BRONCHOPULMONARY ASPERGILLOSIS. A CORRELATION OF THE CLINICAL AND LABORATORY FINDINGS IN 272 PATIENTS INVESTIGATED FOR BRONCHOPULMONARY ASPERGILLOSIS

Surgical management of pulmonary aspergilloma-12 years' experience from a tertiary care centre in India

Introduction and purpose

Pulmonary aspergilloma is the formation of saprophytic colonies of fungus in pre-existing pulmonary cavities. They may cause life-threatening haemoptysis. As medical treatment often fails, surgery is the mainstay of treatment in symptomatic patients. Earlier studies had reported high levels of mortality and morbidity with surgery while more recent studies have shown better results. Hence, being in a large tertiary care centre in India, we decided to analyse the details of our own experience in the surgical management of pulmonary aspergilloma.

Methods

Details of all adult patients treated surgically for pulmonary aspergilloma, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analysed.

Results

There were 102 patients in the study. The average age was 40 years. There was a male (M: F, 3:1) and right side preponderance. Pulmonary tuberculosis (TB) was the commonest cause for cavities in which aspergilloma developed as identified in 84 (82%) patients and diabetes mellitus, the commonest comorbidity present in 28 (27.5%) patients. Parenchyma-preserving lung resections (PPLRs) were feasible in 8 (44%) of the non-tubercular patients, but only in 14 (17%) of the TB patients. Post-operative complications (11.7%) were higher among the patients with TB. There were 2 (1.9%) post-operative mortalities.

Conclusion

Though surgery is technically complex in the presence of pulmonary aspergilloma, it is yielding better results with improvements in treatment strategies. Surgery for aspergilloma in patients with prior or current pulmonary TB has more morbidity and mortality when compared to the non-TB patients.

Prognostic factors of chronic pulmonary aspergillosis: A retrospective cohort of 264 patients from Japan

Background

Chronic pulmonary aspergillosis (CPA) develops in various underlying pulmonary conditions. There is scarce data evaluating interstitial lung disease (ILD)/abnormalities (ILA) as such conditions, and it has not been explored much whether non-tuberculous mycobacterial pulmonary disease (NTM-PD) is a prognostic factor for mortality in CPA patients. Few reports had investigated prognostic factors of CPA including underlying pulmonary conditions.

Objectives

To explore prognostic factors of CPA including pulmonary conditions.

Methods

We conducted a retrospective cohort study of 264 CPA patients from a center for pulmonary aspergillosis in Japan.

Results

Survival rates were 78.7%, 61.0%, and 47.4% at 1, 3, and 5 years, respectively. Of 264 patients, 53 (20.1%) and 87 (33.1%) were complicated with ILA and NTM-PD. Several independent prognostic factors were identified by multivariate Cox proportional analysis: ILA (HR 1.76, 95%CI 1.06–2.92, p = 0.029), age (1.05, 1.02–1.08, p<0.001), male sex (2.48, 1.34–4.59, p = 0.004), body mass index of <18.5 kg/m² (1,87, 1.20–2.90, p = 0.005), presence of aspergilloma (1.59, 1.04–2.45, p = 0.033), and lower serum albumin (0.56, 0.38–0.83, p = 0.004). NTM-PD was not associated with higher mortality (0.85, 0.52–1.38, p = 0.51).

Conclusions

The poor prognosis of CPA and several prognostic factors were revealed. Early diagnosis and intervention is required with reference to such factors.

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.

Mercury affects the phylloplane fungal community of blueberry leaves to a lesser extent than plant age

Mercury (Hg) is a toxic heavy metal pollutant that is globally distributed due to atmospheric deposition to non-point source locations. Leaf surfaces directly sequester atmospheric Hg. Little is known of how phylloplane (leaf surface) fungi are influenced by Hg pollution. Through culture-based methodology, this study analysed fungal phylloplane community identity following a single-dose response to HgCl2 concentrations between 0 and 20 times ambient levels for New Jersey. Time passed following the Hg addition had a strong influence on the fungal phylloplane community, associated with natural successional changes. Mercury, however, did not significantly affect the phylloplane community identity. Notably, the control group was not significantly different than any of the Hg treatments. How the phylloplane functional group responds to Hg pollution has not been previously investigated and more research is needed to fully understand how Hg influences fungal phylloplane ecology.

