Aspergillosis Presenting as Bilateral Pleural Effusion
Aspergillosis Presenting as Bilateral Pleural Effusion
Introduction: Chronic necrotizing pulmonary aspergillosis is an uncommon subacute form of Aspergillus infection. It typically occurs in immunocompromised individuals and in those with underlying lung disease. This interesting case highlights the occurrence of this entity of aspergillosis in an immunocompetent middle-aged woman with atypical radiological findings. To the best of our knowledge this is the first case report of chronic necrotizing pulmonary aspergillosis presenting with pleural effusion.
Case presentation: Our patient was a 64-year-old Malay woman with a background history of epilepsy but no other comorbidities. She was a lifelong non-smoker. She presented to our facility with a six-month history of productive cough and three episodes of hemoptysis. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation. Bronchoscopy revealed a white-coated endobronchial tree and bronchoalveolar lavage culture grew Aspergillus niger. A diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the clinical presentation and microbiological results. She responded well to treatment with oral itraconazole.
Conclusions: The radiological findings in chronic necrotizing pulmonary aspergillosis can be very diverse. This case illustrates that this condition can be a rare cause of bilateral pleural effusion.
Chronic necrotizing pulmonary aspergillosis (CNPA) corresponds to an indolent process of lung destruction caused by the Aspergillus fungus, generally A. fumigates. This entity is different from an aspergilloma, as a pre-existing cavity is not needed, although a cavity may develop in the lung as a secondary phenomenon. In contrast to invasive aspergillosis, CNPA occurs over a period of months to years and there is no vascular invasion or dissemination to other organs. The main risk factors are: chronic obstructive pulmonary disease, sequelae of tuberculosis, pulmonary resection, radiation-induced pulmonary fibrosis, pneumoconiosis, cystic fibrosis, pulmonary infarction and sarcoidosis. Other immunosuppression conditions, such as diabetes mellitus, malnutrition, alcoholism, connective tissue diseases and prolonged corticosteroid therapy, are also situations of increased risk.
Results from chest X-rays may reveal unilateral or bilateral infiltrates with or without cavitation and pleural thickness, especially in the upper lobes and in the upper segments of the lower lobes. In 50% of the cases an aspergilloma occurs simultaneously. The definite diagnosis is made through the histological demonstration of tissue invasion by the fungus and the growth of Aspergillus species in a culture.
Other helpful tests include serum IgG antibodies to Aspergillus and immediate skin reactivity for Aspergillus antigens. Due to the difficulty in confirming the diagnosis, the following diagnosis criteria were established and together are highly indicative of CNPA: characteristic clinical and radiological findings, elevation of inflammatory markers (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR)) and either serological test results positive for Aspergillus or the isolation of Aspergillus from respiratory samples. Active tuberculosis, non-tuberculosis mycobacteriosis, cavitary histoplasmosis and coccidioidomycosis should be excluded. Galactomannan and polymerase chain reaction (PCR) tests from bronchoalveolar lavage, as well as cutaneous sensitivity tests for Aspergillus, do not have a confirmed use in diagnosis.
Therapy with voriconazole or itraconazole has emerged as the first-line treatment and is safer than amphotericin B. The long-term prognosis for patients with CNPA is not well documented. The ideal treatment duration has not yet been defined and depends on the extension of the disease, the patient's response to treatment, the base disease and the patient's immunological condition. In some cases, lifelong therapy may be required.
Abstract and Introduction
Abstract
Introduction: Chronic necrotizing pulmonary aspergillosis is an uncommon subacute form of Aspergillus infection. It typically occurs in immunocompromised individuals and in those with underlying lung disease. This interesting case highlights the occurrence of this entity of aspergillosis in an immunocompetent middle-aged woman with atypical radiological findings. To the best of our knowledge this is the first case report of chronic necrotizing pulmonary aspergillosis presenting with pleural effusion.
Case presentation: Our patient was a 64-year-old Malay woman with a background history of epilepsy but no other comorbidities. She was a lifelong non-smoker. She presented to our facility with a six-month history of productive cough and three episodes of hemoptysis. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation. Bronchoscopy revealed a white-coated endobronchial tree and bronchoalveolar lavage culture grew Aspergillus niger. A diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the clinical presentation and microbiological results. She responded well to treatment with oral itraconazole.
Conclusions: The radiological findings in chronic necrotizing pulmonary aspergillosis can be very diverse. This case illustrates that this condition can be a rare cause of bilateral pleural effusion.
Introduction
Chronic necrotizing pulmonary aspergillosis (CNPA) corresponds to an indolent process of lung destruction caused by the Aspergillus fungus, generally A. fumigates. This entity is different from an aspergilloma, as a pre-existing cavity is not needed, although a cavity may develop in the lung as a secondary phenomenon. In contrast to invasive aspergillosis, CNPA occurs over a period of months to years and there is no vascular invasion or dissemination to other organs. The main risk factors are: chronic obstructive pulmonary disease, sequelae of tuberculosis, pulmonary resection, radiation-induced pulmonary fibrosis, pneumoconiosis, cystic fibrosis, pulmonary infarction and sarcoidosis. Other immunosuppression conditions, such as diabetes mellitus, malnutrition, alcoholism, connective tissue diseases and prolonged corticosteroid therapy, are also situations of increased risk.
Results from chest X-rays may reveal unilateral or bilateral infiltrates with or without cavitation and pleural thickness, especially in the upper lobes and in the upper segments of the lower lobes. In 50% of the cases an aspergilloma occurs simultaneously. The definite diagnosis is made through the histological demonstration of tissue invasion by the fungus and the growth of Aspergillus species in a culture.
Other helpful tests include serum IgG antibodies to Aspergillus and immediate skin reactivity for Aspergillus antigens. Due to the difficulty in confirming the diagnosis, the following diagnosis criteria were established and together are highly indicative of CNPA: characteristic clinical and radiological findings, elevation of inflammatory markers (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR)) and either serological test results positive for Aspergillus or the isolation of Aspergillus from respiratory samples. Active tuberculosis, non-tuberculosis mycobacteriosis, cavitary histoplasmosis and coccidioidomycosis should be excluded. Galactomannan and polymerase chain reaction (PCR) tests from bronchoalveolar lavage, as well as cutaneous sensitivity tests for Aspergillus, do not have a confirmed use in diagnosis.
Therapy with voriconazole or itraconazole has emerged as the first-line treatment and is safer than amphotericin B. The long-term prognosis for patients with CNPA is not well documented. The ideal treatment duration has not yet been defined and depends on the extension of the disease, the patient's response to treatment, the base disease and the patient's immunological condition. In some cases, lifelong therapy may be required.
