Aspergillus Tracheobronchitis Research Articles

Fungal Tracheobronchitis in Lung Transplant Recipients: Incidence and Utility of Diagnostic Markers.

Fungal tracheobronchitis caused by Aspergillus and Candida spp. is a recognized complication after lung transplantation, but knowledge of the incidence of Candida tracheobronchitis is lacking. The diagnosis relies on fungal cultures in bronchoalveolar lavage fluid (BALF), but cultures have low specificity. We aimed to evaluate the one-year incidence of fungal tracheobronchitis after lung transplantation and to assess the utility of diagnostic markers in serum and BALF to discriminate fungal tracheobronchitis from colonization. Ninety-seven consecutively included adult lung-transplant recipients were prospectively followed. BALF and serum samples were collected at 1, 3 and 12 months after transplantation and analyzed for betaglucan (serum and BALF), neutrophils (BALF) and galactomannan (BALF). Fungal tracheobronchitis was defined according to consensus criteria, modified to include Candida as a mycologic criterion. The cumulative one-year incidence of Candida and Aspergillus tracheobronchitis was 23% and 16%, respectively. Neutrophils of >75% of total leukocytes in BALF had 92% specificity for Candida tracheobronchitis. The area under the ROC curves for betaglucan and galactomannan in BALF to discriminate Aspergillus tracheobronchitis from colonization or no fungal infection were high (0.86 (p < 0.0001) and 0.93 (p < 0.0001), respectively). To conclude, the one-year incidence of fungal tracheobronchitis after lung transplantation was high and dominated by Candida spp. Diagnostic markers in BALF could be useful to discriminate fungal colonization from tracheobronchitis.

Aspergillus tracheobronchitis with Birt-Hogg-Dubè syndrome as a rare cause of chronic cough

BackgroundAspergillus tracheobronchitis (ATB) is confined as a condition of chronic superficial infection of tracheobronchial tree. Its diagnosis is difficult due to atypical manifestations and low detective rate of Aspergillus thus far.Case presentation:Herein, we presented a 45-year-old male patient with a sole chronic productive cough for five years referred to our cough specialist clinic. Chest high-resolution computed tomography showed multiple lung cysts predominantly located in the subpleural lesions and near the mediastinum. Neither bacteria nor fungi were identified by sputum culture. However, metagenomic next-generation sequencing in sputum detected Aspergillus fumigatus DNA. The genetic testing of whole blood suggested the germline mutation of the tumor suppressor gene folliculin, supporting a diagnosis of Birt-Hogg-Dubé (BHD) syndrome. His productive cough symptom significantly improved after receiving itraconazole treatment for 2 months. After discontinuation of antifungal treatment, there was no relapse for four months follow-up. A diagnosis of ATB with BHD syndrome was eventually established in this patient.ConclusionATB should be considered in any patient with prolonged unexplained productive cough. Next-generation sequencing technologies may be useful to identify ATB which is uncommon and easily ignored in clinical practice.

FATAL ASPERGILLUS TRACHEOBRONCHITIS IN AN IMMUNOCOMPROMISED HOST ASSOCIATED WITH PARAINFLUENZA VIRUS INFECTION

FATAL ASPERGILLUS TRACHEOBRONCHITIS IN AN IMMUNOCOMPROMISED HOST ASSOCIATED WITH PARAINFLUENZA VIRUS INFECTION

Lung epithelial and myeloid innate immunity in influenza-associated or COVID-19-associated pulmonary aspergillosis: an observational study

BackgroundInfluenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA) affect about 15% of critically ill patients with influenza or COVID-19, respectively. These viral–fungal coinfections are difficult to diagnose and are associated with increased mortality, but data on their pathophysiology are scarce. We aimed to explore the role of lung epithelial and myeloid innate immunity in patients with IAPA or CAPA.MethodsIn this observational study, we retrospectively recruited patients who had been admitted to the intensive care unit (ICU) of University Hospitals Leuven, Belgium, requiring non-invasive or invasive ventilation because of severe influenza or COVID-19, with or without aspergillosis, between Jan 1, 2011, and March 31, 2021, whose bronchoalveolar lavage samples were available at the hospital biobank. Additionally, biobanked in vivo tracheobronchial biopsy samples from patients with IAPA or CAPA and invasive Aspergillus tracheobronchitis admitted to ICUs requiring invasive ventilation between the same dates were collected from University Hospitals Leuven, Hospital Network Antwerp (Belgium), and Amiens-Picardie University Hospital (France). We did nCounter gene expression analysis of 755 genes linked to myeloid innate immunity and protein analysis of 47 cytokines, chemokines, and growth factors on the bronchoalveolar lavage samples. Gene expression data were used to infer cell fractions by use of CIBERSORTx, to perform hypergeometric enrichment pathway analysis and gene set enrichment analysis, and to calculate pathway module scores for the IL-1β, TNF-α, type I IFN, and type II IFN (IFNγ) pathways. We did RNAScope targeting influenza virus or SARS-CoV-2 RNA and GeoMx spatial transcriptomics on the tracheobronchial biopsy samples.FindingsBiobanked bronchoalveolar lavage samples were retrieved from 166 eligible patients, of whom 40 had IAPA, 52 had influenza without aspergillosis, 33 had CAPA, and 41 had COVID-19 without aspergillosis. We did nCounter gene expression analysis on bronchoalveolar lavage samples from 134 patients, protein analysis on samples from 162 patients, and both types of analysis on samples from 130 patients. We performed RNAScope and spatial transcriptomics on the tracheobronchial biopsy samples from two patients with IAPA plus invasive Aspergillus tracheobronchitis and two patients with CAPA plus invasive Aspergillus tracheobronchitis. We observed a downregulation of genes associated with antifungal effector functions in patients with IAPA and, to a lesser extent, in patients with CAPA. We found a downregulated expression of several genes encoding proteins with functions in the opsonisation, recognition, and killing of conidia in patients with IAPA versus influenza only and in patients with CAPA versus COVID-19 only. Several genes related to LC3-associated phagocytosis, autophagy, or both were differentially expressed. Patients with CAPA had significantly lower neutrophil cell fractions than did patients with COVID-19 only. Patients with IAPA or CAPA had downregulated IFNγ signalling compared with patients with influenza only or COVID-19 only, respectively. The concentrations of several fibrosis-related growth factors were significantly elevated in the bronchoalveolar lavage fluid from patients with IAPA versus influenza only and from patients with CAPA versus COVID-19 only. In one patient with CAPA, we visualised an active or very recent SARS-CoV-2 infection disrupting the epithelial barrier, facilitating tissue-invasive aspergillosis.InterpretationOur results reveal a three-level breach in antifungal immunity in IAPA and CAPA, affecting the integrity of the epithelial barrier, the capacity to phagocytise and kill Aspergillus spores, and the ability to destroy Aspergillus hyphae, which is mainly mediated by neutrophils. The potential of adjuvant IFNγ in the treatment of IAPA and CAPA should be investigated.FundingResearch Foundation Flanders, Coronafonds, the Max Planck Society, the Fundação para a Ciência e a Tecnologia, the European Regional Development Fund, “la Caixa” Foundation, and Horizon 2020.

Melting cheese-like appearance in the bronchi: Aspergillus tracheobronchitis.

Melting cheese-like appearance in the bronchi: Aspergillus tracheobronchitis.

Clinical and Microbiological Characteristics of Culture-Positive, Influenza-Associated Pulmonary Aspergillosis: A Single-Center Study in Southern Taiwan, 2016-2019.

This study delineated the characteristics of 24 (11.2%) culture-positive, influenza-associated pulmonary aspergillosis (IAPA) patients out of 215 patients with severe influenza during 2016–2019 in a medical center in southern Taiwan. Twenty (83.3%) patients did not have EORTC/MSG-defined host factors. The mean time from influenza diagnosis to Aspergillus growth was 4.4 days, and 20 (83.3%) developed IAPA within seven days after influenza diagnosis. All patients were treated in intensive care units and all but one (95.8%) received mechanical ventilation. Aspergillus tracheobronchitis was evident in 6 (31.6%) of 19 patients undergoing bronchoscopy. Positive galactomannan testing of either serum or bronchoalveolar lavage was noted in all patients. On computed tomography imaging, IAPA was characterized by peribronchial infiltrates, multiple nodules, and cavities superimposed on ground-glass opacities. Pure Aspergillus growth without bacterial co-isolation in culture was found in 17 (70.8%) patients. A. fumigatus (15, 62.5%), A. flavus (6, 25.0%), and A. terreus (4, 16.7%) were the major causative species. Three patients had mixed Aspergillus infections due to two species, and two had mixed azole-susceptible and azole-resistant A. fumigatus infection. All patients received voriconazole with an all-cause mortality of 41.6%. Of 14 survivors, the mean duration of antifungal use was 40.5 days. In conclusion, IAPA is an early and rapidly deteriorating complication following influenza that necessitates clinical vigilance and prompt diagnostic workup.