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.

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.

Eosinophilic pneumonias

This review starts with discussions of several infectious causes of eosinophilic pneumonia, which are almost exclusively parasitic in nature. Pulmonary infections due specifically to Ascaris, hookworms, Strongyloides, Paragonimus, filariasis, and Toxocara are considered in detail. The discussion then moves to noninfectious causes of eosinophilic pulmonary infiltration, including allergic sensitization to Aspergillus, acute and chronic eosinophilic pneumonias, Churg-Strauss syndrome, hypereosinophilic syndromes, and pulmonary eosinophilia due to exposure to specific medications or toxins.

Clinical features of invasive bronchial-pulmonary aspergillosis in critically ill patients with chronic obstructive respiratory diseases: a prospective study

Introduction

Critically ill patients with chronic obstructive respiratory diseases (CORD) who require intensive care unit (ICU) admission are at particular risk for invasive bronchial-pulmonary aspergillosis (IBPA). The purpose of this study is to investigate clinical features for rapid recognition of IBPA in critically ill patients with CORD.

Methods

We included 55 consecutive CORD patients in a respiratory ICU in a prospective, single-center, cohort study. In this study, IBPA combined two entities: ATB and IPA.

Results

Thirteen of 55 patients were diagnosed with IBPA. Before ICU admission, three variables were independent predictors of IBPA with statistical significance: more than three kinds of antibiotics used before the ICU admission, accumulated doses of corticosteroids (>350 mg) received before the ICU admission, and APACHE II scores >18 (OR, 1.208; P = 0.022; OR, 8.661; P = 0.038; and OR, 19.488; P = 0.008, respectively). After ICU admission, more IBPA patients had a high fever (>38.5°C) (46.2% versus 11.9%; P = 0.021), wheeze without exertion (84.6% versus 50.0%; P = 0.027), dry rales (84.6% versus 40.4%; P = 0.005), higher white blood cell counts (21 × 10⁹/L versus 9.4 × 10⁹/L; P = 0.012), lower mean arterial pressures (77.9 mm Hg versus 90.5 mm Hg; P = 0.019), and serum creatinine clearances (36.2 ml/min versus 68.8 ml/min; P < 0.001), and liver-function and coagulation abnormalities. Bronchospasm, sputum ropiness, and plaque formation were more common for IBPA patients during bronchoscopy (66.7% versus 14.3%; P = 0.082; 18% versus 0; P = 0.169; and 73% versus 13%; P = 0.003, respectively). More IBPA patients had nodules and patchiness on chest radiograph on day 1 of admission, which rapidly progressed to consolidation on day 7. IBPA mortality was higher than that of non-IBPA patients (69.2% versus 16.7%; P = 0.001).

Conclusions

IBPA may be suspected in critically ill CORD patients with respiratory failure and clinical and bronchoscopic manifestations of severe infection, bronchospasm, and rapid progression of radiologic lesions that are irresponsive to steroids and antibiotics. To avoid misdiagnosis and establish the microbiologic etiology, early bronchoscopy and tight radiologic follow-up should be performed.

An alternate method of classifying allergic bronchopulmonary aspergillosis based on high-attenuation mucus

Background and Aim

Allergic bronchopulmonary aspergillosis (ABPA) is classified radiologically based on the findings of central bronchiectasis (CB) and other radiologic features (ORF). However, the long-term clinical significance of these classifications remains unknown. We hypothesized that the immunological activity and outcomes of ABPA could be predicted on HRCT chest finding of high-attenuation mucus (HAM), a marker of inflammatory activity. In this study, we evaluate the severity and clinical outcomes of ABPA with different radiological classifications.

Methods

Patients were classified based on CT chest findings as: (a) serologic ABPA (ABPA-S) and ABPA-CB; (b) ABPA-S, ABPA-CB, and ABPA-CB-ORF; and, (c) ABPA-S, ABPA-CB and ABPA-CB-HAM. The clinical, spirometric and serological (total and A fumigatus specific IgE levels, eosinophil count) severity of the disease and clinical outcomes in various classifications were analyzed.

