Diagnosis of invasive aspergillus tracheobronchitis facilitated by endobronchial ultrasound-guided transbronchial needle aspiration: a case report

Case Report: Sudden Fatal Hemorrhage in Ulcerative Fungal Laryngotracheitis-A Pediatric Case Report

In this report, we describe an autopsy case of a child affected by acute lymphoblastic leukemia and opportunistic pulmonary aspergillosis. The patient died because of a full-thickness tracheal wall ulceration with right inferior thyroid artery lesion and sudden hemorrhage, likely ascribable to undiagnosed invasive Aspergillus laryngotracheitis. Aspergillus infection, particularly in immunocompromised patients, should be considered an urgent risk factor to manage as it may lead to sudden fatal events in absence of evident critical symptoms.

What, where and why: exploring fluorodeoxyglucose-PET's ability to localise and differentiate infection from cancer

PURPOSE OF REVIEW

To review the utility of FDG-PET imaging in detecting the cause of fever and infection in patients with cancer.

RECENT FINDINGS

FDG-PET has been shown to have high sensitivity and accuracy for causes of neutropenic fever, leading to higher diagnostic certainty in this group. Recent advances in pathogen-specific labelling in PET to identify Aspergillus spp. and Yersinia spp. infections in mice, as well as differentiating between Gram-positive, Gram-negative and mycobacterial infections are promising.

SUMMARY

Patients with cancer are vulnerable to infection and fever, and the causes of these are frequently unclear using conventional diagnostic methods leading to high morbidity and mortality, length of stay and costs of care. FDG-PET/CT, with its unique complementary functional and anatomical information as well as its whole-body imaging capability, has demonstrated use in detecting occult infection in immunocompromised patients, including invasive fungal and occult bacterial infections, as well as defining extent of infection. By demonstrating disease resolution following treatment and allowing earlier cessation of therapy, FDG-PET acts as a key tool for antimicrobial and antifungal stewardship. Limitations include at times poor differentiation between infection, malignancy and sterile inflammation, however, exciting new technologies specific to infectious pathogens may help alleviate that issue. Further prospective randomised research is needed to explore these benefits in a nonbiased fashion.

[The tree that hides the forest: aspergillosis associated with bronchial carcinoma (about two cases)]

Endobronchial aspergilloma and intracavitary pulmonary aspergilloma may clinically and radiologically mimic a bronchial neoplasia, hence the importance of systematically searching for an association. A confirmed association completely changes the prognosis as well as the therapeutic approach. We here report two cases with two different forms of pulmonary aspergilloma associated with bronchial carcinoma.

Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

Molecular Imaging of Invasive Pulmonary Aspergillosis Using ImmunoPET/MRI: The Future Looks Bright

Invasive pulmonary aspergillosis (IPA) is a life-threatening lung disease of immuno-compromised humans caused by the ubiquitous environmental mold Aspergillus. Biomarker tests for the disease lack sensitivity and specificity, and culture of the fungus from invasive lung biopsy is slow, insensitive, and undesirable in critically ill patients. A computed tomogram (CT) of the chest offers a simple non-intrusive diagnostic procedure for rapid decision making, and so is used in many hematology units to drive antifungal treatment. However, radiological indicators that raise the suspicion of IPA are either transient signs in the early stages of the disease or not specific for Aspergillus infection, with other angio-invasive molds or bacterial pathogens producing comparable radiological manifestations in a chest CT. Improvements to the specificity of radiographic imaging of IPA have been attempted by coupling CT and positron emission tomography (PET) with [¹⁸F]fluorodeoxyglucose ([¹⁸F]FDG), a marker of metabolic activity well suited to cancer imaging, but with limited use in invasive fungal disease diagnostics due to its inability to differentiate between infectious etiologies, cancer, and inflammation. Bioluminescence imaging using single genetically modified strains of Aspergillus fumigatus has enabled in vivo monitoring of IPA in animal models of disease. For in vivo detection of Aspergillus lung infections in humans, radiolabeled Aspergillus-specific monoclonal antibodies, and iron siderophores, hold enormous potential for clinical diagnosis. This review examines the different experimental technologies used to image IPA, and recent advances in state-of-the-art molecular imaging of IPA using antibody-guided PET/magnetic resonance imaging (immunoPET/MRI).

18F-Fluorodeoxyglucose positron emission tomography and infectious diseases: current applications and future perspectives

PURPOSE OF REVIEW

18F-Fluorodeoxyglucose positron emission tomography/computed tomography is a well-established technique for diagnosis and management of a number of neoplastic conditions. However, in recent years the body of literature regarding its potential role in infectious diseases has progressively increased, with promising results.

RECENT FINDINGS

So far 18F-fluorodeoxyglucose positron emission tomography/computed tomography has a well-established role and is recommended by guidelines only in a few settings, such as prosthetic valve endocarditis, vascular device infections, and chronic osteomyelitis. However, even the lack of large, prospective randomized trials, an increasing number of small series and case reports suggest a potential role in the diagnosis, disease staging, and monitoring of treatment response of several other infective conditions.

