. Airflow obstruction was seen in 77/232 (33.2%) CPA patients. On multivariable logistic regression analysis, we found AS, increasing age and chronic fibrosing pulmonary aspergillosis independently associated with airflow obstruction on spirometry after adjusting for sex and other CPA categories. The relapse-free survival was significantly shorter in the CPA-AS group than in the CPA group.

CONCLUSION

AS is common in CPA and is independently associated with airflow obstruction. More studies are required to confirm our findings.

Bilateral chronic cavitary pulmonary aspergillomas in an adult patient with recurrent tuberculosis: a case report and literature review

BACKGROUND

Aspergillomas are globular growths of Aspergillus fumigatus, a benign aspergillosis of the lungs. It usually affects patients who are immunocompromised and have anatomically defective lung structures. The majority of aspergilloma cases are asymptomatic, despite the fact that 10% of cases spontaneously resolve. Most patients do not have any symptoms from their lesions. Direct serological or microbiological evidence of an Aspergillus species along with radiologic evidence is required for the diagnosis of an aspergilloma.

CASE

We describe a 35-year-old adult Oromo male patient who had been experiencing night sweats, an intermittent productive cough with sparse whitish sputum, loss of appetite, and easy fatigability for 3 months. At 5 years prior, he received treatment for pulmonary tuberculosis that was smear-positive and was subsequently certified healed. Objectively, he was tachypneic and had intercostal, subcostal, and supraclavicular retractions with symmetric chest movement. A high-resolution computed tomography scan revealed bilateral apical cavitary lesions with core soft tissue attenuating spherical masses and an air crescentic sign suggestive of aspergillomas, which were confirmed by sputum light microscopic examination. The patient was managed with antibiotics and antifungals.

CONCLUSION

Aspergilloma is a symptom of chronic pulmonary aspergillosis, a category of lung disorders caused by a persistent Aspergillus infection. Primary aspergillomas are uncommon and frequently occur in people with compromised immune systems. A prolonged cough, fever, chest pain, and hemoptysis are all symptoms of pulmonary aspergillomas. The majority of the time, pulmonary aspergillosis is difficult to identify. Despite high mortality and morbidity rates, surgery is still the most effective treatment for pulmonary aspergilloma.

Mortality and lung function decline in patients who develop chronic pulmonary aspergillosis after lung cancer surgery

BACKGROUND

Lung cancer surgery is reported as a risk factor for chronic pulmonary aspergillosis (CPA). However, limited data are available on its clinical impact. We aimed to determine the effect of developed CPA after lung cancer surgery on mortality and lung function decline.

METHODS

We retrospectively identified the development of CPA after lung cancer surgery between 2010 and 2016. The effect of CPA on mortality was evaluated using multivariable Cox proportional hazard analyses. The effect of CPA on lung function decline was evaluated using multiple linear regression analyses.

RESULTS

During a median follow-up duration of 5.01 (IQR, 3.41-6.70) years in 6777 patients, 93 developed CPA at a median of 3.01 (IQR, 1.60-4.64) years. The development of CPA did not affect mortality in multivariable analysis. However, the decline in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) were greater in patients with CPA than in those without (FVC, - 71.0 [- 272.9 to - 19.4] vs. - 10.9 [- 82.6 to 57.9] mL/year, p < 0.001; FEV₁, - 52.9 [- 192.2 to 3.9] vs. - 20.0 [- 72.6 to 28.6] mL/year, p = 0.010). After adjusting for confounding factors, patients with CPA had greater FVC decline (β coefficient, - 103.6; 95% CI - 179.2 to - 27.9; p = 0.007) than those without CPA. However, the FEV₁ decline (β coefficient, - 14.4; 95% CI - 72.1 to 43.4; p = 0.626) was not significantly different.

CONCLUSION

Although the development of CPA after lung cancer surgery did not increase mortality, the impact on restrictive lung function deterioration was profound.

Aspergilloma in Non-tuberculous Cavities in the Lung: Not to Get Startled

Aspergillus which is normally found as a colonizer in healthy individuals can manifest in various forms in patients with diseased lung or immunocompromised status. Aspergilloma is one such manifestation whereby the fungus makes its way into preexisting cavities in the lung, the most common underlying etiology being old tuberculous cavities, especially in countries with high TB prevalence. However, we hereby report two cases of Aspergillus infestation as aspergilloma in cavities because of extremely rare causes, namely pulmonary thromboembolism and idiopathic pulmonary fibrosis, respectively.

Clinical Features, Diagnostic Test Performance, and Prognosis in Different Subtypes of Chronic Pulmonary Aspergillosis

Objective

The aim of this study was to describe clinical features in different subtypes of chronic pulmonary aspergillosis (CPA)-simple aspergilloma (SA), chronic cavitary pulmonary aspergillosis (CCPA), chronic fibrosing pulmonary aspergillosis (CFPA), aspergillus nodule (AN), and subacute invasive aspergillosis (SAIA), respectively, and identify long-term prognosis of CPA.

Methods

We reviewed patients diagnosed with different subtypes of CPA from 2002 to 2020 at Nanjing Jinling Hospital, China. We analyzed the clinical and survival information of five different subgroups. A Cox regression model was used to explore proper antifungal duration and long-term survival factors of CCPA and SAIA.

Results

A total of 147 patients with CPA were included, consisting of 11 SA, 48 CCPA, 5 CFPA, 12 AN, and 71 SAIA. The most common underlying pulmonary disease was pulmonary tuberculosis (n = 49, 33%), followed by bronchiectasis (n = 46, 31.3%) and chronic obstructive pulmonary disease (COPD) or emphysema (n = 45, 30.6%), while in SAIA and CFPA groups, the most common was COPD or emphysema (45.1 and 100%). Cough (85%), expectoration (70.7%), hemoptysis (54.4%), and fever (29.9%) were common symptoms, especially in CCPA, CFPA, and SAIA groups. The common imaging manifestations included cavitation (n = 94, 63.9%), fungal ball (n = 54, 36.7%), pleural thickening (n = 47, 32.0%), and bronchiectasis (n = 46, 31.3%). SAIA and CFPA groups had a lower value of hemoglobin (HB) and serum albumin (ALB) with higher C-reactive protein and erythrocyte sedimentation rate. The positive rate of sputum culture, serum galactomannan (GM), and bronchoalveolar lavage fluid GM was 32.7% (36/110), 18.4% (18/98), and 48.7% (19/39), respectively. There were 64.6% (31/48) patients with CCPA and 25.4% (18/71) patients with SAIA who received surgery and the 5-year cumulative survival rate was 92.1 and 66.6%, respectively. SAIA, old age, male, low body mass index (BMI), COPD or emphysema, multiple distribution, low serum ALB, and positive sputum culture were adverse prognosis factors for SAIA and CCPA group, and BMI ≤ 20.0 kg/m² was independently associated with increased mortality (hazard ratio (HR) 5.311, 95% CI 1.405–20.068, p = 0.014). Multivariable Cox regression indicated that surgery (HR 0.093, 95% CI 0.011–0.814, p = 0.032) and antifungal duration >6 months (HR 0.204, 95% CI 0.060–0.696 p = 0.011) were related to improved survival.

Conclusion

The clinical features and laboratory test performance are different among SA, CCPA, CFPA, AN, and SAIA. Low BMI was an independent risk factor for survival. Selective surgery and antifungal duration over 6 months were associated with improved survival.