Outcomes of Mechanically Ventilated Patients With Nosocomial Tracheobronchitis.

IntroductionVentilator-associated tracheobronchitis is a condition that occurs prior to the development of ventilator-associated pneumonia among patients who have been intubated. This study aimed to determine the impact of nosocomial tracheobronchitis (NTB) related to new bacteria on the outcome in patients with chronic obstructive pulmonary disease (COPD).MethodologyA prospective, observational study was conducted in the department of surgical ICU of a tertiary care hospital between May 2019 and December 2019. All patients ventilated, irrespective of age and gender, were enrolled in the study. Individuals who had nosocomial pneumonia, before or followed by NTB, were excluded. Throughout the study, endotracheal aspirates for quantitative bacterial cultures were obtained routinely on admission, weekly thereafter, and whenever NTB or nosocomial pneumonia was suspected. All data were prospectively collected by the researchers from admission day till discharge or death of the patient. The outcomes of NTB patients were compared with those without NTB.ResultsA total of 24 patients with NTB and 214 patients without NTB were evaluated. There were a total of 24 patients who were diagnosed with NTB and 214 patients were NTB negative. There was a dominance of the male gender in the NTB group; however, the difference was not significant. The most common complication in patients was renal failure. During hospitalization, the Aspergillus tracheobronchitis (ATB) rate was significantly higher in patients with NTB as compared to patients with no NTB, i.e., 18 (75%) vs. 80 (37.4%) (p < 0.001). The mean length of stay in patients with NTB was significantly greater than the NTB negative group (p < 0.0001). The mortality in the case group was significantly greater than in the NTB negative group, i.e., 66.67% vs. 48.50% (p = 0.03).ConclusionNTB is associated with an increased duration of mechanical ventilation and hospitalization in intensive care units. The mortality rate in the NTB group was considerably higher than in the patients who did not have NTB. Future studies can explore the interventional and management aspect of the disease, such as determining whether early administration of broad-spectrum antibiotics can help improve the prognostic outcome of patients with NTB on mechanical ventilation.

