Invasive pulmonary aspergillosis in an immunocompetent patient
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Case Report Invasive pulmonary aspergillosis in an immunocompetent patient Vikas Pathak a, * , Iliana Samara Hurtado Rendon a, c , Ronald L. Ciubotaru b a Department of Internal Medicine, St. Barnabas Hospital, 4422 Third Avenue Bronx, NY 10457, USA b Department of Pulmonary medicine, Intensive Care Unit, St. Barnabas Hospital, 4422 Third Avenue Bronx, NY 10457, USA article info Article history: Received 12 December 2010 Accepted 13 December 2010 Keywords: Aspergillosis Aspergillus fumigatus Fungal lung disease Immunocompetent host abstract Aspergillosis is the group of diseases caused by the Aspergillus species, which cause a broad spectrum of disease, ranging from hypersensitivity reactions to direct angioinvasion. The major forms of pulmonary aspergillosis range from aspergilloma with a relatively benign course to invasive pulmonary aspergillosis, which is uniformly fatal. Invasive pulmonary aspergillosis more commonly occurs in immunocompro- mised patients, with a rapidly progressing course leading to death. We report a case of an immuno- competent patient who developed fatal pneumonia secondary to Aspergillus fumigatus. Ó 2011 Elsevier Ltd. All rights reserved. Pulmonary aspergillosis usually produces a wide spectrum of lung disease, ranging from aspergilloma with a relatively benign course, to invasive pulmonary aspergillosis, which is uniformly fatal. Invasive pulmonary aspergillosis usually occurs in immuno- compromised patients, with a rapidly progressing course that leads to death. We herein report a case of an immunocompetent patient who developed fatal pneumonia secondary to Aspergillus fumigatus. 1. Case presentation A 25 year-old Hispanic male with a history of pulmonary tuberculosis was admitted to the hospital secondary to gunshot wounds to the abdomen and leg. The patient was alert, awake, and completely oriented upon arrival. His vital signs were stable. Examination of the chest, cardiovascular system, and abdomen were unremarkable, except that he had one entry and exit wound in the left lower quadrant of the abdomen from the gunshot. He did not have any signs of peritonitis. Chest x-ray on admission revealed a cavitary lung lesion on the right upper lobe. All other examina- tions and laboratory tests were within normal limits. On further questioning, the patient revealed that he was treated for pulmo- nary tuberculosis in the past. Patient denied any illicit drug use, alcohol abuse or smoking. The patient underwent successful surgical exploration of the abdomen and was placed on mechanical ventilation post-opera- tively. The patient was recovering well until day 3 of admission, when he developed tachycardia and tachypnea and became febrile while still on the mechanical ventilator. His total leukocyte count had increased significantly with a left shift. Repeat chest x-ray showed new bilateral pulmonary infiltrates. Multiple broad spectrum anti- biotics were started to treat ventilator-associated pneumonia; however, the patient continued to be hypoxic, requiring a high oxygen concentration and high positive end expiratory pressure (PEEP). Since his clinical status did not improve despite treatment with multiple broad spectrum antibiotics, a computed tomography (CT) scan of the chest was done. The chest CT showed bilateral upper lobe cavitary lesions with nodular enhancement and layering fluid/ debris. It also showed pulmonary nodular opacities in the broncho- vascular distribution. A sputum culture grew A. fumigatus. Human immunodeficiency virus (HIV) test was negative. The patient was started on anti-fungal treatment, but he died two weeks after intu- bation. The patient was accepted for autopsy, and the autopsy result confirmed the diagnosis of invasive pulmonary aspergillosis. 