Pulmonary Aspergilloma and Allergic Bronchopulmonary Aspergillosis Following the 2018 Heavy Rain Event in Western Japan

A 16-year-old boy with asthma participated in recovery volunteer work following the 2018 heavy rains in Japan. One month later, he experienced chest pain and dyspnea. Chest computed tomography revealed a cavity with a fungal ball, and Aspergillus fumigatus was detected in his bronchoalveolar lavage fluid. He was treated with voriconazole, but new consolidations appeared rapidly. He also experienced allergic bronchopulmonary aspergillosis. After prednisolone prescription, the consolidations improved; however, his asthma worsened. He underwent partial lung resection to avoid allergens, and his symptoms improved. We must recognize cases of infection after a disaster, especially in patients with chronic respiratory diseases.

Aspergillus-related lung disease in people with cystic fibrosis: can imaging help us to diagnose disease?

In people with cystic fibrosis (PwCF), viscous sputum and dysfunction of the mucociliary escalator leads to early and chronic infections. The prevalence of Aspergillus fumigatus in sputum is high in PwCF and the contribution of A. fumigatus to the progression of structural lung disease has been reported. However, overall, relatively little is known about the contribution of A. fumigatus to CF lung disease. More knowledge is needed to aid clinical decisions on whether to start antifungal treatment. In this review, we give an overview of A. fumigatus colonisation and infection in PwCF and the different types of pulmonary disease caused by it. Furthermore, we discuss the current evidence for structural lung damage associated with A. fumigatus in PwCF on chest computed tomography and magnetic resonance imaging. We conclude that radiological outcomes to identify disease caused by A. fumigatus can be important for clinical studies and management.

Chronic Pulmonary Aspergillosis: A Brief Review

Chronic Pulmonary Aspergillosis (CPA) is a destructive pulmonary disease caused by a fungal infection, affecting mainly individuals with prior or concurrent pulmonary conditions. It has a global prevalence of 42 per 100,000 population, but in the US and Europe, prevalence is less than 1 per 100,000. The clinical definition of CPA is based on various factors accounting for comorbidities, clinical presentation, and duration. It may be categorized into five subtypes that the disease may evolve between over time. Based on global consensus covering the spectrum of low-resource to high-resource settings, diagnosis is a multi-factorial process that involves a combination of clinical presentation persisting over 3 months, radiological findings, positive culture growth, and serological tests. CPA remains underdiagnosed due to a lack of awareness and is often misdiagnosed due to the comorbidities present. Treatment options are limited due to a lack of research. Furthermore, associated comorbidities and drug interactions further complicate treatment plans. Follow-up throughout treatment should be based on understanding the predictors of mortality. Identification of potential relapse or resistance to antifungal therapy is crucial to limit the low long-term survival rate. Awareness surrounding this devastating disease needs to be raised further to enable earlier identification, improve understanding of patient factors associated with prognosis, and the future potential for targeted therapies. This review aims to raise awareness of this rare condition among practitioners, by providing an overview of common risk factors influencing the prevalence and incidence of the disease. We further discuss current approaches and recent advancements in CPA diagnosis and treatment.

Surgical Treatment of Pulmonary Aspergilloma: A 13-year Experience from a Single Clinical Center

BACKGROUND

Pulmonary aspergilloma is chronic and invasive, potentially leading to life-threatening massive hemoptysis. The role of surgery for treating pulmonary aspergilloma and its effect on long-term survival need more study.

METHODS

We reviewed 166 patients with aspergillomas treated at Shanghai Pulmonary Hospital from 2004 to 2017. Surgery indications included destroyed lung parenchyma, recurrent hemoptysis despite appropriate medical treatment and isolated pulmonary nodules suspected to be aspergilloma. Pulmonary aspergillomas are classified as simple (in an isolated thin-walled cavity, ≤3 mm) or complex (a thick-walled cyst, >3 mm) based on CT scan findings.

RESULTS

Aspergilloma was complex in 100 (60.2%) patients and simple in 66 (39.8%) patients. The median size of complex aspergillomas (2.5 [0.3-8.0] cm) was larger than that (2.0 [0.2-6.0] cm) of simple types (p<0.001). Hemoptysis occurred in 72 (72%) patients with complex disease and 35 (53%) with simple disease (p=0.014). Video-assisted thoracoscopic surgeries were performed in 42 (63.6%) simple aspergillomas, while 75 (75%) of complex aspergillomas patients underwent thoracotomy. Prolonged air leakage (>7d) was the most (17, [10.2%]) common postoperative complication. One (0.6%) patient had postoperative bronchopleural fistula. One (0.6%) patient died within 30 days postoperatively due to respiratory failure. Two (1.2%) patients experienced recurrence during follow-up. The overall 10-year survival rates of complex and simple aspergillomas were 87.7% and 94.97% (p=0.478). Diabetes (12, [7.2%], HR [95% CI] = 13.15(1.12-154.46)) was associated with a worse prognosis.

CONCLUSIONS

The perioperative morbidity and mortality of pulmonary aspergillomas are acceptable. Overall survival rates of simple and complex types are comparable.

Monaldi cavernostomy for lung aspergillosis: A case report

Pulmonary aspergillosis in patients with respiratory failure can severely affect the pulmonary functional status and may aggravate it through pulmonary suppuration, by recruitment of new parenchyma and hemoptysis, which can sometimes be massive, with lethal risk by flooding the bronchus. The treatment consists of a combination of medical therapy, surgery and interventional radiology. In small lesions, less than 2-3 cm, medical therapy methods may be sufficient; however, in invasive forms (larger than 3 cm) surgical resection is necessary. Surgical resection is the ideal treatment; nevertheless, when lung function does not allow it, action must be taken to eliminate the favorable conditions of the infection. In such cases, whenever the lung cavity is peripheral, a cavernostomy may be performed. Four cases of lung cavernous lesions colonized with aspergillus, in which the need for a therapeutic gesture was imposed by repeated small to medium hemoptysis and by the progression of respiratory failure, were evaluated, one of which is presented in the current study. Cavernostomy closure can be realized either surgically with muscle flap or spontaneously by scarring, after closure of the bronchial fistulas by epithelization and granulation. There were no recurrences of hemoptysis or suppurative phenomena. There was one death, a patient with severe respiratory failure caused by superinfection with nonspecific germs. However, in the case presented in this study, the patient recovered following cavernostomy, which seems to be an effective and safe method for cases in which lung resection is not feasible.

Chronic Pulmonary Aspergillosis Situation among Post Tuberculosis Patients in Vietnam: An Observational Study

This study provides a brief view of chronic pulmonary aspergillosis (CPA) in the post-tuberculosis treatment community in Vietnam, a high burden tuberculosis (TB) country. In three months in late 2019, 70 post-TB patients managed at Vietnam National Lung Hospital were enrolled. Of these, 38 (54.3%) had CPA. The male/female ratio was 3/1 (28 males and ten females). CPA patients had a mean age of 59 ± 2.3 years (95%CI 54.4-63.6). The mean Body mass index (BMI) was 19.0 ± 0.5 (18.0-20.0) and 16 of 38 (42.1%) patients had concurrent diseases, the most common of which were chronic obstructive pulmonary disease (COPD) and diabetes. Twenty-six patients (68.4%) developed hemoptysis, 21 (55.3%) breathlessness, and weight loss was seen in 30 (78.9%). Anaemia was seen in 15 (39.5%) and 27 of 38 (71.1%) patients had an elevated C-reactive protein (CRP). The most common radiological findings were multiple cavities (52.6%) and pleural thickening (42.7%), followed by aspergilloma (29.0%) and non-specific infiltrates. There were five of 38 patients (13.2%) with a cavity containing a fungal ball on the chest X-ray, but when the high resolution computed tomography (HRCT) was examined, the number of patients with fungal balls rose to 11 (28.9%). Overall, 34 of 38 (89.5%) cases had an elevated Aspergillus IgG with an optical density ≥ 1, and in 2 cases, it was 0.9-1.0 (5%), borderline positive. In nine patients (23.7%) Aspergillus fumigatus was cultured from sputum. CPA is an under-recognised problem in Vietnam and other high burden TB countries, requiring a different diagnostic approach and treatment and careful management. HRCT and Aspergillus IgG serum test are recommended as initial diagnostic tools for CPA diagnosis.