Aspergillus Tracheobronchitis in COVID-19 ARDS Patients – A Cohort Study

Background: Coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome patients are at risk for fungal infections, especially aspergillosis and mucormycosis. COVID-19-associated pulmonary aspergillosis (CAPA) is differentiated in a pulmonary form and Aspergillus tracheobronchitis (ATB). During the first wave of the pandemic, bronchoscopy for diagnosing Aspergillus superinfections was rarely performed in COVID-19 patients, so that detailed on data on ATB in CAPA patients is scarce. We analyzed prevalence and mortality of tracheobronchitis in patients with CAPA.Methods: We conducted a retrospective, single-centre study at the 14-bed intensive care unit (ICU) of the Department I of Internal Medicine of the University Hospital of Cologne, Germany from March 2020 to February 2021. CAPA patients were identified by twice weekly analysis of tracheal aspirates for Aspergillus growth, Aspergillus DNA (PCR) and galactomannan combined with serum galactomannan testing. In case of positive results, bronchoscopy with the examination of trachea and lower airways and bronchoalveolar lavage followed.Findings: A total of 69 COVID-19 patients were admitted to the ICU, with 17 patients developing probable CAPA. All CAPA patients received bronchoscopy resulting in a clinical diagnosis of tracheobronchitis in 8 patients with signs of tracheal lesions, pseudomembranes or vulnerable bloody trachea. Seven bronchoalveolar lavages revealed culture and eight PCR positivity for Aspergillus fumigatus. In 7 of 8 tracheobronchitis patients, bronchoalveolar lavage samples tested positive for galactomannan antigen optical density index of >0.5. The overall mortality of CAPA patients was 52.9% and the overall mortality of ATB patients was 75%.Interpretation: Our data indicate a substantial prevalence of tracheobronchitis in this single-center cohort of CAPA patients. To facilitate early diagnosis bronchoscopic tracheal examination is crucial as computed tomography lacks diagnostic accuracy to enable timely initiation of therapy.Funding Information: This work was in part supported by the German Registry of COVID-19 Autopsies (www.DeRegCOVID.ukaachen.de), funded by the Federal Ministry of Health (ZMVI1-2520COR201), and the project DEFEAT PANDEMICs, funded by the Federal Ministry of Education and Research (01KX2021).Declaration of Interests: PK reports grants or contracts from German Federal Ministry of Research and Education and the State of North Rhine-Westphalia; Consulting fees Ambu GmbH, Gilead Sciences, Noxxon N.V. and Pfizer Pharma; Honoraria for lectures from Akademie für Infektionsmedizin e.V., Ambu GmbH, Astellas Pharma, BioRad Laboratories Inc., European Confederation of Medical Mycology, Gilead Sciences, GPR Academy Ruesselsheim, medupdate GmbH, MedMedia, MSD Sharp & Dohme GmbH, Pfizer Pharma GmbH, Scilink Comunicación Científica SC and University Hospital and LMU Munich; Participation on an Advisory Board from Ambu GmbH, Gilead Sciences, Pfizer Pharma; A pending patent currently reviewed at the German Patent and Trade Mark Office; Other non-financial interests from Elsevier, Wiley and Taylor & Francis online outside the submitted work. SvS none. JGB reports scientific grants and travel expenses from Kite/Gilead outside the submitted work. FF has a clinician scientist position supported by the deans office, medical faculty, University of Cologne. JSG none. FP none. BB reports honoraria, travel expenses and advisory role from/for Astellas, Celgene, Johnson & Johnson, Kite/Gilead, MSD, Novartis, Pfizer, Takeda and financing of scientific research by Astellas, Celgene, Kite/Gilead, MSD and Takeda outside the submitted work. DAE received honoraria from Sanofi and TAKEDA outside the submitted work. ASV reports travel grants from Gilead Sciences outside the submitted work. OK reports payment or honoraria for lectures, presentations or speakers bureaus by Gilead and Pfizer and receipt of equipment, materials, drugs, medical writing, gifts or other services by Pfizer, MSD, Basilea, Gilead, Virotech and Wako Fujifilm outside the submitted work. PB none. MK reports payment or honoraria for lectures, presentations or speakers bureaus by Gilead, MSD and Pfizer outside the submitted work. OAC reports grants or contracts from Amplyx, Basilea, BMBF, Cidara, DZIF, EU-DG RTD (101037867), F2G, Gilead, Matinas, MedPace, MSD, Mundipharma, Octapharma, Pfizer, Scynexis; Consulting fees from Amplyx, Biocon, Biosys, Cidara, Da Volterra, Gilead, Matinas, MedPace, Menarini, Molecular Partners, MSG-ERC, Noxxon, Octapharma, PSI, Scynexis, Seres; Honoraria for lectures from Abbott, Al 344 Jazeera Pharmaceuticals, Astellas, Grupo Biotoscana/United Medical/Knight, Hikma, MedScape, MedUpdate, Merck/MSD, Mylan, Pfizer; Payment for expert testimony from Cidara; Participation on a Data Safety Monitoring Board or Advisory Board from Actelion, Allecra, Cidara, Entasis, IQVIA, Jannsen, MedPace, Paratek, PSI, Shionogi; A pending patent currently reviewed at the German Patent and Trade Mark Office; Other interests from DGHO, DGI, ECMM, ISHAM, MSG-ERC, Wiley outside the submitted work.Ethics Approval Statement: Patients with CAPA were included in the FungiScope® global registry for emerging invasive fungal infections (https://www.clinicaltrials.gov; National Clinical Trials identifier NCT01731353), which was approved by the local ethics committee of the University of Cologne, Cologne, Germany (identifier 05-102).

