Download Aspergilloma in an Open Chest Cavity

have been reported
disease and appeared
steroids
and
with features
of a collagen
vascular
to respond
to treatment
with cortico-
azathioprine.
This
disease
may
actually
be
a
syndrome
of multiple
causes
rather
than a single disease
entity.2 Regardless
of etiology
the disease
is fatal in the
majority
of patients
within
two
years
of the
onset
of
symptoms
due to severe,
progressive
pulmonary
hypertension with right ventricular
failure.’
Nifedipine
has been used
monary hypertension.
In pure
sion
the
sure
and
drug
significantly
increases
successfully
pulmonary
reduces
cardiac
hemodynamic
changes
pulmonary
hypertension
in primary
pularterial hyperten-
pulmonary
output
in
artery
some
pres-
patients.7
These
attenuate
the signs and symptoms
of
and prolong survival in some cases.
This is the only published
report
of pulmonary
venoocclusive
disease
treated
with calcium
antagonists.
Pulmonary vascular
resistance
was reduced
from 937 to 620
dynes.cm
and mean pulmonary
artery
pressure
was reduced from 44 mm Hg to 33 mm Hg in this case after two
years of treatment
with nifedipine.
This suggests
a component of reversible
pulmonary
arterial
vasoconstriction
is
present
in this rare disease.
We found significant
pulmonary
arterial
medial
hypertropy
and intimal
hyperplasia
in this
patient,
and Wagenvoort
et al described
similar pulmonary
arterial
changes
in their cases. If pulmonary
veno-occlusive
disease
involved
only the veins and venules,
a response
to
nifedipine
would not be predicted.
In addition
to the venous
changes,
there
is pathologic
involvement
of pulmonary
arterioles.
We feel the pulmonary
arterial vasodilating
effect
of nifedipine
allowed
additional
time for veno-occlusive
lesions
to resolve
before severe pulmonary
arterial
hypertensive
changes
case
of over
likely
due
occurred.
six years
to the
The
after
effects
prolonged
the onset
survival
of nifedipine.
We
onset
this
was most
cannot
ofthis conclusion
since a patient apparently
treatment
has been reported
to survive
the
in
of symptoms
be
certain
without
seven
after
of symptoms.’
Ricardof
U, Burrow
occlusive
C, Whitaker
disease.
records
J
Quart
of the
occlusive
disease.
disease
CM,
Hum
Churg
following
W, Heath D. Pulmonary
1975; 44:133-59
Med
Massachusetts
1983). N Engl J Med 1983;
3 Wagenvoort
CA, Wagenvoort
4 Lombard
Ceneral
of
Spiro
pulmonary
spergillus
is a ubiquitous
organism
that is associated
with
a number
of pulmonary
syndromes,’
one of which is
aspergilloma.
1.4.5 Aspergillomas
are believed
to result from
saprophytic
with
azathioprine.
5K,
occlusive
7 Rubin
pulmonary
99:433-35
colonization
Pathol
for
SC,
Thorax
Kittle
disease.
U,
Nicod
of
preexisting,
poorly
drained
in-
trapulmonary
cavities.’46
Therapy
is individualized
and is
generally
restricted
to refractory
hemoptysis.
1279
Treatment
has included
resection’28’#{176} and systemic,”2
endobronchial,
or percutaneous8”
therapy
with antifungal
agents.
We present
a unique
case of an aspergilloma
that formed
within
the cavity of an open-window
thoracostomy.
This
allowed us to make direct observations
regarding
formation
and resolution
ofan aspergilloma
in vivo.
CASE
A 35-year-old
gradual
male
onset
daily
fevers.
x-ray
film.
lung
found
biopsy
bronchial
lung
The
histologic
did
contained
not
receive
the
open
and
trans-
sections
from
was
granules,
presence
and
during
a
per-
permanent
of Actinomyces.
at any time
penicillin
later,
a pneumonectomy
sulfur
confirmed
instituted
months
Frozen
and
and
chest
a nonspecific
were
bronchoscopy,
nondiagnostic.
a tumor,
specimen
sections
patient
were
repeat
with
on the
revealed
Several
after
suggested
mass
antibiotics
improvement.
biopsies
thoracotomy
biopsies
1983
of breath,
an infiltrative
lung
performed
October
shortness
Broad-spectrum
clinical
was
in
cough,
to have
Transbronchial
notable
presented
chronic
pneumonitis.
without
REPORT
smoker
of pleurisy,
He was
organizing
14-
1985;
T
Pulmonary
veno-
loss,
and
thoracocentesis
pin
malignant
veno-occlusive
neoplasms.
