Pulmonary sporotrichosis: review of treatment and outcome

Four culture-documented cases of pulmonary sporotrichosis, three primary infections and one with multisystem involvement, are presented. Two of these patients are the first reported cases of primary lung disease treated with ketoconazole. This antifungal agent appears to be ineffective in eradicating this infection. The four cases, as well as a review of the literature, illustrate several important aspects of this rare disease. Pulmonary sporotrichosis is most commonly found in males with a history of alcohol abuse who are between the ages of 30 and 60. The infection is usually confined to the parenchyma of the lung but can involve hilar and mediastinal lymph nodes, pleura, skin, subcutaneous tissue, and joints. All but two cases have been reported in the United States, and the majority reside within states bordering the Missouri or Mississippi rivers. Direct occupational or environmental exposure appears to be an important predisposing risk factor. The onset of the disease is insidious, presenting in a manner similar to many other granulomatous or neoplastic diseases. Tuberculosis is the most common suspected diagnosis before confirmation of sporotrichosis. The chest radiograph most commonly demonstrates upperlobe cavitary disease with surrounding parenchymal infiltrates. The diagnosis can be suspected with high serologic titers or skin-test positivity, but needs to be confirmed by culture. The organism can usually be grown from sputum, as well as routine bronchoscopic procedures, open-lung biopsy specimens or pleural fluid. Histologic examination shows granulomas of both the caseating and noncaseating varieties. Frequently, organisms can be seen in necrotic areas of the lung tissue by diastase-modified GMS or PAS staining. Staining by direct fluorescent antibody technique can also be done and appears to be highly specific. Treatment is controversial, but total surgical resection of diseased lung as well as a perioperative regimen of SSKI or amphotericin B appears to be the most efficacious therapy. Medical therapy alone with SSKI or amphotericin B may be useful in selected cases but has been disappointing in the majority of reports. The imidazoles are usually ineffective, and the search for more effective medical therapy continues.     

Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group

A review of representative cases of invasive aspergillosis was conducted to describe current treatment practices and outcomes. Eighty-nine physicians experienced with aspergillosis completed case forms on 595 patients with proven or probable invasive aspergillosis diagnosed using modifications of the Mycoses Study Group criteria. Pulmonary disease was present in 56%, with disseminated infection in 19%. The major risk factors for aspergillosis were bone marrow transplantation (32%) and hematologic malignancy (29%), but patients had a variety of underlying conditions including solid organ transplants (9%), AIDS (8%), and pulmonary diseases (9%). Overall, high antifungal failure rates occurred (36%), and complete antifungal responses were noted in only 27%. Treatment practices revealed that amphotericin B alone (187 patients) was used in most severely immunosuppressed patients while itraconazole alone (58 patients) or sequential amphotericin B followed by itraconazole (93 patients) was used in patients who were less immunosuppressed than patients receiving amphotericin B alone. Response rate for patients receiving amphotericin B alone was poor, with complete responses noted in only 25% and death due to or with aspergillosis in 65%. In contrast, patients receiving itraconazole alone or following amphotericin B had death due to or with Aspergillus in 26% and 36%, respectively. These results confirm that mortality from invasive aspergillosis in severely immunosuppressed patients remains high even with standard amphotericin B. Improved responses were seen in the less immunosuppressed patients receiving sequential amphotericin B followed by itraconazole and those receiving itraconazole alone. New approaches and new therapies are needed to improve the outcome of invasive aspergillosis in high-risk patients.     

The role and landscape of surgical treatment for mycobacteriosis

[Surgery for pulmonary multi-drug resistant (MDR) tuberculosis] For pulmonary MDR tuberculosis the author (me) had been operating many cases in Fukujuji Hospital JATA in fifteen years. For treatment, the points of operations are as follows: 1) Surgery is one of many treatable events, 2) The strategy is that cavitary foci as major sites of tuberculous expectoration have to be removed and other small foci are treated by not strong chemotherapies, 3) Final goal of surgical treatments is set up preoperatively, and its procedures are stepped up gradually. [Surgery for pulmonary non-tuberculous mycobacteriosis (NTM)] Major sites of pulmonary NTM expectorations are cavitary foci and bronchiectases. Main strategy of surgery for pulmonary NTM is the same as MDR tuberculosis, but multi-resections of cavitary and ectatic foci are more than MDR tuberculosis. Control rate of X-ray images is 80%, negative conversion rate is 88.9% in cases with more than one year postoperatively. But new or residual foci will be gradually growing up for several years postoperatively, so many discussions of surgical strategy for NTM are necessary now. [Surgery for pulmonary aspergillosis] Surgical treatments of pulmonary aspergillosis are difficult. Operations for them are mainly two procedures, resection of foci or no resection. The former is more radical than the later, but mortality rate is higher than usual pulmonary resection. However I think chest surgeons have to challenge to remove aspergillous foci, not aspergilloma but chronic necrotizing pulmonary aspergillosis.     