Results

Of the 234 (123 males, 111 females; mean age, 34.1 years) patients, 55 (23.5%) had normal HRCT, 179 (76.5%) had CB, 49 (20.9%) had HAM, and 27 (11.5%) had ORF. All immunological markers were consistently higher in the HAM classification, while in other classifications these findings were inconsistent. On multivariate analysis, the factors predicting frequent relapses were presence of HAM (OR 7.38; 95% CI, 3.21–17.0) and CB (OR 3.93; 95% CI, 1.63–9.48) after adjusting for ORF.

Conclusions

The classification scheme based on HAM most consistently predicts immunological severity in ABPA. Central bronchiectasis and HAM are independent predictors of recurrent relapses in ABPA. Hence, HAM should be employed in the radiological classification of ABPA.

Interaction of Aspergillus fumigatus Spores with Human Leukocytes and Serum

Serum was necessary for optimal phagocytosis of Aspergillus fumigatus spores by human leukocytes, and its opsonic capacity was greatly diminished by heat inactivation (56 C, 30 min). A germination assay, described in this report, was developed to study the fate of phagocytized spores. After incubation for 3 hr with normal leukocytes and serum, spores ingested by peripheral blood neutrophils and monocytes remained viable. Since we had previously found that myeloperoxidase (MPO), a lysosomal enzyme of human neutrophils and monocytes, exerted fungicidal activity against Candida albicans when combined with H(2)O(2) and chloride or iodide, the effects of these substances on A. fumigatus spores were examined. Spore viability was not impaired by MPO alone, H(2)O(2) alone, or KI alone, but high concentrations of KI and H(2)O(2) in combination caused marked inhibition of subsequent germination. MPO imparted fungicidal activity to concentrations of KI and H(2)O(2) that lacked any effect in its absence. NaCl, in combination with MPO and H(2)O(2), was far less effective than the iodide salt against A. fumigatus. The relative ineffectiveness of chloride in this system could underly the apparent inability of human neutrophils to kill ingested A. fumigatus spores, despite their competence to kill C. albicans.

Indications and outcome of surgery for pulmonary aspergilloma

BACKGROUND

The indications and the outcome of surgery for pulmonary aspergilloma remain highly controversial. The short term and long term results of lung resection or cavernostomy in 24 patients with pulmonary aspergilloma are reported.

METHODS

The case notes of 27 consecutive patients referred for surgical assessment for pulmonary aspergilloma at the Royal Brompton Hospital over the last 14 years were reviewed. Patients were categorised into four classes according to their fitness for lung resection and the severity of their symptoms. Severe symptoms were defined as life threatening haemoptysis or other symptoms requiring more than one hospital admission. Class I (n = 1), fit individual with mild or no symptoms; class II (n = 17), fit individuals with severe symptoms; class III (n = 1), unfit individual with no symptoms; and class IV (n = 8), unfit individuals with severe symptoms. Two asymptomatic patients and one on an IVOX pump were not accepted for surgery. Lung resection was performed in all 17 patients with class II disease, comprising segmentectomy only in five patients, lobectomy and segmentectomy in seven, and a completion pneumonectomy in five patients. Cavernostomy was performed in seven patients with class IV disease.

RESULTS

Surgery was often complicated by prolonged air leakage and infection of residual space. There was no operative mortality in the group treated by resection whereas two of those who underwent cavernostomy died in the early postoperative period. All survivors were followed up for a median of 17 months (range 1-72 months); 19 were alive and had no symptoms attributable to aspergilloma. Late recurrence occurred in two patients in the cavernostomy group. The only late death occurred in the resection group five months postoperatively and was attributed to end stage renal disease.

CONCLUSIONS

Lung resection in selected patients with complicated aspergilloma can be performed with low operative mortality. Cavernostomy is associated with high mortality and morbidity and should therefore only be performed in patients with life threatening symptoms who are unfit for lung resection.

