Successful treatment of invasive pulmonary aspergillosis in chronic granulomatous disease with orally administered itraconazole suspension

Current treatment options for chronic granulomatous disease

Chronic granulomatous disease is a rare inherited disorder of phagocytic cells which results in a susceptibility to infections of catalase-positive bacteria and fungi (especially Aspergillus species), as well as granuloma formation. The mainstay of therapy is antibacterial and antifungal prophylaxis. Trimethoprim sulfamethoxazole is the drug of choice for the prevention of bacterial infection, while itraconazole is most widely used for the prevention of fungal infection. Immunomodulatory agents, such as IFN-phi, have a role in the prevention and treatment of intractable infection. New antifungal agents provide the promise of improved cure rates for invasive Aspergillus, while bone marrow transplants and gene therapy may offer the promise of complete cure.

Effects of itraconazole therapy in allergic bronchopulmonary aspergillosis

STUDY OBJECTIVES

Allergic bronchopulmonary aspergillosis (ABPA) is the result of an immune reaction to antigens of Aspergillus fumigatus, which colonizes the bronchial lumen of affected individuals. Presently, the recommended treatment of ABPA, mainly for acute episodes of exacerbations, is administration of glucocorticoids. We initiated this study to analyze the effects of itraconazole on the clinical, biological, and functional parameters in patients with ABPA.

PATIENTS

in this report, we describe the follow-up of 14 asthmatic patients who presented with ABPA. During the 2-year reference period (a 2-year period before the introduction of itraconazole), 14 patients were treated with inhaled corticosteroids and 12 of the 14 received oral glucocorticoids. During the itraconazole treatment period, the patients were treated with oral itraconazole, 200 mg/d, for at least 12 months.

RESULTS

During the 2-year reference period, no significant clinical, immunologic, and functional improvement was observed on a long-term basis. During the itraconazole treatment period, a clinical improvement was observed. Blood eosinophilia, serum total IgE levels, and serum precipitating antibodies against A fumigatus antigen significantly decreased. No decrease of specific IgE against A fumigatus spp was observed. All patients experienced a partial improvement in pulmonary function tests: FEV(1) significantly increased from 1,433 +/- 185 to 1,785 +/- 246 mL/s (p < 0.01). All patients successfully lowered oral glucocorticoid dose when receiving itraconazole. In 7 of 14 patients receiving itraconazole, the removal of oral glucocorticoids was possible.

CONCLUSION

These results demonstrate the efficacy of itraconazole in ABPA in reducing or eliminating the need for glucocorticoid therapy, along with clinical, biological, and functional improvement.

Brief exposure to 95% oxygen alters surfactant protein D and mRNA in adult rat alveolar and bronchiolar epithelium

Surfactant protein D (SP-D), which has structural homology to C-type lectin binding regions, may play a role in host defense and has no known surfactant function. Because other surfactant proteins have been shown to be increased after prolonged periods of hyperoxia, we sought to evaluate the early effects of hyperoxia (95% O2) on expression of SP-D in the adult male rat lung. Animals were exposed to air or to 12, 36, or 60 h of 95% O2. Northern blot analysis of total lung RNA revealed marked SP-D mRNA increases at 12 h 95% O2 compared with air-exposed controls, with decreasing expression to near that of air-exposed animals by 60 h. Semiquantitative in situ RNA hybridization demonstrated parallel results, with increased numbers of labeled alveolar epithelial (AE) and bronchiolar epithelial (BE) cells at 12 h and increased intensity of labeled alveolar cells, compared with air-exposed controls. After 60 h of exposure to 95% O2, mRNA label intensity in AE and BE was decreased to levels near those seen in air-exposed animals. In contrast, Western blotting showed a decline in total lung SP-D with 95% O2 exposure, beginning at 12 h and continuing at 36 and 60 h, respectively. Semiquantitative immunohistochemistry demonstrated a decline in AE labeling parallel to the total lung Western blot results, but labeled total BE cell numbers increased (P = 0.10). Hyperoxia had differential effects on SP-D abundance in AE and BE cells, and therefore may influence the availability of SP-D to bind microbial pathogens in the airways depending on cell type and location.

Early alterations in intracellular and alveolar surfactant of the rat lung in response to endotoxin

The aim of this study was to characterize early ultrastructural, biochemical, and functional alterations of the pulmonary surfactant system induced by Salmonella minnesota lipopolysaccharide (LPS) in rat lungs. Experimental groups were: (1) control in vitro, 150 min perfusion; (2) LPS in vitro, 150 min perfusion, infusion of 50 microg/ml LPS after 40 min; (3) control ex vivo, 10 min perfusion; (4) LPS ex vivo, lungs perfused for 10 min from rats treated for 110 min with 20 mg/kg LPS intraperitoneally. Morphometry of type II pneumocytes showed that LPS increased stored surfactant. Lamellar bodies were increased in size, but decreased in numerical density, suggesting that giant lamellar bodies observed in LPS-treated lungs may result from fusion of normal bodies. Structural analysis of alveolar surfactant composition showed that LPS elicited an increase in lamellar body-like and multilamellar forms. Bronchoalveolar lavage (BAL) material from LPS-treated lungs was decreased in phospholipids. BAL bubble surfactometer analysis showed a reduction in hysteresis area caused by LPS. We conclude that LPS leads to alterations of intracellular and alveolar surfactant within 2 h: fusion of lamellar bodies, reduction in surfactant secretion, and changes in alveolar surfactant transformation, composition, and function, which may contribute to the development of respiratory distress.

Successful treatment with voriconazole of invasive aspergillosis in chronic granulomatous disease

A 5-year-old boy with chronic granulomatous disease (CGD) was treated with amphotericin B for an invasive pulmonary Aspergillus nidulans infection. The infection progressed during 6 wk of treatment despite the addition of interferon-gamma (IFN-gamma), filgrastim, and transfusions with donor granulocytes. Treatment with a novel antifungal triazole, voriconazole, resulted in an excellent clinical response.

Invasive aspergillosis in human immunodeficiency virus-infected children

BACKGROUND

Aspergillosis is an uncommon yet serious opportunistic infection in patients with AIDS. It has been extensively reported in HIV-infected adult patients. To our knowledge there are no studies that describe the epidemiology, clinical manifestations and outcome of aspergillosis in a large HIV-infected pediatric population.

METHODS

We reviewed the records of all 473 HIV-infected children followed in the Pediatric Branch of the National Cancer Institute for 9 years from 1987 through 1995 for the presence of Aspergillus infection.

RESULTS

Seven (1.5%) patients developed invasive aspergillosis during the study period. All patients had low CD4 counts reflecting severe immunosuppression. Sustained neutropenia (> 7 days) or corticosteroid therapy as a predisposing factor for invasive aspergillosis was encountered in only two patients (28%). Invasive pulmonary aspergillosis developed in five patients and cutaneous aspergillosis in two. The most common presenting features in patients with pulmonary aspergillosis were fever, cough and dyspnea. Patients with cutaneous aspergillosis were diagnosed during life and successfully treated with amphotericin B and surgery, whereas diagnosis of pulmonary aspergillosis was made clinically in only one patient.

CONCLUSIONS

Aspergillosis is an uncommon but highly lethal opportunistic infection in HIV-infected children. Invasive pulmonary aspergillosis should be considered in the differential diagnosis in febrile, HIV-infected children with persistent pulmonary infiltrates.