手术联合化疗治疗耐多药肺结核结果分析

目的临床上耐多药肺结核患者治疗效果往往不佳。探讨手术联合化疗治疗耐多药肺结核患者的疗效。方法对1995年4月—2005年3月住院的48例采用外科手术治疗+化疗的耐多药肺结核患者进行分析。肺部有空洞病变36例(75%),双侧肺均有病变16例(33.3%)。手术方式包括肺叶切除28例,全肺切除15例,胸膜全肺切除3例,肺段切除1例,楔形切除1例。结果术后死亡率2.1%(n=1)。并发症发生率16.7%(n=8)。术后随访6～90个月。痰菌阴转率83.3%。结论耐多药肺结核患者若有良好的心肺功能储备,手术治疗安全有效,配合化疗能提高患者的治愈率。     

205例肺结核合并支气管结核的外科治疗回顾分析

目的探讨肺结核合并支气管结核的外科治疗效果和手术适应症。方法总结1973年1月至2007年底手术切除的205例肺结核合并支气管结核的临床疗效。全组肺结核包括：原发综合征3例、浸润性肺结核19例、空洞性肺结核53例、慢性纤维空洞性肺结核45例、结核瘤或干酪性肺炎48例、结核性支气管狭窄27例、毁损肺10例。按照支气管结核分型,I型30例、Ⅱ型91例、川型50例、IV型34例。结果全肺切除术15例、全肺切除+胸廓成形术（胸改术）32例、肺叶切除术106例、肺叶切除术+胸改29例、支气管袖状成形术14例,其他手术9例。全组临床治愈率93.0%,手术并发症率为11.2%,手术死亡率为0.05%。结论虽然肺结核合并支气管结核是以抗结核药物为主要治疗方法,但目前仍有部分患者需要外科治疗。手术可提高肺结核合并支气管结核的临床治愈率。     

Lipid-based amphotericin in pulmonary zygomycosis: safety and efficacy of high exposure in a renal allograft recipient

Zygomycosis is associated with a high mortality in immunosuppressed patients. Treatment typically includes surgical resection and administration of intravenous amphotericin B. Success of treatment may require withdrawal of immunosuppression, with risk of graft loss. We report the successful treatment of invasive pulmonary zygomycosis, following initial surgical resection, using very high doses of lipid-based amphotericin B without withdrawal of immunosuppression. The patient received daily doses up to 10 mg/kg/day (51 g cumulatively) of lipid-based amphotericin B along with a brief course of intrapleural amphotericin. Despite immunosuppression not being withdrawn, the patient's kidney allograft function remained stable. We conclude that high doses of lipid-based amphotericin B can be safe and effective as part of the treatment regimen for pulmonary zygomycosis.     

Successful treatment of invasive aspergillosis in a heart transplant patient

Infection continues to be a major cause of mortality in cardiac transplant patients, and even though there has been significant progress in diagnosing and treating many infectious disease problems, invasive aspergillosis in the transplant patient represents a serious and usually fatal complication. Even with successful early diagnosis, the use of free amphotericin B (a polyene antibiotic) has failed to cure disseminated infection. We report the case of a 46-year-old transplant patient who failed to respond to treatment with free amphotericin B after a 7-day period of treatment for biopsy-proven pulmonary aspergillosis. However, a subsequent substitution of a liposomal form of amphotericin B was used, and the patient responded well to a total dose of 1.5 mg. After 7 months, the patient continues free of infection. This experience suggests that the introduction of liposomal amphotericin B may give new hope for treating an otherwise lethal infection.     