2. Discussion Some Aspergillus species cause a broad spectrum of disease in humans, ranging from hypersensitivity reactions to direct angioin- vasion. Aspergillus primarily affects the lungs, causing four main syndromes, including allergic bronchopulmonary aspergillosis (ABPA), chronic necrotizing pneumonia, aspergilloma, and invasive aspergillosis. Usually, only immunocompromised patients or those who suffer other chronic lung conditions are susceptible. Immu- nocompetent patients are normally asymptomatic and only inci- dentally are they found to have aspergilloma in a preexisting cavity, bulla, or cyst. 1e3 However, there have been rare cases where an immunocompetent patient had an invasive form of aspergillosis. 4 * Corresponding author. Tel.: þ1 571 230 4087 (mob). E-mail addresses: [email protected] (V. Pathak), samarahurtado@ hotmail.com (I.S. Hurtado Rendon). c Tel.: þ1 571 230 4087 (mob); fax: þ1 718 960 3486. Contents lists available at ScienceDirect Respiratory Medicine CME journal homepage: www.elsevier.com/locate/rmedc 1755-0017/$36.00 Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmedc.2010.12.004 Respiratory Medicine CME 4 (2011) 105e106
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Transcript of Invasive pulmonary aspergillosis in an immunocompetent patient
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Respiratory Medicine CME 4 (2011) 105e106
Contents lists avai
Respiratory Medicine CME
journal homepage: www.elsevier .com/locate/rmedc
Case Report
Invasive pulmonary aspergillosis in an immunocompetent patient
Vikas Pathak a,*, Iliana Samara Hurtado Rendon a,c, Ronald L. Ciubotaru b
aDepartment of Internal Medicine, St. Barnabas Hospital, 4422 Third Avenue Bronx, NY 10457, USAbDepartment of Pulmonary medicine, Intensive Care Unit, St. Barnabas Hospital, 4422 Third Avenue Bronx, NY 10457, USA
a r t i c l e i n f o
Article history:Received 12 December 2010Accepted 13 December 2010
Keywords:AspergillosisAspergillus fumigatusFungal lung diseaseImmunocompetent host
* Corresponding author. Tel.: þ1 571 230 4087 (moE-mail addresses: [email protected] (V
hotmail.com (I.S. Hurtado Rendon).c Tel.: þ1 571 230 4087 (mob); fax: þ1 718 960 34
1755-0017/$36.00 � 2011 Elsevier Ltd. All rights resedoi:10.1016/j.rmedc.2010.12.004
a b s t r a c t
Aspergillosis is the group of diseases caused by the Aspergillus species, which cause a broad spectrum ofdisease, ranging from hypersensitivity reactions to direct angioinvasion. The major forms of pulmonaryaspergillosis range from aspergilloma with a relatively benign course to invasive pulmonary aspergillosis,which is uniformly fatal. Invasive pulmonary aspergillosis more commonly occurs in immunocompro-mised patients, with a rapidly progressing course leading to death. We report a case of an immuno-competent patient who developed fatal pneumonia secondary to Aspergillus fumigatus.
� 2011 Elsevier Ltd. All rights reserved.
Pulmonary aspergillosis usually produces a wide spectrum oflung disease, ranging from aspergilloma with a relatively benigncourse, to invasive pulmonary aspergillosis, which is uniformlyfatal. Invasive pulmonary aspergillosis usually occurs in immuno-compromised patients, with a rapidly progressing course that leadsto death. We herein report a case of an immunocompetent patientwho developed fatal pneumonia secondary to Aspergillus fumigatus.
1. Case presentation
A 25 year-old Hispanic male with a history of pulmonarytuberculosis was admitted to the hospital secondary to gunshotwounds to the abdomen and leg. The patient was alert, awake, andcompletely oriented upon arrival. His vital signs were stable.Examination of the chest, cardiovascular system, and abdomenwere unremarkable, except that he had one entry and exit woundin the left lower quadrant of the abdomen from the gunshot. He didnot have any signs of peritonitis. Chest x-ray on admission revealeda cavitary lung lesion on the right upper lobe. All other examina-tions and laboratory tests were within normal limits. On furtherquestioning, the patient revealed that he was treated for pulmo-nary tuberculosis in the past. Patient denied any illicit drug use,alcohol abuse or smoking.