Surgical Outcome of Chronic Pulmonary Aspergilloma: An Experience from Two Tertiary Referral Hospitals in Addis Ababa, Ethiopia

BACKGROUND

Surgical management of pulmonary aspergillosis is challenging and controversial. This study is designed to assess the clinical profile, indications and surgical outcome of Pulmonary aspergilloma.

METHODS

A retrospective cross-sectional analysis of 72 patients who underwent pulmonary resection for pulmonary aspergilloma over the period from November, 2014, to November, 2019 was done. Data on demographic, clinical and surgical out come were retrieved. Analysis was done using SPSS version 23. Chi-square test was used to assess for significance of the association between variables and surgical outcome.

RESULTS

There were 46(63.9%) males and 26(36.1%) female patients with a mean age of 35.2+/-11.6 years (Range 16- 65 years). All patients were previously treated for tuberculosis. Cough, hemoptysis, and shortness of breath were the main symptoms identified. A ball of fungus together with the surrounding lung was removed. Accordingly, 32(44,4%) lobectomies, 12(16.7%) pneumonectomy, 7(9.7%) Bi-lobectomy, and 21(29.2%) cavernostomy were done. Intraoperative and Postoperative complications were seen in 8(11.1%) and 21(29.1%) patients respectively. Major morbidity encounters included massive intraoperative blood loss, prolonged air leak, empyema, air space, bronchopleural fistula, and wound infection. The hospital mortality was 3(4.2%) and the average hospital stay was 14.8days. Postoperative complications were evaluated for the difference in socio-demographic characteristics and other variables and a statistically significant difference was detected only for the location of aspergilloma, site of the lung involved and type of surgery done. (P-value =0.05.).

CONCLUSION

Pulmonary resection done for pulmonary aspergilloma showed favorable outcomes when done with good patient selection, meticulous surgical techniques, and good postoperative management. However, its long term outcome and role of antifungal treatment as adjunctive therapy for surgical resection need further investigation.

Hemoptysis from complex pulmonary aspergilloma treated by cavernostomy and thoracoplasty

BACKGROUND

In high-risk patients with complex pulmonary aspergilloma but unable for lung resection, cavernostomy and thoracoplasty could be performed. This study aimed to evaluate this surgery compared two compressing materials.

METHODS

A total of 63 in high-risk patients who suffered from hemoptysis due to complex pulmonary aspergilloma and underwent cavernostomy and thoracoplasty surgery from November 2011 to September 2018 at Pham Ngoc Thach hospital were evaluated prospectively studied. Patients were allocated to two groups: the table tennis ball group and tissue expander group. We evaluated at the time of before operation, 6 months and 24 months after operation.

RESULTS

Tuberculosis was the most common comorbidity diseases in both groups. Upper lobe occupied almost in location. Hemoptysis symptoms plunged from time to time. Statistically significant Karnofsky score was observed in both groups. Postoperative pulmonary functions (FVC and FEV1) have remained in both groups at all time points. The remarkable results were no deaths related to surgery and low complications both short and long-term. There was no statistical significance between two groups in operative time, blood loss during operation, ICU length-stay time. Four patients died because of co-morbidity in 24 months follow-up.

CONCLUSION

Cavernostomy and thoracoplasty was safe and effective surgery for the treatment of complex pulmonary aspergilloma with hemoptysis in high-risk patients. No mortality related to surgery and low complications were recorded. The was no inferiority when compared two compressing materials .

The fate of aspergilloma patients after surgical treatment-experience from 22 cases

Background

Patients with pulmonary aspergillomas occasionally undergo surgery but it is somewhat unclear who of these patients benefit from surgical treatment.

Methods

We retrospectively evaluated all 22 patients that underwent surgery in Helsinki University Central Hospital between 2004 and 2017. We assessed their clinical backgrounds, anti-fungal medication, indication for surgery, complications, recurrent infections and survival.

Results

Of the 22 patients, 14 male and 8 female, mean age 56, an underlying pulmonary disease was present in 20. On immunosuppressive medication were 8 (36%). Most received anti-fungal medication preoperatively (n=12) and/or postoperatively (n=17), 3 patients did not receive anti-fungal medication. Length of the medication periods were diverse. Main indication for surgery was haemoptysis. One in-hospital-death occurred, and other complications included prolonged air-leak, postoperative pneumonia, pneumothorax and pneumomediastinum. No Aspergillus empyema or pleurites occurred. Five-year survival was 54%. One in-hospital-death and one other death were the result of Aspergillus disease, other deaths were unrelated to Aspergillus. Recurrent disease occurred in four cases. Three of these patients were asthma patients with allergic bronchopulmonary aspergillosis (ABPA).

Conclusions

Overall results of surgery in this cohort were good and number of complications was low. Therapy with antifungals was diverse. Surgical treatment of aspergilloma can be life-saving for patients suffering of haemoptysis, and patients with restricted disease and well-preserved pulmonary capacity may benefit from surgery. Careful patient selection is crucial.

Risk factors of severe hemoptysis in patients with fungus ball

Background

Hemoptysis is one of the most important complications associated with fungus ball. However, the association of the primary size of the fungus ball and its change with the incidence of hemoptysis was not fully established. This study aims to determine the clinical risk factors of severe hemoptysis and natural course of fungus ball.

Methods

A retrospective study on patients with fungus ball was performed. Patients with severe hemoptysis-related events were compared to those without events, and the predictors for severe hemoptysis were investigated by Cox regression analysis. Three subgroups (decreased, stable, and increased) were classified according to the long-term size change, and the severe hemoptysis-free survival duration was analyzed by the Kaplan-Meier survival curve.

Results

Among 173 patients, 50 (28.9%) experienced severe hemoptysis-related events. Risk-adjusted analysis revealed that age [hazard ratio (HR), 0.964; 95% confidence interval (CI), 0.939-0.989], blood-tinged sputum [HR, 2.717; 95% CI, 1.513-4.879], and thick wall cavitary fungus balls [HR, 2.332; 95% CI, 1.290-4.215] were significant predictors of severe hemoptysis-related events in patients with fungus ball. However, the baseline size of the fungus ball and its change rate were not independent risk factors for severe hemoptysis-related events. Besides, the decreased group did not have a favorable outcome in severe hemoptysis related to fungus ball.

Conclusions

In a tertiary hospital, the incidence of severe hemoptysis-related events in patients with fungus ball was not low and reached 28.9%. Young patients, those with thick wall cavitary fungus ball, and those with complaints of blood-tinged sputum should be considered for early surgical treatment to prevent severe hemoptysis.

Surgical management of pulmonary aspergillosis in pediatric population

INTRODUCTION

Aspergillosis is an invasive infection that affects mainly immunocompromised patients, and the lung is the most common site of infection. We reviewed our experience with the surgical management of pulmonary aspergillosis (PA) in pediatric population at a tertiary care institution.

METHODS

A retrospective chart review was conducted for pediatric patients (<16 years) who were managed for PA over the period from January 2001 to December 2016. Demographic, clinical, and outcome data were retrieved, and descriptive data were generated.