SUMMARY

In this article, we summarize the available evidence and potential future applications of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in the diagnosis and management of infectious diseases.

Infections causing central airway obstruction: role of bronchoscopy in diagnosis and management

Central airway obstructive infections (CAOI) are challenging medical conditions that may represent an advanced and complicated process of ongoing infections. The epidemiology of CAOI is unknown as well as the pathophysiology and the mechanism of development. This is due to sparse data in the literature that consists mainly of case reports and retrospective case series. CAOI can be caused by fungal, bacterial, parasitic and viral infections. Most patients with CAOI can be diagnosed clinically and with chest imaging, which demonstrate obstruction of the central airways. However, bronchoscopy is commonly used to confirm and obtain a specific diagnosis to guide specific therapy. In recent years, interventional pulmonology (IP) is becoming widely available and offer a minimally invasive approach for the management of central airway diseases such as cancers, benign strictures, and other conditions. Various bronchoscopic modalities are used to treat central airway obstruction (CAO), such as mechanical debulking, endobronchial laser therapy, electrocautery, argon plasma coagulation, cryotherapy, and airway stenting. In patients with CAOI, the role of therapeutic bronchoscopy is not clearly defined, but many isolated reports in the literature described bronchoscopic intervention in combination with medical therapy as the initial management approach. In this paper, we present cases of CAOI that underwent bronchoscopic intervention as part of their management. We described the infectious etiology, locations, bronchoscopic findings and bronchoscopic modalities for airway management.

Plugs of the Air Passages: A Clinicopathologic Review

Although mucus is a normal product of the tracheobronchial tree, some diseases of the respiratory tract are characterized by unusually thick (inspissated) forms of mucus that accumulate within the airways. These are known as mucus plugs. The pathologic composition of these plugs is surprisingly diverse and, in many cases, correlates with distinctive clinical, radiologic, and bronchoscopic findings. The best-known conditions that involve mucus plugs are allergic bronchopulmonary aspergillosis, plastic bronchitis, and asthma. Other lung diseases occasionally associated with plugs within the airways include Aspergillus tracheobronchitis, hyper-IgE syndrome, exogenous lipoid pneumonia, pulmonary alveolar proteinosis, and chronic eosinophilic pneumonia. In this review, we describe and illustrate the bronchoscopic, pathologic, and imaging findings in respiratory disorders characterized by mucus plugs or plugs composed of other similar materials. Recognition of the characteristic appearance and differential diagnosis of mucus plugs will hopefully facilitate diagnosis and management of these diseases.

[Endobronchial aspergilloma revealing a bronchial carcinoma]

Endobronchial aspergillosis is a rare presentation of pulmonary aspergillosis in immunocompetent patients; this raises questions about structural changes inducing airflow stasis in order to colonize the bronchial lumen. We present the case of a patient diagnosed with endobronchial aspergilloma covering a bronchial adenocarcinoma.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration as a New Diagnostic Tool for Invasive Pulmonary Mycoses

Early diagnosis of invasive pulmonary mycoses in immunocompromised patients is a major determinant of effective treatment. However, making a reliable diagnosis is challenging and often requires transbronchial or even surgical lung biopsy. We provide evidence that endobronchial ultrasound-guided transbronchial needle aspiration may be an attractive, less invasive diagnostic method. Endobronchial ultrasound-guided transbronchial needle aspiration was not only a diagnostic clue in the presented kidney transplant recipient with invasive pulmonary mycosis but was useful in assessment of treatment efficacy.

Pulmonary aspergillosis diagnosed by endoscopic ultrasound fine-needle aspiration

Pulmonary aspergillosis generally occurs in patients with prolonged neutropenia or immunosupression. Definitive diagnosis depends on the demonstration of the organism in tissue, as positive culture result from sputum, needle biopsy, or bronchoalveolar lavage fluid. Even though endoscopic ultrasound (EUS) fine needle aspiration (FNA) of paraesophageal/mediastinal lesions has been used numerous times, this is the first case that reports an aspergilloma diagnosed by EUS-FNA, allowing us to reach a definitive diagnosis. We present a patient with a nodular lesion located in the right upper lobe lung, with ground-glass opacity. Upper EUS revealed an ill-defined hypoechoic paraesophageal lesion with a central annular image. Culture results from EUS-FNA were positive for Aspergillus fumigatus. There are no previous reports of EUS imaging features of pulmonary aspergillosis. We believe that this central annular image in an ill-defined hypoechoic paraesophageal lesion may be a characteristic feature.

Primary aspergillosis of the kidney in systemic lupus erythematosus and positron emission tomography-computed tomography

Primary aspergillosis of the kidney is a rare complication of immunosuppression in systemic lupus erythematosus. Symptoms can be insidious and can mimic malignancies, such as lymphomas. Herein, we report a case of a woman with systemic lupus erythematosus with recent history of lymphoma, who presented with a history of prolonged pyrexia without localizing symptoms. Repeat biopsy of the kidneys was crucial in obtaining histological diagnosis, and this was aided by findings on positron emission tomography - computed tomography.

