Complex Pulmonary Aspergilloma: Surgical Challenges in a Third World Setting

Factors affecting survival after anatomical lung resection in pulmonary aspergilloma: Our 10-year single institution experience

Background

The aim of this study was to investigate the long-term outcomes of patients who underwent anatomic lung resection for pulmonary aspergilloma and to evaluate the prognostic factors affecting early postoperative morbidity.

Methods

Between January 2007 and January 2017, we retrospectively evaluated a total of 55 patients (40 males, 15 females; mean age: 44.6 years; range, 18 to 75 years) who underwent lobectomy and pneumonectomy for pulmonary aspergilloma. All patients were evaluated for simple or complex aspergilloma based on imaging and thoracotomy findings.

Results

Thirty-two (58.2%) patients presented with hemoptysis. Seven (12.7%) patients underwent emergency surgery due to massive hemoptysis. Postoperative morbidity was observed in 15 (27.3%) patients. Prognostic factors that had an effect on morbidity were resection type, Charlson Comorbidity Index >3, and massive hemoptysis (p<0.05). There was no intra- or postoperative mortality. The five-year survival rate was 89.4%. None of the factors evaluated in the study were associated with survival.

Conclusion

The main finding of this study is the absence of mortality after surgical treatment for pulmonary aspergilloma. The success of surgical treatment depends on the management of postoperative complications.

Mapping of Chronic Pulmonary Aspergillosis in Africa

Africa has a high burden of tuberculosis, which is the most important risk factor for chronic pulmonary aspergillosis (CPA). Our goal was to systematically evaluate the burden of CPA in Africa and map it by country. We conducted an extensive literature search for publications on CPA in Africa using the online databases. We reviewed a total of 41 studies published between 1976 and 2021, including a total of 1247 CPA cases from 14 African countries. Most of the cases came from Morocco (n = 764, 62.3%), followed by South Africa (n = 122, 9.9%) and Senegal (n = 99, 8.1%). Seventeen (41.5%) studies were retrospective, 12 (29.3%) were case reports, 5 case series (12.2%), 5 prospective cohorts, and 2 cross-sectional studies. The majority of the cases (67.1%, n = 645) were diagnosed in men, with a median age of 41 years (interquartile range: 36–45). Active/previously treated pulmonary tuberculosis (n = 764, 61.3%), human immunodeficiency virus infection (n = 29, 2.3%), diabetes mellitus (n = 19, 1.5%), and chronic obstructive pulmonary disease (n = 10, 0.8%) were the common co-morbidities. Haemoptysis was the most frequent presenting symptom, reported in up to 717 (57%) cases. Smoking (n = 69, 5.5%), recurrent lung infections (n = 41, 3%) and bronchorrhea (n = 33, 3%) were noted. This study confirms that CPA is common in Africa, with pulmonary tuberculosis being the most important risk factor.

Surgical management of chronic pulmonary aspergillosis in Africa: A systematic review of 891 cases

Chronic pulmonary aspergillosis (CPA) is an emerging fungal infectious disease of public health importance. We conducted a systematic review of studies reporting the outcomes of patients with CPA managed surgically in Africa. A search of Medline, Embase, Web of Science, Google Scholar and African Journals Online was conducted to identify studies indexed from inception to June 2021 that examined surgical management of CPA in Africa. All articles that presented primary data, including case reports and case series, were included. We excluded review articles. A total of 891 cases (557 males (62.5%), mean age 39.3 years) extracted from 27 eligible studies published between 1976 and 2020 from 11 African countries were included. Morocco (524, 59%) and Senegal (99, 11%) contributed the majority of cases. Active or previous pulmonary tuberculosis was reported in 677 (76.0%) cases. Haemoptysis was reported in 682 (76.5%) cases. Lobectomy (either unilateral or bilateral, n = 493, 55.3%), pneumonectomy (n = 154, 17.3%) and segmentectomy (n = 117, 13.1%) were the most frequently performed surgical procedures. Thirty (4.9%) cases from South Africa received bronchial artery embolisation. Empyema (n = 59, 27.4%), significant haemorrhage (n = 38, 173.7%), incomplete lung expansion (n = 26, 12.1%) and prolonged air leak (n = 24, 11.2%) were the most frequent complications. Overall, 45 (5.1%) patients died. The causes of death included respiratory failure (n = 14), bacterial superinfection/sepsis (n = 10), severe haemorrhage (n = 5), cardiopulmonary arrest (n = 3) and complications of chronic obstructive pulmonary disease (n = 3). The cause of death was either unknown or unspecified in 9 cases. We conclude that surgical treatment had very low mortality rates and maybe considered as first-line management option in centres with experience and expertise in Africa.