RESULTS

Eighty patients had microbiologically-proven PA over the period of the study, and 38 of them (48%) had a surgical intervention during their management. Among the surgical group, there were 19 males and 19 females with a mean age of 9.4 years (0.5-16). Thirty-five patients (92%) were in an immunocompromised state (10 of them have had bone marrow transplant), 2 patients had cystic lung disease, and 1 had scleroderma. All had fever and respiratory symptoms at presentation and received systemic antifungal medications. All had Computerized tomography (CT) scan examinations which showed features suggestive of the disease. Surgical procedures included lung biopsy in 13 patients (34%), segmentectomy in 12 patients (32%), lobectomy in 8 patients (21%), debridement/cavernostomy in 3 patients (8%), and 2 patients had pneumonectomy (5%). Histopathological examination revealed invasive fungal infection in 20 patients (53%) and aspergilloma in 18 (47%). Eleven patients (29%) died owing to a combination of fungal infection and the underlying disease. Three other patients, not included in the surgical series, died secondary to severe pulmonary hemorrhage while waiting for surgery. All had cavitation on CT scan near the hilum of the lung.

CONCLUSIONS

Pulmonary aspergillosis is a severe invasive infection with a significant mortality. Early surgical intervention is recommended in patients who do not improve on antifungal medication, especially in those with cavitating lesions, in order to improve outcome.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

IV.

Exacerbation of chronic pulmonary aspergillosis was associated with a high rebleeding rate after bronchial artery embolization

BACKGROUND

Hemoptysis is a common symptom associated with chronic pulmonary aspergillosis (CPA). While surgery is the primary choice to manage hemoptysis, it is often avoided because patients with CPA are more likely to have complications such as respiratory insufficiency and low pulmonary function. Bronchial artery embolization (BAE) may be considered one of the treatments of massive and persistent hemoptysis for such patients.

METHODS

We retrospectively reviewed medical records of 41 patients, admitted to National Hospital Organization Tokyo National Hospital, Tokyo, Japan with hemoptysis arising from CPA between January 2011 to December 2016, who were considered inoperable and had undergone BAE.

RESULTS

Out of the 41 cases analyzed in this study, 21 (51.2%) developed rebleeding after BAE within the mean follow-up duration of 24 months. The non-rebleeding rate of patients after BAE was 92.7% within a month and 65.8% within a year. Patients who developed rebleeding had significantly more non-bronchial systemic arteries responsible for the bleeding compared with patients who did not develop rebleeding (mean of 2.55 vs. 4.86, respectively, P = 0.011). Patients with stable or improved radiological findings demonstrated significantly lower rebleeding rates than those with radiological deterioration (P < 0.001). The non-rebleeding patients had significantly better survival than those with rebleeding (79.7% vs. 39.9% over 5 years, P = 0.046).

CONCLUSIONS

Bronchial artery embolization was effective in controlling hemoptysis in patients with CPA, especially those who could not undergo surgical resection. However, disease control of CPA was important to prevent rebleeding over the long term and to improve survival after BAE.

Is adjuvant antifungal therapy after video-assisted thoracic surgery for pulmonary aspergilloma necessary?

Background

The aim of this current retrospective study was to assess the necessity of postoperative antifungal therapy for pulmonary aspergilloma (PA) patients who underwent video-assisted thoracic surgery (VATS) lung resection.

Methods

We enrolled 22 PA patients who underwent VATS lung resection between 2014 and 2018. Of these, 12 patients were prescribed antifungal agents during the perioperative period (group A), and the other 10 were treated with surgery alone without any antifungal therapy postoperatively (group B). All patients were immunocompetent.

Results

Seven patients (58.3%) developed postoperative complications in group A, including 2 cases of empyema (16.7%), 1 case of bronchopleural fistula (8.3%), 1 case of pneumonia (8.3%), 1 case of wound infection (8.3%), 1 case of bleeding (8.3%) and 1 case of atelectasis (8.3%). In group B, 3 patients (30%) developed postoperative complications, including 2 cases of pneumonia (20%) and 1 case of empyema (10%). There was no significant difference between the groups with respect to postoperative complications rates (P=0.23). The follow-up period ranged from 1 to 38 months (a median of 19 months), during which no hospital deaths, recurrence of disease or lesion relapses were noted in either group.

Conclusions

Our results suggested that postoperative adjuvant antifungal therapy has limited advantages for the surgical treatment of PA in immunocompetent patients.

Respiratory failure in the hematopoietic stem cell transplant recipient

The number of patients receiving hematopoietic stem cell transplantation (HSCT) is rapidly rising worldwide. Despite substantial improvements in peri-transplant care, pulmonary complications resulting in respiratory failure remain a major contributor to morbidity and mortality in the post-transplant period, and represent a major barrier to the overall success of HSCT. Infectious complications include pneumonia due to bacteria, viruses, and fungi, and most commonly occur during neutropenia in the early post-transplant period. Non-infectious complications include idiopathic pneumonia syndrome, peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary veno-occlusive disease, delayed pulmonary toxicity syndrome, cryptogenic organizing pneumonia, bronchiolitis obliterans syndrome, and post-transplant lymphoproliferative disorder. These complications have distinct clinical features and risk factors, occur at differing times following transplant, and contribute to morbidity and mortality.

Surgical management of non-mycobacterial fungal infections

Fungal infections of the lung are common in endemic areas and in immunocompromised patients. Antifungal therapy is the cornerstone of medical therapy for most pulmonary fungi but surgery is an important adjunct in cases of complicated disease or resistant organisms. A multidisciplinary approach including pulmonary medicine, infectious disease, interventional radiology, and thoracic surgery is favored. This article reviews the surgical management of common fungal pulmonary infections and their sequelae.

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.

A comparison of the functional parameters of operability in patients with post-inflammatory lung disease and those with lung cancer requiring lung resection

Background

It is a common, yet unproven, belief that patients with post-inflammatory lung disease have a better functional reserve than patients with lung cancer when compared with their respective functional parameters of operability – forced expiratory volume in one second (FEV₁), maximum oxygen uptake in litres per minute (VO₂ max) and the diffusion capacity for carbon monoxide (DLCO).

Objectives

The aim of this study was to compare a group of patients with lung cancer with a group with post-inflammatory lung disease according to their respective functional parameters of operability. We also aimed to investigate any associations of FEV₁ and/or DLCO with VO₂ max within the two groups.

Methods

We retrospectively included 100 adult patients considered for lung resection. All patients were worked up using a validated algorithm and were then sub-analysed according to their parameters of functional operability.

Results

Two-thirds of patients had post-inflammatory lung diseases whilst the rest had lung cancer. The majority of the patients in the lung cancer group had coexistent chronic obstructive pulmonary disease (COPD) (n=18). Most (n=47) of the patients in the post-inflammatory group were diagnosed with a form of pulmonary TB (active or previous). Among the two groups, the lung cancer group had a higher median %FEV₁ value (62.0%; interquartile range (IQR) 51.0 - 76.0) compared with the post-inflammatory group (52%; IQR 42.0 - 63.0; p=0.01). There was no difference for the %DLCO and %VO₂ max values. The lung cancer group also had higher predicted postoperative (ppo) values for %FEV₁ (41.0%; IQR 31.0 - 58.0 v. 34.0%; IQR 23.0 - 46.0; p=0.03, respectively) and %VO₂ max (58.0%; IQR 44.0 - 68.0 v. 46.0%; IQR 35.0 - 60.0; p=0.02). There was no difference in the %DLCO ppo values between the groups.

Conclusion

Patients with lung cancer had higher percentage values for FEV₁ and ppo parameters for %FEV₁ and %VO₂ max compared with those who had post-inflammatory lung disease. Our findings suggest that lung cancer patients have a better functional reserve.

Feasibility of surgery for pulmonary aspergilloma: analysis of the operative modes

PURPOSE

We evaluated the feasibility of surgery for pulmonary aspergilloma.