Chest
1987;
Hendry
CF,
Ann
hypertension
disease
1977;
Faber
Thorac
P. Hillis
AT, Turnev.Warwick
LD,
with
responding
to
month
His
Surg
Jensik
The
the
course
after
of
WBC
count
monocytes).
The
was
patient
yellow-green
of 11 mg/dl,
1976;
Firth
nifedipine.
BC.
Ann
Intern
was
a protein
inserted.
of primary
intracellulare,
Med
ethambutol.
1983;
*From
the
HIV-antibody
antigen,
an
LDH
level
of 7 g/dl,
fistula.
which
Division
was
air
7 percent
showed
and
Cultures
were
only
sensitive
of Pulmonary
polymor-
and
had
IU,
a glucose
a pH
of 8.0;
the
Medicine,
and
a
level
a chest
presence
of
for M avium-
positive
in vitro
elevarevealed
suggested
again
cutaneous
nonspecific
of 5,357
leak
to
and
(59 percent
thoracocentesis
level
came
fevers,
negative,
and
A
A persistent
a bronchopleural
22:249-53
Treatment
tube
with
mm
rifam-
months.
the patient
persistent
lymphocytes,
immunoglobulins.
fluid
and
for four
tube,
10/cu
X
the
avium-intracellu-
instituted
of fluid,
weight
from
pyrazinamide,
percent
to mumps
serum
Cultures
was
was 6.0
hospital
hemithorax.
of the chest
reaccumulation
34
treatment
veno-
removal
with
local
a 23 kg (50-lb)
Mycobacterium
for
drainage
leukocytes,
in
left
to his
sweats,
ethambutol,
tube
phonuclear
tions
RJ. Pulmonary
in the
isoniazid,
presented
night
positive
Chest
hospital
again
chills,
level
with
begun.
M. A case
32:140-48
LP,
patient
were
Therapy
was
our
the
fevers,
an air fluid
malaise.
16:1033-41
S. Pulmonary
later,
progressive
tare.
(case
year
with
One
W, Takahashi
veno-occlusive
6 Chawla
FC.C.P
the
hypersensitivity
JE,
M.D.,
findings
in a patient
who underwent
and developed
a chronic
bronchopleural
fistula
and empyema
and who developed
an intrathoracic
aspergilloma
after open-window
thoracostomy.
To our
knowledge,
formation
of an aspergilloma
in an open intrathoracic
cavity has not been reported
previously.
(Chest
1989; 95:1156-58)
308:823-34
A, Wnokur
therapy
Hospital
veno-
92:871-76
5 Sanderson
and
his illness.
REFERENCES
2 Case
M.D.;t
Gonzalez-Rothi,
We present
pneumonectomy
One
1 Thadani
in an Open Chest
A. Thomas,
Dwayne
formed.
specific
years
Aspergilloma
Cavity*
to
University
rifampin
and
of Florida
College
of Medicine,
and the Research
Service
(Dr. Thomas),
VA
Medical
Center,
Cainesville,
Fla.
Supported
by the Research
Service
ofthe Veterans
Administration.
tFellow
in Pulmonary
Medicine,
supported
by the Florida
Lung
Association.
1156
Aspergilloma
in an Open
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21593/ on 05/11/2017
Chest
Cavity
(Thomas,
Gonzalez-Roth!)
calcification,
etc)
before
it can
third
stage
and
develop
being
result
of
to the
ination
localized
described
1 . Intrathoracic
thoracostomy.