Treatment of leishmaniasis in HIV-positive patients

Although, in southern Europe, there has been considerable experience in the treatment of visceral leishmaniasis (VL) in HIV-positive patients, the optimal therapy has yet to be established. Pentavalent antimony salts, free amphotericin B deoxycholate (ABD) and lipidic formulations of amphotericin B are the drugs most commonly used. Treatment with pentavalent antimonials requires daily injections for 28 days, is not well tolerated and leads to initial clinical cure in only 66% of the co-infected cases. Free ABD has to be given, intravenously, for just as long, has significant toxicity and leads to initial clinical cure in even fewer cases (62%). In a prospective, comparative trial, treatment of co-infected cases with a pentavalent antimonial was found to have similar efficacy and toxicity to treatment with free ABD. The duration of treatment and the associated toxicity may both be reduced by the use of lipidic formulations of amphotericin B. Anecdotal evidence and the results of non-randomized trials indicate that treatment with liposomal amphotericin B is highly effective. In a comparative trial, amphotericin B lipid complex was found to be not only as effective as a pentavalent antimonial but also better tolerated. At the moment, however, such lipidic formulations have only been tested against VL/HIV cases in Europe, not elsewhere in the world, and they remain very expensive. However successful the treatment in terms of initial clinical cure, almost all VL/HIV cases develop VL relapses. Although the data available on secondary prophylaxis are limited and often inconclusive, it appears that regular treatment with a pentavalent antimonial drug, liposomal amphothericin B or amphotericin B lipid complex can reduce the incidence of leishmanial relapses in HIV-positive patients with VL. The development of new regimens, use of new oral drugs (such as miltefosine) and the development of new antileishmanial drugs could all improve the treatment of HIV-related VL in the future.     

Evaluation of surgical risk in palliation and resection of pancreatic cancer. Perspective study and tables to calculate the risk.

High morbidity and mortality rates are reported for bypass and resective surgery of pancreatic cancer. In a retrospective study we correctly predicted the postoperative course in 88% of the patients who underwent bypass surgery and 83% of those who had a resection for pancreatic cancer. Before starting with clinical application of this scoring system, we undertook a prospective study to confirm its predictive value. Sixty-seven consecutive patients with pancreatic cancer were included: 42 patients underwent bypass surgery and 25 pancreatic resections. The operative mortality was 14% for palliative surgery and 0% for resective surgery. Surgical team and nurses were totally unaware of the predicted risk. The preoperative forecast proved to be correct in 81% of bypass surgery and in 88% of resective surgery, although surgical mortality had decreased from 21 to 14% for bypass surgery and from 17 to 0% for resective surgery. Tables are included to calculate the surgical risk for each of 162 combinations of the risk factors considered in the predictive model (81 for bypass surgery and 81 for resective surgery). Calculation of surgical risk is important when evaluating different treatments for pancreatic cancer are available.     

Primary pulmonary sporotrichosis complicated by perirectal abscess.

A 48-year old, retired mounted policeman was followed for 4 years through 4 hospitalizations for progression of his bilateral, cavitary lung disease. His sputum was always negative for acid-fast bacilli and fungi. Subsequently, a painful perianal swelling appeared that was incised and drained of purulent material. Five years after first seen, sputum and rectal drainage revealed Sporothrichum schenckii in many cultures. Serologic evidence of sporotrichosis was also present. With amphotericin B therapy, the patient showed marked clinical improvement. Unfortunately, he died from an episode of acute respiratory failure. Although most patients with primary cutaneous or primary pulmonary sporotrichosis are horticulturists, the writers believe that this disease should be considered in any undiagnosed, chronic, cavitary lung disease, even in the absence of this occupational history.     

Pulmonary sporotrichosis in Oklahoma in susceptibilities in vitro

Six cases of pulmonary sporotichosis were observed in 2 institutions in Oklahoma City, Okla. Three of the patients were treated with iodides with or without surgery. Although one patient required a second course of iodides, the patients have remained well after at least 34 months of follow-up. Three patients treated with amphotericin B, single course as well as multiple courses, and other antifungal agents (hydroxystilbamidine and miconazole) have all relapsed. These cases and a reviewed of more than 40 cases of pulmonary sporotrichosis susceptibilities of Sporothrix schenckii that we observed in vitro suggest that amphotericin B is not an effective agent for the treatment of pulmonary sporotrichosis. It is our opinion that the treatment of choice for pulmonary sporotrichosis is a supersaturated solution of potassium iodide. If the patient is allergic to the medication or fails to respond, then a combination of amphotericin B plus flucytosine may be tried.     