METHODS

We retrospectively evaluated 35 surgical patients with pulmonary aspergilloma. The clinical characteristics and perioperative surgical morbidity were compared based on the operative modes. Preoperative artery embolization (PAE) was selectively performed to reduce the expected surgical stress caused by intraoperative blood loss.

RESULTS

The cohort comprised 19 males and 16 females with a mean age of 56 years. Lobectomy was performed in 22 patients, segmentectomy in 5, wedge resection in 4, and palliative surgery in 4. Postoperative morbidities were found in 12 (34%) patients, however, life-threatening complications or resurgence of the infection after surgery never occurred. PAE was performed in 9 (26%). Intrathoracic adhesions were significantly observed in patients who underwent PAE (p = 0.003), however, operative time and intraoperative blood loss were not significantly different between the patients with and without PAE (operative time, 202 vs. 164 min, p = 0.143: blood loss, 173 vs. 195 ml, p = 0.871). There was no 30-day mortality at a median follow-up period of 41.5 months.

CONCLUSIONS

Surgical results for pulmonary aspergilloma were feasible and the postoperative morbidities were acceptable. PAE was considered effective in lessening surgical stress.

Complications of surgery for infectious lung cavities

Background Infectious lung cavities are a common entity for the respiratory physician. Sometimes these lesions require surgical treatment, but surgery is challenging, and complications are common. Methods Patients with infectious lung cavities amenable to surgical treatment were included in a case-control study. The control group included patients with no complications. The cases group comprised patients with any of the following complications up to 90 days after surgery: death, persistence of hemoptysis, empyema, operative blood loss > 500 mL, vascular lesion requiring repair, massive transfusion (>5 units of packed red blood cells per 48 h) or reoperation for bleeding, postoperative mechanical ventilation, intensive care unit stay > 48 h, prolonged air leak, and persistent atelectasis. The potential risk factors for complications analyzed were demographic data, exposure to contaminants, comorbidities, preoperative embolization, surgical indication, spirometry results, and sputum test positive for Mycobacterium tuberculosis. Results Forty-five patients were included in the study and divided into 24 cases and 21 controls. We found a significant difference in the time to removal of chest tubes in favor of the noncomplicated cases (6.45 vs. 4.05 days, p = 0.030), and persistent active infection at the time of surgery tended to be a risk factor for complications (odds ratio = 6.6, 95% confidence interval: 0.7-60, p = 0.061). Conclusion The presence of persistent active infection at the time of surgery could be a risk factor for complications in resection surgery for infectious lung cavities.

Complex Pulmonary Aspergilloma: Surgical Challenges in a Third World Setting

BACKGROUND

Surgery for pulmonary aspergilloma (PA), especially complex forms, is greatly challenging in a resource-poor setting such as Cameroon. We report our experience of surgical management of PA in this environment.

METHOD

We prospectively assessed patients who underwent surgery for PA from January 2012 to May 2015, at the University Hospital Center of Yaoundé. Records were reviewed for demographics, history and physical examinations, radiological findings, surgical procedures, and outcomes. The study has received approval from the institutional ethics committees.

RESULTS

In total, 20 patients (17 males and 3 females (sex ratio, 5.66); mean age, 30 years; range, 23-65 years) with a past history of tuberculosis were assessed. The median follow-up was 21.5 months. The primary symptom was hemoptysis, followed by cough and chest pain. All patients underwent surgical treatment and lung resection. Postoperative complications (bleeding, air leak, empyema, and severe anemia) occurred in 4 patients and 1 patient died. Although 3 patients were lost to follow-up, the survival rate was 80% with improvement of the preoperative symptoms.

CONCLUSION

Although surgery for complex aspergilloma is very challenging in environments such as ours, we believe that it is the best treatment modality for symptomatic diseases in our setting.

Surgical treatment for pulmonary aspergilloma - early and long-term results

Introduction

Pulmonary aspergilloma is a difficult therapeutic problem due to the low effectiveness of conservative treatment and high surgical morbidity.

Aim

To analyze the early and late results of surgical treatment for pulmonary aspergilloma.

Material and methods

From 2005 to 2015, 49 patients were treated surgically for pulmonary aspergilloma. Symptoms occurred in 85.7% of cases, including recurrent hemoptysis in 53%. A history of immunosuppressive therapy or chemotherapy was noted in 24.5% of patients. Complex aspergilloma was diagnosed in 79.6% of cases. Immunological test results were positive in 10.2%, and bronchoalveolar lavage samples were positive for Aspergillus species in 18.5% of cases. In 59.2% of patients, the surgical risk was assessed as ASA 3. Thirty seven patients underwent lobectomy, 3 – pneumonectomy, 7 – wedge resection, 1 – decortication, and 1 – cavernostomy.

Results

In-hospital mortality was 4.1%. Postoperative complications occurred in 63.3% of patients. The most common complications were: prolonged air leak (26.3%), arrhythmias (20.4%), residual pneumothorax (16.3%), respiratory failure (14.3%), atelectasis (12.3%), and bleeding (12.3%). Of the three patients that underwent pneumonectomy, one died, two required repeat thoracotomy because of bleeding, and all three required prolonged mechanical ventilation. Two patients died during the follow-up period. Aspergilloma did not recur in any of the patients who underwent pulmonary resection.

Conclusions

Due to the high risk of complications, surgical treatment of pulmonary aspergilloma should be restricted to symptomatic patients in whom lobectomy can be performed. The long-term results of surgical treatment are good, preoperative symptoms abate in most patients, and the rate of aspergillosis recurrence is very low.

Chronic pulmonary aspergillosis complicating sarcoidosis

Chronic pulmonary aspergillosis (CPA) complicating sarcoidosis (SA) is associated with high mortality, and there is a lack of clarity regarding the relative contributions of SA or CPA.

This was a retrospective single-centre study on CPA-SA.

In total, 65 patients (44 men), aged 41.4±13.5 and 48.3±11.9 years at the time of SA and CPA diagnoses, respectively, were included between 1980 and 2015. Of these, 64 had fibrocystic SA, most often advanced, with composite physiological index (CPI) >40 (65% of patients) and pulmonary hypertension (PH) (31%), and 41 patients (63%) were treated for SA (corticosteroids or immunosuppressive drugs). Chronic cavitary pulmonary aspergillosis (CCPA) was the most frequent CPA pattern. Regarding treatment, 55 patients required long-term antifungals, 14 interventional radiology, 11 resection surgery and two transplantation. Nearly half of the patients (27; 41.5%) died (mean age 55.8 years); 73% of the patients achieved 5-year survival and 61% 10-year survival. Death most often resulted from advanced SA and rarely from haemoptysis. CPI, fibrosis extent and PH predicted survival. Comparison with paired healthy controls without CPA did not show any difference in survival, but a higher percentage of patients had high-risk mould exposure.

CPA occurs in advanced pulmonary SA. CPA-SA is associated with high mortality due to the underlying advanced SA rather than to the CPA. CPI, fibrosis extent and PH best predict outcome.

Predictors of mortality in chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a chronic progressive infection that destroys lung tissue in non-immunocompromised patients. Contemporary series suggest 50-85% 5-year mortality, with few prognostic factors identified.A cohort of 387 CPA patients referred to the UK's National Aspergillosis Centre from 1992 to June 2012 was studied until June 2015. The impact of objective and subjective variables including age, sex, previous pulmonary conditions, dyspnoea score, quality of life, serum albumin and C-reactive protein and radiological appearances were assessed using Kaplan-Meier curves, log rank tests and Cox proportional hazards modelling. In samples of patients, retrospective review of time from likely onset of CPA to referral and cause of death were also investigated.Survival was 86%, 62% and 47% at 1, 5 and 10 years, respectively. Increased mortality was associated with nontuberculous mycobacterial infection (hazard ratio 2.07, 95% CI 1.22-3.52; p<0.001) and chronic obstructive pulmonary disease (1.57, 1.05-2.36; p=0.029) as well as higher age (1.053, 1.03-1.07 per year; p<0.001), lower albumin (0.92, 0.87-0.96 per g·L^-1), lower activity (1.021, 1.01-1.03 per point increase in St George's Respiratory Questionnaire activity domain; p<0.001) and having one, and especially, bilateral aspergillomas (p<0.001).Several factors impact on mortality of CPA, and can be evaluated as tools to assess CPA prognosis.