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 .

Chronic pulmonary aspergillosis commonly complicates treated pulmonary tuberculosis with residual cavitation

Chronic pulmonary aspergillosis (CPA) complicates treated pulmonary tuberculosis (TB), with high 5-year mortality. We measured CPA prevalence in this group.398 Ugandans with treated pulmonary TB underwent clinical assessment, chest radiography and Aspergillus-specific IgG measurement. 285 were resurveyed 2 years later, including computed tomography of the thorax in 73 with suspected CPA. CPA was diagnosed in patients without active TB who had raised Aspergillus-specific IgG, radiological features of CPA and chronic cough or haemoptysis.Author-defined CPA was present in 14 (4.9%, 95% CI 2.8-7.9%) resurvey patients. CPA was significantly more common in those with chest radiography cavitation (26% versus 0.8%; p<0.001), but possibly less frequent in HIV co-infected patients (3% versus 6.7%; p=0.177) The annual rate of new CPA development between surveys was 6.5% in those with chest radiography cavitation and 0.2% in those without (p<0.001). Absence of cavitation and pleural thickening on chest radiography had 100% negative predictive value for CPA. The combination of raised Aspergillus-specific IgG, chronic cough or haemoptysis and chest radiography cavitation had 85.7% sensitivity and 99.6% specificity for CPA diagnosis.CPA commonly complicates treated pulmonary TB with residual chest radiography cavitation. Chest radiography alone can exclude CPA. Addition of serology can diagnose CPA with reasonable accuracy.

The Burden of Serious Fungal Infections in Cameroon

Fungal infections are frequent in Cameroon, and invasive fungal infections are sometimes detected, usually in HIV-infected patients. For these reasons, we have estimated the burden of fungal infections. Using published literature and population estimates for the at-risk group, we used deterministic modelling to derive national incidence and prevalence estimates for the most serious fungal diseases. HIV infection is common and an estimated 120,000 have CD4 counts <200 × 10⁶/mL and commonly present with opportunistic infection. Oesophageal candidiasis in HIV is common, and in poorly controlled diabetics. We estimate 6720 cases of cryptococcal meningitis, 9000 of Pneumocystis pneumonia, 1800 of disseminated histoplasmosis annually complicating AIDS, and 1200 deaths from invasive aspergillosis in AIDS, but there are no data. We found that 2.4% of adults have chronic obstructive pulmonary disease (COPD) and 2.65% have asthma, with "fungal asthma" affecting 20,000. Chronic pulmonary aspergillosis probably affects about 5000 people, predominantly after tuberculosis but also with COPD and other lung diseases. Also, tinea capitis in schoolchildren is frequent. Overall, an estimated 1,235,775 people are affected by a serious fungal infection. There is an urgent need for government and clinician attention, improved laboratory facilities, fungal diagnostic tests, and competent laboratory technicians, as well as all World Health Organization (WHO)-endorsed essential antifungal drugs to be made available, as only fluconazole is registered and available in the country.

Unusual Life-Threatening Pneumothorax Complicating a Ruptured Complex Aspergilloma in an Immunocompetent Patient in Cameroon

An aspergilloma is a well-recognized lesion of the lung caused most of the time by the fungus Aspergillus fumigatus. Its main complication is hemoptysis and has been very rarely associated with tension pneumothorax. We present the case of a 47-year-old man with a history of treated and healed tuberculosis, which was successfully managed in our service for a ruptured right upper lobe complexed aspergilloma, complicated by a massive and tension pneumothorax. The patient underwent thoracotomy and lung resection with quick recovery. Conclusively, although rare, an aspergilloma may rupture and cause a life-threatening air leakage.