Cavitary lung disease in AIDS: etiologies and correlation with immune status

To investigate the etiology and differential features of cavitary lung disease in patients with acquired immune deficiency syndrome (AIDS), chest computed tomography (CT) records from a 2-year period were reviewed to identify all human immunodeficiency virus (HIV)-positive patients with cavitary lung disease. Medical records were reviewed for the documentation of specific causes of lung cavitation and the CD4 count at the time of imaging. Of 25 HIV-positive patients with cavitary lung disease, 20 had specific diagnoses. Infection was the etiology in all the cases. Polymicrobial infection was found in 17 patients (85%) and unimicrobial in 3 (15%). Seventeen patients (85%) had bacterial organisms, 10 of whom had other pathogens as well. Mycobacteria were isolated in 8 patients (40%), fungi in 3 (15%), cytomegalovirus (CMV) in 3 (15%), and Pneumocystis carinii pneumonia (PCP) in 1 (5%). Mediastinal or hilar lymphadenopathy and additional noncavitary ill-defined nodular opacities were found more frequently in patients with mycobacterial pathogens. Mean CD4 count in patients with cavitary disease because of bacterial pathogens alone was significantly higher than in patients with nonbacterial pathogens (alone or combined with bacterial pathogens) (203 vs. 42, p < 0.05). Four patients expired during the diagnostic hospital admission; 2 of them had pulmonary cavitary disease associated with Nocardia asteroides. Cavitary lung disease in patients with AIDS undergoing chest CT should be assumed infectious and is generally polymicrobial.     

经蝶窦垂体瘤显微切除术治疗Cushing病的疗效分析

总结了自1980年初至1992年底经蝶显微外科手术治疗Cushing病103例的手术疗效。其中41例进行了选择性垂体腺瘤切除术,62例行垂体瘤及瘤周垂体前叶组织大部切除术。结果:近期有效率为83.5％,远期痊愈率为60.2％,复发率为11.4％。术后病理发现肿瘤者痊愈率为63.1％,而未见肿瘤者痊愈率为48.1％。垂体瘤及瘤周垂体前叶组织大部切除术的痊愈率72.6％,明显高于选择性肿瘤切除术的41.5％（P<0.001）。痊愈者术后48小时内血浆皮质醇水平即降至正常或低于正常,术后好转和无效者,其水平一般仍明显高于正常。术后有1.6％的病例（1/60例）出现继发性甲减,62.5％（30/48例）术前月经紊乱者在术后恢复正常。垂体瘤及瘤周垂体前叶组织大部切除术的疗效优于选择性肿瘤切除术;术后病理检查发现肿瘤者及术后48小时内血浆皮质醇水平明显下降或低于正常者预后良好。     

Evaluation of surgical risk in palliation and resection of pancreatic cancer Perspective study and tables to calculate the risk

High morbidity and mortality rates are reported for bypass and resective surgery of pancreatic cancer. In a retrospective study we correctly predicted the postoperative course in 88% of the patients who underwent bypass surgery and 83% of those who had a resection for pancreatic cancer. Before starting with clinical application of this scoring system, we undertook a prospective study to confirm its predictive value. Sixtyseven consecutive patients with pancreatic cancer were included: 42 patients underwent bypass surgery and 25 pancreatic resections. The operative mortality was 14% for palliative surgery and 0% for resective surgery. Surgical team and nurses were totally unaware of the predicted risk. The preoperative forecast proved to be correct in 81% of bypass surgery and in 88% of resective surgery, although surgical mortality had decreased from 21 to 14% for bypass surgery and from 17 to 0% for resective surgery. Tables are included to calculate the surgical risk for each of 162 combinations of the risk factors considered in the predictive model (81 for bypass surgery and 81 for resective surgery). Calculation of surgical risk is important when evaluating different treatments for pancreatic cancer are available.     

Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice?

If liver transplantation is not feasible, partial resection is considered the treatment of choice for hepatocellular carcinoma (HCC) in patients with cirrhosis. However, in some centers the first-line treatment for small, single, operable HCC is now radiofrequency ablation (RFA). In the current study, 218 patients with single HCC 相似文献   

Candida Glabrata Arthritis: Case Report and Review of the Literature of Candida Arthritis

We report a case of arthritis due to Candida (Torulopsis) glabrata in two different joints at different times in the same patient. The first episode of arthritis was situated in the right ankle and lasted more than 1 year before the patient agreed to the proposed treatment. Therapy with intravenous amphotericin B and oral fluconazole failed. A cure was achieved with weekly intra-articular administration of amphotericin B, which was continued for more than 20 weeks and combined with oral itraconazole. Several weeks later the patient developed Candida glabrata arthritis of the left knee while still taking itraconazole. Immediately, intravenous amphotericin B therapy was started and was successful. Because there were no previous invasive point manipulations or trauma, the infections were considered to be haematogenously disseminated. Chronic corticosteroid and repeated antibiotic therapy for infectious exacerbations of chronic obstructive pulmonary disease and alcohol abuse are the presumed risk factors in this otherwise immunocompetent patient. Received: 1 September 1998 / Accepted: 12 February 1999     