Video-assisted thoracoscopic surgery for pulmonary aspergilloma

Introduction:

Surgical management of pulmonary aspergilloma in symptomatic patients offers a significant chance of cure. Video-assisted thoracic surgery is a valid alternative for properly selected cases. We herein report our experience with thoracoscopic management of pulmonary aspergilloma.

Patient and Methods:

This retrospective analysis was performed on 41 patients operated between 2012 to 2015. The patient records were thoroughly analyzed for demography, clinical presentation, computed tomography, the procedure performed, post-operative complications and course during 6 month's follow up.

Results:

Out of total 41 patients, 23 (56%) were treated by VATS and 18 (44%) by thoracotomy. Average intraoperative blood loss was 214 ml (±106) in VATS group and 461 ml (±167) in thoracotomy. Mean operative time was 162 (±14) minutes in VATS and 239 (±12) minutes in thoracotomy group. In VATS group, postoperative complications were found in 5 patients and in 11 patients in the thoracotomy group. Average duration of chest tube was 5.43 () days in VATS group and 8.94 () days in thoracotomy group. Average length of hospital stay was 5.04 in VATS group and 6.55 days in thoracotomy group.

Conclusions:

VATS for pulmonary aspergilloma, if applicable, may be a safe and efficacious option in experienced hands. Simple aspergilloma, in particular, is considered to be a good indication for VATS. Some cases of complex aspergilloma may also be amenable to VATS. However, the long term results need to be further analyzed using a larger study group.

Intrabronchial Voriconazole is a Safe and Effective Measure for Hemoptysis Control in Pulmonary Aspergilloma

BACKGROUND

Hemoptysis is common in pulmonary aspergilloma. Current treatment modalities such as surgical resection or bronchial artery embolization (BAE) are limited by lack of technical expertise and risk of recurrence, respectively. We describe our experience of treating aspergilloma and hemoptysis with bronchoscopic instillation of voriconazole.

METHODS

We retrospectively reviewed records of patients with symptomatic aspergilloma undergoing bronchoscopic voriconazole instillation. Four sessions were carried out at weekly intervals using 400 mg voriconazole dissolved in 20 mL 0.9% normal saline.

RESULTS

A total of 82 subjects were evaluated [66 males; mean (SD) age, 43.2 (14.1) y]. The commonest underlying etiology was posttubercular sequelae (95.1%). Of these, 18 patients (22%) had BAE within the last 1 year. The mean (SD) size of aspergilloma was 4.5 cm (1.5 cm). Following voriconazole instillation, 25 patients (30.5%) had significant resolution of hemoptysis after first session, and 52 patients (68.3%) after the second session. Transient postprocedure cough (n=38; 46.3%) was the commonest procedure-related adverse event. Follow-up CT (n=47) showed reduction in aspergilloma size in 54% and no change in 40.4%. The median (IQR) hemoptysis-free period was 12 months (IQR, 9 to 15.5 mo). Recurrence of significant hemoptysis occurred in 24 (29.3%) patients during a median follow-up of 14.5 months (IQR, 9-18 mo). A history of prior BAE and baseline aspergilloma size were significantly associated with recurrence of significant hemoptysis.

CONCLUSION

Intrabronchial voriconazole instillation seems to be a safe and effective modality for hemoptysis control in pulmonary aspergilloma.

Complex pulmonary aspergilloma treated by cavernostomy

OBJECTIVE

To evaluate the effectiveness of cavernostomy in patients with complex fungal balls.

METHODS

We analyzed the medical records of patients undergoing cavernostomy between January 2005 and May 2013, evaluating: age, gender, preoperative signs and symptoms, predisposing disease, preoperative tests, location of the aspergilloma, etiologic agent, cavernostomy indication, postoperative outcome.

RESULTS

Ten patients were male. The mean age was 42.9 years (34-56). The most frequent symptom was repeated pulmonary bleeding. Cavernostomy was proposed for patients at high risk for lung resection. It was performed in 17 patients and all of them had pulmonary tuberculosis sequelae, with cavitations. The indication in all cases was hemoptysis and elimination of phlegm. The cavernostomies were performed in a single surgical procedure. In all 17 patients the cavity was left open after the withdrawal of the mycetoma. In all patients hemoptysis ceased immediately. Operative mortality was 9.5% (1).

CONCLUSION

cavernostomy is an effective treatment alternative in patients at high risk. It may be useful in some patients with complex aspergilloma, irrespective of lung function or bilateral disease. It is technically easy, has low-risk, saves parenchyma, and may be performed in a single operative time.

Characterization of patients with chronic pulmonary aspergillosis according to the new ESCMID/ERS/ECMM and IDSA guidelines

Recently, the Infectious Diseases Society of America (IDSA) and the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) in cooperation with the European Respiratory Society (ERS) and the European Confederation of Medical Mycology (ECMM) published guidelines for the diagnosis of chronic pulmonary aspergillosis (CPA). Both guidelines, however, carry significant differences. We retrospectively applied the diagnostic recommendations on a patient cohort of 71 previously diagnosed CPA patients in order to compare both guidelines. In 50 patients (70%) the diagnosis was confirmed by the diagnostic criteria of both guidelines, while nine patients (13%) fulfilled neither the ESCMID/ERS/ECMM nor the IDSA criteria. Reasons were lack of mycological evidence in respiratory samples. These patients were not tested for the presence of Aspergillus-specific IgG antibodies, which is strongly recommended by both guidelines. Seven patients did not fulfil the diagnostic criteria of the IDSA guideline, because of severe immunosuppression, while five patients didn't fulfil the diagnostic criteria of the ESCMID/ERS/ECMM guideline, because of uncommon image findings. The comparison of both guidelines highlight that the combination of a chest CT scan with the performance of an Aspergillus-specific IgG antibody assay are key diagnostic features to establish a guideline-based diagnosis of CPA.

A Series of Transbronchial Removal of Intracavitary Pulmonary Aspergilloma

BACKGROUND

Intracavitary pulmonary aspergilloma is a chronic, debilitating fungal infection. Without definitive therapy, death can occur from massive hemoptysis, cachexia, or secondary infection. Although surgical resection is the standard therapy, it is not possible for many patients owing to poor pulmonary function or medical comorbidities. Aspergilloma removal through bronchoscopy is an important alternative therapy that may be available in select cases.

METHODS

We retrospectively reviewed all cases referred to the University of Calgary Interventional Pulmonary Service for transbronchial removal of intracavitary aspergilloma from January 1, 2009, to January 1, 2014.

RESULTS

Ten patients with intracavitary pulmonary aspergilloma were identified. In 3 patients, the aspergilloma cavity was not accessible by bronchoscopy. Successful removal of the aspergilloma with symptom improvement or resolution was achieved in 6 of 7 cases. One of the patients was lost to follow-up. Minor hypoxia lasting 12 to 72 hours was observed in 5 cases. Severe sepsis requiring an extended critical care unit stay occurred in 1 case. Follow-up ranged from 9 months to 5 years.

