Invasive infection by Aspergillus terreus treated successfully with liposomal amphotericin B

A woman of 75 years old was admitted at our hospital for evaluation of worsening and weakness in inferior limbs. Several vertebral fractures by crushing, one doubtful discitis, an infiltrate with cavitation in the right superior lobe and one infiltrate in the left superior lobe were detected. In the biopsy of the consolidation a filamentous fungus was watched and in the bronchial washing specimen culture grew Aspergillus terreus. The infiltrates disappeared with liposomal Amphotericin B remaining with oral Itraconazol during three months more. The clinical and analytical data demonstrate the existence of a Overlap syndrome associate to antiphospholipid-antibody syndrome. We comment the peculiarity of the infection by Aspergillus terreus in patients who have not been in critical care and the good response at treatment with liposomal Amphotericin B. It contrasts with the high mortality referred in a recent review. Other aspects to comment are the coexistence with a collagen vascular and an antiphospholipid-antibody syndrome with the higher titles of IgM ACA that we have found in literature.     

Two cases of pulmonary aspergillosis successfully treated with combinated micafungin and itraconazole therapy

We report 2 cases of pulmonary aspergillosis treated successfully by combining micafungin and traconazole. Case 1: A 51-year-old man with hemoptysis and dyspnea on effort treated for pulmonary tuberculosis and aspergillosis was found on chest CT on admission to have a fungus ball in the left upper lobe and increasing consolidation around the cavity of both lung fields. Bronchoscopy proved positive for aspergillus PCR in bronchial lavage. He was diagnosed with chronic necrotizing pulmonary aspergillosis, based on clinical and radiological findings and the positive reaction for aspergillus PCR. He was treated with micafungin alone at first, this proved ineffective, so itraconazole was added, resulting in improvement. Case 2: A 24-year-old woman with stabilized Hodgkin's disease (mixed). She had suffered from a cough and back pain, and chest CT showed increasing consolidation inside and around a giant bulla. She was diagnosed with chronic necrotizing pulmonary aspergillosis, based on isolation for Aspergillus sp. in sputum culture and a positive reaction for Aspergillus antigen in bronchial lavage and Aspergillus antibody in serum. She was treated with the combined micafungin and itraconazole, which rapidly improved symptoms and radiological findings. Pulmonary aspergillosis therapy is often difficult, because delivery of the drug to the infection site is limited and drug tolerance is poor. We found that combination micafungin and itraconazole therapy is tolerable and effective in these cases.     

Abdominal wall mucormycosis successfully treated with amphotericin and itraconazole

The routine management of cutaneous mucormycosis consists of combined surgical and medical therapy. We present a case of successful medical therapy with sequential liposomal amphotericin B and itraconazole for a peri-ostomal cutaneous Rhizopus infection in a 59-year-old woman following treatment for pyoderma gangrenosum in the setting of inflammatry bowel disease.     

A case of chronic necrotizing pulmonary aspergillosis]

A 70-year-old woman with diabetes mellitus who was following a therapeutic diet showed an infiltrative shadow in the right upper lung field on chest roentgenogram in April, 1986. She was diagnosed as having pneumonia and was treated for five months with several antibiotics, but the abnormal shadow on chest roentgenograms increased in size. Therefore, she was admitted to our hospital in October 1986. Although tubercle bacilli were not isolated from her sputum or from materials obtained by bronchoscopic examination, we made an initial diagnosis of pulmonary tuberculosis based on the findings of chest roentgenograms, tomographs and CT scanning. In spite of treatment with antituberculous drugs, the infiltrative shadow with cavity on chest roentgenograms continued to increase in size, and the patient developed occasional hemoptysis. Percutaneous needle biopsy was performed in February 1987 to establish a definite diagnosis, and the presence of Aspergillus fumigatus was confirmed by microscopic examination and culture. After treatment with miconazole and 5-FC for 3 to 4 months, the abnormal shadow on the chest roentgenogram gradually disappeared and was almost undetectable one year later. The clinical course of this patient was considered to be strongly indicative of chronic necrotizing pulmonary aspergillosis, which was described by Binder et al. in 1982.     

