Portal de Periódicos da CAPES

Invasive Aspergillosis

1988; Elsevier BV; Volume: 94; Issue: 5 Linguagem: Inglês

10.1378/chest.94.5.1117

1931-3543

Ann L. Dehart, Loren H. Ketai,

Fungal Infections and Studies

To the Editor: Over the last decade, divisions between the syndromes of Aspergillus-related diseases have become less distinct. Case reports have described the rapid development of aspergillomas in the setting of allergic bronchopulmonary Aspergillosis (ABPA), and the progression of ABPA to invasive Aspergillosis.1Israel R.H. Pose R.P. Bomba P.A. Gross R.A. The rapid development of an aspergilloma secondary to allergic bronchopulmonary aspergillosis.Am J Med Sci. 1980; 1: 41-44Crossref Scopus (27) Google Scholar, 2Anderson C.J. Craig S. Bardana E.J. Allergic bronchopulmonary aspergillosis and bilateral fungal balls terminating in disseminated aspergillosis.J Allergy Clin Immunol. 1980; 65: 1940-1944Abstract Full Text PDF Scopus (39) Google Scholar, 3Stark I.D. Keal E.E. Cerebral aspergilloma in a patient with allergic bronchopulmonary aspergillosis.Br J Dis Chest. 1980; 74: 301-305Abstract Full Text PDF Scopus (12) Google Scholar We wish to report the rapid development of invasive Aspergillosis in a patient with ABPA, and the effects of subsequent treatment with systemic amphotericin B. A 70-year-old man with longstanding asthma was diagnosed with ABPA in 1980 on the basis of a positive immediate skin test for Aspergillus, marked eosinophilia, central bronchiectasis, and repeated expectoration of mucopurulent plugs containing Aspergillus. The patient was treated with systemic corticosteroid therapy intermittently over the following six years. In October, 1986, the patient complained of increased fatigue. Chest film revealed a new 2.5 cm mass in the superior segment of the right lower lobe. Bronchoscopy and transthoracic needle aspiration (TTNA) were performed. Aspergillus was cultured from the TTNA specimen; however, pathology from both procedures was nonspecific. Despite low complement fixation titers for Aspergillus antibodies, IgE levels were persistently elevated (2,400 to 3,000 IU/ml). Therapy was started with prednisone (40 mg per day) as treatment for a presumed exacerbation of ABPA. Three weeks later, the patient returned with complaints of purulent sputum and fever. Chest film and subsequent CAT scan revealed a thick-walled cavity which was peripheral and not contiguous with a major bronchus (Fig 1). Repeat transbronchial biopsies revealed chronic granulomatous inflammation with abundant Aspergillus hyphae penetrating the cavity wall. Steroid therapy was rapidly tapered, and the patient begun on intravenous amphotericin (total dose 1.2 g). At completion of therapy, the patient's radiographic abnormality had cleared completely. IgE levels fell to less than 1,500 IU/ml and remained below that level with a maintenance prednisone dosage of 5 mg every other day. This case is unique in that it describes the successful chemotherapeutic treatment of locally invasive aspergillosis in a patient with underlying ABPA. The outcome has been poor in previously reported cases of ABPA-related Aspergillus tissue invasion, despite the use of resectional surgery.2Anderson C.J. Craig S. Bardana E.J. Allergic bronchopulmonary aspergillosis and bilateral fungal balls terminating in disseminated aspergillosis.J Allergy Clin Immunol. 1980; 65: 1940-1944Abstract Full Text PDF Scopus (39) Google Scholar,3Stark I.D. Keal E.E. Cerebral aspergilloma in a patient with allergic bronchopulmonary aspergillosis.Br J Dis Chest. 1980; 74: 301-305Abstract Full Text PDF Scopus (12) Google Scholar Our success may be due to the early recognition and treatment of this entity. Rather than disseminated disease, our patients course was characterized by symptomatic local invasion of the pulmonary parenchyma, resulting in progressive cavitation. This therefore represents “semi-invasive” or chronic necrotizing aspergillosis.4Binder E.B. et al.Chronic necrotizing pulmonary aspergillosis: a discrete clinical entity.Medicine. 1982; 61: 109-124Crossref PubMed Scopus (306) Google Scholar,5Geffer W.B. Weingard T.R. Epstein D.M. Ochs R.H. Miller W.T. Semi-invasive” pulmonary aspergillosis.Radiology. 1981; 140: 313-321Crossref Scopus (231) Google Scholar The patients obstructive pulmonary disease and low-dose corticosteroid regimen appear to be an adequate predisposition for this entity.4Binder E.B. et al.Chronic necrotizing pulmonary aspergillosis: a discrete clinical entity.Medicine. 1982; 61: 109-124Crossref PubMed Scopus (306) Google Scholar A more limited degree of tissue invasion may occur in uncomplicated ABPA and could have served as a nidus for the parenchymal destruction seen in this patient.6Wiley D.J. et al.Allergic bronchopulmonary aspergillosis: evidence of limited tissue invasion.Am Rev Respir Dis. 1975; 111: 232-236Google Scholar Others have suggested that patients with ABPA may develop rapidly progressive cavitary lesions due to the development of an aspergilloma within a bronchiectatic central bronchus.1Israel R.H. Pose R.P. Bomba P.A. Gross R.A. The rapid development of an aspergilloma secondary to allergic bronchopulmonary aspergillosis.Am J Med Sci. 1980; 1: 41-44Crossref Scopus (27) Google Scholar We believe that the size and peripheral location of the lesion in this patient is more compatible with necrotizing aspergillosis within the lung parenchyma. Lastly, it is interesting that total IgE levels diminished during amphotericin treatment despite falling doses of corticosteroids. Although early studies have shown amphotericin to be ineffective in eradicating Aspergillus from sputum, a recent study has demonstrated clinical and immunologic improvement in patients with ABPA receiving antifungal therapy.7Hammerman K.J. Sarosi G.A. Tosh F.E. Amphotericin B in the treatment of saprophytic forms of pulmonary aspergillosis.Am Rev Respir Dis. 1974; 109: 42-57Google Scholar,8Shale D.J. Faux J.A. Lane D.L. Trial of ketoconazole in non-invasive pulmonary aspergillosis.Thorax. 1987; 42: 26-31Crossref PubMed Scopus (64) Google Scholar We speculate that treatment with systemic amphotericin may have similarly decreased the intensity of Aspergillus hypersensitivity in this patient.