FIGURE
aspergilloma
visualized
through
open-
Because
of persistent
later,
an
despite
apparent
visualized
tins
stains
revealed
were
with
not
appear
That
would
suggest
of fungus
(100,000
units
sprayed
into
intracavitary
not
serum
Aspergillus
growth,
was
dissolved
cavity
(Fig
times
has
been
2) without
eral
formation
of
graphic
and
second,
the
ically
apparent
comparison
that
vegetative
dead
with
signs
are
and
prior
In
first
to be
size
alone
phase,
composed
to be
size.
films,
our
of
empiric
about
the
clinical
(ie,
healing
In
granulation
fistula
of both
fact
a 3-cm
density
of
the
se.
as
and
have
of
Our
be
suggest
more
in
than
also
the
suggest
may
was
of
in
impaired
a cavity
fungus
size
that
important
observations
the
reduction
temporally
hypotheses
but
within
once
documenaspergilloma.
mycetoma
of a inycetoma
tissue,
retard
eradicated,
bronchopleural
ensued.
mass
would
of
REFERENCES
in
that
was
suggest
mycelia,
1 Dar
NI, Ahmad
aspergillosis:
Weinstein
A,
and
Mehta
J.
A, Golish
aspergillon3a.
Cleve
Thoracic
Q
Clin
1984;
51:615-30
J,
Kay
P, Paneth
3 Varkey
B, Rose
H.
E. The
tion
description
and
ofhuman
Hailer
clinical
CRC
Clinical
animal.
tory
Berne,
WSC.
system.
farmer’s
Huber,
aspergilloma:
Crit
aspects
F, eds.
Rev
lung
in
ofaspergillus
and
Hans
of
2. classificavariants
85: 159
in man.
farn3er’s
Huber,
Suter
animal.
approach
invasive
F, eds.
Berne,
lung
In:
de
in man
1974:61-8
of aspergillosis
R,
and
and
infection
Aspergillosis
Hailer
man
survey
Lab Sci 1980;
Clin
Switzerland:
de
and
a rational
allergic
Histopathology
In:
aspergilloma:
hemoptysis
1976; 61:626-31
spectrum
ofaspergillosis:
ofsaprophytic,
R, Suter
6 Symmers
K. Pulmonary
to
38:572-78
Pulmonary
disease.
J.
5 Batten
1983;
An3 J Med
4 Bardana
Citron
in relation
Thorax
to treatment.
and
M,
of prognosis
treatment.
of the
respira-
Aspergillosis
and
Switzerland:
Hans
1974:75-8
7 Hamamoto
nazole
Intrathoracic
cavity
visualized
through
open-window
thoracostomy
after
two months
of treatment
with
nystatin
spray.
Mucosa
lining
cavity
is healing
progressively,
and
there
is no
evidence
of recurrence
of aspergilloma.
M,
1. overview
analysis
2.
per
a cavity
of
2 Jewkes
FIGURE
growth
presence
allowed
previous
may
the
radiograph-
The
patient
drainage
radiothe
intracavitary
in
of tissue.
of aspergilloma,
vascularity
been
Aspergillus
case
some
fungal
has
bronchopleural
intracavitary
confirm
tissue
fostering
of
stages
and
There
of
of
of drainage
healing
ofthis
observations
Application
of the
presence
hindered
stages
formative
in cavities.
fragmented
inycobacterial
size
more
colonization
negative.
circumstances
the
Our
that
subsequent
to be
of increased
in
sex’-
colonization
with
this
thought
x-ray
through
first,
occur,
it is presumed
chest
than
progress
the
is believed
fungus,
apparent
other
In
may
as a result
radiographically
factors
‘
mycelia.
aspergilloma
and
to
tissue
clinical
living
not
stages.
pulmonary
unusual
of
Repeat
the
have
perhaps
reduction
in the
that
may
is
cavity
noticeable
.
were
cavity
fungus
open
12,3
lesions
spontaneously
the
been
inflamed,
fostering
saprophytic
consistently
suggesting
somehow
tation
in
reduction
compromised
hypothesized
developmental
necrotic
been
definite
The
marked
DiscuSSION
are
but
vial)ility
in
was
has
a well-drained
tissue
recurrence
have
tissue
recurrence
through
resulted
contam-
studies.
fungal
in
tissue
growth
chronically
drainage
ofthis
that
what
satellite
flO
the aspergilloma
prevented
cultures
fistula,
daily
or mycobacteria.