Aspergillus tracheobronchitis, bronchopleural fistula and empyema after lobectomy for aspergilloma

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

Imaging pneumonia in immunocompetent and immunocompromised individuals

PURPOSE OF REVIEW

The article aims to indicate the current role of radiological imaging in immune competent and immunocompromised patients with pneumonia. The radiological findings in the most common conditions will be reviewed.

RECENT FINDINGS

Three basic patterns of radiographic abnormality are recognized: lobar (nonsegmental) pneumonia; bronchopneumonia (lobular pneumonia); and interstitial pneumonia. The chest radiograph remains the initial radiological investigation. Computed tomography (CT) is more sensitive than the chest radiograph. The appearances on CT with certain infections such as mycoplasma, invasive aspergillosis, and pneumocystis, in the appropriate clinical setting, may allow a treatment decision to be made when obtaining fluid or tissue for culture is problematical. MRI technology is advancing and this technique may provide an option for follow-up of chronic disease in younger patients in whom radiation exposure is a concern, but MRI does not yet match CT as a diagnostic test in this field.

SUMMARY

Radiology retains a key role in diagnosing pneumonia, excluding pneumonia, following up patients to check for resolution and to evaluate potential complications. The chest radiograph remains the initial examination. CT is more sensitive and with certain infections more specific. MRI provides an option for monitoring progress, although cannot yet match CT as an initial diagnostic test.

Tracheobronchial manifestations of Aspergillus infections

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

Scientific evidence and principles for the use of endobronchial ultrasound and transbronchial needle aspiration

Endobronchial ultrasound (EBUS), using the radial EBUS probe and convex-probe EBUS-guided transbronchial needle aspiration, are increasingly advocated for a wide array of minimally invasive thoracic procedures. The effectiveness of EBUS-guided procedures has been demonstrated to a degree that, in many institutions, EBUS is becoming standard of practice for the diagnosis, staging and restaging of mediastinal lymphadenopathy in lung cancer, the diagnosis of sarcoidosis, and for bronchoscopic biopsy of peripheral lung lesions. Its role in other bronchoscopic procedures requires further study despite an already strong body of literature: diagnosis of lymphoma and benign infectious disease, diagnosis of early lung cancer and airway wall disorders, imaging of thoracic vascular disease such as pulmonary embolism, and therapeutic procedures such as placement of fiducial markers. In this article, we illustrate some of the principles of EBUS, describe major technical aspects pertaining to the procedure itself and provide a narrative review of original research addressing proposed roles of EBUS in a variety of indications. In closing, we describe future perspectives including new educational processes and philosophies that could favorably impact the rapid and safe dissemination of this evolving technology into clinical practice.

Invasive aspergillosis in developing countries

To review invasive aspergillosis (IA) in developing countries, we included those countries, which are mentioned in the document of the International Monetary Fund (IMF), called the Emerging and Developing Economies List, 2009. A PubMed/Medline literature search was performed for studies concerning IA reported during 1970 through March 2010 from these countries. IA is an important cause of morbidity and mortality of hospitalized patients of developing countries, though the exact frequency of the disease is not known due to inadequate reporting and facilities to diagnose. Only a handful of centers from India, China, Thailand, Pakistan, Bangladesh, Sri Lanka, Malaysia, Iran, Iraq, Saudi Arabia, Egypt, Sudan, South Africa, Turkey, Hungary, Brazil, Chile, Colombia, and Argentina had reported case series of IA. As sub-optimum hospital care practice, hospital renovation work in the vicinity of immunocompromised patients, overuse or misuse of steroids and broad-spectrum antibiotics, use of contaminated infusion sets/fluid, and increase in intravenous drug abusers have been reported from those countries, it is expected to find a high rate of IA among patients with high risk, though hard data is missing in most situations. Besides classical risk factors for IA, liver failure, chronic obstructive pulmonary disease, diabetes, and tuberculosis are the newly recognized underlying diseases associated with IA. In Asia, Africa and Middle East sino-orbital or cerebral aspergillosis, and Aspergillus endophthalmitis are emerging diseases and Aspergillus flavus is the predominant species isolated from these infections. The high frequency of A. flavus isolation from these patients may be due to higher prevalence of the fungus in the environment. Cerebral aspergillosis cases are largely due to an extension of the lesion from invasive Aspergillus sinusitis. The majority of the centers rely on conventional techniques including direct microscopy, histopathology, and culture to diagnose IA. Galactomannan, β-D glucan test, and DNA detection in IA are available only in a few centers. Mortality of the patients with IA is very high due to delays in diagnosis and therapy. Antifungal use is largely restricted to amphotericin B deoxycholate and itraconazole, though other anti-Aspergillus antifungal agents are available in those countries. Clinicians are aware of good outcome after use of voriconazole/liposomal amphotericin B/caspofungin, but they are forced to use amphotericin B deoxycholate or itraconazole in public-sector hospitals due to economic reasons.