A case of primary pulmonary sporotrichosis

We report the first case of primary pulmonary sporotrichosis in Japan. A 53-year-old man was admitted to our hospital for further examination of the abnormal shadows on chest X-ray film. Six months before admission, he was admitted to another hospital because of alcoholic liver disease and diabetes mellitus. Since the initial chest film showed cavities with infiltration in the left upper lung field, he was treated with antituberculous drugs despite negative sputum cultures for mycobacterium. In spite of the medication, his chest X-ray film revealed another cavitary lesion, so he was referred to our hospital. He had been asymptomatic during this period. Chest X-ray on admission disclosed multiple cavities in the left upper lobe and a cavity in the right lower lobe. Repeated sputum specimens, bronchial washings and brushings for cytology and cultures were all negative. In an attempt to clarify the pathogen, percutaneous lung aspiration (PLA) was performed. The PLA sample yielded a positive culture of Sporothrix shenckii. After the diagnosis, S. schenckii was also cultured from sputa. A sporothrix skin test and yeast agglutination test for S. schenckii were positive. In the absence of a history for skin lesion, the patient was diagnosed as a primary pulmonary sporotrichosis. As iodide therapy was ineffective, he was started on a regimen of intravenous amphotericin B. However his renal function progressively deteriorated, so amphotericin B was discontinued. Now he receives miconazole intravenously and is still under careful observation. As far as we know, this is the first report of primary pulmonary sporotrichosis in Japan. The possibility of sporotrichosis should be considered in any cases of undiagnosed cavitary lung diseases.     

Surgical treatment of drug-resistant tuberculosis

The global emergence and spread of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis has led to the re-examination of surgery as a possible adjunctive treatment. We present the case of a 26-year-old HIV-seronegative patient with XDR pulmonary tuberculosis refractory to medical therapy. Surgical resection of the patient's solitary cavitary lesion was done as adjunctive treatment, and a successful outcome with a combination of surgery and drug therapy was achieved. We review the history of surgical therapy for tuberculosis and reports of its role in treatment of MDR and XDR tuberculosis. 26 case series and cohort studies were included, and together showed that surgical resection is beneficial in the treatment of drug-resistant tuberculosis. However, the results might not be applicable in all settings because investigations were observational and typically included patients with less severe disease, and all surgeries were done at specialised thoracic-surgery centres. Well designed studies are needed to establish the efficacy of surgery in treatment of drug-resistant tuberculosis.     

Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America.

Guidelines for the treatment of blastomycosis are presented; these guidelines are the consensus opinion of an expert panel representing the National Institute of Allergy and Infectious Diseases Mycoses Study Group and the Infectious Diseases Society of America. The clinical spectrum of blastomycosis is varied, including asymptomatic infection, acute or chronic pneumonia, and extrapulmonary disease. Most patients with blastomycosis will require therapy. Spontaneous cures may occur in some immunocompetent individuals with acute pulmonary blastomycosis. Thus, in a case of disease limited to the lungs, cure may have occurred before the diagnosis is made and without treatment; such a patient should be followed up closely for evidence of disease progression or dissemination. In contrast, all patients who are immunocompromised, have progressive pulmonary disease, or have extrapulmonary disease must be treated. Treatment options include amphotericin B, ketoconazole, itraconazole, and fluconazole. Amphotericin B is the treatment of choice for patients who are immunocompromised, have life-threatening or central nervous system (CNS) disease, or for whom azole treatment has failed. In addition, amphotericin B is the only drug approved for treating blastomycosis in pregnant women. The azoles are an equally effective and less toxic alternative to amphotericin B for treating immunocompetent patients with mild to moderate pulmonary or extrapulmonary disease, excluding CNS disease. Although there are no comparative trials, itraconazole appears more efficacious than either ketoconazole or fluconazole. Thus, itraconazole is the initial treatment of choice for nonlife-threatening non-CNS blastomycosis.     

32例空洞性肺结核的外科治疗

目的　探讨外科手术在空洞性肺结核治疗中的地位、适应症及手术方式。方法 对我院外科1987～1997年手术的空洞性肺结核32例进行回顾分析。结果 手术疗效满意,手术治愈率96.9%。结论 外科手术仍是目前我国消灭慢性传染源和解决空洞性肺结核病人复治失败以及严重后遗症的一种有效的治疗手段。