CONCLUSIONS

Although not without risk of minor hypoxia and possible sepsis, for carefully selected patients, bronchoscopic removal of symptomatic intracavitary pulmonary aspergilloma may be an alternative therapy to surgical resection for this life-threatening disease.

[Opportunistic infections and sarcoidosis]

Opportunistic infections (OI) are uncommon in sarcoidosis (1 to 10%) and mostly occur in patients with previously diagnosed disease or can rarely be the presenting manifestation. The most common OIs are, in descending order: aspergillosis, cryptococcosis, and mycobacterial infections. Treatment with corticosteroids is the most frequent risk factor for OI occurrence during sarcoidosis but immunosuppressive drugs and therapy with anti-TNFα are also risk factors. Overall, clinical presentation, treatment, and outcome are identical to that occur in other conditions complicated with the occurrence of OIs. However, some atypical presentations of OIs can mimic sarcoidosis exacerbation and misdiagnosis may lead clinicians to increase immunosuppression, causing worsening of the OI. The meticulous collection of patient's history along with factors differentiating OI from sarcoidosis exacerbation is key factor to optimally manage these patients.

Massive Hemoptysis: Pathogenesis and Management

Massive hemoptysis is a life-threatening complication of many pulmonary disorders, and it occurs most com monly in association with longstanding inactive tuber culosis, bronchiectasis, lung abscess, bronchogenic car cinoma, and fungal disease. It is generally a neovascular change or local erosive effect of chronic pulmonary dis ease and may originate from either bronchial or pulmo nary circulation. Recurrent bleeding is unpredictable; therefore, diagnostic and therapeutic intervention must be undertaken with urgency. The immediate priorities must be protection of the airway to the nonbleeding lung and localization of the site of hemorrhage prefera bly by bronchoscopy, which has a high yield when per formed during active hemorrhage. Immediate control of bleeding may be obtained by local tamponade with a balloon-tipped Fogarty catheter, use of a double-lumen endotracheal tube, or angiographically guided emboliza tion. Surgical resection is the preferred definitive treat ment for those who meet operative criteria; those who lack adequate pulmonary reserve are candidates for em bolization of sites with persistent bleeding. The high mortality of conservatively treated massive hemoptysis and the current inability to predict which patients will have fatal hemorrhage mandate rapid assessment and intervention.

Analysis of Surgical Treatment for Pulmonary Aspergilloma

Surgery for pulmonary aspergilloma is reputed to be risky. The results of surgical treatment of pulmonary aspergilloma in 41 patients between 1988 and 2003 were evaluated retrospectively. Hemoptysis occurred in 31 patients (75.6%) and it was massive (> 300 mL in 24 hr) in 3. The underlying lung disease was tuberculosis in 35, bullous lung disease in 2, hydatid cyst in 2, and lung carcinoma in 2 patients. Lobectomy, bilobectomy, wedge resection, and pneumonectomy were performed in 27, 4, 6, and 4 patients respectively. The postoperative complication rate was 24.4%. One patient, who had a right pneumonectomy, died due to respiratory failure; the mortality rate was 2.4%. Recurrent hemoptysis was observed in only one patient. Early surgical treatment of patients with pulmonary aspergilloma resulted in a satisfactory outcome with acceptable morbidity, low mortality, and effective prevention of recurrent hemoptysis. Pneumonectomy has a high morbidity, thus it should be avoided if possible.

Surgical Management of Pulmonary Aspergilloma

Records of 59 patients (41 males and 18 females) who underwent 70 operations for pulmonary aspergilloma in a 23-year period were examined retrospectively. Sixty-three operations were for primary treatment of pulmonary aspergilloma, and 7 were for complications of surgery. Twenty-six postoperative complications occurred in 19 patients. Three lobectomies that resulted in bronchopleural fistula were managed by intercostal muscle-flap closure and partial thoracomyoplasty. Two patients died within the first week of surgery. Surgery is the treatment of choice for most patients with pulmonary aspergilloma. Selective bronchial artery embolization is helpful only in combating hemoptysis, and this has been considered a temporary measure in most reports. Thus, open thoracotomy and anatomical resection are recommended as early as possible after the diagnosis is established.

Cavernostomy for Pulmonary Aspergillosis Associated with Destroyed Lung after Surgery for Lung Cancer: Report of 3 Cases

Slow, progressive, and destructive changes in the residual lung after surgery for lung cancer, known as “destroyed lung,” are delayed nonrecurrent complications. Destroyed lung can be a difficult condition to treat due to repeated infections and is therefore a complication that should not be ignored. We had three cases of intractable pulmonary aspergillosis difficult to treat associated with destroyed lung, after lung cancer surgery. Two of these patients followed a characteristic clinical course, which started with a cystic change just below the pleura and subsequently led to respiratory failure and death due to repeated infections. The third patient followed a similar clinical course and is currently under regular follow-up. Our cases suggest that concomitant occurrence of severe complications following surgery for lung cancer, such as destroyed lung and pulmonary aspergillosis, should be monitored because these complications can lead to respiratory failure and fatal clinical course. Radical surgery is not possible, especially when medical treatment is ineffective in controlling repeated infections and the patient's general condition is worsened due to prolonged chronic inflammation. Therefore, aggressive surgical intervention should be considered before patients worsen.

Development of chronic pulmonary aspergillosis in adult asthmatics with ABPA

BACKGROUND

Chronic pulmonary aspergillosis (CPA) is an occasional complication of allergic bronchopulmonaryaspergillosis (ABPA) but the transition is poorly understood.

METHODS

All patients referred to the UK's National Aspergillosis Centre with CPA between May 2009 and June 2012 were screened with serum total IgE and anti-Aspergillus IgE for a dual diagnosis of ABPA and CPA. Those patients suspected of having both conditions were re-evaluated and their imaging reviewed.

RESULTS

Of 407 referred patients, 42 screened positive and 22 were confirmed as having both ABPA and CPA. Asthma was present from early childhood in 19 (86%), the median interval between ABPA and onset of CPA was 7.5 years; one patient developed ABPA and CPA simultaneously. Aspergillus IgG levels varied from 23 to 771 mg/L, median 82 mg/L. All 22 patients had bronchiectasis. In patients with ABPA, CT typically demonstrated varicose or cystic bronchiectasis primarily affecting segmental and proximal subsegmental upper lobe bronchi. Other findings included mucoid impaction and centrilobular nodules. Radiological changes associated with CPA included pleural thickening which was often bilateral and accentuated by adjacent hypertrophied extrapleural fat, upper lobe volume loss, thick walled apical cavities, some of which contained aspergillomas, and cavitating pulmonary nodules. CPA secondary to ABPA has more subtle radiological appearances than when due to other underlying diseases.

CONCLUSIONS

CPA may complicate ABPA and have distinct radiology features, in addition to bronchiectasis. A novel biomarker is required to anticipate this serious complication, as current serology is not specific enough.

