[Pulmonary aspergilloma: results of surgical treatment. Report of a series of 206 cases]

Estimated Incidence and Prevalence of Serious Fungal Infections in Morocco

Few data are published from Morocco on fungal disease, although numerous case reports attest to a wide range of conditions in the country. Here, we estimate for the first time the incidence and prevalence of serious fungal diseases in the country. Detailed literature searches in English and French were conducted for all serious fungal infections. Demographic and individual underlying condition prevalence or annual incidence were obtained from UNAIDS (HIV), WHO (TB) and other international sources. Deterministic modelling was then applied to estimate fungal disease burden. Morocco's population in 2021 was 36,561,800. Multiple publications describe various fungal diseases, but epidemiological studies are rare. The most frequent serious fungal infections were tinea capitis (7258/100,000) and recurrent vulvovaginal candidiasis (2794/100,000 females). Chronic pulmonary aspergillosis is also common at a prevalence of 19,290 (53/100,000) because of the relatively high rate of tuberculosis. The prevalence of asthma in adults exceeds one million, of whom fungal asthma (including allergic bronchopulmonary aspergillosis (ABPA)) probably affects 42,150 (115/100,000). Data are scant on candidaemia (estimated at 5/100,000), invasive aspergillosis (estimated at 4.1/100,000), HIV-related complications such as cryptococcal meningitis and Pneumocystis pneumonia and mucormycosis. Fungal keratitis is estimated at 14/100,000). Mycetoma and chromoblastomycosis are probably rare. Fungal disease is probably common in Morocco and diagnostic capacity is good in the teaching hospitals. These estimates need confirmation with methodologically robust epidemiological studies.

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.

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.

Lung resection in pulmonary aspergilloma: experience of a Moroccan center

Background

This study was conducted to determine the efficacy of surgery in the treatment of complex aspergilloma comparatively with simple aspergilloma.

Methods

From January 2006 to December 2014, 115 cases of pulmonary aspergilloma were admitted in our department. One operation on one side was counted as one case and the patients were divided into two groups. In group A: 61 cases of complex aspergilloma. In group B: 50 patients underwent 54 cases of lung resection for simple aspergilloma. People who underwent arteriography and embolization were excluded. Surgical treatment was indicated when 1) recurrent aspergilloma-related hemoptysis, 2) definite simple or complex aspergilloma and 3) a simultaneous bilateral aspergilloma.

Results

People with complex aspergilloma were big smokers with lower BMI, and had reduced lung function parameters. The main symptoms were repeated hemoptysis, chronic cough, abundant purulent expectoration and respiratory infections. Lobectomy was the most performed indication. In group B, number of wedge resections was larger than group A with statistical significant difference (p = 0.001). In the post-operative course morbidity was higher in group A (16 %) vs (9 %) in group B with statistical difference (p = 0.026). The median follow-up was 30 months (range 19–52 months).

The median duration of chest tube drainage was 4 days. The duration of chest tube drainage was longer in the group A (4.7 ± 1.4 versus 2.9 ± 1.3; p = 0.005). The prolonged postoperative air leakage occurred more frequently in group A (14.75 %; versus 1.8 % p = 0.015). In group A, 3 cases and 2 in group B underwent a secondary operation for post operative hemothorax. Bronchopleural fistula occurred exclusively in group A (n = 4).

Conclusions

The surgical resection should be used in a multidisciplinary approach. Preoperative Interventional therapies could optimize the conditions for the operation. Total surgical resection must be the treatment of choice of localized causative lesions.

Surgical treatment of aspergilloma grafted in hydatid cyst cavity

Aspergilloma is a saprophytic infection that colonizes pre-existing cavities in the lung. These cavities are caused by tuberculosis, bronchiectasis, lung cancer and other pulmonary diseases. Development of aspergilloma in the residual cavities after pulmonary hydatid cyst surgery is rarely described in terms of coexistence of the two conditions. We describe 3 cases of pulmonary aspergilloma grafted in a residual cavity of cystectomy for hydatid disease.

[Result of surgical treatment of pulmonary aspergillosis secondary to a sequelae of tuberculosis in CHU/JRA]

La prise en charge d’un aspergillome pulmonaire, dans le cas des lésions limitées accessibles, est une des activités courantes en chirurgie thoracique dans les pays endémique à la tuberculose comme Madagascar. Sur une période allant de janvier 2005 en mars 2010, 15 patients, ancien tuberculeux, atteints d’une aspergillome pulmonaire sont traités par une résection segmentaire ou une lobectomie. La circonstance de découverte repose sur la clinique par des tableaux très polymorphes. L’imagerie garde une place importante. L’examen histologique des pièces d’exérèse chirurgicale confirme le diagnostic. Tous les patients ont été opérés de manière élective. Le résultat a été pour l’ensemble des patients jugés satisfaisant. Ces patients sont suivis pendant 1 à 39 mois. L’étude des résultats à distance est encore en cours et est fondamentale si le traitement chirurgical a un effet bénéfique sur la survie et la qualité de vie des malades. Le but de ce travail a été, à partir de la revue de la littérature et de notre petite expérience, de définir quels éléments pertinents mis en exergue sur le sujet.

