Local Treatment With Amphotericin B Through a Fiberoptic Bronchoscopy for Aspergillus Colonization

Abstract

To the Editor: Intracavitary aspergillosis is the most common form of localized, noninvasive, and chronic infection of the lung produced by the Aspergillus species.1 The fungal growth takes place inside lung cavities often caused by tuberculosis, sarcoidosis, pneumoconiosis, ankylosing spondylitis, or other mycotic infections such as histoplasmosis or coccidioidomycosis.1,2 Hemoptysis is the main symptom, occurring in 50% to 80% of cases,1 and could be massive and life-threatening. Other clinical manifestations are chronic cough, mucopurulent expectoration, malaise, and weight loss. Chest x-rays usually show alterations in shape and size of preexisting cavities; fungus ball is a late radiologic feature of Aspergillus colonization.2 In symptomatic patients, surgical resection is the treatment of choice because medical therapy is often disappointing. Itraconazole by oral route, at a daily dose of 400 mg per day, is beneficial in less than 50% of cases, whereas percutaneous instillations of amphotericin B may be helpful in some patients.3-12 The optimum dosage of this latter treatment has not been established. A 73-year-old nonsmoking woman with a history of pulmonary tuberculosis in childhood presented with a respiratory tract infection with bronchorrhea. A computed tomography scan of the chest revealed bronchiectasis involving the lingula and in the medial basal segment of the left lower lobe. She received a course of antibiotics and fully recovered. However, as a result of frequent and severe exacerbation of bronchiectasis, a medial basal segmentectomy and resection of the lingula was performed. One year after the surgery, once again she presented with cough, purulent secretions, and hemoptysis and showed no response to a trial with empiric antibiotics. The sputum and bronchoalveolar lavage cultures were positive for Aspergillus fumigatus, whereas there was no evidence of reactivation of tuberculosis. A computed tomography scan of the chest revealed reappearance of bronchiectasis in the left lung without evidence of a fungus ball. Treatment with 400 mg itraconazole per day was started. There was a significant improvement in her symptom for the 6-month duration of her treatment. However, within 2 weeks of discontinuation of itraconazole, the patient developed a relapse with the same symptoms. Once again, Aspergillus fumigatus was isolated as the sole infectious agent in the sputum and bronchoalveolar lavage. Serologic tests, immunodiffusion, and counterimmunoelectrophoresis were positive for Aspergillus fumigatus. At that point, treatment with 200 mg oral itraconazole per day during the first year along with a local treatment with monthly instillations of amphotericin B (15-mg dose diluted in 6 mL of 5% dextrose solution) through a flexible bronchoscope was instituted, 3 mL in the left upper lobe and 3 mL in the lower lobe bronchi. We decided to instill amphotericin simultaneously in both bronchi because of the diffuse involvement of the left lung. The treatment was continued for 24 months and was performed as an outpatient procedure; there were no side effects.10 Coughing and hemoptysis resolved on the seventh day of the first procedure. During her treatment and in her follow up for 18 months without receiving itraconazole or amphotericin B treatment, the patient has done well without any exacerbation of her bronchiectasis. Her anemia disappeared and sedimentation rate has returned back to normal within 2 months of beginning the treatment. All bronchoalveolar lavage cultures and serology up to date have remained negative. We like to report usefulness of endobronchial instillations of amphotericin B in a case of Aspergillus colonization in which surgical resection had failed and the treatment with oral itraconazole alone was less effective. This treatment was well tolerated and less expensive than systemic antifungal treatments because it was performed on an outpatient basis. It would be interesting to consider this method in the future among patients who present with a fungus ball in the computed tomography scan. José Rodriguez Gimenez, MD* Fernando Javier Vazquez, MD‡ Roberto Negroni, MD† Alicia De la Canal, MD* Luis Marcelo Mayorga, MD‡ *Division of Pulmonary Medicine Hospital Italiano de Buenos Aires Buenos Aires, Argentina, †Division of Micology and Infectology Hospital Mu˜iz Buenos Aires, Argentina, ‡Department of Internal Medicine Hospital Italiano de Buenos Aires Buenos Aires, Argentina