Topical treatment of life threatening haemoptysis from aspergillomas

BACKGROUND

The efficacy of topical treatment of 12 episodes of severe life threatening haemoptysis from a pulmonary aspergilloma in 11 patients is reviewed.

METHODS

A retrospective review was performed on five white and six African-American patients of mean age 49 years. The underlying diseases were bronchiectasis, sarcoidosis, tuberculosis, or histoplasmosis. The patients were prospectively considered poor surgical risks because they had a forced expiratory volume in one second (FEV1) of < 50% predicted and an arterial oxygen tension (PaO2) of < 7.95 kPa breathing room air. As surgical intervention was not possible, local intracavitary instillation of sodium or potassium iodide was performed. Two patients were previously treated with amphotericin B. In one patient sodium iodide alone was used and in the remaining eight potassium iodide alone was instilled. The transcricothyroid approach was used in six patients and the percutaneous approach in five.

RESULTS

Haemoptysis ceased within 72 hours in all patients after the instillation of sodium or potassium iodide. There was no morbidity or mortality, and side effects included slight irritation on instillation of the iodide solution and occasional cough which was easily controlled. All patients were alive at least one year later.

CONCLUSION

Intracavitary treatment is a viable option in the poor risk patient with life threatening haemoptysis from an aspergilloma.

Immunodiagnosis of aspergillosis

Aspergillus species are ubiquitous fungi and have been implicated as the causative agents of a variety of lung disorders in humans. These disorders include allergic, saprophytic, and systemic manifestations. The allergic disorders mainly affect atopic persons, and invasive or systemic diseases affect immunosuppressed individuals. Immunodiagnosis can help the practitioner diagnose these diseases. Demonstration of circulating antibodies is a useful criterion, but the lack of dependable and standardized antigens is a limiting factor in the diagnosis of most Aspergillus-induced diseases. Despite this limitation, however, immunodiffusion and enzyme-linked immunosorbent assays have been widely used for the detection of antibodies in the sera of patients with aspergillosis. Similarly, crude and semipurified antigens are being used to demonstrate skin hypersensitivity in patients, and several methods have been useful in the detection of antigenemia in patients with invasive aspergillosis. With a growing number of reports on the incidence of aspergillosis and an increase in the number of immunosuppressed individuals in the population, more rapid methods and more reliable reagents for immunodiagnosis are needed. With recent attempts at obtaining reliable reagents for through hybridoma technology and molecular biological techniques, substantial progress toward efficient immunodiagnosis may be achieved.

Management of pulmonary aspergilloma in the presence of active tuberculosis

Eleven cases of pulmonary aspergilloma complicating active cavitating pulmonary tuberculosis are reviewed. Nine of the 10 patients who had combined medical (antituberculosis drugs) and surgical treatment were cured of their disease; one patient, who had bilateral multiple aspergillomas, died from massive haemoptysis after resection of one of the affected lobes. The only medically treated patient who refused surgery had fatal haemoptysis at home. Pulmonary resection is recommended for patients who are fit for operation whenever the diagnosis of aspergilloma is made because most published reports indicate that only a few patients benefit from drug treatment alone.

What happens to patients with pulmonary aspergilloma? Analysis of 23 cases

The problems associated with pulmonary aspergilloma were assessed retrospectively in 23 patients presenting from 1953 to 1982. Haemoptysis occurred in over half the patients and in two it was fatal. Invasive aspergillosis occurred in five patients, a higher proportion than in earlier reports, and two of these died. Amphotericin B in combination with either flucytosine or natamycin and, more recently, ketoconazole have proved useful in the treatment of this condition.