Micafungin therapy for a case of chronic necrotizing pulmonary aspergillosis]

The patient was a 42-year-old man who visited a physician with fever, and was diagnosed with pulmonary abscess. Antibiotic therapy was ineffective, and he was referred to our hospital. Chest CT scanning revealed a lesion with cavity formation with an infiltrative shadow in the right upper lobe, and another infiltrative shadow in the left upper lobe. Chronic necrotizing pulmonary aspergillosis (CNPA) was diagnosed on the basis of positive culture of bronchial lavage specimens and positive serological test results for Aspergillus, in addition to the clinical and radiographic features. Intravenous administration of micafungin (MCFG) was initiated with combination therapy of percutaneous cavity drainage, inhaled amphotericin B and oral itraconazole. Clinical symptoms and findings gradually improved, and he was discharged after 40 days of MCFG therapy. MCFG was safe and effective therapy in this case, and may be considered a new therapeutic option for CNPA.     

Disseminated aspergillosis treated with amphotericin B and surgery in a boy with chronic granulomatous disease

Summary A case of systemic infection caused byAspergillus fumigatus in a seven-year-old boy suffering from chronic granulomatous disease is described. The fungus had infiltrated his lungs, his left foot and the popliteal and inguinal lymph nodes. Amphotericin B, 1 mg/kg daily, was given for three months via a central venous catheter. Progressive anaemia made amputation of his left leg necessary. The bone tissue was heavily infiltrated with fungal elements. The regional lymph nodes were also resected because of fungal growth. After six months no fungi were found in liver aspirates taken on account of liver abscesses due toStaphylococcus aureus. The combined medical and surgical approach resulted in complete eradication of theAspergillus infection, as verified by the disappearance ofAspergillus precipitins.

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Disseminierte Aspergillose bei einem Jungen mit septischer Granulomatose behandelt mit Amphotericin B und Operation

Zusammenfassung Ein Fall von systemischer Infektion durchAspergillus fumigatus bei einem sieben Jahre alten Jungen mit septischer Granulomatose wird beschrieben. Der Pilz hatte sich in den Lungen, dem linken Fuß, den poplitealen und inguinalen Lymphknoten ausgebreitet. Amphotericin B, 1 mg/kg pro Tag, wurde drei Monate lang über einen zentralen Venenkatheter gegeben. Eine zunehmende Anämie machte die Amputation des linken Beines notwendig. Das Knochengewebe war stark mit Pilzelementen durchsetzt. Die regionalen Lymphknoten wurden wegen Pilzbefalls ebenfalls entfernt. Nach sechs Monaten fanden sich in einem Leberpunktat, das wegen eines Leberabszesses, verursacht durchStaphylococcus aureus, entnommen wurde, keine Pilze mehr. Die kombinierte medikamentös-chirurgische Behandlung führte zu einer kompletten Eradikation derAspergillus-Infektion, was durch das Verschwinden derAspergillus-Präzipitine verifiziert wurde.

     

Chronic necrotizing pulmonary aspergillosis in the surgically treated lung]

A 76-year-old man was admitted because of bloody sputum persisting for 3 months. Right upper lobectomy had been performed for non-small cell lung cancer (well-differentiated adenocarcinoma, pT1NOMO) 6 years prior, and the patient had uncontrolled diabetes. Chest computed tomography on admission showed a 1-cm nodule (fungus ball) in a cavitary lesion and consolidation with an air bronchogram were present in the right lung. Aspergillus flavus was detected in the patient's sputum, and laboratory tests were positive for Aspergillus antigen and antibody. Chronic necrotizing pulmonary aspergillosis (CNPA) was diagnosed in the surgically treated lung.     

Zygomycosis over‐infection during voriconazole therapy for aspergillosis in a heart transplant patient,successfully treated with liposomal amphotericin and posaconazole

Aspergillosis and zygomycosis are life‐threatening fungal infections in immunocompromised patients. We report a heart transplant recipient with an early pulmonary invasive aspergillosis successfully treated with association of voriconazole and caspofungin. Zygomycosis sinusitis, which was diagnosed while he still was on voriconazole therapy, was successfully treated with the use of combination antifungal therapy including liposomal amphotericin plus posaconazole and conservative surgical debridement.     