Aspergillomas
and
fact
as a
of
postmortem
grew
poor
growth
spray
a 3-
occurred
confirms
and
and
impaired
dislodged
to
or by external
The
tissue
aspergilloina
patient
nystatin
slow
begun
in physiologic
three
There
mucosa
of the
precipi-
treatment
USP)
the
and
stains
necrotic,
subsequent
and
was
1). Cultures
Fungal
and
the
prior
have
c#{224}vit;although
that
described
colonization
fistula
in surgical
the
than
In our
radio-
fistula
(Fig
was discontinued.
therapy
in the
but
fungal
and
could
cavit
of the
In the
fragment,
a month
with
SOC5
healing
previously
noted.
months
mass
negative.
ofAspergillus,
and
Antituberculosis
improvement
were
To inhibit
Four
bronchopleural
window
cavity
fevers,
done.
grayish-black
to the
thoracostomy
tablets
solution
adjacent
the
mycelia
negative.
nystatin
saline
the
from
recurrent
was
a 3.0-cm
but
through
acid-fast
drainage,
thoracostomy
improvement,
graphically
mass
purulent
open-window
poorly
remainder
important
malaise,
of
intrathoracic
to
mycetoina
detected.
bronchopleural
of the
patient
nearly
aspergillolna
inhalation
the
to soften,
Our
for
incidentally
the
within
roentgenography.
is thought
calcification.
patient
adjacent
window
mycetoina
focal
mass
did
present
by plain
of fragments
In our
The
be
detected
the
dislodgment
cm
must
be
T, Watanabe
for
pulmonary
K, Ikemoto
H.
aspergilloma.
Endobronchiai
Ann
Intern
micoMed
1983;
98:1030
8 Faulkner
tysis
and
treatment.
5, Vernon
R, Brown
pulmonary
Ann
P, Fischer
aspergilloma:
Thorac
Surg
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21593/ on 05/11/2017
R, Bender
operative
versus
1978;
25:389-92
CHEST
I 95
H.
Hemop-
nonoperative
I 5 I MAY, 1989
1157
9 Krakowka
P, Kazimierz
Pawlicka
L. Local
paste
T,
containing
J,
Walczak
treatment
Halweg
of aspergiiloma
nystatin
or
H,
Elsner
of the
amphotericin
B.
lung
Z,
with
Tubercle
a
have
Daly
R,
Cardiovasc
Surg
J,
Hargis
Bone
aspergillomas.
Am
JC.
pir
13
J,
Schwarz
cated
Med
P
J Thorac
N,
Hiller
C.
Baum
not significant.
and
68:389-94
calcification
in the
pulmonary
tumor-like
aspergilloma.
form
Am
Rev
of
Res-
was
intermittently
the
physical
C,
Straub
ball.
J
Am
M.
Cavitary
Med
1961;
histoplasmosis
The
chest
and
dl;
Lanie
M.D.;t
Francisco
, Ph.D.;
D.VM.
Eagleton,
Rarnirez,
in
M.D.;
soil.
haeohyphomycosis
tation
to
spread
to
skin.
site
neous
spread
report
of
of
dermatitidis,
which
and
was
the
had
a history
failed
to
secretions
*From
of
taken
the
Department
this
first
rate,
Nov
bloody
28 per
sputum
unremarkable.
no
The
.
The
significant
7,
1985,
minute.
She
remainder
chest
was
of
clear
to
lymphadenopathy
or
had
normal
a normal
level
night
in the
(Fig
was
3.7
Mantoux
lower
cell
value
count
was
110 mg/
was
Immunoglobulin
14 mn,
and
no major
hemoglobin
blood
glucose
was
lobe
showed
admission,
white
g/dI.
test
left
1) and
On
indices;
differential;
of admission,
she
hypotension
there
and
was
originating
and
multiple
choscopy.
levels
were
two subsequent
but
lingula.
transfusions.
grew
was
Mycology
Infectious
Diseases
Laboratory.