Analysis of the Clinical Features of Tracheobronchial Fungal Infections with Tumor-Like Lesions

Background: Tracheobronchial fungal infections (TBFI) cause life-threatening complications in immunocompromised hosts but are rarely reported. Misdiagnosis and delayed antifungal treatment are associated with the high mortality rate of patients with TBFI. Objectives: This study analyzed the bronchoscopic features of TBFI and their roles in the early diagnosis of TBFI. Methods: The demographic, clinical, radiologic, and bronchoscopic data of 53 patients diagnosed with TBFI in our department during a 15-year period were retrospectively analyzed. Results: Most of the TBFI patients were male, and mass was the most common radiologic abnormality. Obvious predilection in primary bronchus distributions was observed. 41.9% of the 43 Aspergillus tracheobronchitis (AT) patients, 70% of the 10 tracheobronchial mucormycosis (TM) patients, and 100% of the 3 endobronchial cryptococcosis patients had been misdiagnosed as having cancer on bronchoscopy because of the presence of tumor-like lesions. The most common features of AT were bronchial occlusion with a mass or mucosal necrosis, bronchial stenosis with mucosal hyperplasia, or uneven mucosa. The main descriptions of TM were bronchial stenosis or obstruction due to mucosal necrosis, uneven mucosa, or a mass. The endoscopic characteristics of endobronchial cryptococcosis included occlusion due to uneven mucosa or mass, or external compressive stricture. Conclusion: Immunocompromised patients and immunocompetent patients with underlying disease displaying tumor-like lesions on bronchoscopy should be differentially diagnosed with cancer. Bronchial biopsy is indispensable for the early diagnosis of TBFI.

Crash the Aspergillus Party Before It Gets Out of Hand

SESSION TITLE: Fungal Infections 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: 10-20% of Aspergillus pulmonary infections have concomitant endobronchial (EB) involvement. Neutropenic or immunocompromised patients are at high risk. Tracheobronchial Aspergillosis (TBA) can be obstructive, ulcerative, invasive or pseudomembranous (1). CASE PRESENTATION: A 65-year-old woman with hemophagocytic lymphohistiocytosis on etoposide and dexamethasone was intubated for respiratory distress in the setting of new neutropenia. Chest CT revealed consolidative opacities with a 4.4 cm area causing mass effect and near-total occlusion of the left main pulmonary artery and left mainstem bronchus (LMSB). Flexible bronchoscopy demonstrated circumferential pseudomembranes of exudate and necrotic tissue in the LMSB extending into the upper lobe and lingula, with a plug of debris almost completely occluding the LMSB. Due to the high suspicion for Aspergillosis the patient was started on combination therapy with voriconazole and micafungin. 2 days later the results of the EB biopsies and BAL revealed acute-angled branching septate hyphae consist with Aspergillus. The patient’s condition continued to deteriorate despite treatment, and she passed away on day 7 after her family decided to pursue only comfort measures. DISCUSSION: TBA carries a mortality of up to 50% despite anti-fungal therapy, with the pseudomembranous form carrying the worst prognosis (1). It has a typical bronchoscopic appearance characterized by extensive inflammation and invasion of the bronchial mucosa with circumferential pseudomembranes composed of necrotic debris, exudate and hyphae, often with concurrent mucus/ fungus plugs occluding the airway. While microscopy of respiratory specimens is the most sensitive tool to confirm the diagnosis, the characteristic bronchoscopic appearance makes it possible to start antifungal therapy immediately (2). New antifungal agents with better tissue penetration may improve patient outcome. CONCLUSIONS: Culture and histological examination of tracheobronchial mucus plugs and necrotic material should be performed in all immunocompromised patients to diagnose TBA. Pseudomembranous TBA carries an especially high mortality, but can be diagnosed early based on its characteristic bronchoscopic appearance, allowing immediate institution of anti-fungal therapy. Reference #1: Karnak D et al. Endobronchial fungal disease: an under-recognized entity. Respiration. 2007;74(1):88-104 Reference #2: Tasci S et al. Pseudomembranous and obstructive Aspergillus tracheobronchitis - optimal diagnostic strategy and outcome. Mycoses. 2006;49(1):37-42 DISCLOSURE: The following authors have nothing to disclose: Udit Chaddha, Rahul Chilappa, Aaron Glucksman, John Kern, Ramyar Mahdavi No Product/Research Disclosure Information

Failure to Recognize the Diagnosis of Cytomegalovirus Colitis in an Immunocompetent Male: Need for Heightened Index of Suspicion