Lung collapse caused by allergic bronchopulmonary aspergillosis in non-asthmatic patients

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Allergic bronchopulmonary aspergillosis (ABPA): studies on the general and specific humoral response

Serum specimens from 138 patients suffering from chronic respiratory disorders including 63 with allergic bronchopulmonary aspergillosis (ABPA), 2o with suspected ABPA, 15 with pulmonary tuberculosis, 14 with bronchial asthma, 10 with chronic bronchitis and 6 with miscellaneous pulmonary conditions were studied for circulating antibodies to Aspergillus. The ammonium sulfate test was empolyed with an iodine-125 labeled mycelial component derived from Aspergillus fumigatus. When compared to normal controls from the same area, this test indicated that sera from 82 per cent of patients with ABPA had elevated binding titers to the radiolabeled antigenic component. Immunodiffusion using a culture filtrate antigen from A. fumigatus, revealed precipitating antibody to this fungus in 89 percent of sera from ABP patients. The majority of patients with ABPA demonstrated marked elevations of total serum IgE, moderate elevations of serum IgA and IgD and slightly increased levels of IgG and IgM.

Two unusual organisms, Aspergillus terreus and Metschnikowia pulcherrima, associated with the lung disease of ankylosing spondylitis

Two male patients with ankylosing spondylitis and upper lobe fibrosis and cavitation are described. A pneumonic disease in one was associated with mycological and serological evidence of infection with Aspergillus terreus but no other aspergillus species. A large pulmonary mycetoma developed in the second patient and among a number of other fungal isolates was found the yeast Metschnikowia pulcherrima. The association of ankylosing spondylitis with bronchopulmonary aspergillosis is considered; A. terreus is described for the first time as a human pulmonary pathogen, and the possible pathogenicity of M. pulcherrima in the debilitated human subject is discussed.

Use of the immunodiffusion test in the serodiagnosis of aspergillosis

The diagnostic value of an immunodiffusion (ID) test with standardized precipitinogens derived from five Aspergillus species was determined with sera from 60 proven and 12 suspected cases of aspergillosis. The data demonstrated that the greatest number of aspergillosis cases were detected by the concurrent use of A. fumigatus and A. niger precipitinogens. With these precipitinogens, the ID test permitted the serodiagnosis of aspergillosis in 82% of the 60 proven cases and in 83% of the 12 suspected cases. The presence of one or more precipitins was indicative of aspergilloma, of allergic bronchopulmonary aspergillosis, or of invasive aspergillosis. Precipitins were detected in 93% of the sera from patients with aspergilloma, in 50% of the sera from patients with allergic bronchopulmonary aspergillosis, and in 88% of the sera from patients with invasive aspergillosis. Although the presence of one or two precipitin bands could indicate any form of aspergillosis, the presence of three or four was strong evidence of either aspergilloma or invasive aspergillosis. The ID test was found to be 100% specific in an evaluation of its effectiveness with 65 sera from individuals with other systemic mycotic infections, bacterial or neoplastic diseases, and from apparently normal humans. In diagnosed cases of aspergillosis, the examination of serial serum specimens provided information about the clinical course of the disease. A reduction in the number of precipitin bands and significant titer changes were noted as the patients responded to therapy.

Pulmonary aspergillosis caused by Aspergillus flavus

Bronchopulmonary aspergillosis is usually caused by Aspergillus fumigatus. The six cases from the Sudan reported here were due to Aspergillus flavus. Three of the patients had primary invasive disease, one had Aspergillus mycetoma in a pre-existing lung cavity, and two had allergic aspergillosis. A special feature of the invasive disease was the clinical and radiographic simulation of malignancy, particularly in one patient who had multiple disseminated nodules of fungal granulomata in the skin of the lower abdomen.

Necrotizing pulmonary aspergillosis

Necrotizing or invasive aspergillary infection of the lungs has previously been considered a rare condition affecting only the debilitated or seriously ill. Four patients with necrotizing pulmonary aspergillosis are described, and the mycological and histopathological findings are discussed. The diagnosis in the first patient was not made until necropsy, following death from fulminating pulmonary infection. Of three patients treated with natamycin, two made a satisfactory recovery; the other died later from bronchial carcinoma. Previous multiple antibiotic therapy in each case may have been a contributory factor to infection with Aspergillus fumigatus. We suggest that fungal infection of the lungs should be actively sought in patients with pulmonary disease, especially in those receiving multiple antibiotic or corticosteroid therapy.