The patient underwent successful surgical exploration of theabdomen and was placed on mechanical ventilation post-opera-tively. Thepatientwas recoveringwelluntil day3of admission,when
b).. Pathak), samarahurtado@
86.
rved.
he developed tachycardia and tachypnea and became febrile whilestill on the mechanical ventilator. His total leukocyte count hadincreased significantly with a left shift. Repeat chest x-ray showednew bilateral pulmonary infiltrates. Multiple broad spectrum anti-biotics were started to treat ventilator-associated pneumonia;however, the patient continued to be hypoxic, requiring a highoxygen concentration and high positive end expiratory pressure(PEEP). Since his clinical status did not improve despite treatmentwith multiple broad spectrum antibiotics, a computed tomography(CT) scan of the chest was done. The chest CT showed bilateral upperlobe cavitary lesions with nodular enhancement and layering fluid/debris. It also showed pulmonary nodular opacities in the broncho-vascular distribution. A sputum culture grew A. fumigatus. Humanimmunodeficiency virus (HIV) test was negative. The patient wasstarted on anti-fungal treatment, but he died two weeks after intu-bation. The patient was accepted for autopsy, and the autopsy resultconfirmed the diagnosis of invasive pulmonary aspergillosis.
2. Discussion
Some Aspergillus species cause a broad spectrum of disease inhumans, ranging from hypersensitivity reactions to direct angioin-vasion. Aspergillus primarily affects the lungs, causing four mainsyndromes, including allergic bronchopulmonary aspergillosis(ABPA), chronic necrotizing pneumonia, aspergilloma, and invasiveaspergillosis. Usually, only immunocompromised patients or thosewho suffer other chronic lung conditions are susceptible. Immu-nocompetent patients are normally asymptomatic and only inci-dentally are they found to have aspergilloma in a preexisting cavity,bulla, or cyst.1e3 However, there have been rare cases where animmunocompetent patient had an invasive form of aspergillosis.4
V. Pathak et al. / Respiratory Medicine CME 4 (2011) 105e106106
Pneumonia caused by Aspergillus is non-specific and clinicallyindistinguishable from bacterial or viral pneumonia. The mostcommon presenting symptoms are fever, cough, dyspnea, and flu-like symptoms.5e13 The most common chest radiographic abnor-malities in these patients are bilateral diffuse chest infiltrates.Patients can also have cavitary lung lesions on presentation, withsome developing cavity a few days later. The presence of cavity onadmission usually points toward the diagnosis of aspergillosis, butit is not specific.4e13 Because of its non-specific nature, the mediantime from onset of symptoms to presumptive diagnosis is twoweeks. These cases are found to be uniformly fatal4e11 due to delayin the diagnosis.
The definitive diagnosis of invasive pulmonary aspergillosis ismade when the fungus growth is demonstrated within tissue uponbiopsy. Positive sputum cultures are not necessarily reliable fordiagnosis because Aspergillus is frequently a contaminant insputum. However, given that invasive aspergillosis has a 100%mortality rate, a respiratory secretion culture positive for Asper-gillus should not be routinely dismissed as a contaminant.4 Thelonger the delay in diagnosis and treatment, the more likely it isthat anti-fungal treatment will be ineffective and the outcome willbe fatal.
3. Conclusion
Invasive pulmonary aspergillosis should be included in thedifferential diagnoses for a patient presenting with diffuse bilateralchest infiltrates, with or without cavity. Any indication of asper-gillosis, by positive sputum culture or lack of response to routineantibiotic therapy, should compel the physician to conduct a lungbiopsy and initiate anti-fungal treatment.
Conflict of interest statementNeither the author nor any of the co-author has any financial or
personal relationships with other people or organizations thatcould inappropriately influence (bias) our work.
Acknowledgment
The authors thank the Marshfield Clinic Research Foundation’sOffice of Scientific Writing and Publication for editorial assistancein the preparation of this manuscript.
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