Background: Cytomegalovirus (CMV) disease affects mainly immunosuppressed individuals such as stem cell and solid organ transplant recipients as well as those patients infected with the human immunodeficiency virus (HIV). Cytomegalovirus colitis has been diagnosed increasingly in normal hosts. Case Presentation: A 65-year-old male with a history of alcohol abuse had been hospitalized for severe bloody diarrhea for three months in an outside hospital; he tested negative for clostridial toxin. He was transferred to our intensive care unit in septic shock and multi-organ failure with bloody diarrhea and a megacolon on computed tomography (CT) scan. Emergency sigmoid colectomy was performed, however, the patient continued to have bloody diarrhea; subsequently, completion sub-total colectomy with ileostomy was performed. On immunohistochemistry a diagnosis of CMV colitis was made; blood CMV polymerase chain reaction (PCR) was positive, the patient tested positive for anti-CMV immunoglobulin (Ig) G but non-IgM antibodies. Ganciclovir was started and the patient's CMV PCR became negative within one week. The patient developed multiple other complications including Aspergillus tracheobronchitis, Pseudomonas aeruginosa sepsis, and Candida krusei pneumonia, but ultimately recovered from the multiple infections. A low natural killer (NK) cell count (<1%) was found on immunologic workup; the patient tested negative for HIV. Conclusion: Cytomegalovirus colitis is a rare disease in the non-immunocompromised host but should be considered in patients with pseudomembranous colitis testing negative for clostridial toxin.

Aspergillus pseudomembranous tracheobronchitis in an immunocompetent individual: A diagnostic conundrum with therapeutic challenge.

Aspergillus tracheobronchitis is an extremely uncommon manifestation of Aspergillus infection. Most of the cases described in the literature are in the immunosuppressed individuals and is almost uniformly fatal. Immunocompetent individuals do manifest the disease, but the disease if diagnosed early can be appropriately treated and thus can be life-saving. Here, we describe a similar case which was diagnosed only at autopsy.

A Case of Ulcerative Aspergillus Tracheobronchitis Complicated with Eosinophilic Granulomatosis with Polyangiitis

A Case of Ulcerative Aspergillus Tracheobronchitis Complicated with Eosinophilic Granulomatosis with Polyangiitis

Case Report of a Child after Hematopoietic Cell Transplantation with Acute Aspergillus Tracheobronchitis as a Cause for Respiratory Failure.

Rapid respiratory failure due to invasive mycosis of the airways is an uncommon presentation of Aspergillus infection, even in immunocompromised patients, and very few pediatric cases have been reported. Patients with Aspergillus tracheobronchitis present with nonspecific symptoms, and radiologic studies are often noninformative, leading to a delay in diagnosis. Prompt initiation of adequate antifungal therapies is of utmost importance to improve outcome. We report the case of a 9-year-old girl with chronic myelogenous leukemia who developed respiratory distress 41 days after hematopoietic cell transplantation and rapidly deteriorated despite multiple interventions and treatment modalities.

Lesson of the month 1: A cough that doesn’t fit the mould

Aspergillus disease has a wide spectrum of manifestations within the lungs; however invasive Aspergillus is most commonly associated with immunocompromise or pre-existing respiratory disease. Here we present a case of Aspergillus tracheobronchitis causing right middle lobe collapse, masquerading as late-onset asthma in a patient with no pre-existing risk factors following massive inhalation of Aspergillus spores from working with compost. This case highlights the importance of having a high index of suspicion for Aspergillus-related disease even in those with no traditional risk factors.

Aspergillus Tracheobronchitis With Endobronchial Obstruction: A Rare but Deadly Complication After Bone Marrow Transplant

Aspergillus Tracheobronchitis With Endobronchial Obstruction: A Rare but Deadly Complication After Bone Marrow Transplant

Aspergillus tracheobronchitis, bronchopleural fistula and empyema after lobectomy for aspergilloma

Aspergillus tracheobronchitis and Aspergillus empyema are two rare manifestations of Aspergillus infection. This case report presents a patient with chronic obstructive pulmonary disease who developed a pseudomembranous Aspergillus tracheobronchitis, bronchopleural fistula and empyema 16 months after lobectomy for an aspergilloma. Bronchoscopy proved to be important for assessment of severity. Combined systemic anti-fungal treatment (voriconazole) and open window thoracostomy were used to successfully treat the patient.