[Bronchopulmonary aspergillosis infections in the non-immunocompromised patient]

The definition of broncho-pulmonary aspergillosis infections in non-immunocompromised patients remains vague and a wide range of clinical, radiological and pathological entities have been described with a variety of names, i.e. simple aspergilloma, complex aspergilloma, semi-invasive aspergillosis, chronic necrotizing pulmonary aspergillosis, chronic cavitary and fibrosing pulmonary and pleural aspergillosis, pseudomembranous tracheobronchitis caused by Aspergillus, and invasive aspergillosis. However, these disease entities share common characteristics suggesting that they belong to the same group of pulmonary aspergillosis infectious disorders: 1- a specific diathesis responsible for the deterioration in local or systemic defenses against infection (alcohol, tobacco abuse, or diabetes); 2- an underlying bronchopulmonary disease responsible or not for the presence of a residual pleural or bronchopulmonary cavity (active tuberculosis or tuberculosis sequelae, bronchial dilatation, sarcoidosis, COPD); 3- generally, the prolonged use of low-dose oral or inhaled corticosteroids and 4- little or no vascular invasion, a granulomatous reaction and a low tendency for metastasis. There are no established treatment guidelines for broncho-pulmonary aspergillosis infection in non-immunocompromised patients, except for invasive aspergillosis. Bronchial artery embolization may stop hemoptysis in certain cases. Surgery is generally impossible because of impaired respiratory function or the severity of the comorbidity and when it is possible morbidity and mortality are very high. Numerous clinical cases and short retrospective series have reported the effect over time of the various antifungal agents available. Oral triazoles, i.e. itraconazole, and in particular voriconazole, appear to provide suitable treatment for broncho-pulmonary aspergillosis infections in non-immunocompromised patients.

Treatment of chronic pulmonary aspergillosis by voriconazole in nonimmunocompromised patients

BACKGROUND

There is no recognized medical treatment for chronic pulmonary aspergillosis (CPA) apart from surgery in patients with simple aspergilloma. To evaluate the efficacy of voriconazole in this setting, we conducted a retrospective multicenter study over a 3-year period.

METHODS

For inclusion in the study, patients had to have received voriconazole for treatment of confirmed or probable CPA with a follow-up of at least 6 months. Clinical, radiologic, and mycologic data were collected at baseline, every 2 to 3 months, and at the end of treatment or at the date point.

RESULTS

Twenty-four patients were included in the study, among which 9 patients presented with chronic cavitary pulmonary aspergillosis and 15 presented with chronic necrotizing pulmonary aspergillosis (CNPA). Voriconazole was given as a first-line treatment to 13 patients. The median duration of treatment and follow-up were 6.5 and 10 months, respectively. Three patients had to stop treatment with voriconazole because of toxicity. Symptoms and imagery findings were improved in 16 of 24 patients and 17 of 24 patients, respectively, at the end of follow-up. Mycology, which was positive at baseline in 21 of 23 patients, was negative in 18 of 19 patients at the end of follow-up; serologic test results were also negative in 6 of 19 evaluable patients, all of whom had CNPA. Improved radioclinical findings and mycologic eradication were observed at the end of follow-up in 11 of 19 patients (58%). Patients in whom the disease was controlled had a significantly longer median duration of treatment than patients in whom it was uncontrolled (9 vs 6 months, respectively; p = 0.04).

CONCLUSION

Voriconazole provides effective treatment of CPA with an acceptable level of toxicity.

Die chirurgische Therapie des pulmonalen Aspergilloms. Surgical treatment of pulmonary aspergilloma

Invasive pulmonary aspergillosis is a life-threatening disease, developing from infection mostly by Aspergillus fumigatus. It is an opportunistic infection and occurs mostly in immunosuppressed patients, after tuberculosis, in patients with AIDS or malignomas. The most common symptom and complication is hemoptysis up to massive bleeding. Surgical treatment is obligatory on patients with a pulmonary aspergilloma. Time and form of intervention should be discussed between surgeon and pulmonologist. Resection should follow anatomical borders like lobectomy or pneumectomy. Any remaining intrathoracic cavities should be filled either with remaining lung tissue or with muscle flaps of latissimus or pectoralis muscle or omentum majus. Following these rules, intervention can be performed with reasonable mortality and morbidity rate.

The ability of fungal isolates from human lung aspergilloma to produce mycotoxins

This study included 11 adult patients (seven men and four women) who had been surgically treated for pulmonary aspergilloma in the Republic of Croatia within two years. Mycological analysis was positive for Aspergillus genus in five samples of surgically removed tissue. A. fumigatus was isolated in three and A. versicolor in two samples. Their mycotoxigenic potency was determined by thin layer chromatography. A. fumigatus strains were found to produce aflatoxin B1 (AFB), and two of them aflatoxin G1. A. versicolor strains produced AFB1 and sterigmatocystin. Neither isolated Aspergillus strain produced aflatoxin G2 or ochratoxin A. Fungal growth and production of mycotoxins are the consequences of interaction of fungus, host and environment. One has also to take into consideration that the production of mycotoxins in vitro does not reflect what these fungi may produce in human organisms.

Chronic forms of pulmonary aspergillosis

Aspergillus is a genus of fungi commonly found in all environments. Remarkably, only a few species cause disease and equally remarkably, those same species cause multiple diseases. In the lung, exposure to the fungus, the immunological status of the individual and the condition of the lung determine the pattern of disease. In asthmatic patients and those with cystic fibrosis, allergic bronchopulmonary aspergillosis (ABPA) is a complication that reduces pulmonary function and, in asthmatics, is substantially improved by itraconazole therapy. Patients with pre-existing lung cavities develop aspergillomas (fungal masses inside the cavity). Aspergillomas carry a 40% 5 years survival, and it not clear whether antifungal therapy is helpful. Similar in presentation to aspergilloma is chronic necrotizing pulmonary aspergillosis (CNPA). Development of new or expansion of existing pulmonary cavities with surrounding paracavitary shadowing is the hallmark of CNPA These two entities are probably a continuum of the same pathological process. Patients with CNPA respond to systemic antifungal therapy, but this may need to be lifelong. Surgery is appropriate for isolated aspergillomas, but not pleural or multicavity lesions. Aspergillus empyema is a complication of aspergilloma and CNPA, or surgery for these diseases and is slow to respond to treatment.