Evaluation of the Double Agar Gel Immunodiffusion Test and of the Enzyme-Linked Immunosorbent Assay in the Diagnosis and Follow-Up of Patients with Chronic Pulmonary Aspergillosis

The diagnosis of chronic pulmonary aspergillosis (CPA) depends on the radiologic image and the identification of specific antibodies. The present study aimed to evaluate accuracy parameters of enzyme-linked immunosorbent assay (ELISA) and of the determination of serum galactomannan level in the diagnosis of patients with CPA, comparing these results with the double agar gel immunodiffusion (DID) test. In addition, the prevalence of cross-reactivity and the serological progression after treatment were evaluated by comparing DID and ELISA. Six study groups were formed: G1: 22 patients with CPA, 17 of whom had Aspergillus fungus ball, one chronic cavitary pulmonary aspergillosis (CCPA) and four chronic fibrosing pulmonary aspergillosis (CFPA); G2: 28 patients with pulmonary tuberculosis (TB); G3: 23 patients with histoplasmosis (HST); G4: 50 patients with paracoccidioidomycosis (PCM); G5: 20 patients with cryptococcosis (CRC); and G6: 200 healthy controls. Serum antibodies were measured by DID and ELISA, with two antigen preparations—Aspergillus fumigatus (DID₁, ELISA₁) and a pool of A. fumigatus, A. flavus and A. niger antigens (DID₂, ELISA₂). The Platélia Aspergillus Enzyme Immunoassay (EIA) kit was used to measure galactomannan. The cut-off points of ELISA were determined for each antigen preparation and for the 95% and 99% confidence intervals. Despite the low sensitivity, DID was the technique of choice due to its specificity, positive and negative predictive values and positive likelihood ratio–especially with the antigen pool and due to the low frequency of cross-reactivity. ELISA₁ and a 0.090 cut-off showed high sensitivity, specificity and negative predictive value, but a high frequency of cross-reactivity with CRC. The best degree of agreement was observed between ELISA₁ and ELISA₂. The detection of serum galactomannan showed high sensitivity, comparable to ELISA₂. The immunodiffusion test showed an excellent relationship with the progression after treatment, which made it the reaction of choice for patient follow-up.

Pulmonary aspergillosis presenting with recurrent haemoptysis

Pulmonary aspergillosis presents with a variety of clinical forms including invasive pulmonary aspergillosis, chronic necrotising aspergillosis, aspergilloma, chronic cavitary pulmonary aspergillosis and allergic bronchopulmonary aspergillosis. Haemoptysis is a devastating complication of pulmonary aspergillosis and a common indication for surgery. We report a case of a 54-year-old man with a history of pulmonary tuberculosis and diabetes mellitus, who presented with productive cough and haemoptysis for 2 months. Chest CT revealed a 30 mm diameter soft tissue mass in the upper lobe of the right lung. Haemoptysis subsided with conservative measures, but 2 weeks later the patient developed a new episode of persistent haemoptysis, which was only partially controlled with bronchial arterial embolisation. He underwent right upper and middle lobectomy. Histology examination confirmed the presence of a fungal cavitary lesion. The patient was started on voriconazole, and recovered with no recurrence at 18 months follow-up.

Surgery for localized pulmonary mycotic infections in patients with hematopoietic disorder

Background

Surgical resection is considered to be the most effective treatment for localized pulmonary mycotic infections. However it is also a particularly challenging procedure because it is associated with considerable mortality and morbidity. Furthermore, hematopoietic disorders usually cause immunosuppression, anemia, and coagulopathy, which are definite risk factors for surgery. The purpose of this study is to evaluate the surgical outcomes of pulmonary mycotic infections in hematopoietic disorder patients.

Methods

Between 2011 and 2013, 23 patients underwent surgical treatment for pulmonary mycotic infections at a single institution. The patients were divided into two groups; Group A (hematopoietic disorder patients, n = 9) and Group B (n = 14). We retrospectively reviewed medical and radiologic data.

Results

The complex type was more frequent in group A (66.6 %) than in group B (35.7 %). Postoperatively, there was no mortality. However, morbidity was 22.2 % (2 incomplete expansion) in group A, and 35.6 % (1 prolonged air leak, 3 bleeding, 1 Bronchopleural fistula) in group B. The difference in morbidity between the groups did not show any statistical significance (p = 0.657) as well as duration of chest tube drainage, and postoperative hospital stay. The hematopoietic disorder patients did not impose a risk factor for morbidity and mortality.

Conclusions

Although hematopoietic disorder patients have many surgical risk factors, the surgical treatment of pulmonary mycotic infections produces very acceptable outcomes in selected cases.

The spectrum of opportunistic diseases complicating sarcoidosis

Sarcoidosis is an inflammatory disease marked by a paradoxical immune status. The anergic state, which results from various immune defects, contrasts with the inflammatory formation of granulomas. Sarcoidosis patients may be at risk for opportunistic infections (OIs) and a substantial number of cases have been reported, even in untreated sarcoidosis. It is not clear how OIs in patients with sarcoidosis are different from other groups at risk. In this review, we discuss the most common OIs: mycobacterial infection (including tuberculosis), cryptococcosis, progressive multifocal leukoencephalopathy, and aspergillosis. Unlike peripheral lymphocytopenia, corticosteroids are a major risk factor for OIs but the occurrence of Ols in untreated patients suggests more complex predisposing mechanisms. Opportunistic infections presenting with extrapulmonary features are often misdiagnosed as new localizations of sarcoidosis. Aspergillomas mostly develop on fibrocystic lungs. Overall, physicians should be aware of the possible occurrence of OIs during sarcoidosis, even in untreated patients.

Misdiagnosis of invasive pulmonary aspergillosis: a clinical analysis of 26 immunocompetent patients

The clinical feature of invasive pulmonary aspergillosis (IPA) in immunocompromised patients is well studied in the past decades. While the manifestations of IPA in immunocompetent patients remain unclear. The purpose of this study was to determine the clinical and radiological manifestations of invasive pulmonary aspergillosis (IPA) in patients without immunosuppression, as well as the reasons for the misdiagnosis of IPA. We retrieved and retrospectively reviewed the records of 102 patients from whom surgical lung specimens of chronic inflammatory granulomas were harvested. 26 patients were eventually diagnosed with pulmonary aspergillosis on Grocott methenamine silver staining. We investigated these patients in detail. We found that the rate of misdiagnosis before the lung surgery was as high as 73%. The most common symptom was hemoptysis, and the main feature in radiology was nodule or mass lesion. Air crescent sign or Halo sign were not common in our study. The atypical radiological manifestations and non-specific clinical findings make the diagnosis of IPA difficult and lead to a high misdiagnosis rate.

Treatment of chronic pulmonary aspergillosis with voriconazole: review of a case series

PURPOSE

Chronic pulmonary aspergillosis (CPA) is a rare disease that primarily affects subjects with moderate immunodepression and/or structural alterations in the lung.

METHODS

Data for patients with probable CPA were collected over 24 months. Patients with probable CPA received oral voriconazole, and clinical, laboratory and radiological follow-up was performed at 3, 6 and 12 months.

RESULTS

21 patients (mean age 52.4 years) were evaluated. Factors predisposing to CPA were tuberculosis (n = 8), chronic obstructive pulmonary disease (n = 7), corticosteroids (n = 14), chemo- or radio-therapy (n = 6), tracheostomy or endotracheal prosthesis (n = 5), smoking (n = 4), asthma (n = 3), and chronic liver disease (n = 3). Sputum or bronchial aspirate cultures were positive for Aspergillus spp. in 14 cases (66.6 %). (1,3)-β-D-glucan on serum was positive in 16 cases (76.2 %). Excavated pulmonary thickening was evident in 14 patients (66.6 %) and in 9 of these cases (64.2 %) aspergilloma was present. [(18)F]2-fluoro-2-deoxy-D-glucose-PET-CT was positive in 13/15 patients, and simple aspergilloma was diagnosed after surgical excision in one of the negative cases. All patients were treated with oral voriconazole. Therapy was discontinued due to skin toxicity (n = 3), liver toxicity (n = 2) and severe mental disorder (n = 1). At 12 months' follow-up, nine patients (42.9 %) were considered cured or improved. Seven patients (33.3 %) died during follow-up, mainly due to underlying disease.

CONCLUSIONS

A reasonable proportion of patients achieved cure or improvement with voriconazole, but 28.5 % of treated patients had to discontinue therapy because of toxicity. The high mortality makes it difficult to fully assess the real efficacy of voriconazole and to establish the correct duration of therapy.