Aspergillus tracheobronchitis in critically ill patients with chronic obstructive pulmonary diseases

Aspergillus tracheobronchitis (ATB) is considered as an unusual form of invasive aspergillosis and has a fatal outcome. There is little current information on several aspects of chronic obstructive pulmonary diseases (COPD) complicated by ATB, the frequency of which is expected to increase in the coming years. In a prospective study of invasive bronchial-pulmonary aspergillosis (IBPA) in a critically ill COPD population, three proven cases of ATB were identified. The three new cases, combined with eight previously reported cases of COPD with ATB over a 30-year period (1983-2013), were analysed. Among 153 critically ill COPD patients admitted to the ICU, eight cases were complicated by ATB [23.5% of IBPA (8 of 34); and 5.2% of COPD (8 of 153)], and three cases were finally diagnosed as proven ATB by histopathological findings. Among the three new cases reported and the eight published cases, the overall mortality rate was 72.7% (8 of 11 cases), with a median of 11.5 days (range, 7-27 days) between admission to death. The mortality rate was significantly higher in patients with invasive pulmonary aspergillosis (IPA) [100% (8 of 8 patients)] than in patients without parenchyma invasion [0% (0 of 3 patient), P = 0.006]. Seven patients (77.8%) received systemic corticosteroid therapy and three patients (33.3%) inhaled corticosteroids before diagnosis with ATB. Dyspnoea resistant to corticosteroids (77.8%) was the most frequent symptom. The radiological manifestations progressed rapidly in three patients (75%) who had normal chest X-rays (CXRs) at admission. Pseudomembranous lesions were the most frequent form (54.5%) observed by bronchoscopy. Aspergillus fumigatus was the most frequently isolated pathogen (40%). ATB is an uncommon cause of exacerbation in approximately 5% of critically ill COPD patients admitted to the ICU, and may progress rapidly to IPA with a high mortality rate. Dyspnoea resistant to corticosteroids and appropriate antibiotics with a negative CXR should raise the suspicion of ATB. Early diagnosis of ATB is based on bronchoscopic examination and proven diagnosis maybe safely established with a bronchial mucous biopsy.

Aspergillus Tracheobronchitis and Influenza A Co-infection in a Patient with AIDS and Neutropenia.

Aspergillus tracheobronchitis (AT), an unusual form of invasive pulmonary aspergillosis (IPA), is characterized by pseudomembrane formation, ulcer or obstruction that is predominantly confined to tracheobronchial tree. Hematologic malignancies, neutropenia, solid organ transplantation, chronic corticosteroid therapy and acquired immunodeficiency syndrome (AIDS) are known to be major predisposing conditions. However, since the introduction of highly active antiretroviral therapy, there is only one reported case of AT in AIDS patient. After pandemic of influenza A/H1N1 2009, there are several reports of IPA in patient with influenza and most of them received corticosteroid or immunosuppressive therapy before the development of IPA. We present a 45 year-old AIDS patient with influenza A infection who developed pseudomembranous AT without corticosteroid use or immunosuppressive therapy.

Aspergillus tracheobronchitis in a mild immunocompromised host.

Aspergillus tracheobronchitis is a form of invasive pulmonary aspergillosis in which the Aspergillus infection is limited predominantly to the tracheobronchial tree. It occurs primarily in severely immunocompromised patients such as lung transplant recipients. Here, we report a case of Aspergillus tracheobronchitis in a 42-year-old man with diabetes mellitus, who presented with intractable cough, lack of expectoration of sputum, and chest discomfort. The patient did not respond to conventional treatment with antibiotics and antitussive agents, and he underwent bronchoscopy that showed multiple, discrete, gelatinous whitish plaques mainly involving the trachea and the left bronchus. On the basis of the bronchoscopic and microbiologic findings, we made the diagnosis of Aspergillus tracheobronchitis and initiated antifungal therapy. He showed gradual improvement in his symptoms and continued taking oral itraconazole for 6 months. Physicians should consider Aspergillus tracheobronchitis as a probable diagnosis in immunocompromised patients presenting with atypical respiratory symptoms and should try to establish a prompt diagnosis.