Relapse of visceral leishmaniasis in an HIV-infected patient successfully treated with a combination of miltefosine and amphotericin B

The present report documents a 49-year-old HIV-infected man receiving antiretroviral therapy with a suboptimal immune response and a CD4 count of 95 cells/mm³, despite virological suppression. Investigation of bone marrow was conducted and yielded a diagnosis of visceral leishmaniasis. The clinical course was complicated by gastrointestinal involvment and relapse occurred after amphotericin B therapy. With the addition of miltefosine, the patient no longer presented with bone marrow amastigotes, and displayed an increased CD4 count and negative Leishmania polymerase chain reaction results. The present case highlights atypical presentation of visceral leishmaniasis, including poor immune reconstitution and gastrointestinal involvement. The high likelihood of relapse and response to combination therapy are illustrated.     

A case of chronic necrotizing pulmonary aspergillosis due to Aspergillus flavipes associated with pulmonary fibrosis]

The patient was a 76-year-old man with complaints of fever, productive cough, and purulent sputum. He was on home oxygen therapy for pulmonary fibrosis. Antibiotics were administered, but with no improvement. Because the inflammatory condition persisted, the patient was admitted. Computed tomographic (CT) scans of the chest demonstrated infiltrative shadows and a fungus ball, and pulmonary aspergillosis was suspected. The patient was given an antimycotic agent and his symptoms gradually resolved. Subsequent chest CT scans revealed a reduction of the infiltrative shadows, but no reduction in the size of the fungus ball. Aspergillus flavipes was cultured from samples of bronchoalveolar lavage fluid. Aspergillus fumigatus is the most common causative agent of pulmonary aspergillosis. In this respect, our case was considered rare and of value to the diagnosis and treatment of future cases of pulmonary aspergillosis.     

A case of hyper-IgE syndrome complicated by chronic necrotizing pulmonary aspergillosis]

A 46-year-old man afflicted with recurring infection and bone fracture consulted our hospital because of general malaise and increase of sputum. He was given a diagnosis of chronic necrotizing pulmonary aspergillosis, and underwent right lower lobectomy. Six months later, chronic necrotizing pulmonary aspergillosis become exacerbated. Slightly improvement was obtained with voriconazole. Two months later, this disease become reactivated, and slightly improved with itraconazole and amphotericin B. Subsequently, hyper-IgE syndrome was diagnosed in him by pathognomonic face, recurring infection and bone fracture, chronic necrotizing pulmonary aspergillosis, elevated IgE, and eosinophilia. We suggested that the pathogenic cause of chronic necrotizing pulmonary aspergillosis in this case was hyper-IgE syndrome. After that, chronic necrotizing pulmonary aspergillosis was reexacerbated. We added micafungin, increased itraconazole, interferon gamma, and so on. As a result, his chest radiograph and symptoms improved slowly. Cases of hyper-IgE syndrome are rare.     

Two cases of successfully treated invasive pulmonary aspergillosis following influenza virus infection]

While invasive pulmonary aspergillosis usually occurs in immunocompromised hosts, it has been described after influenza virus infection in healthy individuals. The first case was a 76-year-old previously healthy woman admitted because of chest pain, cough, sputum, fever, and a chest radiograph abnormality. A transbronchial biopsy specimen showed fungal hyphae. Amphotericin B (AMPH) and Itraconazole (ITCZ) were given, and she improved gradually. A viral test showed a titre of 1/128 to influenza A. Case 2 was a 72-year-old previously healthy man admitted because of cough, fever, chest pain and a consolidation and cavitation on the chest radiograph. Antibiotics were ineffective. Cavitation with a halo sign appeared on the contralateral lung. Because his daughter was infected with Influenza B, we suspected he had been infected with IPA following influenza infection. AMPH and ITCZ and Micafungin sodium were given. His respiratory failure worsened, and on the tenth hospital day he required artificial ventilation; his condition improved gradually, (extubation after 40 days.) A viral test showed a titre of 1/128 to influenza B. IPA must be considered for the differential diagnosis of complications of influenza virus infection.