The
bronchoscopy
the
microscopic
at the
the
was
lavage
of the
examination
weeks
dermatitidis
lingula
of the
later,
on the
Institute
26,
of Public
1986,
lavage
basis
the
and
Health
stopped.
and
grew
a
both
of Allergy
were
again
have
at bronby
Department
Nov
to
obtained
medications
on
lung,
rifampin,
characteristics
Illinois
done
t’o
National
antituberculosis
thought
specimen
physiologic
Section
and
However,
At
left
ethambutol,
as Exophiala
2) and
the
was
with
activity.
from
She
the
episode
seizure
isoniazid,
from
identified
a syncopal
bleeding
with
blood
(Fig
from
the
treated
fungus
This
had
questionable
profuse
in
was
of morphology
cultures
infiltrate
roentgenograms.
with
initial
dematiaceous
repeat
an
thickening
no induration.
the
Clinical
had
A
subsequent
E dermatitidis.
showed
a moderate
and
conidia
in
a patient
source
is the
of cuta-
first
case
due
published
of
due
infection
to
isolated
Exophiala
to
this
fungus
REPORT
(an unmarried
hemoptysis.
cause
bronchoscopy
ofLaboratory
retired
schoolteacher)
A bronchoscopy
of
bleeding.
were
in
Cultures
negative
Medicine,
Center
and
Southern
Illinois
University
Carbondale.
tClinical
Assistant
Professor
of Pathology.
Medical
Resident.
§Professor
of Microbiology.
liProfessor
of Medicine.
1158
admission
Alternatively,
presented
hemoptysis
woman
any
at
of
treated.
recurrent
demonstrate
on
with
local-
of the
documented
it is the
white
a cough
hematogenous
identifiable
knowledge,
CASE
A 79-year-old
progressive
had
implan-
remain
rarely
occurs.’
lung
no
causing
successfully
traumatic
by inhalation
unequivocally
infection
had
to
was
related
in plants
organisms
CNS)
and
To our
an
pulmonary
history
to distant
hemoptysis
infection.
medical
for
progres-
closely
found
by
but
acquired
Phaeohyphomycosis
severe
are
the
(eg,
be
of
initiated
organs
may
hematogenous
with
which
Cenerally,
slowly
variety
of inoculation,
distant
infection
a
is usually
the
the
a chronic,
by
fungi
infection
into
ized
with
The
tuberculosis
and
film
with
albumin
probably
is usually
caused
or dematiaceous
The
the
and
Direct
“black”
continued
and
respiratory
was
previous
bronchoscopy,
and
M.D. , F.C.C.PII
infection
treated
She
she had
months
time
was
pleural
11 g/dl
mm
normal.
tests
x-ray
documented
retired
schoolteacher
had a history
of bronchiectasis.
She developed
recurrent
hemoptysis
requiring
multiple
blood
transfusions.
Exophiala
dermatitidis
was
cultured
repeatedly
from bronchial
lavages.
To our knowledge, this is the first documented
case ofisolated
pulmonary
phaeohyphomycosis
due to E dermatitidis,
and it was
successfully
treated
with
amphotericin
B
and
5fluocytosine.
(Chest 1989; 95:1158-60)
sive
the
there
apical
from
was
On
A 79-year-old
P
six
37.0#{176}Cand
and
lingula
compli-
31:692-700
Pulmonary
Phaeohyphomycosis
a Patient with Hemoptysis*
P Tewari,
Past
to admission,
for
was
lung.
weeks.
examination
11,600/cu
Barenfanger,
of the
on bronchoscopy,
and
hepatosplenomegaly.
value
Rain
Prior
expectorating
auscultation,
have
of hemoptysis.
at
was
findings
to
lingula
loss
examination,
change
I oan
the
weight
for two
history,
thought
episodes
weakness
On
94:208-16
by fungus
occasional
the
was
involving
temperature
pulmonary
upon
she
otherwise
Intracavitary
of symptomatic
1980;
Pulmonary
1966;
Rector
treatment
aspergillosis:
Dis
W, Bernatz
treatment.
films,
hemoptysis
J,
the
J
V, Payne
of surgical
92:981-88
R, Stewart
B in
pulmonary
results
1986;
amphotericin
Pimentel
J, Trastek
P, Piehler
aspergilloma:
11
12
Pairolero
Pulmonary
Based
x-ray
bronchiectasis
1970;
51: 184-91
10
microorganisms.
and
for
Memorial
School
of
1979
of
the
pathogenic
Medical
Medicine,
FIGURE
thickening
1 . Infiltrate
over both
in the
apices.
lingula
Pulmonary
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and
lower
Phaeohyphomycosis
left
lobe
with
pleural
(Barenfanger at a!)