B. Invasive aspergillosis
Figure 1 - CT of chest: shows 3.1 cm Pleural based mass overlying
left upper lobe anteriorly. There is involvement of adjacent chest wall
with anterior displacement of pectoralis major and overlying rib
destruction. No hilar or mediastinal adenopathy. Extensive pulmonary
emphysema and blebs can also be seen.
Figure 2 - Hematoxylin and Eosin (H&E) stain of the biopsy
specimen showing numerous septate acute angled branching fungal hyphae
suggesting Aspergillus species without any evidence of malignancy.
Actinomyces would show up on H&E stain as gram positive thin
filamentous bacteria without septations. Visualization of sulfur granule
is pathognomonic for actinomyces infection.
Discussion
This patient has a lung lesion that ultimately invaded his chest
wall. Lesions invading facial planes are commonly seen in malignancy,
fungal infection or actinomyces infection. Bacterial infections
including bacterial abscesses are usually contained within a fascial
plane. Here, biopsy of the pulmonary nodule showed fungal invasion of
the tissue. Culture of tissue specimen showed Aspergillus Fumigatus.
Thus definitive diagnosis of invasive aspergillosis was made. Due to the
extent of the lesion, surgical resection was considered but the patient
elected a non-invasive approach. The lesion shrank after treatment with
voriconazole and will be followed to radiographic resolution.
Highest risk of invasive aspergillosis is for immunosuppressed
patients who have undergone stem cell or organ transplant and for those
who have prolonged neutropenia (1). It can also occur in less
immunocompromised host like a COPD patient who is receiving
corticosteroids (2). Invasive aspergillosis most commonly involves the
lungs. Patients can present with wide range of symptoms including fever,
cough, shortness of breath, chest pain or hemoptysis. The classic triad
of symptoms in neutropenic patients include fever, pleuritic chest pain
and hemoptysis. Patients who have underlying lung disease has more
indolent forms of the disease characterized by cavities or necrotic
lesions. Common symptoms in those include cough, weight loss, fatigue,
and chest pain.
CT is more sensitive than X-ray in identifying focal lesions.
Radiographic findings of invasive aspergillosis include patchy or lobar
consolidation, single or multiple nodules or peri-bronchial infiltrates.
Histopathologic demonstration of tissue invasion in combination with
culture of Aspergillus species provide definitive evidence of invasive
aspergillus. If biopsy is not feasible in a patient with radiographic
findings of invasive fungal invasion, serum biomarkers like
galactomannan and beta-D- glucan or a bronchoalveolar lavage fluid stain
and culture can aid in treatment decision. Galactomannan assay is
relatively specific for invasive aspergillus whereas beta-D- glucan can
be present in any type of fungal infection.
Treatment is aimed at early initiation of antifungals (3). Triazoles
can be used as a monotherapy at first. If initial treatment fails or if
it is severe invasive aspergillosis, triazole and Echinocandin
combination therapy can be used. Surgical correction can be done in
chest lesions near major vessels or pericardium, if there is risk for
invasion or bleeding, if the lesion has invaded to pleural space or
chest wall and if there is uncontrollable bleeding (3).
References
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Segal BH. Aspergillosis. N Engl J Med. 2009;360(18):1870-84.
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Bulpa P, Dive A, Sibille Y. Invasive pulmonary aspergillosis in
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Patterson TF, Thompson GR, 3rd, Denning DW, Fishman JA, Hadley S,
Herbrecht R, et al. Practice Guidelines for the Diagnosis and Management
of Aspergillosis: 2016 Update by the Infectious Diseases Society of
America. Clin Infect Dis. 2016;63(4):e1-e60.