Inhalation experiments with extracts of Aspergillus fumigatus on patients with allergic aspergillosis and aspergilloma

A description is given of the reaction to inhalation of Aspergillus extract by seven patients with aspergillosis, including five with aspergillomas. The nature of, and possible causes for, such reactions are discussed on the basis of their resemblance to the symptomatology of the vegetable dust syndromes. The findings may contribute to a better understanding of the pathogenesis of fever in aspergillosis.

Allergic aspergillosis: review of 32 cases

The clinical, radiographic, and laboratory findings have been reviewed in a series of 22 patients with definite and 10 with probable allergic aspergillosis. Episodes of segmental shadowing occurred most frequently in the upper lobes and tended to recur in the same segment. Radiologically visible mucoid impaction of a large bronchus was demonstrated in eight cases, and saccular bronchiectasis in six cases, in the affected segments. Two patients have recovered, eight continued to experience episodic symptoms and shadows for up to 13 years, and 11 are on steroid therapy with relief of airways obstruction and prevention of further lung shadows. Four, together with five others who probably represent a late stage of the disease, have upper lobe contraction. One patient developed aspergillomas and one died with invasive aspergillosis. Sputum has remained positive in all except one patient. Precipitins were present in all cases. They varied widely in strength and appeared to be more closely related to the amount of antigenic exposure than to the severity of the allergic manifestations. Allergy to Aspergillus fumigatus probably plays a dominant role in the symptomatology of those with asthma of late onset; evidence of underlying atopic diathesis and of increased spore exposure could usually be adduced in these patients. A quantitative interaction of atopic diathesis and contact with a growing source of fungal antigens will result in a locally florid bronchial reaction, with plugging and subsequent dilatation. The peripheral shadows are consistent with areas of collapse distal to bronchial occlusion. The frequency and distribution of mucoid impaction found in this series suggest that allergic aspergillosis may be a major cause of this uncommon syndrome, which could represent an exaggerated form of bronchial plugging.

Pulmonary aspergillosis. A survey of its occurrence in patients with chronic lung disease and a discussion of the significance of diagnostic tests

The occurrence of pulmonary aspergillosis and of precipitins, positive skin tests, and sputum containing abundant Aspergillus fumigatus has been assessed and correlated in a survey of 107 consecutive patients attending hospital in Bristol with various chronic chest diseases. The series included three with aspergilloma, five with allergic aspergillosis, and one with chronic invasive aspergillosis. Of 46 asthmatic patients, 11% had definite and 22% had probable or definite allergic aspergillosis.

Seven patients (15%) in the asthmatic group were found to have chronic upper lobe contraction, probably attributable to long-standing allergic aspergillosis. One of these patients developed aspergilloma, and another, invasive aspergillosis.

The significance of precipitins is discussed, based on the survey patients together with 21 additional patients who had aspergillosis but were from outside the survey. In the survey patients without definite aspergillosis, precipitins and positive sputum were significantly associated and were found most commonly in patients with asthma, bronchiectasis, or cavitated lungs. Two patients with invasive aspergillosis who had weak precipitins are reported. We think that precipitins reflect recent or continuing fungal growth in body tissues or within damaged bronchi, and that their presence can be a useful indication of occult fungal colonization, which might rarely become invasive if host resistance were lowered as by steroids.

Allergic aspergillosis is a more common condition and a more frequent cause of upper lobe damage than has been appreciated.

Significance and interpretation of laboratory tests in pulmonary aspergillosis

The significance of the isolation of Aspergillus fumigatus from sputum may be difficult to interpret because of the frequent occurrence of this fungus in the atmosphere. Criteria are given for classifying positive sputa into two groups, ;fungus scanty' and ;fungus abundant', on the basis of cultural and microscopical findings. A relationship between sputum findings thus classified and the occurrence of Aspergillus antibodies in the patient's serum is demonstrated. The diagnostic importance of direct microscopical examination of sputum is noted. The precipitation patterns of sera to the unstandardized antigenic extracts of A. fumigatus at present available vary greatly. An arbitrary but practical classification of sera is suggested, based on the ;reactivity', or number of precipitation lines produced, and the ;range', or number of antigenic extracts with which the serum reacts.